Disclosures
Algorithms for Management
of FHR Tracings in Labor
John P. Elliott, MD
Medical Director, Women’s Hospital
Saddleback Memorial Medical Center
Laguna Hills, CA
Partner, Magella Medical Group
Orange, CA
¾ Relevant
z
financial relationships
Nothing to disclose
¾ FDA
z
Nothing to disclose
How Does Acidosis Develop in
Labor?
¾ “Sudden”,
“unexpected”, catastrophic
event
Goal of FHR Monitoring
z
z
Prevent the development of fetal
acidosis
Birth Event Safety Team (BEST)
¾ Primary
nurse
provider (M.D. or C.N.M)
¾ Nursing team leader (charge nurse)
¾ Anesthesia
¾ Patient
¾ Obstetrical
z
Complete cord occlusion
Complete placental abruption
Uterine rupture
Response of BEST
¾ Recognize
the event as quickly as
possible
¾ Patient – turn, O2, IV, terbutaline
¾ Notify team (share your pain)
¾ Move pt to OR for emergency delivery
S.O.C. - Decision to incision time should not
exceed 30" (but ASAP)
How Does Acidosis Develop in
Labor?
¾ Steady
progression of hypoxemia to
acidosis
z
z
Cord compression – variable decels
Uteroplacental insufficiency – late decels
Response of BEST
¾ Recognize
the problem – late or variable
decels
¾ Patient – turn, O2, IV, terbutaline?
z
Notify the team (share your pain)?
z
THEN WHAT?
• Usually OB provider and team leader
What Does ACOG Say?
Physicians and nurses differ considerably in
their understanding of FHR monitoring.
There should be no difference in
understanding the language of the fetus.
Then there are management differences
among physicians and CNM’s.
Category II tracings require evaluation,
continued surveillance, initiation of
appropriate corrective measures when
indicated, and reevaluation.
Practice Bulletin No. 116; Nov 2010 –
Management of Intrapartum FHR Tracings
How are Recurrent Late
Decelerations Evaluated and
Managed?
¾ Intrauterine
resuscitation
¾ Reevaluation
¾ Evaluate variability & acceleration
z
z
z
Moderate variability – no suggested mgmt
Minimal variability – poss fetal acidosis
Potential need for expedited delivery
absent variability – Category III
Health System B.
2004
¾ Problem:
Obstetric claims paid > $30 M
¾ Edict from CEO – “solve this”
¾ CRIT Team
¾ 92% of claims involved FHR monitoring
ACOG Practice Bulletin 116; Nov 2010, p4
Solutions Recommended
¾ Standardize
terminology (speak same
language – Fetalese)
¾ Categorize FHR patterns
z
z
z
Within defined limits
Problematic
Pathologic
¾ Standardize
¾ Standardize
- NIH Cat I
- NIH Cat II
- NIH Cat III
nurse response
physician response
¾ Algorithms
Algorithms
¾ Labor
¾ Early
decelerations
decelerations
¾ Late decelerations
¾ Low baseline
¾ Prolonged decel/bradycardia
¾ Sinusoidal pattern
¾ Tachycardia
¾ Variable
Solution
¾ Depended
on a computer program with hard
stops when appropriate
¾ To control physician behavior and risk-taking
¾ IPROB system – cost Health System B. $9 M
Essential Points of Late Decel
Algorithm
¾
Recognize “late” decels
Variability present – yes = no acidosis
Interventions (O2, position, hydration)
20" – notify physician
20" – stop pitocin and observe
20" - give terb and observe
30" - request physician on site
¾
30" - del <30 min
¾
¾
¾
¾
¾
¾
• Physician decides to continue labor
• Del not expected <30 min – C of C
Case Presentation - ML
¾ 30
yo G1 P0
¾ IDDM
¾ 38
1/7 wks us scalp and abd wall edema
for IOL Cx 1 cm/40%/-2 sta
¾ 1515 oxytocin started
¾ 1800 epidural
¾ 1930 AROM – clear fluid
¾ 1947 Cx 3 cm/70%/-1 sta
¾ Dec.
Case Presentation – ML cont’d
¾ 2330
Cx 5 cm/100%/0 sta, bloody show
and one golf ball size clot
¾ 0245 RN reviewed strip – late decels, BL
160
Case Presentation – ML cont’d
¾ 0320
Late decelerations
Minimal variability
¾ Intervention – L lateral position
¾ Clock – 35 minutes
Case Presentation – ML cont’d
¾ 0425
- MD at bedside. Cx 6cm/100%/0
sta/T. 100.6.
z
z
z
z
Late deceleration minimal variability
Intervention – IUPC, scalp stim, cont. PIT,
Gentamicin
Recheck in 2 hours
Clock - 1 hour 35 min.
Case Presentation – ML cont’d
¾ 0555
z
z
z
Case Presentation – ML cont’d
¾ 0635
z
z
z
z
– MD at bedside reviewing strip
Late decelerations minimal variability
Cx: 8 cm/100%/+1
Intervention – recheck in 2 hours
Clock 3 hr 50 min
– RN reviews strip
Late decelerations, minimal variability
Intervention – none
Clock – 3 hours
Case Presentation – ML cont’d
¾ 0745
z
z
z
Case Presentation – ML cont’d
¾ 0814
z
z
z
– RN reviews strip
Variable, late decels – moderate? Variability
Baseline now down to 130 from 140
Intervention – none
¾ 0835
– MD at bedside discussing plan of
care
z
z
Cx 8 cm/100%/+1
Clock 5 hours 50 min
– RN reviews strip
Late decelerations, minimal variability
Intervention – none
Clock 5 hours
Case Presentation – ML cont’d
¾ 0852
¾ 0854
z
z
Late decels, minimal variability, baseline dec
to 120
Interventions – IV bolus, pit off
¾ 0859
z
– FSE – FHR 45-50, terb .25 mg
Intervention – C-section called. To OR
¾ 0909
z
– Nurse calls for “OB Assessment”
– MD and charge nurse at bedside
– skin incision
Clock time 6 hours 9 min
Case Presentation – ML cont’d
¾ 0910
z
– Delivery
Apgar 0/0/1/3 4530 gm
¾ 0930
Was This Outcome
Preventable?
– venous pH 6.8, pCO2 116, BE -
19.2
¾ Dec
to incision – 10 min
¾ Baby with HIE, spastic quadriplegia
Apply the Late Deceleration
Algorithm
Basic Physiology
If a fetus is hypoxemic with contractions and
interventions (O2, hydration, position
change, amnioinfusion) do not correct the
problem THERE ARE ONLY 2 POSSIBLE
OUTCOMES . . . . . . . .
¾
¾
¾
¾
¾
¾
DELIVERY or ACIDOSIS/DEATH
¾
¾
In This Case…….
¾ 0245
– “Late” decels, minimal variability
– Incision in abdomen
¾ 0418 – Delivery
¾ 0415
z
z
Baby is hypoxemic, not acidotic
Apgars ?/? CABG pH? BE?
Recognize “late” decelerations with variability
(category II)
Interventions
20"
- notify physician
20"
- stop pitocin and observe
20"
- give terb and observe
30"
- request MD on-site evaluation
- delivery imminent <30 min
No
30"
- c-section decision to incision
Conclusions
¾ Sudden,
z
unexpected, catastrophic event
Algorithm may or may not help
¾ Steady
progression of hypoxemia to
acidosis
z
Algorithm should help prevent acidotic injury
Thank You