Summary

Class,

As you can see from the videos, rapid intervention is the key to avoiding or minimizing adverse outcomes for the newborn. There a several nursing interventions that can be instituted when bradycardia or other non reassuring fetal heart patterns are identified. They include the following:
1. Apply oxygen via face mask at 8-10 liters/minute to the mother
2. Turn patient on her left side to maximize blood flow to the placenta
3. Turn off a pitocin drip if one is running
4. Open the IV for hydration
5. Most importantly - Notify the physician!!!

Be sure to document the fetal heart tracing as you see it, describing it accurately. Be sure to include the baseline FHR, variability, any accelerations or decelerations, describe the depth and duration of the decelerations, and relationship to the contractions. Be sure to document all communications with physicians.

Please post your final thoughts and comments. I will return again with another blog to continue on our quest to ensure obstetric safety for all mothers and babies.

Hope you all enjoy the video.


http://www.youtube.com/watch?v=RP4abiHdQpc&feature=related

Fetus at Risk for Metabolic Acidemia

Class,
I am posting part 2 of the video on fetal heart rate monitoring. This is a seven and one half minute video that discusses the importance of intervention when fetal bradycardia occurs. The longer the delay in delivery when bradycardia occurs the more chance for an infant to be born with a metabolic acidemic. There is an increase risk for severe fetal injury the longer there is a delay to delivery.

Please post your questions and remarks after viewing the video.

Click on the link below to view.

http://www.youtube.com/watch?v=BXg13t97zfI&feature=related

Fetal Response to Interrupted Oxygenation

Class,

In my last posting, I discussed the environmental causes of interrupted oxygenation to the fetus. This post we will discuss the fetal response to interrupted oxygenation. What information can the fetal heart tracing provide regarding transfer of oxygen?

Interruption of the pathway of oxygen transfer from the environment to the fetus caused by compression of the umbilical cord can result in a variable deceleration.

Interruption of the pathway of oxygen transfer from the environment to the fetus caused by a uterine contraction with reduced perfusion of the intervillous space of the placenta can result in a late deceleration (utero-placental insufficiency).

Interruption of the oxygen pathway at any point can result in a prolonged deceleration.

What do we know about the fetal response to interrupted oxygen transfer?

The fetal response to interrupted oxygenation follows this pathway:

FETUS

↓

HYPOXEMIA

↓

HYPOXIA

↓

METABOLIC ACIDOSIS

↓

METABOLIC ACIDEMIA

↓

POTENTIAL INJURY

Please think about some of the potential injuries you might see with progressive interrupted oxygenation to the fetus and post your response.

Physiology of fetal oxygenation

Fetal Oxygenation Pathway

Class,

In order to understand the fetal response to the lack of oxygenation, you need to understand the oxygenation pathway to the fetus. Oxygen is transferred from the environment to the fetus by maternal and fetal blood along a pathway that includes the maternal lungs, heart, vasculature, uterus, placenta, umbilical cord, and fetus.

ENVIRONMENT

↓

MATERNAL LUNGS

↓

HEART

↓

VASCULATURE

↓

UTERUS

↓

PLACENTA

↓

UMBILICAL CORD

↓

FETUS

Summary of the Oxygen pathway and causes of interrupted oxygen transfer

Oxygen Pathway	Causes of interrupted oxygen transfer
Lungs	Respiratory depression (narcotics, magnesium sulfate) Apnea, seizures (eclampsia) Pulmonary embolus, pulmonary edema Pneumonia, ARDS Asthma, atelectasis
Heart	Decreased cardiac output Hypovolemia Compression of the inferior vena cava Regional anesthesia (sympathetic blockade) Cardiac arrythmias
Vasculature	Hypotension Hypovolemia Compression of the inferior vena cava Regional anesthesia(sympathetic blockade) Medications (hydralazine, labetalol, nifedipine)
Uterus	Excessive uterine activity Uterine stimulants (prostaglandins, oxytocin) Uterine rupture
Placenta	Placental separation Rarely vasa previa Rarely fetal-maternal hemorrhage Placental infarct, infection (usually confirmed retrospectively)
Umbilical cord	Cord compression Cord prolapse “True” knot

Please post your comments and questions.

Next module, I will be discussing the fetal response to interrupted oxygenation.

Miller, L. (2008). Electronic fetal monitoring. HANYS Obstetric Safety Initiative. Train the trainer power point presentation.

