fetal surveillance challenges: interpretation ... · 11/15/2011 1 fetal surveillance challenges:...

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Fetal Surveillance Challenges: Interpretation, Classification

Communication and Documentation

Marie-Josée Trépanier Clinical Nurse Specialist

CAPWHN 1st National Conference

Victoria BC

October 27, 2011

Acknowledgments

Content based on Fetal Health Surveillance Fundamentals Workshop from the Champlain Maternal-Newborn Regional Program (CMNRP)

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Introductions

October 2011 M.J. Trépanier 3

• Your name

• Your work

• How long you have

worked in obs.

• A question or issue

re: FHSL

Workshop Objectives

Discuss EFM risk management strategies

Review key principles of interpretation and classification of FHR characteristics

Discuss how a tool can enhance interprofessional communication related to fetal health surveillance

Practice clear, accurate and clear documentation of FHR characteristics


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A few review questions re: Intermittent Auscultation (IA)…

WHAT women are candidates for (IA) in labour?

WHEN should we do IA?

HOW OFTEN (frequency)?

HOW should we auscultate?

WHAT can be assessed by IA?

WHAT cannot be assessed by IA?

WHAT should be interpreted/documented?

WHY should we auscultate?


A few review questions re: electronic fetal monitoring (EFM)…

WHAT women are candidates for (EFM) in labour?

WHEN should we do EFM?

HOW OFTEN (frequency)?

WHAT can be assessed by EFM?

WHAT cannot be assessed by EFM?

WHAT should be interpreted/documented?

WHY should we use EFM judiciously?


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EFM Risk Management

1. Use strategies to reduce or avoid preventable adverse outcomes

2. Decrease liability exposure through evidence of your awareness and attentiveness to fetal/maternal status Appropriate assessment

Clear communication and documentation

Timely interventions


Practice standardization

Standardized terminology and definitions for fetal monitoring (NICHD, 2008)

Standardized classification of FHR characteristics (SOGC, 2007)

National standards, guidelines, best practice guidelines (MOREOB, CAPWHN, RNAO, etc.)

Clear and up-to-date hospital policies


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Overview of Fetal Health Surveillance Classification

and Definition of Terms

© CMNRP 2011

EFM in Challenging Clinical Situations

©CMNRP 2011 10

Systematic Approach to Tracing Interpretation

CHECK: Tracing quality, paper speed, graph range, internal VS external?

INTERPRET: Uterine Activity Pattern Baseline FHR Baseline Variability Presence of Accelerations & Decelerations

Correlate findings with clinical situation: Normal, Atypical, Abnormal

Document

(SOGC, 2007)

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©CMNRP 2011 11

Paper speed - 3 cm/min

©CMNRP 2011 12

Uterine Activity Assessment

Frequency (in minutes)

Duration (in seconds)

Intensity (mild, moderate, strong)

Resting tone (soft, firm)

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©CMNRP 2011 13

Baseline FHR

Definition: approximate mean FHR rounded to 5 bpm increments in a 10-minute segment, excluding: periodic & episodic changes periods of marked FHR variability (> 25 bpm)

Must be present 2 minutes or is indeterminate

110-160 normal > 160 tachycardia < 110 bradycardia

(SOGC, 2007)

©CMNRP 2011 14

FHR Variability

• Definition: Fluctuations in baseline FHR 2 cycles per minute

• Irregular amplitude and frequency

• Visually quantitated as the amplitude of the peak-to-trough in bpm

120

150

180

90

120

150

180

90

Presence of variability is a crude

indicator of fetal oxygenation as it

reflects an intact CNS

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©CMNRP 2011 15

FHR Variability

ABSENT

MINIMAL

MODERATE

MARKED

Amplitude range undetectable

Amplitude range detectable but 5 bpm

Amplitude range 6-25 bpm

Amplitude range > 25 bpm

(SOGC, 2007)

©CMNRP 2011 16

Acceleration

Definition: Abrupt increase in FHR (onset

to peak in < 30 seconds) 15 bpm above baseline lasting 15 sec.

