2017 Fetal Monitoring Lunch & Learn Series

Beyond the Basics:

The Art and Science of
Tracing Interpretation

Session 5:
November 15, 2017

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Wisconsin Association for Perinatal Care (WAPC)

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 Planners
• Sara Bronson, MSN, RN, CNL
• Julie Bulgrin, BSN, RNC-OB, C-EFM
• Eva Fassbinder Brummel, MPH
• Ann E. Conway, MS, MPA, RN
• Kathy Frigge, MS, RN, C-EFM
• Janice McIntosh, BSN, RNC-OB, C-EFM
• Jeanne Rosendale, MSN, RNC-Inpatient OB, C-EFM
• Chris Van Mullem, MS, RNC, C-EFM

No conflicts to disclose.

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 Faculty

Chris Van Mullem, MS, RNC, C-EFM

Clinical Nurse Specialist

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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
– None to report
• Financial Disclosures
– None
• Sponsorship or commercial support
– None
• Non-endorsement of products
– 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.

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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 [email protected]

• Technical problems: Email Barb Wienholtz

at [email protected] or call at
608-285-5858, ext. 201

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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 fetal monitoring

data to identify the fetal heart rate pattern
classification (category).
2. Discuss interventions/management of the
fetal heart rate patterns based on their
pathophysiology.

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 Learning Outcome
• Identify required actions correctly to
manage women with abnormal fetal heart
rate patterns.

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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"

• Reviewed:
– Nomenclature
– Fetal Heart Rate Interpretation (categories)

• Provided framework for evaluation and management of intrapartum patterns

based on categories

• Assessment algorithm for fetal heart rate patterns

• Intrapartum resuscitative measures

• 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. What is the contraction pattern? (interval,

duration, resting tone if appropriate)
2. What is the baseline fetal heart rate?
3. What is the baseline variability?
4. Are there any periodic changes present?
5. Are there any episodic changes present?
6. What are the probable causes of the changes
present?
7. When was the last time there was either moderate
variability or an acceleration?

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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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FOCUS ON CONTRACTION
MONITORING
 Oxygen Pathway
Environment
Lungs
Heart
Vasculature
Uterus
Placenta
Umbilical Cord
Fetus
Hypoxemia
Hypoxia
Metabolic acidosis
Metabolic acidemia
 Fetal Compensatory Mechanisms
Redistribute Blood Flow

Fetal
Reduce 0₂ Need
Reserves

Increase
Extraction
 Poll Question 1
At what intrauterine pressure are the spiral
arteries compressed?

a. 20-25 mm Hg
b. >80 mm Hg
c. >35-60 mm Hg
 Oxygen Pathway
Environment
Lungs
Heart
Vasculature
Uterus
Placenta
Umbilical Cord

Fetus
Hypoxemia
Hypoxia
Metabolic acidosis
Metabolic acidemia
 Uterine Activity Terminology
• Frequency-the onset of one contraction to the
onset of next contraction (minutes). Number of
contractions in a 10 minute period.
• Duration-length of time from the onset of
contraction to the offset of the contraction
measured from the baseline resting tone (seconds)
• Intensity-Strength. Peak of the contraction minus
the resting tone.
• Resting Tone-intrauterine pressure when uterus is
not contracting (relaxation)
• Relaxation Time-Time from the end of one
contraction to the beginning of the next.
 Assessment-Methodology
• Palpation
• Tocodynamometer
• Intrauterine Pressure Catheter
– Montevideo Units (MVU)
Tracing 1

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 Poll Question 2
What are the Montevideo units?

a. 240 MVU
b. 120 MVU
c. 360 MVU
 Counting Montevideo Units
• Measure the peak intensity or amplitude of
mmHg in a 10 minute period of time and add
numbers together
– Contraction amplitude is the difference between
resting tone and the peak of the contraction

