TEAM COMMUNICATION AND FETAL HEART RATE MONITORING

Texas Center for Quality & Patient Safety

Michael Nix, MD 4/25/2020

GOALS

• • • • Communication strategies NICHD Fetal Heart Rate Terminology Three-Tier Fetal Heart Rate Interpretation System Resuscitative measures

•

COMMUNICATION

The process by which information is transferred between individuals or teams

COMPONENTS OF COMMUNICATION

• • • • Sender Receiver Message Feedback

COMMUNICATION ERROR

• • The leading root cause of sentinel events from 1995-2005 In the category of maternal injury or death • • Implicated in >60% of cases 1995-2004 >80% in 2005

Joint Commission Sentinel Event Root Causes

FOCUS ON GETTING THE MESSAGE TO THE RECIPIENT

• • JCAHO National Patient Safety Goal #2: Improve the effectiveness of communication among caregivers One of the six main competencies of ACGME

• • • • • • • • •

FACTORS THAT CAN IMPEDE EFFECTIVE COMMUNICATION

Different communication styles Expert vs. novice Hierarchy Culture/ethnicity/language difference Gender Socioeconomics History of unresolved conflict Personality/behavior of the patient or provider Level of respect, tone of voice, body language “Clinical Communication and Patient Safety” HHN Magazine, August 2006

PATIENT CARE PROBLEMS RELATED TO POOR COMMUNICATION

• • • Providing care with incomplete or missing information Executing poor patient handoffs with relevant clinical data not clearly communicated Failing to share and communicate known information Achieving Safe and Reliable Healthcare, Leonard, et al 2004

• • • • •

EFFECTIVE COMMUNICATION

Complete Concise Clear Timely Allows Feedback

COMPLETE

CONCISE

CLEAR

TIMELY

ALLOWS FEEDBACK

• • • •

SBAR

Situation: Describe • What is going on with the patient?

Background: Concise and Focused • What is the key clinical background or context?

Assessment: Judgment • What is the problem?

Recommendation: What needs to happen • What do I recommend or what do I want you to do?

From Safer Healthcare ( http://www.saferhealthcare.com

)

INCOMPLETE INFORMATION

• • • • “ Decels in room 3” (Situation) “We need you in room 3” (Recommendation) “I need you to come assess the patient in room 3. She is having decels.” (Situation and Recommendation) “Room 3 is having decels. The FHRT is otherwise reassuring.” (Situation and poor Assessment)

APPROPRIATE COMMUNICATION

S

“I’m Mike, the nurse taking care of Ms. Johnson in room 3. She is having late decels.”

B

“She was admitted by Dr. Not-on-call-anymore at 8 this morning for an induction at 41 weeks of gestation. She received cytotec followed by pitocin starting at 5pm. Until now, she has had a Category I tracing”

A

“For the last 30 minutes, she has had late decelerations with each contraction. The baseline is in the 150’s and shows minimal variability. There are no accelerations. I have stopped the pitocin, and she is contracting every 5 minutes. She was 3/thick/-3 on exam.”

R

“I would like you to come review the FHRT to see if you think that we should continue the induction.”

SBAR

R

?

• • Response: Acknowledge and document the response of the provider Closes the loop of communication

FETAL MONITORING

EFM VS. INTERMITTENT AUSCULTATION

• • • • • Increased c-section rate (RR, 1.66; 95% CI, 1.30-2.13) Increased OVD risk (RR, 1.16; 95% CI, 1.01-1.32) No change perinatal mortality (RR, 0.85; 95% CI, 0.59-1.23) Reduced neonatal seizures (RR, 0.50; 95% CI, 0.31-0.80) No change in CP risk (RR, 1.74; 95% CI, 0.97-3.11) Alfirevic et al 2006

WHY USE EFM?

