Monitoring A Standardized Approach to Interpretation and

Intrapartum Fetal Heart Rate Monitoring

A Standardized Approach toInterpretation and Management

Lesson 4: Management

At the end of this program, participants will be able to:

Describe a standardized intrapartum FHR monitoring management decision model consisting of 4 central concepts that systematically address potential sources of preventable error

Lecture Objectives

Management (n.) The act of handling or controlling something successfully

Success = safe delivery

Birth free from injury caused by interrupted oxygenation

A “standardized management” protocol is NOT a cookbook that determines the timing and method

of delivery

Standardization does not take the “art” out the practice of medicine

The objective of a “standardized management” protocol is to minimize potential sources of

preventable error

Despite our best efforts, not all outcomes will be good…

What happens when the outcome is bad?

Root cause analysis starts with a “sentinel event” and focuses on ascertaining and analyzing potential sources of preventable error in order to establish standard procedures to minimize the chance that they will recur in the future. Root cause analysis does not focus on assigning blame

A medical liability legal action, on the other hand, focuses on assigning blame

Assigning “blame”

Deviation from standard of care↓

Proximate cause↓

Damages

What is your best defense?

1. My actions deviated from the standard of care, but they did not cause the injury

2. My actions did not deviate from the standard of care

We are expected to take reasonable actions to avoid preventable errors in intrapartum management…

What are some potential sources of preventable error??

To delivery

Determine the need for immediate operative intervention

Address common obstacles to rapid delivery

Apply appropriate corrective measures

Communicate accurately and effectively

Interpret FHR tracing accurately

Define FHR tracing accurately (terminology)

Confirm FHR and uterine activity

Potential sources of preventable error from admission

Realistically assess the decision to delivery time

Consider other factors that might be responsible for the FHR changes

By employing a standardized, systematic approach that addresses as many potential sources of preventable error as possible, we can accomplish three major goals:

1. Minimize preventable variations in the decision-making process

2. Minimize the likelihood that critical elements of the decision-making process will be overlooked

3. Demonstrate reasonableness and prudenceTwo elements that define “standard of care”

Intrapartum FHR Monitoring

Terminology Interpretation Management

What do I call it?Baseline rate…130 bpmVariability…moderateAccelerations…presentDecelerations…absentChanges or trends over time…none

1. Terminology

2. Interpretation

3. Management

One end of the FHR spectrum – “Category I”

What does it mean?

What do I do about it? This intrapartum FHR tracing requires no specific action

1. True

2. False

Intrapartum Surveillance

In a “low-risk” patient:

Review the tracing at least every 30 minutes in the active phase of the 1st stage of labor and every 15

minutes in the 2nd stage

In a “high-risk” patient:

Review the tracing at least every 15 minutes in the active phase of the 1st stage of labor and every 5

minutes in the 2nd stage

Confirm FHR

Is immediate intervention indicated?

Does the tracing fall into Category I (normal)?

Is the patient“high risk”?

ROUTINE SURVEILLANCEEvery 30 minutes in 1st stage

Every 15 minutes in the 2nd stage

Yes

No

Yes

No

HEIGHTENED SURVEILLANCEEvery 15 minutes in the 1st stageEvery 5 minutes in the 2nd stage

INTRAPARTUM FHR MONITORINGManagement Decision Model

Category II

1. Terminology

2. Interpretation

3. Management

What do I call it?Baseline rate…150 bpmVariability…moderateAccelerations…absentDecelerations…presentChanges or trends…yes

What does it mean?

What do I do about it?

If there is evidence of interrupted transfer of oxygen from the environment to the fetus, the most logical approach is to

1. Ignore it

2. Assess the oxygen pathway

3. Begin corrective measures if needed

4. Perform immediate cesarean

5. None of the above

6. 2 & 3

Confirm FHR






Yes

No

Yes

No



“ABCD”

No

Standardized Intrapartum FHR Management

Four Central Concepts

“ABCD”A – Assess the oxygen pathwayB – Begin corrective measures

Confirm FHR






Yes

No

Yes

No



“ABCD”

