Electronic Fetal Electronic Fetal MonitoringMonitoring

Terri Imus, RNTerri Imus, RN

Electronic Fetal MonitoringElectronic Fetal Monitoring

Indications for continuous EFMIndications for continuous EFM

Any pregnancy considered high riskAny pregnancy considered high risk Induction or augmentation of laborInduction or augmentation of labor Decreased fetal movementDecreased fetal movement Premature laborPremature labor Premature rupture of membranesPremature rupture of membranes

OligohydramniosOligohydramnios HypertensionHypertension Abnormal fetal heart rateAbnormal fetal heart rate Fetal malpresentation in Fetal malpresentation in

laborlabor IDDMIDDM Multiple GestationMultiple Gestation Previous C/SPrevious C/S TraumaTrauma MeconiumMeconium

ACOG & AAPACOG & AAP When EFM is the method selected for fetal When EFM is the method selected for fetal

assessment. The MD & obstetrical personnel assessment. The MD & obstetrical personnel should be qualified to identify and interpret should be qualified to identify and interpret abnormalities. These guidelines also state abnormalities. These guidelines also state that it is appropriate for MD & Nurse to use that it is appropriate for MD & Nurse to use the descriptive terms that have been given to the descriptive terms that have been given to fetal monitoring patterns in charting and fetal monitoring patterns in charting and reportingreporting

Those not qualified or are unsure of the Those not qualified or are unsure of the

interpretation in FHR patterns should seek interpretation in FHR patterns should seek other professionals to assist in this evaluation other professionals to assist in this evaluation and interpretationsand interpretations

The nurse should document the presence of The nurse should document the presence of MD and nurse, pt position and changes in MD and nurse, pt position and changes in cervix, cervix,

Therapeutic interventions such as O2 Therapeutic interventions such as O2 and medications and medications

Increased or decreased BPIncreased or decreased BP FebrileFebrile Amniotomy, AROM,SROM, color amt. Amniotomy, AROM,SROM, color amt.

consistencyconsistency Is the patient complete/pushingIs the patient complete/pushing All of these descriptive details give a All of these descriptive details give a

picture that indicates what is going on picture that indicates what is going on with the patient and possible cause of with the patient and possible cause of change in FHR pattern change in FHR pattern

AAP/ACOGAAP/ACOG

Guidelines emphasize that when there is a change in the FHR pattern all of those things should be documented as well as a return to baseline

Each tracing should include Pt NameID #Date, Time of admission/deliveryEDC, Gravida Para and any other identifying information

ACOGACOG Has Has not not identified core competencies identified core competencies

in FHR monitoringin FHR monitoring

Standard guidelines Norm 110-160Standard guidelines Norm 110-160 Fetal tachycardiaFetal tachycardia ModMod 161-180161-180 Marked “Marked “ 181-more181-more Fetal BradycardiaFetal Bradycardia ModMod 100-119100-119 Marked”Marked” 90 or less90 or less

4 Basic Features of Fetal Heart 4 Basic Features of Fetal Heart tracingtracing

4 Basic Features4 Basic Features Baseline Baseline VariabilityVariability Bradycardia <110 bpm Bradycardia <110 bpm Tachycardia >160 bpmTachycardia >160 bpm

Periodic changes: FHR accelerations Periodic changes: FHR accelerations or decelerations that occur with or decelerations that occur with contractions. contractions.

Decelerations are routinely Decelerations are routinely described as early, late, or variable. described as early, late, or variable.

Non-periodic changes Non-periodic changes (no changes in variability)(no changes in variability)

Nonperiodic changes can occur Nonperiodic changes can occur spontaneously, spontaneously,

without contraction activity, and are also without contraction activity, and are also

described as accelerations or decelerations.described as accelerations or decelerations.

Variable decelerations can appear during a Variable decelerations can appear during a

Non-stress test and may be a sign ofNon-stress test and may be a sign of

cord compression or oligohydramnios, both of cord compression or oligohydramnios, both of

which can have adverse effects on the fetus. which can have adverse effects on the fetus.

Baseline VariabilityBaseline Variability

Normal FHR 5 bpm greater than or equal Normal FHR 5 bpm greater than or equal to 5 bpm, between contractionsto 5 bpm, between contractions

Nonreassuring FHR less than 5 bpm or Nonreassuring FHR less than 5 bpm or less, but less than 30 min of tracingless, but less than 30 min of tracing

Abnormal FHR less than 5 bpm for 90 min Abnormal FHR less than 5 bpm for 90 min or more.or more.

