Recommendations for intrapartum fetal monitoring are not followed in low-risk women: A study from two Norwegian birth units.

OBJECTIVE: International and national intrapartum fetal monitoring guidelines recommend intermittent auscultation in low-risk women, and admission cardiotocography and continuous cardiotocography in high-risk women. The present study aimed to investigate fetal monitoring practices for low- and high-risk women in two hospitals in Norway, and if practice were according to national and international guidelines. STUDY DESIGN: To this cross sectional study, data on methods of fetal monitoring and women's risk status were collected from the patient journals of 998 women with intended vaginal birth in 2017 and 2018. MAIN OUTCOME MEASURES: Type of fetal monitoring related to risk status. RESULTS: On admission, 401 (40%) of the women were classified as low-risk and 597 (60%) as high-risk. An admission cardiotocography was reported for 327 (82%) low-risk women and 554 (93%) high-risk women. Of the low-risk women, 187 (47%) remained low-risk throughout labor. During labor, 99 (53%) of the women that remained low-risk were monitored with intermittent auscultation, 62 (33%) with cardiotocography, 24 (13%) with partial cardiotocography, and two (1%) had no monitoring documented. In the high-risk women, intermittent auscultation was used for 11 (2%) during labor, cardiotocography for 544 (91%), partial cardiotocography for 35 (6%), and seven (1%) women had no monitoring documented. CONCLUSIONS: The majority of low-risk women had an admission cardiotocography and during labor many low-risk women were monitored with continuous cardiotocography. This is not in accordance with guidelines which recommend intermittent auscultation. In addition, almost one-tenth of high-risk women were not monitored with continuous cardiotocography, as recommended.

Electronic Fetal Monitoring Documentation: Connecting Points for Quality Care and Communication.

Contemporaneous, complete, and objective documentation is the foundation for continuity of patient care and facilitates communication between all levels of healthcare clinicians. The impact of electronic fetal monitoring on obstetric safety has become a high priority, with documentation being essential to evaluating care quality. Over several decades, electronic fetal monitoring documentation has reached a higher level of precision because paper is being replaced with health information technology that incorporates system's features such as checklists, drop-down boxes, and decision analysis. The intent of this article is to provide a synopsis of important concepts regarding electronic fetal monitoring documentation and liability-reduction strategies for perinatal nurses.

Control del bienestar fetal: monitorización biofísica intraparto / Control of fetal well-being: biophysics intrapartum monitoring

En este artículo se presenta una actualización sobre el control del bienestar fetal intraparto que comprende los siguientes aspectos: métodos de control de la frecuencia cardiaca fetal y de la dinámica uterina y parámetros de la contracción uterina. Asimismo, se describe la valoración de los registros cardiotocográficos intraparto analizando la frecuencia cardiaca fetal en relación con la dinámica uterina. Se evalúan los diferentes tipos de deceleraciones de la frecuencia cardiaca fetal: precoces, tardías y variables, su significado clínico y la conducta que seguir en cada una de ellas. Finalmente, se definen los parámetros que componen un registro cardiotocográfico normal (AU)

This article presents an update on the control of the intrapartum fetal wellbeing including the following aspects: methods of monitoring the fetal heart rate and the uterine dynamic and uterine contraction parameters. Moreover, the assessment of intrapartum CTG records is described by analyzing the fetal heart rate in relation to uterine contractions. The different types of fetal heart rate decelerations: early late and variable, its clinical significance and the guidelines to follow in each one of them are evaluated. Finally, the parameters that make up a normal CTG registration are defined (AU)

Control del bienestar fetal. Monitorización biofísica anteparto / Control of fetal well-being: biophysics antepartaum monitoring

En este artículo se presenta una actualización sobre el control del bienestar fetal anteparto, que incluye la monitorización biofísica con el test no estresante y el test estresante y su valoración. Se describen los parámetros de la frecuencia cardiaca fetal -la línea de base, la variabilidad y los ascensos transitorios de la frecuencia cardiaca fetal- en relación con los movimientos fetales, su significado clínico y la actuación que deriva del mismo (AU)

This article provides an update on the control of antepartum fetal well-being, including the biophysical monitoring with nonstressful and stressful test and its evaluation. The fetal heart rate -base line, variability and transitional increases in fetal heart rate- are described based on fetal movements, its clinical meaning and actions derived from it (AU)

ST analysis as an adjunct to electronic fetal monitoring: an overview.