•

Logistics

•

Trials excluded high risk pregnancies

• • • • •

2008 NICHD WORKSHOP ON EFM REPORTING

Multiple discipline groups represented:

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) American College of Obstetricians and Gynecologists (ACOG) The Society for Maternal-Fetal Medicine Royal College of Obstetricians and Gynaecologists (RCOG) Society of Obstetricians and Gynaecologists of Canada (SOCG)

2008 WORKSHOP GOALS

The goals of this workshop were:

• • • • Review & update the definitions for FHRT patterns Assess existing classification systems for interpreting specific FHRT patterns & to make recommendations about a system for use in the U.S. Make recommendations for research priorities for EFM Reaffirm definitions from the previous work group of 1997

PERTINENT PRINCIPLES

Principles defined in the initial publication in 1997, then reaffirmed in 2008 are as follows:

• • • • No distinction between long and short-term (beat to beat) variability External monitoring devices can adequately assess variability The features of FHR patterns are categorized as either baseline, periodic, or episodic Sinusoidal term reserved for the ‘true pattern’ • pseudo-sinusoidal is not defined

PERTINENT PRINCIPLES

• • • Definitions are visual interpretations Gestational age is considered when evaluating patterns A complete description of the EFM tracing includes: • • baseline variability • accelerations • • deceleration contractions

CHANGES & NEW TERMINOLOGY FROM 2008 WORKSHOP

• • • Classification of FHR Patterns Abandon the terms: • Reassuring • Non-Reassuring Three-tiered Classification System FHRT may move back and forth between categories

CHANGES & NEW TERMINOLOGY FROM 2008 WORKSHOP

Uterine Activity Definitions • • Quantified as the number of contractions in a 10 min. window, averaged over 30 min Normal < 5 contractions in a 10 min. period Tachysystole > 5 contractions in 10 min. period • Should always be qualified as to the presence or absence of associated FHR decelerations

CHANGES & NEW TERMINOLOGY FROM 2008 WORKSHOP

• • •

Tachysystole

Perception of pain is not a reliable indicator of potential implication Abandon the terms

• Hyperstimulation • Hypercontractility

A description of duration, intensity, and resting tone can be described

UTERINE TACHYSYSTOLE

2008 NICHD Terms & Definitions

Baseline Rate

-Mean FHR rounded to increments of 5 bpm during a 10 minute segment excluding: accelerations, decelerations, periods of marked variability and segments of baseline that differ by > 25 bpm. Requires a tracing > 2 min. in a 10-min. segment or its indeterminate. ¤

Bradycardia Tachycardia Variability - Absent Variability - Minimal Variability

Baseline rate of < 110 bpm for > 10 min Baseline rate of > 160 bpm for > 10 min ¥ Fluctuation in baseline FHR that are irregular in amplitude & frequency. Visually quantitated as the amplitude of peak-to-trough in bpm.

Amplitude range undetectable Amplitude range > undetectable and < 5 bpm. - Moderate Variability Amplitude range 6-25 bpm.

- Marked Variability

Amplitude range > 25 bpm.

Acceleration

Visually apparent abrupt increase (onset to peak in < 30 sec) in the FHR baseline.

> 32 wks: Peak > 15 bpm for > 15 sec. but lasting less than 2 min < 32 wks: Peak > 10 bpm for > 10 sec. but lasting less than 2 min

Prolonged Acceleration Early Deceleration

Acceleration lasting > 2 min but < 10 min duration.

- Visually apparent usually symmetrical gradual decrease of FHR below baseline and return associated with uterine contractions.

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

-Generally, onset, nadir & recovery of the deceleration are coincident with the beginning, peak & ending of the contraction respectively.

Late Deceleration Variable Deceleration Prolonged Deceleration Sinusoidal Pattern Contractions/Uterine Activity

-Visually apparent usually symmetrical gradual decrease of FHR below baseline and return associated with uterine contractions.

-Delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.

-Generally, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, an ending of the contraction, respectively.

Visually apparent abrupt decrease (onset to nadir is < 30 sec) in the FHR below baseline. Decrease is > 15 bpm. Duration > 15 sec and < 2 min Visually apparent, abrupt decrease (onset to nadir is < 30 sec) in the FHR below baseline. Decrease is > 15 bpm. Duration is > 2 min, but < 10 min Visually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 per min which persist for > 20 min ∆ -Quantified as the number of contractions present in a 10 min window, averaged over 30 min -Frequency alone is a partial assessment of uterine activity. § Duration, intensity, and relaxation time between contractions are equally important.

