Telephone transmission of fetal heart rate monitor data

The experience at the University of Connecticut Health Center

Anthony M. Vintzileos, M.D., Jane T. Montgomery, R.N., David J. Nochimson, M.D., Winston A. Campbell, M.D., Paul J. Weinbaum, M.D., Maryanne P. Blanchfield, R.N., and Jack N. Blechner, M.D.

Farmington, Connecticut

This report reviews the experience at the University of Connecticut Health Center using the Fetal Assessment Consultative Transmission Service (FACTS) system during a 2%-year period. This system,

which permits direct transmission of antepartum and/or intrapartum fetal heart rate tracings via a telephone line, allows the obstetric staffs of smaller community hospitals to obtain an immediate consultation from the University of Connecticut Health CentElr on a 24 hour per day baSis. A total of 511 fetal heart rate tracings were analyzed. Two hundred forty-five were intrapartum, 206 antepartum, and 60

were transmitted for educational purposes. The results indicate an imperative need for such a service from

a tertiary care center to improve the quality of regional perinatal care and to determine the future direction of the regional educational program for physicians and nurses. (AM J OBSTET GVNECOL 1986;155:630-4.)

Key words: Telephone transmission, fetal heart rate, FACTS

During the past decade there have been dramatic changes in the methods used to assess fetal condition. These changes are obviously related to the widespread use of electronic fetal heart rate monitoring, which has become an integral part of the intrapartum as well as antepartum fetal surveillance. The presence of a re­assuring fetal heart rate pattern during the intrapar­tum or antepartum period is an indication for expec­tant management. The presence of an abnormal intra­partum fetal heart rate pattern may be an indication for maternal medical treatment (for instance, positional changes, oxygen administration, discontinllation of oxytocin), further investigation (for instance, fetal acid­base assessment), or intervention (for instance, prompt delivery by cesarean section or forceps). However, fetal heart rate patterns are occasionally confusing and not easy to interpret. Under these circumstances a prompt transmission of the fetal heart rate tracing from a regional hospital to a tertiary care center for an immediate and expert consultation would seem ap­propriate.

Earlier reports have described the transmission of fetal heart rate tracings via a Xerox 400 Telecopierl. 2

or telemetry.' The Xerox metho?, however, had major disadvantages, such as limited transmission time (only

From the Division of Maternal-Fetal Medicine, Department of Ob­stetrics and Gynecology, University of Connecticut Health Center.

Received for publication February 24, 1986; revised April 18, 1986; accepted April 24, 1986.

Reprint requests: Anthony M. Vintzileos, M.D., Division of Maternal­Fetal Medicine, Department of Obstetrics and Gynecology, Uni­versity of Connecticut Health Center, Farmington, CT 06032.

630

an 8-minute portion of the fetal heart rate tracing could be transmitted), lack of darity, and inability to store data for retrospective analysis.

The Fetal Assessment Consultative Transmission Service (FACTS) system was introduced by the Uni­versity of Connecticut Health Center, Division of Ma­ternal-Fetal Medicine, and has been in full operation since January 1, 1983. This program permits assess­ment of continuous recordings of fetal heart rate and uterine activity data, which are transmitted to the Uni­versity of Connecticut via telephone line from small community hospitals (in the region) for interpretation and consultation. The system provides a clear and re­liable hard-copy record (Fig. I) of the transmitted data, which allows us to offer an immediate emergency con­sultation for any hospital irrespective of location or distance. Most of the current models of monitors can be used for transmission.

The purpose of the present communication is to re­port our 2Y2 years' experience with the FACTS system and to discuss the impact of this service in improving perinatal outcome in the region.

Material and methods

FromJanuary 1,1983, toJune 30,1985,17 hospitals throughout North Central Connecticut and Western Massachusetts used the FACTS system. Each local hos­pital is equipped with one or more transmitting units (Litton Model DTlOO). One receiving unit (Litton Model DRIOO) is placed in the Maternal-Fetal Intensive Care Unit, University of Connecticut Health Center, and two additional receiving units are available to fac-

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..