Perinatal SBAR

 Perinatal SBAR Tool

Class,

As you have seen from the video, communication with all members of the healthcare team is critical when minutes count. It is essential that communication is clear and accurate when reporting the events around a non reassuring FHR tracing.

The SBAR (Situational – Background – Assessment – Recommendation) technique provides a framework for communication between members of the health care team about a patient’s condition. SBAR is easy to remember and is useful in any conversation, especially critical ones, that require immediate attention and action. It is an easy and focused way to set expectations for what will be communicated and how the information is communicated between team members which is essential for developing team work and fostering a culture of safety.

I am attaching a sample SBAR tool for you to review. Please post your comments or questions regarding the usefulness of this tool in the L&D setting. As you look at this tool, do you think the tool will be useful in communicating effectively to the physicians? Why? Do you think the recommendations by the nursing staff will be acted upon by physicians?

http://www.ihi.org/NR/rdonlyres/E8DE1B16-7F12-4C80-ABFC-EFAC4EA97063/3237/SetonPerinatalSBARReportTooltophysicianaboutacriti.pdf

Institute for Healthcare Improvement (2008). Perinatal SBAR. Retrieved from:

http://www.ihi.org/IHI/Topics/PerinatalCare/PerinatalCareGeneral/EmergingContent/Peri

natalSBARTools.htm

NICHD definitions and terminology

Class, today I am posting a power point presentation that discusses the NICHD definitions and terminology for FHR baseline, variability, late and variable decelerations. Please post any questions or comments you may have after viewing the presentation.
Please click on the link below to view power point.



www.slideshare.net/dhastee/electronic-fetal-monitoring-ppt

Emergency response

Class

This post contains a 9 minute video on emergency response. This is the first part of a four part series on indentifying and responding to non- reassuring fetal heart patterns, SBAR communication, and appropriate documentation. This video is emergency response. Please post your comments when you finish viewing the video.
I had the pleasure of attending a two day fetal monitor interpretation education with the presenter, Michael Fox on the video a few years ago.


http://www.youtube.com/watch?v=1PwGRDnXwow

Electronic Fetal Monitoring definitions

Class,
            The previous post described the six components to interpretation of the fetal monitor tracing. This post contains the pattern definitions. We will be referring to the contents of these two posts as we explore fetal heart tracing interpretation and the significance of the various patterns to fetal well being.    

Pattern Definitions

Baseline • The mean FHR rounded to increments of 5 beats per minute during a 10-minute segment, excluding:

—Periodic or episodic changes

—Periods of marked FHR variability

—Segments of baseline that differ by more than 25 beats per minute

• The baseline must be for a minimum of 2 minutes in any 10-minute segment, or the baseline for that time period is indeterminate. In this case, one may refer to the prior 10-minute window for determination of baseline.

• Normal FHR baseline: 110–160 beats per minute

• Tachycardia: FHR baseline is greater than 160 beats per minute

• Bradycardia: FHR baseline is less than 110 beats per minute

Baseline variability • Fluctuations in the baseline FHR that are irregular in amplitude and frequency

• Variability is visually quantitated as the amplitude of peak-to-trough in beats per minute.

—Absent—amplitude range undetectable

—Minimal—amplitude range detectable but 5 beats per minute or fewer

—Moderate (normal)—amplitude range 6–25 beats per minute

—Marked—amplitude range greater than 25 beats per minute

Acceleration • A visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR

• At 32 weeks of gestation and beyond, an acceleration has a peak of 15 beats per minute or more above baseline, with a duration of 15 seconds or more but less than 2 minutes from onset to return.

• Before 32 weeks of gestation, an acceleration has a peak of 10 beats per minute or more above baseline, with a duration of 10 seconds or more but less than 2 minutes from onset to return.

• Prolonged acceleration lasts 2 minutes or more but less than 10 minutes in duration.

• If an acceleration lasts 10 minutes or longer, it is a baseline change

.

Early deceleration • Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction

• A gradual FHR decrease is defined as from the onset to the FHR nadir of 30 seconds or more.

• The decrease in FHR is calculated from the onset to the nadir of the deceleration.

• The nadir of the deceleration occurs at the same time as the peak of the contraction.

• In most cases the onset, nadir, and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction, respectively.

Late deceleration • Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction

• A gradual FHR decrease is defined as from the onset to the FHR nadir of 30 seconds or more.

