EFM - the research & the realities

SmilingBluEyes · Feb 9, 2007

While we are not a Level III facility I chose to respond in hopes I can help you. My responses are in bold type.

1. What is your level of care & how many births/mo or yr? Level of care is Level 2. We do about 750-800 births/month

2. Do you use central monitoring?

Yes we do.

3. Do all women get continuous EFM?

Not all, some get intermittent if:

low risk (meaning NOT a VBAC or having other high-risk profile)

Not on pitocin/cytotec

Not on an epidural drip

This means, in reality, about 80% do stay on continuous EFM cause

most elect to have epidurals where I work. And we do VBAC trials also.

4. Is intermittent EFM or intermittent auscultation a possibility?

Sure if they are low risk and not on pit or a VBAC, etc.

5. Do you use telemetry? Telemetry in tubs?

We have neither telemetry nor tubs.

6. Do you vary your EFM according to a woman's risk factors in L&D?

Yes. See above.

THANK YOU ALL SO MUCH!

You are welcome. Good luck with the project.

We can't make even small changes for women if we don't all work together for those women.

I totally agree with you. I find hospital birthing increasingly hard to deal with and disasatisfactory for me, personally, due to increased intervention and c/section rates, endless paperwork that really get in the way of providing the care I want to-----as well as the propagation of the concept of 9-5 obstetrics by so many OBs who want to get "on with their lives" after hours! If I had a dime for every change-of-shift c/s or OB who hollered cause a patient was not delivered when office hours were ending, and how it would affect their dinner plans-----well, I would not have to work for a living. I do wish I could be a CNM or work in a CNM-run birth center, due to this. But liability and insurance concerns really put a hole in that dream for me, as well....sigh. I guess you did not ask for personal commentary did you? Sorry I digressed.

Mrs.S · Feb 9, 2007

I read an interesting editorial in the Nov. 23, 2006, edition of the NEJM by Dr. Michael F. Greene. It's entitiled "Obstetricians Still Await a Deus ex Machina" & it is about the research into EFM over the past 30 years. The last sentence reads "We now find ourselves in the far less noble position of seeking new technology to mitigate the unintended and undesirable consequesnces of our last ineffective, but nonetheless persistent, technologic innovation." It is interesting how our professional organizations promote evidence-based care, but are totally blind to this one topic. I would really appreciate nurses from Level I, II & III hospitals answering a few questions for me as I try to promote a more reaonable approach to EFM in a Level III facility. PLEASE RESPOND:
1. What is your level of care & how many births/mo or yr?
2. Do you use central monitoring?
3. Do all women get continuous EFM?
4. Is intermittent EFM or intermittent auscultation a possibility?
5. Do you use telemetry? Telemetry in tubs?
6. Do you vary your EFM according to a woman's risk factors in L&D?
THANK YOU ALL SO MUCH! We can't make even small changes for women if we don't all work together for those women.

1. level II doing 1500/year

2. yes

3. no

4. yes

5. not yet, but I hear it's coming

6. everyone gets an NST on admission, after that we can do intermittent auscultation for low-risk labor patients. Epidural or Pit equals continuous EFM.

HappyNurse2005, RN · Feb 9, 2007

1. What is your level of care & how many births/mo or yr?

level III. 275-300+ births a month (320 or so in january)

2. Do you use central monitoring?

yes

3. Do all women get continuous EFM?

high risk women do, those with medical conditions deeming them high risk, those on pitocin/epidural

4. Is intermittent EFM or intermittent auscultation a possibility?

the low risk woman who requests it can have intermittent efm...though most are happy to be in bed, monitors on, epidural in.

5. Do you use telemetry? Telemetry in tubs?

no. and we dont have tubs.

6. Do you vary your EFM according to a woman's risk factors in L&D?

see above. all women get 20 mins monitoring on admission and further monitoring is per MD orders. low risk women have the option of intermittant monitoring, high risk women do not.

RNLaborNurse4U · Feb 10, 2007

1. What is your level of care & how many births/mo or yr?

I don't know what our level is designated as, but I work in the 2nd busiest L&D unit in my state. We turn no one away. We provide care from basic low risk deliveries, all the way up to the most complicated of OB cases. We deliver about 4500-5000 babies per year. We sometimes have OB patients who are ICU-type patients, but, they are only transferred to the ICU if they need more invasive monitoring (swan/ganz lines, etc)

2. Do you use central monitoring? yes (and I admit, I love it)

3. Do all women get continuous EFM? no

4. Is intermittent EFM or intermittent auscultation a possibility? yes - and I would much rather practice in this fashion when feasible

5. Do you use telemetry? Telemetry in tubs? no to both, our managers will not purchase telemetry units for EFM.

6. Do you vary your EFM according to a woman's risk factors in L&D?

Absolutely!

~ low risk (no epid, no pit) - initial reactive NST, then auscultate Q 1 hr for early labor, Q 30 min in active labor, Q 15 min when pushing.

~epidural/pitocin infusion - continuous EFM

~high risk - more often than not, are continuous EFM

~magnesium sulfate - continuous EFM while on L&D if unstable. If stable, and MgSO4 is for preterm labor, then they may only need a daily NST. If MgSO4 is for preeclampsia, more than likely they will be on continuous EFM.

~VBAC - treated like a normal labor patient (see: low risk/no epid/no pit)

~cytotec - EFM x 1-2 hours after placement, then off EFM until next dose due. These patients are always admitted, and cytotec is never done outpatient.

~dinoprostone gel - EFM x 30 minutes after placement. Off EFM until next dose due. Pt might be sent home between doses.

eden · Feb 10, 2007

What is your level of care/how many births a year - We are a teriatry care facility with 5000-6000 deliveries/year.

Do you have central monitoring?- No

Do all your patients have continuous EFM - No

Is intermittant EFM or IA a possibility- Yes

Do you vary EFM based on the patient - Yes

a)low risk labour pt- An initial strip in triage then IA. We listen q30min in early labour,q 15 min in active phase and q5 min while pushing unless we hear a decel. If decel is heard we listen after the next contraction, if still present we put them of EFM. If the srtip is reactive we can go back to IA

b) thick mec - EFM

c) epidural/ Iv narcotics - EFM for at least 20 minutes, the we can go to IA

d) Vbac - EFM for 20 min then IA, unless on pit then they are on EFM regardless

I love IA, it gives the pt so much more freedom and mobility to speed up the labour progress. The outcomes are comprable to EFM, fewer interventions and we have great sucess rates. We regularly go entire labours without EFM, minus the intial strip. I will add though that if there is any concern I have no problem putting them on EFM to either confirm/dismiss my concern.