Telephone transmission of fetal heart rate monitor data 631

'JB~

...=--

Fig. 1. The upper panel represents an external fetal heart rate tracing from a patient in early labor, and the lower panel represents the transmitted hard copy. Note the similarity and clarity of the obtained information.

ulty members on call. The service operates on a 24 hour per day basis.

The transmission process is simple. The transmitting unit is connected to a telephone line and a fetal heart rate monitor. Once electronic fetal heart monitoring begins, the transmitting unit is activated and stores fetal heart rate and uterine contraction data. Maximum stor­age capacity is 2 hours. When a telephone call request­ing a consultation is received at the University of Con­necticut Health Center, the patient'S history is obtained and logged into our records. Then, using the telephone connected to the transmitting unit, the person who re­quests the transmission dials a number assigned to the receiving unit, activates the transmitting unit, and the transmission begins. The stored data are received at 12 times real time; therefore, a 2-hour retrospective rec­ord is transmitted in 10 minutes. After the transmission of the stored data, the unit continuously updates the information (on-line data) for as long as the interpreter feels it is necessary.

After the data are interpreted, the obstetric health care provider in the transmitting hospital is offered advice based on the information obtained from the fetal heart rate tracing and the clinical circumstances of each case. The perinatal nursing specialists at the health cen­ter are responsible for the fetal heart rate tracings that are transmitted for educational purposes. The mater­nal-fetal medicine faculty members are responsible for fetal heart rate tracings transmitted for consultations. No written follow-up of the consultation was provided to the transmitting hospital.

The transmitted antepartum fetal heart rate tracings consisted of nonstress tests or contraction stress tests. The nonstress tests were interpreted as (1) reactive, (2) nonreactive, or (3) unsatisfactory. The criteria used for the definition of a reactive nonstress test were two or

more accelerations (of at least 15 bpm above the base­line lasting at least IS seconds) within a 10-minute pe­riod. When these criteria were not fulfilled the test was interpreted as nonreactive. The contraction stress tests were interpreted as (1) negative, (2) positive, or (3) suspicious according to the criteria of Freeman and Garite.' Our recommendations for the transmitted an­tepartum fetal heart rate tracings were: delivery, repeat the testing within a week, further evaluation with the fetal biophysical profile, or maternal transport to our center (in the presence of prematurity or other com­plications requiring expert care in a tertiary center).

The transmitted intrapartum fetal heart rate tracings had been obtained by using external and/or internal fetal heart rate monitoring. The intrapartum fetal heart rate tracings were interpreted as (1) normal, (2) suspicious, (3) threatening, or (4) ominous. Fetal heart rate patterns were interpreted as suspicious in the pres­ence of one of the following: (1) mild to moderate vari­able decelerations, (2) fetal tachycardia (> 160 bpm) with good variability, (3) fetal bradycardia « 120 bpm) with good variability, and (4) nonrepetitive late decel­erations with good variability. Threatening fetal heart rate tracings were diagnosed in the presence of (1) se­vere variable decelerations, (2) fetal tachycardia with decreased variability (3 to 5 bpm), (3) repetitive late decelerations, and (4) decreased beat-to-beat variability not related to analgesia. Fetal heart rate patterns were interpreted as ominous in the presence of one of the following: (1) absent beat-to-beat variability «2 bpm) not related to analgesia, (2) severe variable decelera­tions with absent variability, (3) fetal tachycardia (> 160 bpm) with absent variability, (4) persistent late decel­erations with absent variability, and (5) fetal bradycar­dia «120 bpm) with decreased or absent variability.

Based on this interpretation and the clinical circum-

632 Vintzileos et al.

Table I. Recommended management for antepartum fetal heart rate transmissions (total number = 206)

Management No.

Delivery 24 Repeat testing within a 145

week Fetal biophysical profile 30

assessment Transport 7

Total 206

Table II. Recommended management for intrapartum fetal heart rate transmissions (total number = 217)

Management

Observation Delivery Fetal scalp blood

sampling Medical treatment Transport

Total *

No.

