Aug 242010

“We always do continuous fetal monitoring, not because we think it helps, but just for legal reasons.” -A L&D nurse

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 August 24, 2010  Fetal Monitoring, L&D Nurse  Add comments

  51 Responses to “"We Always Do Continuous Fetal Monitoring…For Legal Reasons."”

  1. I give this nurse points for honesty.

  2. Yeah, at least they acknowledge that it’s not actually very accurate or helpful.

    Now if only they could/would get it together to untether their Mamas. Sigh.

  3. I was told this too. They attach the monitor to the mother to keep the lawyer happy. In my ex-hospital, you couldn’t even sign a waiver saying you didn’t want the monitor.

    (BTW, if you change positions constantly while wearing the monitor, the monitor won’t get a good tracing anyhow, and the nurses will get tired of coming back to adjust the monitor. So they spend five minutes getting it right when you’re lying still, and as soon as they leave the room you flip to all-fours and rock, and the monitor isn’t picking up anything anyhow. Then they either have to come back and readjust it (and you repeat the process) or eventually they decide it’s not worth it. I didn’t have to repeat this too much because I discovered it in my last monitored labor, which went very fast.)

    • When they kept having to readjust mine, they scolded me for not staying still and wanted to use an internal monitor. Fortunately my midwife got there and would just hold the monitor in place while I did what I needed to do. (There was no getting off the monitor because I was on pitocin. I would, however, take a very long time when I went to the bathroom, giving myself a break from it.)

      • forgive the poor typing my 1yo is in the way.

        i had CFEM with #1 because they drugged me that bad (I was given 2 doses of pethidine to curb the back labour instead of just one and I was in and out of consciousness). The monitor hurt. I hated it. I couldnt move anyway, but that had me basically strapped down. My son had marked decels, but as I was already 10cm and he was coming down, they opted for forceps over a CS.

        I had no foetal monitoring at all with #2, even tho she was induced. was by far my easiest L&D. She wouldnt cry though so it was humidicrib for 2 hours (after I had held her a while though :) ).

        #3 (back labour again) was also an induction and I had intermittent monitoring for a while, then she dropped below my iliac crest so they switched to internal monitoring. If I had not been so ill I would not have needed it, and would not have had it. She was the smallest of all 3, but also the sickest so I think the monitoring was a good idea in this situation.

  4. As a mother, I found this terribly annoying and unnecessary. I knew my baby was fine, I didn’t want the monitoring, I was moving around so it didn’t work, and studies have shown that it’s not always accurate anyway.

    But as a nurse, I completely understand where this nurse is coming from. Let’s say mom has been in labour for more than 48 hours, she’s dilated to 4cm and has been that way for a while, and baby’s heart rate drops to 60 and stays there. Obviously that’s not good, and something needs to be done. (And hopefully it can be helped without a cesarean delivery. Lol). If baby’s heart rate stays there it’s going to cause problems, and if the nurse or doctor does nothing about it because mom wasn’t on EFM, then it’s major grounds for a lawsuit. That’s a way simplified example, but it’s the truth. This is where I campaign for midwives and homebirth because: you get one on one care, constant observation for problems, you are allowed to listen to your body and follow your gut, and if FM is used it’s usually a fetoscope (which is incredibly accurate when used correctly. Lol).

    I know I’m probably going to be hated for this comment, but you have to understand what this nurse has on the line if she doesn’t do what is required of her. And as a side note, messing up the tracing just makes for a lot more paperwork for the nurse, meaning a lot less time for her mamas. Every odd tracing on the strip has to be accounted for by the nurse both on the strip and in the chart (at least in my state. Lol) and that is very time-consuming.

    Just my 2 cents, from both viewpoints.

    • I totally see where you’re coming from, professionally, and thank you for having the courage to speak up for this perspective. :)

      This is very much a case of needlessly burdening the nursing staff so, yes, the lawyers stay happy. It’s a sad commentary on the state of our medical system, rather than on the nurse. The nurse was actually refreshingly honest about the situation, and I’d prefer to hear the above than “We need to monitor you every second or YOUR BABY COULD DIE!”

