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Fetal Monitoring: Lessons Learned

PQCNC Learning Session, March 2020


Mona Brown Ketner MSN, RN, C-EFM
Nurse Educator, Northwest AHEC
Wake Forest School of Medicine
Conflicts - Learning Objectives

n No conflicts to report

n Identifysafe principles of electronic fetal


monitoring use.
n Discuss strategies for risk reduction.
Before Hospital Arrival

n Keep a record of “cold calls”

n Establish policy: no advice, call


MD/CNM, come to hospital,
individualized advice
EFM

n Subjective at times
n May be difficult to reach consensus

n NICHD terminology only


n Greater objectivity
n Do not invent terms
Quiz! Absent FHR Variability

1. Zero
2. 0 – 2 bpm
3. Less than 5 bpm
4. Undetectable
Minimal FHRV + Recurrent Late
Decels:

n 1. Category I
n 2. Category II
n 3. Category III
Define Fetal Tachycardia

n 1. FHR > 160 bpm


n 2. FHR > 160 for 10 mins
n 3. FHR > 180 for 10 mins
n 4. FHR > 160 for 10 mins
n 5. FHR > 200
Antepartum NST

n NST: Reactive v. Nonreactive

n Reactive: 2 accels in 20 mins


n Continue EFM for at least 20 mins even
if accels in first 5 or 10 mins
n Accel: 10 x 10 v. 15 x 15
n Accel: peak v. sustained
More NST Thoughts

n Compare yesterday & today: preterm


n Who interprets: 1 or 2 nurses?
n Who determines discharge at 0300?

n If 3 UCs/10 mins: interpret as CST

n Cat I, II, III helpful if NST could be


categorized as Cat III
Category II

n Big hole – 80% of labors


n Indeterminate: “not exactly known”

n Nursing interventions & follow up


n Use standard algorithm/decision tree
n Look at changes over time
About Oxygen

n Appropriate by 10 lpm per mask for


absent/minimal FHRV not resolved with
other measures
n Examine your policy for O2 time use
n Not needed for moderate FHRV
n Not to be used with ongoing oxytocin
drip
FHRV

n Indicator
of infant neurological outcome
n Moderate: no hypoxia/acidosis

n Minimal FHRV without decels almost


always unrelated to fetal acidemia
n No FHRV assessment in decel nadir
(examine 2008 NICHD publication)
Tachysystole Thoughts

n UT (uterine tachysystole) factors:

n> 5 UC’s in 10 mins averaged/30 mins


n UC > 2 mins long
n UC’s occurring within 1 min of each
other
n Insufficient return to baseline tonus
UT Research

n UT prevalent, but under-reported


n Rate as high as 30%
n One study: rate as high as 41%

n Mostcommon finding = < 60 sec rest


between UC’s
» Kunz, 2013
UT

n Bestto avoid prolonged periods of


tachysystole

n Donot delay nursing interventions for


tachysystole
Criteria for Ripening/Induction

n Personnel familiar with effects of uterine


stimulation on mother/fetus
n Ripening agents at or near labor & birth
suite for EFM
n FHR and UC monitoring as any high-
risk patient in active labor
n MD readily available for possible C/S
2018: EFM Fetal Assessment

n Low-risk without oxytocin –


n Latent phase < 4 cm: CNM/MD decision
n Latent phase 4 – 5 cm: every 30 mins
n Active phase > 6 cm: every 30 mins
n Second stage, passive: every 30 mins
n Second stage, active: every 15 mins
2018: EFM Fetal Assessment

n High-risk or with oxytocin –


n Latent phase < 4 cm: every 15 mins
with oxytocin OR every 30 without
n Latent phase 4 – 5 cm: every 15 mins
n Active phase > 6 cm: every 15 mins
n Second stage, passive: every 15 mins
n Second stage, active: every 5 mins
Criteria for Augmentation

n UCfrequency is less than 3 per 10


minutes

n Or
if UC intensity less than 25 mm Hg
above baseline
Ripening Agents

n Misoprostol & Cervidil & Prepidil

n At or near L&D ~ FHR & UA monitored


continuously
Misoprostol (Cytotec) Tablets

n 100 & 200 mcg tablet unscored


n
n Hospital pharmacist should prepare
n Administered by MD, CNM or RN with
approval
Misoprostol - Cytotec

n Dosage: 25 mcg (1/4 tab) in vagina


n Max 6 doses / 24 hrs
n No use if prior C/S

n Re-dose: cx still unfavorable, minimal


UC’s, FHR Cat I, at least 3 hrs since
last dose
Oxytocin in Labor

n Increases free intracellular calcium

n Oxytocin
receptors increase in uterine
myometrium throughout pregnancy and
labor
Nursing Assessments