No

“A” - Assess oxygen pathway“B” - Begin corrective measures

“A”Assess Oxygen

Pathway

“B”Begin Corrective

Measures if Indicated

“C”Clear Obstacles to

Rapid Delivery

“D”Determine Decision

to Delivery Time

Lungs Airway and breathingPulse oximetry or ABG

Supplemental oxygenTreat pulmonary disordersAlter breathing technique

FacilityOR availabilityInstrumentsEquipment

Realistic estimate of facility response time

Heart Heart rate and rhythmCardiac output

IV fluid bolusTreat arrhythmia Staff

NotifyObstetricianSurgical assistantAnesthesiologistNeonatologistPediatricianNursing staff

Consider staff:AvailabilityTrainingExperience

Vasculature Blood pressureVolume status

Maternal position changesCorrect hypotension Mother

Informed consentAnesthesia optionsLaboratory testsBlood productsIntravenous accessUrinary catheterAbdominal prepTransfer to OR

Surgical considerations(prior abdominal or uterine surgery uterine fibroids)

Medical considerations(obesity, hypertension, diabetes,

SLE)Obstetric considerations

(parity, pelvimetry, placental location)

UterusContraction strengthContraction frequencyBaseline uterine toneExclude uterine rupture

Stop/reduce oxytocin Remove prostaglandin Uterine relaxants if neededConsider IUPCAlter pushing technique Fetus

ConfirmFetal heart rateGestational ageFetal weightPresentationPosition

Consider FSE

Consider factors such as:Baseline FHR changesLoss of variabilityLoss of accelerationsRecurrent decelerationsGrowth restrictionMacrosomiaPresentation, positionPrematurity, infection Meconium

Placenta Placental separationBleeding vasa previa Rapid delivery if indicated

Cord Vaginal examExclude cord prolapse

Consider amnioinfusionConsider elevating fetal head Labor Consider tocolytic

Consider IUPC

Consider factors such as:Arrest disorderProtracted laborRemote from deliveryPoor expulsive efforts


Pathway




Rapid Delivery


to Delivery Time

Lungs Airway and breathingPulse oximetry or ABG Supplemental oxygen Facility

OR availabilityInstrumentsEquipment


Heart Heart rate and rhythmCardiac output IV fluid bolus Staff











Stop or reduce stimulant Consider uterine relaxant

Fetus


Consider FSE


Placenta Placental separationBleeding vasa previa

Cord Vaginal examExclude cord prolapse Consider amnioinfusion Labor Consider tocolytic

Consider IUPC


Do “conservative measures” really improve fetal oxygenation?Measures Evidence

Supplemental oxygen Direct – Pulse oximetry

Maternal position changes Direct – Pulse oximetry

IV fluid bolus Direct – Pulse oximetry

Correcting hypotension Indirect – FHR

Amnioinfusion Indirect – FHR

Reducing uterine activity Indirect – FHR, pulse oximetry

Altered pushing technique Indirect – FHR, pulse oximetry

Altered breathing technique Indirect - FHR

KR Simpson J Midwifery Womens Health. 2007 May-Jun;52(3):229-37

Category III

1. Terminology

2. Interpretation

3. Management

What do I call it?Baseline rate…165Variability…absentAccelerations…absentDeceleration…present, recurrentChanges or trends…yes

What does it mean?

What do I do about it?

If you have done “A” and “B”, but the tracing has not improved, the next step is…

1. Panic

2. Crash Cesarean

3. Nothing

4. Discharge home

5. “C”

Standardized Intrapartum FHR Management

Four Central Concepts

“ABCD”A – Assess the oxygen pathwayB – Begin corrective measuresC – Clear for deliveryD – Decision to delivery time

Confirm FHR






Yes

No

Yes

No



“ABCD”

No


Minimal-absent variability?or

Recurrent decelerations?

