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2014 Fetal Monitoring Lunch & Learn Series
Beyond the Basics:
The Art and Science of
Strip Interpretation
Session 3:
July 23, 2014
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Wisconsin Association for Perinatal Care (WAPC)
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Faculty
Sara Bronson, MSN, RN, CNL
Clinical Specialist
Appleton Medical Center/
ThedaCare
Appleton, WI
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Notice of Disclosures
•
Notice of requirements for successful completion
– Registrants must attend full session and complete evaluation to receive
contact hours
•
Conflicts of Interest
•
Financial Disclosures
•
Sponsorship or commercial support
•
Non-endorsement of products
– None to report
– None
– None
– The speaker does not endorse the use of any particular medications or
products as part of this educational session
•
Off-label use
– The speaker may discuss the off-label use of misoprostol and terbutaline as
they relate to labor and delivery.
•
Expiration date for awarding contact hours
– 12/31/2014
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Before we begin…
• Listen-only mode
• Questions – please ask, please answer!
– Raise your hand
– Type into the Question Pane
– Out of time? Email wapc@perinatalweb.org
• Technical problems: Email Barb Wienholtz
at wienholtz@perinatalweb.org
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Before we begin…
The content presented today is a case study. Components of
this case were chosen based on their applicability to achieve
learning objectives for this presentation. Do not assume the
patient featured in the case was cared for by the instructor or
at the facility at which the instructor is employed.
The discussion will focus on interpretation of the electronic
fetal monitoring (EFM) tracings for the purpose of education. At
times, the discussion may lead to the care decisions made
based on EFM interpretation.
IF the instructor shares details regarding actual or potential
care decisions, please note those decisions do not necessarily
reflect the opinions of the instructor, a particular provider, the
standard of care for any particular institution or facility, or of
WAPC.
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Objectives
At the conclusion of the session, participants will be able to:
1. Systematically review the electronic fetal monitor strip
2. Identify and categorize the FHR pattern
3. Identify and discuss uterine activity patterns and their influence on the FHR
baseline
4. Discuss the pathophysiology related to the tracing patterns identified
5. Discuss interventions for management and documentation of intrapartum
fetal heart rate tracings
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2008 NICHD Report
The 2008 National Institute of Child Health
and Human Development (NICHD)
Report of Fetal Heart Rate Monitoring
• Defined standard fetal heart rate
nomenclature
• Identified three categories for fetal heart
rate interpretation
• Proposed future research
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2008 NICHD Report
• Report endorsed by:
– ACOG (2009) Practice Bulletin #106 "Intrapartum Fetal Heart Rate
Monitoring: Nomenclature, Interpretation and General
Management Principles”
– AWHONN-endorsed and incorporated in fetal monitoring
curriculum
– American College of Nurse Midwives
– American Academy of Family Practice
American College of Obstetricians and Gynecologists (2009, July). ACOG Practice Bulletin #106:
Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General
Management Principles. Washington, D.C.: Author
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ACOG Practice Bulletin #116 (2010)
"Management of Intrapartum Fetal Heart Rate Tracings"
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Reviewed:
– Nomenclature
– Fetal Heart Rate Interpretation (categories)
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Provided framework for evaluation and management of intrapartum patterns
based on categories
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Assessment algorithm for fetal heart rate patterns
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Intrapartum resuscitative measures
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Management of uterine tachysystole
American College of Obstetricians and Gynecologists (2009, July). ACOG Practice Bulletin #106: Intrapartum
Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles.
Washington, D.C.: Author
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Systematic Review of Case Studies
The following questions are used to evaluate every tracing,
followed by specific questions:
1.
2.
3.
4.
5.
6.
7.
What is the contraction pattern? (interval,
duration, resting tone if appropriate)
What is the baseline fetal heart rate?
What is the baseline variability?
Are there any periodic changes present?
Are there any episodic changes present?
What are the probable causes of the changes
present?
When was the last reassuring sign of fetal well-being?
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Strip Review Discussion
• Interpretation
• Interventions/Communication
• Documentation in chart
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Intervention/Communication
• SBAR
– Situation
– Background
– Assessment
– Recommendation
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Case Information
Patient history:
• 21 year old G1 P0
• Uncomplicated pregnancy
• Prenatal lab work normal
• EFW is AGA
• History of migraine headaches,
depression, and a BMI of 47.
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Tracing 1
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Tracing 2
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Tracing 3
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Insert Clark algorithm
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Tracing 4
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Tracing 5
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Tracing 6
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Tracing 7
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Tracing 8
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Tracing 9
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Tracing 10
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Tracing 11
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Tracing 12
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Tracing 13
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Tracing 14
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Tracing 15
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Tracing 16
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Tracing 17
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Tracing 18
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Tracing 19
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Tracing 20
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Tracing 21
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Outcome
Male, 3805 gram infant delivered by cesarean section at 1803.
•
•
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Apgars 1/2/3
Nuchal cord x1.
Non-vigorous infant, flaccid, no respiratory effort.
Intubated for meconium suctioning with no meconium below the vocal
cords.
Extubated and given non-invasive positive-pressure ventilation and chest
compressions.
Re- intubated at approximately 15 minutes of life and continued to
receive positive-pressure ventilation.
Subsequently transferred to NICU for right-sided tension pneumothorax,
respiratory distress secondary to perinatal depression, possible sepsis.
Placenta showed moderate chorioamnionitis and 2 vessel cord with
moderate funisitis.
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References
ACOG Practice Bulletin No. 106. (2013). Intrapartum fetal heart rate monitoring:
Nomenclature, interpretation, and general management principles. Retrieved
from: http://www.acog.org/Resources-And-Publications/PracticeBulletins/Committee-on-Practice-Bulletins-Obstetrics/Intrapartum-Fetal-HeartRate-Monitoring-Nomenclature-Interpretation-and-Management
ACOG Practice Bulletin No. 116. (2013). Management of intrapartum fetal heart
rate tracings. Retrieved from: http://www.acog.org/Resources-AndPublications/Practice-Bulletins/Committee-on-Practice-BulletinsObstetrics/Management-of-Intrapartum-Fetal-Heart-Rate-Tracings
Clark, S.L., Nageotte, M. P., Garite, T.J., … Hankins, G. D. V. (2013). Intrapartum
management of category II fetal heart rate tracings: Towards standardization of
care. American Journal of Obstetrics and Gynecology, 209 (2), p. 89-97. doi:
10.1016/j.ajog.2013.04.030
Miller, L.A., Miller, D.A., & Tucker, S.M. (2013). Mosby’s pocket guide to fetal
monitoring: A multidisciplinary approach. St. Louis, MO: Mosby, Inc.
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Discussion
Questions?
Comments?
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Remember
• Fax or email attendance list to WAPC
– fax: 608-285-5004
– email: wapc@perinatalweb.org
• Evaluation will be sent via email from WAPC. Please
complete to receive Continuing Education Credit.
• Continuing Education Certificate will be sent via email
upon completion of evaluation.
• Become a member of WAPC! Join online:
https://www.perinatalweb.org/npay/membership.asp
• Save the date for the 2015 WAPC Annual Perinatal
Conference April 26-28, 2015, in Appleton.
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Thank-you
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