Presentation on theme: "Top 10 Mistakes Made During Interpretation of Fetal Heart Rate"— Presentation transcript:
1 Top 10 Mistakes Made During Interpretation of Fetal Heart Rate M. Sean Esplin MDIntermountain Medical CenterUniversity of Utah Health Sciences Center
2 EFM InterpretationEFM as a stand-‐alone tool is ineffective in avoiding preventable adverse outcomesEFM is only effective when usedin accordance with published standards and guidelinesBy professionals skilled in correct interpretation and when appropriate timely intervention is based on that interpretationInterpretation 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 expertsPersonal experienceTeacher 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 ambiguityTracing the mother and not the baby
10 Signal AmbiguityMay arise from faulty Doppler equipment or inability of the cardiotocograph to differentiate between maternal and fetal heart ratesWhen to suspect itFHR runs in low normal rangeFHR 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 minuteUse a pulse oximeter on the maternal pulse and record on the same screen as the FHRConfirm fetal rate with an ultrasoundHow to correctUse 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 obtainedPlace a scalp electrode
12 Case 2 28 year old G3 P2002 at 41 weeks 0 days for postdates induction No complications with the pregnancyCervix 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 dataProlonged periods of uninterpretable FHR and uterine activity tracing imply that there was no one attending the mother and fetusIf 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: DecreasingRisk of Adverse Outcomes and Liability Exposure, 2000
27 Importance of Clinical Scenario The significance of individual characteristics of the fetal heart rate tracing depend on the state of the fetusLate decelerations are more concerning in the context of vaginal bleeding, known growth restriction or decreased fetal movementSudden onset of severe variable decelerations are more concerning in the context of a history of previous cesarean section30% 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 presentWhen 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 deliveryPresents in spontaneous labor
30 Patient reaches C/C/-1Pushing is started at 19:50
31 Patient continues to push Contraction frequencyEvery 1-2 minutes for > 60 minutes
33 Situational Awareness Clear understanding of all of the factors at play in a clinical situationCan be lost when we are focused too intensely on one aspect of careOften happens during pushingLose track of the amount of time that has passed without reassuring features about fetal statusCan be lost at the time of hand off from one care provider to anotherHistory of previous cesarean section not relayed to next care team
34 Situational Awareness Other providers with different perspective must restore awareness by raising concernsCan 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 careConcerns of every team member must be adequately addressedThis is part of good communication
38 2 hours of pushing eventually results in vaginal delivery. APGARS 1,5,7pH not available
48 Tachysystole Management Reassuring (Normal) FHRMaternal repositioning (left or right lateral)IV fluid bolus approx. 500 mL lactated Ringer’sIf uterine activity (UA) has not returned to normal after min.Decrease oxytocin rate by at least halfUA has not returned to normal after more mindiscontinue oxytocin until UA is no more than 5 contractions in 10 min
49 Tachysystole Management Nonreassuring FHR – category 2 or greaterDiscontinue oxytocinMaternal repositioning (left or right lateral)IV fluid bolus of approx. 500 mL lactated Ringer’sConsider L/min/nonrebreather maskConsider 0.25 mg terbutaline subQDocument actions and maternal-fetal response
50 Resumption of Oxytocin After Resolution of TachysystoleOxytocin discontinued <20–30 minFHR reassuringUterine activity normalResume oxytocin at no > 1/2 rate that caused tachysystoleGradually increase rate if needed, based on protocol/ maternal-fetal status
51 Resumption of Oxytocin After Resolution of TachysystoleOxytocin discontinued >30-40 minFHR reassuringUterine activity normalResume oxytocin at initial dose orderedFollow standard protocol
52 5 contractions in 10 minute Window over 30 minutes Tachysystole Is the FHR reassuring?(Moderate variability and absence ofrecurrent late/variable decelerations)Category 2 or 3 tracingCategory 1 tracingNoYes- 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 x1Reposition patient to left or right lateral positionIV fluid bolus of at least 500mL lactated Ringers solutionIncrease frequency of assessmentDid tachysystole resolve after10-15 minutes observation?How long until FHR reassuring andresolution of tachysystole?YesNoManage oxytocininfusion as ordered toachieve contractionsevery 2-3 minutes with60 seconds restingtone between ctx.Decrease the oxytocin by ½.Continue to observe for an additional minutesOxytocin off < 30 min:- resume oxytocin at no more than ½ the previous rateOxytocin off > 30 min:- resume oxytocin atthe initial dose per order.If tachysystole does not resolve 30minutes after initial interventions:discontinue oxytocin infusionnotify the provider.Consider Terbutaline.Gradually increase oxytocin rate as ordered andmonitor maternal-fetal statusRepeat steps per algorithm as needed
54 Limiting Misinterpretation A clear definition of fetal well-‐being should be used to simplify communication between nurses and physiciansDefinition of fetal well-‐being isa 15 beat per minute acceleration of the FHR lasting 15 seconds.An initial FHR tracing that demonstrates fetal well-‐beingCategory I tracingFetal well-‐being should be the criteria formaternal dischargeintermittent auscultationmaternal medication administrationuse of cervical ripening and induction agentsregional anesthesia in most clinical situationsAbsence of fetal well-‐being necessitates direct physician evaluation with written documentation of further clinical management.
56 Purpose of Documentation Communication between caregiversDecreasing 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 includesappropriate interventions at frequencies reasonably consistent with institutional policiesprovides 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 careare able to apply that knowledge in clinical practice.
58 What is Needed to Limit Mistakes Common EFM language in all documentation and conversationsJoint nursing and physician education sessionsCollaboration and mutual respect among care giversClear definition for fetal well-being on admitClinical resources needed for timely interventionInterdisciplinary case reviewsCompetent care providersAccurate monitoringClear 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 occursEnsure that all providers on labor and delivery are qualified to read, appropriately interpret, and respond to fetal heart rate tracingsrequires a credentialing processAn explicit escalation policy that would have to be audited and enforcedwould have to be rapid and therefore avoid unnecessary duplication of effortThere is an identified responsible provider at all timesThere must be the capability of a rapid responseMinkoff et al. Obstet Gynecol 2009