Transcript Electronic Fetal Monitoring CTG CASES

Electronic Fetal
Monitoring
Terri Imus, RN
Electronic Fetal Monitoring
Indications for continuous EFM
Any pregnancy considered high risk
 Induction or augmentation of labor
 Decreased fetal movement
 Premature labor
 Premature rupture of membranes
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Oligohydramnios
Hypertension
Abnormal fetal heart rate
Fetal malpresentation in
labor
IDDM
Multiple Gestation
Previous C/S
Trauma
Meconium
ACOG & AAP
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When EFM is the method selected for fetal
assessment. The MD & obstetrical personnel
should be qualified to identify and interpret
abnormalities. These guidelines also state that
it is appropriate for MD & Nurse to use the
descriptive terms that have been given to fetal
monitoring patterns in charting and reporting
Those not qualified or are unsure of the
interpretation in FHR patterns should seek
other professionals to assist in this evaluation
and interpretations
The nurse should document the presence of MD
and nurse, pt position and changes in cervix,
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Therapeutic interventions such as O2 and
medications
Increased or decreased BP
Febrile
Amniotomy, AROM,SROM, color amt.
consistency
Is the patient complete/pushing
All of these descriptive details give a picture
that indicates what is going on with the
patient and possible cause of change in FHR
pattern
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AAP/ACOG
Guidelines emphasize that when there is a change in the
FHR pattern all of those things should be documented as
well as a return to baseline
Each tracing should include
Pt Name
ID #
Date, Time of admission/delivery
EDC, Gravida Para and any other identifying
information
ACOG
Has not identified core competencies in
FHR monitoring
Standard guidelines Norm 110-160
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 Fetal
tachycardia
 Mod
161-180
 Marked “ 181-more
 Fetal Bradycardia
 Mod
100-119
 Marked” 90 or less
4 Basic Features of Fetal Heart
tracing
4 Basic Features
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Baseline
Variability
Bradycardia <110 bpm
Tachycardia >160 bpm
Periodic changes: FHR accelerations or
decelerations that occur with
contractions.
Decelerations are routinely described as
early, late, or variable.
Non-periodic changes
(no changes in variability)
Nonperiodic changes can occur spontaneously,
without contraction activity, and are also
described as accelerations or decelerations.
Variable decelerations can appear during a
Non-stress test and may be a sign of
cord compression or oligohydramnios, both of
which can have adverse effects on the fetus.
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Baseline Variability
Normal FHR 5 bpm greater than or
equal to 5 bpm, between contractions
Nonreassuring FHR less than 5 bpm or
less, but less than 30 min of tracing
Abnormal FHR less than 5 bpm for 90
min or more.
Baseline variability
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The minor fluctuations on baseline FHR
at 3-5 cycles p/m will reflect baseline
variability
Examine 1 min segment and estimate
highest peak and lowest trough
Normal is more than or equal to 5 bpm
Factors affecting Baseline
variability
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Para-Sympathetic affects short
term variability
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Sympathetic affects long term
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CNS Drugs reduces Variability
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Increased gestational age may increase variability
Mild Hypoxia may cause both Sympathetic and
Parasympathetic stimulation
Accelerations
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Accelerations transient increase in
FHR of 15 bpm or more lasting for 15
sec
Absence of accelerations on an
otherwise normal Fetal heart tracing
remains unclear
Presence of FHR Accelerations usually
have good outcome
Accelerations
Early Decelerations
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Head compression
Begins on the onset of contraction
and returns to baseline as the
contraction ends
Should not be disregarded if it
appears early in labor or in the
antenatal period
EARLY DECELERATION
Early Decelerations
Late Decelerations
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Uniform periodic slowing of FHR
with the on set of the contraction
Reduced baseline variability together
with late decelerations and
repetitive late deceleration
increases risk of fetal acidosis and
an Apgar score of less than 7 at
5/min with an increased risk of
adverse outcome
Late Deceleration
Late Deceleration
Late Decelerations
Due to acute and chronic utero-placental
insufficiency
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Occurs after the peak and past the length of
uterine contraction, often with slow return to the
baseline
Is precipitated by hypoxemia
Associated with respiratory and metabolic
acidosis
Common in patients with PIH, DM, IUGR or
other forms of placental insufficiency
Variable Decelerations
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Variable intermittent periodic slowing of
FHR with rapid onset recovery and
isolation
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They can resemble other types of
deceleration in timing and shape
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Atypical associated with an increased risk
of umbilical artery acidosis and Apgar
score less than 7 at 5 min
Additional components
Loss of 1 or 2 degree rise in baseline rate
 Slow return to baseline FHR after and end of
contraction
 Prolonged secondary rise in Base FHR
 Biphasic deceleration
 Loss of variability during deceleration
 Continuation of the baseline at a lower rate
Variable Deceleration (Vagal activity)
Inconsistent in configuration
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No uniform temporal r-ship to the onset of
contraction, are variable and occur in
isolation
