Fetal Monitor Tracings: What do I call it? What do I know? Julie Zimmerman MSN, RNC-OB, C-EFM AWHONN EFM Instructor Trainer AWHONN Section Advisory Council, Region 4 (includes South Dakota) j.zimmermanrn@gmail.com

Disclosure statement No financial contributions which would impact today’s presentation This Photo by Unknown Author is licensed under CC BY-NC

Objectives: Identify components of the EFM tracing which indicates oxygenation Review NICHD terminology and importance of relationship to fetal oxygenation Discuss interpretation myths List risk reduction strategies

Plan for next hour: Review Identify Describe Review components of the EFM tracing; baseline; variability; periodic and episodic changes through case studies Identify Identify the significance of the above listed components Describe Describe expected changes of the fetus through the first and second stages of labor

“It ain’t so much the things we don’t know that get us into trouble. It’s the things we know that just ain’t so,”

FHR Reflects Fetal Oxygenation Extrinsic (outside the fetus) Maternal Oxygenation Uterine blood flow Placental exchange Umbilical blood flow Intrinsic (inside the fetus) Fetal circulation Oxygenation of tissues FHR Regulation

Standardizing EFM for clinicians What do I call it? Standardized terminology: NICHD What does it mean? Standardized interpretation using the oxygen pathway and differentials What should we do about it? Standardized management using a simple series of questions and evaluating the risk of developing fetal metabolic acidemia vs safely obtaining a vaginal delivery Know your definitions; first thing that is done in a deposition What is the significance of what you are seeing, the physiology, what do we know, what is a myth Actions, do we need to do anything; is this part of normal labor; expected? Anything of concern, or are we reassured by seeing it; we don’t know what will happen totally but there are things that we need to be alarmed by

Moderate variability is associated most specifically with the absence of A. Acute fetal hypoxemia B. Respiratory acidemia C. Fetal metabolic acidemia D. Fetal hypoxia E. Fetal anemia National expert put this question to a conference; less than 60 per cent got this correct; they were like you, the cream of the crop; the people that go to conferences; engaged in their practice

C: Fetal metabolic acidemia

Variability Provides reassurance about the oxygen reserves available and the functioning of the medulla oblongata and autonomic nervous system May indicate oxygen reserves are still present with late or variable decelerations but still calls for need to reduce stressors

Variability - Fluctuations in the baseline of 2 cycles/minute or greater. These fluctuations are irregular in amplitude and frequency and are visually quantified as the amplitude of the peak to trough in bpm. Absent - Amplitude undetectable Minimal – Greater than Undetectable but equal to or less than 5 Moderate – 6-25 Marked - > 25 Definition;

Fetal acidemia and electronic fetal heart rate patterns: Is there evidence of an association? J. T. Parer a;  T. King a;  S. Flanders a;  M. Fox a; S. J. Kilpatrick b The Journal of Maternal and Fetal Medicine, Volume 19 Issue 5 May 2006 98% of the fetuses with moderate FHR variability, whether or not there are decelerations or bradycardia, will be either not significantly acidemic and/or vigorous. The presence of moderate variability has > 99% negative predictive value for adverse outcome, defined as 5-minute Apgar score <7 This is an old publication (13 years ago) but won’t be replicated; came from the scalp ph; which are no longer done

Development of acidemia Parer et al, 2006 When initially normal tracing develops abnormal FHR patterns in absence of a catastrophic event….. SIGNIFICANT ACIDEMIA Need to identify cause of change Intervene Decide to Deliver 60-90 minutes

Category system Category 1 Category 2 Category 3 Normal baseline Moderate Variability Accels/early may have No lates; no variables Assume normal ph Category 2 Everything else Indeterminate ph Category 3 Absent variability with lates or variables Sinusoidal Absent var w/ bradycardia Assume abnormal ph

