Posted by My OB said WHAT?!?.
Feb
24
Posted by My OB said WHAT?!?.
“ACOG Guidelines State…You Must Be On The Strip Every 5 Out Of 15 Minutes.”
“ACOG guidelines state that if you’re dilated past 5cm, you must be on the strip (External Fetal Heart Rate Monitor) for every 5 out of 15 minutes.” -OB to mother during her labor.
There are 21 comments to this post.
Even if this were true, I still wouldn’t consent. Guidelines are not laws, and I have the right to refuse. Maybe this OB was such an idiot he didn’t know how to use a hand-held doppler, which is all my midwives used during my homebirth.
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Katiecnm Reply:
February 24th, 2010 at 7:30 pm (Quote)
You have a very good point, Molly. Thanks for reminding us (me) that women can refuse interventions, and that “guidelines” are just that. I’m a home birth CNM, so I manage to get along without any electronic fetal monitoring at all!
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Den Reply:
September 14th, 2010 at 3:37 pm (Quote)
But if something goes wrong you be the first to go running to the lawyer, and never assumed any personal responsibility clamming you weren’t properly informed. Yes they are guidelines, but they are in place for a reason, all of these guidelines are with patient’s best interest first and with proven (scientifically or evidence base) that is the best care. When a lawyer is in court all he has to ask is “Doctor did followed the guidelines put in place by ACOG?” “Did you meet the standard of care?” Meeting the standard of care is following the guidelines! Whether you want to accept it or not thats how it is. When the lawyer is dangling a check in your face, filling your head “we can get $00000000” you are going to forget that you refused the treatment or intervention and hide behind “he never told me that could happen” or “you have explained it better” so therefore is the doctors fault.
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Actually, I believe their guidelines are 20 minutes out of every hour, so according to that his math is right (meaning, one third of the time), but he’s lying.
She doesn’t have to go on it every 15 minutes for five minutes, she has to go on it every hour for 20 minutes (and then they ‘forget’ to take her off…). According to their guidelines.
That said, she doesn’t really HAVE to go on anything. Remember? The mom has a right to refuse treatment, even refuse hospital policy! *gasp*
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Wow, where’s a Code Mec when you need one?
Would you believe I managed to give birth to my first baby without any monitoring whatsoever?! And shocker, he was fine! The plan was to labor at home as long as possible with my doula… I thus unintentionally showed up at the hospital crowning when my labor unexpectedly went from 0 to 60 in one contraction when my water broke. Anyway, they were really bitter at the hospital that they didn’t get to “do things” to me. And my son was born with Apgars of 7 and 9!
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Sounds like BS to me. Even if it was in the guidelines, I’d refuse it; there are many recommendations from the ACOG that I disagree with completely!
I had a home VBAC planned and a non-emergent transfer to the Naval hospital. Even being a VBAC, the awesome OB on that day didn’t want me to go on the EFM for 20 min an hour. I told her I was fine with 20 min every 2.5-3 hrs, and she was totally amenable. 
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Wow…. I wish I had read this before the birth of my 2nd (11/08). I knew there were things I could refuse, and I had a doula with me, but I think I was still too scared to refuse too many things because I had mechonium in my fluid and the nurse said the baby’s heart rate wasn’t showing any decells during contractions (which my doula who is also an RN explained is normal… if I wasn’t even feeling them, the baby wouldn’t really be reacting to them anyways), so I had to be on continuous fetal monitoring….
My husband is completely against homebirth and the nearest birth center is 2 hours away (even though my labors have so far lasted 25 and 21 hours from water breaking to delivery, so I doubt there would be any issues…), so I am honestly just freaked out to have another baby! I am meeting with a new OB in the AM, my old CNM (who left the practice to teach med students how to handle non emergent natural births in WV) recommended him. She said he approached her about running a freestanding birth center under him, but the hospital wouldn’t approve it. Hopefully he will ease my mind…
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A 20 minute race won’t tell much. What if the baby is asleep? The trace will show poor variability and be unreactive. We know the baby will probably wake up after about 40 minutes, but then we have to keep the monitor on. Intervention leads to further fiddling. It has been shown that using CTG’s has increased instrumental deliveries by about 30% and c-sections by up to 160% (Haverkamp, 1976 and MacDonald, 1985), while reducing morbidity and mortality by negligible amounts (Thacker, 2005) for both high and low-risk women. It has also been shown that information has been skewed by those who wish to sell the idea of safety (de Vries and Lemmens,2006). Alfirevic, (2006) suggest, in a study of 37000 women worldwide, that a neonatal seizure would be prevented in 1:660 cases, while increasing the risk of emergency section to 1:58. They also show that the use of continual monitoring reduces the focus on woman-centred care. This has led to professional bodies in the US and Australia, along with NICE in UK, advocating judicious use of CTG in line with evidence (Walsh, 2007).
So, Nyah!!!!
Anyway, it is a GUIDELINE, not a protocol. There is an element of discretion there, which allows a)flexibility by the practitioner, and b) the right for women to refuse.
