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OBSTETRICS

Intrapartum management of category II fetal heart ratetracings: towards standardization of careSteven L. Clark, MD; Michael P. Nageotte, MD; Thomas J. Garite, MD; Roger K. Freeman, MD; David A. Miller, MD;Kathleen R. Simpson, RN, PhD; Michael A. Belfort, MD, PhD; Gary A. Dildy, MD; Julian T. Parer, MD;Richard L. Berkowitz, MD; Mary D’Alton, MD; Dwight J. Rouse, MD; Larry C. Gilstrap, MD; AnthonyM. Vintzileos, MD;J. Peter van Dorsten, MD; Frank H. Boehm, MD; Lisa A. Miller, CNM, JD; Gary D. V. Hankins, MD

nterpretation and management of
There is currently no standard national approach to the management of category II fetalheart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Undersuch circumstances, it would be difficult to demonstrate the clinical efficacy of FHRmonitoring even if this technique had immense intrinsic value, since there has neverbeen a standard hypothesis to test dealing with interpretation and management of theseabnormal patterns. We present an algorithm for the management of category II FHRpatterns that reflects a synthesis of available evidence and current scientific thought. Useof this algorithm represents one way for the clinician to comply with the standard of care,and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.
Key words: fetal heart rate monitoring, neonatal encephalopathy, patient safety

I fetal heart rate (FHR) patterns duringlabor remains one of the most prob-lematic issues in obstetrics. Multiplebasic science investigations and clinicaltrials have been published since theintroduction of this technique in the late1950s.1-7 Unfortunately, this body ofwork has primarily served to raise morequestions than it has answeredeas amedical community, we seem to knowless than we thought we did 30 years agoregarding the utility of this ubiquitoustechnique.

In recent years, several specific issuesrelating to the interpretation and man-agement of FHR patterns have receivedconsiderable attention in the medicalliterature. These include the lack ofagreement in interpretation even amongrecognized experts, the role of FHRpatterns as a primary driver of a risingcesarean rate, and the explosion oflitigation involving FHR patterns, de-spite the consistent absence of scien-tific evidence to support the contentionthat intervention based on any singleFHR pattern or combination of FHR

From the Hospital Corporation of America (Dr ClarkTN; Long Beach Memorial Hospital, Long Beach (D(Drs Garite and Freeman), University of Southern CofCalifornia, San Francisco (Dr Parer), CA;MercyHoof Medicine and Texas Children’s Hospital (Drs BelfoHouston, TX, and University of Texas Medical BranPresbyterian/Columbia University, New York (Drs BHospital, Mineola (Dr Vintzileos), NY; Brown UniverIsland, Providence, RI (Dr Rouse); Medical UniversiDorsten); and Perinatal Risk Management and Con

Received Jan. 21, 2013; revised March 27, 2013;

Management recommendations discussed in this ddo not necessarily reflect endorsement by affiliated

The authors report no conflict of interest.

Reprints not available from the authors.

0002-9378/$36.00 � ª 2013 Mosby, Inc. All rights reser

patterns in fact prevents cerebralpalsy or other types of neurologicimpairment.8-12

Against this background, however,there remains in many of us suspicion(albeit based primarily upon anecdotalexperience and the original basic scienceinvestigations) that at least a portionof the conflicting evidence regardingthe clinical utility of intrapartum FHRmonitoring results from ad hoc inter-pretation of terminology, and the lack ofstandardized protocols for managementand intervention based onwhat are often

) and Vanderbilt University (Dr Boehm), Nashville,r Nageotte), University of California, Irvinealifornia, Los Angeles (Dr Miller), and Universityspital, St. Louis,MO (DrSimpson); BaylorCollegert and Dildy) and University of Texas (Dr Gilstrap),ch, Galveston (Dr Hankins), TX; New Yorkerkowitz and D’Alton) and Winthrop Universitysity and Women and Infant’s Hospital of Rhodety of South Carolina, Charleston, SC (Dr vansultation Services, Portland, OR (Ms Miller).

accepted April 24, 2013.

ocument reflect the opinions of the authors. Theyinstitutions or organizations.

ved. � http://dx.doi.org/10.1016/j.ajog.2013.04.030

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challenging patterns. In a very real sense,the FHRmonitor is a medical device thatwas introduced into clinical practicewithout an instruction manual, withoutthe now common premarket testing tosupport the unrealistic expectationsof efficacy, and without clearly definedparameters for use. Under such cir-cumstances, it would be difficult todemonstrate clinical efficacy even of adevice with immense intrinsic value,since there has never been a standardhypothesis to test dealing with interpre-tation and management of abnormalpatterns. With respect to the assessmentof the clinical value of FHR monitoring,an evolving consensus exists in thematernal-fetal medicine community thatit is time to start over and establish somecommon language, standard interpreta-tion, and reasonable management prin-ciples and guidelines.13-19

A Eunice Kennedy Shriver NationalInstitute of Child Health and HumanDevelopment (NICHD) consensus panelin 2008 proposed a uniform system ofterminology inwhich any FHR pattern isclassified as category I, II, or III, based onthe presence or absence of well-definedaspects of the FHR.20 Once univer-sally adopted in clinical practice, these

merican Journal of Obstetrics & Gynecology 89

http://dx.doi.org/10.1016/j.ajog.2013.04.030

FIGURE 1Algorithm for management of category II fetal heart rate tracings

Yes

No

NoNo Yes No Yes

Yes Yes

No

No

Yes

Significant decelerations with ≥50% of contractions for 1 hour

Moderate variability or accelerations

Significant decelerations with ≥50% of contractions for 30 minutes

Latent Phase Active Phase Second Stage Observe for 1 hour

Normal labor progress Normal progress Persistent pattern

Manage per algorithmCesarean or OVDObserve ObserveCesarean Cesarean or OVD

OVD, operative vaginal delivery.

aThat have not resolved with appropriate conservative corrective measures, which may include supplemental oxygen, maternal position changes, intravenous fluid administration, correction of hypotension,reduction or discontinuation of uterine stimulation, administration of uterine relaxant, amnioinfusion, and/or changes in second stage breathing and pushing techniques.

Clark. Category II FHRT. Am J Obstet Gynecol 2013.

Clinical Opinion Obstetrics www.AJOG.org

definitions should serve as an importantfirst step in both the investigation of thesignificance of various FHR patterns,and the development of a uniformstandard of care in the interpretationand management of such patterns. Withthis in mind, subsequent recommenda-tions have been developed by theAmerican Congress of Obstetricians andGynecologists (ACOG) for the manage-ment of category I (normal) and cate-gory III (pathologically abnormal) FHRpatterns.20,21 Although useful, theserecommendations remain insufficientsince �80% of fetuses in labor demon-strate FHR patterns that fall into cate-gory II, patterns for which no specificACOG management recommendationsexist.21,22

The management of category II FHRpatterns remains the most importantand challenging issue in the field ofFHRmonitoring, and is arguably second

90 American Journal of Obstetrics & Gynecology

only to preterm birth as the mostpressing issue in clinical obstetrics. Inaddition, the overall cesarean deliveryrate exceeded 32% in the United States in2011, and exceeds 50% of all births insome US hospitals.23 While dystocia andprior cesarean delivery remain the lead-ing indicators for such surgical inter-vention, the presence of a category II orIII FHR in labor is a frequent indicationas well.11,24 For cesarean deliveries, thereis a wide variance in the reportedindications and their frequency, bothbetween hospitals and among membersof the medical staff practicing obstet-rics.24 Concern regarding FHR patternsis perhaps the indication that has thegreatest such variance; we believe thisobservation is directly related to theabsence of defined management pro-tocols for category II patterns.Accordingly, we present a suggested

algorithm for the management of

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category II FHR patterns (Figure 1)along with several important specificclarifications (Table). As outlined inFigure 1, it is reasonable to initiatemanagement of a category II FHRpattern with an assessment of variabilityand accelerations, thus allowing theclinician to immediately rule out thepresence of clinically significant meta-bolic acidemia. For nonacidemic fetuses,the focus then shifts to assessing thelikelihood of developing significantacidemia prior to delivery. While no al-gorithm can predict all cases of suddendeterioration due to sentinel events, evenwith category I FHR patterns, analysis ofthe frequency and nature of de-celerations and the progress in laborprovides the clinician with a reasonableapproach to such decision making(Figure 1).

With category II FHR tracings thatdo not exhibit moderate variability or

TABLEManagement of category II fetal heart rate patterns: clarifications for use in algorithm

1. Variability refers to predominant baseline FHR pattern (marked, moderate, minimal, absent) during a 30-minute evaluation period, as definedby NICHD.

2. Marked variability is considered same as moderate variability for purposes of this algorithm.3. Significant decelerations are defined as any of the following:

� Variable decelerations lasting longer than 60 seconds and reaching a nadir more than 60 bpm below baseline.� Variable decelerations lasting longer than 60 seconds and reaching a nadir less than 60 bpm regardless of the baseline.� Any late decelerations of any depth.� Any prolonged deceleration, as defined by the NICHD. Due to the broad heterogeneity inherent in this definition, identification of a prolonged

deceleration should prompt discontinuation of the algorithm until the deceleration is resolved.4. Application of algorithmmay be initially delayed for up to 30minutes while attempts are made to alleviate category II pattern with conservative

therapeutic interventions (eg, correction of hypotension, position change, amnioinfusion, tocolysis, reduction or discontinuation of oxytocin).5. Once a category II FHR pattern is identified, FHR is evaluated and algorithm applied every 30 minutes.6. Any significant change in FHR parameters should result in reapplication of algorithm.7. For category II FHR patterns in which algorithm suggests delivery is indicated, such delivery should ideally be initiated within 30 minutes of

decision for cesarean.8. If at any time tracing reverts to category I status, or deteriorates for even a short time to category III status, the algorithm no longer applies.