132 38 16

25 6

217

%

11.6 70.5

14.5

3.4

100

%

61 17.5 7.3

11.5 2.7

100

*Twenty-eight tracings were excluded from the initial number of 245 because the interpretations were not re­corded.

stances of each case, our recommendations were: ob­servation, delivery, fetal acid-base assessment (fetal scalp blood sampling), medical treatment (positional changes, oxygen administration, discontinuation of oxytocin, etc.), or maternal transport (in the presence of prematurity or other complications).

After delivery, follow-up information of maternal and neonatal outcome was requested from the regional hospital. All information obtained from the patient's history, the fetal heart rate tracing, recommended man­agement, and follow-up is coded and entered into a computer.

Results

From January 1, 1983, to June 30, 1985, a total of 511 fetal heart rate tracings were received through the FACTS system. Of these, 206 (40.3%) were antepartum, 245 (48%) intrapartum, and 60 (11.7%) were trans­mitted for educational purposes. These 60 were elim­inated from further analysis.

Of the 206 antepartum fetal heart rate tracings, 188 (91.3%) were nonstress tests and 18 (8.7%) were con­traction stress tests. The interpretations for the 188 nonstress tests were: reactive, 115 of 188 (61.2%); non­reactive, 65 of 188 (34.5%); and unsatisfactory, eight of 188 (4.3%). The recommendations for the 65 non-

September 1986 Am J Obstet Gynecol

reactive nonstress tests were: repeat testing, 22 of 65 (34%); delivery, 16 of 65 (24.6%); further evaluation with fetal biophysical profile assessment, 20 of 65 (30.7%); and maternal transport, seven of 65 (10.7%). The interpretations of the 18 contraction stress tests were: negative, eight of 18 (44.4%); positive, five of 18 (27.8%); and suspicious, five of 18 (27.8%). The uterine activity pattern in 10 of the 18 contraction stress tests (55.6%) was normal, in four (22.2%) it was difficult to determine, and in the remaining four (22.2%) there was hyperstimulation. The recommendation for the positive contraction stress tests was delivery in all five cases; delivery was also recommended in three of the five suspicious contraction stress tests and fetal bio­physical profile assessment was proposed in the re­maining two of the five suspicious contraction stress tests.

The overall recommendations for a total of 206 an­tepartum fetal heart rate tracings are illustrated in Table I. Of the 206 antepartum fetal heart rate con­sultations follow-up information was obtained in 70 cases. In 68 instances (97.2%) the Apgar scores were good (5-minute Apgar score~ 7) and in two (2.8%) the Apgar scores were low (5-minute Apgar scores <7). The recommendation for both cases with low Apgar scores was delivery, while the recommendations for the 68 cases with good Apgar scores were delivery in 17 (25%), repeat testing within a week in 29 (42.6%), fetal biophysical profile assessment in 17 (25%), and mater­nal transport in five (7.4%).

Of the 245 intrapartum fetal heart rate tracings, 107 (43.6%) were interpreted as normal, 77 (31.5%) sus­picious, 22 (9%) threatening, 11 (4.5%) ominous, and in 28 instances (11.4%) the interpretation was not re­corded. These 28 fetal heart rate tracings were there­fore excluded from further analysis. The recommen­dations for the 107 normal fetal heart rate tracings were observation in 99 of 107 (92.5%), delivery in one of 107 (0.9%), medical treatment in three of 107 (2.8%), and maternal transport in four of 107 (3.8%). For the 77 suspicious tracings the recommendations were ob­servation in 30 (38.9%), delivery in 19 (24.6%), fetal scalp blood sampling in 10 (12.9%), medical treatment in 17 (22%), and maternal transport in one (1.3%). For the 22 threatening tracings the recommendations were observation in three (13.6%), delivery in nine (40.9%), fetal scalp blood sampling in four (18.1%), medical treatment in five (22.7%), and maternal transport in one (4.5%). For the 11 ominous fetal heart rate tracings the recommendations were delivery in nine (81.8%) and fetal scalp blood sampling in two (18.1 %). The overall recommendations for the total of 217 (28 were excluded from the initial 245) intrapartum fetal heart rate tracings are illustrated in Table II. Table III illus­trates the relationship between prenatally identified

