Archives May 2022

In this post, I’ll be addressing the most current evidence, published standards of care, and guidelines from professional associations, and regulatory agencies specific to fetal heart rate interpretation and management. 

Fetal heart rate pattern interpretation, communication, and documentation continues to be one of the most common areas of perinatal liability claims. It is best practice to utilize current practice guidelines, and standards of care as a guide for the revisions, and development of institutional policies as a means to decrease professional liability exposure, and minimize the risk of perinatal injury.

Common Themes: In review of birth injury cases, I have observed common themes (allegations):

• Failure to interpret a non-reassuring fetal heart rate (FHR) tracing
• Failure to accurately assess maternal-fetal status
• Failure to recognize a deteriorating fetal condition
• Failure to appropriately treat an indeterminate or abnormal FHR in a timely manner (E.g., failure to initiate intrauterine resuscitation based on FHR pattern and/or plan for expeditious birth when clinically indicated)
• Failure to accurately communicate the maternal-fetal status to the physician/certified nurse midwife
• Failure to request bedside evaluation based on concern for fetal status to the physician/certified nurse midwife
• Failure of the physician/certified nurse midwife to respond appropriately when notified of indeterminate or abnormal fetal status
• Failure to initiate the chain of command (communication) when there is a clinical disagreement between the nurse, and responsible physician/certified nurse midwife, regarding fetal status   

Standards of Care:

• Use of EFM definitions and descriptions based on the 2008 National Institute of Child Health and Human Development (NICHD) Working Group findings (ACOG Practice Bulletin, Intrapartum Fetal Heart Rate Monitoring, 2017)
• In the presence of an EFM tracing with minimal or absent variability, and without spontaneous accelerations, an effort should be made to elicit accelerations by means of vibroacoustic stimulation, or scalp stimulation.  When there is an acceleration with stimulation, acidemia is unlikely, and labor can continue (ACOG Practice Bulletin, Intrapartum Fetal Heart Rate Monitoring, 2017).
• Be aware of the EFM findings consistent with an abnormal acid-base status: absence of accelerations; minimal to no variability (ACOG Practice Bulletin, Intrapartum Fetal Heart Rate Monitoring, 2017).
• Be aware of when to implement intrauterine resuscitation based on interpretation of EFM: Category 2, and category 3 FHR tracings, uterine tachysystole (dependent on FHR pattern, and presence or absence of oxytocin (ACOG Practice Bulletin, Intrapartum Fetal Heart Rate Monitoring, 2017).
• Implement intrauterine resuscitation based on the presumed etiology of the FHR pattern: maternal repositioning, intravenous fluid bolus, oxygen administration (if oxygen is being administered for intrauterine resuscitation, oxytocin should be discontinued), reduction of uterine activity, correction of maternal hypotension, amnioinfusion, modification of maternal pushing efforts during second stage labor (AWHONN Perinatal Nursing, 2021).
• Be able to recognize uterine tachysystole: 5 contractions in 10 minutes, averaged over 30 minutes. 
• Be aware of the interventions to manage tachysystole in the presence, and absence of oxytocin.  E.g., uterine tachysystole in the presence of oxytocin with a Category 1 tracing requires a reduction in oxytocin.  Uterine tachysystole in the presence of oxytocin with a Category 2 or 3 tracing requires a reduction or discontinuation of oxytocin, and implementation of intrauterine resuscitative measures.  If no resolution, a tocolytic should be considered.
• During induction or augmentation of labor with oxytocin, the FHR should be evaluated and documented before each dose increase, and following each dose increase (AWHONN Position Statement, Fetal Heart Monitoring, 2015)
• If continuous EFM is ordered, monitoring of FHR, and uterine activity should continue until birth (AWHONN Perinatal Nursing, 2021).
• Development of institutional policies, procedures, and protocols that outline responsibility for ongoing FHM documentation (AWHONN Position Statement, Fetal Heart Monitoring, 2015).
• Documentation should include communication with providers (AWHONN Position Statement, Fetal Heart Monitoring, 2015).
• Documentation should include communication within the chain of resolution / chain of command (AWHONN Position Statement, Fetal Heart Monitoring, 2015).
• Ongoing education and competency validation for RN’s, and other healthcare providers responsible for FHM (AWHONN Position Statement, Fetal Heart Monitoring, 2015).
• Use of oxytocin safety checklists are recommended as they provide prerequisites to safely initiate oxytocin, and to help identify situations that require discontinuation (ACOG Optimizing Protocols in Obstetrics, Oxytocin for Induction, 2011).  

