Electronic Fetal Monitoring
Department of Family Medicinespecial thanks toDr. Gary Viner,
Dr. Dave Millar, Dr. Kristine Whitehead, Nursing Care Facilitators
& Champlain Maternal Newborn Regional ProgramJuly 2015
Family Medicine Obstetrics Orientation1FM Maternity Care -
Resourceshttp://youtu.be/nizKRUv37lsHuman Labor and Birth, Oxorn -
Foote, Sixth Edition Dr. Glenn Posner et al.SOGC Clinical Practice
Guidelines, sogc.orgmyHospital -> Policies and Procedures ->
Obstetrics, Gynecology and Newborn CareCmnrp.ca, Champlain Maternal
Newborn Regional ProgramV-driveDFM Website UptodateOngoing teaching
in the Units and at Academic DayLow Risk ObstetricsSession 1: Role
in Obstetrical Triage & Birthing RoomTechnical SkillsFetal
Health Surveillance Triage assessments
Session 2: Management of LaborHospital-based Postpartum Care
Session 3:OBS emergencies
Perineal repair: July 17, 2015 Academic Day
3ObjectivesDescribe FM residents role in intrapartum maternity
care Review expected competencies and e-fieldnotesReview important
skills & protocolsIntroduce Fetal Health Surveillance
(FHS)Prepare for triage assessments
NB. this information is available on DFM website, including Mat
and NB fieldnote
NEW in 2014 FIRST SHIFTS ARE WITH R2, BU walk through with Care
Facilitator Day 14Intra-partum CompetenciesDiagnose SROMPerform
accurate cervical assessmentManage labour / fetal surveillanceScalp
electrode placementManage amniotomy & labour augmentationManage
spontaneous vaginal deliveryManage obstetrical
emergenciesParticipate in assisted vaginal deliveryPerform
uncomplicated perineal repairCommunicate/collaborate effectively
(patient,family, team)66
77
Mandatory RequirementsDemonstrate sufficient competency on the
Maternity and Newborn Field Note (FN) from across the different
pregnancy stages antenatal, intra-partum and post-partum
skills.Effective 2014 - 2015:PGY1s: must demonstrate exposure to
80% of intrapartum, antenatal and postpartum competenciesPGY2s:
must demonstrate attainment of 80% of intrapartum, antenatal and
postpartum competenciesCompleted FNs should be completed
electronically (eFN) or faxed immediately (fax no. bottom right
corner of form)FM Resident OB SupervisorsMaternity & Newborn
Field Note - can be completed by:Family Physicians Staff
Obstetrician Senior OB/Gyn ResidentsObstetrical Nurses9New DFM
Evaluation Policy:when no designated/continuous preceptorMaternity
& Newborn Field notes (FNs): 1/day expectedRN &/or Ob-Gyn
residents (>PGY2)60% of FNs must be staff MD (FMOB or
OBGyn)name, role & PGY level (if resident) of evaluator MUST be
clear or FN WILL BE DISCARDEDInitiated by Resident or assessor
FM Resident Role in ObstetricsSenior for FM-OB but Junior for OB
serviceEnvironment provides opportunity to work with manySpecial
role of OB Nurseappreciate different approachesWatch, Listen, Learn
and Do!!
Communicate status of each patient to:Staff (OB, FM-OB) or
Senior (OB resident)- on admission, prior to d/c or any significant
intervention - q2-4h in labour- q1h when pushing11
At the start of each shift
Identify yourself to Care Facilitator (CF) or Team Leader (TL)
Introduce yourself to RNs, staff OB, OB resident Write contact info
on white board & link to your patients (white board at Nursing
station and in patient room)
FM Resident to FM Resident handover 0700 weekdays and 0800 on
Sat/Sun/holidays vitally important skill
Attend interdisciplinary rounds with team in AM and PM variable
time, around 0745 and 1700Staff OB, OB ResidentCare Facilitator /
Team Leader and NursingSometimes: med student, anesthesia, MFM
Meet your patients - review history & plan prior to entering
the room, introduce yourself to patient and RN Name on whiteboard
If patient is Family Practice patient/low risk, ask RN to call you
for ALL assessments At OGH Interdisciplinary handover is 0745 at
the CF desk Mon, Tue, Thurs and Friday. 0830 on Wednesdays and 0845
on Sat. and Sun. Evening handover is 1700 Mon-Fri and 2000
Sat/SunAt OCH Interdisciplinary handover is 0745 Mon, Tue, Friday
and 0845 Wed and Thurs. Handover is 0800 on weekends. Evening
handover is 1715 Mon to Thurs, 1615 on Friday and 2000 on
weekends
Family Practice patients 1st priority: responsible for all
assessments management of labor attendance at deliveries &
newborn assessments involve staff FM-OB, NOT OB resident in plan of
care
Also follow LOW RISK, term OB patients Include OB resident in
plan of care (keeping them updated of changes) any concerns ->
speak to OB resident first, then on-call staff Obstetrician prn
Keep CF/TL & census (white) board up to date
Check In with your patients progress at least Q2 hourly -write
note after each assessment
Update the CF and supervising staff after each patient
assessment. Discuss any concerns with the Family Physician or OBS
resident. (i.e. slow progress, abnormal FHS, meconium etc.)