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Telephone transmission of fetal heart rate monitor data 633

Table III. Relationship between prenatal high-risk factors and fetal heart rate interpretation in patients

requiring intrapartum transmission

Normal Prenatal high-risk No. of

I factor cases No. %

Postdates 135 63 46.6 Intrauterine growth 14 10 71.5

retardation Premature rupture of 5

membranes Premature labor 18 17 94.5 No high-risk factor 45 17 37.7

present No interpretation 28

available

high-risk factors and fetal heart tracing interpretation in patients requiring intrapartum transmission. Post­datism was the most frequent prenatal high-risk factor (135 cases), while in 45 cases no prenatal high-risk fac­tor was identified. Premature labor was associated with the highest incidence of normal fetal heart rate tracings (17 of 18 or 94.5%) and cases with premature rupture of the membranes had the highest incidence of threat­ening (four of five or 80%) and ominous (one of five or 20%) fetal heart rate patterns.

Oxytocin administration (augmentation or induc­tion) was associated with 109 (44.4%) of the total of 245 intrapartum tracings. In these 109 cases there was hyperstimulation in 31 (28.4%) and a normal uterine contraction pattern in 70 (64.2%); the uterine activity pattern was difficult to determine in the remaining eight (7.3%) cases.

Follow-up information was obtained in 112 of the 245 cases that required intrapartum fetal heart rate transmission. Of these 112 cases, 99 (88.4%) had good Apgar scores and 13 (11.6%) had low Apgar scores. The recommendations for the group with good Apgar scores were observation in 68 (68.6%), delivery in 20 (20.2%), fetal scalp blood sampling in one (1 %), medical treatment in eight (8%), and maternal transport in two (2%). The recommendations for the group with low Apgar scores were delivery in 10 (76.9%), fetal scalp blood sampling in one (7.6%), medical treatment in one (7.6%), and observation in one (7.6%).

Comment

The use of the FACTS system, which provides a con­tinuous hard-copy communication between the pri­mary community hospitals and the University of Con­necticut Health Center, has been in effect since January 1, 1983. The reported results of our experience during the first 21/2 years of its use are very interesting in many respects.

Fetal heart rate interpretation

Suspicious Threatening Ominous

No. I % No. I % No. I %

53 39.3 12 9 7 5.1 4 28.5

4 80 20

I 5.5 20 44.5 6 13.3 2 4.5

Sixty fetal heart rate tracings, transmitted for edu­cation purposes, were excluded from the analysis. Therefore the analysis was confirned to 206 antepar­tum and 245 intrapartum fetal heart rate tracings, which were transmitted because the primary obstetric health care provider had serious concerns about the condition of the fetus. Subsequently 28 intrapartum tracings were also excluded because the interpretations were not recorded. It is unknown what the manage­ment might have been in these cases without a consul­tation from our regional center. In the great majority of cases the fetal heart rate tracings, according to our interpretations, were compatible with fetal well-being, and therefore conservative (expectant) management was recommended. Sixty-one percent of the transmit­ted antepartum fetal heart rate tracings were reactive and expectant management was recommended in all these cases. Similarly, the most frequent interpretation of the intrapartum fetal heart rate tracings (43.6%) was compatible with fetal well-being, and conservative management was recommended in 99% of these cases. We recommended intervention, in terms of prompt delivery, in only 11.6% of the transmitted antepartum fetal heart rate evaluations (Table I) and in 17.5% of the cases transmitted during the intrapartum period (Table II). Retrospectively these recommendations were proved to be appropriate since prompt delivery was advised in both antepartum cases with low Apgar scores and in 10 of 13 intrapartum cases with low Apgar scores. The recommended intervention rate (usually by cesarean section) of 17.5% in the intrapar­tum cases is very low if one considers the national av­erage cesarean section rate of 17.9% in 1981.5 Accord­ing to the interpretation of the regional care providers, apparently normal fetal heart rate tracings were not transmitted, but only nonreassuring tracings; it would appear therefore that the FACTS system had a major impact in reducing the intervention rate in the regional

