Electronic Fetal Monitoring Terri Imus, RN

Electronic Fetal Monitoring Indications for continuous EFM Any pregnancy considered high risk Induction or augmentation of labor Decreased fetal movement Premature labor Premature rupture of membranes

Oligohydramnios Hypertension Abnormal fetal heart rate Fetal malpresentation in labor IDDM Multiple Gestation Previous C/S Trauma Meconium

ACOG & AAP When EFM is the method selected for fetal assessment. The MD & obstetrical personnel should be qualified to identify and interpret abnormalities. These guidelines also state that it is appropriate for MD & Nurse to use the descriptive terms that have been given to fetal monitoring patterns in charting and reporting Those not qualified or are unsure of the interpretation in FHR patterns should seek other professionals to assist in this evaluation and interpretations The nurse should document the presence of MD and nurse, pt position and changes in cervix,

Therapeutic interventions such as O2 and medications Increased or decreased BP Febrile Amniotomy, AROM,SROM, color amt. consistency Is the patient complete/pushing All of these descriptive details give a picture that indicates what is going on with the patient and possible cause of change in FHR pattern

AAP/ACOG Guidelines emphasize that when there is a change in the FHR pattern all of those things should be documented as well as a return to baseline Each tracing should include Pt Name ID # Date, Time of admission/delivery EDC, Gravida Para and any other identifying information

ACOG Has not identified core competencies in FHR monitoring Standard guidelines Norm 110-160 Fetal tachycardia Mod 161-180 Marked “ 181-more Fetal Bradycardia Mod 100-119 Marked” 90 or less

4 Basic Features of Fetal Heart tracing

4 Basic Features Baseline Variability Bradycardia <110 bpm Tachycardia >160 bpm Periodic changes: FHR accelerations or decelerations that occur with contractions. Decelerations are routinely described as early, late, or variable.

Non-periodic changes (no changes in variability) Nonperiodic changes can occur spontaneously, without contraction activity, and are also described as accelerations or decelerations. Variable decelerations can appear during a Non-stress test and may be a sign of cord compression or oligohydramnios, both of which can have adverse effects on the fetus.

Baseline Variability Normal FHR 5 bpm greater than or equal to 5 bpm, between contractions Nonreassuring FHR less than 5 bpm or less, but less than 30 min of tracing Abnormal FHR less than 5 bpm for 90 min or more.

Baseline variability The minor fluctuations on baseline FHR at 3-5 cycles p/m will reflect baseline variability Examine 1 min segment and estimate highest peak and lowest trough Normal is more than or equal to 5 bpm

Factors affecting Baseline variability Para-Sympathetic affects short term variability Sympathetic affects long term CNS Drugs reduces Variability

Increased gestational age may increase variability Mild Hypoxia may cause both Sympathetic and Parasympathetic stimulation

Accelerations Accelerations transient increase in FHR of 15 bpm or more lasting for 15 sec Absence of accelerations on an otherwise normal Fetal heart tracing remains unclear Presence of FHR Accelerations usually have good outcome

Accelerations

Early Decelerations Head compression Begins on the onset of contraction and returns to baseline as the contraction ends Should not be disregarded if it appears early in labor or in the antenatal period

EARLY DECELERATION

Early Decelerations

Late Decelerations Uniform periodic slowing of FHR with the on set of the contraction Reduced baseline variability together with late decelerations and repetitive late deceleration increases risk of fetal acidosis and an Apgar score of less than 7 at 5/min with an increased risk of adverse outcome

Late Deceleration

Late Deceleration

Late Decelerations Due to acute and chronic utero-placental insufficiency Occurs after the peak and past the length of uterine contraction, often with slow return to the baseline Is precipitated by hypoxemia Associated with respiratory and metabolic acidosis Common in patients with PIH, DM, IUGR or other forms of placental insufficiency

Variable Decelerations Variable intermittent periodic slowing of FHR with rapid onset recovery and isolation They can resemble other types of deceleration in timing and shape Atypical associated with an increased risk of umbilical artery acidosis and Apgar score less than 7 at 5 min

Additional components Loss of 1 or 2 degree rise in baseline rate Slow return to baseline FHR after and end of contraction Prolonged secondary rise in Base FHR Biphasic deceleration Loss of variability during deceleration Continuation of the baseline at a lower rate

