fetal monitoring
TRANSCRIPT
Definitions FHR Interpretation Fetal Reserve Interventions Communication
› SBAR› Chain of Command
Documentation› During Emergent
Events
Professional Responsibility
Elements of Malpractice
Minimizing Liability Risk
Sources of Liability Claims
Fetal heart rate patterns are defined by the characteristics of:› Baseline› Variability› Accelerations › Decelerations
(JOGNN, 2008)
Baseline
Normal: 110-160 Bradycardia: < 110 Tachycardia: > 160
(NCC Monograph, 2006)
Variability Fluctuations in the fetal heart rate
baseline that are two cycles per minute or more and that are irregular in amplitude.
Absent: Undetectable 0-4 BPM Minimal: < 5 BPM Moderate: 6-25 BPM Marked: > 25 BPM
(NCC Monograph, 2006)
Variability
“Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed” (AWHONN, 2008)
Acceleration
Abrupt increase in FHR above the baseline. The peak must be > 15 bpm and last > 15 seconds. Before 32 wks they must be >10 bpm above baseline and last >10 seconds.
(JOGNN, 2008)
Acceleration
“The presence of FHR accelerations (either spontaneous or stimulated) reliably predicts the absence of fetal metabolic acidemia” (AWHONN, 2008)
Accels can be stimulated by:› Vibroacustic› Direct scalp stimulation
Variable Deceleration
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 < 30 seconds. The decrease in FHR is calculated from the onset to the nadir of the deceleration.
Early Deceleration
Gradual decrease and return of FHR associated with a UC. A gradual decrease is defined as one from the onset to the FHR nadir of > 30 seconds.
The nadir of the decel occurs at the same time as the peak of the UC.
Late Deceleration
Gradual decrease and return of the FHR associated with a UC.
The decel is delayed in timing, the nadir of the decel occurs after the peak of the UC.
Prolonged Deceleration
Decrease in FHR from the baseline that is > 15 bpm, lasting > 2 minutes, but < 10 minutes.
All 5 components of fetal monitoring must be considered to interpret the pattern completely › Baseline rate› Variability› Accelerations (presence or absence)› Decelerations (presence or absence and
type: Periodic or episodic)› Trends over time/Pattern evolution
(American Academy of Pediatrics, 2007)
Pattern interpretation must also take into account influencing factors:
Gestational ageMaternal medical historyMaternal medications
(American Academy of Pediatrics, 2007)
Systematic Approach to FHR Assessment
Baseline rate Variability Periodic or episodic changes Uterine activity Pattern evolution Accompanying clinical characteristics Urgency
(American Academy of Pediatrics, 2007)
The degree of hypoxemia that the fetus can tolerate before true tissue hypoxia and acidosis occur.
Fetus has reserve Decreased reserve
Normal baseline range
Abnormal baseline range
Accelerations No accelerations
Moderate variability Min/absent variability
No decelerations Decelerations present
(AWHONN fetal monitoring)
Help
Physiological goal for interventions:› Maximize utero-placental blood flow› Maximize umbilical cord circulation› Maximize oxygenation› Reduce uterine activity
Position
change
Oxygen Stop Pitocin
LR Bolus
NotifyProvider
Delivery
Communication
Poor communication skills are a major medical legal risk factor (#1 Root Cause for law suits)
Good patient centered communication practices are highly effective in reducing medical legal exposure
Providing high quality patient care is the best protection against legal liability
(AWHONN fetal monitoring) & Gruenbaum, 2007
Communication
Be Direct: When you know what you want ask for it
Use SBAR and stress urgency Be assertive Inform the provider if you will be going
up the chain of command
(AWHONN fetal monitoring)
“I am Concerned”
Get their attention
Expressconcern
State the problem
Propose action and/or solution
Reach a decision
Nurse
ResidentPACNMIntern
AttendingPhysician
Charge RN
Assistant RNManager
RN Manager
Chief of OBDr. Valenzuela
Medical Director
Continue through the chain of command until the issue is resolved
FHR Baseline Variability Accelerations Decelerations (type) Changes in pattern
(evolution of pattern) UC pattern & resting
tone
Patient’s condition› Vital Signs› Cervical exam› etc
Interventions Patient’s response
to interventions
(AWHONN)
Documentation Time frames
First Stage Every 30 minutes
First Stage Every 15 minutes
Second Stage Every 15 minutes
Second Stage Every 5 minutes
Low Risk High Risk
Documentation of Emergent Events
Time FHR or maternal status was recognized as nonreassuring
Actions initiated for fetal or maternal resuscitation › Chronologies of interventions performed
and who performed them Continued assessment of fetal
response to interventions Communication of team members
(providers) and their response(AWHONN)
Documentation of Communication
Provider’s name Time they were notified How they were notified (person or
telephone) Exactly what was
said (Use quotes) Their response When they arrive at bedside
Professional accountability applies to everyone involved in health care.
Teamwork among health care providers is critical to provide safe and effective patient care.
(Derricott, 2008)
Effective Teamwork
Teams rather than individuals create optimal performance
Effective teams work collectively to achieve agreed upon goal: best possible outcome
Each team member is valued for their unique experience, knowledge and contributions
Professionals are responsible &accountable for their individual behavior
(AWHONN, 2008)
Duty (relationship recognized by law) Breach of Duty Causation Damages
Breach of duty that causes damage (failure to meet the standard of care)
Failure to recognize and/or respond to antepartum and/or intrapartum fetal compromise
Delayed C-section Inability to appropriately resuscitate a
depressed neonate (this is why NRP skills are so important)
Inappropriate use of Pitocin and/or Cytotec Inappropriate use of vacuum and
preventable shoulder dystocia (know EFW)
Continuing education Maintain competency Obtain new knowledge Incorporate new technology and skills into
practice Maintain awareness of current research
(AWHONN Advanced FM)
“Good care, compassionately delivered and well documented is the key to avoiding suits”(Melvin Belli, 1989)
American Academy of Pediatrics, 2007. Maternal and Fetal Evaluation and Immediate Newborn Care.
JOGNN, 2008. The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on Definitions, Interpretation, and Research Guidelines. Vol 112, No3.
AWHONN Intermediate and Advanced Fetal Monitoring Workshop Student Materials.
NCC, 2006. Applying NICHD Terminology and Other Factors to Electronic Fetal Monitoring Interpretation. NCC Monograph, vol 2, No 1.
Derricott, B, 2008. Professional Accountability. www.bellaonline.com
Then…..
And now!!!!!!