Have you ever wondered as an Labor and Delivery RN how many hours during your shift you spend staring at fetal heart tracings? I’ll bet you have never tried to tally such a figure, but I’d venture to guess it encompasses not only a large portion of your daily practice, but an enormous part of your career as well. During a 12-hour shift of managing labor induction, you could easily spend approximately 5-6 hours or more actually staring at the monitor. That’s 50% of your shift! This translates into the possibility that half of your intrapartum career is immersed in FHR tracings!
This enormity speaks volumes to expectations of your ability to understand and manage the fetal tracing. Your knowledge base should be solidly comprehensive and your ability to articulate standardized definitions rapid. If litigation were ever to knock at your door, would you be able to defend your actions surrounding your interpretation and analysis of the FHR tracing?
Failure to recognize, failure to act, and failure to communicate have been cited as three litigious areas of concern regarding FHR monitoring. Let’s take a look at six common “pitfalls” that can get you into trouble regarding tracing analysis.
1) Looking at the Tracing but Not at Your Patient
You are responsible for caring for two patients in the intrapartum setting: both mother and fetus. The FHR tracing provides information about the fetus, but the maternal-fetal dyad is hemodynamically inextricably linked. If the maternal hemodynamic status is not “in-check,” the fetus will not have stability either. Initiate your assessment with maternal hemodynamic evaluation.
- What is her blood pressure and pulse?
- Is she bleeding?
- What is her oxygen status?
- Is she in pain or anxious (catecholamine release)?
Maternal physiology is critical to ensuring adequate fetal oxygenation. Follow the maternal-fetal oxygen pathway and look for interruption along that pathway. (Pathway = maternal lungs, heart, vasculature, uterus, placenta and umbilical cord.) Alteration of maternal hemodynamics or interruption at any point along this pathway has the potential to impede fetal oxygenation. It is sometimes easy to focus on an isolated event on an FHR tracing, but the fact is that consideration of the “bigger picture” in a clinical context would help solve an FHR issue. In other words, is an upstream or downstream issue of the maternal-fetal pathway causing the isolated event?
2) Failure to Identify an Abnormal Tracing
Maintaining fetal oxygenation is crucial to fetal well-being, and fetal metabolic acidemia is a precursor to fetal injury. The ability to correctly interpret an FHR tracing comes with experience and ongoing education, but there are some key concepts that you should be aware of.
FHR monitoring is not a perfect science. In fact, many differing opinions may surround one tracing. However, the beauty of the FHR monitor lies in its ability to provide information that assures fetal oxygenation is present when moderate variability and/or accelerations are witnessed. This core concept is central to evaluation of fetal well-being during labor and is pinnacle to its existence as a screening tool for fetal oxygenation. While FHR monitoring is not diagnostic for oxygenation problems, it does have strong reliable predictability of adequate fetal oxygenation. This central principle should guide you during your frequent analysis and interpretation of the FHR tracing. With moderate variability and/or accelerations (spontaneous or induced), one can be assured that the fetus is not acidotic at the moment in time when either one is witnessed on the FHR tracing. Understanding this core concept will help you in your interpretation of the tracing. A well-oxygenated fetus will not be acidotic. Clinicians should always be cognizant of the most recent time frame when they are able to say with assurance that fetal metabolic acidemia can be ruled out due to the presence of moderate variability and/or accelerations (induced or spontaneous) on the tracing.
The National Institute of Child Health and Human Development (NICHD) nomenclature and definitions should become second nature to you. NICHD definitions have been in existence since the 1990s and were reaffirmed in 2008 by expert consensus panels. It is in your best interest to use terminology that is nationally supported and viewed as essential standard of care to intrapartum practice. Standardization is known to prevent randomness, promote safety and overcome system deficiencies. The NICHD standardized definitions and nomenclature hold true to these values and promote the use of common language between OB professionals. It helps us to communicate with well-defined terminology versus ambiguous non-descript terms. For example, think about these two statements: “well-oxygenated fetus” versus “happy baby.” It is clear which of these would provide professional credibility during a deposition.
