1. Intrapartum Computer Monitoring
Presented by
Yvette M. Kreitz, RN

2. Objectives Definitions.
Describe the purpose of intrapartum computer monitoring.
Describe the hardware and software utilized with this technology.
Assess the role and function of the nurse involved with this technology.
Examine related legal and/or ethical issues.
Discuss the advantages and disadvantages from a nursing perspective.
Review the objectives.

3. Definitions Electronic fetal monitoring (EFM) Fetal heart tracing
Intrapartum computer monitoring
Intrauterine pressure catheter (IUPC)
Tocodynamometer (“Toco”)
(Taber’s, 2005)
Electronic fetal monitoring (EFM) – a method of placing a fetal monitor on the fetus in order to obtain a continuous tracing of the fetal heart rate, which allows many characteristics of the fetal heart rate to be observed and evaluated. This can be done externally on the mother with an ultrasound transducer or Doppler, or internally with a fetal scalp electrode.
Fetal heart tracing – a continuous graph paper record of the fetal heart rate and contraction pattern.
Fetal monitor – monitor used to display and record (on a paper tracing and archived in the network) the following information:
Fetus - heart rate in utero (being internally or externally monitored), and response to uterine contraction patterns (being internally or externally monitored),
Mother - blood pressure, heart rate, oxygen saturation, pulse, respirations, and temperature.
Intrapartum computer monitoring – the cumulative computer system of hardware and software used to enter, store, retrieve, and analyze maternal and fetal date during the intrapartum period. Hardware includes a centralized station with server/network, bedside terminals, and remote access sites.
Intrauterine pressure catheter (IUPC) – an internal device used to provide accurate measurement of uterine contraction intensity.
Tocodynamometer (“Toco”) – an external device for estimating the force of uterine contractions.
(Tabers, 2005)

4. Examples
Discuss photographs in relation to definitions from previous page. This is a general overview as more detail will be provided later in the powerpoint.

5. Purpose of intrapartum computer monitoring
Comprehensive, computerized network consisting of:
Centralized server/network
Bedside stations
Remote access points
Printers
Comprehensive, computerized system consisting of:
Centralized server/network
Located at the nurse’s station with multiple screens to monitor several patients simultaneously, from different locations at the station.
Printed reports following delivery are generated at the nurse’s station and included in patient records.
Bedside stations
Local CPU/printer.
Includes fetal monitoring equipment and strips.
Remote access points
Mobile access.
Stations located in physician sleep rooms.
Stations located in physician offices (outside of the hospital).
Stations located in nurse break room.
Stations located in hospital conference room.

6. Purpose of intrapartum computer monitoring
Diverse access points allow for:
Remote patient surveillance
Increased participation from support staff
Continuous monitoring
Improved continuity of care
(Sandelowski, 2000)
Diverse access points allow for:
Remote patient surveillance for improved patient care at the hospital and in the physician’s office.
More than one nurse/physician can have access to the information and provide input to improve patient care.
Physicians not in the hospital can quickly respond to inquiries about the best plan of action for a patient, or proactively monitor a patient in labor with remote or mobile access.
Allows for continuous monitoring in multiple patient settings.
Improved continuity of care.
(Sandelowski, 2000)

7. Purpose of intrapartum computer monitoring
Software advancements enable:
Comprehensive data over a nine-month period
Point-of-care and real-time charting
Immediate alarm features and critical value notifications
Software integrated with evidence-based practices
( 2009)
Software advancements enable:
Comprehensive patient data to be retained for the entire nine month prenatal period. Archiving of patient history, past visit information, x-rays/lab data and fetal heart tracings makes it readily available in a safe and secure environment.
Point-of-care and real-time charting.
Remote alarm system for critical values such as elevated blood pressure, increased contraction pattern, and non-reassuring fetal heart rate.
Evidence-based practices are in the database to assist in adherence to clinical standards.
( 2009)

8. System hardware Centralized server/network Network printers
Main station computers
Bedside stations
Remote access points
Discuss system set-up.
System can be tailored for the size of the unit, providing computers and networks for as small as 1 bed, and as large as 100 beds.
Hardware doesn’t have to be solely allocated for this software. Will easily accommodate other hospital programs.
Internet-based remote access points provide secure access to historical and real-time patient information.