      • Exactly, so. People are so “sue happy” that hospitals are, in a sense, forced to take all these measures to “ensure the safety” of their patients. Even if they don’t really work (as in this case).

    • The overall problem is that the hopsital mandates that a medical text be performed on a woman and a baby for the *hospital’s* benefit, not for the mother’s benefit. It puts a burden on the nurses that doesn’t need to be there. Most often, the heart tracing is used to justify a cesarean section when the need is questionable. (They’ve proven this by giving the same tracing to multiple doctors and having them assess the danger to the baby, and they seldom agree.)

      When medical decisions are made only to benefit a third party, that’s a dangerous precedent.

      • I agree with you in a sense. CFM is not proven to significantly improve patient outcomes. However, many mothers believe that it will help. Imagine the following: a mother comes in but does not have CFM (although she did not decline it, it just wasn’t offered). She has a vaginal birth, but her baby is born with severe problems resulting from oxygen deprivation as a result of severe decels. An emergency cesarean actually could have prevented this, but you didn’t know about the decels because there wasn’t CFM. Even though you monitored with a doppler you didn’t catch those decels because you had 2 other labouring mamas to take care of, who also didn’t have CFM. Mama sues for damages because CFM could have potentially saved her child from oxygen deprivation and thereby all the developmental effects to follow.

        I don’t think CFM is gold on paper, but it can detect serious decels or low baseline heart rates. If those are detected, you then follow-up with that and double-check the strip with a doppler or fetoscope. If a mama doesn’t want CFM, that’s fine, and completely within her rights. But because we live in a society that believes everything can (and should) be prevented doctors and hospitals are forced to do things to cover themselves.

        It’s a difficult situation for everyone. Nurses don’t like having to keep those monitors placed perfectly on moving mamas, mamas don’t like having to be interrupted every five minutes to have it moved, or having to stay still to keep from being interrupted.

        • My chief objection to CFM is that women are NOT ALLOWED to decline it. There was no piece of paper I could sign at my hospital that would ALLOW me (as if I were a child) to deliver with out the stupid machine being attached.

          When a procedure is mandated by the hospital for every single laboring mom despite the fact that it had no proven benefit and some proven disadvantages, *only* to benefit the hospital’s legal stance, then we’ve initiated a medical test/procedure for the benefit of a third party.

          In your scenario, the hospital could have ensured itself against a lawsuit by giving the mother the right to make an informed decision (eg, a booklet handed out in the 5th month explaining about fetal monitoring, with the mother having to sign the back of the book stating she’d read it, understood it, and wanted to decline or had read it, understood it, and wanted to accept), and more importantly, by hiring enough nurses to cover the L&D unit.

          BTW, fetal monitoring is useless when the unit is understaffed, because with no one to read the monitor–or not to read the monitor often enough–what good is it? Problems can continue for long stretches of time without anyone noticing.

          • I’m sorry your hospital didn’t have anything available for you to sign that took away their liability. That’s the issue for hospitals, doctors, and nurses here. I truly am sorry you had to deal with this situation. It is the mother’s choice what happens to her during her labour and delivery, even if that means taking the “liability” upon herself. Doctors, nurses, and hospitals don’t really have any right to tell a mama what to do, although they often try.

            I know my example seems crazy, but it has happened. It is part of the reason that CFM is now “mandatory” in every hospital in my area. CFM does have its uses, but the results from CFM need to be double-checked, just as anything in the medical field. (It seems obstetrics is a specialty that is lacking in many areas.) You mention education and informed decisions, but not every mother wants to be as “educated” as we are. Many mothers (at least in my area) have no real desire to make decisions, they simply trust the staff to tell them what is best (I say this based on my clinical experiences and my family and friends who have this attitude). Now this, I believe, is a result of our society being “dumbed down”, but that’s another story. ha Anyway, in all our area hospitals, parents are given educational materials (and should have discussions regarding them) at every prenatal visit. These topics include: CFM and other monitoring options, pain relief, labour techniques such as movement, breathing, etc., nutrition during pregnancy, you get the idea. This mama could have made an “informed decision” but chose not to. She was the mama that did not care to learn it for herself, but blindly trusted others to do what was best.

