Fetal Monitoring

Definitions FHR Interpretation Fetal Reserve Interventions Communication

› SBAR› Chain of Command

Documentation› During Emergent

Events

Professional Responsibility

Elements of Malpractice

Minimizing Liability Risk

Sources of Liability Claims

Fetal heart rate patterns are defined by the characteristics of:› Baseline› Variability› Accelerations › Decelerations

(JOGNN, 2008)

Baseline

Normal: 110-160 Bradycardia: < 110 Tachycardia: > 160

(NCC Monograph, 2006)

Variability Fluctuations in the fetal heart rate

baseline that are two cycles per minute or more and that are irregular in amplitude.

Absent: Undetectable 0-4 BPM Minimal: < 5 BPM Moderate: 6-25 BPM Marked: > 25 BPM

(NCC Monograph, 2006)

Variability

“Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed” (AWHONN, 2008)

Acceleration

Abrupt increase in FHR above the baseline. The peak must be > 15 bpm and last > 15 seconds. Before 32 wks they must be >10 bpm above baseline and last >10 seconds.

(JOGNN, 2008)

Acceleration

“The presence of FHR accelerations (either spontaneous or stimulated) reliably predicts the absence of fetal metabolic acidemia” (AWHONN, 2008)

Accels can be stimulated by:› Vibroacustic› Direct scalp stimulation

Variable Deceleration

Abrupt decrease in FHR. An abrupt FHR decrease is defined as from the onset of the deceleration to the beginning of the FHR nadir of < 30 seconds. The decrease in FHR is calculated from the onset to the nadir of the deceleration.

Early Deceleration

Gradual decrease and return of FHR associated with a UC. A gradual decrease is defined as one from the onset to the FHR nadir of > 30 seconds.

The nadir of the decel occurs at the same time as the peak of the UC.

Late Deceleration

Gradual decrease and return of the FHR associated with a UC.

The decel is delayed in timing, the nadir of the decel occurs after the peak of the UC.

Prolonged Deceleration

Decrease in FHR from the baseline that is > 15 bpm, lasting > 2 minutes, but < 10 minutes.

All 5 components of fetal monitoring must be considered to interpret the pattern completely › Baseline rate› Variability› Accelerations (presence or absence)› Decelerations (presence or absence and

type: Periodic or episodic)› Trends over time/Pattern evolution

(American Academy of Pediatrics, 2007)

Pattern interpretation must also take into account influencing factors:

Gestational ageMaternal medical historyMaternal medications

(American Academy of Pediatrics, 2007)

Systematic Approach to FHR Assessment

Baseline rate Variability Periodic or episodic changes Uterine activity Pattern evolution Accompanying clinical characteristics Urgency

(American Academy of Pediatrics, 2007)

The degree of hypoxemia that the fetus can tolerate before true tissue hypoxia and acidosis occur.

Fetus has reserve Decreased reserve

Normal baseline range

Abnormal baseline range

Accelerations No accelerations

Moderate variability Min/absent variability

No decelerations Decelerations present

(AWHONN fetal monitoring)

Help

Physiological goal for interventions:› Maximize utero-placental blood flow› Maximize umbilical cord circulation› Maximize oxygenation› Reduce uterine activity

Position

change

Oxygen Stop Pitocin

LR Bolus

NotifyProvider

Delivery

Communication

Poor communication skills are a major medical legal risk factor (#1 Root Cause for law suits)

Good patient centered communication practices are highly effective in reducing medical legal exposure

Providing high quality patient care is the best protection against legal liability

(AWHONN fetal monitoring) & Gruenbaum, 2007

Communication

Be Direct: When you know what you want ask for it

Use SBAR and stress urgency Be assertive Inform the provider if you will be going

up the chain of command

(AWHONN fetal monitoring)

“I am Concerned”

Get their attention

Expressconcern

State the problem

Propose action and/or solution

Reach a decision

Nurse

ResidentPACNMIntern

AttendingPhysician

Charge RN

Assistant RNManager

RN Manager

Chief of OBDr. Valenzuela

Medical Director

Continue through the chain of command until the issue is resolved

FHR Baseline Variability Accelerations Decelerations (type) Changes in pattern

(evolution of pattern) UC pattern & resting

tone

Patient’s condition› Vital Signs› Cervical exam› etc

Interventions Patient’s response

to interventions

(AWHONN)

Documentation Time frames

First Stage Every 30 minutes

First Stage Every 15 minutes

Second Stage Every 15 minutes

Second Stage Every 5 minutes

Low Risk High Risk

Documentation of Emergent Events

Time FHR or maternal status was recognized as nonreassuring

Actions initiated for fetal or maternal resuscitation › Chronologies of interventions performed

and who performed them Continued assessment of fetal

response to interventions Communication of team members

(providers) and their response(AWHONN)

Documentation of Communication

Provider’s name Time they were notified How they were notified (person or

telephone) Exactly what was

said (Use quotes) Their response When they arrive at bedside

Professional accountability applies to everyone involved in health care.

Teamwork among health care providers is critical to provide safe and effective patient care.

(Derricott, 2008)

Effective Teamwork

Teams rather than individuals create optimal performance

Effective teams work collectively to achieve agreed upon goal: best possible outcome

Each team member is valued for their unique experience, knowledge and contributions

Professionals are responsible &accountable for their individual behavior

(AWHONN, 2008)

Duty (relationship recognized by law) Breach of Duty Causation Damages

Breach of duty that causes damage (failure to meet the standard of care)

Failure to recognize and/or respond to antepartum and/or intrapartum fetal compromise

Delayed C-section Inability to appropriately resuscitate a

depressed neonate (this is why NRP skills are so important)

Inappropriate use of Pitocin and/or Cytotec Inappropriate use of vacuum and

preventable shoulder dystocia (know EFW)

Continuing education Maintain competency Obtain new knowledge Incorporate new technology and skills into

practice Maintain awareness of current research

(AWHONN Advanced FM)

“Good care, compassionately delivered and well documented is the key to avoiding suits”(Melvin Belli, 1989)

American Academy of Pediatrics, 2007. Maternal and Fetal Evaluation and Immediate Newborn Care.

JOGNN, 2008. The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on Definitions, Interpretation, and Research Guidelines. Vol 112, No3.

AWHONN Intermediate and Advanced Fetal Monitoring Workshop Student Materials.

NCC, 2006. Applying NICHD Terminology and Other Factors to Electronic Fetal Monitoring Interpretation. NCC Monograph, vol 2, No 1.

Derricott, B, 2008. Professional Accountability. www.bellaonline.com

Then…..

And now!!!!!!