FETAL HEART RATE PATTERN INTERPRETATION, COMMUNICATION, AND DOCUMENTATION: A COMMON AREA OF PERINATAL LIABILITY

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.