Laboring Morbidly Obese Women

klone, MSN, RN · Oct 18, 2014

I've never labored a morbidly obese woman where I absolutely could not monitor externally. Absolutely it's challenging, and often requires 1:1 with physically holding the monitor on her abdomen. And then insert an FSE (and an IUPC, if necessary) as soon as conceivably possible.

Davida67 · Oct 18, 2014

That's what we ended up doing but it would only work when she was in one position. Of course she needed to change positions frequently due to chronic lower body pain. Intermittent monitoring made it stressful especially after intrathecal was given. We don't do epidurals. I was relieved when she was dilated enough for ISE!

klone, MSN, RN · Oct 18, 2014

Why don't you do CLE?

perfexion, ASN, RN · Oct 18, 2014

I usually place gauze between the belt and the monitor to hold it into place. But honestly it depends on how big they are. I had an 600lb patient once and nothing worked. someone had to physically press it against her belly in order to pick up the baby. Oh and she had a preemie with IUGR. That was the worst!

ETA: I'm sorry. She was 400 lbs.

Davida67 · Oct 19, 2014

No CLE in our department because we don't have the anesthesia staff available to be in house 24/7

Davida67 · Oct 19, 2014

Perfexion- same size Mom here. We ended up going to C/S. What happened in your case?

cayenne06, MSN, CNM · Oct 20, 2014

It is challenging to do continuous monitoring on very obese women. Strategy #1 is to use intermittent auscultation (listening through and after one contraction every 15-30 min depending on stage of labor) for low risk women. Unfortunately CEFM is the norm in most units, when in reality this does not improve outcomes for mom or baby and can actually lead to increased morbidity for mom. When continuous monitoring is clinically necessary and an FSE can't be used, I find that very often I can get the FHR in one of the upper quadrants, which makes keeping the monitor in place much easier.

I second the gauze idea, especially when coupled with some tape to keep the monitor squarely in place.

perfexion, ASN, RN · Oct 22, 2014

Davida67 said:
Perfexion- same size Mom here. We ended up going to C/S. What happened in your case?

They all end up with sections at some point, don't they? I used to work in outpatient OB and I had to take out the staples of the post ops and the wounds of the obese patients would always dehisce and I'd have to pack it for weeks until it healed. That's another risk of being pregnant and obese.

babyktchr, BSN, RN · Oct 31, 2014

Unfortunately this is going to be a norm or us and will continue to be problematic as acog stacks more and more "Guidelines for induction" onto the already monstrous list. Most morbidly obese women have comorbidities attached (htn, gd, iugr) and are brought in for induction sooner rather than later. Intermittent monitoring is not going to cut it for these babies. We just recently dropped some money on the monika monitor which is designed to assist with monitoring the obese patient. It works similarly to a tens unit as far as uterine activity goes and ecg monitoring for fhr. It consists of electrodes being placed strategically after a vigorous prep of the skin. While this piece of technology has merit and will be on the forefront of monitoring technology of any patient in the future, I fear that it misses the mark for this situation. Too many positional parameters have to be met, such as the uterus always has to be center to the patient, even if the pt is on her side? Huh? Although fda approved, a lot of the studies came from european use where a bmi of 30 was used as as a reference. Sigh. Really? 30?

This topic needs be be addressed sooner than later in the world of those with power. Staff nurses are put to the test when monitoring these patients, and outcomes are going to be scrutinized because of the multiple risk factors. C/s is not the answer. With technology as it is now, I find it hard to believe that other avenues have not been explored.

Anyone else have experience with MONIKA??

RunBabyRN · Nov 1, 2014

babyktchr said:
Unfortunately this is going to be a norm or us and will continue to be problematic as acog stacks more and more "Guidelines for induction" onto the already monstrous list. Most morbidly obese women have comorbidities attached (htn, gd, iugr) and are brought in for induction sooner rather than later. Intermittent monitoring is not going to cut it for these babies. We just recently dropped some money on the monika monitor which is designed to assist with monitoring the obese patient. It works similarly to a tens unit as far as uterine activity goes and ecg monitoring for fhr. It consists of electrodes being placed strategically after a vigorous prep of the skin. While this piece of technology has merit and will be on the forefront of monitoring technology of any patient in the future, I fear that it misses the mark for this situation. Too many positional parameters have to be met, such as the uterus always has to be center to the patient, even if the pt is on her side? Huh? Although fda approved, a lot of the studies came from european use where a bmi of 30 was used as as a reference. Sigh. Really? 30?
This topic needs be be addressed sooner than later in the world of those with power. Staff nurses are put to the test when monitoring these patients, and outcomes are going to be scrutinized because of the multiple risk factors. C/s is not the answer. With technology as it is now, I find it hard to believe that other avenues have not been explored.
Anyone else have experience with MONIKA??

I had never heard of this, but I just looked it up. Sounds like there are narrow parameters, from what you're saying. That's a major bummer, because it looks from the site like this could be a good alternative to the way we've been monitoring, as it allows for freedom of movement, no belts, etc., but I'm sure these benefits are exaggerated in advertising.

For anyone else that's curious: Introducing the Monica AN24, wireless fetal heartbeat monitor

Katie71275 · Nov 1, 2014

It is very difficult. I have found putting an unopened alcohol swab under the toco helps to pick up contractions and usually tilt to the left or right(mom not the toco). Also for continues FHM I turn mom to right or left and try to find the sweet spot It can be very difficult, but I was able to get the monitors to pick up by doing this on my patient who had a BMI of about 50-52. And most of my morbidly obese patients go on to have normal lady partsl deliveries. I try to get internals in ASAP if we are not picking up, especially if the patient is on Pitocin.