References:
Walsh, D. Evidence Based Care for Normal Labour and Birth pub. Routledge 2007
Alfiveric, Z, et al, CTG as a form of electronic fetal monitoring for fetal assessment in labour, Cochrane Database of Systematic Review, 2006
de Vries, R. and Lemmens, D. The cocial andcultural shaping of mdical evidence, Social Science and Medicine, 62. 2694 – 2706
Thacker, S. et al, Continuous electronic fetal heart monitoring during labour, Cochrane Library Issue 1
MacDonald, D., et al. The Dublin randomised control trial of intrapartum electronic fetal monitoring. American Journal of obs and gynae, 152(5) 524-539
Haverkamp, A., et al. The evaluation of continuous electronic fetal heart rate monitoring in high- risk pregnancy. American journal of obs and gynae, 125(3) 310-320
So there, evidence as to why this doctor is talking through is hat, and how you can refute it.
Andy
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Sheva Reply:
February 25th, 2010 at 3:59 am (Quote)
Thank you! I’m going to save this to give friends and clients, so they can make their own INFORMED decision!
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The Deranged Housewife Reply:
February 25th, 2010 at 11:58 am (Quote)
Andy, Tina Cassidy talks alot about this in her book (The Surprising History of How We are Born) – how many of these monitors, etc. have done little more than making nursing a ‘hands off’ profession anymore, where they can hook up multiple women to one computer and decrease patient/nurse interaction. She also said this about epidurals – nurses typically bug the mom about getting one, because then she’s quiet, resting and not bugging the nurse. :0
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Andy Reply:
February 25th, 2010 at 3:25 pm (Quote)
We have done a lot of work over here to minimise use of the CTG. We have actually got to the point where some doctors openly oppose it’s use. The idea of the ‘admission CTG’ has been discontinued now- the habit of putting all admissions on the monitor ‘just for 20 minutes’ on admission, which has probably caused a lot of unnecessary intervention. A quick trace becomes poor variability, which you know is probably just sleepy, but you can’t take her off until it wakes up. Then there is a dip (probably baby fiddling with the cord) so she needs a bit longer just in case. Before you know it the 20 min trace before she gets in the pool becomes a managed labour and the woman feels devalued (actually she probably thinks ‘thank God for technology’- it saved my baby’).
Now, we do traces if we feel it is indicated (ie high risk). If not we just listen in with a hand held doppler- every 15 min until she pushes then after each contraction when she pushes. This is cited in the National Institute for Clinical Excellence Intrapartum Care guideline (www.nice.org.uk) and the Royal College of Midwives Low Risk Care Guideline (www.rcm.org.uk).
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Maybe he/she was right in saying that it’s a guideline- but guidelines are not protocols, at least not in the world of science. And hospitals. It’s more of a “we PREFER it” and it’s generally to help avoid a frivolous lawsuit (not all of them are, but plenty of them have been)at a later time.
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Attaching the acronym “ACOG” to a set of guidelines hardly gives them credibility. It’s the geniuses at ACOG who are saying that despite all of the evidence of there being no harm to food or drink during labor, they will only “let” women have chicken broth and ice chips.
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Sheva Reply:
February 27th, 2010 at 7:47 pm (Quote)
They’re letting us have chicken broth now? I didn’t hear that one!
They’re also the ones who are saying that although midwives have a lower c-section rate, lower episiotomy rate, lower maternal and infant death rate, for crying out loud, they STILL say docs are the way to go, and that home births are still not as safe as hospital births.
Apparently math was never their ‘thing’.
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Its crazy what women feel “forced” into… or are truly forced into… Its super frustrating that you have to battle with staff the entire time on what you don’t want…
Two articles recently published on the issue…
http://prepforbirth.com/2009/07/22/acog-refines-guidelines-for-fetal-monitoring-in-labor/
http://www.philly.com/inquirer/health_science/weekly/20100426_Test_leads_to_needless_C-sections.html
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I am a labor and delivery nurse, a BSN and Certified in Inpatient Obstetrics. I have been in my field at a regional hospital for 14 years, and the stuff I have seen gives me grey hair. Yes, the majority of the time, monitoring does not improve outcomes, and babies are born all the time without monitoring with positive outcomes, but in a few very critical cases, the only way I and the OB were able to improve the outcome was through current real time monitoring. I am certain the parents of the babies we saved from permanent brain damage would be monitored again, and again, for it saved their child. I have also see midwife transfers come to our hospital, who have not been monitored, and delivered their infants with acidotic brain damage. I am certain they would welcome a monitoring strip once an hour if it meant their babies would be bborn neurologically intact. Monitors, while not mandatory, give your OB team (Parents, OB, Nurses, Nursery team) information. We are not evil, hospitals are not evil, and OB’s are not evil, trying to do evil, unneccesary things to our patients. We care for them, work tirelessly and diligently to delivery happy moms, happy babies. I do not question those who design and build nuclear subs. I trust their training, education, and expertise. I would ask respectfully as an RN in the OB field, that we would not be vilified, but treated with respect. I am an OB nurse, and I work hard for my patients, doing what is right every time. It offends that some out there discredit what we try to do, safely, in this highly litigous environment.
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OK, that sounds like a bold-faced lie to me to get the laboring woman to do what they want her to do. There is no ACOG guideline like that. I’d be asking the OB to show me the guideline. They have ACOG Guideline books on L & D units.
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Den Reply:
September 14th, 2010 at 3:21 pm Den(Quote)
Once you pass 5 cm in dilation you are in active phase of labor. In active labor the fetal monitoring is either intermittently or continuous. And yes there are ACOG guidelines is call the ACOG compendium is a collection of publications by ACOG (Committee Opinions, Practice Bulletins, and Policy Statements) that is published every year. If you don’t know of its existence, you should not even be rendering any advice or opinions off anything obviously you know nothing about.
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