Variable Deceleration (Vagal activity) Inconsistent in configuration No uniform temporal r-ship to the onset of contraction, are variable and occur in isolation Worrisome when Rule of 60 is exceeded (i.e. decrease of 60 bpm,or rate of 60 bpm and longer than 60 sec)

Caused by compression of the umbilical cord Often associated with Oligo-hydramnios with or without rupture of membranes Acidosis if prolonged and recurrent

Variable Decelerations

Variable Decelerations

Prolonged Deceleration Drop in FHR of 30 bpm or more lasting for at least 2 mins Is pathological when it crosses 2 contractions in 3 mins Results in reduced of O2 transfer to placenta Associated with poor neonatal outcome

Prolonged Decelerations CAUSES Cord prolapse Maternal hypertension/hypotension Uterine hypertonia Epidural/spinal or pudendal anesthesia Can follow a vag exam, AROM or SROM with high presenting part

Prolonged Deceleration

Intrauterine Resuscitation Have the mother lie on her left/right side or in a knee chest position To alleviate possible cord compression Reduce or stop any oxytocin Initiate tocolysis To decrease uterine activity and increase placental blood flow Increase IV fluid To increase maternal blood/fluid volume      Give oxygen @ 10-12 L/min via mask    

Physician may apply an internal monitor to verify the accuracy of external monitor reading  Physician may administer amnioinfusion   to decrease pressure on cord or dilute mec. If the heart rate is not restored to normal within 30 minutes, prompt delivery is needed.  Cesarean section may then become necessary. Goal is to deliver ASAP

Causes of Baseline Change Postdates Drugs Idiopathic Arrhythmias Hypothermia Increased vagal tone Cord Compression Management depends on the clinical situation

Causes of Bradycardia Asphyxia Drugs Prematurity Maternal Fever Maternal thyrotoxicosis Maternal Anxiety Idiopathy Management depends on the clinical situation

Baseline Tachycardia Asphyxia Drugs Prematurity Maternal fever Maternal thyrotoxicosis Maternal Anxiety Idiopathy

Sinusoidal Pattern Regular Oscillation of the Baseline long-term Variability resembling a Sine wave fixed cycle of 3-5 p min with amplitude of 5-15bpm and above but not below the baseline Should be viewed with suspicion as poor outcome has occurred (maternal/fetal hemorrhage)

Sinusoidal pattern

Sinusoidal pattern - distinctive smooth undulating Sine-wave baseline Cord compression Hypovolemia Ascites Idiopathic (fetal thumb sucking) Analgesics Anemia Abruption Management depends on clinical situation

Summary of tracing Normal with all 4 Features Suspicious one non reassuring category and remainder are reassuring Pathological 2 or more non-reassuring categories or one or more abnormal categories.

At Birth Need to Consider Cord pH if tracing suspicious Preterm labor Mec. stained amniotic fluid FBS intrapartum (lab availability) Lack of tone delivery Operative or instrumental delivery

COMMUNICATION DESCRIBE THE PATTERN ACCURATELY MAKE AN ATTEMPT TO ASSESS WHETHER THE FETUS IS IN TROUBLE IF YOU WANT THE PHYSICIAN THERE, COMMUNICATE THAT THE NURSE HAS MORE DATA THAN THE PHYSICIAN

Communication SYSTEMATIC APPROACH REDUCES ERRORS DESCRIBE WHAT YOU SEE AVOID THE NEED TO CLASSIFY EVERY DECELERATION ASSESS THE OVERALL CONDITION OF THE FETUS

Electronic Fetal Monitoring Improve knowledge for all staff Improve clinical skills Training should include instruction on documentation and storage Training should include appropriate clinical responses to suspicious or pathological tracings Training should include local guidelines relating to fetal monitoring both intermittent and EFM

DOCUMENTATION OF COMMUNICATION DO NOT JUST SAY THAT Dr. Whoduneit WAS NOTIFIED RECORD THE PHYSICIAN’S RESPONSE and any ORDERS

COMMUNICATION DESCRIBE FHR PATTERN I AM CONCERNED ABOUT THE CONDITION OF THIS BABY IT IS OMINOUS AND NON-REASSURING IF PERSISTENT, REQUIRES PHYSICIAN EVALUATION