PROTOCOL: Active Management of Labor
Expect to be called for triage assessments maintain a high
profile around the Nursing stationObstetrical AreasOAU Obstetrical
Assessment Unit (Triage)Birthing Unit (BU/Case Room)Postpartum ward
A4 OCH, 8E OGH1. Obstetrical Assessment Unit (OAU) = TriageAssess
outpatientsPatient documentation required:History & Physical
(RN supervised)AssessmentPlanReview with FMOB staff/OB senior or OB
staffAll vaginal exams confirmed by RN initially
prior to OAU discharge of FM patient you must ALWAYS contact
attending FM or OB resident/staff
Notify FM staff or OB resident of all admissions to the Birthing
Unit 2. Birthing Unit Expectations Attend all low risk deliveries
assist with clean up (discard sharps, count instruments) Complete L
& D documentation and Birth Record Complete PP orders Sign
Medication Reconciliation form Complete newborn exam (&
documentation) and orders for FM babies
3. Postpartum CarePost Partum RoundsAfter birthing unit rounds
~08:30Patient lists from Ward Clerk on A4/8E both PP and
newbornsSee, assess & 1st call for FM moms &
babiesCommunicate with FM-OB Staff review concerns and before all
dischargesMay assist with OB PP roundsReinforce newborn need for
F/U 2 days after discharge PP care review/expectations in teaching
session #2 and in-unit20Learning Opportunities! 1. Follow your
patients through labor & birth (including C/S, if available) 2.
Postpartum rounds/Newborn care 3. OB/gyn rounds Wednesday mornings
0730 4. Gyne (floor and ER) sometimes, as per OB resident 5.
Medical students learn with them and teach them 6. Participate in
MORE OB skills drills 7. Review TOH protocols/procedures on
myHospital
Technical SkillsClinical Assessment:Abdominal Exam (Leopolds
Maneuvers)Cervical Exam - confirmed by RN initiallyAssessment of
SROM, vag/cx swabs prn, FFN prnARM amniotomyInduction ->
Cervidil, foley catheterScalp ElectrodeAttend spontaneous vaginal
deliveryPerform uncomplicated perineal repairApproach to assisted
vaginal delivery and management of OBS emergencies221. Clinical
assessment every patient (triage and BU)Introduce yourself to
patient & supportsReview the antenatal recordsDevelop
relationship, project secure/safe environmentCommunicate directly
with patient and with RNDiscuss all patients with Senior OB
resident, OB staff or FM staffNever discharge a patient without
reviewing with staff
231. a) Leopolds Maneuvers
FirstSecondThirdFourthMartin, 2002Fundal GripUmbilical Grip
fetal backPawlicks Grip presenting partPelvic Grip fetal browFetal
Health Surveillance - Instructor Notes PPPESO, 2009Copyright
PPPESO, 2009241.b) Vaginal examWith RN supervision, with consent.
Gently, avoid clitoris/urethra anteriorly1) CervixLocation of
cervix vs. presenting part: posterior, mid-position or
anteriorConsistencyEffacement/Length (avoid % - use
cm)DilatationMembranes - ? bulging
251.b) Vaginal exam 2) Presenting PartVertex / breech /
other?position261.b) Vaginal exam
Posterior fontanel: smaller fontanel - intersection of sagittal
two lambdoid sutures.Anterior fontanel: larger fontanel -
intersection of sagittal, frontal & two coronal sutures.
Occiput anterior positionsROALOAOA1.b) Vaginal exam
Occiput posterior position1.b) Vaginal exam
Occiput transverse positionsROTLOT1.b) Vaginal exam3)
StationStation of presenting part should be positively
determinedPelvis is divided into 5ths -5 to +5 (fetal head visible
at the introitus)0station or spines usually represents engagement
of the fetal head ( i.e. biparietal plane of the fetal head has
passed through the pelvic inlet)
30
Assessing descent by vaginal examination -2 station: - leading
bony edge of presenting part is 2cm above ischial spines 0 station:
- head is engaged
1.b) Vaginal exam4) Pelvic ArchitectureAssess ischial spines,
pelvic sidewalls & sacrum for adequacy
5) Amniotic Fluid AssessmentFerningNitrazine Clear or
meconium?