n Record UC status before pit increase


n SVE: Dilatation, effacement, station ~
record all three factors
n MVU: 150 – 350 MVU = normal labor
n Less than 150 MVU = inadequate
n Adhere to your own policies
AWHONN Staffing Guidelines

n Current guidelines ~
n 1:2 for ripening with pharmacologic tx
n 1:1 nurse/patient ratio for oxytocin
induction or augmentation
If…

n Ifnurse unable to evaluate oxytocin


every 15 mins or if MD with C/S
privileges not readily available ~

n Infusionshould be discontinued
n Subsequent doses of misoprostol
delayed
Continued Oxytocin Increases

n Over long periods of time: possible


frequent/low intensity UCs, coupling,
tripling, tachysystole

n Do not “pit through pattern”


n Do not “pit to distress”
Other Tips

n No oxytocin increase because the


patient feels no UCs

n ACOG: no set max oxytocin dose


n 2017: suggested 20 mU as max dose
n > 25 mm Hg = hypertonus
AWHONN 2009 Info

n Resolving oxytocin-induced
tachysystole
n Oxytocin D/C: resolution in 14.2 mins
n Oxytocin D/C + 500 cc LR IV fluid bolus:
resolution in 9.8 mins
n Oxytocin D/C + 500 cc LR bolus +
change to lateral position: resolution in
6.1 mins
Resume Pit Only After
Tachysystole Resolved
n If oxytocin discontinued less than 20 - 30
mins, may restart at half previous rate if EFM
reassuring

n However, if discontinued for more than 30 -


40 mins = low plasma level
n Then resume at initial does ordered
2015 Update: Oxytocin-Induced
Tachysystole
n Normal FHR:
n Lateral position
n IV bolus, 500 cc LR
n After 10 – 15 mins: decrease pit by ½
n After 10 – 15 more mins: stop pit until
UCs less than 5/10 mins
2015 Update: Oxytocin-Induced
Tachysystole
n Indeterminate or abnormal FHR:

n Discontinue pit
n Lateral position
n IV bolus, 500 cc LR
n Possible oxygen until FHR normal
n Possible 0.25 mg terbutaline SQ
Cord Blood Gases

n Do you collect at your hospital?


n Who collects?
n Which vessel(s)?
n BD or BE?

n Adopt
reference - based values for
normal
EFM Associations/Cord Gases

n Respiratory acidosis: Quickly develops,


variable decels, easily reversed
n Metabolic acidosis: Insidious, absent
FHRV, late decels, may be difficult to
reverse
n Mixed acidosis: Variable + late decels,
ongoing, minimal followed by absent
FHRV, may be more difficult to reverse
Strategies: Risk Reduction

n Check your algorithm and policy


n EFM huddles – interdisciplinary
n EFM education/competencies
n Peer review
n MHR vs. FHR – your auscultation policy
n Drills
Policies: Risk Reduction

n Examine precise wording


n Use: “may, could, using nursing
judgment”
n Try to avoid: “shall, must, will”
n Orient nurses to policies
n Assessment v. documentation
n Induction documentation frequency
Communication – MD/CNM

n Oral: when to call? admission? 10 cms?


EFM change?
n Written: who called whom?
n What precisely was reported v.
“updated on patient”
n Orders received from secretary?
n Chain of command usage
Timing of Cesarean

n 30-minute decision-to-incision time frame


n Recommended by ACOG and AAP in
1989 Guidelines for Perinatal Care
n Based on consensus opinion

n Some studies: actually seeing worse


outcomes within 30 minutes – poor
intrauterine resuscitation & OR rush
Thank you

n mketner@Wakehealth.edu

n 336 - 713 - 7730


References
n AAP & ACOG. Guidelines for Perinatal Care, 8th ed, 2017.
n AWHONN. Fetal Heart Monitoring: Principles and Practice, 5th
ed., 2015.
n Davis J, Kenney TH, Doyle JL, McCarroll M, vonGruenigen VE.
Nursing peer review of late deceleration recognition and
intervention to improve patient safety. JOGNN 42 (2): 215-224,
2013.
n Kunz, MK, Loftus, RJ, Nichols, AA. Incidence of uterine
tachysystole in women induced with oxytocin. JOGNN 42(1):
12-18, 2013.
References
n Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The
2008 National Institute of Child Health and Human Development
Workshop Report on Electronic Fetal Monitoring: Update on
Definitions, Interpretation, and Research Guidelines. JOGNN
37(5):510-515, 2008.
n Miller LA, Miller DA, Cypher, RL. Fetal Monitoring and
Assessment, 8th ed. St. Louis: Mosby, 2017.
n Simpson KR. Cervical Ripening and Labor Induction and
Augmentation, 4th ed., AWHONN, 2013.