From the Editor
Transfer to the hospital for women planning a home birth: A high-risk obstetrics problem
Do you have a written clinical guideline for pregnant women planning a home birth who are transferred to your hospital?
If interventions result in normalization of the FHR tracing and resolution of tachysystole for 20 to 30 minutes, then oxytocin may be restarted if necessary for labor progress at no more than half the rate that produced tachysystole.
TIP #2: Recognize an abnormal FHR tracing--and what it means
Misinterpretation of the FHR tracing occurs when there is a failure to recognize characteristics that should raise concern about fetal well-being. Failure to recognize an abnormal FHR tracing occurred in 77% of sentinel cases involving intrapartum birth injury or death.1,12,13 To limit misinterpretation of the FHR tracing, it is critical for nurses and physicians to use standardized terminology for clear, effective communication.
In 2008, the Eunice Kennedy Schriver National Institute of Child Health and Human Development (NICHD) published guidelines standardizing the terminology used to describe cardiotocography and to create consensus around its interpretation.15 Any description of an intrapartum FHR tracing should include a designation of category (I, II, or III). Fetal well-being is reasonably established with a category I FHR tracing. A category III tracing indicates the high likelihood of fetal acidemia and the need for immediate intervention. A category II FHR tracing is considered indeterminate, and further characterization is required to reasonably exclude fetal metabolic acidosis and a risk of fetal injury.
The presence of moderate variability and fetal response to scalp stimulation are considered reassuring findings that reasonably exclude significant metabolic acidosis. In assessing variability, one pitfall is mistaking the appearance of "variability" within a deceleration (including during return to baseline) for baseline FHR variability. In the event of a persistent category II FHR tracing (>30 minutes), nursing staff should request direct physician review of the FHR tracing. In any case in which fetal well-being is uncertain, nursing staff should request direct physician evaluation of the mother in person and also the FHR tracing, with clear documentation of the findings, interpretation, and plan of care.16
TIP #1: Document, document, document
Nursing and physician documentation about the FHR tracing within the patient-specific clinical context is crucial for effective caregiver communication and patient safety. Thoughtful documentation also reduces liability exposure for providers by demonstrating maternal-fetal surveillance, early identification and treatment of an abnormal or indeterminate FHR tracing, and timely intervention on fetal behalf when necessary.
When the medical record aligns with the electronic FHR tracing and includes appropriate descriptions, interpretations, and interventions in line with national guidelines and institutional policy, the record demonstrates that the providers have a thorough understanding of the physiology behind cardiotocography and, more importantly, that they are able to apply that knowledge in clinical practice.6
Minimizing missteps
Several straightforward interventions can help clinicians overcome the most common pitfalls during FHR monitoring. These include accurate and high-quality cardiotocography, a collaborative team-based approach to patient care, and sustained situational awareness among providers. The consistent use of common language for the description and interpretation of FHR monitoring, adherence to hospital oxytocin protocols, and well-defined expectations for fetal surveillance and provider communication are critical to overcoming these challenges. Regularly scheduled nursing and physician education sessions and interdisciplinary case review can promote the adoption and sustained incorporation of these simple techniques into daily practice.3
Some have advocated for an "electronic fetal monitoring bundle," which would serve as a checklist of clinical evaluation steps that should occur every time a given process occurs.17 This approach would ensure that all providers on labor and delivery are qualified to read, accurately interpret, and respond to FHR tracings. It would require a credentialing process to confirm the competency of team members and reinforce the presence of a common language. It would also include an explicit escalation policy for rapid initiation of the chain of command in cases wherein there is a disagreement among team members about the FHR interpretation. Finally, each patient would be required to have, at all times, an identified responsible provider capable of a rapid response.
Although continuous FHR monitoring may not effectively reduce intrapartum fetal asphyxia, it is clearly here to stay. Recognizing--and addressing--the most common challenges encountered during intrapartum FHR monitoring may reduce unnecessary morbidity and potential liability for caregivers.
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