634 Vintzileos et al.

hospitals. The low intervention rate combined with the recognition of the need for prompt delivery in the great majority of cases with low Apgar scores is a testimony for the efficacy of the system in improving regional perinatal care.

Further analysis of the results, according to the pres­ence or absence of prenatal high-risk factors in patients who were delivered in smaller community hospitals and had nonreassuring intrapartum fetal heart rate pat­terns revealed that the majority (135 of 245 or 55.1 %) were postdates. There was no difference in the inci­dence of abnormal fetal heart rate patterns between patients with postdates and patients with no prenatal high-risk factors (Table III). Premature labor tracings transmitted had the higher incidence of normality (17 of 18 or 94.5%), while tracings transmitted from pa­tients with premature rupture of the membranes had the highest incidence of abnormal fetal heart rate pat­terns (80% threatening, 20% ominous). The observa­tion of a high incidence of abnormal fetal heart rate tracings in the presence of premature rupture of the membranes may not be pertinent because of the small number of patients with ruptured membranes (five cases).

According to these data, in the region the most fre­quent problem associated with nonreassuring intra­partum fetal heart rate tracings is postdatism. The ef­forts therefore in the future should and will be directed to further education of the obstetric staff of these hos­pitals (physicians and nurses) in managing postdate pregnancy, as well as in fetal heart rate interpretation. Since 28.4% of the intrapartum tracings had evidence of uterine hyperstimulation, the efforts should also be directed toward educating the regional hospitals in ju­dicious use of oxytocin and formulating low-dose pro­tocols.

The FACTS system has also helped us to identify those high-risk patients who need care in a tertiary center for further evaluation and treatment. A total of 13 (2.8%) such cases among the 451 transmission con-

September 1986 Am J Obstet Gynecol

sultations were identified, and the patients were trans­ferred to the University of Connecticut Health Center for further evaluation and treatment. In cases of a re­quested maternal transport, the regional hospitals are encouraged to use the FACTS system to transmit the fetal heart rate tracing before the transfer, especially in cases where the condition of the fetus may be in question. If it is felt that the fetal heart rate tracing indicates fetal jeopardy, prompt delivery at the primary community hospital is recommended. In such cases, the neonatal team at the health center is notified and arrives at the regional hospital as soon as possible in order to provide expert resuscitation and immediate care of the potentially sick neonate.

It is also our opinion that the FACTS system has a great educational potential since it provides the op­portunity to smaller community hospitals (physicians and nurses) for an immediate consultation and edu­cational discussion.

In summary, it is our opinion, based on the present reported experience, that the use of the FACTS system improves the quality of perinatal care in the regional hospitals, it helps in the identification of those high­risk patients who may benefit from maternal transport, and it is a tool that could be effectively used to discover specific areas toward which educational efforts should be directed in the smaller community hospitals.

REFERENCES

I. Boehm FH, Goss DA. The Xerox 400 Telecopier and the fetal monitor. Obstet Gynecol 1973;42:475.

2. Boehm FH, Haire MF. Xerox telecopier transmission of fetal monitor tracings: A 4-year experience. AM J OBSTET GYNECOL 1979;53:520.

3. Giacoia GP, Cash J, Gray J,et al. Telephone transmission of fetal monitor data. Am J Perinatol 1985;2: II.

4. Freeman RK, Garite TJ. Fetal heart rate monitoring. Bal­timore: Williams & Wilkins, 1981: 113-29.

5. Gleicher N. Cesarean section rates in the United States. The short-term failure of the National Concensus Devel­opment Conference in 1980. JAMA 1984;252:3273.