However, algorithm should be reinstituted if category I pattern again reverts to category II.9. In fetus with extreme prematurity, neither significance of certain FHR patterns of concern in more mature fetus (eg, minimal variability) or

ability of such fetuses to tolerate intrapartum events leading to certain types of category II patterns are well defined. This algorithm is notintended as guide to management of fetus with extreme prematurity.

10. Algorithm may be overridden at any time if, after evaluation of patient, physician believes it is in best interest of the fetus to intervene sooner.

FHR, fetal heart rate; NICHD, Eunice Kennedy Shriver National Institute of Child Health and Human Development.


www.AJOG.org Obstetrics Clinical Opinion

accelerations, but do exhibit patterns ofpersistent late or significant variabledecelerations, as defined in the Table,significant metabolic acidemia cannotbe excluded. Further, these decelerationpatterns signify the presence of physio-logic stresses that increase the riskof developing such acidemia. In suchcases, we recommend expeditious de-livery. Examples of the application ofthis algorithm are demonstrated inFigures 2-5. These examples assume thatthe 20-minute period shown in thefigures is representative of the 30-60minute observation period referred toin the algorithm. Should the patterneither improve or deteriorate during thistime frame, management should bechanged accordingly.

In assessing and implementing thisalgorithm, we wish to bring specificattention to a number of considerationswhich we consider to be particularlygermane.1. This algorithm follows the foun-

dational NICHD definitions andrecommendations.20,21

2. This algorithm should be un-derstood as a next step in the

development of management rec-ommendations for category II FHRpatterns. The effectiveness andassociated intervention rates of thisalgorithm may be further definedand refined in future studies.

3. Category II patterns identify fetusesthat may potentially be in somedegree of jeopardy but are either notacidemic, or have not yet developed adegree of hypoxia/acidemia thatwould result in neonatal encepha-lopathy.12,20,21 However, we believeone important goal of intrapartumcare is delivery of the fetus, whenpossible, prior to the development ofdamaging degrees of hypoxia/acid-emia. We offer this algorithm toassist the attending physician inaccomplishing this goal. We recog-nize that adherence to the algorithmcannot alter the course for an alreadyinjured fetus, or one that experiencesan unexpected catastrophic eventduring labor.

However, since any algorithmfor the management of category IIpatterns will apply to the majorityof fetuses during labor, the

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algorithm must also avoid unnec-essary intervention, and encouragevaginal delivery in women whoseFHR patterns suggest minimal riskof significant deterioration prior todelivery. We designed this algo-rithm with both goals in mind, butwith a primary focus on theavoidance of preventable injury.

4. The appropriateness of select con-servative attempts to relieve certaincategory II patterns is well estab-lished.25-29 However, valid scientificevidence affirming the effectivenessof such measures varies widely. Forexample, while amnioinfusion forrelief of oligohydramnios-associatedvariable decelerations is well sup-ported in the literature, no evidenceexists to support the efficacy ofmaternal oxygen administrationin commonly achievable concen-trations in increasing fetal tissueoxygenation, or in improving new-born outcomes regardless of oxygenconcentration.28,29 Nevertheless, anyof the commonly accepted ap-proaches to relief of abnormal FHRpatterns may be appropriately


FIGURE 2Tracing exhibits minimal to absent variability without decelerations, despite regular contractions

Medication effect has been excluded clinically as part of the initial period of intrauterine resuscitation attempts. While the fetus may have experienced

prelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus. However, since such

fetuses may not tolerate labor without sudden deterioration and demise, cesarean delivery would be appropriate, per algorithm, if pattern persists for

1 hour.



attempted in specific situations.Their effect should be apparentwithin 30 minutes of application(Figure 1). If theFHRtracing remainscategory II following these efforts, thealgorithm is applied to the patternobserved following these attempts attherapeutic intervention.

Attention should be given to theprompt elimination of excessiveuterine activity including tachysystoleor prolonged contractions, especiallywhen uterine stimulants (oxytocin orprostaglandin-containing agents) arebeing applied.30,31 Oxytocin infusionshould be reduced or discontinuedin the presence of excessive uterineactivity and a persistent category

FIGURE 3Tracing exhibits minimal to absent v

Per algorithm, expedited delivery is indicated rega



II FHR pattern.21 Acceptable ap-proaches to monitoring of uterineactivity are well described in availableliterature.30,31

5. Recent data suggest that no singlequantitative value of fetal arterialpH serves to define a point ofhypoxia-induced damage applicableto all fetuses.32 However, the litera-ture is consistent in its demonstra-tion that for any individual fetus,baseline variability and accelera-tions will reliably be depressedbefore the pH has reached a level ofacidemia associated with neurologicinjury for that fetus, regardless ofits quantitative value.33,34 Hencethis algorithm relies strongly on the

ariability and late decelerations occurrin

rdless of labor progress.

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presence of moderate baseline vari-ability or accelerations. In contrast,conflicting data exist regardingthe significance of variability withindeceleration nadirs.35,36 Variabilitywithin decelerations alone cannotbe reliably used to exclude fetalacidemia and accordingly is notaddressed in this algorithm.

6. FHR patterns cannot be inter-preted in isolation. Accordingly,we have incorporated labor prog-ress as described in traditionalterms (stage I latent phase, stage Iactive phase and second stage) intothis algorithm. This is of signifi-cance since the expected remaininglength of labor may influence

g with >50% of contractions

FIGURE 4Tracing exhibits moderate variability and accelerations, thus excluding clinically significant acidemia

Late decelerations represent protective cardiovascular response to contraction-induced reductions in fetal oxygenation. Per algorithm, if labor is

progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery, delivery would be

appropriate.



the likelihood of, and responseto, deterioration of category IIpatterns. A category II patternmay have a different indicatedmanagement when presenting inearly first-stage labor than anidentical pattern presenting in thelate second stage. We acknowledgerecent data suggesting that cesareandelivery based on classic definitionsof protracted active phase, arrest ofdilatation, or arrest of second-stagedescent alone may not be necessary,and that longer periods of obser-vation may yield lower interventionrates.10,37 However, data demon-strating the safety of these more

FIGURE 5Tracing exhibits moderate variability

Significant variable decelerations seen here sugges

Per algorithm, if labor is progressing normally in a

delivery, delivery would be appropriate.


conservative approaches in thepresence of persistent category IIFHR patterns are lacking. Forexample, we hesitate to recommendnonintervention for an arrest ofactive phase dilatation of 4 hours inthe presence of recurrent late de-celerations, even in the presence ofmoderate variability. The superbreliability of accelerations andmoderate variability in excludingany degree of hypoxia-related cen-tral nervous system depression orrisk of ongoing hypoxic injurywould allow observation of patternswith these features and adequatelabor progress regardless of the

and acceleration, thus excluding clinic

t umbilical cord compression during contraction, wh

ctive phase or second stage, careful observation w

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deceleration pattern (Figure 1).However, intervention in patientswith certain category II patternsand slow, but technically adequatelabor progression may also be anappropriate option.

7. Some well-defined features ofcategory II patterns (eg, fetal tachy-cardia or marked variability) arenot included in the algorithm-based decision tree for interven-tion. This does not signify that suchpatterns are innocuouseindeed, itmay be exactly these features of atracing that mandate considerationas a category II pattern, and the useof this algorithm. However, in such

ally significant acidemia

ich could, over time, lead to significant acidemia.

ould be appropriate. If the fetus is remote from



cases, it is our expectation thatother concerning patterns includedin the algorithmwill appear prior tothe need for intervention.

8. This algorithm is intended toaddress the challenge of progressiveintrapartum hypoxia/acidemia dueto the effects of labor contractionson a susceptible fetus. Neither this,nor any other management ap-proach to labor, will ever predict,or prevent, unexpected sentinelevents that may occur withoutwarning and rapidly change a FHRpattern from category II to categoryIII. In such situations, even themost expeditious response may beinsufficient to avoid neonatal en-cephalopathy and its sequelae.38,39

However, 2 clinical situations existin which category II patterns, whileexcluding ongoing hypoxia/acid-emia, may be harbingers of sentinelevents that may rapidly lead toprofound hypoxia. These condi-tions are vaginal bleeding sufficientto suggest possible placental ab-ruption, and any woman undergo-ing a trial of labor after a previouscesarean.40-42 In both cases, thisalgorithm does not apply, as expe-ditious cesarean delivery is oftenindicated based on the suddenappearance of decelerations in acontext (moderate variability andaccelerations) that would be other-wise reassuring.

9. This algorithm does not address theissue of prolonged deceleration,as defined by the NICHD. Thisdefinition is too broad to be clini-cally useful in isolation.20,21 A 121-second deceleration to 90 beats/minand a 9-minute and 59-seconddeceleration to 50 beats/min are,from a clinical standpoint, verydifferent, yet both are, by definition,prolonged decelerations. The situa-tions associated with prolongeddecelerations also greatly impactthe decision makingea prolongeddeceleration following an epiduralshould give rise to a completelydifferent set of management con-siderations than an identical patternin a woman laboring with a scarred


uterus.40,42,43 Such variations arelegion and cannot be adequatelyaddressed with a single algorithmeindeed, their rarity and physiologicheterogeneity probably precludemeaningful study as a group.We canonly comment that tolerance forsuch recurrent patterns remotefrom delivery ought to be smallunless the etiology is apparent andcan be promptly ameliorated.