Evolution of fhr variability: jagged & unpredictable Evolution of fhr variability: jagged & unpredictable evolves to smooth & round Evolution of FHR Variability JagEvoged and Unpredictable Moderate Variability Moderate Variability Minimal Variability Minimal Variability Absent Variability Absent Variability Smooth, Round, Blunted, Flat

Principle #1 Variable, late or prolonged decelerations signal interruption of the oxygen pathway at one or more points Principle #2 Moderate variability or accelerations exclude ongoing hypoxic injury

Early Decelerations Definition: visually apparent gradual decrease (onset to nadir (lowest point) is >30 seconds) of the FHR and return to baseline associated with a uterine contraction. Coincident in timing, with the nadir of deceleration, occurring at the same time as the peak of the contraction.

Late Decelerations Visually apparent gradual decrease (onset to nadir is > 30 seconds) of the FHR and return to baseline associated with a uterine contraction. It is delayed in timing, with the nadir of deceleration occurring after the peak of the contraction.

Variable Decelerations Definition: apparent abrupt decrease (onset to nadir is <30seconds) in the FHR; lasting at least 15 seconds and less than 2 minutes, decreasing at least 15 bpm below the baseline Onset: abrupt, may be a jagged slope

Prolonged Decelerations Definition: Visually apparent decrease in fetal heart rate below baseline, Deceleration of the FHR will be > 15 bpm that lasts 2 to 10 minutes from onset to return to baseline URGENT

If a tracing remains in Category 2 after conservative measures, how do you decide whether it is safe to continue labor? Why not exclude metabolic acidemia? (moderate variability and/or accelerations) And exclude significant interruption of oxygenation? (no significant decelerations) Category 2; 80% of labor is in there; not category 1 where I can assume a normal ph, not category 3 where I can assume not; everything in between

Can You Read it??? 2008 NICHD report The record of both the FHR and uterine activity should be of adequate quality for visual interpretation. A full description of an EFM tracing requires a qualitative and quantitative description of: 1. Uterine contractions. 2. Baseline fetal heart rate. 3. Baseline FHR variability. 4. Presence of accelerations. 5. Periodic or episodic decelerations. 6. Changes or trends of FHR patterns over time. 2008 NICHD report Must have these for interpretation to occur

Defense: • NICHD Terminology • Pattern Evolution • Special concerns in 2nd stage labor Example of signal ambiguity

Second Stage Labor Common Problems Fetal status often overlooked in efforts to “get the baby out” Physiologically inappropriate oxytocin-induced tachysystole Supine lithotomy positioning (lumbosacral spine and lower extremity nerve injuries) Fundal pressure (should be extinct) Foley catheters during pushing efforts Lack of patience/convenience over safety Routine episiotomy Operative vaginal Birth Kathleen Rice Simpson, PhD, RNC

Majority of perinatal claims occurred in the second stage, missteps in communication, delays in response in fetal distress and a timely rescue Failures in clinical judgment fueled by loss of individual perspective (situational awareness) and lack of collaborative discussion social media; everything is retrievable; record should reflect that the family was brought into the discussions; description of recommendations and rationale; reason if patient refuses or if there are delays; do not show disagreement in the record; do not use words such as “fetal distress; inadvertent, accidentally or erroneously; watch for medical record discrepancies; point them out to each other

Baird 2017 national conference Electronic Fetal Monitoring • Failure to correctly interpret EFM pattern • Inappropriate management of EFM pattern • Failure to advocate for fetal concerns (chain of command)

20% of obstetrics-related cases resulted in intrauterine hypoxia and birth asphyxia

IS this reasonable? Expectations: AWHONN: Position change IV bolus Pitocin off (reduce stressors) oxygen (second line) AWHONN; Clark et all

Most common legal allegations in efm: Failure to diagnose-recognize Failure to respond-intervene Delay in delivery “And, even when these allegations are unfounded, how well do clinicians do in providing an explanation of the plan of care? Our inability to articulate as a team is a serious issue for the defense- Lisa Miller CNM”