• Subtract the baseline resting tone from peak

contractions pressure for each contraction
• Example:
• 20+20+20+20+25+20 = 125 (Note baseline
subtracted from each contraction)
 Montevideo Units and Labor
• Contraction intensity of 40 mmHg and
MVU’s of 80-120 are generally sufficient to
initiate labor
• 200 MVU’s in a ten minute period is
considered adequate labor
• Usually range from 100-250 MVU in the
first stage of labor
• May rise to 400 MVU in the second stage
 Excessive Uterine Activity
• Normal-5 contractions or less in a 10 minute
period of time
• Tachysystole- > 5 contractions in a 10 minute
period averaged over 30 minutes
• Hypertonus- Uterus does not relax between
contractions. Elevated resting tone.
• Inadequate relaxation time
• Tetanic contractions-excessive contraction
duration-contractions lasting 2 minutes or
more
 Tachysystole-
> 5 contractions in a 10 minute period
averaged over 30 minutes
Doubling
 Tripling
• Insert tracing 4
• Quadruple
 Low Amplitude High Frequency Contractions

• Insert tracing here Tracing 6

 Factors That Effect Uterine Perfusion
• Uterine Overdistension
– Multiple gestation
– Hydramnios
– Amnioinfusion
• Disease states
– Preeclampsia
– Infection
– Abruption
• Maternal Position
 Factors That Effect Uterine Perfusion

• Stimulating • Inhibiting
– Acetylcholine – ꓐ Sympathomimetics
– Ergonovine – Calcium channel blockers
– Estrogen – Nitroglycerin
– Norepinephrine – Atosiban
– Oxytocin – Halothane
– Propranolol – Magnesium Sulfate
– Prostaglandins – Progesterone
– Quinine – Prostaglandin synthetase
– Sparteine inhibitors
– Vasopressin
 The Research

Effects of oxytocin-induced uterine

hyperstimulation during labor on fetal
oxygen status and fetal heart rate
patterns.
Kathleen Rice Simpson, PhD, RNC; Dotti C. James, PhD, RNC

*Hyperstimulation was associated with

significant oxygen desaturation.*
Simpson, James (2008). AJOG199 (34). 34, e1
 The Research

Elevated uterine activity increases the

risk of fetal acidosis at birth
P.C.A.M. Bakker, MD; P.H.J. Kurver, MSc; D.J. Kuik, MSc; H.P.
Van Geijn, MD, PhD.

*Compared uterine activity parameter to UA pH

Inter-contraction interval <63 seconds is
associated with increased incidence of UA pH <7.1*
 Decreasing Excess Uterine Activity
Specific to Contractions
• Change maternal position to side lying
• Administer IV bolus
• Remove cervical ripening agents
• Decrease or discontinue oxytocin
• Use tocolytic
 Interventions at Work
• Turn off oxytocin: resolution in 14 minutes

• Turn off oxytocin + IV bolus of at least 500

ml of Lactated Ringer’s: resolution: 9-10
minutes

• Turn off oxytocin + IV bolus of at least 500

ml of Lactated Ringer’s + change to lateral
position resolution: 6 minutes
 Poll Question 3
Your patient on oxytocin is experiencing
runs of doubling and tripling.

You would:
a. Continue to observe
b. Increase the oxytocin
c. Decrease or discontinue the oxytocin
 Management of Tachysystole
Uterine tachysystole

Spontaneous labor Labor induction or augmentation

Cat. I Cat. II or III Cat. I Cat. II or III

No Intrauterine Decrease Decrease or

interventions resuscitative uterotonics stop
required measures uterotonics

If no resolution, Intrauterine
consider tocolytic resuscitative
measures

If no resolution,
ACOG Practice Bulletin No. 116 1232-40. consider tocolytic
 Poll Question 4
Your patient is 4 cm and contracting every 2
minutes with coupling. She is on oxytocin.
How often should you perform an
assessment?

a. Every hour
b. Every half hour
c. Every 15 minutes
 Poll Question 5
An assessment of uterine contractions
includes:

a. Intensity or strength
b. Duration
c. Resting tone
d. Frequency
e. All of above
 Recommendations for Assessment of Fetal Status
During Labor with EFM)
AWHONN (2015). Position Statement: Fetal Heart Monitoring

Latent Phase Latent Phase Active Phase Second Stage Second Stage
(<4cm) (4-5 cm) (>6cm) (passive fetal (active
descent) pushing)

Low risk At least Every 30 Every 30 Every 15 Every 15

without hourly minutes minutes minutes minutes
Oxytocin

With Oxytocin Every 15 Every 15 Every 15 Every 15 Every 5

or risk factors minutes with minutes minutes minutes minutes
oxytocin,
every 30
minutes
without

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 Poll Question 6
What is your Recommendation?