Baseline variabilityBaseline variability

The minor fluctuations on baseline FHR at The minor fluctuations on baseline FHR at 3-5 cycles p/m will reflect baseline 3-5 cycles p/m will reflect baseline variabilityvariability

Examine 1 min segment and estimate Examine 1 min segment and estimate highest peak and lowest troughhighest peak and lowest trough

Normal is more than or equal to 5 bpmNormal is more than or equal to 5 bpm

Factors affecting Baseline Factors affecting Baseline variabilityvariability

Para-Sympathetic affects short term Para-Sympathetic affects short term variability variability

Sympathetic affects long term Sympathetic affects long term

CNS Drugs reduces VariabilityCNS Drugs reduces Variability

Increased gestational age may increase Increased gestational age may increase variabilityvariability

Mild Hypoxia may cause both Sympathetic Mild Hypoxia may cause both Sympathetic and Parasympathetic stimulationand Parasympathetic stimulation

AccelerationsAccelerations Accelerations transient increase in FHR of Accelerations transient increase in FHR of

15 bpm or more lasting for 15 sec15 bpm or more lasting for 15 sec

Absence of accelerations on an otherwise Absence of accelerations on an otherwise normal Fetal heart tracing remains unclearnormal Fetal heart tracing remains unclear

Presence of FHR Accelerations usually Presence of FHR Accelerations usually have good outcomehave good outcome

AccelerationsAccelerations

Head compressionHead compression

Begins on the onset of contraction and Begins on the onset of contraction and returns to baseline as the contraction returns to baseline as the contraction endsends

Should not be disregarded if it appears Should not be disregarded if it appears early in labor or in the antenatal periodearly in labor or in the antenatal period

Early Decelerations Early Decelerations

EARLY DECELERATIONEARLY DECELERATION

Early Decelerations

Late DecelerationsLate Decelerations Uniform periodic slowing of FHR with Uniform periodic slowing of FHR with

the on set of the contractionthe on set of the contraction

Reduced baseline variability together Reduced baseline variability together with late decelerations and repetitive with late decelerations and repetitive late deceleration increases risk of fetal late deceleration increases risk of fetal acidosis and an Apgar score of less acidosis and an Apgar score of less than 7 atthan 7 at

5/min with an increased risk of adverse 5/min with an increased risk of adverse outcomeoutcome

Late DecelerationLate Deceleration

Late DecelerationLate Deceleration

Late DecelerationsDue to acute and chronic utero-placental insufficiencyDue to acute and chronic utero-placental insufficiency

Occurs after the peak and past the length of uterine Occurs after the peak and past the length of uterine contraction, often with slow return to the baselinecontraction, often with slow return to the baseline

Is precipitated by hypoxemiaIs precipitated by hypoxemia

Associated with respiratory and metabolic acidosisAssociated with respiratory and metabolic acidosis

Common in patients with PIH, DM, IUGR or Common in patients with PIH, DM, IUGR or other forms of placental insufficiencyother forms of placental insufficiency

Variable DecelerationsVariable Decelerations Variable intermittent periodic slowing of Variable intermittent periodic slowing of

FHR with rapid onset recovery and FHR with rapid onset recovery and isolationisolation

They can resemble other types of They can resemble other types of deceleration in timing and shapedeceleration in timing and shape

Atypical associated with an increased risk Atypical associated with an increased risk of umbilical artery acidosis and Apgar of umbilical artery acidosis and Apgar score less than 7 at 5 minscore less than 7 at 5 min

Additional componentsAdditional components

Loss of 1 or 2 degree rise in baseline rateLoss of 1 or 2 degree rise in baseline rate Slow return to baseline FHR after and end of Slow return to baseline FHR after and end of

contractioncontraction Prolonged secondary rise in Base FHR Prolonged secondary rise in Base FHR Biphasic decelerationBiphasic deceleration Loss of variability during deceleration Loss of variability during deceleration Continuation of the baseline at a lower rateContinuation of the baseline at a lower rate

Variable Deceleration (Vagal activity) Variable Deceleration (Vagal activity) Inconsistent in configuration Inconsistent in configuration

