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Electronic Fetal Monitoring Terri Imus, RN. Electronic Fetal Monitoring Indications for continuous EFM Any pregnancy considered high risk Any pregnancy.

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Presentation on theme: "Electronic Fetal Monitoring Terri Imus, RN. Electronic Fetal Monitoring Indications for continuous EFM Any pregnancy considered high risk Any pregnancy."— Presentation transcript:

1 Electronic Fetal Monitoring Terri Imus, RN

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

3 Oligohydramnios Oligohydramnios Hypertension Hypertension Abnormal fetal heart rate Abnormal fetal heart rate Fetal malpresentation in labor Fetal malpresentation in labor IDDM IDDM Multiple Gestation Multiple Gestation Previous C/S Previous C/S Trauma Trauma Meconium 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 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 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, The nurse should document the presence of MD and nurse, pt position and changes in cervix,

5 Therapeutic interventions such as O2 and medications Therapeutic interventions such as O2 and medications Increased or decreased BP Increased or decreased BP Febrile Febrile Amniotomy, AROM,SROM, color amt. consistency Amniotomy, AROM,SROM, color amt. consistency Is the patient complete/pushing 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 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 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 Has not identified core competencies in FHR monitoring Standard guidelines Norm Fetal tachycardia Fetal tachycardia Mod Mod Marked “181-more Marked “181-more Fetal Bradycardia Fetal Bradycardia Mod Mod Marked”90 or less Marked”90 or less

8 4 Basic Features of Fetal Heart tracing

9 4 Basic Features Baseline Baseline Variability Variability Bradycardia <110 bpm Bradycardia <110 bpm Tachycardia >160 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 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 Examine 1 min segment and estimate highest peak and lowest trough Normal is more than or equal to 5 bpm Normal is more than or equal to 5 bpm

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

14 Increased gestational age may increase variability Increased gestational age may increase variability Mild Hypoxia may cause both Sympathetic and Parasympathetic stimulation 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 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 Absence of accelerations on an otherwise normal Fetal heart tracing remains unclear Presence of FHR Accelerations usually have good outcome Presence of FHR Accelerations usually have good outcome

16 Accelerations

17 Head compression 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 Should not be disregarded if it appears early in labor or in the antenatal period Early Decelerations

18 EARLY DECELERATION

19 Early Decelerations

20 Late Decelerations Uniform periodic slowing of FHR with the on set of the contraction 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 5/min with an increased risk of adverse outcome

21 Late Deceleration

22

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 Variable intermittent periodic slowing of FHR with rapid onset recovery and isolation They can resemble other types of deceleration in timing and shape 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 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 Slow return to baseline FHR after and end of contraction Prolonged secondary rise in Base FHR Prolonged secondary rise in Base FHR Biphasic deceleration Biphasic deceleration Loss of variability during deceleration Loss of variability during deceleration Continuation of the baseline at a lower rate 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 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) 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 Caused by compression of the umbilical cord Often associated with Oligo-hydramnios with or without rupture of membranes Often associated with Oligo-hydramnios with or without rupture of membranes Acidosis if prolonged and recurrent Acidosis if prolonged and recurrent

28 Variable Decelerations

29

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

31 Prolonged Decelerations CAUSES Cord prolapse Cord prolapse Maternal hypertension/hypotension Maternal hypertension/hypotension Uterine hypertonia Uterine hypertonia Epidural/spinal or pudendal anesthesia Epidural/spinal or pudendal anesthesia Can follow a vag exam, AROM or SROM with high presenting part 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 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  To increase maternal blood/fluid volume Give L/min via mask Give L/min via mask

34 Physician may apply an internal monitor to verify the accuracy of external monitor reading Physician may apply an internal monitor to verify the accuracy of external monitor reading Physician may administer amnioinfusion Physician may administer amnioinfusion t 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 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 Causes of Baseline Change Postdates Postdates Drugs Drugs Idiopathic Idiopathic Arrhythmias Arrhythmias Hypothermia Hypothermia Increased vagal tone Increased vagal tone Cord Compression Cord Compression Management depends on the clinical situation

36 Causes of Bradycardia Causes of Bradycardia Asphyxia Asphyxia Drugs Drugs Prematurity Prematurity Maternal Fever Maternal Fever Maternal thyrotoxicosis Maternal thyrotoxicosis Maternal Anxiety Maternal Anxiety Idiopathy 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 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) 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 Hypovolemia Ascites Ascites Idiopathic (fetal thumb sucking) Idiopathic (fetal thumb sucking) Analgesics Analgesics Anemia Anemia Abruption Abruption Management depends on clinical situation

