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

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.

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

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

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

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

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

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

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

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

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

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

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

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

To OR for Cesarean section

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 = ?

7) No regard for clinical scenario

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

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?

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

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

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

6) Loss of situational awareness

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

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

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

5) Not giving appropriate response to concerns from other caregivers

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

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

4) Failure to initiate the chain of command

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

3) Continuing to give oxytocin in the wrong setting

2) Failure to appropriately treat tachysystole

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 10-15 min. Decrease oxytocin rate by at least half UA has not returned to normal after 10-15 more min discontinue oxytocin until UA is no more than 5 contractions in 10 min

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 oxygen @10 L/min/nonrebreather mask Consider 0.25 mg terbutaline subQ Document actions and maternal-fetal response

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

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

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 10-15 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

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

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.

1a) Inadequate documentation

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

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.

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

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

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