Transcript Team Communication and Fetal Heart Rate Monitoring

TEAM COMMUNICATION AND FETAL HEART
RATE MONITORING
Texas Center for Quality & Patient Safety
Michael Nix, MD
7/7/2015
GOALS
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Communication strategies
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NICHD Fetal Heart Rate Terminology
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Three-Tier Fetal Heart Rate Interpretation System
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Resuscitative measures
COMMUNICATION
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The process by which information is transferred between individuals or teams
COMPONENTS OF COMMUNICATION
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Sender
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Receiver
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Message
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Feedback
COMMUNICATION ERROR
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The leading root cause of sentinel events from 1995-2005
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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
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JCAHO National Patient Safety Goal #2: Improve the effectiveness of communication
among caregivers
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One of the six main competencies of ACGME
FACTORS THAT CAN IMPEDE EFFECTIVE
COMMUNICATION
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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
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Providing care with incomplete or missing information
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Executing poor patient handoffs with relevant clinical data not clearly communicated
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Failing to share and communicate known information
Achieving Safe and Reliable Healthcare, Leonard, et al 2004
EFFECTIVE COMMUNICATION
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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
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“
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
B
A
R
“I’m Mike, the nurse taking care of Ms. Johnson in room 3. She is having late decels.”
“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”
“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.”
“I would like you to come review the FHRT to see if you think that we should
continue the induction.”
SBAR
R?
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Response: Acknowledge and document the response of the provider
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Closes the loop of communication
FETAL MONITORING
EFM VS. INTERMITTENT AUSCULTATION
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Increased c-section rate (RR, 1.66; 95% CI, 1.30-2.13)
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Increased OVD risk (RR, 1.16; 95% CI, 1.01-1.32)
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No change perinatal mortality (RR, 0.85; 95% CI, 0.59-1.23)
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Reduced neonatal seizures (RR, 0.50; 95% CI, 0.31-0.80)
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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:
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Review & update the definitions for FHRT patterns
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Assess existing classification systems for interpreting specific FHRT patterns
& to make recommendations about a system for use in the U.S.
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Make recommendations for research priorities for EFM
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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
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Definitions are visual interpretations
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Gestational age is considered when evaluating patterns
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A complete description of the EFM tracing includes:
• baseline
• variability
• accelerations
• deceleration
• contractions
CHANGES & NEW TERMINOLOGY
FROM 2008 WORKSHOP
Classification of FHR Patterns
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Abandon the terms:
• Reassuring
• Non-Reassuring
• Three-tiered Classification System
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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
- Moderate Variability
- Marked Variability
Acceleration
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.
Amplitude range 6-25 bpm.
Amplitude range > 25 bpm.
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
-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.
Variable Deceleration
Prolonged Deceleration
Sinusoidal Pattern
Contractions/Uterine
Activity
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.
-Normal
< 5 contraction in a 10-min. window, averaged over 30 min
-Tachysystole >5 contractions in a 10-min window, averaged over 30 min
-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
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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
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Rounded to increments of 5
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Normal 110-160
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Bradycardia: < 110 for 10 minutes
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Tachycardia: >160 for 10 minutes
BRADYCARDIA
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Must be distinguished from prolonged deceleration (2-10 minutes)
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90-110 bpm usually innocuous
• Variability?