10. The current NICHD classificationsystem uses the classic descriptionsof deceleration patterns initiallydeveloped by Kulbi and colleagues.1

However, because different types ofdecelerations have unique etiol-ogies, a given fetus may have >1pathologic process ongoing duringlabor. One example would be agrowth-restricted fetus with oligo-hydramnios demonstrating bothvariable decelerations secondary tocord compression and late de-celerations due to hypoxia duringcontractions based on uteropla-cental insufficiency. This may giverise to a less well-defined, hybridpattern of decelerationsefor exam-ple, late decelerations superim-posed upon variable decelerations.Because relatively benign variabledecelerations are visually moredramatic than the subtle, yet moreconcerning, late decelerations, thelatter may be easily overlooked.In such cases, the patient shouldbe managed with a focus on thelate, rather than the variable de-celerations. Such hybrid decelera-tion patterns differ from the morecommonly seen “atypical” variabledecelerations that have no correla-tion with fetal acidemia.35 It isimportant for clinicians to carefullyevaluate any atypical-appearingvariable decelerations in this light.

11. The algorithm presented authorizesjudgment in some situations be-tween cesarean delivery and opera-tive vaginal delivery. We wish toemphasize that operative vaginaldelivery is not universally appli-cable, but rather depends on thepatient meeting appropriate criteriafor vacuum or forceps, as well as

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operator expertise in use of thesetechniques.44,45 Because deliverybased on this algorithm will beprincipally driven by concern forfetal well-being, and because vari-able levels of expertise in operativevaginal delivery exist among prac-titioners, we anticipate that cesareandelivery will be the most commonprocedure elected in many situa-tions. In contrast to some types ofcategory III tracings in which theurgency of intervention may occa-sionally justify acceptance of somedegree of risk for trauma, the vastmajority of category II tracings inwhich delivery is indicated onlywarrant initiation of delivery within30 minutes of the decision fordelivery. A limited attempt at oper-ative vaginal delivery by an ex-perienced clinician may representoptimal care in some circumstances.However, the physician with limitedexperience in operative vaginal de-livery should not delay preparationsfor cesarean, nor persist in attemptsat operative vaginal delivery withoutprogressive descent with each con-traction. Without real expertise inoperative vaginal delivery, a deteri-orating category II FHRT will oftenbe best managed by prompt cesar-ean delivery.

12. The most vexing issue in the devel-opment of this algorithm was theissue of decreased vs absent vari-ability. We accept the accuracy ofdata concluding that FHR vari-ability must be absent to reliablyreflect a high degree of correla-tion with severe fetal acidemia.20,21

However, we caution against delay-ing delivery of a deteriorating FHRpattern because criteria indicatingprobable severe metabolic acidemiahave not yet been met. We havechosen to treat persistent minimaland absent variability as one for thefollowing reasons.
a. Variability cannot be considered
to be a strictly binary feature ofa FHR pattern. It is evident thata fetus with moderate vari-ability (thus excluding concur-rent fetal metabolic acidemia)


that devolves to a state of frankasphyxia and severe metabolicacademia with absent variabilityas a result of episodes of intra-partum hypoxia must first passthrough a stage of minimalvariability, unless the deteriora-tion is abrupt and catastrophic asseen in a sentinel event.

b. While it is possible for apparentvariability to be exaggeratedwith the use of a first-genera-tion external, ultrasound-basedheart rate monitoring device,autocorrelation techniques em-ployed with most currentmonitoring systems have mini-mized this tendency.46 Unfortu-nately erratic signal detection ortransient artifact may give rise toperiods of apparent “minimalvariability” that could be falselyreassuring to some cliniciansand lead to delay in delivery. Iftechnically feasible, the fetuswith a category II pattern andpoor FHR signal quality shouldbe monitored with a fetal scalpelectrode.

c. An external FHR monitor thatyields a consistent high-qualitytracing, or a continuous fetalscalp lead tracing, will generallyallow the qualified clinician todistinguish different degrees ofvariability, even in the presenceof classic late or variable de-celerations. Unfortunately, sucha determination may be ren-dered more difficult by many ofthe category II patterns actuallyencountered in clinical practice.Such difficulties are especiallycommon in the presence ofatypical variable decelerations,in which determination of re-turn to baseline may be difficult.In such cases, a “baseline”apparently exhibiting some de-gree of variability may in factstill be a part of a recoveringdeceleration.

With exceptional expertise, most ofthese situations can be appropriatelydelineated. However, that level of

expertise is not universal among prac-ticing obstetricians. Indeed, even amongrecognized experts there is significantinterobserver variation in the differen-tiation of FHR patterns with minimal vsabsent variability.9 A basic principle ofany safety protocol is the direction ofsuch guidelines to the least, not thegreatest expected level of user compe-tence. Thus, we have used moderaterather than moderate or minimal vari-ability as a defining reassuring feature ofour algorithm. While we acknowledgethat such a decision will lead to inter-vention in cases that, in hindsight, mightbe proven to be unnecessary, we believethat following the algorithm as writtenwill avoid preventable neurologic injurydue to lack of intervention for a categoryII FHR pattern, and will be associatedwith an appropriate intervention rate.Cases of fetal hypoxia/acidemia duringlabor due to unexpected sentinel eventsremain largely unpreventable.38,39

13. A fetus presenting with persistentminimal to absent FHR variabilityand absent accelerations butwithout significant decelerationsposes a significant diagnostic andmanagement dilemma. In many ofthese cases, such a pattern repre-sents preexisting central nervoussystem injury with marked meta-bolic acidemia. In other cases, in-trauterine events leading to theinjury may have resolved (eg, um-bilical cord compression) and thefetus will have recovered metaboli-cally, but not neurologically. Devel-opmental anomalies unrelated tohypoxia/acidemia may give riseto a similar picture. Although thebenefit of cesarean delivery inimproving neurologic outcome insuch fetuses has never beendemonstrated, these fetuses may beless likely to tolerate the additionalhypoxia and acidemia that accom-panies even normal labor withoutintrapartum demise. In the absenceof significant decelerations however,the clinician may be assured thatwhile the fetus may be damaged, it isnot being damaged. Under thesecircumstances, a limited period of

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observation is appropriate, and isembraced in the algorithm.

14. The algorithm presented here rep-resents a consensus of the bestthoughts of 18 authors regard-ing one reasonable approach tocategory II FHR patterns given ourpresent scientific understanding.All authors are highly experiencedclinicians with significant peer-reviewed research experience andpublications in the area of fetalevaluation. They also represent abroad geographic spectrum andexperience in both the academicand private practice worlds andrepresent the disciplines of medi-cine, nursing, and midwifery. Assuch, it is reasonable for cliniciansto utilize this algorithm in themanagement of category II FHRpatterns; compliance with this pro-tocol is one way to meet thestandard of care in the UnitedStates. Importantly, as with mostother areas of medicine, the estab-lishment of this algorithm as oneway to comply with the standardof care does not exclude the exis-tence of other equally acceptableapproaches. While the authors uni-formly agree on the appropriatenessof this model for any laboringpatient, each of us can think ofnumerous situations in which al-ternative approaches to any branchof the algorithm would be equallyacceptable.

15. This algorithm is supported byavailable clinical experience, a sub-stantial body of basic science evi-dence, and indirect clinical data.Given the current state of obstetricknowledge, we do not believe it ispossible to simultaneously eliminatepreventable fetal neurologic injuryand significantly reduce the cesar-ean delivery rate for abnormal FHRpatternseseveral decades of suchattempts have resulted in the cur-rent state of Brownian motionin which neither goal has beenmeasurably achieved. Our goal indeveloping this algorithm has beento fix one variable in this equationby presenting an algorithm, which if



implemented as one component ofgood obstetrical care, will assist theclinician in avoiding preventableintrapartum fetal hypoxia, meta-bolic acidemia, and hypoxic injurybased on failure to deliver in the faceof certain persistent category II FHRpatterns. Of course, as with anyset of recommendations, clinicalstudies directly applying this algo-rithm both retrospectively to largeseries of category II patterns, andprospectively to large populations,are needed to potentially improvethe efficacy of the algorithm, and tobetter ascertain the actual inter-vention rate associated with itsapplication. It is anticipated thatsuch studies may facilitate refine-ment of this basic algorithm toreduce the intervention rate withoutincurring preventable morbidity ormortality.

16. Wemake no claim of the superiorityof this algorithm over other ap-proaches that might have beendeveloped. We began with thepremise that standardization andsimplification of critical care pro-cesses are fundamental principlesof patient safety. In virtually anyhuman endeavor, particularly onethat relies on the performance ofmultiple team members in an effortto achieve an optimal result, stan-dardization will yield improved re-sults.47-50 As such, unless one idealapproach to care has been demon-strated to be superior to all others byvirtue of well-performed clinicaltrials, it is not necessary to demon-strate the superiority of one specificapproach over others that are, whenconsidered individually, likely tobe equivalent. Rather, the adoptionby the clinical care team of oneappropriate specific managementplan will, by virtue of standardiza-tion alone, yield results superiorto those achieved by randomapplication of several individuallyequivalent approaches. This is par-ticularly true at the facility level.47-50

For example, protocols used toguide the provision of cardiopul-monary resuscitation have not been


demonstrated to be superior to allothers in randomized clinical tri-als.51 Yet the near universal adop-tion of these standard approacheshas resulted in improved outcomesfor cardiac arrest patients. Such al-gorithms have, over time, also un-dergone modification due toadvances in clinical understandingbased on new data. It is alsoimportant to note that in thisinstance, our algorithm does notseek to replace any establishedmethodical approach to the man-agement of category II patterns.Rather, we suggest that this algo-rithm will be helpful in the currentclinical setting in the United Statesin which a lack of clear direction hasled to divergent decision makingregarding cesarean section for FHRabnormalities.24