No uniform temporal r-ship to the onset of No uniform temporal r-ship to the onset of contraction, are variable and occur in contraction, are variable and occur in isolationisolation

Worrisome when Rule of 60 is exceeded Worrisome when Rule of 60 is exceeded (i.e. decrease of 60 bpm,or rate of 60 bpm (i.e. decrease of 60 bpm,or rate of 60 bpm and longer than 60 sec) and longer than 60 sec)

Caused by compression of the umbilical Caused by compression of the umbilical cordcord

Often associated with Oligo-hydramnios Often associated with Oligo-hydramnios with or without rupture of membraneswith or without rupture of membranes

Acidosis if prolonged and recurrentAcidosis if prolonged and recurrent

Variable DecelerationsVariable Decelerations

Variable Decelerations

Drop in FHR of 30 bpm or more lasting for at Drop in FHR of 30 bpm or more lasting for at least 2 minsleast 2 mins

Is pathological when it crosses 2 contractions inIs pathological when it crosses 2 contractions in

3 mins3 mins Results in reduced of O2 transfer to placentaResults in reduced of O2 transfer to placenta Associated with poor neonatal outcomeAssociated with poor neonatal outcome

Prolonged Deceleration

Prolonged DecelerationsProlonged DecelerationsCAUSESCAUSES

Cord prolapseCord prolapse

Maternal hypertension/hypotensionMaternal hypertension/hypotension

Uterine hypertoniaUterine hypertonia

Epidural/spinal or pudendal anesthesiaEpidural/spinal or pudendal anesthesia

Can follow a vag exam, AROM or SROM Can follow a vag exam, AROM or SROM with high presenting partwith high presenting part

Prolonged Deceleration

Intrauterine ResuscitationIntrauterine Resuscitation

Have the mother lie on her left/right Have the mother lie on her left/right sideside

or in a knee chest positionor in a knee chest positionTo alleviate possible cord compressionTo alleviate possible cord compression

Reduce or stop any oxytocinReduce or stop any oxytocin Initiate tocolysisInitiate tocolysis ToTo decrease uterine activity and increase decrease uterine activity and increase

placental blood flowplacental blood flow Increase IV fluidIncrease IV fluid To increase maternal blood/fluid volume  To increase maternal blood/fluid volume 

        Give oxygen @ 10-12 L/min via maskGive oxygen @ 10-12 L/min via mask

      

Physician may apply an internal monitorPhysician may apply an internal monitor to to verify the accuracy of external monitor reading verify the accuracy of external monitor reading 

Physician mayPhysician may a administer amnioinfusiondminister amnioinfusion     tto decrease pressure on cord or dilute mec.

If the heart rate is not restored to normal If the heart rate is not restored to normal within 30 minutes, prompt delivery is within 30 minutes, prompt delivery is needed.  Cesarean section may then needed.  Cesarean section may then become necessary. Goal is to deliver ASAPbecome necessary. Goal is to deliver ASAP

Causes of Baseline ChangeCauses of Baseline Change

PostdatesPostdates DrugsDrugs IdiopathicIdiopathic ArrhythmiasArrhythmias HypothermiaHypothermia Increased vagal toneIncreased vagal tone Cord CompressionCord Compression

Management depends on the clinical situationManagement depends on the clinical situation

Causes of BradycardiaCauses of Bradycardia

AsphyxiaAsphyxia DrugsDrugs PrematurityPrematurity Maternal FeverMaternal Fever Maternal thyrotoxicosisMaternal thyrotoxicosis Maternal AnxietyMaternal Anxiety IdiopathyIdiopathy

Management depends on the clinical situationManagement depends on the clinical situation

Baseline TachycardiaBaseline Tachycardia

AsphyxiaAsphyxia DrugsDrugs PrematurityPrematurity Maternal feverMaternal fever Maternal thyrotoxicosisMaternal thyrotoxicosis Maternal AnxietyMaternal Anxiety IdiopathyIdiopathy

Sinusoidal PatternSinusoidal Pattern

Regular Oscillation of the Baseline long-Regular Oscillation of the Baseline long-term Variability resembling a Sine wave term Variability resembling a Sine wave fixed cycle of 3-5 p min with amplitude of fixed cycle of 3-5 p min with amplitude of 5-15bpm and above but not below the 5-15bpm and above but not below the baselinebaseline