Yes

“ABCD”“C” - Clear for delivery

Clear for delivery

If conservative measures do not correct recurrent decelerations and improve variability, it is prudent to plan ahead for the possible need for rapid delivery

There are many common sources of unnecessary delay

Addressing them in a systematic fashion reduces the likelihood that important factors will be overlooked

It also demonstrates reasonableness and prudence…two elements that define the standard of care

Clear obstacles to rapid delivery

These simple precautions are not often emphasized in a systematic way, but failing to

address them can be a major source of criticism in the event of an untoward outcome

FacilityStaffMotherFetusLabor

Consider individual characteristics of


Pathway




Rapid Delivery


to Delivery Time

Lungs Airway and breathingPulse oximetry or ABG

Supplemental oxygenTreat pulmonary disordersAlter breathing technique

FacilityOR availabilityInstrumentsEquipment


Heart Heart rate and rhythmCardiac output

IV fluid bolusTreat arrhythmia Staff











Stop/reduce oxytocin Remove prostaglandin Uterine relaxants if neededConsider IUPCAlter pushing technique Fetus


Consider FSE


Placenta Placental separationBleeding vasa previa Rapid delivery if indicated

Cord Vaginal examExclude cord prolapse

Consider amnioinfusionConsider elevating fetal head Labor Consider tocolytic

Consider IUPC


Confirm FHR






Yes

No

Yes

No



“ABCD”

No




Yes

“ABCD”“C” - Clear for delivery“D”- Decision to delivery time


Pathway



“C”Clear Obstacles

to Rapid Delivery


to Delivery Time

Lungs Airway and breathingPulse oximetry or ABG Supplemental oxygen Facility

OR availabilityInstrumentsEquipment


Heart Heart rate and rhythmCardiac output IV fluid bolus Staff







Medical considerations(obesity, hypertension, diabetes, SLE)

Obstetric considerations(parity, pelvimetry, placental location)


Stop/reduce stimulantsConsider uterine relaxants

Fetus


Consider FSE


Placenta Placental separationBleeding vasa previa

Cord Vaginal examExclude cord prolapse Consider amnioinfusion Labor Consider tocolytic

Consider IUPC


If I have a checklist of standard operating procedures posted on L&D, I could be held accountable for failing to address all of the standard operating procedures in the event of a bad outcome

1. True

2. False

The fact of the matter…We are required by the standard of care to follow the standard operating procedures that would be expected from a reasonable and prudent practitioner in the same or similar circumstances

Checklist or no checklist

Why not use a checklist as a reminder?

Assess oxygen pathway

Begin corrective measures

Clear for delivery

Determine decision to delivery time

√

√

√

√

Now what?

Confirm FHR






Yes

No

Yes

No



“ABCD”

No




Yes


Is vaginal delivery likely before metabolic acidemia?

Is vaginal delivery likely to occur before the onset of metabolic acidemia?

This is ALWAYS a prediction of unknown future events

It ALWAYS involves multiple interacting factors

It ALWAYS relies on clinical judgment

There will NEVER be a “cookbook” answer

USE INDIVIDUAL CLINICAL JUDGMENT TO ESTIMATE:

Time to vaginal delivery

Consider cervical dilatation, effacement, station, adequacy of uterine activity, past rate of progress and expected rate of progress in the future

With recurrent decelerations and minimal-absent variability, fetal metabolic acidemia can evolve over

approximately 60 minutes (assuming a previously normal FHR tracing and no acute events)

In the setting of acute events, absent variability, absent accelerations and decelerations that are

deeper, longer and more frequent, metabolic acidemia might occur more rapidly

The information supporting these statements is limited:

Fleischer A, Schulman H, Jagani N, Mitchell J, Randolph G: The development of fetal acidosis in the presence of an abnormal fetal heart rate tracing. I. The average for gestational age fetus, Am J Obstet Gynecol 144(1):55-60, 1982.

Ingemarsson I, Herbst A, Thorgren-Jerneck K: Long-term outcome after umbilical artery acidemia at term birth: Influence of gender and fetal heart rate abnormalities, Br J Obstet Gynaecol 104(10):1123-1127, 1997.

Low JA, Galbraith RS, Muir DW, Killen HL, Pater EA, Karchmar EJ: Factors associated with motor and cognitive deficits in children after intrapartum fetal hypoxia, Am J Obstet Gynecol 148:533-539, 1982.

Parer JT, King T, Flanders S, Fox M, Kilpatrick SJ: Fetal acidemia and electronic fetal heart rate patterns. Is there evidence of an association? J Matern Fetal Neonatal Med 19(2):289-294, 2006.

