trends Monitoring at a Community Hospital Nurses Undertake Direct and Indirect Fetal PHASE I : Indirect Monitoring

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1 trends Nurses Undertake Direct and Indirect Fetal Monitoring at a Community Hospital LINDA J. CHAGNON, RN and CHERYLL L. HELDENBRAND, RN In order to fully utilize their new fetal monitoring equipment and to monitor all labor patients, a small, community hospital elected to allocate to OB nurses responsibility for direct and indirect monitoring, including application of internal devices (per physicians orders) and interpretation of tracings. The staff originated a training program and internal accreditation, which they called certification. Both are mandatory for nurses who are monitoring labor patients. They also established procedures and instructions for monitoring. Wherever it is used, fetal monitoring has broadened the role of the obstetric nurse. In the obstetric unit of Evergreen General Hospital, Kirkland, Washington, the nurse has assumed more than the standard nursing responsibilities for monitoring, especially internal monitoring. The nurse artificially ruptures the bag of waters and applies the internal catheter and electrode, and she is responsible for interpreting fetal heart rate patterns and providing immediate treatment.l Although Evergreen General is a small, community hospital, the obstetric unit has the capabilities of monitoring every labor patient. With minimum capital outlay each labor patient receives the comprehensive care that was formerly available only to high-risk patients. This article is a step-by-step account of the development of a successful fetal monitoring program which makes full use of the monitoring equipment and in which the obstetric nurse is key. PHASE I : Indirect Monitoring When Evergreen General opened in March of 1972, we were excited to learn that a fetal monitoring system had been ordered and would arrive in a few months. We were the only nurses at Evergreen General who had experience in fetal monitoring. We had worked with fetal monitors for three years at the University of Washington Hospital and had attended several comprehensive workshops on fetal monitoring. Therefore, the decision was made to use our knowledge and experience to set up a monitoring program. We knew of other hospitals where monitoring equipment sat in corners collecting dust, and we were determined that this would not happen at Evergreen General. Remembering our misgivings on our first exposure to fetal monitoring, we felt we should first help the other nurses overcome any apprehension. So we mounted a campaign to acquaint medical and nursing personnel with the concept of fetal monitoring. When the monitoring equipment arrived, the manufacturer s representative came to the hospital to help assemble the two bedside monitors and the central desk display. The two bedside monitors were equipped to monitor both externally and internally. The representative also presented an inservice education program on the technique and mechanics of fetal monitoring for all general practitioners, obstetricians, and obstetric nurses on the staff. The film Intrapartum Fetal Monitoring 2 was shown, and the booklet An Introduction to Fetal Heart Rate Monitoring3 distributed. The first phase of inservice training was supervised by the authors. The nursing staff is divided into two teams; each works seven consecutive ten-hour days, one week on and one week off. The authors worked on the same team, and in order to teach and advise the other team, we were on call on our weeks Off. After the nurses were initiated into fetal monitoring, we developed the following procedures and references as daily aids: 1. Procedure for Intrauterine Fetal Monitoring (Appendix I). This procedure was designed for use by the nurse assisting with the application of the internal fetal monitor. It is encased in clear plastic and taped to the top of each monitor for ready access by the staff. 2. Illustrated instructions on operating the strain gauge (Appendix 111). Because so much emphasis is put on the cost and sensitivity of the strain gauge, September/October 1974 JOGN Nursing 4