9. (Ladewig, London & Davidson, 2006)
System hardware
Fetal monitor & belts
Toco or IUPC
Ultrasound transducer or fetal scalp electrode
Blood pressure cuff
Pulse oximeter
(Ladewig, London & Davidson, 2006)
The fetal monitor is used to display and record the fetal heart rate in utero, as well as the fetus’s response to contractions. The monitor also displays and records the maternal blood pressure, heart rate, oxygen saturation, pulse, respirations, and temperature. The corresponding rates and patterns are recorded on a continuous graph which prints from the monitor. This data is also recorded and stored in the computer archive.
For external monitoring, the toco and the ultrasound transducer are attached to the mother by adjustable velcro belts. The toco and ultrasound transducer are then plugged into the fetal monitor. The toco measures the external force of the contractions, and records that pattern on the strip. The ultrasound transducer externally monitors the fetal heart rate.
During fetal monitoring, health care professionals routinely analyzes the graph, either in the patient’s room, or by remote location, to determine fetal and maternal conditions and contraction patterns. Based upon these conditions, the nurse and physician tailor a plan to help deliver the baby in the best possible manner.
(Ladewig, London & Davidson, 2006)

10. System hardware
For improved reading of the fetal heart rate and contraction patterns, internal monitoring may be utilized. Maternal obesity, multiple fetuses, pre-eclampsia and non-reassuring patterns are a few of the reasons internal monitoring is preferred.
For fetal heart monitoring, a scalp electrode is attached directly on the fetus’s scalp through the cervix. The other end is attached to the monitor.
Additionally, for improved reading of uterine contraction intensity, an internal IUPC can be placed by the physician. The catheter is placed through the cervix and lies to the side of the fetus.

11. System software
Top 5 Windows-based intrapartum software monitoring programs:
Clinical Computer Systems: OBiX Perinatal Systems
GE Healthcare: Centricity Perinatal
Hill-Rom: NaviCare WatchChild Solutions
LMS Medical: CALM Suite
Philips: IntelliVue OB Care
( 2009)
KLAS Enterprises, LLC, provides ratings of healthcare technology.

12. System software Modular design for flexibility and efficiency
Patient-focused surveillance and continuous monitoring
On-line documentation
Alerts and reminders
( 2009)
The top-5 Windows-based programs all provide the same services, just in different formats. The main services are:
Modular design for flexibility and efficiency
System is scalable to provide one feature/program (such as NICU monitoring), or expandable to include all programs and features.
Can provide charting for as few as 2 beds to as large as 100 beds.
Easy access to well-organized information improves efficiency, allowing for the nurse to focus more attention on patients.
- Generates monthly statistical reports.
2. Patient-focused surveillance and continuous monitoring
Continuous monitoring allows for monitoring of mother and fetuses (including triplets).
Complete point-of-care allows fetal, maternal, and newborn charting at the bedside.
With remote access, physicians can review patient’s progress and provide timely responses.
3. On-line documentation
Data entered one time in the computer program, and is automatically placed wherever relevant in the patient’s record.
Real-time charting menus and consistent time stamps on all EFM strips.
Intuitive point-and-click menus and preprogrammed drop-down lists simplifies the charting process.
Nurses notes and annotations are charted quickly and easily.
Admission, allergies, medicine reconcilation, standards of care, anesthesia records, operation data, delivery records, and other applications can be incorporated easily into one program.
Print-outs of hand-off reports are quickly generated and are in a easy-to-follow format.
- Meets all HIPAA and JCAHO regulations.
4. Alerts and reminders
Integrated alerts and reminders notify nurse and physician at the patient’s bedside of specific protocols or lab results, enabling faster response to events.
Fetal trace alerts alarm at multiple stations to ensure critical events are addressed in a timely fashion.
( 2009)

13. System software Archival of data
Functions and communicates with other hospital programs and departments
Maintains patient confidentiality and data security.
Decision support
( 2009)
5. Archival of data
Centralized, electronic patient record for mother and baby.
Entire nine month perinatal period is readily available.
- Data can be stored for up to thirty years.
6. Functions and communicates with other hospital departments and programs
Laboratory data, imaging, and pharmacy data are integrated without difficulty.
7. Maintains patient confidentiality and data security
- Secure access is provided to encrypted views via a Web-based browser.
8. Decision support
On-site education
24-hour help line and computer support
( 2009)