Before 32 weeks: 10 bpm for 10 sec. Prolonged acceleration is 2 minutes Acceleration 10 minutes is a baseline

change NORMAL finding

Accelerations are a sympathetic response indicating an intact,

oxygenated CNS

(SOGC, 2007)

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©CMNRP 2011 17

Variable Deceleration

Definition: Abrupt decrease in FHR (onset

to peak in < 30 seconds) that is 15 bpm below the baseline for 15 sec., and < 2 minutes from onset to return to baseline

When periodic, their onset, depth and duration commonly vary with successive contractions

Can be NORMAL, ATYPICAL or ABNORMAL

120

150

180

90

120

150

180

90

100

25

50

75

0

100

25

50

75

0

Reflex response to cord compression during or between

contractions (SOGC, 2007)

©CMNRP 2011 18

Complicated Variable Decelerations

Deceleration <70 bpm >60 sec.

Loss of variability of baseline and in the trough

Biphasic deceleration

Overshoot (20 bpm increase by 20 seconds

Slow return to baseline

Continuation of baseline rate at a lower level than prior to the deceleration

Presence of tachycardia or bradycardia

(SOGC, 2007)

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©CMNRP 2011 19

Late Deceleration

Definition: Gradual decrease in the FHR (onset to peak in 30 seconds) associated with a contraction

Onset, nadir & recovery occur after the beginning, peak & end of contraction

ATYPICAL or ABNORMAL

120

150

180

90

120

150

180

90

100

25

50

75

0

100

25

50

75

0

Chemoreceptor & vagal response to utero-placental insufficiency ,

reflecting marginal fetal oxygenation

(SOGC, 2007)

©CMNRP 2011 20

Prolonged Deceleration • Visually apparent decrease in FHR below baseline, > 15

bpm, lasting > 2 minutes, but < 10 minutes from onset to return to baseline

• Decrease calculated from the most recently determined portion of baseline

• Prolonged deceleration > 10 min is a baseline change

• ABNORMAL

Chemoreceptor, baroreceptor & CNS

responses to profound changes in

fetal environment

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©CMNRP 2011 21

Classification of EFM Tracings

Previous Reassuring Non-reassuring

New Normal Tracing Atypical

Tracing

Abnormal

Tracing

Action EFM may be

interrupted for

≤30 min. if

maternal-fetal

condition stable

+/or oxytocin rate

stable

Further

vigilant

assessment

required,

especially when

combined

features

present.

URGENT

ACTION

REQUIRED

Obtain scalp

pH if

appropriate

/prepare for

delivery.

(SOGC, 2007)

©CMNRP 2011 22

Parameter

NORMAL Tracing

Baseline

110-160 bpm

Variability

6-25 bpm

<5 for < 40 min.

Decelerations

None or occasional uncomplicated

variables or early decelerations

Accelerations

Spontaneous accelerations present

Accelerations present with fetal scalp

stimulation

(SOGC, 2007)

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©CMNRP 2011 23

Parameter

ATYPICAL Tracing

Baseline

Bradycardia 100 - 110 bpm

Tachycardia >160 for >30 min to

< 80 min.

Rising baseline

Variability

<5 for 40 - 80 min.

Decelerations

Repetitive (≥ 3)uncomplicated variable

decelerations

Occasional late decelerations

Single prolonged deceleration > 2 min.

but < 3 min.

Accelerations

Absence of acceleration with fetal scalp

stimulation

(SOGC, 2007)

©CMNRP 2011 24

Parameter

ABNORMAL Tracing Baseline Bradycardia < 100 bpm

Tachycardia >160 for >80 min.

Erratic baseline

Variability

<5 bpm for > 80 min.

>25 bpm >10 min.

Sinusoidal

Decelerations

Repetitive (>3) complicated variables:

- deceleration to < 70 bpm for > 60 secs.

