FHR monitoring

miss81, BSN, RN · Aug 18, 2011

We now only use continuous FHM for high risk pt's. We use intermittent monitoring for low risk pt's. It's SOCG best practice guidelines. Hope this link works...

http://www.sogc.org/guidelines/documents/112_march2002_Eng.pdf

MandaRN94 · Aug 18, 2011

I haven't woked in L&D for years but our Docs were old school and ordered cont FHR monitoring regardless of low risk. The article also said the trend was cut out all the FHR terms and use only 3 categories- 1 being good, 2 being atypical, and 3 bad. The thought was to make it more standard.

MKS8806 · Aug 18, 2011

Interesting. Do you have a link to the original article? We monitor all patients continuously - even cervidil and foley bulb inductions. I would be a little nervous not too, but then again, I've seen a patient go from a fine strip to abruption and immediate loss of heart tones, with no warning. The strip just looked like the baby moved - you know, how just all of a sudden your not picking up heart tones. So, things can happen and I'm thankful that patient was monitored continuously, despite the reactive strip beforehand. We did all we could, but the baby could not be saved. Weird things happen. I am thankful for FHM.

miss81, BSN, RN · Aug 18, 2011

i haven't woked in l&d for years but our docs were old school and ordered cont fhr monitoring regardless of low risk. the article also said the trend was cut out all the fhr terms and use only 3 categories- 1 being good, 2 being atypical, and 3 bad. the thought was to make it more standard.

yes, the guidelines suggest that it cuts down on unnecessary interventions (c/s, forceps, etc.) without compromising fetal outcomes. we not longer use reactive and non-reactive. we also now use the terms "normal, atypical, and abnormal" and follow algorithms for what interventions are (or aren't) needed with each term. typical = continue with intermittent fhm, atypical = monitor more closely (for example, decreased variability= reposition mom, wait 40-80 min. with continuous fhm as this may be fetal sleep, if not increased in variability then contact provider). abnormal = contact provider immediately. we also don't use "beat to beat variability" anymore.

here is the link with the actual table/algorithm we have posted in our case room (refer to page s16, have a look, it's really easy to read!

http://www.perinatalservicesbc.ca/sites/bcrcp/files/guidelines/obstetrics/guideline_6.pdf

MandaRN94 · Aug 18, 2011

The article is from "The Female Patient" April 2011. Very interesting reading and food for thought about the future of FHR monitoring.

AprilAZRN · Aug 20, 2011

Can someone link the article? I'd like to read it.

Hushi05 · Aug 21, 2011

This is not new information (I say that not to criticize you for posting it- I'm really glad you did). I'm really astonished that people don't know this. Our RESIDENTS don't know this.

tntrn, ASN, RN · Aug 21, 2011

I plan to take a longer, better look later, but that algorithm on S16 appears to be for NST's, not labor. I, for one, would be very happy to not have to remember multiples of classifications. It's getting out of hand.

luv4nursing · Aug 21, 2011

Im a brand new LRDP nurse and just started orienting...but I took basic fetal monitoring and we were given similar statistics. I tend to be more in line with the midwifery model of care with little intervention and intermittent monitoring for low risk pregnancies.

What I dont get is it is beng emphasized again and again that the most common complications are caused by medical interventions...yet we go on business as usual when evidence based practice is proving current standards to be ineffective. My hospital has an alarmingly high c section rate and it saddens me...

tntrn, ASN, RN · Aug 21, 2011

Im a brand new LRDP nurse and just started orienting...but I took basic fetal monitoring and we were given similar statistics. I tend to be more in line with the midwifery model of care with little intervention and intermittent monitoring for low risk pregnancies.
What I dont get is it is beng emphasized again and again that the most common complications are caused by medical interventions...yet we go on business as usual when evidence based practice is proving current standards to be ineffective. My hospital has an alarmingly high c section rate and it saddens me...

What evidence based practice fails to cover is the skyrocket rates of litigations we have in this country. The OB docs where I work have malpractice insurance premiums of over $100K a year. People want a perfect delivery every time, and that just isn't going to happen.

I believe that if there were some limitation on lawsuits, EFM use could be used less. Even lawsuits where the doc does nothing wrong will end with an out of court settlement from the doc to the patient. I have been deposed twice in cases exactly like that. The doc/the staff/the hospital did nothing wrong, but the patient got a settlement anyway.

NurseNora, BSN, RN · Aug 21, 2011

What evidence based practice fails to cover is the skyrocket rates of litigations we have in this country. The OB docs where I work have malpractice insurance premiums of over $100K a year. People want a perfect delivery every time, and that just isn't going to happen.
I believe that if there were some limitation on lawsuits, EFM use could be used less. Even lawsuits where the doc does nothing wrong will end with an out of court settlement from the doc to the patient. I have been deposed twice in cases exactly like that. The doc/the staff/the hospital did nothing wrong, but the patient got a settlement anyway.

Anytime you take a damaged infant in front of a jury, they want to throw money at the parents because it's so sad. Even if no one was at fault, they figure the money comes from the big insurance company and the parents need it more than the company or the hospital. They have no idea how much the doctors have to pay and how that increases the fees the doc has to charge. Also, when an OB quits his practice, he has to pay a "tail" to cover any cases that may come up later. A plantif has 3 years ( I think 3) after the discovery of an injury to file a claim, and something may not show up for years ( a learning disorder not found until the child has been in school for a few years, for instance). And the child has 3 years after reaching majority to sue for "birth injuries" that his parents did not sue for earlier. So the poor doc is liable for a really long time.

EFM was initiated before "evidence based practice" became the vogue. But it is now so much a part of the usual practice that the docs are reluctant to not use it. No one wants to explain to jury why this baby wasn't monitored and had a bad outcome. Since their was a bad outcome, a lawyer will insist that the mother must have been high risk and was just not diagnosed properly.

The answer is for moms to educate themselves and and make informed decisions before labor starts, discuss their goals and desires with their doc and be willing to go to someone else ot to a different hospital that will be supportative of their desires. If they live in a rural area with no choice of hospitals, they have to be willing to be assertive in getting what they want. If a patient refuses. The usual procedures ( IV or saline lock), a nurse cannot force her to have one. That would be battery. In my hospital if they refuse treatment ordered by the doctor, we. Ask them to sign an " against medical advice" form after explaining risks and benefits of the refused treatment and risks and benefits of not having the treatment. For instance a previous C/S who comes in in labor and refuses a repeat section or transfer to a facility that does do VBACs (the nearest one is 4 hours by car from us and would involve a helicopter or fixed wing plane ride which costs a lot and probably wouldn't be covered by any insurance.