NQF (National Quality Forum) Never events Maternal or infant death associated with a medication error, ie overdose of oxytocin, mgso4 Death or serious disability of a fetus/infant with a normal FHR pattern on mother’s admission for labor, barring any acute unpredictable event Prolonged periods of untreated uterine tachysystole during oxytocin or misoprostol administration Ruptured uterus following prostaglandin administration for cervical ripening/labor induction to a woman with a known uterine surgical scar Infant death or disability after multiple attempts with instruments to effect an operative vaginal birth Infant death or disability after prolonged periods of coached second stage labor pushing efforts during an indeterminate/abnormal FHR pattern

HCA Perinatal Safety Initiative Fetal Assessment indicates: At least 1 acceleration of 15 bpm x 15 seconds in 30 minutes or adequate variability for 10 of the previous 30 minutes. No more than 1 late deceleration occurred. No more than 2 Variable decelerations exceeding 60 seconds in duration and decreasing greater than 60 bpm from the baseline within the previous 30 minutes. Uterine Contractions No more than 5 uterine contractions in 10 minutes for any 20 minute interval No two contractions greater than 120 seconds duration Uterus palpates soft between contractions If IUPC is in place, MVU** must calculate less than 300 mm Hg and the baseline resting tone must be less than 25 mm Hg. *If Oxytocin is stopped the Pre-Oxytocin Checklist will be reviewed before Oxytocin is reinitiated. ** MVU = Montevideo Units HCA Perinatal Safety Initiative Recommended Oxytocin “In Use” Checklist for Women with Term Singleton- Babies “This Oxytocin “In Use” Checklist represents a guideline for care: however, individualized medical care is directed by the physician.” Checklist will be completed every 30 minutes. Oxytocin should be stopped or decreased if the following checklist cannot be completed. Date and time completed ______________ Checklists are great but need to be used, Rachel Woodard states she reviews charts and it says they have one and then it’s not completed; not ok to add something without the education; training and practice to go with it

Julie

Myth buster: EFM is NOT a diagnostic tool, rather it is a highly effective screening tool “…in a fetus exhibiting either moderate variability or accelerations of the FHR, damaging degrees of hypoxia‐induced metabolic acidemia can reliably be excluded. In contrast, because of the poor predictive values of most abnormal FHR patterns, prediction of the fetus at risk of neurologic injury is much less certain.”

Parer & Fox There has been an overemphasis on the seriousness of late decelerations to the exclusion of other features of the pattern. Only in recent years was it discovered that there are, in fact, two mechanisms of late decelerations, the first caused by vagal reflex and the second caused by myocardial hypoxia Whereas both appear to be caused by a change in fetal arterial oxygen tension with uterine contraction, the former type is more tolerable to the fetus, whereas the latter type signifies a risk of deep central asphyxia. Clinically, these two types can be discriminated on the basis of the presence or absence of FHR variability.]

Myth Buster: Fetal Rescue Barring any acute event (umbilical cord prolapse, uterine rupture, placental abruption, rupture of vasa previa, amniotic fluid embolism) there is ample time to rescue a fetus in jeopardy

Development of acidemia Parer et al, 2006 When initially normal tracing develops abnormal FHR patterns in absence of a catastrophic event….. SIGNIFICANT ACIDEMIA Need to identify cause of change Intervene Decide to Deliver 60-90 minutes We have time, time to get them over to the unit, must notify or get someone else’s opinion, 2 sets of eyes always better, think of fatigure, work pressue This Photo by Unknown Author is licensed under CC BY-SA

Ways to reduce risk This Photo by Unknown Author is licensed under CC BY Single greatest deterrent to litigation remains a strong practitioner-patient relationship rich with positive interactions and communications Practice complete, legible and timely documentation Maintain continuing education requirements Read current, practice relevant journals Participate in quality management, risk management and patient safety activity