-Term applies to both spontaneous onset and stimulated labor. -Should always be qualified as to the presence or absence of associated FHR decelerations.

Abbreviations: FHR-Fetal Heart Rate, bpm-beats per minute, min-minute, sec-seconds

_ Emphasis Added ¤ Indeterminate: Institute interventions to improve tracing & refer to the prior 10 min window.

Abandoned Terms:

¥ Short term (beat to beat) & Long Term Variability (assessed as one unit) § Hyperstimulation/Hypercontractility (duration, intensity, relaxation time and Tachysystole used) ∆ Pseudo-Sinusoidal

BASELINE

• • • • • Established by • • IA: counting FHR at repeated intervals for at least 30 seconds after uterine contraction EFM: 2 minutes of interpretable FHR data in at least 10 minutes of monitoring Rounded to increments of 5

Normal

110-160

Bradycardia

: < 110 for 10 minutes

Tachycardia

: >160 for 10 minutes

BRADYCARDIA

• • • • • • • Must be distinguished from prolonged deceleration (2-10 minutes) 90-110 bpm usually innocuous • Differentiate from maternal heart rate Sudden and profound bradycardia is a medical emergency • Variability?

Drop in maternal oxygenation Acute impairment of uteroplacental exchange Prolonged occlusion of the cord Profound vagal stimulation

TACHYCARDIA

Maternal Causes

Fever Chorioamnionitis Dehydration Hyperthyroidism Illicit substance use Medications: Beta-sympathomimetics Parasympatholytics

Fetal Causes

Anemia Heart failure Hypoxia Infection or Sepsis Tachyarrhythmia • • Not associated with fetal hypoxia in absence of decelerations Increases myocardial oxygen demand

VARIABILITY

• • • • Fluctuations in the FHR over time Absent : amplitude range undetectable Minimal : 1-5 bpm Moderate : 6-25 bpm Marked : >25 bpm

MODERATE VARIABILITY

• • Intact nervous pathway Predicts adequate fetal oxygenation

MINIMAL VARIABILITY

• • • • • Fetal sleep cycle Medication Fetal acidemia Previous fetal insult Fetal neurologic or cardiac congenital anomaly

ABSENT VARIABILITY

• • Fetal acidemia Preexisting neurologic insult

MARKED VARIABILITY

• Unknown significance

ACCELERATIONS

• • • • 15 bpm x 15 seconds • 10 bpm x 10 seconds for < 32 weeks Predictive of: • • adequate fetal oxygenation pH > 7.19

Rules out acidemia 2-10 minutes are “prolonged”

ACCELERATIONS

DECELERATIONS

• • • Four types: •

Early

• • •

Late Variable Prolonged Recurrent

if occur with >50% of ctx in 20 min

Intermittent

if occur with < 50%

EARLY DECELERATION

• • • • Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine ctx Gradual decrease (> 30 sec to nadir) Nadir occurs with peak of ctx Head compression No intervention necessary

EARLY DECELERATIONS

LATE DECELERATION

• • • • • Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine ctx Gradual decrease (> 30 sec to nadir) Nadir is after the peak of the ctx Uteroplacental insufficiency Initiate intrauterine rescuscitative measures Variability?

LATE DECELERATIONS

CAUSES OF UTEROPLACENTAL INSUFFICIENCY

FACTOR RELATED CAUSES OR CHARACTERISTICS

Hypotension Hypertension Placental changes Decreased Hgb or Oxygen Sat Tachysystole Other high risk conditions • Supine positioning • Regional anesthesia • Maternal trauma or hemorrhage • Chronic, gestational, or preeclampsia • Drugs • Postmaturity • Placental infarctions • Placenta previa • Small or malformed placenta • Abruption • Hyperventilation or hypoventilation • Cardiopulmonary disease • Severe anemia • Uterine contractile agents • Preexisting chronic disease • Smoking • Poor nutrition • Multiple gestation

Adapted from “Fetal Heart Monitoring: Principles and Practices” AWHONN, 2009

VARIABLE DECELERATION

• • • • • • Visually abrupt decrease in FHR < 30 seconds to nadir Decrease is 15 bpm or greater Lasts 15 seconds to 2 minutes Variable in their temporal relationship to ctx Cord compression Variability?