            That being said, I still don’t vouch for CFM. I think if a mama wants it or doesn’t mind it, let her have it. If something comes up that looks distressing, double-check it with a doppler or fetoscope. We have monitors at every nurses station with the CFM strips from every room so you don’t have to be in the room every minute to watch the strip. And I know at one particular hospital the nurse must document every 15 minutes (I think, I don’t work at that hospital) that the strip looks reassuring and mama has no complaints.

            I don’t know if all this rambling makes any sense (it’s late here! haha) but I hope you understand my point. CFM is not perfect, but can be useful when used correctly. It can detect problems that really require a some serious repositioning, other “interventions”, or even a cesarean delivery. However, most often it is treated as the defining answer when the monitors can be wrong. This is why you often hear stories of babies who were “in distress” being born by “emergency” cesarean who are, in fact, just fine. The CFM monitors were a little off and the strip was false. The reason this becomes a sticky situation is, that if a doctor doesn’t do something when the strip says something is wrong and he thinks its fine, he gets in big trouble if something really is. People are much more likely to sue because you didn’t do something than because you did (even though its not always the best).

    • I get what you’re saying, and I understand that doctors and nurses have to cover themselves. But the point is that a baby’s heart rate naturally fluctuates during labor, and these tracings are being used to justify unnecessary c-sections. You said: “If baby’s heart rate stays [down] it’s going to cause problems, and if the nurse or doctor does nothing about it because mom wasn’t on EFM, then it’s major grounds for a lawsuit.” If a mom wasn’t on EFM, they wouldn’t KNOW about heart decels. I think they are opening themselves up for MORE lawsuits. The tracing is a record that can be shown to prove almost anything (I think a previous reply mentioned the studies that found out how unreliable interpretation was). If they were smart, they’d stop doing it, and there would be nothing to sue about.

  5. I was lucky enough to have a good Midwife in the hopsital I asked to not be monitored any more than was hospital policy 20 mins upon arrival and then the midwife held it to me for one contraction.. but then I did not arrive at the hospital till in well established labour…

    And at least she did admit that they do EFM for legal reasons only.. but you can Still refuse it!!…

  6. So I typed out this nice comment on my phone but it’s not showing up. :( I will be back later though, because this is a big issue for me. Lol I can see from the mom and the nurse here.

  7. That was one of my first questions when I went to the hospital tour for my second baby. My OB had switched from both local hospitals, to one. The one that he could deliver at told me they’d do monitoring, but a feature was they had the wireless devices. So I asked for those bad boys and didn’t get stuck in bed. They did let me know when I wandered out of range of the machines, and the signal stopped, but all I got was “ok, so apparently they don’t work *that* far from the room.” They came by to readjust it when I had to use the bathroom and it slipped, but again it was “hang on, it slipped again.*adjust*, ok, good to go!”
    I wish more people could have positive and honest experiences with silly “legal” things like the monitors. I don’t think as many people would hate them if they weren’t used to keep moms strapped to bed and if the nurses were more laid back with them if they slip. They’re just monitors…if they slip or mess up it’s not like the mom is actively trying to hurt the baby.

  8. Well, at least she was being honest. But seriously that is why I could never be a L&D nurse…I wouldn’t ever be able to keep my mouth shut about stuff like that. Also if I were the patient I hope I would have been able to come up with some witty comeback.

    I feel like I have nothing to contribute to a lot of these discussions since I’ve only had the one baby and I didn’t really have a home birth, but not a hospital birth either. Labored at home, pushed her out at the hospital before anyone could strap anything to me or check anything. I mean, it was great, but I still feel a little left out!

    • No time to monitor me for my last birth, either, Sara. I told them that I wanted to use the bathroom one last time before being hooked up and came out saying, “It’s time to push.” Believe me, it’s well worth feeling left out. LOL!

      • I’ve had the same thing happen with my births so far- laboring at home and arriving at the hospital just in time to push the baby out. And I agree, Yvonne- it is WELL worth it to feel left out in that way! Although it is interesting, I hadn’t really thought of it as not really having a home birth or a hospital birth…although I guess I will consider it a hospital birth since they still charged me out the wazoo for “birthing” :)

  9. It is so sad that it has come to this. I too applaud the nurse’s honesty. It’s just horrible that medical decisions aren’t being made for medical reasons these days, and while this may be non-life threatening, unnecessary c-sections aren’t.