- loss of variability in trough or in baseline

- biphasic decelerations

- overshoots

- slow return to baseline

- baseline lower after deceleration

- presence of tachycardia or bradycardia

• Late decelerations > 50% of contractions

Single prolonged deceleration > 3 min but <10 min

Accelerations Usually absent

(SOGC, 2007)

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©CMNRP 2011 25

GOALS: Improve uterine blood flow Improve umbilical circulation Improve oxygen saturation Reduce uterine activity

INTERVENTIONS: •Change position •Give O2 per mask ? •Decrease/discontinue oxytocin •Temporary increase IV rate •Support woman / family •Communicate / Document

Intrauterine Resuscitation

©CMNRP 2011 26

Responses to Atypical and Abnormal FHR

Consider total clinical picture

Further assessments to identify potential causes (maternal, fetal, placental) and to assess fetal well-being Fetal scalp stimulation

Fetal scalp sampling

Clinical actions to: ◦ Remove aggravating condition(s)

◦ Institute intrauterine resuscitation techniques

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©CMNRP 2011 27

Normal U.A. Acid-Base Values Normal Ranges Criteria

for concern

pH 7.27 7.20 - 7.34 < 7.0

pCO2 50.3 39.2 - 61.4

HCO3 22.0 18.4 - 25.6

BD 2.7 5.5 - 0.1 12

(Riley, 1993) (SOGC, 2007)

©CMNRP 2011 28

Respiratory Acidosis

Retained CO2 (diffusion impaired - e.g. cord

compression) pH carbonic acid Carbonic acid is rapidly excreted across

placenta (if blood flow restored) Fetus may have a 1-minute Apgar score

but will respond to O2 and stimulation ◦ pH low < 7.20 ◦ pCO2 high > 60 ◦ HCO3

- normal 18 - 25 ◦ B.D. normal 0 to 5.5

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©CMNRP 2011 29

pH low < 7.20 pCO2 normal 40 - 60 HCO3

- low < 18 B.D. high > 12

Base excess/deficit is the BEST measure of metabolic acidosis

Metabolic acidosis

©CMNRP 2011 30

Mixed Acidosis

carbonic acid and lactic acid

◦pH low < 7.20

◦pCO2 high > 60

◦HCO3- low < 18

◦B.D. high > 12

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DOCUMENTATION


Fundamental principle of documentation

Notes must provide a comprehensive picture of patient care

◦ To support professionals’ answers to questions raised at deposition or trial, often many years later!


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Documentation Standards (CNO, 2008)

Records must be an accurate, true and honest account of WHAT occurred and WHEN it occurred

Documentation method should allow information to be organized in such a way that it presents a clear picture of: ◦ client’s needs ◦ nurse’s actions based on needs assessment ◦ outcomes and evaluation of those actions

• Proper, standard terminology

• Systematic approach

• User-friendly flow charts to:

– ensure clarity, completeness & consistency

– decrease charting time

• Avoid double-charting

• Follow institution policies / standards

Documentation principles

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CLEAR documentation

Contemporaneous

Logical

Explicit

Accurate

Readable


Documentation should include:

• Date & time of care/event & recording

• Who provided the care

• Meaningful information (avoid meaningless phrases such as "usual day")

• What was observed (avoid statements such as "seems to" , " appears to")

• Signatures / initials & professional designation

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Documentation content

• Assessments, interventions, evaluations – Subjective (statements/feedback from client in " ")

– Objective (observed/measured, actions, etc)

• Communication with care providers: – Who was called, and time of call

– Information reported and request(s) made

– Care provider’s response (or refusal to come in)

– Agreed-upon plans of action

– Outcomes

• Third-party information (family member, etc)

• Client’s non-compliant or risk-taking behaviour

If LATE ENTRY needed…

Should include:

• Notation that it is a "Late Entry"