Should be viewed with suspicion as poor Should be viewed with suspicion as poor outcome has occurred (maternal/fetal outcome has occurred (maternal/fetal hemorrhage)hemorrhage)

Sinusoidal patternSinusoidal pattern

Sinusoidal pattern - distinctive smooth Sinusoidal pattern - distinctive smooth undulating undulating

Sine-wave baselineSine-wave baselineCord compressionCord compression HypovolemiaHypovolemia AscitesAscites Idiopathic (fetal thumb sucking)Idiopathic (fetal thumb sucking) AnalgesicsAnalgesics AnemiaAnemia AbruptionAbruptionManagement depends on clinical situationManagement depends on clinical situation

Summary of tracingSummary of tracing Normal with all 4 FeaturesNormal with all 4 Features

Suspicious one non reassuring category Suspicious one non reassuring category and remainder are reassuringand remainder are reassuring

Pathological 2 or more non-reassuring Pathological 2 or more non-reassuring categories or one or more abnormal categories or one or more abnormal categories.categories.

At BirthAt Birth

Need to ConsiderNeed to Consider

Cord pH if tracing suspicious Cord pH if tracing suspicious

Preterm laborPreterm labor

Mec. stained amniotic fluidMec. stained amniotic fluid

FBS intrapartum (lab availability)FBS intrapartum (lab availability)

Lack of tone deliveryLack of tone delivery

Operative or instrumental deliveryOperative or instrumental delivery

COMMUNICATIONCOMMUNICATION

DESCRIBE THE PATTERN ACCURATELYDESCRIBE THE PATTERN ACCURATELY

MAKE AN ATTEMPT TO ASSESS WHETHER MAKE AN ATTEMPT TO ASSESS WHETHER THE FETUS IS IN TROUBLETHE FETUS IS IN TROUBLE

IF YOU WANT THE PHYSICIAN THERE, IF YOU WANT THE PHYSICIAN THERE, COMMUNICATE THATCOMMUNICATE THAT

THE NURSE HAS MORE DATA THANTHE NURSE HAS MORE DATA THAN THE THE PHYSICIANPHYSICIAN

CommunicationCommunication SYSTEMATIC APPROACH REDUCES SYSTEMATIC APPROACH REDUCES

ERRORSERRORS

DESCRIBE WHAT YOU SEEDESCRIBE WHAT YOU SEE

AVOID THE NEED TO CLASSIFY EVERY AVOID THE NEED TO CLASSIFY EVERY DECELERATIONDECELERATION

ASSESS THE OVERALL CONDITION OF ASSESS THE OVERALL CONDITION OF THE FETUSTHE FETUS

Electronic Fetal MonitoringElectronic Fetal Monitoring

Improve knowledge for all staffImprove knowledge for all staff Improve clinical skillsImprove clinical skills

Training should include instruction on documentation Training should include instruction on documentation and storageand storage

Training should include appropriate clinical responses Training should include appropriate clinical responses to suspicious or pathological tracingsto suspicious or pathological tracings

Training should include local guidelines relating to Training should include local guidelines relating to fetal monitoring both intermittent and EFMfetal monitoring both intermittent and EFM

DOCUMENTATION OF DOCUMENTATION OF COMMUNICATIONCOMMUNICATION

DO NOT JUST SAY THATDO NOT JUST SAY THAT

Dr. Whoduneit WAS NOTIFIEDDr. Whoduneit WAS NOTIFIED

RECORD THE PHYSICIAN’S RECORD THE PHYSICIAN’S

RESPONSE and any ORDERSRESPONSE and any ORDERS

COMMUNICATIONCOMMUNICATION DESCRIBE FHR PATTERNDESCRIBE FHR PATTERN

I AM CONCERNED ABOUT THE CONDITION I AM CONCERNED ABOUT THE CONDITION OF THIS BABYOF THIS BABY

IT IS OMINOUS AND NON-REASSURINGIT IS OMINOUS AND NON-REASSURING

IF PERSISTENT, IF PERSISTENT, REQUIRESREQUIRES PHYSICIAN PHYSICIAN EVALUATIONEVALUATION

COMMUNICATIONCOMMUNICATION

THE FETUS HAS INCREASED THE FETUS HAS INCREASED VARIABILITY AND THE BASELINE IS VARIABILITY AND THE BASELINE IS HARD TO NTERPRETHARD TO NTERPRET

