EFM question

Jolie, BSN · May 29, 2006

I don't know the professional answer to your question, but from my experience as a high-risk OB patient, I'll give it a shot. I began noticing uterine tightening at about 16 weeks, but it wasn't visible on the monitor at that time. By 22 weeks, my contractions could be seen on a monitor.

As far as FHT's, they can be picked up very early in the 2nd trimester with a fetal monitor, but contining to monitor them for any length of time is nearly impossible, as the baby still has plenty of room to "swim", and must constantly be chased. In my experience, this gets to be very stressful for mom and staff. Unless there is a pressing need for continuous FHT's, I think it is better to get intermittant heart tones, and monitor continuously for contractions.

imenid37 · May 29, 2006

It is difficult to simultaneously monitor both fh's and uc's until about 24-25 weeks (even then it can be quite difficult). The utuerus is too small until about then to accomodate both transducers. Sometimes we will listen for fht's, then monitor for uc's only on a mom who is abt. 20-22 weeks at the earliest. We might try to stop u'cs at this gestation, but some institutions do not stop them prior to the age of viability.When EFM was intro'd, just think of how much further in gestation viability was, probably 28 weeks or so.

jaka1 · May 29, 2006

Thanks for your responses. I was summoned to the ER to monitor someone who was 14wks. I thought it was a bit absurd but haven't found any literature that actually says when it is appropriate to use EFM. I only find "late pregnancy" as a time line.

SmilingBluEyes · May 29, 2006

It is absurd. You can't "monitor" a 14 weeker and the fetus is non-viable anyhow, if something is amiss. If anything, you can doppler the FHT and document them for the ED and leave the rest of the triage process to them.

RNLaborNurse4U · May 29, 2006

14 weeks? Good luck finding FHT's with EFM. I would use a hand held doppler from 12 weeks and beyond. I wouldn't use the toco unless they were 16 weeks or later, and even then, you probably won't pick up any UC's/irritability until 20-22 weeks. (Our policy is: we see anyone 16 weeks and above for bleeding/cramping/labor in OB, anyone under 16 weeks is seen in the ED).

You should be able to trace a 24 weeker on EFM, and you should even get preterm (10 beats x 10 seconds) accels as early as 24 weeks. But good luck keeping the baby on continuously :-D

Unless I have an order to do otherwise, I only use the hand held doppler intermittantly under 24 0/7 weeks. Some of our docs will want continuous EFM with u/s on the gestations under 24 weeks, in hopes of getting to viability, so they can tocolyze and start betamethasone.

texas-rn-fnp · May 30, 2006

You best bet is to have a policy in place outlining what your hospital requires. Then you are supported in case of conflict.

RNnL&D · May 31, 2006

Thanks for your responses. I was summoned to the ER to monitor someone who was 14wks. I thought it was a bit absurd but haven't found any literature that actually says when it is appropriate to use EFM. I only find "late pregnancy" as a time line.

Who wrote the order? In our facility, ER docs can't write fetal monitoring orders, only the OB's. And I can't imagine any OB using anything but Doppler on a 14 weeker. ER uses Doppler only.

jaka1 · Jun 1, 2006

Our OB policy says that under 20 weeks goes to the ER as well as non obstetrical problems over 20 wks. In this case it was the ER nurse who called 3 times saying "I don't care what you think you need to do, someone better come put her on the monitor", they just don't get it. Two days later it was the PA who insisted we monitor someone who was 17 weeks "so it looks like we tried to do something" even after the OB-GYN called us and said he was sending her to the ER and needs to stay in the ER and does not need to be monitored except to doppler heart tones.

RNnL&D · Jun 1, 2006

In this case it was the ER nurse who called 3 times saying "I don't care what you think you need to do, someone better come put her on the monitor", they just don't get it. Two days later it was the PA who insisted we monitor someone who was 17 weeks "so it looks like we tried to do something" even after the OB-GYN called us and said he was sending her to the ER and needs to stay in the ER and does not need to be monitored except to doppler heart tones.

It would be good to have a policy in place for these instances. Our ER has to consult with the OB attending for all OB pts. They are not able to write EFM orders as they are not qualified to interpret the results. The only time we have done off unit monitoring is for pts in the main OR, detox, etc. Pts who are pg but require more care than we are capable of giving in OB.

I think that would be an important part of your policy, is the person ordering EFM qualified to interpret it. We get calls throughout the hospital, "can you come monitor this 18 weeker, she wants to hear the heartbeat?" Uh, not without an order from an OB.