[feebebe23]

RNINWCH....

I agree with you...If I did not have central monitoring....I would not put someone on cont. efm unless necessary.....and then they should be 1to1....for the reason you stated....

I work at a very busy....very hmmmm how shall we say this "upscale" hospial and surrounding area....

We could not function w/o central monitoring.

And let me tell ya....where I work......avoiding litigation is the #1 priorty.....so some of my opinions may differ from someone with different work experiences.

[rninwch]

Originally Posted by feebebe23

I could not imagin not having central monitoring....ahhhh

And I agree sometimes you do pick up mom not baby with a mom moving around alot.

And yes.....babies decel all the time when no one is looking....as in the entire pregnancy...babies roll on their cords....so i agree with what your saying.....so here's the questions.

mom comes in....a bradley mom....she's 3 cm....having regular ctx....appears umcomfortable/early labor....she would like intermittent monitoring...for me FHTs q30 min means I get 5 min strip every 25 min...making sure before/during/after ctx....so getting an etire 5 min....hey thats just me.....so 25 min has gone by....you go in fhts 60's...how long has baby been down 2 min or 10?....you do all your stuff...call MD/IV bolus/position/O2...minutes go by....off to the OR...baby out well before the 30 min to incision.

All things be equal.....do they have a case? In your opinion?

Well...some people are going to sue regardless of the why, and some are going to win. Many times a jury gives a pt big $$ based on emotion...so it doesn't matter what you do.

I'm going to assume that there is a bad outcome, otherwise you wouldn't pose this question. So it comes down to:

1. Did you follow hospital procedure? If hospital procedure doesn't allow for IA, then it really should be changed, since anytime you don't use continuous EFM you are violating hospital policy, which is going to look bad. (Our policy for healthy mom in routine labor is NST, if reactive pt may be intermittent monitored following the awhonn guidelines. If anything is funky with IA then a minimum of a 30 min strip is run. If that is OK then we can go back to IA if desired.

2. Does that procedure follow the normal standard of care? It won't matter if you followed a policy that is wrong.

We used to use rice socks for back pain..had a policy in place, pts loved them. Well one day a well meaning, but not exactly bright nurse allowed an epiduralized pt to use one. Pt ended up with a 2x3cm blister/burn just above her tailbone, we put abx ointment on it. Pt didn't follow up at 6 wks, but chose to sue when baby was 4 months old for loss of intimacy with her husband because she was ashamed of the scar...our policy didn't actually state not to use the heated rice sock on pts with numbness/epidurals so case settled for $90,000 out of court.

3. Did you follow doctors orders? If doctor orders the treatment/intervention, you don't do it because pt doesn't want it and you don't tell the doc...you are setting yourself up for trouble.

4. Did the dr's orders follow the normal standard of care? Of course if the order is wrong or dangerous then you should refuse...we have all seen those types of stories...

5. Were the options explained to the parents, did they understand the risk vs benefit? Everything we do has a risk as well as a benefit. The prn loc I put in gives me immediate venous access in an emergency, but introduces the risk of infection, allergy...

That EFM gives me a better idea whats going on, but it limits my pts mobility which increases discomfort increasing the need for pain meds as well as slowing labor. Not moving makes it more likely that cord compression will occur increasing the chance of distress, which makes it more likely that more interventions will be used. Every time I intervene I increase the risks...now I'm not saying hospitals are bad places to give birth BUT I am saying that alot of what we do is completly based on "what we've always done" and faulty reasoning and bad science.

[Belinda-wales]

What a hot topic- Many of you know that I am a nurse midwife from the uk where all women recieve care from midwife and if high risk doctor as well- only high risk moms have IV and cont montioring- the care is research based and very safe. I now work a a clinical manager with in L&d and things are different here- usally the justification is litigations but no worries people sue inthe UKjust as much if the out is poor. I have a lot of admiration for the nurses I work with I think that they do a really great job under sometimes very stressful circumstands-I am very confident letting the clients take charge of there own birth and with good comunication it can work well for all - every nurse that works on l&d in the uk is a trained midwife so that helps with confidence the course is 18 months long full time this long with nursing course which is three years full time equals nearly five years of education -we have nurses on our unit who do there nursing in 16 months and then 12 weeks orentation are left to look after a labouring family- I think they do a great job- it would benifit L&D nursing if a national course for L&D nurses was offered to all.

[eden]

rninwhc got to the reply before I could but said everything I would have.

I use both EFM and IA readily in practice, depending on the situation. I just don't think that someone not agreeing to EFM, if an initial 30 minute strip is reactive, is being unreasonable.

[canoehead]

Originally Posted by eden

It is scare tatctic when you say "if you don't have EFM your baby's HR can go down but may not be dectected for 5-30 minutes".