VARIABLE DECELERATIONS

PROLONGED DECELERATION

• •

Visually apparent decrease in the FHR below the baseline

Decrease is 15 bpm or greater Lasts 2-10 minutes

Uteroplacental Insufficiency

Tachysystole Acute maternal hypotension Acute maternal hypoxia Abruption placenta Uterine rupture

Interruption of Cord Blood Flow

Cord compression Cord prolapse Ruptured vasa previa

Vagal Stimulation

Head compression Rapid fetal descent

Adapted from “Fetal Heart Monitoring: Principles and Practices” AWHONN, 2009

PROLONGED DECELERATION

SINUSOIDAL

• • •

Visually apparent, smooth, sine wave-like undulating pattern in FHR

Cycle frequency of 3-5 per minute Persists for 20 minutes or more Fetal anemia, hypoxia, infection, anomalies

2008 NICHD Three-Tier Fetal Category & Interpretation

CATEGORY I CATEGORY II Category II tracings include all FHR tracings not categorized as Category I or III CATEGORY III

 

Includes all of the following:



Baseline: 110-160 bpm



Variability: moderate



Late or Variable Decels: absent Early Decels: present or absent Accelerations: present or absent Interpretation: Tracing in this category are strongly predictive of normal acid-base status at the time of observation.

      

Include any of the following:



Bradycardia not accompanied by absent variability Tachycardia Minimal variability Absent variability without recurrent decels Marked variability Absence of induced accel after fetal stimulation



Recurrent variable decels with minimal or moderate variability Prolonged decal Recurrent late decels with moderate variability



Variable decel with “slow return or baseline”, “overshoots” or “shoulders”.

Interpretation: Tracings in this category are not predictive of abnormal acid-bas status, however there are insufficient data to classify them as either I or II.

  

Include Either: 1.

Absent variability and any of the following: Recurrent late decels 1.

Recurrent variable decels Bradycardia Sinusoidal Pattern Interpretation: Tracing in this category are predictive of abnormal acid-base status at the time of observation.

Abbreviations: FHR-Fetal Heart Rate, BPM-beats per minute, Accel-Acceleration, Decel-Deceleration

Derived from: Original Commentary - 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: 661–666 .

MANAGEMENT ALGORITHM BASED ON THREE TIERED CLASSIFICATION

Adapted from ACOG Practice Bulletin #116: Management of Intrapartum Fetal Heart Rate Tracings, November 2010

RESUSCITATIVE MEASURES FOR CATEGORY II AND III TRACINGS

Goal Fetal Heart Rate Abnormality Potential Intervention

Promote fetal oxygenation and improve uteroplacental blood flow Reduce uterine activity • • Recurrent late decelerations • Prolonged decelerations or bradycardia • Minimal or absent variability Tachsystole • Initiate lateral positioning • Maternal oxygen • IV fluid bolus • Reduce contraction frequency • Discontinue oxytocin or cervical ripening agents • Administer tocolytic Alleviate umbilical cord compression • Recurrent variable decelerations • Prolonged decelerations or bradycardia • • • Maternal repositioning Amnioinfusion Evaluate for prolapsed cord Adapted from ACOG Practice Bulletin #116: Management of Intrapartum Fetal Heart Rate Tracings, November 2010

QUESTIONS?

REFERENCES

 ACOG, Intrapartum fetal heart monitoring: Nomenclature, interpretation, and general management principles. Practice Bulletin Number 106, July 2009.

 ACOG, Management of Intrapartum Fetal Heart Tracings, Practice Bulletin Number 116, November 2010.

 NICHD, Commentary workshop report on electronic fetal monitoring, September 2008.

 Journal on Quality and Patient Safety: The Joint Commission. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes & costs of liability claims. Vol. 35, No. 11, November 2009.

REFERENCES

• • • Journal of Obstetric Gynecological and Neonatal Nursing (JOGNN), workshop report electronic fetal monitoring: Update on definitions, interpretations, and research guidelines. Vol. 37, Issue 5, 2008.

Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066. (Meta-analysis) AWHONN, Fetal Heart Monitoring: Principles and Practices, 2009