TJC Sentinel Event Alert #30-Suggested Risk Reduction Strategies Revise orientation & training 70% Physician education & counseling 36% Revise communication protocols 36% Reinforce chain of communication 28% Revise competency assessment 25% Conduct team training 25% Revise consultation/on-call policies 23% How to train ourselves, how to keep that learning alive and real and make sure it works with each patient, shouldn’t “depend on” if it’s certain day of the week, certain time of the day; those do not matter to the baby; birth happens when it happens and the rest is up to us

How to reduce risk? If there is any belief the fetus may be depressed at birth, alert the nursery to have necessary resuscitators and care providers at delivery If possible cord blood gasses should be obtained on every delivery, but for sure if the baby is at all depressed at birth; and, if the baby is depressed the placenta should be retained and examined.

Standard of Care: is a legal term Jury instructions vary, but a “reasonableness” standard is the norm Expert testimony is used to establish standard of care, thus each side will have experts testifying to the appropriate standard of care and it will be up to the jury to ultimately decide

Plaintiffs attorneys: Cases that are not “turbos” are the type of cases that do not have well-documented histories and well documented physicals, physician, consultant and nursing progress, operative and delivery note, and postpartum physician and nursing notes that well document the baby’s clinical. Plaintiffs’ attorneys stay away from well-documented malpractice cases because they know that in defense of the obstetrical and neonatal providers, the jury will see that the care provided was within accepted standards of care. In those cases, when presented to a jury, the juries usually will side on the part of the providers, not the plaintiffs Need we say more

Fetal Kick counts Maternal perception of decreased fetal movement is significant No contraindications to counting Fetal movement counts begin 23 weeks, literature recommends NST @ 28 weeks Concern: change in mother’s perception Instruct to come to hospital for EFM “more valuable than any single proposed fetal movement counting guideline is the mother’s perception of fetal activity in relation to previously perceived fetal movement levels (AAP & ACOG, 2012)”

NST (non stress test) and CST (contraction stress test) comparison CST false negative (per 1000) 0.4 NST false negative 3.4 CST false positive: 30% NST false positive: 55%

Biophysical Profile (ultrasound) Nonstress Test Qualitative Amniotic Fluid Volume Fetal Tone Gross Body Movements Fetal Breathing Movements False positive rate: 50% False negative rate: 0.6 per 1000 women tested

Documentation in EFM NICHD nomenclature provides a standardized terminology Describes what should be included in tracing evaluation Discusses quantification of decelerations Does not use summary terms NICHD states decelerations may be further quantified by the depth of the nadir in the BPM and the duration in minutes/seconds from onset to offset Standard of care is based on reasonableness

Consider…… Optimal intrapartum management requires a plan You only need one plan This is a plan (hope is not a plan!!*) It is not the only plan But it is a good plan

Miller presentation recommendations Use standard definitions and interpretation Be as consistent as possible Multidisciplinary teamwork is KEY Develop and maintain a “shared mental model” KEEP IT SIMPLE Don’t hesitate to use flow charts and checklists Avoid “kicking the can down the road”

THANK YOU!! SAFE TRAVELS!! This Photo by Unknown Author is licensed under CC BY-ND

References Baird, S.M., Kennedy, B.B. & Baudhuin, S. (2016). Intrapartum liability issues. In Kennedy, B.B. & Baird, S.M. (Eds.) Intrapartum Modules Modules; A Perinatal Education Program, 5th edition. Philadelphia, PA: Lippincott. Chez, B.F. & Baird, S.M. (April/June 2011). Electronic fetal heart rate monitoring: Where are we now? Journal of Perinatal and Neonatal Nursing, 25(2), 180‐192. Clark SL, Nageotte MP, Garite TJ, Freeman RK, Miller DA, Simpson KR, et al. (2013). Intrapartum management of category 8th ed. Pocketbook of EFM (Miller, Miller, and Cypher) 5th ed. AWHONN EFM text