41 Summary of tracing Normal with all 4 Features Normal with all 4 Features Suspicious one non reassuring category and remainder are reassuring Suspicious one non reassuring category and remainder are reassuring Pathological 2 or more non-reassuring categories or one or more abnormal categories. 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 DESCRIBE THE PATTERN ACCURATELY MAKE AN ATTEMPT TO ASSESS WHETHER THE FETUS IS IN TROUBLE MAKE AN ATTEMPT TO ASSESS WHETHER THE FETUS IS IN TROUBLE IF YOU WANT THE PHYSICIAN THERE, COMMUNICATE THAT IF YOU WANT THE PHYSICIAN THERE, COMMUNICATE THAT THE NURSE HAS MORE DATA THAN THE PHYSICIAN THE NURSE HAS MORE DATA THAN THE PHYSICIAN

44 Communication SYSTEMATIC APPROACH REDUCES ERRORS SYSTEMATIC APPROACH REDUCES ERRORS DESCRIBE WHAT YOU SEE DESCRIBE WHAT YOU SEE AVOID THE NEED TO CLASSIFY EVERY DECELERATION AVOID THE NEED TO CLASSIFY EVERY DECELERATION ASSESS THE OVERALL CONDITION OF THE FETUS 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 appropriate clinical responses to suspicious or pathological tracings Training should include local guidelines relating to fetal monitoring both intermittent and EFM Training should include local guidelines relating to fetal monitoring both intermittent and EFM

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

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

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

49 COMMUNICATION NOTIFY IF NO DRUGS WERE GIVEN 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. 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 PHYSICIAN PRESENCE MAY NOT BE REQUIRED but inform

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

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

52 Tracings Tracings Unsatisfactory or Missing Abnormal tracing ignored or not recognized Abnormal tracing ignored or not recognized Tracings not done 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 If removed for teaching purposes or etc, should be easily located They minimize incidence of adverse outcome They minimize incidence of adverse outcome

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

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

55 Professional Responsibility To act within scope of practice To act within scope of practice To seek support and guidance To seek support and guidance Work within organizational standards Work within organizational standards Duty of care to the patient and your profession Duty of care to the patient and your profession Maintain knowledge and skills (Evidence Based Practice) Maintain knowledge and skills (Evidence Based Practice) Be prepared to defend your actions or lack of 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 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 Lapse in documentation may leave doubt about the quality of care given Hospital policy and procedure manuals will be examined Hospital policy and procedure manuals will be examined Competency levels will be evaluated, expert witness (plaintiff/defense)will determine if acceptable standards were applied 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 appropriately monitor the mother and fetus status Failure to notify the physician in a timely manner Failure to notify the physician in a timely manner Initiation of procedures without adequate client information or consent (informed consent) Initiation of procedures without adequate client information or consent (informed consent)

58 MORE Legal issues MORE Legal issues Use EFM effectively and efficiently Use EFM effectively and efficiently Interpret the tracing and respond accordingly Interpret the tracing and respond accordingly It is permanent record that is scrutinized in a litigation case It is permanent record that is scrutinized in a litigation case May be pivotal in determining liability 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 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 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. 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 has a duty to the patient A nurse commits a breach of duty A nurse commits a breach of duty A patient suffers damages A patient suffers damages Causal connection between the nurse’s actions and the patient’s 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 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 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 The chart is the witness that never dies and is discoverable for up to 21yrs Not charted not done Not charted not done RN (expert witness) help to identify when a breech of duty of standards of practice 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 Know your institution’s policy on what is to be documented on the monitor strip Routine information Routine information Identify strip with patient’s name Identify strip with patient’s name Medical record number Medical record number Date and time Date and time Procedures done Procedures done Nurses name or initials Nurses name or initials

63 OMISSION Failure to appropriately monitor client/fetus (ACOG recommendation Q 15mins 1 st stage Q 5 mins 2 nd stage) Failure to appropriately monitor client/fetus (ACOG recommendation Q 15mins 1 st stage Q 5 mins 2 nd stage) Inappropriate Pitocin monitoring/utilization Pitocin orders/continuous monitoring/ having access to physician for further instruction/orders Pitocin orders/continuous monitoring/ having access to physician for further instruction/orders Improper sponge/instrument counts during C/S Improper sponge/instrument counts during C/S Initiation of procedures without adequate client information consent (informed consent) 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: 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 Repeat notifications per institutions policy and utilize the chain of command for your institutions when no appropriate response

65 Technology

66

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


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