Adoption of this algorithm for themanagement of category II FHR patternsby the clinician is one approach toachieving compliance with the currentstandard of care. Application of thealgorithm, along with the integrationof future evidence-based modificationsdriven by additional research, willprovide clinicians with a standardized,simple, rational, evidence-based, andnationally accepted approach to themanagement of category II FHRpatterns. -

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1. Kubli FW, Hon EH, Khazin AF, Takemura H.Observations on heart rate and pH in the humanfetus during labor. Am J Obstet Gynecol 1969;104:1190-4.2. Meyers RE. Two patterns of brain damageand their conditions of occurrence. Am J ObstetGynecol 1972;112:246-51.3. Martin CB Jr, De Haan J, van der Wildt B,et al. Mechanisms of late decelerations in thefetal heart rate: a study with autonomic blockingagents in fetal lambs. Eur J Obstet GynecolReprod Biol 1979;9:361-73.4. Lee ST, Hon EH. Fetal hemodynamicresponse to umbilical cord compression. ObstetGynecol 1963;22:553-62.5. Haverkamp AD, OrleansM, Langendoerfer S,et al. A controlled trial of differential effects ofintrapartum fetal monitoring. Am J ObstetGynecol 1979;134:399-412.6. Banta HD, Thacker SB. Costs and benefitsof electronic fetal monitoring: a review of theliterature. April DHEW publication no. (PHS)

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79-3245. Hyattsville, MD: National Center forHealth Services Research, US Department ofHealth, Education, and Welfare; 1979.7. Freeman R. Intrapartum fetal monitoringeadisappointing story. N Engl J Med 1990;322:624-6.8. Chauhan SP, Klauser CK,Woodring TC, et al.Intrapartum nonreassuring fetal heart ratetracing and prediction of adverse outcome:interobserver variation. Am J Obstet Gynecol2008;198:623.9. Blackwell SC, Grobman WA, Antoniewitz L,et al. Interobserver and intraobserver reliabilityof the NICHD 3-tier fetal heart rate inter-pretation system. Am J Obstet Gynecol 2011;205:375.10. Spong KY, Berghella V, Wenstrom KD,Mercer BM, Saade GR. Preventing the first ce-sarean delivery. Obstet Gynecol 2012;120:1181-93.11. Clark SL, Hankins GDV. Temporal anddemographic trends in cerebral palsy: factand fiction. Am J Obstet Gynecol 2003;188:628-33.12. American College of Obstetricians andGynecologists and American Academy ofPediatrics. Neonatal encephalopathy and cere-bral palsy: defining the pathogenesis andpathophysiology. Washington, DC: AmericanCollege of Obstetricians and Gynecologists;2003.13. Avres-de-Campos D, Bernardes J. Twenty-five years after the FIGO guidelines for the use offetal monitoring: time for a simplified approach?Int J Gynaecol Obstet 2010;110:1-6.14. The National Institute of Child Healthand Human Development Research PlanningWorkshop. Electronic fetal heart rate moni-toring: research guidelines for interpretation.J Obstet Gynecol Neonatal Nurs 1997;26:635-40. (and in Am J Obstet Gynecol1997;177:1385-90.)15. The Royal Australian and New ZealandCollege of Obstetricians and Gynecologists.Intrapartum fetal surveillance: clinical guidelines,2nd ed. Victoria, Australia: RANZCOG; 2006.16. The Royal College of Obstetricians andGynecologists. Clinical guidelines on intra-partum fetal surveillance. London: RCOG Press;2001.17. Liston R, Sawchuck D, Young D. Fetalhealth surveillance: antepartum and intrapartumconsensus guideline. J Obstet Gynaecol Can2007;29(Suppl):S3-56.18. Parer JT, Ikeda T. A framework for stan-dardized management of intrapartum fetal heartrate patterns. Am J Obstet Gynecol 2007;197:26.e1-6.19. Elliot C,Warrick PA,GrahamE,Hamilton EF.Graded classification of fetal heart rate tracings:association with neonatal metabolic acidosisand neurologic morbidity. Am J Obstet Gynecol2010;202:258.e1-8.20. Macones GA, Hankins GD, Spong CY, et al.The 2008 National Institute of Child Health andHuman Development workshop report on elec-tronic fetal monitoring; update on definitions,

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interpretation and research guidelines. ObstetGynecol 2008;112:661-6.21. American College of Obstetricians andGynecologists. Management of intrapartumfetal heart rate tracings: ACOG practicebulletin no. 116. Obstet Gynecol 2010;116:1232-40.22. Jackson M, Holmgren CM, Esplin MS, et al.Frequency of fetal heart rate categories andshort-term neonatal outcome. Obstet Gynecol2011;118:803-8.23. Hamilton BE, Martin JA, Ventura SJ. Births:preliminary data for 2011. Natl Vital Stat Rep61;5:1-20.24. Clark SL, Belfort MA, Hankins GDV, et al.Variation in the rates of operative delivery in theUnited States. Am J Obstet Gynecol 2007;196:526-7.25. Simpson KR, James DC. Efficacy of intra-uterine resuscitation techniques in improvingfetal oxygen status during labor. Obstet Gynecol2005;105:1362-8.26. Hofmeyr GJ. Amnioinfusion for potentialor suspected umbilical cord compression inlabor. Cochrane Database Syst Rev 2005;2:CD001182.27. Garite TJ, Simpson KR. Intrauterine resus-citation during labor. Clin Obstet Gynecol 2011;54:28-39.28. Haydon M, Gorenberg D, Nageotte M, et al.The effect of maternal oxygen administration onfetal pulse oximetry during labor in fetuses withnon-reassuring fetal heart rate patterns. Am JObstet Gynecol 2006;195:735-8.29. Dildy GA III, Clark SL. Effects of maternaloxygen administration on fetal pulse oximetry.Am J Obstet Gynecol 2007;196:13-6.30. Clark SL, Belfort MA, Saade GA, et al.Implementation of a conservative, checklistbased protocol for oxytocin administration:maternal and fetal outcomes. Am J ObstetGynecol 2007;197:480.e1-5.

31. Clark SL, Rice-Simpson K, Knox E,Garite TJ. Oxytocin: new perspectives on anold drug. Am J Obstet Gynecol 2009;200:35.e1-6.32. Shankaran S, Laptook AR, Ehrenkrantz RA,et al.Whole-body hypothermia for neonateswithhypoxic-ischemic encephalopathy. N Engl JMed 2005;353:1574-84.33. Clark SL, GimovskyML, Miller FC. The scalpstimulation test: a clinical alternative to fetalscalp blood sampling. Am J Obstet Gynecol1984;148:274-7.34. Nageotte MP, Gilstrap LC. Intrapartum fetalsurveillance. In: Creasy RK, Resnik R, Iams JD,et al., eds. Maternal-fetal medicine, principlesand practice, 6th ed. Philadelphia: Saunders;2009.35. Cahill AG, Roehl KA, Odibo AO,Macones GA. Association of atypical deceler-ationswith acidemia. Obstet Gynecol 2012;120:1387-94.36. Hamilton E, Warrick P, O’Keefe D. Vari-able decelerations: do size and shape matter?J Matern Fetal Neonatal Med 2012;25:648-53.37. Zhang J, Landy HJ, Branch W, et al.Contemporary patterns of spontaneous laborwith normal neonatal outcomes. Obstet Gynecol2010;116:1281-7.38. Martinez-Biarge M, Madero R, Gonzalez A,Quero J, Garcia-Alix A. Perinatal morbidity andrisk of hypoxic-ischemic encephalopathy asso-ciated with intrapartum sentinel events. Am JObstet Gynecol 2012;206:148.e1-7.39. Nageotte MP, vander Waal B. Achievementof the 30 minute standard in obstetrics. Can itbe done? Am J Obstet Gynecol 2012;206:104-7.40. Leung AS, Leung EK, Paul RH. Uterinerupture after previous cesarean delivery:maternal and fetal consequences. Am J ObstetGynecol 1993;169:945-50.

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41. Oyelse Y, Ananth CV. Placental abruption.Obstet Gynecol 2006;108:1005-16.42. American College of Obstetricians andGynecologists. Practice bulletin no. 115: vaginalbirth after previous cesarean delivery. ObstetGynecol 2010;116:450-63.43. Cheng SL, Bautista D, Leo S, Sia TH.Factors affecting fetal bradycardia followingcombined spinal epidural for labor analgesia.J Anesth 2013;27:169-74.44. Hankins GD, Uckan E, Rowe TF, Collier S.Forceps and vacuum delivery: expectationsof residency and fellowship training programdirectors. Am J Perinatol 1999;16:23-8.45. Yeomans ER. Operative vaginal delivery.Obstet Gynecol 2010;115:645-53.46. Boehm FH, Fields LM, Hutchison JM,Bowen AW, VaughnWK. The indirectly obtainedfetal heart rate: comparison of first- and second-generation electronic fetal monitors. Am JObstet Gynecol 1986;155:10-4.47. Clark SL, Belfort MA, Meyers JA, et al.Improved outcomes, fewer cesarean deliveriesand reduced litigation: results of a new paradigmin patient safety. Am J Obstet Gynecol 2008;199:105.e1-7.48. Clark SL, Meyers JA, Frye DK, Perlin JA.Patient safety in obstetrics: the HospitalCorporation of America experience. Am JObstet Gynecol 2011;204:283-7.49. Institute of Medicine. To err is human:building a safer health care system.Washington,DC: National Academy Press; 2000.50. Institute of Medici Medicine. Crossing thequality chasm: a new health system for the 21stcentury. Washington, DC: National AcademyPress; 2001.51. Field JM, Hazinski MF, Sayre MR, et al. Part1: executive summary; 2010 American HeartAssociation guidelines for cardiopulmonaryresuscitation and emergency cardiovascularcare. Circulation 2010;122(Suppl):S640-56.





























































































































LWW/JPNN JPN200167 April 22, 2011 16:57

Continuing EducationJ Perinat Neonat Nurs � Volume 25 Number 2, 180–192 � Copyright C© 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

DOI: 10.1097/JPN.0b013e31821643c6

Electronic Fetal Heart Rate MonitoringWhere Are We Now?

