Slide 1

Slide 2 Fetal Health Surveillance (FHS) Part 2 Electronic Fetal Monitoring * Maternal Newborn Orientation Learning Module Reproductive Care Program of Nova Scotia, 2012 *FHS: Part 1 should be viewed prior to review of this module Slide 3 References www.sogc.org Slide 4 Objectives 1.Review skilled use of the electronic fetal monitor (EFM) during labour Risks/benefits of electronic fetal monitoring Indications Methods of electronic fetal monitoring Analysis, interpretation and classification of tracings Appropriate interventions in the event of atypical or abnormal tracings Communication and documentation Slide 5 Risks/benefits Some association with a reduction in neonatal seizures; no difference in cerebral palsy or perinatal mortality in C-sections and operative vaginal births Slide 6 SOGC Recommendation (2007) The normal, healthy fetus is well-equipped to withstand the repeated, transient hypoxia associated with labour contractions. Intermittent auscultation (IA) is the preferred method of fetal surveillance for healthy women without risk factors for adverse outcomes. For those at risk for adverse outcomes, electronic fetal monitoring is advised. Slide 7 Indications for using the EFM Examples of risk factors for adverse outcomes: Antepartum maternal HDP Hemorrhage Diabetes Morbid Obesity Antepartum fetal Prematurity Oligohydramnios IUGR Multiple pregnancy Slide 8 Indications for using the EFM Examples of risk factors for adverse outcomes: Intrapartum maternal Prolonged ROM Postterm pregnancy > 42+0 Previous C/S Augmented/induced labour* Intrapartum fetal Meconium staining Abnormal FHR on auscultation *Augmentation continuous EFM * Induction EFM can be interrupted periodically once the infusion is stable, and provided there are no additional risks and the tracing has been normal Slide 9 Methods of electronic fetal monitoring Slide 10 Applying the external EFM Leopolds Maneuver Slide 11 Internal Fetal Monitoring Scalp electrode IUPC Slide 12 1 minute 10 sec. Equipment - Monitor Paper 20 bpm Slide 13 Quality of the tracing FHR Slide 14 Quality of the tracing - contractions Contn Slide 15 Features of the tracing Contractions FH Baseline Variability Accelerations Decelerations Slide 16 Contractions Estimate frequency from the start one contraction to the start of the next Duration estimated in seconds Estimate over 10 min Document range q 2-3 min x 50-60 sec Resting tone soft or firm by palpation; approx. 20 mmHg measured by IUPC frequency Resting tone Slide 17 Abnormal contraction patterns Tachysystole more than 5 contractions in 10 minutes, averaged over 30 minutes Hypertonus resting tone > 20 to 25 mmHg Slide 18 Baseline FHR Approximate mean of the FHR (rounded to 5 bpm) assessed over 10 minutes Excludes accelerations and decelerations Normal baseline 110 to 160bpm Slide 19 Tachycardia Causes: Prematurity Maternal anxiety/medication Prolonged fetal activity Fever/infection Chronic fetal hypoxemia Baseline > 160 bpm x > 10 min Slide 20 Slide 21 Bradycardia Causes : Postmaturity Fetal heart block Vagal stimulation Fetal hypoxia/acidosis (late sign) Atypical if baseline 100 to 110 bpm; Abnormal if baseline < 100 bpm Slide 22 Slide 23 Variability Refers to fluctuations in the baseline FHR Occurs because of push and pull between sympathetic nervous system (pushes the FHR up) and parasympathetic nervous system (pulls the FHR down) Requires an intact, well functioning nervous system and oxygenated brain stem Slide 24 Variability To determine variability: Select a 1-minute section of the tracing Look at the amplitude/range of fluctuations Ensure there is a minimum of 2 fluctuations/cycles within the minute Average # of cycles 2 to 4/min Moderate variability (amplitude) 6 to 25 bpm 120 150 180 90 120 150 180 90 CMNRP Slide 25 Classification of variability Absent range undetectable Minimal 5 bpm Moderate 6-25 bpm Marked > 25 bpm Slide 26 Minimal or absent variability Causes: Fetal sleep Prematurity Medications Hypoxia/acidemia Atypical if 5 bpm x 40 to 80 min Abnormal if 5 bpm x > 80 min Slide 27 Slide 28 Slide 29 Marked Variability Causes: Uncertain etiology Mild hypoxia Catecholamines Abnormal if 25 bpm x > 10 minutes *rule out artifact Slide 30 Accelerations Causes: Normal response of a well-oxygenated, non- acidotic fetus to sympathetic stimulation or fetal activity If not spontaneous, may be elicited by fetal scalp stimulation Abrupt increases in the FHR at least 15 bpm above the baseline, lasting 15 sec to 2 min (> 32 weeks gestation) Slide 31 Describe this tracing including features reviewed so far Slide 32 Slide 33 Decelerations - Early Mirror image of contractions Nadir of deceleration occurs with peak of contraction; FHR returns to baseline as the contraction ends Mechanism vagal response from head compression Benign CMNRP Slide 34 Decelerations - Late Gradual decrease in the FHR with nadir after peak of contraction and gradual return to