Conventional electronic fetal monitoring in the United States has value as a screening tool but is extremely limited as a diagnostic tool. ST analysis was developed as an adjunctive technology, able to measure changes in the ST segment of the fetal electrocardiogram during periods of hypoxia, improving the identification of the fetus at risk for metabolic acidemia at birth. Currently used only in a handful of hospitals in the United States, studies abroad have demonstrated that an integrated approach utilizing electronic fetal monitoring, ST analysis, and standardized guidelines in a selected patient population can improve neonatal outcome, decrease acidemia at birth, and decrease obstetric operative delivery. Research is needed to determine whether similar results are possible in the US population.

A randomised-controlled trial evaluating a fetal monitoring education programme.

OBJECTIVE: to evaluate the effectiveness of a fetal monitoring education programme on midwives' fetal monitoring knowledge and intrapartum cardiotocograph interpretation skills. DESIGN: two group, before-after, randomised-controlled trial. SETTING: two maternity hospitals in the Republic of Ireland. PARTICIPANTS: 55 midwives were randomly assigned to either the experimental group (n=27) or the control group (n=28). INTERVENTIONS: the experimental group participated in a 1.5 hr fetal monitoring education programme, whereas the control group attended an alternative education programme consisting of a non-fetal-monitoring-related video presentation. MEASUREMENTS: the primary outcomes of interest were fetal monitoring knowledge and intrapartum cardiotocograph interpretation skills test. FINDINGS: in the fetal monitoring knowledge post-test, the median percentage correct responses for the control and experimental groups were 56% (IQR 18.75) and 88% (IQR 12.5), respectively. This difference, 31.2%, was statistically significant (U=78.5, 95.1% CI -31.25 to -18.75, p<0.001). In the intrapartum cardiotocograph interpretation skills post-test, the median percentage correct responses for the control and experimental groups were 55.6% (IQR 16.7) and 66.7% (IQR 22.2), respectively. This difference, of 11.1%, was statistically significant (U=186, 95.2% CI -16.67 to -5.56, p<0.001). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: attendance at a short (1.5 hr), in-service fetal monitoring education programme can increase midwives' fetal monitoring knowledge and cardiotocograph interpretation skills. The availability of in-service fetal monitoring education programmes is sporadic, often less than recommended, and is a cause for concern.

Use of CTG monitoring: are recommendations suitable?

The National Institute for Clinical Excellence (NICE) guideline for cardiotocograph (CTG) monitoring in labour (NICE, 2001) recommends intermittent monitoring for low-risk labours and discourages the use of an admission CTG. The guideline sets out risk factors that would classify a labour as high risk, for which it recommends continuous CTG monitoring. An audit conducted in a consultant-led maternity unit found that nearly a half of the labours were classified as high risk at the onset of labour. Of those classified as low risk, almost half of them went on to have continuous CTG during the course of labour. The majority of the reasons given by the midwives agree with indications specified by NICE. Midwives in the unit where the audit took place showed good compliance with the guidelines, except in the case of admission CTGs. Just under half those classified as low risk were found to have had an admission CTG.

Monitoring the preterm fetus during labor.

The purpose of this article is to discuss special challenges in monitoring the preterm fetus during labor, review implications of preterm fetal heart rate (FHR) patterns, and highlight appropriate nursing interventions that contribute to the best outcomes for mothers and babies. With the current incidence of preterm birth, monitoring the preterm fetus during labor is a common perinatal nursing responsibility. Most of the published research on this topic was conducted in the 1980s; there has been little attention to FHR monitoring during preterm labor in recent studies. There has been much more accumulated evidence about antepartum testing techniques involving electronic fetal monitoring (EFM) for the preterm fetus in contrast to FHR patterns during labor. Thus, this is an area of opportunity for nursing research. The perinatal nurse has a key role in promoting positive outcomes when caring for women during preterm labor. The condition of the fetus during labor and birth has a significant impact on the likelihood of survival and the odds of developing serious complications of prematurity.