Bonnie Flood Chez, RNC, MSN; Suzanne McMurtry Baird, RN, MSN

ABSTRACTElectronic fetal heart rate monitoring (EFM) continues tobe the primary method utilized for fetal assessment in theUnited States. Standardization of nomenclature associatedwith this perinatal technology has evolved over the past40 years such that the current nomenclature recommendedby the National Institute of Child Health and Human De-velopment (NICHD) has been adopted by professionalperinatal organizations as the agreed-upon method forprofessional communication and documentation. Currentresearch continues to focus on the optimal managementof intrapartum fetal heart rate tracings. The clinical contro-versies and challenges related to electronic fetal heart ratemonitoring continue to evolve.

Key Words: electronic fetal heart rate monitoring,management, NICHD, nomenclature

Electronic fetal heart rate monitoring (EFM) forantepartum and intrapartum evaluation of fetalstatus has been utilized for the last 40 years. It

continues to be the most commonly used adjunct in thecare of the approximately 4.2 million women who givebirth in the United States each year.1

It is not possible to consider where we are now re-garding EFM without an appreciable understanding ofwhere we have been. As such, a brisk walk throughEFM history is integral to the celebration of the Journalof Perinatal and Neonatal Nursing’s 25th anniversaryissue regarding this subject. This brief review will fo-cus on the historical highlights of the clinical applica-tion of EFM and discuss present and future expectations

Author Affiliations: Nursing Education Resources, Tampa, Florida(Ms Chez); and Vanderbilt School of Nursing, Nashville, Tennessee(Ms Baird).

Corresponding Author: Bonnie Flood Chez, RNC, MSN, 3203Bayshore Blvd. #402 Tampa, FL. 33629 ([email protected]).

Submitted for publication: February 17, 2011; Accepted for publication:February 17, 2011

for EFM regarding the following: nomenclature systemsthat have been proposed and adopted over time, inter-pretation and documentation of data derived from EFM,research related to management algorithms that havebeen proposed for consideration to further identify thefetus who has a greater likelihood for the developmentof significant fetal acidemia, and recommendations re-garding selected issues in EFM.

EVOLUTION OF EFM NOMENCLATUREEarly work in EFM nomenclature focused primarilyon the research of 3 pioneer clinicians. In 1958, Ed-ward Hon, MD, developed a method for continuousfetal heart rate (FHR) recording and described 3 pat-terns of decelerations: early, variable, and late, whichwere related to head compression, cord compression,and uteroplacental insufficiency, respectively.2 Subse-quently, in 1963, Hon improved the quality of FHRrecording with the introduction of a fetal scalp elec-trode. Caldeyro-Barcia in 1966 defined the significanceof similar FHR decelerations, named them type 1 andtype II “dips,” and proposed, for the first time, the con-cept of long- and short-term variability.3 Also, in 1966,Hammacher first suggested that neonates demonstratingFHR late decelerations had lower Apgar scores after de-livery and a higher stillbirth rate.4 Finally, in 1969, Ham-macher linked FHR accelerations to fetal well-being andfurther proposed a slightly different definition of vari-ability but focused more on the significance of its as-sociation with the term “fetal distress.”4 Each of theseresearchers published reports on their respective obser-vations of FHR patterns over years of study. As interna-tional interest grew, the first International Conferencesfor common nomenclature were convened in New Jer-sey in 1971 and in Amsterdam in 1972, where generalagreement was accepted for a common nomenclaturefor periodic changes (early, late, and variable).4

Fast forward to the next chapter in the EFMnomenclature discussion. In an effort to improve

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180 www.jpnnjournal.com April/June 2011


Table 1. Definition of terms: NICHD 1997 (Ref 5)

Acceleration: A visually apparent abrupt increase (defined as onset of acceleration to peak in <30 seconds) in FHR(fetal heart rate) above the baseline. The increase is calculated from the most recently determined portion of thebaseline. The acme is ≥15 bpm above the baseline, and the acceleration lasts ≥15 seconds and <2 minutes fromthe onset to return to baseline. Before 32 weeks of gestation, accelerations are defined as having an acme ≥10 bpmabove baseline, and a duration of ≥10 seconds. Prolonged acceleration is of duration ≥2 minutes and <10 minutes.Accelerations of ≥10 minutes in duration is a baseline change.

Baseline (FHRB): The approximate mean FHR rounded to increments of 5 bpm during a 10-minute segment,excluding periodic or episodic changes, periods of marked FHR variability or segments of the baseline, which differby >25 bpm. In any 10-minute window, the minimum baseline duration must be at least 2 minutes; otherwise, thebaseline for that period is indeterminate.

Baseline fetal heart rate variability: Fluctuations in the baseline FHR of 2 cycles per minute or greater. Thefluctuations are irregular in amplitude and frequency and are visually quantitated as the amplitude of thepeak-to-trough in bpm as follows:• Amplitude range undetectable—absent FHR variability• Amplitude range > undetectable ≤ 5 bpm—minimal FHR variability:• Amplitude range 6–25 bpm—moderate FHR variability• Amplitude range >25 bpm–marked FHR variability

Bradycardia: Fetal heart rate baseline less than 110 bpm for at least 10 minutes.Decelerations

Early deceleration (early): A visually apparent gradual decrease (defined as onset of deceleration to nadir ≥30seconds) and return to baseline FHR associated with a uterine contraction. The decrease is determined from themost recently determined portion of the baseline. The nadir of the deceleration occurs at the same time as thepeak of the contraction.

Late deceleration (late): A visually apparent gradual decrease (defined as onset of deceleration to nadir ≥30seconds) and return to baseline FHR associated with a uterine contraction. The decrease is determined from themost recently determined potion of the baseline. The deceleration is delayed in timing, with the nadir of thedeceleration occurring after the peak of the contraction.

Prolonged deceleration: A visually apparent decrease in FHR at least 15 bpm below the baseline, lasting ≥2minutes but <10 minutes from onset to return to baseline.

Variable deceleration (variable): Visually apparent abrupt decrease (defined as onset of deceleration to beginningof nadir <30 seconds) in FHR below the baseline. The decrease in FHR (below the baseline) is at least 15 bpmbelow the baseline, lasting ≥15 seconds and ≤2 minutes from onset to return to baseline.

Periodic pattern: FHR changes, either accelerations or decelerations from the baseline lasting less than 10 minutes.Tachycardia: baseline FHR greater than 160 bpm lasting for 10 minutes or longer.

communication between physicians and nurses respon-sible for the interpretation of EFM data, updated termi-nology and a new category system of assessment wereintroduced in the mid-1990s as a result of meetings withinvited subject matter experts convened to discuss theissue. This initiative evolved from the Eunice KennedyShriver National Institute of Child Health and HumanDevelopment (NICHD) workshops whose goals wereto develop standardized definitions for use in the in-terpretation of FHR tracings generated from continuousEFM. Their recommendations for FHR terminology werepublished in 1997 and are defined in Table 1.5

This nomenclature has since been endorsed bythe American College of Obstetricians and Gynecolo-gists, the Association of Women’s Health Obstetric andNeonatal Nurses, and the American College of NurseMidwives.6–9

Several years later, in 2004, the Joint Commissionissued Sentinel Event Alert No. 30, July 21, 2004: Pre-venting infant death and injury during delivery. Itspecifically recommended that institutions should de-

velop clear guidelines for fetal monitoring of potentialhigh-risk patients, including protocols for the interpre-tation of fetal heart rate tracings and educate nurses,residents, nurse midwives, and physicians to use stan-dardized terminology to communicate abnormal fetalheart rate tracings.10

A new NICHD workgroup (NICHD II) convened in2008.11 This group reviewed, affirmed, and refined theearlier EFM terminology for FHR decelerations notedin Table 1. The definition of sinusoidal FHR (a visuallyapparent, smooth, sine wavelike undulating pattern inthe FHR with a cycle frequency of 3 to 5 per minute,which persists for 20 minutes or more) was added toprevious descriptions and is depicted in Figure 1.

Pseudosinusoidal patterns were not defined. In addi-tion, this group categorized FHR patterns for interpre-tation in clinical practice into 3 categories, which aredepicted in Table 2. This 3-tiered nomenclature systemutilizes categories I, II, and III to describe tracings thatrange from “normal” (category I), which is thought torule out fetal metabolic acidemia, to the opposite end


The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 181


Table 2. Guideline: Fetal heart rate and uterine activity monitoring4−9,11,12,14

Level: InterdependentGuideline objectives• Define FHR (fetal heart rate) patterns for visual interpretation that have been produced from either a direct fetal electrode

detecting the fetal electrocardiogram or an external Doppler device detecting the fetal heart rate events with use of theautocorrelation technique.

• Define parameters for auditory assessment of the FHR in low-risk women during childbirth.• To provide a format for evaluation of FHR patterns in context with gestational age, prior results of fetal assessment,

medications, maternal medical, and fetal conditions (eg, growth restriction, known congenital anomalies, fetal anemia,arrhythmia, etc).

• Outline the management of FHR information obtained from auditory and/or electronic fetal monitoring assessments.I. Methods of fetal heart rate monitoring

A. Auscultation—Generally involves intermittent assessment of the FHR and may be accomplished by Doppler, ul-trasound transducer, or fetoscope. The FHR is auscultated for a full 60 seconds and the rate is counted in beatsper minute. If the patient is in labor, the FHR is auscultated before, during, and after a uterine contraction at theappropriate time intervals. Intermittent auscultation may not be appropriate for all pregnancies (eg, laboring womenwith “risk” factors).