2 personnel tend to be nervous about working with it. These instructions are also enclosed in clear plastic and taped to the tops of the monitors for ready reference. 3. Monitor Tracing Notebook. From sample tracings we obtained from another hospital, the authors staff selected tracings characteristic of various fetal heartrate patterns, abnormal labor patterns, and mechanical malfunctions of the monitors. The samples were labeled and taped into a notebook. Although the hospital later received the booklet Intraparturn Monitoring Case Exmples,4 the nurses still refer to the tracing notebook. This basic tool is used in orienting new nursing personnel and is used by physicians for inservice and continuing education. 4. Obstetric Nursing Libraries. A library was established in each obstetric nursing station. Each includes notebooks in which copies of articles about fetal monitoring and other information on obstetrics are kept. 5. Patient Teaching Diagram (Appendix 11). Patient cooperation, which is necessary for effective monitoring, can be obtained through education. In prenatal classes offered by the hospital, nurses explain the purpose of fetal monitoring and familiarize patients with the equipment. They discuss the placement of the internal monitors, using the Patient Teaching Guide to illustrate. This information is reiterated when the patient is admitted to the labor suite. The husband is included in this discussion because it may be his first exposure to the monitor. PHASE 11: Direct Monitoring Evergreen has approximately 40 deliveries per month, and our main goal was to monitor labor and fetal heartrate for every patient. The Chief of Obstetrics and Gynecology issued recommendations and prerequisites for fetal monitoring in a directive which encouraged the use of the fetal monitor on every labor patient (Appendix IV). Initially the staff concentrated on mechanical operation of the equipment. When three months had elapsed since the arrival of the monitors, it was decided that the time had come to focus on interpreting fetal heartrate and uterine contractile patterns. In reviewing the tracings that had been saved we found, to our disappointment, that the majority were from external monitoring. Since many of the physicians were unfamiliar with the technique of internal monitoring, the direct method was not being used to capacity. We felt that the monitoring equipment would be used more fully if the nurses assumed greater responsibility for direct monitoring. We discussed this with the physicians at the hospital s next monthly OB-GYN meeting, and it was decided that the manufacturer s representative should be contacted to determine whether nurses were being used to apply the internal monitor at any other hospital. Everyone expressed interest in the legalities and concurred that the Nursing Services Coordinator should obtain the opinion of the hospital s attorney. The attorney felt that it would be legal for nurses to apply the internal monitor with a physician s order but that it would be best to establish a formal program to train and accredit nursing personnel to perform this procedure at Evergreen General. We learned from the manufacturer that nurses were applying the internal monitor at a few other hospitals but that none of these hospitals had initiated a formal program to train them. This information was presented and discussed at the next OB-GYN meeting, and during the discussion it became evident that, for the program to be effective, the nurses should also be trained to artificially rupture the bag of waters. Finally, the program was approved by the physicians, and they agreed to train the nurses. Each nurse was to work with an obstetrician on a one-to-one basis. For the first few times the physician would rupture the bag of waters and decide whether the nurse would apply the internal devices. With the physician at the patient s bedside, offering reassurance and guidance, the nurse would proceed with the application. If any difficulty arose, the physician could assist. After the nurse became skilled in applying the internal devices, she progressed to artificially rupturing the bag of waters. When the physician and nurse agreed that the nurse was sufficiently competent to proceed on her own, her name was submitted for accreditation. The actual accreditation of each nurse is approved at an OG-GYN department meeting. Then a form (Appendix V), printed on hospital letterhead, is signed by the nurse, her nursing coordinator, and the Chief of Obstetrics and Gynecology. Copies of this form are placed in the nurse s file and in a policy manual located in the labor and delivery area. The accreditation is not nationally recognized; it permits nurses to perform the designated procedures only at Evergreen General Hospital. Over a three-month period, all full-time labor and delivery room nursing staff were trained and certified. Since that time, the nurses with credentials have trained new and parttime personnel. With the nursing personnel successfully attaching the internal monitor, a standard procedure for application was formulated (Appendix VI). 42 September/October 1974 JOGN Nursing

