1. 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)

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

3. 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

4. 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

5. “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,”

6. 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

7. 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

8. 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

9. C: Fetal metabolic acidemia

10. 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

11. 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;

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. 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

21. 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

22. 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

23. 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

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

27. 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

28. 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

29. 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)

30. 20% of obstetrics-related cases resulted in intrauterine hypoxia and birth asphyxia

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

32. 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”

33. 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

34. 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

35. Julie

36. 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.”

37. 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.]

38. 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

39. 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

40. 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

41. 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

42. 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.

43. 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

44. 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

46. Fetal Kick counts
Maternal perception of decreased fetal movement is significant
No contraindications to counting
Fetal movement counts begin 23 weeks, literature recommends 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)”

47. 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%

48. 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

49. 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

53. 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

54. 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”

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

56. 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