Intra-Op Fetal Monitoring

[sevoflurane]

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Simple question: When should you use it?

 

[Planktonmd]

Simple question: When should you use it?

Viable fetus (more than 22 weeks) and when it is possible from a technical point of view without interfering with the surgical field.
If you decide to do intra-op monitoring you should have someone who can do a c section immediately available.

 

[sevoflurane]

Is it standard of care after 22 weeks? If not why not?

 

[pgg]

Our policy -

>12 weeks, document FHR before & after, watch for uterine activity in PACU, no intraop monitoring
>24 weeks, have c-section setup, 30 min tracing pre & postop, FHR/toco monitor in PACU until discharged, intraop monitoring only if both feasible and rec'd by OB

To be done by a L&D nurse, not random PACU nurse.

 

[Planktonmd]

Is it standard of care after 22 weeks? If not why not?

I hate to use the word "standard of care" in a clinical discussion since it usually means something that you have to do to keep the lawyers away rather than something you do in the best interest of the patient.
But, If the fetus is viable (22 weeks in this country), the surgery is possible technically with the monitoring applied, and you have the ability to perform an emergency C section if needed, then you should monitor the fetus because if you don't and there is a fetal demise there will be many "experts" who would love to testify against you and accuse you of negligence.

 

[sevoflurane]

Gotcha Plank. For the lawyers out there: Intra-op fetal monitoring is NOT standard of care as far as I can tell.

This bugs me however, and I don't like OB to determine if FHR it is to be used or not. Say you get a 32 weeker for ORIF of radius. She goes supine, gets GA and you have a slow surgeon. No sir, I don't like it. Get someone down here!

Some OB's don't like sending staff down to the OR to monitor the fetus since it is not SOC.

Plank is right: Some would easily point the finger at you if you don't do it. It should not be up to OB. It should be up to us. I think. However, I have met some resistance at some of the places where I've provided anesthesia services.

As an example: during residency a patient received GA for MVA. OB did not send staff to OR to do intra-op FHR. Patient sent to the ICU. By the time OB finally came down to ICU, they lifted up blankets to find an aborted fetus with mom still on the vent. Who does the blame fall on? I bet any good lawyer will go for BOTH OB and Anesthesia.

What are other people doing out there in practice? Are you letting OB dictate whether or not you use FHR monitoring?

 

[Mman]

What are other people doing out there in practice? Are you letting OB dictate whether or not you use FHR monitoring?

How can OB not be involved in the decision to use monitoring? I mean if you are going to monitor, who is monitoring it? What do you do if you have a questionable tracing?

ASA and ACOG released a joint statement in October 2009 concerning this very scenario. Basically a viable fetus should at minimum have FHR tracing plus tocometer before and after. Intraoperative monitoring can be considered if patient consents to emergency c-section and obstetrician is standing by.

http://www.asahq.org/publicationsAndServices/standards/51.pdf

 

[sevoflurane]

They need to be involved. That is the point. I would argue that every case that makes it do the OR witha viable fetus needs an Intra-op FHR monitor unless you can't monitor because the surgical site would not allow it to happen. The monitoring should always be done by a OB nurse. I just don't understand why you wouldn't do this? Pre and post for sure.

 

[sevoflurane]

Thx for the link Mman:

3.4.3 : "Intraoperative electronic fetal monitoring may be appropriate when all of the following apply:

1. The fetus is viable; It is physically possible to perform intraoperative electronic fetal monitoring;
2. A provider with obstetrical surgery privileges is available and willing to intervene during the surgical procedure for fetal indications.
3. When possible, the woman has given informed consent to emergency cesarean delivery.

Supine patient (aorto-caval compression) + GA = intra-op FHR moitoring every time in my book. Maybe I'm just overly cautious. But that is what we do in anesthesia right?

 

[Planktonmd]

Sevo, you are absolutely right in your concerns and if in your judgement the surgery warrants intra-op fetal monitoring then you should address that with the obstetrician, if the obstetrician disagrees then document your concerns and discussion in the chart and proceed.

 

[jwk]

We do a fair amount of surgery on patients in their 3rd trimester - appy's, gallbladders, kidney stones, etc. They all get pre and post op FHT's checked, and an OB doc is consulted. Intra-op fetal monitoring is a rarity, since most of the procedures we do are abdominal.

BTW - all these patients get some left lateral uterine tilt - none are supine, regardless of the type of surgery.

 

[hoyden]

Simple question: When should you use it?

When the fetus is viable and everyone is prepared for emergency CS if the FHR shows a worrisome trend. And when you have a designated nurse to observe it.