a. Stop the oxytocin and restart in one hour

b. Leave the current oxytocin dose in place
c. Reduce the oxytocin by ½
d. Continue to increase the oxytocin
 Suggested Clinical Protocol -
Oxytocin-Induced Tachysystole-Normal FHR
• Assist the mother to a lateral position
• Give IV bolus of at least 500 ml lactated Ringer’s solution as
indicated
• If uterine activity has not returned to normal after 10-15 minutes,
decrease oxytocin rate by at least half; if uterine activity has not
returned to normal after 10-15 more minutes, discontinue the
oxytocin until uterine activity is less than 5 contractions in 10
minutes
• To resume oxytocin after resolution of tachysystole: If oxytocin
has been discontinued for less than 20-30 minutes, the FHR is
normal and contraction frequency, intensity, and duration are
normal, resume oxytocin at no more than half the rate that caused
the tachysystole and gradually increase the rate as appropriate
based on unit protocol and maternal-fetal status. If oxytocin has
been discontinued for more than 30-40 minutes, resume oxytocin
at the initial dose ordered.

Simpson and O’Brien-Abel (2013). In, AWHONN’s Perinatal Nursing 343-344.

 Suggested Clinical Protocol --
Oxytocin-Induced Tachysystole-
Indeterminate or Abnormal FHR
• Discontinue the oxytocin
• Assist the mother to a lateral position
• Give IV bolus of at least 500 ml of lactated Ringer’s solution as
indicated
• Consider oxygen at 10L/min via non-rebreather face mask
(discontinue as soon as possible based on the FHR pattern. If no
response, consider 0.25 mg terbutaline SQ)
• To resume oxytocin after resolution of tachysystole: If oxytocin has
been discontinued for less than 20-30 minutes, the FHR is normal
and contraction frequency, intensity, and duration are normal,
resume oxytocin at no more than half the rate that caused the
tachysystole and gradually increase the rate as appropriate based
on unit protocol and maternal-fetal status. If oxytocin has been
discontinued for more than 30-40 minutes, resume oxytocin at the
initial dose ordered.
Simpson and O'Brien-Abel (2013). In, AWHONN’s Perinatal Nursing 343-344.
 Poll Question 7
Modification of second stage management to
promote fetal well-being includes all of the
following except:
a. Stop pushing
b. Push in a lateral position
c. Perform closed glottis pushing
d. Push every second or third contraction
Case Study
Tracing 2
Tracing 3
Tracing 4
Tracing 5
Tracing 6
Tracing 7
 Tracing 8
• Insert 18
 Tracing 9
• Insert 17
 Tracing 10
• Insert 16
 Tracing 11
• Inset 15
 Tracing 12
• Insert 14
 Tracing 13
• Insert 13
 Why Focus on Oxytocin?

• High Alert Medication

• Most commonly used induction agent
• Varying protocols-
• Medico-legal implications in adverse outcomes
Common Allegations:
FHR Pattern and Communication
Elective Induction of Labor
Misoprostol for Cervical Ripening and Induction
Oxytocin for Labor/Induction/Augmentation
Uterine Tachysystole
 Oxytocin Facts
• Onset of action 3-4 minutes (IV)
• Half-life-10-15 minutes
• 30-40 minutes to reach a steady state
– Initial dose (incremental) increases in
frequency, strength, and duration
– Stable phase-continued increases in oxytocin
does not increase contractions
• “Push the pit; Pit through the pattern;
Pit to distress.”
– Continued increases lead to tachysystole
 Patient Safety, Risk Management, Documentation

• Standardization
– Nomenclature (NICHD, 2008, ACOG Practice Bulletin #116
– Policies, procedures, protocols that are interdisciplinary
using guidelines and resources from professional
organizations
– Fetal assessments until birth
• Multidisciplinary Interpretation and Management
– ACOG Practice Bulletin #116 “ Intrapartum Fetal Heart
Rate Monitoring: Nomenclature, Interpretation and
General Management Principles”
• Communication/Collaboration
– Chain of Communication
– SBAR
– Multidisciplinary Case Reviews
– Joint provider/nurse FM education
 Competency
Antepartum and Intrapartum Fetal Heart Rate Monitoring: Clinical
Competencies and Education Guide-AWHONN (2016) 6th Edition
– Competency
• Intermittent Auscultation: palpate uterine contractions for
frequency, duration and intensity, assess resting tone
between contractions, and determine whether abnormal
findings are present; (normal or tachysystole)