COMMUNICATION THE FETUS HAS INCREASED VARIABILITY AND THE BASELINE IS HARD TO NTERPRET PHYSICIAN PRESENCE NOT REQUIRED

COMMUNICATION NOTIFY IF NO DRUGS WERE GIVEN THE FETUS HAS HAD A SINUSOIDAL PATTERN FOR 20 MINUTES. I HAVE NOT GIVEN ANY NARCOTICS AND THE PATTERN PERSISTS DESPITE POSITIONING, HYDRATION AND OXYGEN. PHYSICIAN PRESENCE MAY NOT BE REQUIRED but inform

COMMUNICATION what if THE FETUS SUSTAINED A PROLONGED DECELERATION ASSOCIATED WITH HYPERSTIMULATION THE PATTERN RESOLVED AFTER …. PHYSICIAN PRESENCE MAY NOT BE IMMEDIATELY REQUIRED, BUT SHOULD BE NOTIFIED

Effective communication to avoid Litigation COMMUNICATE EFFECTIVELY TO THE PHYSICIAN DESCRIBE WHAT YOU SEE AND DOCUMENT WHAT YOU TOLD THE PHYSICIAN DOCUMENT HER/HIS RESPONSE AVOID CHART WARS

Tracings Unsatisfactory or Missing Abnormal tracing ignored or not recognized Tracings not done Risk Management EFM traces should be kept up to 21 years. If removed for teaching purposes or etc, should be easily located They minimize incidence of adverse outcome

What Influences Litigation Consumer Expectation The profession –education The employer (policies/procedures) Legislation (duty of care/scope of practice/ registration)

Legal issues- Consumer expectation Good outcome (healthy baby/mother) Bad outcome Someone to blame Someone must pay

Professional Responsibility To act within scope of practice To seek support and guidance Work within organizational standards Duty of care to the patient and your profession Maintain knowledge and skills (Evidence Based Practice) Be prepared to defend your actions or lack of

When EFM is the focus of Malpractice Comparison of consistency of documentation contained on the trace and in the chart Lapse in documentation may leave doubt about the quality of care given Hospital policy and procedure manuals will be examined Competency levels will be evaluated, expert witness (plaintiff/defense)will determine if acceptable standards were applied

Major Omission in Liability Failure to appropriately monitor the mother and fetus status Failure to notify the physician in a timely manner Initiation of procedures without adequate client information or consent (informed consent)

MORE Legal issues Use EFM effectively and efficiently Interpret the tracing and respond accordingly It is permanent record that is scrutinized in a litigation case May be pivotal in determining liability

A normal EFM can be used to indicate that there were no abnormalities with no indication for intervention An abnormal EFM or suspicious trace may provide evidence for inappropriate or lack of treatment, giving more insight for litigation EFM could be viewed as part of “defensive medicine”, as litigation is reported to be on the increase.

Elements of a Successful Malpractice Action A nurse has a duty to the patient A nurse commits a breach of duty A patient suffers damages Causal connection between the nurse’s actions and the patient’s damages

RN Obligation Help patient to process information when outcomes are poor, explain situation and reinforce learning/teaching RN must chart carefully and defensively to support the care given The chart is the witness that never dies and is discoverable for up to 21yrs Not charted not done RN (expert witness) help to identify when a breech of duty of standards of practice

Documentation and the Monitor Know your institution’s policy on what is to be documented on the monitor strip Routine information Identify strip with patient’s name Medical record number Date and time Procedures done Nurses name or initials

OMISSION Failure to appropriately monitor client/fetus (ACOG recommendation Q 15mins 1st stage Q 5 mins 2nd stage) Inappropriate Pitocin monitoring/utilization Pitocin orders/continuous monitoring/ having access to physician for further instruction/orders Improper sponge/instrument counts during C/S Initiation of procedures without adequate client information consent (informed consent) Failure to notify MD in a timely manner: When in doubt shout

Failure to notify MD in a timely manner: Notify the physician and note time and orders or lack there of orders Repeat notifications per institutions policy and utilize the chain of command for your institutions when no appropriate response

Technology

References Manual Obs and Gyn. by Niswander, MD Fetal Monitoring, RCOG UK CTGs, RANZCOG Literature review articles American Family Physician Electronic Fetal Monitoring, Menihan, Zottoli