    I had continuous monitoring with my delivery, and I had it for legitimate medical reasons, but that doesn’t change the fact that it SUCKED. It made my labor sooo stressful, and I wonder sometimes if that contributed to a 40 hour labor that ended in a c-section. It’s hard to focus on progressing when nurses are in your room every 5 minutes to move the monitor because your kid won’t hold still.

    Seriously, even though it was important to keep an eye on my high risk kid, I cannot emphasize enough how truly stressful the monitoring made my birth experience. BOOOO.

  10. At least this nurse was honest. My client the other night got “this is to protect you and protect your baby”. Ummm, no, this is to protect your backside, nurse.

    • Well, it DOES protect mom and baby, in the way a bank vault protects your your cheap jewelry. Can we say overkill?

      • Actually, some of the research says continuous monitoring leads to cesareans where the baby wasn’t truly in jeopardy and this can lead to infection and excess bleeding for mom and breathing difficulties for baby. So it isn’t always even protective.

      • Rebecca, I KNOW this isn’t what you meant, but I wouldn’t use that analogy because it really sounds like you’re comparing the mother and baby’s life to cheap jewelry that isn’t worth putting in a vault. Again, I KNOW you didn’t mean it that way.

        That being said, yes to Ann’s reply. Fetal monitoring doesn’t protect mothers, and it doesn’t protect babies any better than a doptone or fetoscope used intermittently. Since unnecessary cesareans aren’t in babies’ best interests, and since causing harm to mothers via cesareans can result in difficulty nursing and other problems which affect the baby, I’d venture to say that electronic fetal monitoring isn’t in baby’s best interest either. Yes it does protect the baby, but it is not the best way to protect the baby.

        And did you know that those seemingly innocuous 20-minute strips result in more c-sections without improving outcomes as well?

  11. So when their hospital realizes (if they ever do) that more babies with continuous monitoring are born by cesarean, what do they do then? (rhetorical question)

  12. To Ann S.
    Being a L&D nurse for the past 11 years and seeing many labors go unmonitored and monitored, its hard to say wether it does the mom or babe any good in the long run. I have seen babies come out and do very poorly with great strips, and I have seen babies come out and do wonderfully with the worst strips. All I do know is that if people weren’t sueing hospitals and OB docs left and right, maybe there wouldn’t be such a need for so much monitoring and all the legalities.

    • I would like to see the statistics backing that “getting sued left and right” statement up. (I know they don’t exist btw, lawsuits are actually way down since the beginning of the liability insurance crisis,)

      CFM, internal and external, has been proven repeatedly to do nothing to improve medical outcomes, and to dramatically increase c-sections. Most OBs and hospitals are utterly incapable of accepting the fact that this expensive bit of equipment does no good.

      And if they ARE making the decision based on being sued, well that’s financial. So they can’t exactly argue that the extra money they make from doing c-sections is not a driving force, since they have already admitted that their primary driver is financial outcome and not patient outcome.

      • But if it becomes “standard of care” for a certain hospital/practice/area and a doctor doesn’t do it and has a bad outcome (maternal or fetal), then they’re in a much worse place malpractice-wise.

        It’s most certainly CYA medicine, and if enough OBs would step away from it then CFM would no longer be standard of care and they wouldn’t have to worry about it. But it takes a lot of courage to be the one to buck the trend.

  13. they renovate to make room for a bigger NICU (I wish I was joking).

  14. At least she was honest, we can’t really fault her for that.

    Just my experience, but being monitored like that sucks. Of course my son wouldn’t stay still at all so they couldn’t keep the external monitors on. Despite catching my son’s heartbeat a few different times and knowing he wasn’t in distress they wanted to do an internal monitor. I still wonder why I consented to that. Oh wait, I felt like I didn’t have a choice.

