FHR: Is mom big or is baby down?

[starry01]

I am a new l&d nurse with close to 30 days on the floor. I work on a high-risk unit at a teaching hospital. I have 10 days left on orientation but have been caring for patients independently for a week (with my preceptor keeping a close eye, which I feel very comfortable with and appreciate).

I have found that CEFM on morbidly obese moms is difficult and finding that FHR after mom repositions is even more difficult. Yesterday I had an obese mom who was SROM, CEFM and on pitocin, with contractions registering on the monitor. She was only 1 cm dilated so an IUPC was placed when she reached 2 cm. After the OB resident placed the IUPC, I had a difficult time finding the FHR externally and called my preceptor for help after about 40 seconds - a minute. She then immediately initiated the chain of command. An U/S reassured FHR was in the 130's. After an FSE was placed. When the FSE was placed, it picked up a late decel. By this time, pitocin was off and the teams were paged to an emergent c/s as a precaution. Thankfully baby recovered from the decel and mom was allowed to labor on.

My preceptor advised me to be more proactive calling for help when needed. I relayed that I was unsure if I was having trouble finding the FHR because mom was obese (since I was having a hard time finding the FHR all throughout the shift and had even called her a couple of times for FHR placement) or because baby was down. Her token of advise was "if you're not sure, call for help." Her advise, in retrospect, is valid and rational. I'm not disputing it.

My question is, how long should I attempt to find a FHR on an a mom before calling for help?

[chare]

Not an L&D nurse, but I will give you my perspective as a nurse in the PICU. I tell all of our new nurses: anytime you aren't sure or have a question, you need to be asking for help. As soon as the question arises or the situation occurs. I would rather you ask me 100 questions, than not ask one and there be an adverse outcome.

And always remember this. If you find yourself in a situation where you don't feel comfortable asking questions it's long past time to find e new place of employment.

Wishing you the best of luck in your nursing career.

[cayenne06, MSN, CNM]

How long you are comfortable trying to get FHT is dependent on your experience and your specific patient. Ideally, low risk women should be intermittently auscultated. So with that in mind, and acknowledging the fact that most units still practice almost universal CEFM, I am quite comfortable searching for the FHR in a low risk woman in early labor who has had a great strip.

Now, if I am at ALL concerned, I wouldn't putz around searching. I'd call for help immediately. Better call and find the FHR while they are coming down the hall, rather than waiting and discovering that you couldn't find the FHR because it's not there.

A tip for larger women- I often find it easier to get FHT in an upper quadrant, kind of angled across/up from where the heart would be. And sometimes some gauze and tape can help hold it down a bit better so you don't lose it whenever you take your hand off the monitor. I had a patient on pit the other day (as a student CNM) with a BMI of 42, and the nurse had to hold the monitor on the entire time she was in labor. Luckily mom progressed quickly, or else I would have had to put in an FSE because you can really only do that for so long.

[queenanneslace, ADN, MSN, APRN, CNM]

[quote=starry01;8382733

My question is, how long should I attempt to find a FHR on an a mom before calling for help?

I had to think about this question for a little bit before responding. The answer is, there is no hard and fast answer.

There are times I have a low-risk, active, moving, ambulatory mother in labor - and I can go quite a while without a good tracing - this is after the admission tracing where baby demonstrations moderate variability, accels, absence of decels. I'm not intermittently auscultating, but I'm not getting worked up about a 10 minute period where baby's FHR isn't continually tracing.

There are other times where a few seconds of no tracing have had me call for help. Polyhydramnios + bulging BOW + uncertain presentation + HUGE gush of fluid with contraction - I'll search for HR for about 5 seconds, then call for help. Because if the umbilical cord washes down - I'm going to need everyone and their cousin in there helping. It's a judgment call. I can feel a little foolish, but at the same time, sometimes waiting minutes to get the FHR isn't really an option. The whole clinical picture needs to be taken into account.

As far as getting FHR on larger women - it can be tough. It really can. I have held monitors in place for hours..... (if pt is not ruptured, FSE not indicated)..... SIGH. But I tell myself - this is why we're assigned 1-1. Sometimes I ask for help. Sometimes a coworker knows which washcloth, chux, or tape roll works best at positioning those monitors.