Possible Interventions and Their Purposes During Labor
Your caregiver has various procedures at his disposal to obtain diagnostic information, prevent complications, and even alter the course of labor. Any intervention carries with it some degree of risk and therefore should never be used unless medically necessary.
You need to discuss the various interventions with your caregiver prior to labor, letting him know your desires concerning their possible use and having him tell you at what point he feels they are indicated. If you are clear on his intentions in advance, you will avoid misunderstandings later, during labor.
An intravenous fluid (IV) is a solution that is fed into the body through a vein. It may be indicated in a prolonged labor to prevent dehydration. It is also used during induction of labor because it provides the most accurate administration of Pitocin. (For a discussion of induction, see “Induction and Augmentation of Labor”.) Prior to an epidural, IVs expand the blood volume to reduce the risk of a drop in the woman’s blood pressure. They are also an easy access for medication or blood, if needed. Some doctors routinely use IVs “just in case” a problem arises. During a cesarean birth and the immediate postsurgical period, an IV is important for supplying fluids and administering medication.
To start an IV, a nurse inserts a needle into the patient’s vein. Next, a thin plastic catheter is threaded through the needle into the vein, and the needle is withdrawn. The catheter is securely taped into place. Generally, an IV is placed into the hand or forearm. Ask the nurse to use your nondominant arm. Once the IV is started, a solution of water, normal saline, or Lactated Ringers (a solution of sodium chloride, sodium lactate, potassium chloride, and calcium chloride), with or without dextrose (sugar), is continuously infused into the vein.
If you are well hydrated and allowed to drink, and your labor is progressing normally, you probably will not need IV fluids. Normal, healthy women at term store up to 1 to 2 liters of body water. They also experience dependent edema, which adds to their store of fluid. This fluid is readily available for use by the laboring woman. IVs restrict mobility and hamper effective relation. If you do have an IV and you would like to walk around during labor, ask for a moveable pole. Or, you could request a heparin lock or a saline lock, in which the catheter is flushed with either a heparin solution or saline to keep the vein open, and the bag of fluid can be disconnected.
Complications that can result from IV use include infiltration (leakage of fluid into surrounding tissues) and phlebitis (inflammation of a vein). You may also experience some discomfort during the insertion of the needle. A more serious complication, water intoxication, can occur from the use of electrolyte-free IV fluids, such as 5-percent dextrose in water (D5W). Water intoxication can result in vomiting, convulsions, and pulmonary edema in the woman. Therefore, the use of D5W should be limited to 1 liter during labor. Another problem associated with the administration of a dextrose solution is the higher level of glucose in the woman’s system. This, in turn, increases the fetus’s sugar level (hyperglycemia), which can rapidly drop and become too low (hypoglycemia) in the newborn period. This is most common when the infusion lasts for longer than 4 hours.
Electronic Fetal Monitor
An electronic fetal monitor (EFM) is a device that measures and records the intensity, frequency, and duration of the uterine contractions as well as the baby’s heart rate. Of special interest to the caregiver is the way the baby’s heart rate is affected during and immediately after contractions. A normal fetal heart rate is between 120 and 160 beats per minute. Recurrent deviations from this range may indicate that the baby is in distress.
Monitoring can be done either externally or internally. External monitoring is used more frequently, as it is noninvasive and easy to apply. Internal monitoring provides more accurate information. The internal monitor is inserted through the vagina, and it requires that the membranes be ruptured. In both types of monitoring, the leads are connected to a bedside unit that records and prints out the information on graph paper. The information is also relayed to monitors at the nurses’ station.
The baby’s heart rate can be monitored externally by securing an ultrasound transducer on the woman’s abdomen with an adjustable belt. A more accurate method monitors the fetal heart rate internally by inserting an electrode through the vagina and partially dilated cervix, and placing it beneath the skin of the baby’s head or buttocks using a spiral projection. A small percentage of babies have developed scalp abscesses from the use of an internal electrode.
The most common method of measuring uterine contractions is to apply a pressure sensitive transducer to the woman’s abdomen using an adjustable belt. When the uterus hardens, the transducer picks up the muscle contraction, and a corresponding wave appears on the graph paper. If a more accurate determination of the contractions is needed, an intrauterine pressure catheter (IUPC) may be inserted through the cervix and into the uterus.
An IUPC measures the exact amount of pressure exerted by the contractions and may be indicated in a labor involving the use of Pitocin. The IUPC can also be used to infuse saline into the uterus to increase the volume of fluid. This is called amnioinfusion and can be helpful if the baby is showing signs of fetal distress caused by compression of the cord. A low level of amniotic fluid does not provide buoyancy, and the cord can become compressed during contractions. Also, if the amniotic fluid is heavily stained with meconium, additional saline can thin the meco- nium and reduce the risk of the baby aspirating thick meconium.
EFM use is indicated for pregnancies that are considered “higher risk.” An EFM is also used if labor is induced or stimulated with Pitocin, to determine how well the baby is handling the stress of labor and to assess the strength and duration of the contractions. Some doctors feel that monitoring even low-risk women is beneficial in determining fetal well-being or distress. Others monitor all patients because they fear a lawsuit if a problem arises and the monitor was not used. It is also believed that the documentation provided by the monitor will be beneficial in a potential lawsuit. But, because monitor strips are open to interpretation, litigants can often find an “expert” to state that any decelerations (decreases in the baby’s heart rate) can cause permanent brain damage. Rather than a benefit, the documentation can become a detriment to many hospitals and caregivers.
