40 Years of Evidence, Zero Change in Practice: The EFM Problem
The Dublin trial showed continuous monitoring increased cesareans without improving outcomes. That was 1985. We are still doing it.
The Dublin randomized controlled trial was published in the American Journal of Obstetrics and Gynecology in 1985.
It enrolled over 12,000 women in labor and randomly assigned them to continuous electronic fetal monitoring (EFM) aka cardiotocography or intermittent auscultation. The results were clear: continuous EFM increased cesarean delivery rates and operative vaginal delivery rates without improving neonatal outcomes or reducing the rate of cerebral palsy.
That was 40 years ago.
Subsequent Cochrane reviews, incorporating data from multiple randomized trials totaling more than 37,000 women, confirmed and strengthened the finding. Continuous EFM in low-risk labor increases surgical intervention without improving neonatal outcomes.
Continuous EFM remains nearly universal in American obstetrics.
This is not an evidence gap. The evidence is unambiguous. This is not a practice that has been slow to change. It has not changed. Forty years after the definitive trial was published in the journal most obstetricians read, continuous EFM for low-risk labor remains standard practice at virtually every hospital in the United States.
The EFM story is the single most important example of the evidence-to-practice gap in modern obstetrics. Understanding why the practice persists, despite the evidence, tells us more about how American obstetrics works than any guideline or committee opinion.
🎯 Free Subscriber Bottom Line: Multiple randomized controlled trials and Cochrane reviews have demonstrated that continuous electronic fetal monitoring in low-risk labor increases cesarean and operative vaginal delivery rates without improving neonatal outcomes or reducing cerebral palsy. The evidence has been available since 1985. The practice has not changed. Understanding why is essential to understanding the evidence-to-practice gap in American obstetrics.
Below, paid subscribers get: - The Dublin trial deep dive: design, findings, and why it should have changed practice - Fraser’s amnioinfusion trial (NEJM 2005): another monitoring intervention that failed - The medicolegal paradox: does EFM actually protect against lawsuits, or does it create them? - What intermittent auscultation would require and why hospitals resist it - The complete EFM evidence timeline: trial, year, finding, impact on practice - The resource and cost analysis of universal monitoring.
