Transcript The Top 10 Mistakes Made During Fetal Heart Rate Interpretation

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
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
– 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
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
Category 1 tracing
Is the FHR reassuring?
(Moderate variability and absence of
recurrent late/variable decelerations)
Yes
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?
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
If tachysystole does not resolve 30
minutes after initial interventions:
-discontinue oxytocin infusion
- notify the provider.
-Consider Terbutaline.
Category 2 or 3 tracing
No
- 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
How long until FHR reassuring and
resolution of tachysystole?
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.
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
•
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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
Thank You
Questions?