3 We feel that our objectives were accomplished through the monitoring program. All labor patients are now monitored internally whenever this is technically possible. Internal devices are applied almost exclusively by the nursing personnel. Accuracy in interpreting fetal heart rate and uterine contractile patterns is continually improving among the entire staff. Patient acceptance is promoted by prenatal education which stresses the fact that it is normal for every patient to have her labor monitored. Finally, use of the monitor allows the nurse more time to give supportive care to the patient. APPENDIX I: Procedure for Intrauterine Fetal Monitoring 1. Explain the monitor and procedure to the patient and her husband, using the teaching diagram (Appendix 11). 2. Have the patient empty her bladder; clean the patient s perineum. 3. Prepare the monitor: a. Connect the ground wire to the bed and turn on the power. b. Place a clean stopcock on the top of the strain gauge. c. Fill a clean 20-cc syringe with sterile water and irrigate the strain gauge by injecting 3 cc. d. Adjust the strain gauge to the height of the patient s abdomen. e. Put electrode paste on the back of the leg plate and place the plate on the patient s upper thigh. f. Zero the machine by opening the strain gauge to air and turning the zero pen until it is on the zero line. 4. Support the patient while the catheter is placed, remove the guide and attach the catheter to the top of the strain gauge. Irrigate the catheter with 5-10 cc of sterile water by turning off the stopcock to the patient s leg. Connect the electrode wires to the leg plate (red to red and green to green). S. Rezero machine. 6. If the fetal heart rate is not being recorded, check the electrode wires, replace the ground wire, check all plugs, and check the electrode to be sure it is firmly attached. If all else fails, replace the electrode. 7. Be sure to tell the patient she may turn or move, but will need assistance. Some reexplanation of the monitor may be needed at this time. APPENDIX 11: Patient Teaching Diagram Used to Illustrate Application of the Internal Fetal Monitor September/Occober 1974 JOGN Nursing 43

4 APPENDIX I11 : Illustration of Strain Gauge Operation (1) Fill a clean 20-cc syringe with sterile water. (2) Attach the syringe to Stopcock 1 and turn the valve lever up so that the syringe is open to the strain gauge. (3) Open Stopcock 3 so that the strain gauge is open to air (lever in middle position). (4) Flush the strain gauge, making sure there is no air in the gauge (about 3 cc). D. Rezero (1) Make sure the strain gauge is level with the patient s xiphoid. (2) Leave Stopcock 2 as is (closed to the strain gauge 1 - (3) Turn valve lever on Stopcock 1 toward catheter and remove syringe. (4) Rezero machine. B. Zero (1) Turn the valve on Stopcock 2 so that the strain gauge is closed (lever to strain gauge). (2) Leave Stopcock 1 as is with the valve lever up, and remove syringe. (3) The strain gauge is now open to air and you may zero the machine. (4)Replace syringe. E. Monitoring (1).On Stopcock 1 turn valve lever to syringe. (2) Leave Stopcock 2 as is (closed to strain gauge). C. Irrigate catheter (1) Leave Stopcock 2 closed to strain gauge (lever to strain gauge). (2) Turn valve lever on Stopcock 1 down so that the line between the syringe and the catheter is open. (3) Flush the catheter with 5 cc water. i l I F. Storage (1) Fill clean 6-cc syringe with sterile water. (2) Flush strain gauge by turning Stopcock 2 valve lever to middle position as shown in A. Irrigate. (3) Flush strain gauge with 3 cc sterile water. (4) Turn both valve levers to strain gauge. (5) Label syringe with date and time. 44 September/October 1974 JOGN Nursing

5 APPENDIX IV: Directive on Fetal Monitoring 1. Should be used for all patients in labor, either spontaneous or induced, if technically possible. 2. Internal monitoring is recommended, if technically feasible, in the following cases: a. b. C. d. Prolonged labor and failure to progress in labor Induction or augmentation in labor High-risk patients 1. Toxemia 2. Maternal diabetes 3. Maternal hypertension 4. Dymaturity or post maturity 5. Premature labor 6. Bleeding, if definitely not due to placenta previa or low lying placenta Evidence of fetal heart tone abnormality with external monitoring or unsatisfactory recordings with external monitoring. 