Somedays I just wish EFM would go away....

LizzyL&DRN · Apr 27, 2007

In reference to the issue of transferring patients from triage to room: It is my opinion that all patients need to be seen in triage first. How many patients do you see that think they are in PTL and turn out to have indigestion or constipation or something completely unrelated to PTL? I think immediately putting the patients on the labor floor might overload the unit a bit. Another idea, our hospital just got new EFM monitors that allow for wireless monitoring of patients. It might be beneficial to your hospital to think about purchasing these wireless units for transferring these types of patients. That is so sad for your patient that lost her baby. I'm so sorry for your nurses too. If the strip was indeed reassuring who would have thought a 20 minute span off the monitor would reveal such a tragic outcome??? Patients are frequently off the monitor longer than that to shower or eat etc etc. Do they know why the baby died? Cord accident? Abruption?

For the second part: It has always been my practice that patients with a hx of HSV whether active or not, I will not put an FSE in place unless absolutely necessary. I even follow that practice in reference to GBS+ patients, even if they are treated. It might need to be a case by case basis and I think approval from a doctor in these cases is a great idea. There is evidence now that suggests HSV can be spread from person to person even though there are no symptoms of an outbreak. Why not from mother to baby?

Good Luck.

JaneyW · Apr 27, 2007

Your story just breaks my heart. I always get weak-kneed and sweaty when I can't find FHTs after moving a patient or if they have been off monitor--what happened to you is a nightmare of mine. I do know from Lisa Miller's class that "reassuring" is no longer an acceptable description of a tracing. The new guidelines (adopted by our unit) means using universally accepted terms when talking about a strip. For example: FHR baseline of 125 with moderate variability, accels present, no decels. Yes, this is reassuring but more descriptive than just "reassuring".

I don't know about changing the way you triage. What does the MD involved suggest? What does he think went wrong? How "reassuring" was the strip? It's just tragic. I feel for the nurses involved. I know something like that might send me out of the profession.

babyktchr, BSN, RN · Apr 27, 2007

One of the things a nurse MUST do when placing a patient on a fetal monitor is PROVE that what she is tracing is actually fetal, and not maternal. A "fetal" strip can certainly be reactive even when tracing mom's heartrate. Mom will have an acceleration heartrate when she is having pain/contractions. My first question after reading this post was: WAS IT MATERNAL?? What was mom's HR? From a physiologic standpoint, if the strip was indeed fetal, and met the requirements for being a reactive NST (presence of MOD variablilty and accels) then this certainly tells me the baby is not acidemic. In a 20 minute period, there certainly had to be a catastrophic event to have caused a stillbirth. The other questions I have is concerning the PTL. Why is the NURSE diagnosing PTL?? Where was the MD? Were there cervical changes with the contractions, or just contractions? What were the quality of the contractions and were they symptomatic of perhaps and abruption? As far as 'indefensible'. As long as there is documentation of the strip being having absence of acidemia, and there is PROOF that this is not a maternal strip, then taking her off the monitor was prudent. Documentation of fetal tones/strip within 30 mins is within standard.

It is heartbreaking for the family AND the nurse when this happens. It doesn't help matters when a physician interjects negativity. Remember...EFM is only as good as the person reading it. If you have no phyiologic understanding, then it certainly can be your adversary.

HappyNurse2005, RN · Apr 27, 2007

1. A G1P0 at 34 weeks is put in the Triage Room c/o contractions. Patient detemined by the RN to be in PTL with "reassuring" FHTs & to be admitted to stop labor. Pt. taken off EFM & moved via W/C to a labor room just down the hall. Entire move takes 15-20 minutes. No FHTs found when hooked back up to the EFM. US showed no cardiac movement & patient delivered of stillborn later that day. Then the Chief of OB tells the nurses this is "indefensible" & they are further devastated. I have come up with several process changes, but wonder if any of you have more or better ideas. There isn't much in the literature on this particular type of situation:
A. Don't put PTL patients in Triage at all. That's less than 36 weeks around here because no MD stops labor after 36 weeks. Assess them in a labor room right from the start & avoid movement that may stimulate more UCs & causes a break in the EFM tracing.
B. If there are no labor rooms (anyone have that one happen?) & she has to start in Triage & then later be moved to another room:
a. take her off the monitor at the last minute
b. bring the tracing paper cartridge from the Triage room with you
c. move her in the bed as quickly as safely possible rather than a W/C
d. put the original tracing paper cartridge in the new EFM & get her back on the monitor as quickly as possible (this gives you a more accurage timeline since all EFM machines seem to have different times
C. I guess if you were fortunate enough to have a teletry unit you could monitor wherever you had to move her on the unit. Any other ideas???