baseline following the contraction Deceleration may be almost undetectable; nadir usually not more than 10 to 20 bpm below the baseline Mechanism uteroplacental insufficiency CMNRP Chronic/Acute Conditions Slide 35 Decelerations - Late Slide 36 Slide 37 Decelerations - Variable Abrupt decrease in the FHR, at least 15 bpm below the baseline, lasting 15 seconds and < 2 minutes Uncomplicated variables have shoulders accelerations before and following decel Mechanism cord compression 120 150 180 90 120 150 180 90 100 25 50 75 0 100 25 50 75 0 CMNRP Normal if occasional; Atypical if repetitive ( 3) Slide 38 Complicated variable decels to 60 seconds Loss of variability Slow return to baseline Baseline continues at a lower rate Prolonged secondary acceleration (overshoot) Biphasic Tachycardia or bradycardia Overshoot CMNRP Biphasic Slide 39 Slide 40 Prolonged decelerations In FHR 15 bpm below baseline (most often 30 bpm), lasting 2 min, < 10 min Possible causes include cord prolapse, hypertonus, uterine rupture, and sudden fetal descent Slide 41 Rare, distinctive tracings Slide 42 Slide 43 Classification of EFM Tracings (SOGC, 2007) Parameter NormalAtypicalAbnormal Baseline 110 to 160 bpm Bradycardia 100 to 110 bpm Tachycardia > 160 bpm x > 30 min to < 80 min Rising Baseline Bradycardia < 100 bpm Tachycardia >160 bpm x > 80 min Erratic baseline Variability 6 to 25 bpm 5 bpm x < 40 min 5 bpm x 40-80 min. 5 bpm x > 80 min 25 bpm x > 10 min Sinusoidal Decelerations None or occasional uncomplicated variables Early decels Repetitive ( 3) uncomplicated variables Occasional lates Single prolonged > 2 min, < 3 min Repetitive ( 3) complicated variables Lates >50% of contractions Single prolonged >3, < 10 min Accelerations Spontaneous accelerations Accelerations with scalp stimulation No acceleration with fetal scalp stimulation Usually absent Slide 44 Recommended actions NormalAtypicalAbnormal Action May interrupt EFM for periods up to 30 minutes if condition stable and oxytocin rate stable Further assessment required Review overall clinical situation; scalp pH may be obtained; prepare for delivery pH > 7.25 continue monitoring; repeat scalp gas in 30 minutes if atypical or abnormal tracing persists pH 7.20 to 7.25 - repeat scalp gas in 30 minutes pH Interventions in response to abnormal features Late decelerations uteroplacental insufficiency maximize uteroplacental blood flow left lateral maternal position promote intrauterine resuscitation Minimal/absent variability for > 40 minutes scalp stimulation to elicit accelerations promote intrauterine resuscitation Slide 48 Promoting intrauterine resuscitation Discontinue oxytocin Position change/left lateral position IV rate to improve hydration Modify breathing and pushing techniques (2 nd stage) Administer oxygen at 8-10 l/min* *Prolonged use of oxygen should be avoided; its effectiveness varies depending on the clinical situation; increases fetal pO 2 only slightly. Slide 49 G1, 40 3/7 wks; SRM x 26 hours, spontaneous labour, 3 cm, 0 Slide 50 Slide 51 G1 induced for HDP at 40 4/7 wks; 4 cm dilated, station 0, strong contractions, meconium stained fluid Slide 52 Slide 53 Communication Always keep the labouring woman informed of findings of FHS including rationale for interventions Effective, interprofessional communication is essential Suboptimal communication was identified as a root cause in 72% of reported adverse outcomes Slide 54 Communication tools SOGC recommends CHAT C Current Condition H History A Assessment T Treatment SBAR is commonly used in NS S Situation B Background A Assessment R Recommendation Slide 55 Documentation-clear, concise, and accurate Contraction pattern and details of the FHR q 15 to 30 minutes during active labour (q15 minutes when oxytocin running), and every 5 minutes during 2 nd stage. Tracing interpretation/classification Actions undertaken to improve atypical or abnormal tracings Plan of care Slide 56 Legal protection Consistent terminology and classification Regular interprofessional education and review of tracings Effective communication and complete documentation Consistent times on a high quality tracing, in the partogram and throughout the record Each portion of the tracing labeled; do not circle or mark suspicious findings but do note adjustment of transducers and/or tocodial Slide 57 In summary Regular interprofessional education related to fetal health surveillance and electronic fetal monitoring is essential for all health care providers who care for labouring women. This education should promote consistent terminology and a common approach that is based on current SOGC guidelines and standards of care. Slide 58 Thank you! We welcome your feedback. Please take a few moments to complete a short evaluation: http://rcp.nshealth.ca/education/learning-modules/evaluation If you have any questions, please contact the RCP office at rcp@iwk.nshealth.ca or 902-470-6798rcp@iwk.nshealth.ca