When Machines Drive Birth Decisions: What Every Laboring Person Should Know About Electronic Fetal Monitoring and C-Sections
Electronic fetal monitoring (EFM) — the continuous tracing of a baby’s heart rate and contractions during labor — has become nearly universal in U.S. hospitals. While originally introduced in the 1970s with the intent of reducing infant injury and stillbirth, mounting evidence suggests that routine EFM for low-risk labors does not significantly improve neonatal outcomes, yet it does appear to increase the rate of cesarean births.
A 2025 New York Times article highlighted how, in many hospitals, round-the-clock EFM has become a standard part of labor management — and that this practice may be a major driver of America’s high cesarean section rate. This article responds to that discussion by outlining what EFM is, the evidence behind its use, and — most importantly — how birthing people can advocate for themselves when facing monitoring and intervention decisions during labor.
What Is Electronic Fetal Monitoring — and Why Is It Used?
Electronic fetal monitoring records a baby’s heart rate and laboring parent’s uterine contractions. Continuous EFM typically straps sensors around the parent’s abdomen throughout labor, providing a visual heartbeat and contraction pattern called a cardiotocograph (CTG). In many hospitals, this has become a default practice for all laboring people, not only those with high-risk pregnancies.
The assumption is that continuous EFM can alert clinicians to signs of fetal distress early — potentially preventing hypoxia and other complications. However, decades of research have not demonstrated clear benefit in most low-risk labors. In fact, studies show that routine continuous EFM does not reduce the incidence of cerebral palsy or other long-term injuries but is associated with higher operative delivery rates.
Some of the evidence highlights the limitations of EFM interpretation, including poor specificity and high false-positive rates, meaning the monitor may appear concerning even when the baby is well.
What Research Says About EFM and Cesarean Birth
Several studies suggest that continuous EFM use can lead to a “cascade of interventions.” For example, research on low-risk pregnancies found that EFM was associated with a 10–40% increased risk of cesarean delivery without reducing infant mortality in full-term births.
A systematic review also observed that compared with intermittent auscultation (periodic listening using a handheld Doppler or stethoscope), continuous EFM does not reduce adverse outcomes but does correlate with higher operative birth rates.
Despite these critiques, continuous EFM remains ingrained in many settings — in part due to hospital policy, staffing limitations, and medico-legal concerns that make providers reluctant to deviate from “standard of care.”
Why More Monitoring Doesn’t Always Mean Better Outcomes
Understanding why EFM persists despite mixed evidence requires looking beyond the technology itself.
1. Interpretation Variability
Interpreting fetal heart rate patterns is complex and subjective. Even experienced clinicians often disagree about what a tracing means, especially for intermediate patterns. This variability can lead to unnecessary interventions.
2. A Culture of Risk Aversion
Hospitals and providers often default to conservative policies that favor intensive monitoring. Part of this comes from fear of missing a rare but serious event, potential malpractice liability, and institutional protocols that require continuous data. Many clinicians report that the presence of a continuous EFM trace influences decisions — even when the laboring person and baby appear clinically stable.
3. Equipment as Evidence
Electronic tracings can feel like “hard data” compared with intermittent auscultation, which relies on periodic listening. In environments where medical decisions are defended retrospectively, continuous tracings can be used in medicolegal discussions even if they are not highly predictive of outcomes. This reinforces the practice, even without strong evidence of benefit.
Intermittent Auscultation: A Valid Alternative
For many low-risk pregnancies, intermittent auscultation (IA) — listening periodically to the baby’s heart rate with a handheld device — is a scientifically supported alternative. Several international guidelines and researchers have noted that IA can reduce the likelihood of cesarean birth without increasing adverse outcomes, when labor support is adequate.
The World Health Organization and other professional groups have recommended IA for healthy, uncomplicated labors. However, staffing constraints and hospital policies often make IA impractical without additional support. Continuous labor support, such as from a doula, increases the feasibility of intermittent monitoring and is independently associated with lower intervention rates.
What Patients Can Do: Advocacy Strategies
Given the complexity of labor care and the limitations of EFM, here are practical ways expectant parents can advocate for themselves:
1. Ask Questions Early
During prenatal care:
Ask if continuous EFM will be routine for your birth.
Inquire about alternatives like intermittent auscultation and under what circumstances EFM would be medically indicated.
Clarify what the care team considers a “non-reassuring” tracing and what clinical actions would follow.
2. Build an Informed Birth Plan
Include your preferences around monitoring in your birth plan:
State whether you prefer intermittent auscultation if you’re low-risk.
Indicate that continuous EFM be used only when medically necessary.
Documentation helps ensure your care team knows your goals in advance and can prompt discussion before labor begins.
3. Partner With Supportive Providers
The style of your provider matters. Midwives and clinicians who practice physiological birth and evidence-based monitoring may be more open to intermittent approaches or shared decision-making.
4. Invite Shared Decision-Making
During labor:
Advocate that data from the monitor be discussed in the context of how you and your baby are clinically doing.
Ask for explanations if the monitor shows concerning patterns. What exactly is the concern? Are there correlating clinical signs?
Ask “Why do you recommend this intervention?” and “Is this urgent?” when suggested.
This kind of dialogue helps center decisions on your experience, not solely on a machine readout.
5. Enlist Continuous Support
Evidence strongly supports that continuous labor support — especially from doulas — reduces cesarean rates, shortens labor, and decreases the use of interventions. A doula can help you stay mobile, advocate for your monitoring preferences, and interpret information from the care team. Research has consistently shown the benefits of continuous support in labor outcomes.
Documenting Decisions and Questions
Keeping a birth journal or checklist with your questions and responses can help you feel more empowered. You can bring up:
“What pattern did the monitor show, and what clinical findings support this interpretation?”
“Can we pause and reassess how I’m doing before making a decision?”
“Is this intervention time-sensitive?”
These questions frame the discussion as clinical decision-making rather than automatic escalation.
The Bigger Picture: Shared Responsibility for Safe Care
The persistence of continuous EFM in low-risk labors is not just a medical issue; it’s also a systemic issue shaped by hospital culture, staffing, and risk management. Comprehensive advocacy combines individual preparation with broader awareness:
Know your rights as a patient.
Understand common practices versus evidence-based options.
Engage your support team (partners, doulas, midwives).
Prepare for discussions about monitoring and interventions.
Being informed does not guarantee your preferences will always be honored — but it significantly improves your agency and the quality of your care experience.
Beyond the Monitor: What Birth Workers Can Do
Birth professionals including doulas and childbirth educators play a critical role in advocating for patient-centered care. They can help clients:
Review monitoring literature and guidelines together.
Facilitate communication with medical providers.
Encourage the use of evidence-based alternatives when appropriate.
When birth workers support one another in continuing education about monitoring practices and advocacy strategies, the entire maternity care ecosystem benefits.
Closing Thoughts
Electronic fetal monitoring has been around for decades, yet its widespread use has outpaced the evidence supporting universal application. While it remains a valuable tool in specific scenarios, routine continuous use may contribute to higher cesarean rates without improving outcomes in low-risk labors.
By understanding the limitations of EFM, engaging in open communication, and developing actionable advocacy strategies, expectant parents can participate more actively in care decisions. Creating a birth plan that reflects your values — and supporting it with education and support — can help you navigate monitoring decisions with confidence and clarity.
At CT Doulas, we believe in empowering families with knowledge, support, and advocacy tools for the birth journey ahead. That includes understanding not just what is being done during labor, but why — and how to be an active partner in decision-making throughout.