B. Electronic fetal monitoring may be accomplished by the following 2 methods1. External appliances

a. Doppler ultrasound transducer permits evaluation of baseline FHR, baseline variability (FHRV), and the presenceor absence of periodic patterns.

b. Tocodynamometer permits evaluation of uterine contraction (UC) frequency and approximate duration. Intensityof the UC and resting tone must be estimated by abdominal palpation.

2. Internal appliancesa. Direct fetal electrode (FECG) detecting the fetal electrocardiogram permits evaluation of baseline FHR, FHRV

and the presence or absence of periodic patterns.b. Intrauterine pressure catheter (IUPC) permits evaluation of contraction frequency, intensity, duration and uterine

resting tone. Uterine activity may also be quantified by calculation of Montevideo units (MVU). Research indicatesthat 180–250 MVUs should allow normal progression along labor curves.

II. Assessment ParametersA. Auscultation

1. FHR assessment includes the following:a. Rate in beats per minuteb. Presence/absence of audible decelerations or accelerations

2. Uterine activity assessment may be completed at the time of FHR assessment and includes palpation of frequency,duration and intensity of uterine contractions, along with palpation of uterine resting tone.

3. 1:1 nurse to patient ratio should be providedB. EFM (Electronic fetal heart rate monitoring)—during intermittent or continuous EFM, the following parameters are

assessed:1. FHR

a. Baseline rateb. Baseline variabilityc. Presence/absence or periodic patterns (accelerations or decelerations)

2. Uterine activitya. Frequency, duration and intensity of uterine contractionsb. Uterine resting tone

III. Frequency of Assessment during the Intrapartum PeriodA. Auscultation

1. Active first stage of labor—every 15 minutes2. Second stage of labor—every 5 minutes

B. EFM“Low Risk” Status “High Risk” Status

Active phase Q 30 minutes Q 15 minutes

Second stage Q 15 minutes Q 5 minutes

IV. Interpretation of dataA. Auscultation

1. Reassuring FHRBaseline rate between 110 and 160 bpmPresence of audible accelerationsAbsence of audible decelerationsRegular rhythm (continues)




Table 2. (Continued )

2. Nonreassuring FHRAbnormal baseline rate <110 bpm or>160 bpmAudible decelerations with or withoututerine activityIrregular rhythm

B. EFM—3-tier systemCategory I Normal

√Strongly predictive of normal fetal acid base status at the time of obser-vation

Baseline rate 110–160 bpmBaseline FHR variability moderateLate or variable decelerations absentEarly decelerations present or absentAccelerations present or absent

Category II Indeterminate√

Not predictive of abnormal fetal acid-base status; not adequate evidenceto classify into category I or III

Bradycardia or tachycardia not accompanied by absent baseline variabilityMinimal or marked baseline variabilityAbsent baseline variability without recurrent decelerationsAbsence of induced accelerations after fetal stimulationRecurrent variable decelerations accompanied by minimal or moderate base-

line variabilityProlonged decelerationRecurrent late decelerations with moderate baseline variabilityVariable decelerations with other characteristics such as slow return to base-

line, overshoots or shouldersCategory III Abnormal

√Predictive of abnormal fetal acid base status at the time of observation

Absent baseline FHR variability and any of the following:Recurrent late decelerationsRecurrent variable decelerationsBradycardiaSinusoidal pattern

V. Management ConsiderationsA. Auscultation1. Normal FHR responses—Continue as-

sessment at appropriate intervals2. Indeterminate FHR responses—Initiate

continuous EFM. Further interven-tions are dependent upon subse-quent EFM assessment, diagnosis,gestational age of the fetus, and ma-ternal status.

B. EFM—3-tier systemCategory I ActionNormal Routine managementCategory II ActionIndeterminate Continue surveillance

Intrauterine fetal supportive techniques may include, but are not limited tomaternal lateral positioningmaternal oxygen administrationintravenous fluid bolus of 500–1000 mL Lactated Ringers solutionreduce uterine activity by decreasing or discontinuing uterine stimulants(eg, oxytocin, cervical ripening agents) if indicatedalleviate umbilical cord compression evidenced by variable decelerationsor FHR bradycardia with initiation of amnioinfusion, elevate presentingpart if indicated while preparing for operative deliveryIf no improvement or FHR tracing progresses to Category III, considerdelivery

(continues)




Table 2. (Continued )

Category III ActionAbnormal Prepare for delivery

Intrauterine fetal supportive techniquesVI. Consultation with the primary care provider should be considered for the

following:Significant maternal system assessment findingsSustained BP readings >140/90 or <80/40Sustained maternal heart rate >120 or <60Maternal temperature >100.4Vaginal bleeding greater than bloody showPain unrelieved by prescribed therapyImminent deliveryCord prolapseCategory II FHR patterns not resolved with intrauterine fetal supportivetechniquesCategory III/abnormal FHR patterns

VII. Patient/family educationPlan of careUnit routineMethod of fetal monitoringInterventions

of the spectrum (category III) with tracings consideredto be “abnormal” and most consistently associated withfetal acidemia.11

Category II is the largest of the 3 categories and rep-resents those patterns whose characteristics meet nei-ther category I nor category III criteria. As such, it is re-ferred to as “indeterminate,” because it is inconsistentlyassociated with fetal acidemia.11 Examples of each cat-egory can be found in Figure 2. While this 3-tieredtemplate addresses a majority of EFM categories, it isimportant to note that it does not specifically address

all patterns that may be seen in clinical practice or a“requirement” for the presence of accelerations of theFHR throughout labor.

The NICHD II committee further recommended thatdescriptive terms for uterine activity such as “hyper-stimulation” and “hypercontractility” not be used, be-cause both are imprecise and nonspecific. Rather, theterm “tachysystole” is recommended for use to describeuterine activity (contractions) that exceeds normal in-tervals (greater than 5 contractions in a 10-minutewindow, evaluated more than 3 consecutive 10-minute

Figure 1. Sinusoidal fetal heart rate.




Figure 2. Examples of category I, II, III fetal heart rate strips. A, Category I. Normal interpretation: Nor-mal baseline rate with moderate variability. B, Category II. Indeterminate interpretation: Fetal tachy-cardia with moderate variability and late decelerations. C, Category II. Indeterminate interpretation:Normal baseline rate, moderate variability with recurrent variable decelerations. D, Category III. Abnor-mal interpretation: Absent baseline variability with recurrent prolonged decelerations. E, Category III.Abnormal interpretation: Absent baseline variability with recurrent late decelerations.




Figure 2. (Continued)

windows).11 In addition, when tachysystole is identi-fied, an associated change or lack of change in the FHRshould be noted, as depicted in Figure 3.

Finally, decelerations are to be described in generalas “repetitive” if they occur with greater than 50% ofuterine contractions and “intermittent” if they occur withless than 50% of uterine contractions in any 20-minutewindow.11

CLINICAL MANAGEMENTDespite numerous attempts in the past 30 years by theobstetric community to define and classify EFM param-eters, interobserver variability remains with providersdebating interpretation and management of variouspatterns.12,13 In 2007, Parer and Ikeda identified 134FHR patterns, which were classified by baseline rate,baseline variability, and type of deceleration and evalu-ated each pattern for the risk of associated acidemia.The findings were color-coded such that green wasassociated with no threat of acidemia (no interven-tion required) to the color red suggesting a severethreat of acidemia (rapid delivery recommended).12 The

3 intermediate categories (blue, yellow, and orange)typify what is commonly encountered in clinical prac-tice as the largest population of patients, representedby NICHD category II, who may require escalating lev-els of potential intervention depending upon the FHRtracing assessment, and the logistics, facilities, and per-sonnel available.

In a recent publication, American College of Obstetri-cians and Gynecologists Practice Bulletin 116 reviewedthe management of heart rate patterns on the basis ofthe NICHD 3-tiered classification system and discussednot only the category designation, but also suggestedresponse(s) to tracings in each respective category asdescribed in Table 2.14 However, controversy remainsregarding management of category II patterns, whichrepresent approximately 80% of all variant patterns. Cat-egory II contains a broad spectrum of heterogeneousEFM patterns, based on variations in baseline rate, vari-ability, and decelerations, some of which cause higherconcern for the potential of fetal acidemia and progres-sion to category III. As such, absent further subdivisionof category II, management guidance remains impre-cise and vague leaving the management of category II




Figure 3. A, Uterine activity: Tachysystole: FHR: Category II. B, Uterine tachysystole: Fetal heart rate: Category III.




patterns up to the nurse and physician’s judgment.15

Therefore, some have questioned the 3-tiered system’sability to relate certain EFM patterns to degrees ofacidemia and fetal damage, and support the use ofa 5-tiered system with the subdivision of category IIpatterns.15 A similar system has been described and uti-lized in Japan.15

If there is a question or concern regarding interpre-tation and/or management of EFM tracings, providershave a clearly defined escalation policy (chain of com-mand) that may be followed to clarify interpretation andplan of care. Documentation regarding pattern specificintrauterine fetal supportive techniques implemented,the fetal response, and provider communication are in-tegral to this process. Lastly, a qualified provider, whocould intervene in case of an emergent situation andneed for rapid response, may be identified (eg, an ob-stetrician) and communicated to the attending staff.16

OTHER EFM CLINICAL CONSIDERATIONS

Signal ambiguityThere has been recent attention drawn to the conceptof signal ambiguity following unexpected outcome withexternal fetal heart rate monitoring. Improved sensitiv-ity of electronic fetal monitors has resulted in an un-derstandable decreased use of the internal fetal scalpelectrode and greater reliance on external transducers.As a consequence, rare cases have been reported inwhich the fetal signal has been replaced by an alter-native signal from the mother or a second (or more)fetus without the usual recognizable transition associ-ated with such signal source shifting as demonstratedin Figure 4.

