Internal/External Monitoring Show Equal Rates of Fetal Distress, C-Section

By Danelle Frisbie © 2010
newborn baby bruised/scratched by internal monitor

The New England Journal of Medicine recently published a study that looked at labor (contraction) monitoring and different birth outcomes in hospitals. The study was conducted in the Netherlands (where rates of neonatal and maternal health and well-being are much better than in the United States). 734 women were assigned to internal monitoring (tocodynamometry) and 722 to external monitoring.

The purpose of the study was primarily to determine if there is a form of monitoring (internal or external) that leads to less unnecessary interventions, and therefore less fetal distress, better regulation of pitocin or other augmenting drugs, and less resulting c-section surgeries.

Continuous contraction monitoring is performed to (theoretically) monitor and artificially regulate contraction frequency, duration and magnitude. Because so many U.S. women today have their labors artificially started or augmented in some way via artificial oxytocin (pitocin), it has become necessary to monitor uterine contractions or face potential severe consequences to baby and/or mom such as uterine hyperstimulation and fetal hypoxia (lack of oxygen), which continues to take place anyway. [See video clip below for more on how this domino effect plays out.]

There had been speculation by some within obstetrics that internal monitoring (tocodynamometry) would lead to more effective 'feedback' and less intervention than the more commonly used external monitor (the belt).

Contraction and fetal monitoring is notorious for increasing unnecessary interventions and leading to cesarean section birth. It is hypothesized that this (along with the ubiquitously high use of pitocin and labor augmentation) in the United States is one reason we see our c-section rates souring while our neonatal and maternal morbidity and mortality rates worsen.

Typically, when an internal contraction monitor (tocodynamometry) is used, an internal fetal monitor is also placed (screwed into baby's scalp) or has already been in use prior to the tocodynamometry.

The results of this NEJM study conclude that there is no significant difference in outcome between internal or external monitoring. Both lead to unnecessary intervention and consequences equally as often including such things as:
-an intrauterine pressure catheter being inserted at some point during labor (whether or not this was the instrument used initially)
-amount of pitocin given to the birthing mother
-increased time to delivery
-adverse neonatal health at birth.

Both internal and external monitoring end in distress to baby, hypoxia, and consequential c-section to the same rate.

Moral of the study?

Do not believe (or allow it) if you are told you need to have an internal monitor during labor to monitor your contractions OR the baby's heartbeat (internal fetal monitor). This monitoring, whether for contractions or fetal heartbeat, does nothing more than the external (belt) monitor, and in no way improves your likelihood of a safe and healthy birth experience, or your baby's outcome.

Internal monitoring does, however, increase your risk of placental or fetal vessel damage, infection, and anaphylactic reaction. Previous studies have demonstrated that as much as 38% of the time an internal monitor is used, it is misplaced during insertion (hitting the placenta, the baby, or being passed between the membranes and uterine wall). This occurs no matter the skill or experience of the practitioner doing the insertion. For all of these reasons, authors of this study have made the recommendation that internal monitoring not be performed.

Above: correct placement of an internal (contraction) monitor
(in amniotic fluid next to baby)

Above & Below: incorrect placement of internal (contraction) monitor

BOTH forms of monitoring (internal and external) increase your chance of unnecessary interventions, the domino effect of hospital birth, distress to your baby, and the likelihood of having birth end in c-section.

Best thing? Ditch the monitoring altogether and find a birth attendant who believes in birth and is willing to do periodic (not continuous) checks on you and your baby.

If you'd like a gentle, normal, natural, peaceful birth that is as mother/baby-friendly as possible, the best thing to do may just be, as perinatologist, Dr. Marsden Wagner, so plainly put it - "get the hell out of the hospital!"

Related Reading:

Born in the USA


Gentle Birth, Gentle Mothering

Gentle Birth Choices

Your Best Birth

The Thinking Woman's Guide to a Better Birth

Ina May's Guide to Childbirth

Related Videos:

Pregnant in America

Birth As We Know It

Orgasmic Birth

The Business of Being Born

Born in the U.S.A.

[End Note: I 100% agree with Rosemary Romberg when she states that it is utterly hypocritical to have a gentle birth (for mom and/or baby) only to cut up this newborn after s/he enters the world. Gentle birth does not end at baby's initial entrance into the world. This is only the beginning and the entire process -- being protected, cared for, loved, nursed, and mothered from the first second earthside -- matters a great deal! Genital cutting ('circumcision') has absolutely NO place in or around birth.]

Outcomes after Internal versus External Tocodynamometry for Monitoring Labor
Jannet J.H. Bakker, M.Sc., Corine J.M. Verhoeven, M.Sc., Petra F. Janssen, M.D., Jan M. van Lith, M.D., Ph.D., Elisabeth D. van Oudgaarden, M.D., Kitty W.M. Bloemenkamp, M.D., Ph.D., Dimitri N.M. Papatsonis, M.D., Ph.D., Ben Willem J. Mol, M.D., Ph.D., and Joris A.M. van der Post, M.D., Ph.D.


Background: It has been hypothesized that internal tocodynamometry, as compared with external monitoring, may provide a more accurate assessment of contractions and thus improve the ability to adjust the dose of oxytocin effectively, resulting in fewer operative deliveries and less fetal distress. However, few data are available to test this hypothesis.

