Beyond the Basics: The Art and Science of Strip Interpretation - PowerPoint PPT Presentation

2014 Fetal Monitoring Lunch & Learn Series Beyond the Basics: The Art and Science of Strip Interpretation Session 5: December 10, 2014 1

Wisconsin Association for Perinatal Care (WAPC) 2

Faculty • Chris Van Mullem, RNC, MS Clinical Nurse Specialist Aurora Sinai Hospital Milwaukee, WI 3

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. • Expiration date for awarding contact hours – 12/31/2014 4

Before we begin… • Listen-only mode • Questions – please ask, please answer! – Raise your hand – Type into the Question Pane – Out of time? Email wapc@perinatalweb.org • Technical problems: Email Barb Wienholtz at wienholtz@perinatalweb.org 5

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. 6

Objectives At the conclusion of the session, participants will be able to: 1. Systematically review the electronic fetal monitor strip 2. Identify and categorize the FHR pattern 3. Identify and discuss uterine activity patterns and their influence on the FHR baseline 4. Discuss the pathophysiology related to the tracing patterns identified 5. Discuss interventions for management and documentation of intrapartum fetal heart rate tracings 7

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 8

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 9

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 10

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 reassuring sign of fetal well-being? 11

Strip Review Discussion • Interpretation • Interventions/Communication • Documentation in chart 12

Intervention/Communication • SBAR – S ituation – B ackground – A ssessment – R ecommendation 13

History Patient is a 24 year old G5P2022 female at 23w1d with EDD of 11/18/2014 by US done today who initially presented to triage with complaint of lower abdominal cramping. No prenatal care. FHR were unable to trace, so US was obtained showing fetal tachycardia to 210-240bpm with infrequent baseline rate of 110. Breech, AC 47%, EFW 561 g, (39%), BPP 6/8 Patient reports + fetal movements Patient history not contributory. BP 100/54. P 79, BMI 19.97, Spo2 98% She was admitted for observation to L&D.

Poll question Q1. The most common cause of fetal tachyarrhythmia is: a. Supraventricular tachycardia b. Sinus tachycardia c. Atrial flutter/atrial fibrillation

Poll question Q2. The preferred method for monitoring the fetal heart rate in the presence of a fetal arrhythmia is: a. Fetal scalp electrode b. External monitoring c. Auscultation

Poll question Q3. The ultrasound transducer may half-count an elevated fetal heart rate of more than 180 bpm. a. True b. False

Tracing 1

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Supraventricular Tachycardia SVT • Sustained, rapid regular atrial arrhythmia. • Rate may range from 210-320 bpm. Typical-240-260

Mechanisms of SVT • Increased automaticity of ectopic pacemaker above bundle of HIS • Reentrant tachycardia (circular) most commonly within AV node �

Evaluation of SVT • Ultrasound • Pulsed wave Doppler • Fetal Echocardiogram • Fetal Magnetocardiography • M-Mode EchoCG • External fetal heart rate monitoring

SVT • Increases the workload of the fetal heart • Increases oxygen demand Effect: • depending on gestational age of fetus and persistence of SVT • CHF (pericardial or pleural effusion, cariomegaly, polyhydramios, scalp edema, ascites • Hemolysis of red blood cells • Development of non-immune hydrops fetalis and fetal death

Treatment �

Maternal Assessment • Medical history especially cardiac • Medication History • ECG • Blood pressure • Labs (electrolytes, renal and hepatic function, urine protein, platelet function)

Drug Treatment

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Heart Block Absence of conduction of the impulse from SA node through AV node Causes: • Cardiac structural defects, • CMV, • anti-phospholipid syndrome, • maternal antibodies Treatment: • Steroids • Increase fetal heart rate (terbutaline) • Close monitoring • Fetal movement counting • Real time US to assess for decompensation 35

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Outcome • AROM/meconium • FSE/IUPC • Vaginal forceps delivery • Male • 8 1, , 9 5 • pH 7.34 • 5# 10.5 oz • EKG and Echo normal

Discussion Questions? Comments? 60

Remember • Fax or email attendance list to WAPC – fax: 608-285-5004 – email: wapc@perinatalweb.org • Evaluation will be sent via email from WAPC. Please complete to receive Continuing Education Credit. • Continuing Education Certificate will be sent via email upon completion of evaluation. • Become a member of WAPC! Join online: https://www.perinatalweb.org/n- pay/membership.asp • Save the date for the 2015 WAPC Annual Perinatal Conference April 26-28, 2015, in Appleton. 61

Thank you! 62