3. Prerequisites for internal monitoring: a. Ruptured membranes b. Presenting part at a minus station or lower c. Cervix at least three centimeters dilated 4. Physicians doing obstetrics were invited to two classes in the use of the monitor, including application of the internal devices. Those who are not familiar with the technique should request consultation, if internal monitoring is needed. APPENDIX V: Certification Form This memo is to advise the medical and nursing staff that. had demonstrated the skill and judgment necessary to artificially rupture the bag of waters and apply the internal monitor (catheter and electrode). This will be done with verbal or written order from the physician. CHIEF OF OBSTETRICS OBSTETRICS C O O R D I N A T O L STAFF NURSE, - - APPENDIX VI: Procedure for Application of the Internal Fetal Monitor 1. Prerequisites : a. Ruptured membranes b. Presenting part of fetus at a minus one station or lower c. Cervix at least three centimeters dilated d. Physician s order 2. Explain the procedure completely to the patient and also preferably, her husband, using the teaching diagram. 3. Have the patient empty her bladder; clean the patient s perineum. 4. Prepare the monitor: a. Connect the ground wire to the bed and turn on the power. b. Place a clean stopcock on the strain gauge. c. Adjust the strain gauge to the height of the patient s abdomen. d. Put electrode paste on the back of the leg plate and place plate on patient s upper thigh. e. If someone will be working with you, fill a 20-cc syringe with sterile water. 5. Open a four-towel pack on the overbed table. Open the intrauterine pressure kit and electrode and place on the top of the pack. If you will be working alone, open a 20-cc syringe and place it on the pack also. The syringe can be filled by gloving one hand and taking the syringe from the table. Place the needle on the syringe with the ungloved hand and also hold the bottle of sterile water to fill syringe with ungloved hand. 6. Glove. Drape the patient with towels by placing one towel over each leg and one under the patient s buttocks. 7. Thread the catheter into the guide and flush the catheter with 5 cc of sterile water, leaving the syringe attached. 8. Insert the catheter by placing the guide between the cervix and the fetal head and then threading the catheter inside the uterus until the black mark on the catheter is at the introitus. If resistance is met, withdrawing the catheter and guiding and reinserting it in a different quadrant will usually help. Remove the guide after the catheter is in place. 9. Attach the electrode to the fetal head by placing the guide flat against the head and turning the electrode clockwise until resistance is met. Caution: Be careful not to place the electrode over the fontanels or fetal face. Withdraw the guide and connect the electrode wires to the leg plate (red to red and green to green). September/October 1974 JOGN Nursing 45

6 10. Tape the catheter to the inside of the patient s thigh. Remove the drapes and position the patient comfortably. 11. Attach the catheter to the top of the strain gauge and irrigate the strain gauge. Zero the machine by opening the strain gauge to air and turning the zero pen until the pen is on the zero line. Irrigate the catheter with 5-10 cc of sterile water by turning the stopcock off to the strain gauge. 12. If the fetal heart rate is not recording, check the electrode wires, replace the ground wire, check all plugs and check the electrode to be sure that it is firmly attached to the fetal head. If all else fails, replace the electrode. 13. Be sure to tell the patient she may move but will need assistance. Some reexplanation of the monitor may be needed at this time. REFERENCES 1. Hon, E. H.: The Treatment of Fetal Distress, in An Introduction to Fetal Hemt Rate Monitoring. New Haven, Connecticut, Harty Press, Inc., pp 52-60, Paul, R. H., and E. H. Hon: Intrapartum Fetal Monitoring. Distributed by Los Angeles County-USC Medical Center, Los Angeles, California, Hon, E. H.: An Introduction to Fetal Heart Rate Monitoring. New Haven, Connecticut, Harty Press, Inc., Paul, R. H.: Intraparturn Monitoring Case Examples. University of Southern California, 1971 Address reprint requests to Mrs. Linda J. Chagnon, SE 45th Place, Issaquah, WA The authors are staff nurses in Obstetrics at Evergreen General Hospital, Kirkland, Washington, and are members of NAACOG, ANA, and the Washington State Nurses Association. Linda Chagnon (left) is a graduate of Emamal Hospital School of Nursing; Cheryl1 Heldenbrand (right), an alumnus of Central Washington Deaconess School of Nursing. 46 September/October 1974 IOGN Nursing