1. Did an MD see the patient in triage? the statement "the RN determined the pt to be in ptl" isn't clear. if we had this pt come in, the RN would have her on the monitor, would certainly not do a sve on a preterm patient. the MD would have to be the one to give the admitting orders. did he/she see the strip and think it was okay? why do you say "reassuring"? in quotes like that? are you implying it wasn't reassuring and seh just thought it was?

2. why did it take 15-20 mins to go down the hall? we unhook the cords from the monitor, the actual efm's are still on the pt's belly, so when we arrive in teh new room, we just plug them in to the monitor in that room. off monitor for 5 mins.

no, i dont think its feasible to put all women who claim to be in preterm labor in the labor rooms. as another person said, how many people think htey are in preterm labor and they aren't? lots. why fill up the labor rooms for that? triage is perfectly capable of doing efm's and evaluating ptl vs braxton hicks vs constipation. and no, we dont put them on the portable monitor down the hall. should we make all women in labor pee on bedpans? they might be off hte monitor for 5 mins to go to the bathroom.

crissrn27, RN · Apr 28, 2007

This sounds like a tragic situation, and not a normal one. We all know that really sad things happen from time to time, but why change the policy at all for one freak thing? I know that liability is a big issue, but I think it could be argued that you guys followed standards of care (just from what you posted, I don't know the whole story) and this was just a freak, once or twice in a lifetime event.

NPinWCH · Apr 28, 2007

Babyktchr makes a good point to ensure you have a FHR not a maternal one. A few years ago we had a pt come in with a c/o "My car was rearended yesterday and the baby hasn't been moving as much and I think I'm having some contractions" the pt was 39 wks. The nurse on the shift ahead of me had reported a "semi-reactive" strip of 120s with mod variability and occasional 10 sec. accels. She also charted, "occasional irregular/irritable contractions". Pt had no bleeding and mild pain. She had called the doc and had received orders to observe and call me back in 1 hour.

When another RN and I arrived in pt's room after report we took one look at the tracing and mom's VS and called the doctor in stat. Mom's pulse was 122with a BP of 98/53. The "occasional irregular ucs" were screaming abruption. We quickly got a Spo2 monitor on mom and verified that the FHR was indeed maternal.

We did a stat c-section after the doc came in and claimed to see cardiac mov't on u/s, he also verified a moderately large abruption. We coded the baby, but it was obvious he had been dead at least 12 hrs.

As far as EFM use goes...there is no reason that a woman with a reactive strip can't be off the monitor for short, or long periods of time. I get that this was PTL, but if this pt did have some strange event, it could have just as easily been a term pt, and in that case why wouldn't you let the pt up and off the monitor after a reactive strip. I keep my "normal" labor pt's off the monitor as much as possible, and I wouldn't use it if the docs didn't want strips...I'd much rather auscultate and palpate q 15-30 min, until second stage.

We put atomic clocks in all our rooms, and OR suites, so that the time is the same in each room. We "named" all our monitors and now we either reset the EFM to the wall clock or make an entry on the start of each EFM strip such as, "Monitor A-Wall clock time 1453" then mark the strip so that any discrepency between monitor times can be accounted for. (Also good for when you stat section a pt to prevent time discrepencies between labor room and OR suite.)

We rarely use FSE, and almost NEVER in pts with HSV...our docs won't allow them even in pts GBS+. IF the doc thinks the pt is going to c/s, they won't put them on...in fact it's against our policy to waste time putting a FSE on a kid who obviously is in trouble as seen with the external monitor. If it's failure to progress then why even bother with the FSE, unless you're REALLY not getting a good tracing externally.

Sorry this got really long.... :bugeyes: