Every time someone comes into Labor and Delivery with a natural birth plan, I cannot help but find myself hoping they are not assigned to me. It’s not for the reason you might think. I actually like taking care of naturally laboring women. I feel like I can be a much greater help to them than somebody who is just going to come in and get an epi. The reason it is so hard is because it is impossible to monitor them. Either I am running in there every fifteen minutes getting a heart rate, in the middle of everything else I have to do, or I am trying to figure out a way to keep the stupid bands in place while they are moving all over the place. I never actually get a good strip and then I have to sit there and chart that. Depending on who the doctor is, it can also be difficult. A lot of them still want the patients continuously monitored, which is nearly impossible. I had one doctor tell me they didn’t give a damn if I had to sit on the floor and hold the monitor in place the entire labor. I wish my job was so easy that I could take the time to do that. I wish there was a better way to let women labor the way they want and still make sure the baby is okay. I also have to say, even though I have read the research that says it’s okay for moms to be off the monitor, every time they are I still hold my breath whenever I go to put that monitor back on. It gives me angina. I guess I am just too anxious.
—S. R., Labor and Delivery Nurse
The first challenge in regards to fetal monitoring in healthy natural labors is gaining acceptance among hospitals and obstetricians that there are alternatives to continuous electronic fetal heart rate monitoring (EFM). As discussed in Chapter 5, despite the lack of evidence in support of EFM in low-risk mothers, the practice is widespread and deeply entrenched in standard obstetrics practice. Nurses, doctors, and hospital administrators need to reacquaint themselves with the evidence concerning effective fetal monitoring in order to become more open minded about options such as intermittent auscultation. However, it is unlikely that this will change anytime soon and most naturally laboring women will find their hospital and/or provider will recommend electronic monitoring for at least some portion of their labor.
Thus, practically speaking, the real challenge for women, their nurses, and their providers is to find ways to monitor that do not inhibit ambulation, positioning, and access to hydrotherapy. Mothers undergoing EFM have traditionally been restricted to the bed because monitoring was conducted via abdominal transducers, which were attached with approximately 3-feet long wires to large, bulky machines. The majority of maternity units still utilize these large monitors for some or all of their fetal monitoring. However, within the last 10 years, mobile and wireless technology has enabled a significant step in the right direction in supporting natural labor. Mobile monitors have become much more widespread and permit mothers to remain ambulatory, even during continuous EFM. The mechanism is the same, abdominal transducers are connected to a large, central monitor, except in the case of mobile monitors, the wires actually attach to a purse size receiver which transmits the signal wirelessly to the central machine. Newer monitors even bypass the receiver and the wires, allowing the transducers themselves to transmit the wireless signal to the central unit. Studies have demonstrated comparable quality of fetal heart rate tracings when compared to directly connected monitoring, with improvement in patient mobility and satisfaction.1,2 Mobile monitors utilizing the purse-like receiver even allow mothers access to hydrotherapy while monitored, as the receiver can simply be kept outside of the shower or tub while the abdominal transducers, which can get wet, remain attached to the mother.
The most common frustration in mobile EFM is maintaining the proper position of the abdominal transducers, which are held in place with two separate, 1.5-inch wide elastic straps and often slide or flip as the laboring mother changes position. There are many more effective ways to attach the transducers to ambulatory mothers. All that is involved is a little creativity and patience. While no studies have been performed on these techniques, many motivated nurses, doulas, midwives, and doctors are using these techniques every day and achieving adequate fetal monitoring.
Belly bands offer a simple, inexpensive alternative to the usual double-strapped monitoring. Belly bands are soft, fabric bands with interwoven elastic that cover the entire abdomen of the laboring mother. The transducers are held much more securely in one position on the belly as the mother changes position and the band prevents flipping of the transducer as well. The connecting wires can also be tucked into the band, reducing the risk of trips and falls (Figure 10-1).