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Worrisome when Rule of 60 is exceeded
(i.e. decrease of 60 bpm,or rate of 60 bpm
and longer than 60 sec)
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Caused by compression of the umbilical
cord
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Often associated with Oligo-hydramnios
with or without rupture of membranes
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Acidosis if prolonged and recurrent
Variable Decelerations
Variable Decelerations
Prolonged Deceleration
Drop in FHR of 30 bpm or more lasting for at
least 2 mins
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Is pathological when it crosses 2 contractions in
3 mins
Results in reduced of O2 transfer to placenta
Associated with poor neonatal outcome
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Prolonged Decelerations
CAUSES
Cord prolapse
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Maternal hypertension/hypotension
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Uterine hypertonia
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Epidural/spinal or pudendal anesthesia
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Can follow a vag exam, AROM or SROM with
high presenting part
Prolonged Deceleration
Intrauterine Resuscitation
Have the mother lie on her left/right side
or in a knee chest position
To alleviate possible cord compression
Reduce or stop any oxytocin
 Initiate tocolysis
 To decrease uterine activity and increase
placental blood flow
 Increase IV fluid
 To increase maternal blood/fluid volume
Give oxygen @ 10-12 L/min via mask
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Physician may apply an internal monitor to
verify the accuracy of external monitor
reading
Physician may administer amnioinfusion
to decrease pressure on cord or dilute mec.
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If the heart rate is not restored to normal
within 30 minutes, prompt delivery is
needed. Cesarean section may then
become necessary. Goal is to deliver ASAP
Causes of Baseline Change
Postdates
 Drugs
 Idiopathic
 Arrhythmias
 Hypothermia
 Increased vagal tone
 Cord Compression
Management depends on the clinical situation
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Causes of Bradycardia
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Asphyxia
Drugs
Prematurity
Maternal Fever
Maternal thyrotoxicosis
Maternal Anxiety
Idiopathy
Management depends on the clinical situation
Baseline Tachycardia
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Asphyxia
Drugs
Prematurity
Maternal fever
Maternal thyrotoxicosis
Maternal Anxiety
Idiopathy
Sinusoidal Pattern
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Regular Oscillation of the Baseline longterm Variability resembling a Sine wave
fixed cycle of 3-5 p min with amplitude of
5-15bpm and above but not below the
baseline
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Should be viewed with suspicion as poor
outcome has occurred (maternal/fetal
hemorrhage)
Sinusoidal pattern
Sinusoidal pattern - distinctive smooth
undulating
Sine-wave baseline
Cord compression
 Hypovolemia
 Ascites
 Idiopathic (fetal thumb sucking)
 Analgesics
 Anemia
 Abruption
Management depends on clinical situation
Summary of tracing
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Normal with all 4 Features
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Suspicious one non reassuring category
and remainder are reassuring
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Pathological 2 or more non-reassuring
categories or one or more abnormal
categories.
At Birth
Need to Consider
Cord pH if tracing suspicious
Preterm labor
Mec. stained amniotic fluid
FBS intrapartum (lab availability)
Lack of tone delivery
Operative or instrumental delivery
COMMUNICATION
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DESCRIBE THE PATTERN ACCURATELY
MAKE AN ATTEMPT TO ASSESS
WHETHER THE FETUS IS IN TROUBLE
IF YOU WANT THE PHYSICIAN THERE,
COMMUNICATE THAT
THE NURSE HAS MORE DATA THAN THE
PHYSICIAN
Communication
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SYSTEMATIC APPROACH REDUCES
ERRORS
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DESCRIBE WHAT YOU SEE
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AVOID THE NEED TO CLASSIFY EVERY
DECELERATION
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ASSESS THE OVERALL CONDITION OF
THE FETUS
Electronic Fetal Monitoring
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Improve knowledge for all staff
Improve clinical skills
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Training should include instruction on documentation
and storage
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Training should include appropriate clinical responses
to suspicious or pathological tracings
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Training should include local guidelines relating to
fetal monitoring both intermittent and EFM
DOCUMENTATION OF
COMMUNICATION
DO NOT JUST SAY THAT
Dr. Whoduneit WAS NOTIFIED
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RECORD THE PHYSICIAN’S
RESPONSE and any ORDERS
COMMUNICATION
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DESCRIBE FHR PATTERN
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I AM CONCERNED ABOUT THE CONDITION
OF THIS BABY
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IT IS OMINOUS AND NON-REASSURING
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IF PERSISTENT, REQUIRES PHYSICIAN
EVALUATION
COMMUNICATION
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THE FETUS HAS INCREASED
VARIABILITY AND THE BASELINE IS
HARD TO NTERPRET
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PHYSICIAN PRESENCE NOT REQUIRED
COMMUNICATION
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NOTIFY IF NO DRUGS WERE GIVEN
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THE FETUS HAS HAD A SINUSOIDAL
PATTERN FOR 20 MINUTES. I HAVE NOT
GIVEN ANY NARCOTICS AND THE
PATTERN PERSISTS DESPITE
POSITIONING, HYDRATION AND OXYGEN.
