Question

Discuss informed consent related to fetal monitoring and care measures instituted by physicians and facilities that may differ from personal choice.

Answer 1

Ans.

Electronic fetal monitoring is a procedure in which instruments are used to continuously record the heartbeat of the fetus and the contractions of the woman's uterus during labor. The method that is used depends on the policy of your ob-gyn or hospital, your risk of problems, and how your labor is going.

Doctors most often perform fetal heart monitoring in the delivery room. It's critical for your doctor to monitor your baby's heart rate throughout labor. The timing of your baby's heartbeats can indicate whether they're in distress or at physical risk.

A nonstress test is a common prenatal test used to check on a baby's health. During a nonstress test, the baby's heart rate is monitored to see how it responds to the baby's movements. The term "nonstress" refers to the fact that nothing is done to place stress on the baby during the test.

The dominant culture in labor and birth is the medical model, not the midwifery model of woman-centered care. Consensus among professional and governmental groups is that, based on the evidence, intermittent auscultation is safer to use in healthy women with uncomplicated pregnancies than electronic fetal monitoring (EFM). Barriers impact the laboring woman’s ability to give informed choice regarding fetal monitoring. Lack of informed choice denies a woman her right to be in control of her birth experience, and is in opposition to a woman’s right to autonomy and self-determination.

women have been acculturated to continuous electronic fetal monitoring (EFM) during childbirth, and accept this type of labor management as part of the normal birth process. Not all women need EFM. Women with preeclampsia, type 1 diabetes, preterm birth, and suspected intrauterine fetal growth restriction have high risk conditions and should be monitored with EFM; healthy women without complications would be considered low risk and can use intermittent auscultation. Continuous EFM is associated with many known medical risks to women, without providing any benefit to the fetus in low-risk pregnancies . An alternative option for healthy women with uncomplicated pregnancies is intermittent auscultation (IA). IA is a safe and acceptable fetal monitoring method that is recommended during labor with low-risk pregnancies .

Many barriers exist preventing nurses from implementing intermittent auscultation during the intrapartum period.

Continuous EFM was embraced by the obstetric community, including nursing even though clinical trials did not show evidence supporting its use in low-risk women when compared to intermittent auscultation .

Factors influencing fetal monitoring :-

Fetal monitoring is used to assess the adequacy of fetal oxygenation during labor with the goal being to prevent metabolic acidemia. Metabolic acidemia can develop over 60 min following a fetus being deprived of adequate oxygenation . Hypoxia during labor can be caused by compression of the umbilical cord, or in more serious cases, by decreased placental perfusion during a uterine contraction seen in late decelerations.

Metabolic acidemia is associated with increased rates of neonatal morbidity, specifically cerebral palsy. however, fetal hypoxia during labor is a very rare cause of cerebral palsy . children have cerebral palsy with the main risk factors for cerebral palsy being low birth weight, intrauterine infections, and multiple gestations . Hypoxia that can contribute to negative changes in fetal heart rate patterns include the presence of maternal fever and infection, medications, and hyperthyroidism . Maternal infection has been linked to low Apgar scores, neonatal seizures and cerebral palsy . Other causes of fetal heart rate changes include conditions involving the fetus: sleep cycle; infection; anemia; arrhythmia; preexisting neurologic injury; heart block; and congenital anomalies.

DIFFERENT TYPES OF FETAL MONITORING DIFFER FROM THE PETSONAL CHOICE :-

1) Continue electronic fetal monitoring -

External continuous cardiotocographic monitoring (EFM) is the most common method of assessing fetuses in the United States while in labor and it requires a woman to be immobile to obtain accurate readings. Two straps are placed around her abdomen, with one strap containing the Doppler ultrasound transducer to monitor the fetus’s heart rate and the other having a pressure transducer to monitor uterine contractions . EFM is associated with high false positive rates and inconsistent fetal heart rate tracing interpretations, both of which contribute to an inability to accurately predict fetal hypoxia .

Continuously monitoring the fetus during labor is associated with a significant increase in cesarean surgery, instrumental vaginal births, and maternal infection with no reduction of cerebral palsy or neonatal death when it is compared to Intermittent auscultation . Although neonatal seizures are rare events the incidence is decreased with the use of EFM, but only in high-risk pregnancies, not in uncomplicated pregnancies for every 661 women who receive EFM during labor, one neonatal seizure will be prevented

2 ) Central fetal monitoring -

Many hospitals have switched to central fetal monitoring, a type of monitoring system that allows nurses to remain at the nurses’ station to observe many fetal monitoring tracings at one time. This centralization of care runs the risk of nurses not entering a laboring woman’s room as frequently. Central fetal monitoring is expensive to set up and maintain, and has not been shown to be of benefit in comparison to EFM at the bedside In a study comparing central fetal monitoring with no central monitoring, there was a statistically significant increase in cesareans and operative vaginal births for nonreassuring fetal heart rate tracings associated with central monitoring.

3)

Intermittent Auscultation

The Pinard fetal stethoscope and the handheld Doppler are used to assess the fetus intermittently, which allows the woman to move about more freely and have more control. The Pinard fetal stethoscope was developed and the handheld Dopper was discovered . Both of these methods are relatively simple to use, and are commonly used during prenatal visits. The advantage of the handheld Doppler is that the woman and others in the room can also hear the fetal heart beat, whereas with the Pinard, only the clinician can hear the fetal heart sounds. Intermittent auscultation also provides the human element of touch and being cared for by a person, and not a machine.

4) Additional Testing With EFM

Internal monitoring is added to EFM if fetal distress is suspected and includes fetal scalp blood sampling, fetal pulse oximetry, or ST segment analysis.

Fetal blood sampling (FBS) is not a new procedure and was used in women with preeclampsia and in postterm fetuses directly assess the fetus for metabolic acidosis. The problems encountered during that time are the same now, specifically, this procedure is invasive, uncomfortable for the laboring woman, requires membranes to be ruptured, and requires an adequately dilated cervix . Fetal pulse oximetry, like FBS, is used to improve the specificity of EFM , and when compared to EFM only, versus EFM and FBS, did have a statistically significant decrease in cesarean surgeries for nonreassuring fetal heart rate .it was not beneficial in reducing cesareans when used in labors with dystocia . There were no differences in neonatal outcomes.

Nursing and medicine should perform a test or provide a treatment to improve an outcome. Continuous EFM is not effective in improving outcomes in healthy women with uncomplicated pregnancies, yet to try to make it more effective, additional procedures are being added to EFM, with no change in neonatal outcomes; limited benefit in decreasing the risk of a cesarean surgery when a nonreassuring FHR is noted; and increased pain and discomfort to the laboring woman.

In care institutions many more facilities are provided by physicians , specialist or multispecilist who are not able or uneducated by techniques. They have many more device or instruments with assess to them . They can be provided best monitering or a handle every fetal so personl care are different from the hospitality or physician monitoring.