LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.
First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”
Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.
“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.
To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”
In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”
Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?
“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”
Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.
“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”
Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.
“Be as general as possible in your policy,” she said.
For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”
In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”
She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”