1. Electronic Fetal Monitoring
Terri Imus, RN

2. 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

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

4. 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,

5. 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

6. 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

7. ACOG Has not identified core competencies in FHR monitoring
Standard guidelines Norm
Fetal tachycardia
Mod
Marked “ 181-more
Fetal Bradycardia
Mod
Marked” 90 or less

8. 4 Basic Features of Fetal Heart tracing

9. 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.

10. 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.

11. 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.

12. 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

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

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

15. 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

16. Accelerations

17. 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

18. EARLY DECELERATION

19. Early Decelerations

20. 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

21. Late Deceleration

22. Late Deceleration

23. 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

24. 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

25. 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

26. 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)

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

28. Variable Decelerations

29. Variable Decelerations

30. 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

31. 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

32. Prolonged Deceleration

33. 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 L/min via mask
   

34. 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

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

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

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

38. 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)

39. Sinusoidal pattern

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

41. 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.

42. 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

43. 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

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

45. 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

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

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

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

49. 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

50. 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

51. 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

52. 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

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

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

55. 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

56. 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

57. 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)

58. 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

59. 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.

60. 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

61. 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

62. 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

63. 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

64. 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

65. Technology

67. 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