Spectral analysis of heart rate variability: an emerging tool for assessing stability during transition to extrauterine life.

Transition from fetal to neonatal life is likely the most physiologically demanding time of life. Complex changes in major organ system functioning and reorganization of metabolic processes must occur rapidly to achieve postnatal homeostasis. Identifying the neonate with subtle signs of unsuccessful transition is a challenge to the perinatal health care provider. Alterations in fetal or neonatal heart rate and heart rate variability may serve as an indicator of the neural control influencing cardiac function and a sensitive indicator of compromised health. Evaluation of the neural control of the heart can be done noninvasively and provides a discriminating measure of the level of stress vulnerability the fetus or newborn may be experiencing. This article reviews the origins of physiological variability of the fetal and neonatal heart rate in the transition to extrauterine life. The technique of spectral analysis as a new tool for surveillance of the at-risk fetus and neonate is then introduced, and implications for clinical practice and future research avenues are discussed.

A randomised controlled trial of admission electronic fetal monitoring in normal labour.

AIM: To test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. DESIGN: A randomised controlled trial. SETTING: The Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. PARTICIPANTS: Healthy pregnant women admitted in normal labour, deemed low risk based on the midwives' birth unit admission criteria. INTERVENTION: Women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). OUTCOME MEASURES: Primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. SECONDARY OUTCOMES: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. KEY FINDINGS: There was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. CONCLUSION: The use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.

Midwives' attitudes to the use of the cardiotocograph machine.

BACKGROUND: The literature would suggest that midwives' attitudes towards the use of birth technology are mainly focused around issues of "trust and dependence" yet there has been no published research to refute or substantiate these beliefs. AIM: This paper reports on an empirical study that aimed to identify midwives' attitudes to technology usage in the labour ward and specifically the use of the cardiotocograph machine (CTG) for electronic foetal monitoring. DESIGN: A postal survey was conducted and the questionnaire included a 25-item attitude scale, which was designed to assess attitudes towards the use of the CTG machine. All midwives (1086) on the United Kingdom Central Council register for Northern Ireland were surveyed. The data were factor analysed and compared using several categorical groupings including age, perceived skill, prior training with computers and trust in the machines. RESULTS: The results indicate that midwives reject any notion of them being, or becoming, dependent on machines in their practice. However, midwives who trust machines are more disposed to their use and trust is affected by perceived competence. CONCLUSION: The paper concludes with a recommendation for the future education of midwives to develop and maintain competence based craft skills in natural birth as well as high-tech birth.

History and development of fetal heart assessment: a composite.

Methods of assessing the fetal heart remained unchanged for approximately 150 years until the first commercial monitor suitable for clinical practice was sold in 1968. The impact and events of the last 30 to 40 years surrounding fetal heart assessment are revealed in perspectives of the past, present, and near future. Assessment practices have been shaped by the development of biotechnology, unrealistic expectations, interpretation disagreement, consumer response, and the practice and educational resources written by nursing and medicine.

Perioperative assessment of fetal heart rate and uterine activity.

Improvements in surgical techniques and anesthesia allow women the option to schedule needed surgery during pregnancy. However, perioperative monitoring of the fetus and uterine activity remains a matter of controversy. Monitoring may allow rapid improvement of the fetal status or uterine activity when early compromise or contractions are detected. The reassurance and decreased medicolegal risks provided by perioperative monitoring may offset the cost of a perinatal nurse and use of monitoring equipment even though the drug and anesthetic effect on the fetal heart limit the benefits of monitoring. Simply providing adequate maternal respiratory support during surgery may improve the fetal pattern but will not eliminate external surgical effects. The need for additional research is described, and the role of the perinatal nurse is detailed in a suggested protocol.