Intermediate Fetal Monitoring

AWHONN is the primary source of evidence based practice information that Women's Health nurses use. In another post I will go over all of the ways that my hospital does not follow AWHONN guidelines in our practice, but for now I would like to chit chat for a minute about Fetal Monitoring.

I just went through a 2 day long Intermediate Fetal Monitoring course and there are so many things to discuss...

First, I was struck by how over and over we were looking a strip with the baby's heartbeat in the gutter when the pertinent information given about the patient was she "just had an epidural". Seriously, over and over. Post epidural women can have a tendency to become hypotensive because the medications often used in the epidural causes vasodilation of all of the blood vessels. When mom's blood pressure drops her body automatically shunts all of her blood to HER vital organs, namely her heart and lungs and in the process stops sending the oxygenated maternal blood to the placenta. Baby's heartrate will drop correspondingly. The hypotension can often be corrected by bolusing the mother with lots of IV fluids, calling anesthesia to give ephedrine (to increase her blood pressure), giving her oxygen so that her blood is now super saturated with O2 and thereby baby gets more, and repositioning her for optimal blood flow to the baby. BUT (and here is the clincher), those things don't always work. There are times where baby can never recover after the post-epidural hypotension and the patient ends up stat'ing back to the OR. Even if baby does recover, we have almost always just stressed that baby right out into passing meconium and into a NICU attended delivery where baby can't be placed directly on mom's belly.

I was so surprised that AWHONN recognized this, but I was shocked as I looked around the room at my coworkers and they just didn't get it. Really? Are you so pro-epidural that you can't admit that sometimes it causes an emergency c-section? That it sometimes causes prolonged fetal hypoxia? That it sometimes causes babies to stress out right back to the OR? Aaarrgghh!

I was looking around the room excitedly, hoping to see someone's "holy shite I get it now" expressions. And nothing. I really try not to preach at people at work. I like my job and I like my coworkers. I just don't understand how they just don't seem to connect the dots and make the decision to be the best supporters of natural childbirth that they can be.

All of that said, I am not entirely anti-epidural. With pitocin, with c-sections, with prolonged first babies, it is a really useful intervention. I also recognize that at a busy county hospital most of our patients get pitocin, artificial rupture of membranes, and are stuck in bed for the length of their labors. Le sigh. I can see the changes that need to happen, but I have no idea how to make that possible.

One other thing about this fetal monitoring course... Who knew that doctors aren't required to take any fetal monitoring courses? They make decisions for care based on a baby's strip and yet they have never had any formal training on it. They learned from the resident the year before them, who learned from the resident the year before them, and so on back for decades. Do they have knowledge of the latest information in fetal monitoring? I think NOT. If so, we would be able to intermittently monitor most of our patients, women would be allowed to walk during labor, and their interventions would decrease. They have to take CPR and NRP, why not fetal monitoring? I think that if the course was taught by ACOG and not by AWHONN, they would be on board. They just don't want to learn beside nurses and from nurses.