1. Top 10 Mistakes Made During Interpretation of Fetal Heart Rate
M. Sean Esplin MD
Intermountain Medical Center
University of Utah Health Sciences Center

2. EFM Interpretation
EFM as a stand-‐alone tool is ineffective in avoiding preventable adverse outcomes
EFM is only effective when used
in accordance with published standards and guidelines
By professionals skilled in correct interpretation and when appropriate timely intervention is based on that interpretation
Interpretation and intervention are best accomplished as a collaborative perinatal team rather than individual activity.

3. Top Mistakes Compilation of mistakes taken from: Published reports
Malpractice experts
Personal experience
Teacher of EFM interpretation

4. Case 1 19 yo G1 P0 at 38 weeks in spontaneous labor
Uncomplicated pregnancy

9. Tracing the mother and not the baby
10) Signal ambiguity
Tracing the mother and not the baby

10. Signal Ambiguity
May arise from faulty Doppler equipment or inability of the cardiotocograph to differentiate between maternal and fetal heart rates
When to suspect it
FHR runs in low normal range
FHR accelerations are noted with > 50% of contractions (especially when pushing)
An apparent FHR deceleration to the maternal range that does not recover

11. Signal Ambiguity How to evaluate How to correct
Count maternal radial pulse for one minute
Use a pulse oximeter on the maternal pulse and record on the same screen as the FHR
Confirm fetal rate with an ultrasound
How to correct
Use ultrasound to locate fetal heart rate and replace external monitor until a rate that is at least 5-10 BPM different from the maternal rate is obtained
Place a scalp electrode

12. Case 2 28 year old G3 P2002 at 41 weeks 0 days for postdates induction
No complications with the pregnancy
Cervix is 1+/90/-3

16. 9) Tracing is inadequate for interpretation
What is your interpretation?
9) Tracing is inadequate for interpretation

17. Quality of FHT Absence of data makes interpretation impossible
Includes FHR and tocometry data
Prolonged periods of uninterpretable FHR and uterine activity tracing imply that there was no one attending the mother and fetus
If there are difficulties in obtaining an interpretable FHR tracing, documentation in the medical record about ongoing efforts should be noted.
Simpson, Risk Management and Electronic Fetal Monitoring: Decreasing
Risk of Adverse Outcomes and Liability Exposure, 2000

18. 2 hours later
Cervix: 4/80/-3
New onset recurrent
Variable decelerations

20. 2 hours later
Cervix: 7/C/-2
Continued variables
Now Uncontrollable pain
Nurse calls attending
“Patient uncomfortable”
Response “Have anesthesia
Evaluate patient”

21. 8) Failure to communicate the urgency of the situation when discussed with others

22. 1 hour 30 min later
Cervix:7-8/c/-1
Attempted manual
rotation

24. To OR for Cesarean section

25. Outcome
Large rent in the lower uterine segment with the fetal hand protruding through
Birth weight 9 pounds
Apgars 1 and 9
Art pH 6.97 BE = ?

26. 7) No regard for clinical scenario

27. Importance of Clinical Scenario
The significance of individual characteristics of the fetal heart rate tracing depend on the state of the fetus
Late decelerations are more concerning in the context of vaginal bleeding, known growth restriction or decreased fetal movement
Sudden onset of severe variable decelerations are more concerning in the context of a history of previous cesarean section
30% of fetuses will have a nonreassuring fetal heart rate (FHR) pattern at some time during labor

28. EFM Interpretation Combination of three important judgments
What are the risks in this particular setting?
Where are we starting from?
What should we be watching for?
How is the baby right now?
Variability and accelerations are present
When was the last time I was reassured?
What is the risk that the baby will develop acidemia prior to delivery?
Are there decelerations that indicate an ongoing process of oxygen deprivation?
How long until delivery occurs?

29. Case 3 28 year old G2P1 at 40 weeks gestation
Previous vaginal delivery
Presents in spontaneous labor

30. Patient reaches C/C/-1
Pushing is started at 19:50

31. Patient continues to push
Contraction frequency
Every 1-2 minutes for > 60 minutes

32. 6) Loss of situational awareness

33. Situational Awareness
Clear understanding of all of the factors at play in a clinical situation
Can be lost when we are focused too intensely on one aspect of care
Often happens during pushing
Lose track of the amount of time that has passed without reassuring features about fetal status
Can be lost at the time of hand off from one care provider to another
History of previous cesarean section not relayed to next care team

34. Situational Awareness
Other providers with different perspective must restore awareness by raising concerns
Can be catastrophic if other team members are afraid to raise concerns or if their concerns are ignored

35. Nurse raises concern about fetal heart rate tracing to physician who is in the
Room pushing with the patient.
No response from the physician.