Tracing analysis that encompasses a standardized approach and encourages review of individual components will also promote equality of interpretation between clinicians:
- FHR baseline
- FHR variability
- Analysis of periodic/episodic events, trends and evolution
- Analysis of uterine activity, including frequency, strength/intensity, duration, relaxation time, and resting tone
The three FHR categories have helped to delineate normal from clearly abnormal tracings as well as those which are deemed indeterminate tracings. Clinicians should be able to cite the criteria that confirms a clearly abnormal Category III FHR tracing, but also have full awareness for the possibility of fetal deterioration in Category II tracings. Learn to recognize which tracings call for heightened vigilance and which require immediate interventions, including the possibility of emergency delivery. Lack of corrective intervention on a tracing that warrants intervention can be viewed as negligence. Using standardized tools provided by our profession’s experts will help to guide decision-making and management.
3) Lack of Situational Awareness Regarding Tracing Evolution
Tracing evolution speaks directly to fetal tolerance of labor or any alteration of maternal-fetal hemodynamics. Vigilance of tracing evolution is a crucial component to your interpretation of the tracing and fetal tolerance of labor. Vigilance-fatigue is a realistic phenomenon; it’s similar to alarm-fatigue, in which there is lack of attention and loss of responsiveness to stimuli over time. This is tough to remedy when inductions become long and hours staring at a monitor are inevitable. We all need to do our best to not lose situational awareness of the tracing over time. Review of tracing evolution at each documentation point in the EMR may be one helpful solution in preventing this from occurring.
- Was the FHR tracing normal at the time of patient admission and now presents with minimal or absent variability?
- Is there evidence that the baseline is rising or declining over time? How is the fetus tolerating labor over time?
- Is fetal reserve being compromised?
- Are corrective measures warranted to improve the tracing?
Progressive awareness of FHR evolution can be lost with use of the “copy & paste” function for charting in the EMR. Auto-population into the EMR template can have unintended consequences and perpetuate error. Be sure you know what you are charting, and specifically, for which time frame you are charting to ensure accuracy.
- Does your charting truly reflect the tracing at the correct time listed in the EMR documentation?
- Does the time of the charting match the correct events that are occurring with the matching time segment of the FHR tracing?
Habitual automation using “copy & paste” while managing oxytocin induction of labor is risky business. Litigious process extracts the chronological timeline from the EMR. If charting does not match the real-time events of the FHR tracing, it will be a “red flag” that you were not actually analyzing the tracing, and the burden of proof will be on you to prove otherwise.
4) Lack of Recognition or Understanding Excessive Uterine Activity
While uterine activity has been blatantly overlooked in years past, recent advances in the understanding of uterine physiology as it relates to fetal oxygenation highlights its crucial role. Maintaining adequate uterine activity during labor is vital to fetal oxygenation; this was clearly stated in Bakker’s data1. Clearly distinct from excessive uterine activity, adequate and appropriate uterine activity allows for adequate fetal recovery from the hypoxia that is induced during the normal course of labor.
Tachysystole, defined as >5 contractions in 10 minutes averaged over 30 minutes, is now understood to be a detriment to fetal oxygenation. Safe and appropriate management of oxytocin should include prevention of tachysystole during the course of labor induction. Corrective intervention for >5 contractions in 10 minutes should occur prior to changes of the fetal heart rate. In other words, corrective intervention should happen at tachysystole onset rather than waiting until witnessing fetal responsiveness appears on the FHR tracing.
In the realm of patient safety and fetal vulnerability, all of the following place the fetus at risk for compromise and the nurse at risk for professional liability:
- Failure to understand uterine physiology as it relates to fetal oxygenation
- Failure to prevent uterine tachysystole
- Failure to palpate uterine activity regularly
5) Lack of Confidence to Escalate the Level of Care or Execute the Chain of Communication
It is not unusual for physicians to say they weren’t notified of fetal deterioration. It is also common for nurses to state they were not taken seriously or were misunderstood when they communicated a sense of urgency to the physician to have immediate bedside presence; sometimes nurses report feeling intimidated by someone of higher authority regarding their interpretation of the FHR tracing.
Communication about the FHR tracing needs to be a mutually respectful interaction. There should be no tolerance for intimidating behaviors in the professional workplace at any time, but especially in the realm of patient safety. AWHONN and ACOG have addressed the importance of physicians and nurses having shared learning modules and learning experiences for FHR education so that everyone is speaking the same language when referring to the tracing. Teams that work in close collaboration should be educated and trained together.