PHYSICIAN PRESENCE NOT REQUIREDPHYSICIAN PRESENCE NOT REQUIRED

COMMUNICATIONCOMMUNICATION NOTIFY IF NO DRUGS WERE GIVENNOTIFY IF NO DRUGS WERE GIVEN

THE FETUS HAS HAD A SINUSOIDAL THE FETUS HAS HAD A SINUSOIDAL PATTERN FOR 20 MINUTES. I HAVE NOT PATTERN FOR 20 MINUTES. I HAVE NOT GIVEN ANY NARCOTICS AND THE GIVEN ANY NARCOTICS AND THE PATTERN PERSISTS DESPITE PATTERN PERSISTS DESPITE POSITIONING, HYDRATION AND OXYGEN.POSITIONING, HYDRATION AND OXYGEN.

PHYSICIAN PRESENCE MAY NOT BE PHYSICIAN PRESENCE MAY NOT BE

REQUIRED but informREQUIRED but inform

COMMUNICATION what if COMMUNICATION what if

THE FETUS SUSTAINED A PROLONGED THE FETUS SUSTAINED A PROLONGED DECELERATION ASSOCIATED WITH DECELERATION ASSOCIATED WITH HYPERSTIMULATIONHYPERSTIMULATION

THE PATTERN RESOLVED AFTER ….THE PATTERN RESOLVED AFTER ….

PHYSICIAN PRESENCE MAY NOT BE PHYSICIAN PRESENCE MAY NOT BE IMMEDIATELY REQUIRED, BUT SHOULD IMMEDIATELY REQUIRED, BUT SHOULD BE NOTIFIEDBE NOTIFIED

Effective communication to avoid LitigationEffective communication to avoid Litigation COMMUNICATE EFFECTIVELY TO THE COMMUNICATE EFFECTIVELY TO THE

PHYSICIANPHYSICIAN

DESCRIBE WHAT YOU SEE AND DESCRIBE WHAT YOU SEE AND DOCUMENT WHAT YOU TOLD THE DOCUMENT WHAT YOU TOLD THE PHYSICIANPHYSICIAN

DOCUMENT HER/HIS RESPONSEDOCUMENT HER/HIS RESPONSE

AVOID CHART WARSAVOID CHART WARS

TracingsTracings

Unsatisfactory or MissingUnsatisfactory or Missing Abnormal tracing ignored or not recognizedAbnormal tracing ignored or not recognized Tracings not doneTracings not done

Risk ManagementRisk Management

EFM traces should be kept up to 21 years.EFM traces should be kept up to 21 years. If removed for teaching purposes or etc, should If removed for teaching purposes or etc, should

be easily locatedbe easily located They minimize incidence of adverse outcomeThey minimize incidence of adverse outcome

What Influences LitigationWhat Influences Litigation Consumer ExpectationConsumer Expectation

The profession –educationThe profession –education

The employer (policies/procedures)The employer (policies/procedures)

Legislation (duty of care/scope of practice/ Legislation (duty of care/scope of practice/ registration)registration)

Legal issues- Legal issues- Consumer expectationConsumer expectation

Good outcome (healthy baby/mother)Good outcome (healthy baby/mother)

Bad outcomeBad outcome

Someone to blameSomeone to blame

Someone must paySomeone must pay

Professional ResponsibilityProfessional Responsibility To act within scope of practiceTo act within scope of practice

To seek support and guidance To seek support and guidance

Work within organizational standardsWork within organizational standards

Duty of care to the patient and your professionDuty of care to the patient and your profession

Maintain knowledge and skills (Evidence Based Maintain knowledge and skills (Evidence Based Practice)Practice)

Be prepared to defend your actions or lack ofBe prepared to defend your actions or lack of

When EFM is the focus of MalpracticeWhen EFM is the focus of Malpractice Comparison of consistency of documentation Comparison of consistency of documentation

contained on the trace and in the chartcontained on the trace and in the chart

Lapse in documentation may leave doubt about Lapse in documentation may leave doubt about the quality of care giventhe quality of care given

Hospital policy and procedure manuals will be Hospital policy and procedure manuals will be examinedexamined

Competency levels will be evaluated, expert Competency levels will be evaluated, expert witness (plaintiff/defense)will determine if witness (plaintiff/defense)will determine if acceptable standards were appliedacceptable standards were applied

