Re: EMF
From: art fougner, md (evsono@pipeline.com)
Wed Jul 18 20:35:30 2007
EFM - The hits just keep on coming ...
AJOG Volume 197, Issue 1, Pages 26.e1-26.e6 (July 2007)
A framework for standardized management of intrapartum fetal heart rate
patterns
Julian T. Parer, MD, PhD1Corresponding Author Informationemail address,
Tomoaki Ikeda, MD, PhD2
... Each FHR pattern has been color-coded, from no threat of fetal
acidemia (green, no intervention required) to severe threat of acidemia
(red, rapid delivery recommended). Three intermediate categories (blue,
yellow, and orange) require escalated informing of appropriate
individuals for intervention and resuscitation (obstetrician,
anesthesiologist, and neonatal resuscitator) and preparation for urgent
delivery (eg, staff and surgical suite availability and conservative
techniques to ameliorate the FHR patterns).
Conclusion
This framework is applicable potentially to the institutions where it
was developed and will need to be modified for other situations,
depending on the logistics, facilities, and personnel available. This
may provide a framework for developing algorithms for the standardized
management of FHR patterns during labor, which can be tested for
validity.
...
Color coding? So now EFM meets Homeland Security. It appears EFM has
now jumped the shark.
Of course, that's just my opinion. I could be wrong.
Art
At Wed, 18 Jul 2007, D. Ashley Hill wrote:
>
>I remember reading the original article and wondering where the evidence
>was to support (among other things) using an internal monitor for every
>patient during the second stage. If one believes that this practice
>prevents fetal harm, then prove it. If not, it's a potentially harmful
>procedure we are advised to use only to prevent lawsuits. Sounds like
>bad medicine.
>
>Ashley
>
>At Wed, 18 Jul 2007, Efrain Ramirez wrote:
>>
>>http://contemporaryobgyn.mediwire.com/main/Default.aspx?
>>P=Content&ArticleIDB6601
>>
>>Cover Story: Avoiding 5 common mistakes in FHR monitoring
>>Source: Contemporary OB/GYN
>>By: Michael P. Nageotte, MD
>>Originally published: May 1, 2007
>>
>>It's hard to imagine a more basic component of obstetric care than fetal
>>monitoring. While there's little evidence that continuous electronic
>>fetal heart rate monitoring (EFM) during labor improves clinical
>>outcomes, when compared with intermittent auscultation, EFM has
>>essentially replaced auscultation in most American Labor and Delivery
>>units. As a labor-saving device for nursing care and as a way to
>>generate a permanent record of fetal heart rate (FHR) patterns, it would
>>appear EFM is here to stay.1.2
>>
>>Given this reality, it is very important to follow certain standard
>>procedures when using EFM. In our highly litigious society, the L&D
>>unit is often the target of malpractice suits. And since EFM does
>>produce a permanent record, the "strip" becomes a critical piece of
>>evidence in many of these cases, with experts for all parties arguing
>>over the significance of the various changes in the FHR.
>>
>>To provide the best patient care, while at the same time avoiding the
>>nightmare of litigation, clinicians need to avoid at least five common
>>errors, which we'll discuss further on.
>>
>>1. DELAYED USE of INTERNAL MONITORS
>>
>>Most women receiving EFM during labor are connected to an external
>>device that records both uterine activity and FHR. The technology in
>>the newer fetal monitors has improved significantly; for many patients
>>an excellent recording of both the FHR and uterine contractions is
>>obtained with external monitoring. Of course, the tracing may be lost
>>with changes in the mother's position, but it's readily re-established.
>>
>>Often patients and caregivers would prefer to avoid internal monitors
>>because they're invasive, unnatural, and have certain inherent risks,
>>and in fact they are frequently unnecessary. Keep in mind, however,
>>there is one clinical setting in which an internal monitor should be
>>considered: for the patient who has progressed to the second stage and
>>begins pushing. During this period of time, an external monitor often
>>will only intermittently record the FHR. Despite various nursing
>>efforts, an adequate continuous tracing may be difficult or impossible
>>to obtain.
>>
>>Despite this fact, clinicians frequently do not place a fetal scalp
>>electrode. Doing so would eliminate the difficulties involved in
>>external monitoring and more importantly, one can obtain a continuous
>>FHR tracing both between as well as during maternal pushing efforts.
>>This allows for prospective review of the tracing with the ability to
>>better gauge fetal status and tolerance to labor. And finally,
>>replacing external with internal monitoring sidesteps the problem of
>>missing periods of fetal heart tracing that occur with external EFM.
>>When an adverse outcome occurs with the newborn, those gaps can easily
>>lead to allegations of negligent monitoring directed against both the
>>physician and the nurses.
>>
>>2. DISCONTINUING the MONITOR TOO EARLY
>>
>>In this scenario, the patient is progressing to a point where delivery
>>is thought to be imminent. The health-care team decides to remove a
>>previously placed fetal scalp electrode or external monitor. However,
>>for whatever reason, the patient doesn't deliver for several minutes and
>>many subsequent pushing efforts. Then an unexpectedly depressed newborn
>>is delivered and the caregivers realize that there's been no fetal
>>monitoring at all for a protracted period.
>>
>>This sequence of events raises several questions regarding possible
>>acute and unrecognized changes in fetal status and it also means there
>>may have been a lost opportunity to have identified a need to shorten
>>the second stage of labor. In addition, the option to have neonatal and
>>respiratory support for the depressed newborn at the time of delivery
>>never was thought necessary, as such an outcome was not expected.
