MD orders no external monitor on Pt w/ preterm contractions

SilentfadesRPA · May 8, 2011

Is it possible that the patient absolutely refused this as an intervention but still the provider thought that hospitalization for observation was necessary ?

Was there any indications for the rationale in his progress or admitting notes ?

Otherwise it surely would not be in his or the patients with preterm labor interest not to have a monitor should there be litigation. This of course is not considering the medical complications that could be avoided.

JeneraterRN · May 8, 2011

Is it possible that the patient absolutely refused this as an intervention but still the provider thought that hospitalization for observation was necessary ?
Was there any indications for the rationale in his progress or admitting notes ?
Otherwise it surely would not be in his or the patients with preterm labor interest not to have a monitor should there be litigation. This of course is not considering the medical complications that could be avoided.

Thanks for your response! I have to admit that I monitored the Pt anyway when she had an episode of contractions. It's so nice in case of litigation because that particular strip shows her contractions stopping after the meds I gave. Charting "Pt reported contractions ceased" is not backed up. No, she didn't refuse, either. Isn't that odd? I find it funny that she didn't write it as an order. Thanks again!

SilentfadesRPA · May 8, 2011

"she didn't write it as an order"

then along with you I would not have heard it as an order either. This physician knew how to CYA and you beat her to it in taking good care of the patient and yourself legally.

Marc :)

rkitty198, BSN, RN · May 8, 2011

In a case where mom with preterm contractions, md gave phone order to not continue monitoring because pt was stable. However through the night mom ended up losing baby. Despite an order- for which the md then denied, but luckily the charge took the order. Would a prudent nurse leave the monitor on? It is the only way to assess baby.

It was deemed that the md went for review,

Despite an order it is still the prudent judgement of the nurse to monitor- no harm to mom or baby to monitor.

Your situation is different, however you did the right thing.

I would do what you did and take that order up to someone other than yourself and even have an ethics review.

Say something happens to the baby? I cannot believe how reckless that order is.

I don't do OB, this case was discussed between an OB friend and myself and I was told made some sort of headlines.

Jolie, BSN · May 8, 2011

I can't explain the physician's request, but would like to shed some light on external monitoring for preterm contractions/labor.

I was on bedrest starting at 26 weeks with my first, 23 weeks with my second baby due to preterm labor, including shortened cervix, dilation and uterine contractions.

My physician and I found external monitoring (both inpatient and outpatient) to be notoriously inaccurate. I frequently felt contractions that were not picked up by the monitor, no matter how many times or how many ways we adjusted the toco. I was a much better reporter of uterine activity than the monitor, and actually had nurses who tried to hold ordered doses of meds stating that I was having no contractions, even though I could clearly feel them.

At one point, I was at home and called the home health/monitor nurse to report significant contractions. She had me monitor for an hour and called to happily report that I had a clean strip. I gave up and called my physician directly, he met me the hospital and found that my cervix had changed 2 cm since the last evaluation (from 4 cm to 6 cm).

Thank goodness we both had the sense to trust our judgement rather than the monitor.

My doc cited an article at that time that found virtually no difference in preventing prematurity in groups of women with preterm labor who were externally monitored versus those who weren't. Based on my experience, I can understand that. But in the end, we continued because we felt like we had to do something, and there were few, if any other options.

Based upon scientific evidence, it's a wonder that insurance still pays for home OB monitoring.

JeneraterRN · May 8, 2011

Thanks again for the responses! I have a little more information now. The reason the previous nurse was given to not monitor the mother was because it would "concern her" if we were monitoring her (MD's actual words). While fixating on the strip is a common reaction in OB, I don't find that to be a contrindication to monitoring. Jolie's example of the inaccuracies of FHM are a perfect example of not using good nursing judgement, and I certainly hope her situation turned out OK. Other nurses had trouble with this particular OB in getting her contractions to trace, as well, but the nurse who had put her on the monitor prior to med is a bit inexperienced. The strip that was produced for me had a nice tracing of contractions.

In OB, bellies of all shapes and sizes come along, and often you are not going to get the perfect strip. When they are not tracing at all, palpation works the best. We decided that the MD may have meant that, though we're not entirely sure. All in all, baby looked great on the strip and the Mom was fine when I left.

The liabilities of OB cannot be overstated, and we are a rural hospital and the only one that does OB for about at 100 mile radius. I've never worked anywhere else but this place, so this website is a GREAT resource for me to bounce questions off of people to see if that is normal where they practice, too. I cannot tell you how much you all are appreciated, and thanks again!

klone, MSN, RN · May 8, 2011

Did she have daily NSTs?

What would be the purpose of continuous fetal monitoring?

As long as there were NSTs given at regular intervals to monitor fetal wellbeing, that's all that's necessary. Continuous monitoring is not going to change the outcome.

CEG · May 8, 2011

Based upon scientific evidence, it's a wonder that insurance still pays for home OB monitoring.

The ones I have dealt with don't cover it. Not sure if there are any that do-- I have never seen one.

JeneraterRN · May 9, 2011

Nope. No daily NST's. That's why I was puzzled. She was stabilizing, but not out of the woods. She didn't want us to even do prn checks for contractions. I did anyway to protect myself. Thanks!

passionflower, BSN, MSN, RN · May 9, 2011

I always thought you had to have an order for monitoring. Something to do with charges? In an emergency you do what you have to do but if what happens if you can't justify?

klone, MSN, RN · May 9, 2011

Huh. What was her gestational age? Was she pre-viable?