OPTIONS FOR FETAL MONITORING
Not all options for fetal monitoring are created equal
Advocate for monitoring options that enhance your baby's safety
The gold standard for fetal monitoring involves a hand held human element. When an interaction takes place between the mother and the caregiver a greater amount of information is shared. The caregiver is able to observe the mother in real time, instead of from a machine at a different location. She can observe to see the heart rate as the contraction peaks and fades. Mistakes and incorrect interpretations of fetal heart tracings are reduced.
Many midwives excel in finding heart tones without ultrasound waves. They listen through an amazing device that is made for this purpose. The fetoscope is not electronic, is implemented by a care provider, one to one, restricts movement to the smallest degree possible and may be a good option for a mom throughout her pregnancy and birth if she wants to avoid the ultrasound waves that are in hand held dopplers. Some mothers are concerned with the lack of safety data and the few studies that show an increased risk of IUGR and other concerns.
When a midwife or care provider is with the laboring mom and listens to the baby in person with a hand held doppler, she is providing the least amount of interference possible next to the fetoscope. The mother is not inhibited, since the care provider conforms to the mom's space and needs, and the interference with her movement is minimal. The doppler would be used at set intervals of either 15 or 30 minutes and the duration of the time spent listing is around 60 seconds before, during, and 60 second after a contraction. The interval is around 5 minutes during the pushing stage. The care giver simply needs to hear the baby's heart rate as the contraction rises and fades to determine if things are going well, but can follow the mom's movements and conform to the mom's needs to accomplish the task.
To date there are no studies that have determined the optimal frequency of IA during labor. Current recommendations are summarized in Table 3.4-6 In the absence of evidence‐based parameters to define the optimal interval for auscultation, an interval ranging between every 15 to 30 minutes during the active phase, every 15 minutes during the second stage prior to expulsive efforts, and every 5 minutes after initiation of pushing, may be reasonable as long as the auscultated FHR is normal and there are no other labor characteristics that would suggest a need for more frequent monitoring.
In both Canada and the United Kingdom, IA is the preferred method of fetal surveillance in women who enter labor at term with no medical or obstetric conditions that are associated with uteroplacental insufficiency and/or conditions that are associated with an increased risk for fetal acidemia.6, 7 ACOG recommendations for monitoring women in labor state that IA is “acceptable in a patient without complications.”20 The frequency of observations required to monitor labor with IA facilitates other evidence‐based labor support practices, and this method of monitoring the FHR should be the preferred method. IA is associated with fewer cesarean and operative vaginal deliveries when compared to EFM, procedures which have additional attendant risks for the mother and newborn. In addition, IA and EFM have equivalent neonatal outcomes.3, 16-18 Finally, IA allows women more mobility, which in turn increases comfort and progress of labor.
Intermittent Electronic Fetal Monitoring
Many hospitals will monitor a mother every hour for 20 minutes with an electronic machine that produces a paper strip. The downside to this method is that the nursing staff is often overworked and they may forget to take the monitors off the mother at the set time. The laboring mom's partner may need to pay attention to this, so that she is not on the monitors for longer than the absolute minimum. The other downside is that if it is not consistent or if there is a bad reading from the monitors slipping, the nurse will most likely recommend that they stay on longer. This can feel very frustrating and like an endless loop if the mother was promised freedom of movement, yet she is tethered to the monitor due to the finicky nature of the monitoring system.
Wireless Electronic Fetal Monitoring
Some hospitals have embraced newer technology that monitors the mother similarly to the continuous electronic fetal monitoring, but without the cords. Telemetry is helpful when a mother is high risk, and the care provider wants to watch things more closely. It gives her the option to move freely and more easily than with the cords tethering her to the bedside. She can walk around and go to the bathroom. The downsides are that sometimes the wireless monitors do not work well, or they run out of battery. Sometimes they are used so infrequently that the hospital does not have the requisite skills to use the telemetry effectively. It might be helpful to contact the hospital before labor if a mother is planning a birth away from her home and to ask if they have wireless monitors, how many, what brand of monitoring device, and how often they are used.
Here is one of the most popular wireless monitoring devices on the market:
Continuous Electronic Fetal Monitoring
Continuous Fetal Monitoring is a method for recording the fetal heart tracings that is associated with restriction of movement and a higher cesarean rate than other monitoring methods. It has been proven across numerous studies to only increase cesarean rates and not improve outcomes. It is conducted with a machine and the mother's movement if often restricted through the wires that connect to the machine. It is common for the nurse to monitor multiple women at one time from the main desk which is located outside of the labor rooms. She may come in occasionally to adjust the monitor and thereby leaving her desk and is unable to watch the other machines when she attends to one of the moms under her care. This may be stressful for the nurse and is one reason that women often get told to lie in bed and not move. When a laboring mom lies on her back in particular it can slow labor, make labor more painful and result in a request for drugs. When a mother is restrained it may also reduce the blood and oxygen flow to the baby. Insist on freedom of movement and let your partner negotiate with the staff. Your ability to move, work with gravity and listen to your body ultimately protect the baby, protect you and may shorten your labor. If you want to be off the bed, the nurses may need to adjust the monitors more frequently than they like, but it is worth it for your and your baby's safety.
TIP: Make the nurses a snack basket to thank them for their hard work. Place chocolate, energy bars, nuts and other healthy delicious snacks in there to give them energy and love. They are often overworked and have a very stressful job. It is unpredictable, and they are on their feet a ton. They will most likely appreciate the thought and the nourishment. This will help smooth the way for asking them to do more work.
Your partner can thank them for taking the time to help you relax, move freely and work with your body to give birth according to your individual needs. A little gratitude goes a long way. If they do not come around, ask for a different nurse, ask to speak with the head nurse or ask for a patient advocate.
It is also helpful to know that misinterpretation of data is a contributing factor to high cesarean rates:
The unnecessary performance of cesarean deliveries for abnormal or indeterminate fetal heart rate tracings can be attributed to limited knowledge about the ability of the patterns to predict neonatal outcomes and the lack of rigorous science to guide clinical response to the patterns
Intrapartum electronic fetal heart rate monitoring of the high-risk obstetric patient is thought to improve the perinatal outcome. A prospective randomized study of 483 high-risk obstetric patients in labor was carried out comparing the effectiveness of electronic fetal monitoring with auscultation of fetal heart tones. The infant outcome was measured by neonatal death, Apgar scores, cord blood gases, and neonatal nursery morbidity. There were no differences in the infant outcomes in any measured category between the electronically monitored group and the auscultated group. The cesarean section rate was markedly increased in the monitored group (16.5 vs. 6.8 per cent in the auscultated patients). The presumptive benefits of electronic fetal monitoring for improving fetal outcome were not found in this study.
The reliability, validity, and efficacy of electronic fetal monitoring (EFM) remain matters of controversy. In fact, several professional organizations, including the American College of Obstetricians and Gynecologists, have endorsed the use of intermittent auscultation for low‐risk pregnant women. Nevertheless, in 1996, 83% of laboring women in the United States are monitored electronically. Nurses should encourage healthy, low‐risk pregnant women to weigh carefully decisions about the use of EFM.
"Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first. Continuous electronic FHR monitoring during labor, a routine procedure in many hospitals, is associated with an increase in cesarean and instrumental births without improving Apgar score, NICU admission or intrapartum fetal death rates. IA allows women more freedom of movement during labor, enhancing their ability to cope with labor pain and utilize gravity to promote labor progress. Upright positions and walking have been associated with shorter duration of first stage labor, fewer cesareans and reduced epidural use."