>>
>>3. CONFUSING the MATERNAL and FETAL HEART RATES
>>
>>Because external EFM uses ultrasound and interprets the changes in
>>frequency of the reflected energy, it is not uncommon for the monitor to
>>actually record the maternal and not the FHR. This fact is well-known
>>by those who have been taught fetal monitoring, and it is usually
>>readily recognized and corrected. Indeed, basic to such monitoring is
>>the continuous need to distinguish the maternal heart rate from the
>>FHR.3 This is a problem unique to external monitoring, assuming a living
>>fetus.
>>
>>However, if the mother has a fever or is pushing, the maternal heart
>>rate will often increase, at times dramatically. While the FHR
>>generally is more rapid than the maternal, confusion may arise when the
>>fetal heart slows during a deceleration while the maternal heart rises
>>with pushing. The external tracing may appear to indicate
>>accelerations, not record decelerations, and provide misleading
>>information. This can be a problem when it occurs for a protracted time
>>and may be unrecognized by the health-care providers.
>>
>>While easily clarified with placement of a fetal scalp electrode, as
>>well as with frequent and accurate assessment of maternal pulse, this is
>>a clinically dangerous situation that may lead to a compromised newborn;
>>and as you can imagine, it can cause outside observers to criticize your
>>basic monitoring policies and procedures. Don't forget one of the basic
>>tenets of EFM: Be certain that the information generated for the FHR is
>>in fact that of the fetus and not the mother.
>>
>>4. NOT MONITORING the FETUS during PLACEMENT of CONDUCTION ANALGESIA
>>
>>Most hospitals now make high-quality intrapartum conduction analgesia
>>available to their patients. The technique has clinical value and
>>improves patient satisfaction. But it takes time to place the epidural,
>>spinal, or combination conduction analgesic and clinicians often will
>>notice changes in the maternal and fetal vital signs following
>>initiation of such analgesia. Further, as the mother's position changes
>>during analgesia placement, there's often a loss of the FHR tracing when
>>external monitoring is being used. The time it takes to administer
>>conduction analgesia varies considerably as a result of differences in
>>patient habitus and clinicians' experience and differences in
>>techniques.
>>
>>Once the analgesia is in place, maternal hypotension and increased
>>uterine activity may also occur, resulting in changes in the FHR.4 For
>>these reasons, it's important to monitor the fetus at least
>>intermittently during these episodes. In a very challenging patient,
>>consider placing a fetal scalp electrode prior to initiating an
>>epidural. This will provide a continuous tracing throughout the time
>>that conduction analgesia is being placed. You'll especially want to
>>consider such monitoring in a patient with a concerning fetal tracing
>>prior to the decision to place the epidural.
>>
>>5. NOT MONITORING the FETUS in the OR
>>
>>Cesarean births are occurring at historically high frequencies and are
>>only expected to increase. Many of these women have been in active
>>labor when the decision is made to perform a cesarean delivery. Several
>>diverse activities can follow, including discussion and obtaining of
>>informed consent, preparation of the operating room, assembly of a
>>surgical team, moving the patient to the OR, selecting anesthesia, and
>>preparing the surgical field. This all takes time and the amount of
>>time varies with indications, cooperation, consent, and surgical
>>availability. One error to avoid in this common yet challenging
>>scenario is losing sight of the need to continue fetal assessment. This
>>is a setting in which the patient is removed from a clinical environment
>>in which fetal monitoring is the norm and she is placed in the sterile
>>environment of the operating room where fetal assessment may at best be
>>an afterthought.
>>
>>Again, a considerable amount of time may pass between discontinuation of
>>monitoring in the labor room and delivery of the fetus. Don't lose
>>sight of the importance of fetal assessment during this time, except
>>when sudden, frank maternal or fetal compromise mandates immediate
>>delivery. ORs should have fetal monitors or Doppler devices to
>>establish fetal status prior to delivery. This information may at times
>>be critically important and change the urgency level of the delivery to
>>dramatically higher or lower levels. This will further enhance our
>>ability to correctly perform surgery in a setting that balances both
>>maternal and fetal safety issues while maximizing optimal outcomes for
>>both of our patients.
>>
>>REFERENCES
>>
>>1. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG)
>>as a form of electronic fetal monitoring (EFM) for fetal assessment
>>during labour. Cochrane Database Syst Rev. 2006;3:CD006066.
>>
>>2. Graham EM, Petersen SM, Christo DK, et al. Intrapartum electronic
>>fetal heart rate monitoring and the prevention of prenatal brain injury.
>>Obstet Gynecol. 2006;108:656-666.
>>
>>3. Freeman RK, Garite TJ, Nageotte MP. Fetal Heart Rate Monitoring.
>>3rd ed. Lippincott Williams and Wilkins, 2003.
>>
>>4. ACOG Practice Bulletin No. 70. Intrapartum Fetal Heart Rate
>>Monitoring. December 2005;105:1165.
>>
>>At Tue, 17 Jul 2007, Joe Cutchin wrote:
>>>
>>>Question for those teaching residents: So what is being propogated in
>>>regards to EFM? Are we propetuating bad science ? Are we being legally
>>>correct? Are we bowing to the administrators? I suspect EMF exist in
>>>another world which is scientifically unreal. Joe C
>>
>>--
>>“ The greatest obstacle to knowledge is not ignorance,
>>it is the illusion of knowledge.” Daniel J. Boorstin - Historian
>>
>--
>D. Ashley Hill, MD
>Associate Director
>Department of Obstetrics and Gynecology
>Florida Hospital Family Practice Residency
>Medical Director, Loch Haven Ob/Gyn Group
>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>Orlando, Florida
>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