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PHYSICIAN PRESENCE MAY NOT BE
REQUIRED but inform
COMMUNICATION what if
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THE FETUS SUSTAINED A PROLONGED
DECELERATION ASSOCIATED WITH
HYPERSTIMULATION
THE PATTERN RESOLVED AFTER ….
PHYSICIAN PRESENCE MAY NOT BE
IMMEDIATELY REQUIRED, BUT SHOULD BE
NOTIFIED
Effective communication to avoid Litigation
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COMMUNICATE EFFECTIVELY TO THE
PHYSICIAN
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DESCRIBE WHAT YOU SEE AND
DOCUMENT WHAT YOU TOLD THE
PHYSICIAN
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DOCUMENT HER/HIS RESPONSE
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AVOID CHART WARS
Tracings
Unsatisfactory or Missing
 Abnormal tracing ignored or not recognized
 Tracings not done
Risk Management
EFM traces should be kept up to 21 years.
 If removed for teaching purposes or etc, should
be easily located
 They minimize incidence of adverse outcome
What Influences Litigation
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Consumer Expectation
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The profession –education
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The employer (policies/procedures)
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Legislation (duty of care/scope of practice/
registration)
Legal issuesConsumer expectation
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Good outcome (healthy baby/mother)
 Bad
outcome
 Someone
to blame
 Someone
must pay
Professional Responsibility
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To act within scope of practice
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To seek support and guidance
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Work within organizational standards
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Duty of care to the patient and your profession
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Maintain knowledge and skills (Evidence Based
Practice)
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Be prepared to defend your actions or lack of
When EFM is the focus of Malpractice
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Comparison of consistency of
documentation contained on the trace and
in the chart
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Lapse in documentation may leave doubt
about the quality of care given
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Hospital policy and procedure manuals will
be examined
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Competency levels will be evaluated, expert
witness (plaintiff/defense)will determine if
acceptable standards were applied
Major Omission in
Liability
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Failure to appropriately monitor the mother
and fetus status
Failure to notify the physician in a timely
manner
Initiation of procedures without adequate
client information or consent (informed
consent)
MORE
Legal issues
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Use EFM effectively and efficiently
Interpret the tracing and respond
accordingly
It is permanent record that is scrutinized
in a litigation case
May be pivotal in determining liability
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A normal EFM can be used to indicate that
there were no abnormalities with no indication
for intervention
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An abnormal EFM or suspicious trace may
provide evidence for inappropriate or lack of
treatment, giving more insight for litigation
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EFM could be viewed as part of “defensive
medicine”, as litigation is reported to be on the
increase.
Elements of a Successful
Malpractice Action
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A nurse has a duty to the patient
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A nurse commits a breach of duty
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A patient suffers damages
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Causal connection between the nurse’s
actions and the patient’s damages
RN Obligation
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Help patient to process information when
outcomes are poor, explain situation and
reinforce learning/teaching
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RN must chart carefully and defensively
to support the care given
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The chart is the witness that never dies
and is discoverable for up to 21yrs
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Not charted not done
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RN (expert witness) help to identify when
a breech of duty of standards of practice
Documentation and the Monitor
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Know your institution’s policy on what is to
be documented on the monitor strip
Routine information
Identify strip with patient’s name
Medical record number
Date and time
Procedures done
Nurses name or initials
OMISSION
Failure to appropriately monitor client/fetus
(ACOG recommendation Q 15mins 1st
stage Q 5 mins 2nd stage)
Inappropriate Pitocin monitoring/utilization
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Pitocin orders/continuous monitoring/ having
access to physician for further
instruction/orders
Improper sponge/instrument counts during
C/S
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Initiation of procedures without adequate
client information
consent
(informed
consent)
Failure
to notify MD
in a timely
manner:
When in doubt shout
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Failure to notify MD in a timely manner:
Notify the physician and note time and
orders or lack there of orders
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Repeat notifications per institutions
policy and utilize the chain of command
for your institutions when no
appropriate response
Technology
References
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Manual Obs and Gyn. by Niswander, MD
Fetal Monitoring, RCOG UK
CTGs, RANZCOG
Literature review articles American Family
Physician
Electronic Fetal Monitoring, Menihan,
Zottoli