Fetal surveillance in labour, a review of SOGC 2020 Guideline 396
Oversights, omissions and opportunities squandered
In March 2020, the Society for Obstetricians and Gynecologists of Canada (SOGC) delivered Guideline 396 relating to fetal surveillance in labour (hereinafter “SOGC 2020”).1 SOGC 2020 is intended to replace the 2007 SOGC Guideline, No. 197, (hereinafter “SOGC 2007”),2 although SOGC 2007 covers both antenatal and intrapartum fetal surveillance, while SOGC 2020 only addresses the latter.
SOGC 2020 was developed by a working group of the SOGC, approved by the Board of the SOGC, and reviewed by committees of the SOGC, including the Medico-Legal Committee. Reading SOGC 2020, the inference is inescapable that medico-legal considerations have had more influence than they merit for a guideline intended to inform obstetrical care in labour. After all, improved outcomes are the best defence to medical-legal claims, while defensive guidelines work against this goal. Notably, SOGC 2020 is also less ambitious in its objectives than the previous guideline, seeking merely to “minimize” the risks associated with birth asphyxia,3 rather than the more worthy objective of SOGC 2007, which was to “decrease” the incidence of birth asphyxia.
I offer this critique as a lawyer with more than three decades of experience representing children affected by birth trauma, with considerable support from relevant medical literature, and based on advice from some of the very best medical experts in the fields of obstetrics, neurology, neuroradiology and neonatology.
Many old biases continue to be perpetuated in SOGC 2020. These relate to the value of Electronic Fetal Monitoring (EFM), the putative value of intermittent auscultation (IA), the incidence of cerebral palsy (CP), the outcomes following birth asphyxia, and the analysis of timing and mechanism of injury. In my view, SOGC 2020 is deficient with regard to all these issues.
The continued endorsement of IA over EFM in low risk deliveries, which support is based on old research of dubious value in modern obstetrics, is unwarranted in my view. The basis for permitting IA in low risk labours is the presumption that EFM increases the risk of Cesarean section, allegedly without evidence that EFM has reduced the incidence of CP. Carried to extremes, it could be argued that no monitoring at all would reduce the Cesarean section rates even further, without a measurable effect on CP rates – reductio ad absurdum.
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1 SOGC Clinical Practice Guideline, No. 396, Fetal Health Surveillance: Intrapartum Consensus Guideline, March 2020.
2 SOGC Clinical Practice Guideline, No. 197, Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline, September 2007.
3 SOGC 2020 page 316.
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