14. Software usability evaluation
Users must be an early and continuous focus during interface design.
The design process should be iterative, allowing for evaluation and correction of identified problems.
Formal evaluation should take place using rigorous experimental and/or qualitative methods.
(Staggers, 2003), (Effken, 2009)
Users must be an early and continuous focus during interface design.
Software was developed by nurses and physicians.
Software goes through regular reviews by healthcare providers.
Updates are routinely provided to address any issues, incorporate the latest findings, or integrated the newest technology. Prior to updates, trials are conducted by healthcare providers to ensure problems are addressed.
The design process should be iterative, allowing for evaluation and correction of identified problems.
The software has been created and enhanced so that it is simply and streamlined. It’s user-friendly and utilizes a common-sense approach to charting.
The mapping and organization of the software makes sense.
The charting process is understandable and clear.
The software has been designed to reduce charting errors and bring to the users attention potential problems.
Formal evaluation should take place using rigorous experimental and/or qualitative methods.
Software applications are transparent. They fit seamlessly into the daily practice. One doesn’t realize the ease of the application until a situation arises in which one must paper chart.
The software is usable and simplified to make the process enjoyable. The program also enables more time and attention to patient care.
With GE Healthcare’s Centricity Perinatal, the new comprehensive software update was sent to trial groups for a one year period. Their comments and feedback were then utilized to fine-tune the program before distribution to all hospital users.
(Staggers, 2003), (Effken, 2009)

15. Information System Review
What is an information system?
Information system used for intrapartum computer monitoring, and its function.
Part clinical/part special-purpose
A communication system
A patient care system
(McGonigle & Mastrian, 2009)
First, let’s talk about what is an information system. According to McGonigle & Mastrian, (2009), an information system is:
“The manual and/or automated components of a system of users or people, recorded data, and actions used to process the data and information for a user, group of users, or an organization.”
What information system is used for intrapartum computer monitoring? Well the information system is unique. It’s part clinical, part special purpose. Primarily, it serves as a patient care information system (PCIS), incorporating clinical documentation systems, pharmacy and laboratory systems, and imaging systems. Let’s take a moment to discuss those categories and how this system functions.
Patient Care Information System
Clinical documentation –
Collects patient data and facilitates real-time charting.
Provides immediate data to the nurse and physician’s at the patient’s bedside or a remote location.
Patient centered: allow for observations, interventions and outcomes by the nurse and physician.
Care plans, data, lab values, notes, allergies, medications, contraction patterns, fetal response to labor, and how the patient is responding to labor, are all readily available.
Serves as the patient’s record over a nine month period.
Pharmacy information –
Allows for the physician and pharmacist to order, manage and dispense medications to the patient.
Allergies, height/weight information, and previous medical issues are incorporated.
Laboratory information –
Laboratory values, blood type, platelet levels (in anticipation of an epidural), critical values, urinalysis results, etc., are collected from the patient, analyzed in the laboratory, and are readily available in the system.
Imaging systems –
Results of CT scan, ultrasounds, fetal imaging, etc. are available and accessible in this system.
Nine months of imaging is available at a click of the mouse.
Communication Information System
Allows for timely interaction between the physician and nurse.
Remote access, telephones, , pagers and instant messaging are incorporated into the system.
Physicians can access patient information at home, at their sleep room, at their clinic, or at the patient’s bedside.
Nurses can access patient information at remote hospital locations, the nurses main station, or at the patient’s bedside.
(McGonigle & Mastrian, 2009)

16. Information System Review
Who uses the information system?
How is the information system configured?
What data standards are used in this system?
What Disease and Procedure Classification System is used?
Who uses the information system?
Nurses
Physicians
Midwives
Laboratory technicians
Radiology
Nursing administrators
HIS
How is the information system configured?
Centralized server/network
Network printers
Main station computers
Bedside stations
Remote access points
What data standards are used in this system?
American National Standards Institute (ANSI)
What disease and procedure classification system is used?
None

17. Information System Review
Nursing practice standards
NIC
NOC
AWHONN
NICHD
Recommendation regarding this system
Nursing Practice Standards used:
NIC – Nursing Intervention Classifications
NOC – Nursing Outcome Classifications
AWHONN – Association of Women’s Health, Obstetric, and Neonatal Nurses
NICHD – National Institute of Child Health and Development
Recommendation regarding this information system
I highly recommend this software as it provides a more accurate means of monitoring mother and baby prior to, during, and after delivery. The vast majority of clinics and hospitals agree, providing some form of intrapartum computer monitoring to meet the needs of their facility. This information system takes the guess-work out of the care of mother and baby, and allows for a quicker response to critical issues.

