Friday, July 16, 2010
Measure twice, chart once
28 y/o previous mother of three full term healthy babies. African American. Genetic testing done in 1st and 2nd trimester and all was negative. She had been having routine care and had her 20 week ultrasound done. Her fundal measurement was tracking along and at 28 weeks it was 27. then at 32 weeks it was 30, 36 weeks 35, 38 weeks 35, 39 weeks 33. I had measured her and was sure I was wrong. Measured again and then had the preceptor measure. Sure enough we were right. She had crossed over the 3 deviation mark and needed to be seen. We sent her up to L&D where she was admitted. They found decreased amniotic fluid and her cervix was dilated at 1 cm. They were going to induce labor since she was at 39 weeks. The warning signs were there early and were trending downward. The baby was born healthy, but the potential for a bad outcome was definitely there. So remember measure twice, chart once.
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Interesting that you should mention measuring twice and chart once...we had a patient today that was currently 36w4d but according to her last ROB visit (I don't have exact wk/day age) had a fundal height of 41cm. Measuring today (36w4d), her fundal height was 39.5cm. She was sent to L&D after our visit b/c of additional lower pelvic pain and continued cramping. Measuring fundal height myself, I found out how easy it is to mismeasure...so if it seems off...remeasure...if it still seems off, I plan to get a second pair of eyes. If still off...L&D baby!!
ReplyDeleteThat is a great point CPT LIng.. What I find amazing is that throughout clinicals they would allow the medic to measure the fundal height and do the FHT's. I re-did everything when I saw the patient since I was the provider and I needed to ensure that the measurements were accurate. One visit, I noticed the measurement for fundal height was 30 cm and the mom was 36 cm and the FHT's were 110. When I re-did them I had different measurements and heart tones then what the medic had. SO I also had to re-confirm with the Preceptor to ensure that I was not the one that may have been off. When she received the same number and measurements as I did, she asked the medic not to take measurements or heart tones anymore. This is a big issue and if the providers are allowing the medics to do this and not checking up on them, they may miss something critical. The staff needs to ensure that the medic is properly trained and that their is a legitimate competency for the personnel doing them.
ReplyDeleteMeasuring fundal height really is an art that takes repetition to become proficient at. As the uterus enlarges and there is more amniotic fluid, the margin for error increases. Sometimes it can be hard to differentiate baby from fundus and that can account for some of the error. If the fetus changes position that can also significantly change fundal height. I guess the key thing to remember is adequately train your staff, repeat measurements if the seem inaccurate, and follow closely.
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