• The decrease in FHR is calculated from the onset to the nadir of the deceleration.

• The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.

• In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively.

Variable deceleration • Visually apparent 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 less than 30 seconds.

• The decrease in FHR is calculated from the onset to the nadir of the deceleration.

• The decrease in FHR is 15 beats per minute or greater, lasting 15 seconds or greater, and less than 2 minutes in duration.

• When variable decelerations are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions.

Prolonged deceleration • Visually apparent decrease in the FHR below the baseline

• Decrease in FHR from the baseline that is 15 beats per minute or more, lasting 2 minutes or more but less than 10 minutes in duration.

• If a deceleration lasts 10 minutes or longer, it is a baseline change.

Sinusoidal pattern • Visually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3–5 per minute which persists for 20 minutes or more.

Abbreviation: FHR, fetal heart rate.

Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring:

update on definitions, interpretation, and research guidelines. Obstet Gynecol 2008;112:661–6.

Introduction to appropriate use of terms describing FHR patterns

Appropriate clinical management of various fetal heart rate (FHR) patterns is dependent on the use of standardized definitions that have been determined by the NICHD. Adopting a common language for FHR pattern definitions and documentation is agreed upon by providers to enhance communication among care givers and therefore, enhance maternal-fetal safety. Timely intervention during non reassuring FHR patterns is dependent on clear communication between providers who are caring for the individual patient. There are several patterns that are predictive of current or impending fetal asphyxia so severe that the fetus is at risk for neurologic and other fetal damage. Members of the perinatal team have a shared method of interpreting FHR patterns and management guidelines.
A full description of an EFM tracing requires a qualitative and quantitative description of:
            1. Uterine contractions
            2. Baseline FHR
            3. Baseline FHR variability
            4. Presence of accelerations
            5. Periodic or episodic decelerations
            6. Changes or trends of FHR patterns over time

Next posting will include fetal heart characteristics and pattern definitions.


Macones, G., Hankins, G., Spong, C., Hauth, J., and Moore, T. (2008). The 2008 National Institute of Child Health and Development Workshop Report on Electronic Fetal Monitoring. Obstetrics and Gynecology, 112 (3), pp. 661-666.

Simpson, K. & Creehan, P. (2008). Fetal assessment during labor. In Perinatal Nursing, 3^rd ed.  Philadelphia, Pa.: Lippincott, Williams, and Wilkens

Objectives

The objectives for the EFM course are as follows. The student will be able to:

1. Identify fetal oxygenation needs, mechanical and pharmacological factors influencing fetal oxygenation.
2. Recognize EFM elements consistent with normal oxygenation and possible evolving metabolic acidemia, and the interventions for each.
3. Define and recognize all elements of EFM tracing including: FHR baseline, variability, accelerations, decelerations, and uterine contraction characteristics using the standard NICHD nomenclature.
4. Distinguish abnormal FHR tracings from normal
5. Recognize common perinatal complications, noting both maternal and fetal responses.
6. Evaluate interventions and modify plan of care.
7. Apply current standards of practice, documentation essentials and legal principles relative to EFM.

Electronic Fetal Monitoring

Monday, June 13, 2011

Electronic Fetal Monitoring

The introduction of electronic fetal monitoring (EFM) in the late 1960's has had a huge impact on perinatal care and the practice of nursing. With attention on the effects of perinatal morbidity and mortality and the role in healthcare costs and malpracticee litigation, EFM is used in the majority of labor and delivery units in the United States. The National Institute for Child Health and Development (NICHD) introduced standardized FHR pattern definitions and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommended use of standard language for communication and documentation of FHR patterns. In 2005, the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) and the American College of Obstetricians and Gynecologists (ACOG) supported the adoption of the definitions for FHR patterns.
Clincal reliance on EFM is high and is used in the clinical setting to determine adequacy of fetal oxygenation and well-being during labor. Adoption of a common language for FHR pattern definitions and documentation is routinely used by all providers which enhances interdisciplinary communication and maternal-fetal safety.
Over the next 4 weeks, there will be postings that will define FHR patterns, discuss physiologic basis for FHR monitoring, interpretation of FHR, and nursing management of FHR patterns.

Simpson, K. (2009). Fetal assessment during labor. In Simpson, K. & Creehan, P. (2008). Perinatal Nursing, 3rd ed. Philadelphia, Pa: Lippincott, Williams, and Wilkens.