321.b) Vaginal exam
NormalBacterial vaginosisPregnant woman with premature rupture
of membranes. pH of vaginal discharge using nitrazine paperFalse +
from blood, semen, urine, infection1.b) Vaginal exam
FerningPreferred test2. Technical Skills - ARMpractice
Amniohook354. Technical skills - Scalp electrode1) ensure
continuous EFM is indicated
2) consider method of EFM: external vs. internalFetal vs.
Maternal considerations
Technique practice this to be prepared!! (see session 2)
365.Technical skills Perineal RepairAcademic Day July 17,
2015Foam model simulation
6. Technical Skills - AVDAssisted vaginal deliveryIn hands-on
workshops: session 3 (OBS emergencies)
39
FETAL HEALTH SURVEILLANCE
Fundamentals Workshop2009
Fetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009402009 PPPESO41Systematic Approach to
InterpretationCHECK: Tracing quality, paper speed, graph range,
internal vs. externalINTERPRET:Uterine Activity PatternBaseline
FHRBaseline VariabilityPresence of Accelerations &
DecelerationsCorrelate findings with clinical situation: Normal,
Atypical, Abnormal (Reassuring or non-reassuring?)Document Fetal
Health Surveillance - Instructor Notes PPPESO, 2009Copyright
PPPESO, 200941Highlight importance of methodological approach to
interpretation.2009 PPPESO42
Paper speed - 3 cm/minFetal Health Surveillance - Instructor
Notes PPPESO, 2009Copyright PPPESO, 2009422009 PPPESO43Uterine
Activity Assessment (contractions)Frequency (in minutes)Duration
(in seconds)Intensity (mild, moderate, strong) by history and by
palpationResting tone (soft, firm) by palpationFetal Health
Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO,
200943RN can help resident learn how to palpate the uterine
fundus2009 PPPESO44Baseline FHRDefinition: approximate mean FHR
rounded to 5 bpm increments in a 10-minute segment,
excluding:periodic & episodic changesperiods of marked FHR
variability (> 25 bpm)Must be present 2 minutes or is
indeterminate110-160 normal> 160 tachycardia< 110
bradycardiaFetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009442009 PPPESO45FHR VariabilityDefinition:
Fluctuations in baseline FHR 2 cycles per minuteIrregular amplitude
and frequencyVisually quantitated as the amplitude of the
peak-to-trough in bpm 1201501809012015018090Presence of variability
is a crude indicator of fetal oxygenation as it reflects an intact
CNSFetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009452009 PPPESO46FHR VariabilityABSENT
MINIMAL
MODERATE
MARKEDAmplitude range undetectable
Amplitude range detectable but 5 bpm
Amplitude range 6-25 bpm
Amplitude range > 25 bpmFetal Health Surveillance -
Instructor Notes PPPESO, 2009Copyright PPPESO, 2009462009
PPPESO47FHR VariabilityMINIMAL VARIABILITY: 3-5 bpm
ABSENT VARIABILITY : 0-2 bpm
No distinction is made any longer between short-term variability
(or beat-to-beat or R-R wave period differences in ECG) and
long-term variability Fetal Health Surveillance - Instructor Notes
PPPESO, 2009Copyright PPPESO, 2009472009 PPPESO48FHR
VariabilityMODERATE VARIABILITY: 6-25 bpm
MARKED VARIABILITY: > 25 bpmFetal Health Surveillance -
Instructor Notes PPPESO, 2009Copyright PPPESO, 2009482009
PPPESO49AccelerationDefinition: Abrupt increase in FHR (onset to
peak in < 30 seconds) 15 bpm above baseline lasting 15
sec.Before 32 weeks: 10 bpm for 10 sec.Prolonged acceleration is 2
minutesAcceleration 10 minutes is a baseline changeNORMAL
finding
Accelerations are a sympathetic response indicating an intact,
oxygenated CNSFetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009492009 PPPESO50Early
DecelerationDefinition: Gradual decrease in FHR (onset to peak in
30 seconds) associated with a uterine contractionOnset, nadir and
recovery coincide with contractionNORMAL ie.