36. 5) Not giving appropriate response to concerns from other caregivers

37. Team Approach to Patient Care
Each member of the team is engaged in trying to provide optimal care
Concerns of every team member must be adequately addressed
This is part of good communication

38. 2 hours of pushing eventually results in vaginal delivery.
APGARS 1,5,7
pH not available

39. 4) Failure to initiate the chain of command

40. Case 4 19 year old G1 P0 at 42 weeks gestation
Presents for postdates induction

42. 3) Continuing to give oxytocin in the wrong setting

47. 2) Failure to appropriately treat tachysystole

48. Tachysystole Management
Reassuring (Normal) FHR
Maternal repositioning (left or right lateral)
IV fluid bolus approx. 500 mL lactated Ringer’s
If uterine activity (UA) has not returned to normal after min.
Decrease oxytocin rate by at least half
UA has not returned to normal after more min
discontinue oxytocin until UA is no more than 5 contractions in 10 min

49. Tachysystole Management
Nonreassuring FHR – category 2 or greater
Discontinue oxytocin
Maternal repositioning (left or right lateral)
IV fluid bolus of approx. 500 mL lactated Ringer’s
Consider L/min/nonrebreather mask
Consider 0.25 mg terbutaline subQ
Document actions and maternal-fetal response

50. Resumption of Oxytocin
After Resolution of Tachysystole
Oxytocin discontinued <20–30 min
FHR reassuring
Uterine activity normal
Resume oxytocin at no > 1/2 rate that caused tachysystole
Gradually increase rate if needed, based on protocol/ maternal-fetal status

51. Resumption of Oxytocin
After Resolution of Tachysystole
Oxytocin discontinued >30-40 min
FHR reassuring
Uterine activity normal
Resume oxytocin at initial dose ordered
Follow standard protocol

52. 5 contractions in 10 minute Window over 30 minutes Tachysystole
Is the FHR reassuring?
(Moderate variability and absence of
recurrent late/variable decelerations)
Category 2 or 3 tracing
Category 1 tracing No
Yes
- Discontinue the oxytocin infusion if running
- Reposition patient to left or right lateral position
- Administer oxygen 10 L/min tight mask
- IV fluid bolus of at least 500mL lactated Ringers solution
- If no response, obtain order for Terbutaline 0.25mg SQ x1
Reposition patient to left or right lateral position
IV fluid bolus of at least 500mL lactated Ringers solution
Increase frequency of assessment
Did tachysystole resolve after
10-15 minutes observation?
How long until FHR reassuring and
resolution of tachysystole?
Yes No
Manage oxytocin
infusion as ordered to
achieve contractions
every 2-3 minutes with
60 seconds resting
tone between ctx.
Decrease the oxytocin by ½.
Continue to observe for an additional minutes
Oxytocin off < 30 min:
- resume oxytocin at no more than ½ the previous rate
Oxytocin off > 30 min:
- resume oxytocin at
the initial dose per order.
If tachysystole does not resolve 30
minutes after initial interventions:
discontinue oxytocin infusion
notify the provider.
Consider Terbutaline.
Gradually increase oxytocin rate as ordered and
monitor maternal-fetal status
Repeat steps per algorithm as needed

53. 1b) Failure to recognize abnormal fetal heart rate tracing - Misinterpretation

54. Limiting Misinterpretation
A clear definition of fetal well-‐being should be used to simplify communication between nurses and physicians
Definition of fetal well-‐being is
a 15 beat per minute acceleration of the FHR lasting 15 seconds.
An initial FHR tracing that demonstrates fetal well-‐being
Category I tracing
Fetal well-‐being should be the criteria for
maternal discharge
intermittent auscultation
maternal medication administration
use of cervical ripening and induction agents
regional anesthesia in most clinical situations
Absence of fetal well-‐being necessitates direct physician evaluation with written documentation of further clinical management.

55. 1a) Inadequate documentation

56. Purpose of Documentation
Communication between caregivers
Decreasing risk of liability exposure includes methods to demonstrate evidence that appropriate, timely care was provided and that fetal status had not deteriorated significantly before interventions occurred

57. Purpose of Documentation
A well-‐documented medical record that is comparable with the electronic monitoring tracing and includes
appropriate interventions at frequencies reasonably consistent with institutional policies
provides evidence that care providers have a solid knowledge of the physiology of fetal heart rate pattern interpretation, labor and birth, and institutional policies and standards of care
are able to apply that knowledge in clinical practice.

58. What is Needed to Limit Mistakes
Common EFM language in all documentation and conversations
Joint nursing and physician education sessions
Collaboration and mutual respect among care givers
Clear definition for fetal well-being on admit
Clinical resources needed for timely intervention
Interdisciplinary case reviews
Competent care providers
Accurate monitoring
Clear protocol for ongoing assessment of fetal-well being Clear understanding of chain of command

59. EFM Bundle Like a checklist
A series of clinical steps that should occur every time a given process occurs
Ensure that all providers on labor and delivery are qualified to read, appropriately interpret, and respond to fetal heart rate tracings
requires a credentialing process
An explicit escalation policy that would have to be audited and enforced
would have to be rapid and therefore avoid unnecessary duplication of effort
There is an identified responsible provider at all times
There must be the capability of a rapid response
Minkoff et al. Obstet Gynecol 2009

60. Thank You
Questions?