Return on Investment

A pervasive challenge in Obstetrics is how best to monitor the fetus to ensure “fetal well being”. The ultimate goal is to end up with a healthy baby after delivery. One can listen with a stethoscope like device, a hand held doppler or with continuous electronic fetal monitoring. One can perform an ultrasound. The ability to do this well is a challenge in both low and high resource settings. In high resource settings, we over utilize fetal monitoring and this results in inconvenience and discomfort for the mother, a higher rate of cesarean deliveries and other unnecessary interventions. I have been tempted on occasion to hurl the fetal monitors from the heliport at Duke. In low resource settings, there is often no fetal monitoring. This is almost always due to resource limitations, training and personnel shortages. This paradoxically results in higher rates of cesarean deliveries because obstetric providers cannot reassure themselves that all is well and the smallest of things can prompt an “emergency cesarean”. In our first two months here, we reviewed at least a dozen fetal or neonatal deaths that might have been prevented with fetal monitoring. The loss of a pregnancy is hard on everyone: the patient, her family, the nurses and the doctors. The staff at KCMC were eager to prevent this from happening again and we had discussed some practical means of doing so on a few occasions. It might seem like an easy solution to simply monitor all women in labor or perform a cesarean delivery on all high risk patients. Not a simple task on a ward where there are two patients to a bed and a single nurse looks after 40 patients.

It is rare in medicine that you see teaching efforts bear fruit immediately. We taught the ObGyn residents how to perform and interpret continuous electronic fetal monitoring on Thursday morning of this week. We encouraged its selective use in only high risk patients because of significant resource limitations. That afternoon, a woman presented on referral from a local district hospital. She had experienced eclamptic seizures and had a dangerously high blood pressure prior to transfer. On arrival, she was quickly stabilized and magnesium sulfate was administered to prevent further seizures. A decision needed to be made about delivery: Attempt to induce her labor and deliver normally or expedite the process with a cesarean delivery. Already deemed a high risk patient, the residents performed what is called a non-stress test on the fetus with the single electronic fetal monitor system on the labor ward. They had never personally performed this test. The fetal heart tracing was ominous: Late decelerations with no variability followed by a few minutes of bradycardia (slow heart beat) A sign that the fetus was in trouble. This was the kind of tracing one might see in a textbook illustrating what a fetus looks like prior to intra-uterine death.

A cesarean delivery was performed. Dr. Tina Oneko from pediatrics was on hand to resuscitate a floppy looking baby. We have since visited this healthy looking child in the nursery. Her name is Grace.