Electronic Fetal Monitoring: A Standardized Approach

Credit

Handouts/Brochure

Speaker

Rebecca Cypher, MSN, PNNP Related seminars and products

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Rebecca Cypher, MSN, PNNP, is owner of Maternal-Fetal Solutions, LLC, an independent consulting and education service, where she primarily focuses on assisting clinicians and hospitals to be change agents in the delivery of obstetric care. Her professional experience expands over 30 years in the perinatal arena, with 20 years on active duty, serving as a Nurse Corps officer in the United States Air Force, which included a wide variety of inpatient and outpatient obstetric settings in clinical and management positions. After military retirement, she worked as a perinatal nurse practitioner in a maternal-fetal medicine division focusing on obstetrical care and research. Rebecca served on the Board of Directors at the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) including one term as president. Rebecca is passionate about her profession and multidisciplinary education, with her attention devoted to evidence-based practice, clinical judgment, critical thinking, and collaboration within the healthcare team.

Speaker Disclosures:
Financial: Rebecca Cypher is the owner of Cypher Maternal-Fetal Solutions, LLC and a research nurse with the Amniotic Fluid Embolism Foundation. She receives a speaking honorarium from Clinical Computer Systems (OBIX). Rebecca receives a speaking honorarium and recording royalties from PESI, Inc. All relevant financial relationships with ineligible organizations have been mitigated.
Non-financial: Rebecca Cypher is a member of the Association of Women’s Health, Obstetrics, and Neonatal Nurses and the Society of Maternal-Fetal Medicine. She additionally has a professional affiliation with the Washington State Maternal Mortality Review Panel.

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Objectives

1. Define FHR characteristics using NICHD standardized terminology.
2. Distinguish between the 3 elements of EFM standardization.
3. Evaluate an organized, systematic ABCD approach to FHR management.
4. Critique research related to Category II FHR management.

Outline

 ABCD approach

•  Assess the oxygen pathway a. Lungs, heart, vasculature, uterus, placenta, umbilical cord
• Begin corrective measures as previously outlined
• Clear obstacles to delivery
  • Facility
  • Staff
  • Patient
  • Fetus
  • Labor
• Determine decision to delivery time
  • Facility response time
  • Staff
  • Surgical, medical and obstetric considerations
  • Other considerations (e.g., EFW, presentation) 

Terminology

• What is it called
• Consensus statement by NICHD
  • Adopted by AWHONN, ACOG, and ACNM
• Interpretation
  • What does it mean
  • What information does the FHR tracing provide regarding oxygen transfer
    • Head compression, cord compression, uteroplacental dysfunction
    •  All decelerations have the exact same triggers
      • Interruption of oxygen transfer from the environment to the fetus at one or more points along the oxygen pathway
      • moderate variability and/or accelerations exclude ongoing hypoxic injury
• Management
  • What do we do about it
  • Corrective measures
    • IV fluid bolus
    • Lateral positioning
    • Correct hypotension
    • Decrease uterine activity
    • Amnioinfusion
    • Tocolytic administration
    • Alter pushing technique
    • Oxygen administration for maternal pulse ox <96%
  • Introduction to ABCD approach to management 

ABCD approach

• Assess the oxygen pathway
  • Lungs, heart, vasculature, uterus, placenta, umbilical cord
• Begin corrective measures as previously outlined
• Clear obstacles to delivery
  • Facility
  • Staff
  • Patient
  • Fetus
  • Labor
• Determine decision to delivery time
  • Facility response time
  • Staff
  • Surgical, medical and obstetric considerations
  • Other considerations (e.g., EFW, presentation) 

“Intrapartum management of Category II FHR tracings towards standardization of care” 2013 article

• Algorithm
• Expert Opinions a. Not evidence based
• Definition of Significant Decelerations
• Key components of algorithm that are missing
  • Precise cervical dilation
  • When to notify primary clinician
    • “A standardized approach for Category II fetal heart rate with significant decelerations: Maternal and neonatal outcomes”. 2018 article
      • Prospective interventional trial: 29 hospitals
      • Comparison between 2013 expert opinion and this trial algorithm
      • Published results related to maternal and neonatal outcomes
      • Only research conducted with a research protocol 

Target Audience

• Nurses
• Nurse Practitioners
• Physicians
• Physician Assistants
• Midwives
• Doulas