reassuring120150180901201501809010025507501002550750Reflex vagal
response associated withhead compressionFetal Health Surveillance -
Instructor Notes PPPESO, 2009Copyright PPPESO, 200950Remind
participants that these are uncommon, despite the fact that every
babys head obviously gets compressed coming through the pelvis. Why
dont we see these more often? Perhaps they are more common when the
head is de-flexed, asynclitic or otherwise malpositioned. Not a lot
of research into this
No acid-base complications UNLESS associated with nonreassuring
baseline features
No interventions required for the early decels, however, look at
the total clinical picture for lack of progress which might explain
the difficulty of the head in maneuvering through the pelvis2009
PPPESO51Variable DecelerationDefinition: Abrupt decrease in FHR
(onset to peak in < 30 seconds) that is 15 bpm below the
baseline for 15 sec., and < 2 minutes from onset to return to
baselineWhen periodic, their onset, depth and duration commonly
vary with successive contractionsCan be NORMAL, ATYPICAL or
ABNORMAL 120150180901201501809010025507501002550750Reflex response
tocord compression during or between contractionsFetal Health
Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO,
2009512009 PPPESO52Variable Deceleration
Shoulders Overshoots NORMAL (REASSURING)ABNORMAL
(NON-REASSURING)Fetal Health Surveillance - Instructor Notes
PPPESO, 2009Copyright PPPESO, 2009522009 PPPESO53
Complicated Variable DecelerationsDeceleration 60 sec.Loss of
variability of baseline and in the troughBiphasic
decelerationOvershoot (20 bpm increase by 20 secondsSlow return to
baselineContinuation of baseline rate at a lower level than prior
to the decelerationPresence of tachycardia or bradycardia
Fetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 200953532009 PPPESO54Late
DecelerationDefinition: Gradual decrease in the FHR (onset to peak
in 30 seconds) associated with a contractionOnset, nadir &
recovery occur after the beginning, peak & end of
contractionATYPICAL or ABNORMAL ie.
Non-reassuring120150180901201501809010025507501002550750Chemoreceptor
& vagal response toutero-placental insufficiency , reflecting
marginal fetal oxygenationFetal Health Surveillance - Instructor
Notes PPPESO, 2009Copyright PPPESO, 200954Stress to participants
that late decels might be either reflex (and therefore probably
correctable) and occasional or related to some sort of chronic
problem (poor placenta, or hypertension affecting placental blood
flow) that are repetitive and not likely correctable. This doesnt
get documented, but helps care providers think about the likely
success of their interventions.
For example, late decelerations associated with a healthy woman
who happens to be positioned on her back are probably correctable.
2009 PPPESO55Prolonged DecelerationVisually apparent decrease in
FHR below baseline, > 15 bpm, lasting > 3 minutes, but <
10 minutes from onset to return to baselineDecrease calculated from
the most recently determined portion of baselineProlonged
deceleration > 10 min is a baseline changeABNORMAL
(Nonreassuring)
Chemoreceptor, baroreceptor & CNS responses toprofound
changes in fetal environment Fetal Health Surveillance - Instructor
Notes PPPESO, 2009Copyright PPPESO, 2009552009 PPPESO56Rare FHR
changes
Sinusoidal pattern differs from variability in that it has a
smooth, sine wave-like pattern of regular frequency and amplitude,
and is excluded in the definition of FHR variabilityAssociated with
fetal anemiaFetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 200956Is classified as an ABNORMAL
findingIntermittent Auscultation (IA)Appropriate for low risk
labor
Classification of NON STRESS TEST (NST)58Classification of EFM
tracings
2009 PPPESO60Factors to consider wheninterpreting FHR
characteristics Gestational age Fetal behavioral state External
factors / influences Cause of decreased oxygen delivery Duration of
precipitating causeThe overall clinical picture!Fetal Health
Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO,
200960Review each of these factors:QUESTIONS:What is the reason
that we should consider each of the above stated factors?
2009 PPPESO61Responses to Atypical and Abnormal FHRConsider
total clinical pictureFurther assessments to identify potential
causes (maternal, fetal, placental) and to assess fetal
well-beingFetal scalp stimulationFetal scalp samplingClinical
actions to:remove aggravating condition(s)institute intrauterine
resuscitation techniquesFetal Health Surveillance - Instructor
Notes PPPESO, 2009Copyright PPPESO, 2009612009
PPPESO62RECOMMENDATION:Digital Fetal Scalp Stimulation Recommended
with atypical EFMGentle digital pressure over the parietal bonesMax
15 seconds between contractions and between decelsAcceleration
usually = pH > 7.19 ( Murray, 2007)When a acceleratory response
is absent: fetal scalp blood sampling where available (IIB)when
unable to perform fetal scalp sampling, consider prompt delivery
(IIIC)Fetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009622009 PPPESO63GOALS:Improve uterine
blood flowImprove umbilical circulationImprove oxygen
saturationReduce uterine activityINTERVENTIONS:Change positionGive
O2 per mask ?Decrease/discontinue oxytocinTemporarily increase IV
rateSupport woman / familyCommunicate / DocumentIntrauterine
ResuscitationFetal Health Surveillance - Instructor Notes PPPESO,
2009Copyright PPPESO, 2009632009 PPPESO64Documentation
contentAssessments, interventions, evaluations Subjective
(statements/feedback from client in " ")Objective
(observed/measured, actions, etc)Communication with care
providers:Who was called, and time of callInformation reported and
request(s) madeCare providers responseAgreed-upon plans of
actionOutcomesThird-party information (family member, etc)Clients
non-compliant or risk-taking behaviourFetal Health Surveillance -
Instructor Notes PPPESO, 2009Copyright PPPESO, 200964