References:

ACOG (2011). Optimizing protocols in obstetrics, Oxytocin for induction   

ACOG (2017). Practice Bulletin, Intrapartum fetal heart rate monitoring

AWHONN (2021). Perinatal nursing

JOGNN (2015). AWHONN position statement: fetal heart monitoring

P.S. Comment and share your experience with a birth injury case related to fetal monitoring interpretation, communication and/or documentation.

In this blog, I’ll be reviewing the national, and New York State statistics related to maternal mortality associated with obstetrical hemorrhage.  I’ll also highlight one of the risk factors associated with obstetrical hemorrhage, and discuss the standards of care that should be employed to mitigate the risk of maternal morbidity and mortality. 

Statistics: Obstetrical hemorrhage is a preventable cause of maternal morbidity and mortality and continues to be one of the leading causes of maternal death in the U.S.

How the U.S. compares to 10 other developed countries:

In New York State, postpartum hemorrhage is the 2^nd most frequently reported postpartum complication, and accounted for 29% (18) of maternal deaths between 2012-2013 according to the NYS Maternal Morbidity and Mortality Review Report (2017).

Prolonged oxytocin exposure as a risk factor: In a recent (published May, 2022) retrospective cohort study performed by Boston University School of Medicine, prolonged (greater than or equal to 12 hours) oxytocin exposure for induction of labor increased the risk of obstetrical hemorrhage by 52% compared to those women exposed for less than 12 hours.  Use of obstetrical risk assessment tools alert the perinatal team to the risk of obstetrical hemorrhage and prompts evidence-based interventions.

The importance of standardized safety bundles: The American College of Obstetricians and Gynecologists (ACOG) recommends the use of the Obstetrical Safety Bundle as a means to guide standardized management of obstetrical emergencies associated with maternal morbidity and mortality in accordance to evidence-based practice.  ACOG’s Safe Motherhood Initiative (SMI) focuses on the four leading causes of maternal death: maternal sepsis, obstetric hemorrhage (severe bleeding), venous thromboembolism (blood clots), and severe hypertension in pregnancy (high blood pressure).

The Obstetrical Hemorrhage Safety Bundle includes:

• Risk assessments: prenatal, antepartum, labor & delivery, and postpartum.
• Use of a staged obstetrical hemorrhage checklist to guide interventions in real-time.
• Team debriefing recommendations and a standardized debriefing form.
• Suggested standardized obstetrical hemorrhage tool kit.
• Recommendation to perform quantitative blood loss assessment (QBL) with every delivery.

The Joint Commission Perinatal Safety Standards: Effective January 1, 2021, the Joint Commission implemented new perinatal safety standards required of all Joint Commission accredited hospitals.   One of the new standards aims to improve care for women experiencing maternal hemorrhage.  The Joint Commission requirements focus on evidence-based written procedures, education, training, and drills for staff and providers, education for patients and families, and quality review.  The requirement also focuses on evidence-based risk assessments and hemorrhage supply kits. 

References:

ACOG’s Obstetrical Hemorrhage Safety Bundle. https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage

MedPage Today. 2022. https://www.medpagetoday.com/meetingcoverage/acog/98676

NYS Department of Health. 2017. NYS Morbidity and Mortality Review Report

OECD Health Data. 2020

P.S. Comment and share your experience with a maternal death case associated with obstetrical hemorrhage. What were the deviations in the standards of care?