• Date and time of entry

• Reason for late entry

• Signature & professional designation

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2008 © PPPESO 39

Avoiding legal pitfalls

How to chart

• Stick to the facts

• Avoid labeling

• Be specific

• Use neutral language

• Eliminate bias

• Keep the record intact

What to chart

• Significant situations

• Complete assessment data

• Plan of care

• Discharge instructions

2008 © PPPESO 40

Documentation tools

Narrative notes • Chronological account of client status,

interventions & client’s responses

• However, can be lengthy, time-consuming & repetitive

• Useful to chart: – Changes in client’s condition

– Client’s response to treatment/medication

– Client’s or family member’s response to teaching

– Communications with other health care providers

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2008 © PPPESO 41

Documentation tools

Integrated Progress Notes • Advantage: every member of health care team

can document in chronological order.

• Contain narrative information that doesn’t easily fit into flowsheets. – Date & time of entry

– Client’s condition

– Interventions

– Client’s response to care

– Changes in client’s condition

– Evaluation of interventions

2008 © PPPESO 42

Documentation tools

Flowsheets

• Document routine care & frequently recorded information

• Allow quick & concise charting at time care given

• Enable to evaluate client trends at a glance

• Less time-consuming to read and more legible

• Reinforce standards of care

• When using initials, need a master list matching initials to caregivers

• Check marks () OK, as long as it is clear who provided the care

• Must be consistent with progress notes!

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Example of Intrapartum Flowsheet

(CMNRP, 2010)

Documentation tools

What documentation tool are you using in your institution?

What are the most common problems related to documentation? ◦ Ways to overcome these?

If you were to review your notes in 10 years, would you consider your documentation CLEAR?


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"If it’s not charted, it wasn’t done"

…. REALLY???

No real legal basis for this

Many interventions regularly done that are never documented

Various ways to provide evidence of clinical care: ◦ Medical record

◦ Sworn testimony about recollection of events

◦ Sworn testimony of routine, common or standard clinical practice (customary practice)


Frequency of documentation

Every 5, 15, 30, 60 minutes???

What’s the right frequency? Again, common sense to provide credible

evidence of attentive care: ◦ Whenever patient is examined

◦ When significant interventions are done

◦ Whenever a substantical change in progress or condition occurs


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Frequency of documentation (cont’d)

Specific time intervals should be based on acuity level and may vary based on individual patient status

Ex: 2nd stage assessments q 5 min. is documentation required q 5 min.?

Hospital protocols should outline nursing assessment standards with reasonable frequencies for documentation


Communication

What makes communication effective?

What are the barriers to good communication?

What are the risk management issues related to poor communication?


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The CHAT/SBAR Tool (adapted from MOREOB)

How and when to use the CHAT Tool


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Listen carefully…



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Communication exercises

Person #1: ◦ Looks at tracing / interprets it

◦ Prepares report on CHAT tool

◦ Provides CHAT report to Person #2

Person #2: ◦ Listens to report

◦ Draws FHR characteristics on tracing, as described by Person #1

◦ Discusses plan with Person #1


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Tracing 1


Tracing 2


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Tracing 3


Tracing 4


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Consultations

To obtain confirmation,

new perspectives and insight

From fellow colleague with equal or advanced knowledge, training & expertise

Most important aspect is determining who is the most responsible person(MRP) after the consultation has taken place

Document all consultations and the MRP

2008 © PPPESO 59

Collaborative Resolution or Escalation procedure

(formerly called Chain of Command )

If response from primary care provider is not timely, appropriate or safe: ongoing efforts must be activated to resolve the clinical disagreement, including notification of other members of the perinatal team who are in positions of authority to move the process forward successfully.

(Chez, Harvey & Murray, 1990;

Rostant & Murray, 1999;

Simpson, 2005)

2008 © PPPESO 60

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Think of a time when you disagreed with a colleague

about the plan of care.


What did you do?

Summary


Important to standardize interpretation and classification of FHR characteristics

CLEAR documentation is a key risk management strategy

Communication tool can enhance interprofessional communication related to fetal health surveillance

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Questions?


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