18. Advantages of Intrapartum Computer Monitoring
Nurse-patient interaction
Reporting
Storage
Time Management
Flexibility
Safety
( 2009)
Helps increase the nurse-patient interaction
Allows more time at the bedside
Provide a higher quality of records and reporting
Improves patient charting quality
Reduces charting and reporting time
Reduces charting duplication
Helps reduce risks associated with lost paper records
Reduces record storage and retrieval costs
Provides images
Easily monitor patients at multiple locations
Increases staff flexibility and satisfaction
Addresses emergency/crisis issues
AWHONN, HIPPA, and JHACO compliant

19. Disadvantages of Intrapartum Computer Monitoring
Critical thinking
System down-time
Responsibility
Cost
Computerized systems with the ability to “do it all” can create an over-reliance on the system.
Critical thinking can diminish if the nurse becomes over-reliant.
Sometimes the system doesn’t detect small changes in fetal heart rate or contraction patterns. The nurse must be cognizant of these changes and work with the system.
The system is not meant to replace the critical thinking abilities of the nurse. Ultimately, the nurse remains the responsible party.
System down-time can make records access impossible. The nurse must still be capable of monitoring the patient without the software/hardware, and must be able to paper document in the interim.
Cost for intrapartum computer systems is high. In an economic downturn, hospitals cannot afford costs for necessary upgrades. Some hospitals are choosing to go back to early monitoring practices without this important hardware/software, which puts the patient at risk.

20. Ethical and Legal Issues
Privacy, confidentiality
Responsibility
Documentation
System over-reliance
Privacy and confidentiality must be maintained by the nurse. There is a security risk that records can be accessed if log-in files and passwords aren’t kept up-do-date.
The system is not meant to replace the critical thinking abilities of the nurse. Ultimately, the nurse remains the responsible party.
System down-time can make records access impossible. The nurse must still be capable of monitoring the patient without the software/hardware, and must be able to paper document in the interim.
The software developers stand behind their products and will provide coverage if the legal issue is due to the fault of their program.

21. Informatics Competencies
Operates Windows applications
Uses instant messaging and
Knowledge of applicable intrapartum monitoring system – hardware and software
Knows hospital-specific nursing policies for charting, storage & medication administration.

22. Functions and Responsibilities of the Informatics Nurse
Perspective
Theories, principles, concepts
Ergonomics
HCI principles
Social, legal and ethical impacts
Role
(McGonigle & Mastrian, 2009)
Provides a nursing perspective, values, beliefs into the utilization of the intrapartum monitoring system.
Utilizing nursing knowledge and theories in the system application and use.
Integrates ergonomics and HCI principles into the design, development, implementation and evaluation of the system.
Determines social, legal, and ethical impacts on the department, the hospital, and health care in general.
Serves as the educator of fellow nurses, and liaison with management and software/hardware company.
(McGonigle & Mastrian, 2009)

23. Summary Briefly overview benefits of software
Purpose
Hardware/software
Role and function of the nurse
Information system review
Advantages/disadvantages
Nursing informatics
Intrapartum computer monitoring is a comprehensive, computerized system utilized in the delivery process to monitor the mother and baby. It consisting of a centralized server/network, bedside stations, local printers, and remote access points.
Briefly review hardware/software - Fetal monitor & belts, Toco or IUPC, Ultrasound transducer or fetal scalp electrode, Blood pressure cuff, and Pulse oximeter
Briefly overview benefits of software
Briefly review the role and function of the nurse
Information system review
Review advantages/disadvantages
Review role of nursing informatives
Question/Answer Period

24. References
Clinical Computer Systems, Inc. (2009). OBiX Overview. Retrieved from
Effken, J. A. (2009). Improving the Human-Technology Interface. Nursing
Informatics. Sudbury, MA: Jones and Bartlett, (p ).
GE Healthcare, Inc. (2009). Centricity Perinatal Product Technology. Retrieved
from
KLAS Reseach, LLC. (2009). Rating Healthcare Technology. Retrieved from

25. References
Laedwig, P. A., London, M. L, & Davidson, M. R. (2006). Contemporary
Maternal-Newborn Nursing Care. (6th ed.). Upper Saddle River, NJ: Pearson-Prentice Hall, (p ).
LMS Medical, Inc. (2009). High reliability in obstetrics. Retrieved from
McGonigle, D. & Mastrian, K. (2009). Nursing informatics and the foundation
of knowledge. Sudbury, MA: Jones and Bartlett Publishers, (p ).

26. References
Sandelowski, M. (2000, May). Retrofitting technology to nursing: the case of
electronic fetal monitoring. JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing, 29(3), Retrieved September 8, 2009, from CINAHL database.
Staggers, N. (2003). Human factors: Imperative concepts for critical care, 14(3),
Retrieved October 1, 2009, from CINAHL database.
Taber’s cyclopedic medical dictionary (20th ed.). (2005). Philadelphia, PA: F. A
Davis, 749.