  15. This is mine. It was a nurse from a CNM practice. Don’t bother giving her honesty points.

    When I first went to this practice, they gave me a lovely letter stating “research supports the use of CFM and we require it for all our patients.” Knowing that this was a blatant lie, I switched providers.

    Months later, I was attending a birthing conference where this nurse spoke and that’s when she said it was only for legal reasons.

    Honesty? Not so much.

    The sad thing is that the only reason I knew it was a lie was because I was in nursing school at the time. Most women probably just believe it, because why would their provider lie to them? Aren’t Dr’s and midwives ALWAYS acting in the best interest of their patients? (smirk)

    • It doesn’t have to be a state or federal law – it can be a hospital policy/law. They may have an attorney that requires it or they’ve been sued so they now they require it for their own legal purposes. I think the nurse was on par.

  16. I am an L&D nurse and a mother of 3 so I get both sides of the debate, CEFM in labor sucks! But as a nurse I am required to follow standards set out by my national nursing organization, my state and my hospital policy regardless of if I think they are right or not. I would love to doppler more patients but when I have 2 laboring mommas (as is standard where I work, plus the required charting and bedside care) it can not physically be done, plus we only have 1 doppler for 25 rooms.

    • That’s just it, L&D Nurse. Hospitals are doing this so that they can short-staff. Who loses? Laboring women and the nurses who care for them! Women are paying with their bodies (and wallets) for this anti-evidence practice, and nurses are entrenched in a system that doesn’t support them.

      To place financial, professional, and institutional interests over evidence-based care and client welfare is, in my book, profoundly unethical.

    • Dopplers aren’t that much are they? I mean, I have a friend who bought or rented her own doppler because she would have trouble feeling her baby’s kicks and wanted some extra reassurance. I know the wireless get up that my hospital had was expensive, but I’m very thankful that they had the budget to spend on it. They also serve the surrounding counties, so a lot of moms have access to it. I haven’t looked, but the other hospital also renovated their maternity ward since my oldest was born 6 years ago, so I wouldn’t be surprised if they had wireless monitoring too.
      I don’t see why they need it every single minute you’re in labor. Why not just get a 15-20 min strip once an hour? That’s all my nurses and OB seemed to care about. I’m guessing my hospital was a lot smaller then the ones that other people go to because I felt like I had very one on one care.

    • The guidelines where I work states we should ‘listen in’ to the FH with a doppler (or pinnard!) every 15 mins for 1-2 minutes following a contraction once in established labour.
      I (sadly)regularly look after 2 or sometimes 3 women in labour and it is possible to do, even if i can’t always offer the level of support that I would want.
      here, once a woman is on a CTG, you can’t leave her- no point having a monitor on if no-ones gonna watch it! So here, its using dopplers that means they can short staff!!
      Dopplers cost from £500 here where as CTG’s start at £4-5000!!

    • You’re right, L&D. Intermittent auscultation REQUIRES one to one nursing care. Otherwise it is physically impossible.

  17. I was an L&D RN for 15 yrs or so and in our province the standard is doppler only if all is normal. NO STRIP IS BETTER THAN A BAD STRIP is what we used to say – and our courts agree. Monitoring is proven NOT to improve the outcome.

  18. As a midwife practising in the UK, I am always suprised to hear all the discussions about EFM in the US.
    It is well recognised in this country that the liberal use of EFM does not improve outcomes in low risk women, but does increase the risk of c/s four fold.
    I work in a birth centre and even the old ‘admission trace’ is no longer practised.
    I also get the impression that C/S are carried out by a doctor just ‘judging’ the trace?
    Here, if any traces are questionable, there is a further test required, ‘fetal blood sampling’ to determine if the baby is in ditress or not (unless the trace is obviously pathological). In establishments that have EFM, it is required that this facility is also available. Is this not done in the states?

    • No, this is not the common practice in the states.

      At least that I have ever heard of/experienced.

      You get hooked up to a monitor belt. If you’re LUCKY (and low risk) it’s only 15 minutes out of an hour. If the strip looks bad, you get cut.

      If the strip looks bad because it wasn’t positioned correctly, or because the baby shifted position, or because the placenta is anterior… who cares? If the strip says so, it MUST be true. Sigh.

