Alright, so we talked about external monitor
and I know I've been telling you to ignore those other numbers on the chart.
Well, now it's time to figure out how we can begin to use them,
we're going to talk about internal monitoring.
This device or these devices are actually placed inside the uterine cavity.
So the first thing that has to happen is the membranes have to be ruptured,
the sac is usually closed and so we can't put these devices inside the uterus
if the sac is closed it has to be ruptured so we could put these inside.
There are two internal devices we're going to talk about.
The first one is the fetal scalp electrode, the next one is an intrauterine pressure catheter or IUPC.
Now, fetal scalp electrode is a lot to say in some organizations you may here FSC
or you may hear ISC which stands for internal scalp electrode or fetal scalp electrode,
and that may be the acronyms that you see, just so you don't get confused.
So when we think about internal monitor placement,
then let's take a look at this graphic to get an idea where everything goes.
It's called a fetal scalp electrode because it's actually attached to the fetal scalp,
and that sounds really scary and awful, but it's actually a very small little spring.
If you've ever taken a part of a ball point pen and seen a little spring
that's wrapped around the pin, it looks like that with a little sharper edge,
and the provider will actually find the fetal scalp not over our fontanel
or over the suture line because that's a soft spot and that's not where we would put it,
but anywhere else we would actually turn the scalp electrode into the scalp
and then it would directly conduct the fetal heart rate,
so we get a direct monitoring instead of going through using a Doppler on the abdomen,
so it's going to be a little bit more accurate.
Now for the pressure catheter, when you see one of these in labor and delivery,
it looks kind of like, hmm, a long cord almost like IV too big,
and there's a small balloon at the end that actually goes next to the baby.
Now, it shouldn't go through the placenta,
so this is one of the reasons why someone who has skill and advanced degree,
may be the one that needs to put in the internal monitor, but it's going to lie next to the baby.
And then whenever the uterus contracts and the pressure builds up on the inside of the uterus,
it's going to press that balloon and cause those hills
that we saw on the contraction side of the monitor.
So these are two internal monitoring devices
so now we're going to get a more accurate fetal heart rate
and we're also going to be able to measure directly the pressure in the uterus
telling us the strength of the contraction.
So what are the pros and cons?
Well, as I've been saying, one of the pros is that internal monitoring is more accurate, it's direct.
We're not going through the abdomen on the outside to try to figure out
what's going on the inside, so it's right directly where we can get the most accurate information.
We can objectively assess contraction strength.
So, remember if we have adipose tissue, and then the toco,
and then the uterus, that's a lot of space, and if we have a lot of adipose tissue,
then it may not depress the button very well even though we're having very strong contractions,
but if the device is on the inside of the uterus,
then it's a direct measurement, so we can do it objectively.
Otherwise, we're kind of feeling the uterus and saying, I think it feels strong.
You know what? I'm going to show you a trick.
If you have to do an external monitor and you want to observe the strength,
we use this trick called the face trick,
so if you feel the fundus and then you feel your nose,
that goes along with a mild contraction.
If you feel the fundus during a contraction and it feels like your chin,
then that's a moderate contraction.
If you feel the fundus and feel the forehead, then that's a strong contraction,
so that would be a subjective measurement.
But if we have internals, we can do an objective measurement and that's much more accurate.
It's also less affected by maternal movement or if the fetus moves around,
so if the fetus is in there kind of swimming,
we're going to hear that on the external monitors or if the patient is moving from side to side,
we're going to pick up a lot of that noise and artifact
and that may throw off the reading of the monitor.
If the monitors are on the inside, we don't get that.
So, if you have a baby that's really active, or a mother that's really active
and it's really important that we get a good strip
because we have some concerns about how well the baby's doing
or how well the patient is progressing in labor,
then we may need an internal monitor in order to help that, okay?
The other thing that's really cool about the IUPC is it has a port
that actually can pull fluids through, just like an IV,
so let's think about the fact that normally,
there's enough amniotic fluid in the abdominal cavity to keep the cord nice
and moist and also keep it from being compressed,
so if we get a compressed cord, we don't have good oxygenation.
So if there's not a lot of fluid in the cavity, and we need more fluid,
we can actually put normal saline, warm normal saline,
into the uterine cavity to help float the cord and decrease the compression,
and we can use the internal pressure catheter to make that happen, pretty cool, right?
Now there are some cons to that. It's not all good stuff, so let's talk about that.
So, the cons look like this, if we have a device that's hooked up inside the uterine cavity,
that means that the patient really can't walk down the hall,
because it has to be connected to the monitor in order to work,
so this is going to be a patient that's going to actually have to stay in the space of the length of the cord.
Now, it doesn't mean they can't sit up in the chair or sit on the side of the bed,
it just means they probably won't be able to walk
because there's really no extension fetal monitor cord.
The next thing that's not necessarily a positive,
is that the membranes have to be ruptured
so that means that if we have a client where we're not ready to rupture the membranes
because we are far away from delivering then it's not going to be an option for us to use it in this case.
And sometimes, unless we're going to do an amnioinfusion,
which is where we introduce more fluid into the uterine cavity,
then we might not want to decrease the amount of amniotic fluid,
so we have to think about that.
Also, think about the purpose of the amniotic sac.
It's there to protect the fetus from all of the bacteria and things that are in the environment,
so the minute we break the bag of water
and then we slide something into the uterus that's outside,
we're increasing the chances of infection which is not something that we want.
Also, even though, we're being super careful about placing the scalp electrode
or making sure that we're not pushing the IUPC through the placenta,
there's definitely a chance of injury so it's not without risk in that regard either,
and you have to know how to put these devices on or in,
because if you do it incorrectly, you could damage the patient,
you could damage the fetus, and so this is not something that's going to be a beginners skill,
only a skilled person is going to be able to do that.
So these are pros and cons of internal monitoring.
Now that you've thought about that pros and cons, when might we need internal monitoring?
When would you do it?
So I'm going to give you a couple of seconds to write down your answer and see what you come up with.
Okay, here are two answers: If the fetal monitoring is difficult with the external monitor.
If the mother's moving, if the fetus is moving.
Perhaps the mother has a lot of adipose tissue that makes it difficult to track
or for some other reason, the position of the fetus,
you can't really determine what's going on, then we might need internal monitors.
Now, I will tell you that most of the time,
if we try really hard, we can make that external monitor work,
so we don't want to be lazy and use that,
but if we need to do internal monitoring for that, we certainly can.
Also, if we want to objectively measure the strength of the contraction.
So, let's say perhaps the client has been in labor for a really long time
and were not seeing any progression in the cervix and we're trying to figure out,
is the baby too big? Is the pelvis very narrow?
Or maybe, the contractions aren't strong enough.
We don't have enough power, remember our five P's, enough power to push the baby through.
Well, we don't want to just depend on our little finger test,
we're actually going to place an IUPC in
and we'll be able to accurately and objectively measure the strength of the contraction
to determine whether we're doing okay or maybe we need to consider changing position,
doing something else or adding oxytocin which would stimulate more contractions,
this would give us that type of information.
So sometimes when we're doing testing, as in the case of the nonstress test,
we're seeing what the fetus does when nothing is going on, there's no stress, nothing happening.
Well, labor is stressful, not just for the patient but also for Clitus the fetus.
It is very stressful for them because they're being squeezed
and having to basically hold their breath every time a contraction happens,
at least a little bit, because there's decrease blood flow.