It's scary, but it's also true.

If a parent wants to deviate from protocol I tell them I will support whatever decision they make, but I am also obligated to explain why the protocol is there. I can't assume common sense in anybody, especially in a stressful situation. Even the most educated parents have been OK with that.

If the hospital says to do EFM we are pretty much stuck as nurses, and have to act as if it is important. However if the patient declines it after I do my spiel I will be less likely to bring it up again in a "are you sure you don't want that?" moment.

[tvccrn]

Originally Posted by eden

It's not stating the facts because evidence suggests otherwise. Why not tell them that EFM is subject to misinterpretation, is subjective (2 people can interpret the same strip differently) and there is evidence that IA is just as good, in terms of outcomes?

No, the fact is that if the monitoring isn't on the drop in heart rate will go undetected for 5-30 minutes, however long it's not monitored. That has nothing to do with the subjectiveness of such monitoring. After all you can't detect something that not being watched.

tvccrn

[tvccrn]

Originally Posted by HappyNurse2005

but she did say that, in the OP. to quote hte OP:I understand that in some circumstances my baby's heart rate may increase or decrease and go undected for 5-30 minutes depending on my stage of labor. I am aware that these changes could result in the injury or death of my baby.

IMO, she didn't say it in a way that I consider a scare tactic. She simply stated that the patient would be aware of the results. If she had said that it was a definite outcome just because of the undetection, that would be a scare tactic.

tvccrn

[eden]

EFM is subjective. What someone may call a late, someone else may say it's early or miss it entirely. What one says is average variablity, someone else may call decreased. The differences in those interpretations change your plan of action. FHR do drop but it's when and where that is a concern, if you are adept at interpreting strips and let's face it, not everyone is especially when you are new to the field.

The FHR drops with an early decel but we all know that earlys are a benign finding.

Are you telling me there are no protocols for the use of IA in your (general your) facility? Or is just that you (again, a general you) are more comfortable with the use of EFM( because it's fine to prefer one method over the other but don't insist it's hospital policy when there may be other guidelines in place)? It's when there are really rigid policies I find alot more resistance with patient.

I myself like using both and am comfortable with both methods.

At my facility we do an initial strip of 30 minutes. If it's reactive we listen q15 and if a decel is heard, then we listen after the next contraction. If I don't like what I hear I am the first to pop them on the monitor to see what's going on. Depending on the second strip we either continue or go back to EFM.

[midwife2b]

Originally Posted by SmilingBluEyes

Sadly, bad things can happen in the hospital or at home. I will say, from what I learned from two friends who went through nightmare litigation with a doctor in the wake of a very bad outcome, AMA forms are not worth the paper they are printed on, when it comes to protecting you in court. Sad but true. They can still sue and win, if their lawyers are sharp and can produce excellent nurse and physician experts to support their cases. We accomplish such forms the mitigate the potential, but there is no protection on earth that will help in some cases.

And as much as I support free choice, I am pretty certain in the case of a horrible outcome, that was indeed not the fault of hospital personnel or the doctor, suit would be considered in a very large number of cases. It's the way things are. True negligence should be discovered and dealt with. But sometimes, no matter what we do right, bad outcomes can result. It's horrible for everyone when they do. And AMA forms notwithstanding, people are going to sue.

Here is what I think of birth plans. They are a very legitmate attempt by people to take back their birth experiences from what they feel is an increasingly dangerous, hostile, and pro-(sometimes needless)-intervention environment in most hospitals. In most cases, respectful appreciation of folks' needs, and wishes as well as a little education/ communication can go a long way toward a "meeting in the middle". This is my experience, anyhow. Failing that, of course, AMA documentation is necessary. Just don't think it will protect you fully in the end. Because it may not, especially in cases where policy and procedures may be violated by nursing/medical staff in rendering well-intended and competent care. In these cases, in particular, you well may not have much to stand on.

Having been in such situations, I agree with Deb 100%.

Families need to feel that they've been treated well, their choices respectfully addressed, and their needs have been met. The AMA documentation did not save us from several lawsuits and investigations over the last few years when I worked as a L&D nurse. As our attorney so aptly stated, "Policies are for the institution. Guidelines are for the people, and you cannot dictate behavior in a free country".

FWIW my ladies are "forbidden" to have more than one page on their birth plan Their plans actually addresses more newborn and postpartum issues than labor ones, because we talk about the unpredictability of the birth process. Less is more, and a lot of times less is better. That's how our midwifery service "meets in the middle".

[CMCRN]

I don't mind a well thought out birth plan and use it to start a discussion and help pts feel comfortable. What bothers me is long birth plans downloaded from the internet and when I bring up a point for discussion or clairification they don't even know what they have in it, that is a waste of my time.