Methods: We performed a randomized, controlled trial in six hospitals in the Netherlands to compare internal tocodynamometry with external monitoring of uterine activity in women for whom induced or augmented labor was required. The primary outcome was the rate of operative deliveries, including both cesarean sections and instrumented vaginal deliveries. Secondary outcomes included the use of antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes (defined as any of the following: an Apgar score at 5 minutes of less than 7, umbilical-artery pH of less than 7.05, and neonatal hospital stay of longer than 48 hours).

Results: We randomly assigned 1456 women to either internal tocodynamometry (734) or external monitoring (722). The operative-delivery rate was 31.3% in the internal-tocodynamometry group and 29.6% in the external-monitoring group (relative risk with internal monitoring, 1.1; 95% confidence interval [CI], 0.91 to 1.2). Secondary outcomes did not differ significantly between the two groups. The rate of adverse neonatal outcomes was 14.3% with internal monitoring and 15.0% with external monitoring (relative risk, 0.95; 95% CI, 0.74 to 1.2). No serious adverse events associated with use of the intrauterine pressure catheter were reported.

Conclusions: Internal tocodynamometry during induced or augmented labor, as compared with external monitoring, did not significantly reduce the rate of operative deliveries or of adverse neonatal outcomes. (Current Controlled Trials number, ISRCTN13667534 [] ; Netherlands Trial number, NTR285.)

Full Text at the New England Journal of Medicine


  1. Really good article - really good clip. I totally agree with the domino effect - it happened to me, though I did have a vaginal birth. I had the blessing of an epidural that did not work at all, so I knew how intense the pitocin was. I made them turn it off! They were not happy with me, but I knew it was the right thing to do. Once you're in the hospital it is so easy to lose control. The saving grace I had was that I remembered our birth instructor telling us, "This is America and they should not make you do anything. You have the right to refuse!" In the future, though, if I am blessed enough to get to conceive and give birth again, I will have a homebirth assisted by a midwife and doula. For sure!

  2. For my first baby I was unaware of a lot of the things they do in the hospital, even though I did quite a bit of research before delivering. They gave me ptocin and did internal fetal monitoring without my knowledge. When I asked what they were giving me they said, "oh, it's just a little ptocin to help your contractions." - I had only been having conrtactions from friday night to saturday morning and had gotten to 6 cm by myself at home - no drugs to that point. I had only been at the hospital for 1 few hours and it seemed to me that I was progressing just fine. Then I pushed for an hour and had my baby. I was looking her over and saw she had a pin prick in her scalp. NO ONE HAD TOLD ME WHAT THAT WAS!!! If I had known #1 that they were doing that and #2 that they actually breech her skin, in her head no less, I would have said hell no! I was so betrayed and plan to do things VERY differently with future babies.

  3. I'm thankful for the external monitoring of my contractions for each of the pregnancies I had. I chose to have an epidural for both of them, one a full epidural and the other a walking epidural. I could not feel the contractions with my first baby but with my twins I was able to do most things without the monitors. I still would not have given them up because my boys were premature as it was and if not for the monitors we may not have known they would need help immediately after being born. Monitors do not cause fetal distress. My mom is a well informed RN who has worked on both sides and in between of Labor & Delivery, Nursery, and Postpartum. I am glad she was with me through it all and trust her judgement when it comes to fetal monitoring. I don't agree with internal monitoring, however. Never have, never will... Nor do I agree with inductions (breaking the water or administering pitocin) even in the hospital. My mom has told me many times of the doctors who would 'hurry up and induce so they could go home'. And it has all ways bothered me. I love your site, I chose to keep ALL my boys intact without the facts. And I will all ways be thankful I did, thank you for writing your blog so more moms can be informed of the importance of natural, peaceful parenting.

  4. I am curious about the consequences for the mother if an internal contraction monitor is inserted incorrectly. I had one of them forced on me (and I gave birth in the Netherlands, ironically!), and it was EXCRUCIATING having it put in. Worst part of my labour, by far, literally had me screaming and trying to writhe away from the doctor. I have never heard of anyone having a similar experience.

    Four years later I am having constant pain at the exact same spot that I remember that agony. It started when my periods came back about a year postpartum and has *never* stopped since. Occasionally it is worse, depending on where I am in my cycle (worse at ovulation and just before my period), but it certainly chronic. A visit to the gynecologist revealed "nothing wrong." I just don't know....

  5. To the girl that delivered in the Netherlands. I had the same experience here in the states. I had my daughter 9-9-11 by c-section. They inserted a internal contraction monitor in me as well and it was the worst pain i have felt in my life. I have a very high pain tolerance! I had that monitor in me for 3hrs and the whole entire time i was in nonstop pain. I demanded them to take it out and once they did I was breathing through my contractions like a champ. It was like night and day. I seriously wanted to just out a window. I was screaming and crying and all over the bed. At one point they turned me on to my left side and I felt so much pressure that I wanted to push but I was only dilated to a 6. After 19hrs of labor (water broke at home on its own) they decided I needed to have a c-section. My daughter is now 7mnts old and I still have after shock pain from that monitor. My doctor also told me there was nothing wrong. I also use the bathroom (#2) more than I ever have in my life. My body is completely different.



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