Confirm FHR






Yes

No

Yes

No



“ABCD”

No




Yes



OFFER OPERATIVE DELIVERYDocument decision process

Counsel patient

Yes

No

Category I

“Low risk”1st stage q 30 min2nd stage q 15 min

“High risk”1st stage q 15 min2nd stage q 5 min

Category IIAND

Metabolic acidemia CAN be excluded(Moderate variability or accelerations)

Assess Oxygen PathwayLungsHeartVasculatureUterusPlacentaCord

Begin Corrective MeasuresSupplemental oxygenPosition changeFluid bolusCorrect hypotensionStop/reduce uterine stimulantConsider uterine relaxantConsider amnioinfusion

Clear obstacles to deliveryFacilityStaffMotherFetusLabor

Decision-delivery estimateFacilityStaffMotherFetusLabor

Category II - IIIAND

Metabolic acidemia CANNOT be excluded(Minimal-absent variability and no accelerations)

ADMISSION

OUTCOME

SurveillanceConservative

Measures“A & B”

Prepare forDelivery“C & D”

DeliveryDecision

?

If, in your clinical judgment, immediate delivery is necessary, proceed without delay

If, in your clinical judgment, a brief period of expectant management is reasonable, formulate a plan that minimizes potential risks…

According to the best information in the literature…if a normal FHR tracing changes to a tracing with minimal-absent variability and recurrent decelerations, metabolic acidemia can evolve over approximately 60 minutes

How reliable is this information?

What would you consider a reasonable “margin of safety”?

Reducing the time by 50%? That’s the approach we take with risks of radiation exposure during pregnancy…

A suggested reasonable approach…

If a previously normal FHR tracing loses the ability to exclude metabolic acidemia and, in your clinical judgment, a brief period of expectant management is reasonable…

Allow no more than 30 minutes to either accomplish delivery or correct the FHR tracing (approximately 60 minute leeway gleaned from scanty literature minus a reasonable 50% margin of safety)

Remember…that’s 30 minutes until delivery or correction of the FHR tracing…not 30 minutes until the decision to proceed with delivery

Take into account your estimated “decision-to-delivery” time and subtract it from your 30-minute window

The remainder is the amount of time you have to achieve vaginal delivery or correct the FHR tracing before making a decision to proceed with operative delivery

Is this scientific?

As scientific as possible given the dearth of information in the literature

Is it reasonable and prudent?

It is as evidence-based as the current literature allows, it incorporates a 50% margin of safety and it accounts for the estimated “real-life” decision-to-delivery time

But is it “standard of care”?

By definition, if your actions are deemed to be reasonable and prudent, they meet the standard of care

Few things demonstrate reasonableness and prudence more convincingly than a thoughtful, preconceived, standardized, evidence-based, well-prepared, systematically executed plan of action

Category I

“Low risk”1st stage q 30 min2nd stage q 15 min

“High risk”1st stage q 15 min2nd stage q 5 min

Category IIAND

Metabolic acidemia CAN be excluded(Moderate variability or accelerations)

Assess Oxygen PathwayLungsHeartVasculatureUterusPlacentaCord

Begin Corrective MeasuresSupplemental oxygenPosition changeFluid bolusCorrect hypotensionStop/reduce uterine stimulantConsider uterine relaxantConsider amnioinfusion

Clear obstacles to deliveryFacilityStaffMotherFetusLabor

Decision-deliveryFacilityStaffMotherFetusLabor

Category II - IIIAND

Metabolic acidemia CANNOT be excluded(Minimal-absent variability and no accelerations)

ADMISSION

OUTCOME

SurveillanceConservative

Measures“A & B”

Prepare forDelivery“C & D”

DeliveryDecision

Evolution of metabolic acidemia ~ 60 minSubtract 50% safety margin ~ 30 min

Subtract “decision-delivery estimate” ~ X minAllow the remaining time for vaginal delivery or

correction of the FHR tracing

If vaginal delivery does not occur in this time frame and the FHR abnormalities have not been corrected,

it is reasonable to offer operative delivery

Is immediate delivery indicated?

No

Confirm FHR






Yes

No

Yes

No


INTRAPARTUM FHR MONITORINGManagement Decision Model “ABCD”

No




Yes



OFFER OPERATIVE DELIVERYDocument decision process

Counsel patient

Yes

No

Urgently needed standardization of intrapartum FHR management should

not be further delayed because this one question is difficult to anser


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Monitoring A Standardized Approach to Interpretation and