When routine care is not evidence based care

I am studying for my shelf exam (my end of rotation exam, for those of you not well versed in the jargon) on ob/gyn. I am using one of a popular series of board review books. Every single question in the chapter on intrapartum fetal monitoring had the use of an intrauterine pressure catheter (IUPC), and most mentioned a fetal scalp electrode.

Shudder.

I am not sure what the prevalence is of IUPC use. I have not seen it in most of the labors I have been to, but I have definitely seen them used. In one labor I went to, the IUPC and/or fetal scalp electrode had to be replaced three times because of problems.

As far as I know, there is no evidence supporting their use. I found this article, which is a rare randomized trial with a significant number of subjects. There seems to be no advantage to using them. When that is the case, I think it is only ethical to use the less invasive intervention, which would be external monitoring.

There are a few quotes I find interesting in this article. Here’s one:

“The American College of Obstetricians and Gynecologists (ACOG) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) advise the use of internal tocodynamometry in selected circumstances, such as when the mother is obese, when one-on-one nursing care is not available, or when the response to oxytocin is limited. The Dutch Society of Obstetrics and Gynaecology recommends its use in all cases of induction or augmentation of labor.2″

Well, I have never seen one to one nursing in labor and delivery in a hospital. Never.

Also, here’s another one:

Induction or augmentation is necessary in approximately 20% of all deliveries, and internal monitoring is thought to quantify the frequency, duration, and magnitude of uterine activity more accurately than does external tocography.1-3″ (Emphasis mine)

Wow, really? Unfortunately, there are poor statistics on the prevalence of interventions in labor, but Listening to Mothers cites an induction rate of 48% for first time moms, and “Only 41% of the women had a labor that began on its own.” This link didn’t have the statistic for augmentation, but from what I remember, more than 70% of labors were augmented by oxytocin.

So, 20% of that is necessary, and what does that make the rest? Depends on who you ask. Some practitioners will say it is active management, aka “doing what we can to get the baby out…that’s what you’re here for.” I call it excessive interventions that lead to possible iatrogenic risk.

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10 Comments

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10 responses to “When routine care is not evidence based care

  1. My province’s major tertiary care maternity hospital has one-on-one nursing care in every L&D room. And they STILL use IUPC. Not all the time. But often enough.

    • MomTFH

      Most place I have been have at least two patients per nurse in active labor, and one on one care for the second stage only.

  2. Nicole

    Wow – you have never seen one on one care in L&D? That is such a sad state of affairs!! Up here in the frozen north (land of socialized medicine no less) it is standard to have 1:1 care from the time of admission. In triage, the ratio is usually more like 1:3 but as soon as you are in a L&D suite, you have a nurse and she doesn’t leave your side until after delivery. (Unless of course you want her to leave you alone)…

    • MomTFH

      I can’t speak for every hospital, of course, and it may depend on how busy it is on the floor and the staffing at the time. But, usually I see 1:2 or 1:3, then one of the other nurses will cover the other patients during the actual pushing stage, which will push them up to 1:3 at that time.

  3. mommymichael

    I have a friend whose children have ended up being hemophiliacs. In which case they need the most gentle births possible to avoid trauma to their little bodies. Having an IFM placed on a hemo-baby can have bad consequences. :/

  4. I very rarely had 1:1 ratio at the hospitals I worked at. IUPCs were rarely used, but sometimes that depended on the doctor. There were some doctors that felt very uncomfortable not using them. What bothered me was when they wouldn’t work…so we would spend time trying to get one on, the whole while not knowing how the baby was doing. It would have been much easier to just listen really quick with the toco every 10-15 min or so.

  5. doctorjen

    My current hospital does 1:1 nursing for labor as well (small community hospital in the rural midwest.) It always makes me sad that this isn’t routine everywhere.
    I don’t use internal monitoring routinely, but find it useful on occasion. Sometimes, there really is a need to monitor continuously (for example, when using pitocin, or when the previous monitoring is not reassuring and you want to make sure the baby is okay). If there is a need for continuous monitoring and the laboring client is difficult to monitor for whatever reason (often because of maternal shape, or fetal position) using external monitoring can mean the client is stuck in one position, often on her back, so that the monitor will pick up. In those case, using a fetal scalp electrode often means the client can be much freer to move, especially since we have telemetry monitors that can be used with either internal or external monitoring. Usually, I monitor intermittently anyway, but when it is important to monitor continuously, internals can sometimes free the mother up from being stuck in whatever position the external picks up well in.
    Also, occasionally you are not able to pick up contractions well. I really don’t care if I don’t pick up contractions if the fetal heart rate is reassuring and the mother is progressing. But if there is no progress, or we can’t tell if fetal heart rate decels are ominous lates, or just keep-an-eye-on variables because we can’t tell where the contraction is, an IUPC can be pretty helpful. Also, I’d never want to say someone was failure-to-progress without documenting that there truly were adequate contractions, so an IUPC can be useful in that setting.
    I think the technology gets overused for sure, and after seeing just one infant with a scalp infection from fetal scalp electrode use, I make sure I never use one unless there is good reason. Internal monitoring does have some uses, though, and can be another tool for adequately monitoring a laboring client and even avoiding more serious interventions.

  6. Nicole

    Doctor Jen, I really wish we could clone you!!
    I too have seen an internal fetal monitor, when used judiciously, be fabulous because it allowed mum to move in positions that the external monitor didn’t.

  7. I have mostly seen IUPCs used, like Dr. Jen uses them, in induction/augmentation/potential augmentation situations where they want to determine whether contractions are strong enough to make progress happen. But I’ve seen some providers only do it after waiting to see progress, and some put it in almost routinely with any augmentation, especially after the epidural/AROM/Pitocin triad begins. It definitely didn’t seem like a “no 1:1: care” decision. For that matter, how would 1:1 care change anything? Having a nurse dedicated to the patient makes it possible to magically accurately monitor the strength of contractions? (BTW I have never seen 1:1 care either after doula-ing in 3 different states and many different hospitals. I guess it’s possible in some cases that the nurse didn’t have any other patients, but I couldn’t tell because she was still in and out a lot.)

    BTW, I worked last night and while I was helping with a baby breastfeed the parents asked me about a “cut” on top of their baby’s head. I asked if they’d had an internal fetal monitor during labor and they said yes. I explained that the fetal monitor screws into the baby’s scalp. “Oh, THAT’S how it works” Dad said. I knew their labor story and the internal monitor was absolutely indicated, but it doesn’t sound like anybody explained to them what was going on when it was placed.

  8. I once worked for a hospital where 1:1 nursing care was the standard. Just wanted you to know you can find a place like that. Usually small community hospital.

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