Experts are continuing to debate the need for monitoring low-risk labors that are progressing normally. Electronic fetal monitors were introduced into practice in the late 1960s before controlled randomized studies were performed to determine their efficacy and safety. A major controversy concerns the accuracy of the results obtained from monitors, especially from the external type. Many authorities feel that external EFMs show only that the baby is doing well. The information on the printout is open to misinterpretation by the medical staff. Sometimes the monitor picks up the woman’s heartbeat, or stomach and intestinal sounds, rather than the baby’s heartbeat/ Many doctors consider late decelerations of the heart rate (slowdown of the fetal heartbeat at the end of each contraction) as a sign that the baby is in distress. However, several studies have shown that up to 60 percent of fetuses exhibiting late decelerations were not in distress at birth.
Additional studies have concluded that “a specific pattern, or group of patterns, of fetal heart rate monitoring that may predict brain damage is not available for use by the clinician today.” If fetal distress is suspected during labor, the physician may take a sample of the baby’s blood to check the pH. This test is called a fetal scalp sampling and may be used to determine if the baby is truly in distress and immediate delivery is necessary. This procedure is not available in all hospitals.
Skyrocketing cesarean birth rates have also been associated with increased use of EFMs. In one study involving 690 higher-risk women, monitoring did not improve perinatal outcome, but did result in a threefold increase in cesareans. Dr. McFee, one of the researchers, feels that his results refute the contention that monitoring should be universal. He showed that listening frequently (every 15 minutes during the first stage of labor and every 5 minutes during the second stage) with a fetoscope by expert nurses is as dependable as EFMs in “recognizing continuing abnormal fetal heart rate patterns ominous enough to mandate immediate delivery.” In 1988, the American College of Obstetricians and Gynecologists supported Dr. McFee’s statement, yet the majority of hospitals continue to monitor, citing liability or the lack of adequate staff as their reason. Out-of-hospital birth centers and nurse-midwives use a fetoscope or hand-held doptone to monitor the baby at regular intervals.
A more recent analysis done by Dr. Stephen Thacker and colleagues at the Centers for Disease Control (CDC) in Atlanta on twelve controlled randomized studies on EEM use published between 1966 and 1994 agreed that routine EFM use resulted in no significant decrease in maternal or infant morbidity (illness) or mortality (death). Additionally, EFM use has not decreased the incidence of cerebral palsy. The rate of cerebral palsy has remained the same for the past 40 years and is more likely to be the result of prenatal influences such as genetics, toxic exposures, and infection.
Another growing concern is that nurses and doctors are losing the ability to evaluate patients without referring to the “machine.” They pay more attention to the monitor tracing than to the woman and her perception of the labor. Many labor partners even become entranced by the beeps and the readout, and forget their main purpose-to support and encourage their partners during labor.
Most women who labor with an electronic fetal monitor are confined to bed. Bed rest increases the length of labor and the need for medical intervention. The woman’s perception of pain is altered, her stress level is increased, and medication is accepted more frequently. Medication can adversely affect the woman and fetus. Women who have to remain in bed because of the monitor cannot receive the benefits of walking or laboring in water, or the benefits from the personal attention that would be provided by a nurse actually listening to the baby’s heartbeat.
- Encourage her to change position (never let her lie flat on her back).
- Have her sit in a chair or stand next to the bed.
- Pay attention to her, not the monitor.
- Ask to turn down the sound if the “beeping” noises are distracting.
Laboring With a Fetal Monitor
As already discussed, a woman’s mobility and position during labor can significantly affect her labor’s progress. Therefore, if you choose or are required to be monitored during labor, change position frequently, about every 20 to 30 minutes. The monitor may need to be re-positioned to pick up the baby’s heartbeat each time you move, but your mobility and comfort are extremely important. You can also request to be monitored while out of bed. You may be able to stand or walk around next to the bed. Or, you can sit in a chair or rocker close to the monitor.
Do not let anyone tell you that you must stay on your back. This position can cause hypotension and lead to fetal distress, the very problems the monitor was designed to protect against. In addition, the longer you can stand and walk during labor, the more efficient your contractions will be. An upright position promotes descent of the baby and dilation of the cervix. It also helps the uterus to work at maximum efficiency.
If the concept of routine monitoring disturbs you, discuss with your doctor the possibility of limiting your time on the monitor. Your doctor may agree to monitor you intermittently—for example, for 15 minutes of every hour or 30 minutes of every 2 hours. Even just waiting until active labor is well established will give you more time to move about and be comfortable. If an internal monitor is used, it can be disconnected every few hours to allow you to stand up and move around. Some facilities have telemetry units, which allow women to walk around freely.
If you find that the beeping noises coming from the machine are distracting or annoying, ask the nurse to turn down the volume. You could also ask her to reposition the machine so that the readout is not in your constant view.
Note to the labor partner: Remember to continue your active coaching and support measures. Machines do break and malfunction, and leads can be positioned incorrectly. If your partner says that her contractions are becoming more intense, she knows what she is talking about.