• EFM-assess uterine contraction frequency, duration,

intensity, and baseline resting tone (verified by palpation),
MVU, normal uterine activity vs tachysystole

• Competency Validation
– Electronic fetal monitoring tracing reviews
– Simulation with models for skill practice
– Programed self study
– Computer simulation
– ETC
 Documentation
• Evaluation of components of uterine
contractions: Frequency, strength, duration,
resting tone
• Frequency of FHR and uterine contraction
assessment/evaluation
• Institutional policies that address assessment,
communication, and documentation.
– Use of summary statements such as tachysystole vs
component of UC
– Labor or non-laboring patients
 Last Word-Emergency Room
Guidelines for Perinatal Care (2017). 8th ed.

• Triage of the Pregnant Patient

– Assessment
• Maternal VS
• Uterine Contractions
• Chief Complaint
• Status of labor: presence of contractions, vaginal bleeding,
status of membranes
• Woman’s perception of fetal movement
• Any high risk or obstetric conditions as identified in a review of
the history or the woman’s report

• Transfer of the Pregnant Patient

– “Uterine activity of maternal patients and fetal heart rates
need to be monitored before and after transport;
continuous uterine activity or fetal heart rate monitoring
during transport need to be individualized.”
 References
American Academy of Pediatrics and American College of Obstetricians and
Gynecologists. (2017). Guidelines for Perinatal Care. Authors: Washington,
DC.

American College of Obstetricians and Gynecologists. (July, 2009/Reaffirmed

2015). Practice Bulletin #106: Intrapartum fetal heart rate monitoring:
Nomenclature, interpretation, and general management principles. ACOG:
Washington, D.C.

Association of Women’s Health, Obstetric and Neonatal Nurses (2015). Position

statement: Fetal Heart Monitoring, Fetal assessment. Washington, DC. JOGN,
44 (5), 683-686.

Association of Women’s Health and Neonatal Nursing. (2015). Antepartum and

Intrapartum Fetal Heart Rate Monitoring: Clinical Competencies and Education
Guide. (6th ed.). Association of Women’s Health and Neonatal Nursing:
Washington, D.C.
 References
Association of Women’s Health, Obstetric and Neonatal Nurses (2015). Fetal heart
monitoring principles and practice, (5th ed.) Dubuque: Kendall Hunt.

Bakker, P.C., Kurver, P.H. & Van Geien, H.P. (2007). Elevated uterine activity
increases the risk of fetal acidosis at birth. American Journal of Obstetrics and
Gynecology. 196 (313-e1). 313-316.

Freeman, R.K., Garite, T.J., Nageotte, M.P., & Miller, L. A. (2012). Fetal heart rate
monitoring, (4th ed.). Lippincott Williams & Wilkins: Philadelphia, PA.

Garite, T.J. & Simpson, K.R. (2011). Intrauterine resuscitation during labor. Clinical
Obstetrics and Gynecology. 54(1). 28-39.

Macones, G.A., Hankins, G.D.V., Spong, C.Y., Hauth, J. & Moore, T. (2008). The 2008
National Institute of Child Health and Human Development workshop report on
electronic fetal monitoring: Update on definitions, interpretations, and research
guidelines. American Journal of Obstetrics and Gynecology, 112 (3), 661-666.
 References
Miller, L.A., Miller, D. & Cypher, R.L. (2017). Mosby’s Pocket Guide to Fetal
Monitoring: A Multidisciplinary Approach (8thed.). Mosby: Philadelphia, PA.

Miller, L.A. (2011). Intrapartum fetal monitoring: liability and documentation.

Clinical Obstetrics and Gynecology. 54(1). 50-55.

Simpson, K.R. (2016). Fetal assessment and safe labor management. NCC
Monograph. National Certification Corporation. Retrieved NCCWEBSITE.org.

Simpson, K.R. & Creehan, P.A. (2014) Obstetric and Neonatal Nurses
Association of Women’s Health Perinatal Nursing (4th ed.). Lippincot, Williams and
Wilkins: Washington, D.C.

Simpson, K.R. & James, D.C. (2008). Effects of oxytocin-induced uterine

hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns.
American Journal of Obstetrics and Gynecology. 199. 34.e1-e5.
Discussion

Questions?

Comments?
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Thank-you