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Differentiate from maternal heart rate
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Sudden and profound bradycardia is a medical emergency
• 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
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Not associated with fetal hypoxia in absence of decelerations
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Increases myocardial oxygen demand
VARIABILITY
Fluctuations in the FHR over time
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Absent: amplitude range undetectable
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Minimal: 1-5 bpm
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Moderate: 6-25 bpm
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Marked: >25 bpm
MODERATE VARIABILITY
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Intact nervous pathway
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Predicts adequate fetal oxygenation
MINIMAL VARIABILITY
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Fetal sleep cycle
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Medication
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Fetal acidemia
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Previous fetal insult
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Fetal neurologic or cardiac congenital anomaly
ABSENT VARIABILITY
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Fetal acidemia
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Preexisting neurologic insult
MARKED VARIABILITY
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Unknown significance
ACCELERATIONS
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15 bpm x 15 seconds
• 10 bpm x 10 seconds for < 32 weeks
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Predictive of:
• adequate fetal oxygenation
• pH > 7.19
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Rules out acidemia
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2-10 minutes are “prolonged”
ACCELERATIONS
DECELERATIONS
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Four types:
• Early
• Late
• Variable
• Prolonged
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Recurrent if occur with >50% of ctx in 20 min
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Intermittent if occur with < 50%
EARLY DECELERATION
Visually apparent usually symmetrical gradual decrease and return of the FHR associated with
a uterine ctx
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Gradual decrease (> 30 sec to nadir)
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Nadir occurs with peak of ctx
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Head compression
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No intervention necessary
EARLY DECELERATIONS
LATE DECELERATION
Visually apparent usually symmetrical gradual decrease and return of the FHR associated with
a uterine ctx
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Gradual decrease (> 30 sec to nadir)
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Nadir is after the peak of the ctx
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Uteroplacental insufficiency
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Initiate intrauterine rescuscitative measures
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Variability?
LATE DECELERATIONS
CAUSES OF UTEROPLACENTAL INSUFFICIENCY
FACTOR
RELATED CAUSES OR CHARACTERISTICS
Hypotension
•Supine positioning
•Regional anesthesia
•Maternal trauma or hemorrhage
Hypertension
•Chronic, gestational, or preeclampsia
•Drugs
Placental changes
•Postmaturity
•Placental infarctions
•Placenta previa
•Small or malformed placenta
•Abruption
Decreased Hgb or Oxygen Sat
•Hyperventilation or hypoventilation
•Cardiopulmonary disease
•Severe anemia
Tachysystole
•Uterine contractile agents
Other high risk conditions
•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
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< 30 seconds to nadir
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Decrease is 15 bpm or greater
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Lasts 15 seconds to 2 minutes
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Variable in their temporal relationship to ctx
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Cord compression
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Variability?
VARIABLE DECELERATIONS
PROLONGED DECELERATION
Visually apparent decrease in the FHR below the baseline
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Decrease is 15 bpm or greater
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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
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Cycle frequency of 3-5 per minute
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Persists for 20 minutes or more
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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
Includes all of the following:
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Baseline: 110-160 bpm
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Variability: moderate
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Late or Variable Decels: absent
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Early Decels: present or absent
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Accelerations: present or absent
Include any of the following:
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Bradycardia not accompanied by absent
variability
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Tachycardia
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Minimal variability
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Absent variability without recurrent
decels
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Marked variability
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Absence of induced accel after fetal
stimulation
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Recurrent variable decels with minimal or
moderate variability
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Prolonged decal
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Recurrent late decels with moderate
variability
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Variable decel with “slow return or
baseline”, “overshoots” or “shoulders”.
Interpretation:
Interpretation:
Tracing in this category are strongly predictive Tracings in this category are not predictive of
of normal acid-base status at the time of
abnormal acid-bas status, however there are
observation.
insufficient data to classify them as either I or II.
CATEGORY III
Include Either:
1.
Absent variability and any of the
following:

Recurrent late decels
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Recurrent variable decels
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Bradycardia
1.
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 THREETIERED 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
•Recurrent late decelerations
•Prolonged decelerations or
bradycardia
•Minimal or absent variability
•Initiate lateral positioning
•Maternal oxygen
•IV fluid bolus
•Reduce contraction frequency
Reduce uterine activity
•Tachsystole
•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
Promote fetal oxygenation
and improve uteroplacental
blood flow
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
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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.
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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)
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AWHONN, Fetal Heart Monitoring: Principles and Practices, 2009