In addition, ACOG has specifically addressed bullying in the workplace. No one should ever feel afraid to “speak-up”; you should always feel comfortable when reporting an indeterminate or abnormal tracing. If you are an experienced labor and delivery nurse, trust your “gut-feeling” that something is not right on the tracing. If you are facing scrutiny from the care provider or others, have the confidence to seize the moment and move forward with your beliefs as you advance the chain of communication. Defend your thoughts with standardized definitions and management actions. Articulate with clarity why you feel the way you do. State that in the best interest of maternal-fetal safety, you feel further intervention should be taken that is outside the scope of your practice.
6) Lack of OB Team Cohesiveness
A rapid, well-executed response to an emergency situation requires preparation. Mandatory staff training drills help the team to perform with expedience and precision. Have your hospital OB team practice, practice, and practice again until timing and execution are nothing short of stellar; that way you will always be prepared and ready. Novice staff members will appreciate this and gain confidence as they assimilate into your team. It will help everyone improve skill sets and identify areas that require improvement. Simulation drills are a key component known to high-reliability perinatal teams.
Well-defined roles with common and clear goals will also help to facilitate a well-executed response. All team members should reach a comfort level with performing clearly designated roles and responsibilities.
Helpful Hints that Reduce Professional Risk
- Familiarize yourself with your institution’s policy regarding FHR monitoring. Make sure you are practicing within the accepted guidelines/parameters.
- Know the National Institute of Child Health and Human Development (NICHD) FHR definitions/nomenclature, and most importantly, use them! Standardization will help simplify your life and keep you at a national level of intrapartum care.
- If you are unsure about an FHR tracing or questioning how to interpret it, seek out collaboration with more experienced peers. It is always better to err on the side of caution by holding the tracing to a higher level of scrutiny.
- Be mindful of previous fetal behavior and fetal responsiveness to the hypoxic stress of labor.
- Was your tracing previously normal?
- What is the evolution of the tracing over the duration of labor?
- Is an FHR baseline change evident?
- Is the fetus able to recover with interventions?
- Are you able to rule out fetal metabolic acidemia with spontaneous or induced accelerations and or moderate variability?
- When were you last able to say with assurance that the fetus was well-oxygenated?
- Place equally-weighted importance on the evaluation of the uterine portion of the tracing. Work to achieve and promote adequate uterine activity appropriate for the stage of labor. Don’t accept excessive uterine activity or anyone else’s philosophy of “just get her delivered fast.”
- Exercise extreme caution when using the “copy & paste” function in the EMR. Recognize its inherent risks and potential for error.
- Chart all components of the FHR in the EMR. Charting FHR categories is not necessary, but FHR components are necessary for completeness and comprehensive tracing analysis. Ask yourself if 20 years from now you would be able to reconstruct the FHR tracing based on your charting. Reporting FHR categories does not give clarity to what the tracing actually looks like; categories simply state the tracing as normal, abnormal or indeterminate. FHR Baseline, variability, periodic/episodic events and tracing evolution will allow you to have a clear picture of the FHR tracing years later.
- Feel empowered to escalate the level of concern or chain of communication regarding the FHR tracing. Do not allow hierarchy or authority to demean your critical thinking skills, intimidate you, or threaten your ability to do your job or protect fetal safety.
- Embrace learning opportunities that will help you rid yourself of long-standing beliefs and deep-rooted falsehoods about FHR monitoring; use them to gain understanding of maternal-fetal physiology and fetal-oxygenation. Stay up to date with current evidence-based practices that support maternal-fetal homeostasis.
- Utilize tools developed and recognized by experts that assist with the management of tracing analysis and that are designed as a shared mental model for physicians and nurses. Lisa Miller and David Miller’s tool for standardized tracing analysis is an excellent example of this. Another example is Steven Clark’s Algorithm for Management of Indeterminate (Category II) FHR tracings. Experts have embraced such tools.
- Be committed to creating a culture that mitigates risk, promotes safety, and improves perinatal outcomes.
1Bakker PCAM, Kurver PHJ, Kuik DJ, et al. Elevated uterine activity increases the risk of fetal acidosis at birth. Am J Obstet Gynecol. 2007;196;313.e1-313.e6.