Could someone please explain fetal distress and EFM patterns??

[holly6737]

Ok, I'm a volunteer hospital doula who had a homebirth. I'm not big on continuous EFM, but every single one of my clients has it anyway and I'd like to know what a "normal" pattern is supposed to look like. Could someone who knows about what an EFM pattern is "supposed" to look like give me the low down? From what I've gathered eavesdropping, late decels mean perhaps the birthing woman is almost complete and early decels could mean fetal distress. But here's where I get confused: I've heard doctors complain about the heartrate being too variable (fetal distress) and it not being variable enough (fetal distress). So it's supposed to be somewhere in the middle- variable, but not too variable? What could be wrong if the hr isn't variable enough? Reading these things can't be an exact science, right? It just sounds sort of hocus-pocusy, if you know what I mean. I'm just confused about their logic. Could someone fill me in?
Thanks!

[jengacnm]

Originally Posted by holly6737

Could someone who knows about what an EFM pattern is "supposed" to look like give me the low down? From what I've gathered eavesdropping, late decels mean perhaps the birthing woman is almost complete and early decels could mean fetal distress. But here's where I get confused: I've heard doctors complain about the heartrate being too variable (fetal distress) and it not being variable enough (fetal distress). So it's supposed to be somewhere in the middle- variable, but not too variable? What could be wrong if the hr isn't variable enough? Reading these things can't be an exact science, right? It just sounds sort of hocus-pocusy, if you know what I mean. I'm just confused about their logic. Could someone fill me in?
Thanks!

Well. There IS no logic, and it IS hocus-pocus. If a pattern looks good, that's great. If it doesn't, everything is probably still fine. If it's truly horrible, then there are grounds for intervention. But that line between group two and group three falls into that gray "professional judgement" category.

Show two providers the same tracing, and you will get a different opinion and management recommendation. Show the same to tracing to the same provider at different times of the day, same thing.

Here is a SERIOUSLY abridged version:

Early decelerations mean head compression. Generally not a big deal.

Variable decelerations mean cord compression. Generally can be fixed with repositioning; not usually a problem unless they are severe, repetitive, and/or go on for a long time.

Late decelerations mean the placenta is not oxygenating the baby well and are generally considered BAD. Sometimes they can be corrected by repositioning or perhaps turning down pitocin.

Variability means the amount of variation in the baby's heart rate-do not confuse them with variable decelerations! I'm confused that marked variability ("too much") is considered a problem. Decreased variability means the heart rate appears flat on the tracing. It may mean the baby is taking a nap, or that the mom got narcotics, but if it persists and does not become normally reactive again, it is a red flag for fetal distress.

How the baby's heart rate looks needs to be considered in the context of the rest of the clinical picture. I would have a much lower threshold for what I consider a "bad tracing" in an anemic, underweight teenaged drug user than in a thirtysomething healthy woman with excellent nutrition and no health problems.

It takes a VERY bad tracing to get me worried. A few lates here and there, periods of decreased variability,.....whatever. Reposition mom and see what happens. Persistent late decelerations, AND decreased variability for more than an hour, AND a fast fetal heart rate (tachycardia)-those things lead me to involving my doctor in the woman's care.

So there's the reader's digest version. If you want to read more, consider looking at "Antepartal and Intrapartal Fetal Monitoring" by Michelle Murray. That's the War and Peace version.

HTH!

[mwherbs]

here is a family practice full text article you can look over and it has pictures
of tracings so you can get an idea--

http://www.aafp.org/afp/990501ap/2487.html

[SublimeBirthGirl]

I once read about a study where (if I can get these details right) an EFM strip was given to 20 OBs for interpretation. All 20 interpreted it differently. A while later, the same strip was given to the same OBs, and not only did they all interpret it differently from each other, they also all interpreted it differently from how they interpreted it the first time! Having EFM is a total crapshoot and IMO it is best avoided.

[holly6737]

I have heard that study as well. I never want an EFM personally. However, since most of my clients get EFM and there's nothing I can do about that (given that I meet most of them IN labor...) I'd like to know what's going on.

Thanks for the low-down and the links!

[Mamabeakley]

Thanks so much for asking this - I was thinking I should since I am going to my first birth as a doula this month or next, had a homebirth, but will likely be working with EFM as my beeping companion

[junamoss]

I wanted to add that variables look like "v" and earlys and lates are a wavish look. I am a bad fetal monitor user as an L&D RN. I just haven't gotten comfortable enough not to use is so often. With drugs it's always used. And it's so rare that a woman just comes in and baby has a perfect NST and she delivers without drugs. But I always respect the wishes of the pt.
What is most important now, with current findings, correct me if I am wrong, is variablility. that beat to beat up and down. Even if it's tachy or brady, when variablility is lost, baby is in trouble.
Funny thing is, even with EFM we lose babies. Hence more EFM, more sections (still lose babies).

[holly6737]

Originally Posted by Mamabeakley

Thanks so much for asking this - I was thinking I should since I am going to my first birth as a doula this month or next, had a homebirth, but will likely be working with EFM as my beeping companion

Just try to pretend it's not there. My first hospital birth as a doula I caught myself staring at it- looking for when contractions were starting, etc. I had to slap myself a couple of times and remind myself that the woman will let me know when contractions are starting, not a machine.


Problem is, I don't think I've ever attended a hospital birth when there wasn't a freak out over the fetal hr at some point during labor- seriously. I know there is such a thing as true fetal distress, but I also think there is a good amount of false positives with these things, so I just wanted to know what a normal pattern is supposed to look like, yk?

[gratefulmama2isaac]

It occurred to me recently that EFM is the modern equivalent of tying women to the bed (which, horrifyingly, they used to do, in the era of "twilight sleep"). Because continuous EFM pretty much keeps you in bed, or next to it, if those darn belts will stay put. Which is a crapshoot.
The guy who invented the fetal monitor called it a "failed technology".

[junamoss]

efm

Originally Posted by holly6737

Just try to pretend it's not there.

You can turn the heartrate beeping off. And maybe point the whole gizmo away from you. I hate people who, especially in early labor, freak out with 'she's having one!It's huge.' I have to give the talk about asking the mom if it's strong and if she even feels it.