  19. Obviously, we all think this is ridiculous and would (most likely) not sue HCPs over not having CFM. We all think birth is a natural process that should be left alone. But there are women (and men) out there who don’t share the same birthing ideas that we do, who would be more than happy to sue over something they felt was preventable by Dr. Thinks-he’s-God. So all in all, yes, many things are done in hospitals and as pre-natal “care” that aren’t necessary for any other reaeon than to protect the liability of the nurse, doctor, midwife, etc. Is it sad? Absolutely. But must it be done? Sometimes yes.

    Personally, I didn’t want or have anything done during my labour that I felt was an unnecessary intervention (not even an IV “just in case”). But I also know many women who wouldn’t dare give birth without an IV, CFM, epidurals, cervical checks every hour, you get the idea. They have been so ingrained with the belief that birth must be managed that they feel their actions are the only way to have a healthy baby. Is it true? Absolutely not. But it’s what they believe, just like we believe the exact opposite. And, since they have heard that CFM is what’s best, it had better be done. Those are the kinds of people who sue over bad strips that didn’t end with cesarean sections to “save the baby” (even if the baby was fine. You know, because all that emotional stress took a toll on mom). Is that ridiculous? Absolutely. But does it happen? Absolutely.

    I’m not trying to advocate for this particular nurse, but please don’t write off all nurses who make this kind of comment as being rude. Mos likely, they are being honest because they don’t like the practice either, and they’re trying to make you feel better. Being a nurse, at least I’ve found, involves a lot of doing things for legal reasons. It’s not fun, but it’s done because someone, somewhere, decided to sue over it. If I felt my mama didn’t want CFM I might sat something like this to her, trying to let her know that it doesn’t mean there is anything wrong with her or the baby, it’s just part of my job.

    Call me crazy, but I don’t want to get sued because some mama gets mad that she didn’t have CFM that could have gotten her a section. I’d rather have that strip, a happy mama, and my license at the end of the day.

    Once again, just my $0.02. Don’t everyone hate me. Lol

    • Brittany, just curious here….have you ever had a mom refuse the monitoring entirely? Request only doppler/fetoscope? If so, what did you do? What did hospital admin do? (Disclosure: it’s what I’m planning on doing if I stay healthy and the pregnancy continues low risk.)

      • Actually no, I haven’t worked with a mama that did but that’s what I did. It was in my birth plan that I didn’t want CFM so it wasn’t a big deal to my midwife but the nurse looked like she was going to die. Lol I don’t recall any problems whatsoever with the hospital admin, I just signed a waiver (not actually what it was called, but that’s pretty much what it was) saying that I assumed “all resposibility” for any “consequences” that may have resulted from my decision. My area is not big on natural, low-intervention birth of you’re in a hospital. Those mamas choose home birth, which is what I hope to be doing in the next few years after I become a midwife.

  20. While I didn’t particularly mind the monitors (least of my concerns by the time they strapped them on me, truth be told) I can see why some women don’t want them; that being said, I think a majority of us who live in the US will readily admit that people in this country will sue for ANYTHING. You eat McDonald’s 3 meals a day and you’re fat? Sue McDonald’s! You hurt yourself while breaking into someone’s house? Sue the homeowner! You drive drunk and crash into a tree? Sue the bartender! I can’t blame hospitals for keeping all their bases covered in a society where almost nobody will take responsibility for their own decisions and actions. I wish doctors didn’t depend on their machines more than the laboring woman’s voice; but fetal monitoring saved my youngest niece’s life, so I can’t completely discount its possible benefits.

  21. I refused monitors at my last hospital birth. The nurse said “its hospital policy to get 15 mins every hour” and I said “ok but Im still not using them” as I walked to the shower. She just rolled her eyes. I didnt have to sign anything and no one made a big deal about it. You CAN just say no thank you to whatever hospital policy. They can not turn you away if you are in labor.

  22. [...] or negligence should a patient decide to sue.  As one labor and delivery nurse shared on the My OB Said What?!? [...]

  23. [...] or negligence should a patient decide to sue.  As one labor and delivery nurse shared on the My OB Said What?!? [...]

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