Major Omission in Major Omission in LiabilityLiability

Failure to appropriately monitor the Failure to appropriately monitor the mother and fetus statusmother and fetus status

Failure to notify the physician in a timely Failure to notify the physician in a timely mannermanner

Initiation of procedures without Initiation of procedures without adequate client information or consent adequate client information or consent (informed consent)(informed consent)

MORE MORE Legal issues Legal issues

Use EFM effectively and efficientlyUse EFM effectively and efficiently

Interpret the tracing and respond Interpret the tracing and respond accordinglyaccordingly

It is permanent record that is It is permanent record that is scrutinized in a litigation casescrutinized in a litigation case

May be pivotal in determining liabilityMay be pivotal in determining liability

A normal EFM can be used to indicate that A normal EFM can be used to indicate that there were no abnormalities with no indication there were no abnormalities with no indication for interventionfor intervention

An abnormal EFM or suspicious trace may An abnormal EFM or suspicious trace may provide evidence for inappropriate or lack of provide evidence for inappropriate or lack of treatment, giving more insight for litigationtreatment, giving more insight for litigation

EFM could be viewed as part of “defensive EFM could be viewed as part of “defensive medicine”, as litigation is reported to be on the medicine”, as litigation is reported to be on the increase.increase.

Elements of a Successful Elements of a Successful Malpractice ActionMalpractice Action

A nurse has a duty to the patientA nurse has a duty to the patient

A nurse commits a breach of dutyA nurse commits a breach of duty

A patient suffers damagesA patient suffers damages

Causal connection between the nurse’s Causal connection between the nurse’s actions and the patient’s damagesactions and the patient’s damages

RN ObligationRN Obligation Help patient to process information when Help patient to process information when

outcomes are poor, explain situation and outcomes are poor, explain situation and reinforce learning/teachingreinforce learning/teaching

RN must chart carefully and defensively to RN must chart carefully and defensively to support the care givensupport the care given

The chart is the witness that never dies and is The chart is the witness that never dies and is discoverable for up to 21yrsdiscoverable for up to 21yrs

Not charted not doneNot charted not done

RN (expert witness) help to identify when a RN (expert witness) help to identify when a breech of duty of standards of practicebreech of duty of standards of practice

Documentation and the MonitorDocumentation and the Monitor

Know your institution’s policy on what is to Know your institution’s policy on what is to be documented on the monitor stripbe documented on the monitor strip

Routine informationRoutine information Identify strip with patient’s nameIdentify strip with patient’s name Medical record numberMedical record number Date and timeDate and time Procedures doneProcedures done Nurses name or initialsNurses name or initials

OMISSIONOMISSION Failure to appropriately monitor client/fetus Failure to appropriately monitor client/fetus

(ACOG recommendation Q 15mins 1(ACOG recommendation Q 15mins 1stst stage Q 5 mins 2stage Q 5 mins 2ndnd stage) stage)

Inappropriate Pitocin monitoring/utilizationInappropriate Pitocin monitoring/utilization Pitocin orders/continuous monitoring/ having Pitocin orders/continuous monitoring/ having

access to physician for further access to physician for further instruction/ordersinstruction/orders

Improper sponge/instrument counts during Improper sponge/instrument counts during C/SC/S Initiation of procedures without adequate Initiation of procedures without adequate

client information consent (informed consent)client information consent (informed consent)Failure to notify MD in a timely manner: Failure to notify MD in a timely manner: When in doubt When in doubt shoutshout

Failure to notify MD in a timely manner: Failure to notify MD in a timely manner:

Notify the physician and note time Notify the physician and note time and orders or lack there of ordersand orders or lack there of orders

Repeat notifications per institutions Repeat notifications per institutions policy and utilize the chain of policy and utilize the chain of command for your institutions when command for your institutions when no appropriate responseno appropriate response

TechnologyTechnology

ReferencesReferences

Manual Obs and Gyn. by Niswander, Manual Obs and Gyn. by Niswander, MDMD

Fetal Monitoring, RCOG UKFetal Monitoring, RCOG UK CTGs, RANZCOGCTGs, RANZCOG Literature review articles American Literature review articles American

Family PhysicianFamily Physician Electronic Fetal Monitoring, Menihan, Electronic Fetal Monitoring, Menihan,

ZottoliZottoli