Masking of the fetal condition, without attending staffbeing alerted to the loss of fetal signal has occurred withand without adverse fetal outcome. For example, mater-nal tachycardia may be present with excursions of thematernal heart rate depicted in the fetal heart rate rangedespite the fact that the fetus actually has an abnormalFHR. As well, a depiction of what appear to be FHRaccelerations during second stage labor bearing downefforts are most likely a representation of the maternalsignal as a result of the maternal Valsalva maneuver andnot that of the fetus (Figure 5 ). Because the fetal moni-tor’s internal logic determines which signal is displayedas fetal, and when the mother’s heart rate appears morelike that of the fetus, the logic may cause a switch inthe display.17

In addition, in a twin (or higher order) pregnancy,the monitor attempts to discriminate between multifetalheart rate signals and that of the mother. Examples ofclinical situations where there may be a question of fetalversus maternal signal origin commonly include second

stage labor with active pushing, use of beta mimeticmedications, maternal anxiety, and maternal fever. Topromote clinical confidence that the signal source isindeed fetal in origin, palpation of the maternal pulsein comparison to the FHR and/or ultrasound shouldbe considered. While there is neither evidence for norstandards supporting the practice for routine utilizationof additional technology such as placement of a fetalscalp electrode on the presenting fetus, maternal pulseoximetry monitoring or maternal electrocardiographicmonitoring, these modalities are available as adjunctsin situations of potential signal ambiguity.17

Artifact toleranceFetal surveillance via external means is frequently asso-ciated with periods of apparent absent tracing and/orartifact displayed on the tracing (despite the presenceof audible FHR data). This is a common clinical occur-rence and may result from maternal or fetal movement,in association with clinical intervention, transducer dis-placement, or electively as a result of the clinical deci-sion to allow undisturbed maternal rest.18 Occasionally,in medical-legal situations, the presence of what ap-pears to be absent FHR tracing or artifact is alleged torepresent the absence of clinician attention to monitor-ing of the FHR. In fact, this is often a clinical inevitabilityof external antepartum and intrapartum FHR monitor-ing that does not necessarily represent clinical disregardnor ability to audibly appreciate the FHR. The questionoften arises: How much artifact is acceptable to meet thestandard of care? To make this decision, providers relyon an evidence-based approach, which incorporatesexigencies of the individual clinical situation, clinicalexpertise, individualized needs of the woman, and cur-rent recommendations for best practice. Managementmay also be based on recent fetal surveillance, audi-ble findings, maternal/fetal risk status, stage of labor,gestational age, and/or medication use.

EFM of the preterm fetusMonitoring fetal status can present challenges when car-ing for women during preterm labor. One challengeis the routine physician/midwife order for “continuouselectronic fetal monitoring”. As previously discussed,the nurse may have difficulty maintaining a continuousFHR tracing due to fetal size in early gestation, activityof the fetus, maternal body habitus, or positioning. Theresulting signal loss requires frequent adjustments of ex-ternal monitoring devices; it increases acuity and maylimit maternal rest and comfort. In addition, stabilizationof the mother’s preterm labor status may occur and de-crease frequency of assessment requirements and theneed for continuous electronic fetal monitoring. Nurses




Figure 4. Maternal heart rate versus fetal heart rate. A, Fetal heart rate: Category II. B, Fetal heart rate:Category III. C, Conversion to maternal heart rate.




Figure 5. Signal ambiguity: Maternal heart rate: Second stage.

and physicians should construct a reasonable, individu-alized plan of care to balance maternal/fetal assessmentrequirements with maternal needs.

With the exception of accelerations, all other defini-tions of assessment parameters remain unchanged forthe preterm fetus. Before 32 weeks’ gestation, accel-erations are defined as having an acme greater than107nbsp;bpm above baseline, and a duration of greaterthan 10 seconds.5 Accelerations in the preterm fe-tus may also be less frequent.4 Therefore, time lim-its for nonstress testing may be extended up to 90minutes. Even though physiologic development allowsthe sympathetic nervous system to dominate until ap-proximately 28 weeks’ gestation, baseline FHR normalrange remains between 110 and 160 beats per minute.If fetal tachycardia occurs, providers should investi-gate potential causes such as hypoxia, maternal fever,intra-amniotic infection, or medication effects such asterbutabline.17

There is an increase in the occurrence of variabledecelerations in the preterm fetus, even in the absenceof uterine contractions. During labor and birth, there isan incidence of approximately 70% to 75% comparedto the term fetus of approximately 30% to 50%.19 Inthe presence of variable decelerations, the preterm FHRbaseline variability may decrease at a more rapid rate.The combination of both variable decelerations and ab-sent variability has been associated with lower Apgarscores and fetal acidosis at birth.20 However, it is im-

portant to note that the Apgar score was intended asan assessment tool in the term neonate and is not areliable indicator of metabolic acidemia in the pretermneonate.4

Medications given during episodes of preterm labormay influence observed FHR characteristics as well.Magnesium sulfate may cause a decrease in baselinevariability and fewer accelerations.21–23 Corticosteroidsmay cause increased fetal movement resulting in ac-celerations for up to 24 hours after administration.This may be followed by nonpathologic periods of de-creased fetal movement and accelerations during thenext 96 hours.24,25 Lastly, pain medications or sedativesfor sleep may decrease baseline variability and the oc-currence of FHR accelerations.

Monitoring multiplesThe increase in the incidence of multifetal gestationsover the last 20 years has intensified the clinical chal-lenge to electronically monitor multiple fetuses. Ap-proximately 5% of pregnancies among women aged 35to 44 years, and more than 20% of women aged 45 yearsand older (many due to the use of assisted reproductivetechnologies), result in multiple gestations.26 As previ-ously discussed, EFM attempts to discriminate betweenmultiple fetal heart rates. Ultrasound may be utilized tolocate each fetus and maximize the likelihood of secur-ing independent tracings. Designation of “Twin A” isusually for the fetus in the lowest portion of the pelvis.




Dual-channel electronic fetal monitors allow simultane-ous heart rate recordings, which display each FHR in adifferent color and/or one in a bold line and the otherin a faint line. Some electronic monitors utilize discrim-ination technology that uses printing of signal marks onthe tracing, separate monitoring scales, or artificial sep-aration of single-scale tracings into 2 separate tracings.27

Each FHR should be clearly labeled to correlate with themonitoring method and allow differentiation betweenor among fetuses to avoid the phenomenon of fetal syn-chronicity associated with monitoring multiples. Docu-mentation should include a description of each fetalheart rate tracing. There is no standard requiring sepa-rate EFM monitors to evaluate each fetus.

Interprofessional educationTraining to qualify providers for appropriate and consis-tent interpretation of EFM patterns should be standard-ized and cross all disciplines.23 Most clinical agenciesrequire nursing providers to attend continuing educa-tion courses or provide evidence of competency in EFMinterpretation and management. However, physiciansand midwives may not have the same requirement forcredentialing privileges. Providers may attend dissimi-lar education programs with differing curriculum andcourse faculty. The program may have a specific fo-cus for one group of providers. All of these scenariosincrease the likelihood for variances. From a patientsafety perspective, an interprofessional training pro-gram would standardize and increase knowledge, skills,and attitudes for interpretation and management of EFMpatterns. There are many interactive online EFM trainingprograms and certifications available.16 Agency-specifictraining provides opportunity for “team building” andenhanced provider communication. However achieved,comprehensive, uniform training that incorporates stan-dard terminology and management needs to occur.Demonstration of skills through simulation, testing, orcredentialing/certification; ongoing collaborative stripreview sessions; and mentoring may also be utilizedby some clinical agencies to advance or maintain skills.

SUMMARYElectronic fetal heart rate monitoring interpretation hasevolved now with standard, defined nomenclature forassessment parameters. Utilization of the defined termsacross all disciplines optimizes interprofessional com-munication and documentation. However, other chal-lenges in the interpretation of fetal heart rate monitoringdata remain such as electronic monitoring of pretermand multiple gestations, reconciling tracing artifact, andrecognizing maternal versus FHR in labor.

Electronic fetal heart rate monitoring interpretationand management, in the context of assessment of ma-

ternal status, is a multidisciplinary responsibility. Fu-ture NICHD task force recommendations will assist theprovider to determine management strategies for inde-terminate (category II) FHR patterns.

References1. Centers for Disease Control & Prevention (CDC). Births, Mar-

riages, Divorces, and Deaths: Provisional Data for 2009. Na-tional Vital Statistics Report. Vol 58. No. 25. Atlanta, GA: CDChttp://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_25.htm.Published August 2010.

2. Hon EH. The electronic evaluation of the fetal heart rate. AmJ Obstetr Gynecol. 1958;75:1215–1230.

3. Caldeyro-Barcia R, Mendez-Bauer C, Poseiro JJ, et al. Controlof human fetal heart rate during labor. In: Cassels D et al.,ed. The Heart and Circulation in the Newborn Infant. NewYork, NY: Grune & Stratton, Inc; 1966.

4. Freeman RK, Garite TJ, Nageotte MP, eds. Fetal Heart RateMonitoring. 3rd ed. Baltimore, Williams and Wilkins; 2003.

5. Electronic Fetal Heart Rate Monitoring: research guidelinesfor interpretation. National Institute of Child Health and Hu-man Development Research Planning Workshop. Am J Ob-stetr Gynecol. 1997;177:1385–1390.

6. American College of Obstetricians and Gynecologists. Intra-partum Fetal Heart Rate Monitoring. Practice Bulletin No.70.Washington, DC: American College of Obstetricians and Gy-necologists; 2005.

