Birth Small Talk

Talking about birth

“Fetal Distress”: An Epic Tale

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The term “fetal distress” had a finite beginning around the 1840s. The stethoscope had to first be discovered, followed by the realisation that the fetal heart could be heard. Not long after this, changes in fetal heart rate patterns began to be described as a sign of “fetal distress”. The science of physiology was in its’ infancy, and instruments and research methods to investigate this theory were not sufficiently developed to prove or disprove these assumptions. Nonetheless, they appealed to the imagination of obstetricians, and rapidly became accepted as a sound basis to begin to regularly auscultate the fetal heart during labour, and to bring labour to an early end when abnormalities were detected. While the precise patterns that are considered to indicate “fetal distress” have evolved over time, the concept that there is such a thing as “fetal distress” has remained intact.

Several assumptions are built into the term “fetal distress”. They are that –

• Low levels of oxygen in fetal blood and tissues cause injury to fetal organs, particularly the brain.
• Low oxygen levels are a frequent cause of death of the fetus prior to, or soon after birth. Low oxygen levels are also responsible for most cases of brain injury, resulting in conditions such as seizures and cerebral palsy.
• A fetus with low oxygen levels will have predictable changes in their heart rate pattern.
• Most fetuses with these heart rate patterns have low oxygen levels.
• These heart rate pattern changes can be detected and interpreted consistently and with accuracy.
• There is a predictable duration of time after the onset of these changes in the fetal heart rate pattern where damage to the fetal organs has not yet occurred or is reversible.
• Reducing the time to the birth of the fetus (by caesarean section or instrumental birth) once changes in the fetal heart rate pattern have been identified is able to prevent damage to the brain and other organs, or death.

There is limited evidence for most of these claims, and for some there is evidence which suggests that they are not factual. (I’ll explore this more in later posts.) Despite this lack of evidence, there is widespread belief in maternity care, and among the general population, that the theory of “fetal distress” is a proven scientific fact. 

The word “distress” is itself an interesting choice to name the phenomenon of changes in fetal heart rate patterns. Distress implies a subjectively highly unpleasant or painful experience. There is however no way to know what a fetus experiences when oxygen levels fall, and heart rate patterns change. For all we know, it might be quite a pleasant feeling. Some degree of “stress” (termed eustress) appears to be physiologically normal for fetuses during labour, and may trigger important adaptive processes (Dahlen, et al., 2013). Appropriate levels of “stress” during labour might therefore be of benefit.

Stepping from medicine and into postmodern philosophy, the term “fetal distress” can be considered as a meta-narrative. Meta-narratives are “self-legitimising myths” (Appignanesi & Garratt, 1999) – grand stories that sustain particular projects or movements. In this instance, the “fetal distress” meta-narrative has been useful in permitting obstetric knowledge to become seen as the authoritative body of knowledge about the (literally) voiceless fetus. The concept of “fetal distress” has been put to use by the profession of obstetrics to obtain and maintain power (Arney, 1982). Raising concern about the wellbeing of the fetus often shuts down women’s capacity to make decisions about their own wellbeing.

Almost forty years ago, obstetrician Philip Steer suggested that it was time that the term “fetal distress” be abandoned, writing:

It is clear that we should no longer accept the term ‘fetal distress’ as sufficient description of fetal condition.

Steer, 1982, p. 692

In 2020, I would argue that not only should we reconsider the use of the term “fetal distress” as a shorthand to describe all manner of anxieties regarding the fetus, but that it is time to critically examine the nature of the “fetal distress” meta-narrative. Whose interests are best served by this epic tale?

Appignanesi, R., & Garratt, C. (1999). Introducing postmodernism. Icon Books.
Arney, W. (1982). Power and the profession of obstetrics. University of Chicago Press.
Dahlen, H., Kennedy, H., Anderson, C., Bell, A., Clark, A., Foureur, M., Ohm, J., Shearman, A., Taylor, J., Wright, M., Downe, S. (2013). The EPIIC hypothesis: Intrapartum effects on the neonatal epigenome and consequent health outcomes. Medical Hypotheses 80(5), 656 – 662. https://dx.doi.org/10.1016/j.mehy.2013.01.017
Steer, P. (1982). Has the expression ‘fetal distress’ outlived its usefulness? BJOG: An International Journal of Obstetrics & Gynaecology 89(9), 690-693. https://dx.doi.org/10.1111/j.1471-0528.1982.tb05091.x

Categories: History, Philosophy, Reflections

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  1. The invention of the CTG machine: the history of fetal heart rate monitoring – Birth Small Talk
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