7. Lyndon A, Ali LU. eds. Association of Women’s Health, Obstet-rics and Neonatal Nursing Fetal Heart Monitoring: Principlesand Practices. 4th ed. Washington, DC: Kendall Hunt; 2009.

8. Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T.The 2008 National Institute of Child Health and Human De-velopment workshop report on electronic fetal monitoring.JOGNN. 2008;37(5):510–515.

9. American College of Nurse-Midwives. Position statement:standardized nomenclature for electronic fetal monitor-ing. Silver spring, MD: American College of Nurse-Midwives; 2008. http://www.midwife.org/siteFiles/position/Standardized NomenclatureforElectronicFetalMonitoring.pdf

10. The Joint Commission. Sentinel Event Alert, Issue No.30: Preventing Infant Death and Injury During Delivery.http://www.jointcommission.org/Sentinel_Event_Alert_Issue_30_Preventing_infant_death_and_injury_during_delivery_Additional_Resources/.

11. Macones GA, Hankins GDV, Spong CY et al. The 2008 Na-tional Institute of Child Health and Human Developmentworkshop report on electronic fetal monitoring. Obstet Gy-necol. 2008;12(3):661–666.

12. Parer JT, Ikeda T. A framework for standardized managementof intrapartum fetal heart rate patterns. Am J Obstetr Gynecol.2007;97:26.e1–26.e6.

13. Chauhan SP, Klauser CK, Woodring TC, Sanderson M, Mag-ann EF, Morrison JC. Intrapartum nonreassuring fetal heartrate tracing and prediction of adverse outcomes: inter-observer variability. Am J Obstetr Gynecol. 2008;199:623.e1–623.e5.

14. American College of Obstetricians and Gynecologists. Man-agement of intrapartum fetal heart rate tracings. Practice Bul-letin No. 116. Obstetr Gynecol. 2010;116:1232–1240.

15. Parer JT, King TL. Fetal heart rate monitoring: the next step?Am J Obstetr Gynecol. 2010;203(6):520–521.

16. Minkoff H, Berkowitz R. Fetal monitoring bundle. Obstet Gy-necol. 2009;114(6):1332–1335.

17. Simpson KR. Monitoring the preterm fetus during labor. MCNAm J Matern Child Nurs. 2004;29(6):380–388.




18. Neilson DR, Freeman RK, Mangan S. Signal ambiguity re-sulting in unexpected outcome with external fetal heart ratemonitoring. Am J Obstet Gynecol. 2008;198(6):717–724.

19. Westgren M, Holmquist P, Svenningsen NW, Ingemarsson I.Intrapartum fetal monitoring in preterm deliveries: prospec-tive study. Obstet Gynecol. 1982;60:99–106.

20. Westgren M, Holmquist P, Ingemarsson I, Svenningsen N.Intrapartum fetal acidosis in preterm infants: fetal monitoringand long-term morbidity. Obstetr Gynecol. 1984;63(3):355–359.

21. Atkinson MW, Belfort MA, Saade GR, Moise KJ Jr. Therelationship between magnesium sulfate therapy and fe-tal heart rate variability. Obstetr Gynecol. 1994;83(6):967–970.

22. Hiett AK, Devoe LD, Brown HL, Watson J. Effects of magne-sium on fetal heart rate variability using computer analysis.Am J Perinatol. 1995;2(4):259–261.

23. Wright JW, Ridgway LE, Wright BD, Covington DL, BobbittJR. Effect of MgSO4 on heart rate monitoring in the pretermfetus. J Reprod Med. 1996;41(8):605–608.

24. Rotmensch S, Liberati M, Vishene TH, Celentano C, Ben-Rafael, Bellati U. The effect of betamethasone on fetal heartrate patterns and biophysical activities: a prospective ran-domized trial. Acta Obstetr et Gynecol Scand. 1999;78(6):493–500.

25. Subtil D, Tiberghien P, Devos P, Therby D, Leclerc G, Vaast P.Immediate and delayed effects of antenatal corticosteroids onfetal heart rate: a randomized trial that compares betametha-sone acetate and phosphate, betamethasone phosphate, anddexamethasone. Am J Obstetr Gynecol. 2003;188(2):524–531.

26. American Society for Reproductive Medicine. Oversight of As-sisted Reproductive Technology. Birmingham, AL: AmericanSociety for Reproductive Medicine; 2010:4. http://www.asrm.org/uploadedFiles/Content/About_Us/Media_and_Public_Affairs/OversiteOfART%20%282%29.pdf. Accessed January 6,2011.

27. Bowers NA, Curran CA, Freda MC et al., High-risk pregnancy.In: Simpson KR, & Creehan PA et al., eds. AWHONN’s Peri-natal Nursing. 3rd ed. Philadelphia, PA: Lippincott Williams& Wilkins; 2008:259–260.

For more than 46 additional continuing education articles related toneonatal, go to NursingCenter.com/CE



Intrapartum FetalHeart RateMonitoring:A StandardizedApproach toManagement

DAVID A. MILLER, MD

Division of Maternal Fetal Medicine, Department of Obstetricsand Gynecology, Keck School of Medicine, Universityof Southern California, Children’s Hospital LosAngeles, California

Abstract: Recent advances in standardized fetalmonitoring nomenclature and interpretation make itpossible to construct a standardized approach tointrapartum fetal heart rate management that is evi-dence-based and reflects consensus in the literature.Key words: fetal monitoring, definitions, interpreta-tion, metabolic acidemia, fetal heart rate decelerations

A Standardized ManagementDecision ModelRecent advances in standardized fetalmonitoring nomenclature and interpreta-tion make it possible to construct a

standardized approach to intrapartumfetal heart rate (FHR) management thatis evidence-based and reflects consensusin the literature.1–9 The benefits of stan-dardization are addressed in detail else-where in this symposium. A commonmisconception is that standardized FHRmanagement is a ‘‘one-size-fits-all’’ ap-proach that removes individual clinicaljudgment and dictates the timing andmethod of delivery. On the contrary,standardized intrapartum FHR manage-ment is intended to encourage individualclinical judgment and to serve as a sys-tematic reminder of potential sources ofpreventable error in effort to optimizeoutcomes and minimize medicolegal risk.The model described in this chapter usesthe standardized FHR definitions andcategories proposed by the National

22 | www.clinicalobgyn.com

Correspondence: David A. Miller, MD, Division ofMaternal Fetal Medicine, Department of Obstetricsand Gynecology, Keck School of Medicine, Universityof Southern California, Children’s Hospital LosAngeles, 1300 North Vermont Avenue, Doctors’ TowerSuite 301, Los Angeles, CA. E-mail: [email protected]

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 54 / NUMBER 1 / MARCH 2011

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 54, Number 1, 22–27r 2011, Lippincott Williams & Wilkins

License # 3261670209004 Dated - Nov 3, 2013

Institute of Child Health and HumanDe-velopment (NICHD) in 2008.8 It does notinclude adjunctive tests of fetal statussuch as, fetal scalp blood sampling, fetalpulse oximetry, and fetal ST-segment ana-lysis that are currently unavailable forgeneral clinical use in the United States.These techniques are presented in detailelsewhere in this symposium.

Standard of CareThe standard of care mandates that prac-titioners provide patient care that is rea-sonable and prudent. Reasonableness, inturn, is determined by factual accuracyand the ability to articulate a thoughtfulplan. Standard definitions and interpreta-tion help to ensure factual accuracy. Astandardized approach to managementprovides a framework for structured, evi-dence-based planning that can minimize

variation, minimize potential error, andvery importantly, that can be articulated.

Confirm FHR and UterineActivityReliable information is vital to the successof intrapartum FHR monitoring. There-fore, the first step is to confirm that themonitor is recording the FHRand uterineactivity accurately (Fig. 1). If externalmonitoring is not adequate for definitionand interpretation, a fetal scalp electrodeand/or intrauterine pressure cathetermight be helpful. It is essential to distin-guish between maternal and FHRs.

Evaluation of 5 FHRComponentsThorough, systematic evaluation of aFHR tracing includes assessment of uterine

FIGURE 1. Standardized intrapartum fetal heart rate management model.

Intrapartum Fetal Heart Rate Management 23

www.clinicalobgyn.com

contractions along with the 5 FHRcomponents defined by theNICHD: base-line rate, variability, accelerations, decel-erations, and changes or trends in thetracing over time. The 2008 NICHD con-sensus report defined 3 categories of FHRtracings (Table 1).8 If all FHR compo-nents are normal (category I), the FHRtracing reliably predicts the absence offetal metabolic acidemia and ongoing hy-poxic injury. In low-risk patients,AmericanCollege of Obstetricians and Gynecolo-gists (ACOG) Practice Bulletin 106 andACOG-American Academy of PediatricsGuidelines for Perinatal Care recommendthat the FHR tracing should be reviewedat least every 30 minutes during the activephase of the first stage of labor and at leastevery 15 minutes during the secondstage.9,10 In high-risk patients, the FHRtracing should be reviewed at least every15 minutes during the first stage of laborand at least every 5 minutes during thesecond stage. Nursing documentationshould comply with hospital policies andprocedures. ACOG Practice BulletinNumber 106 Guidelines recommend that

provider documentation should be per-formed periodically.

The ‘‘ABCD’’ Approachto FHR ManagementIf assessment of all 5 FHR componentsindicates that the tracing is not category I,further evaluation is warranted. A prac-tical, systematic ‘‘ABCD’’ approach tomanagement is summarized in Table 2.(A) Assess the oxygen pathway and con-sider other causes of FHR changes: Ra-pid, systematic assessment of the pathwayof oxygen transfer from the environmentto the fetus can identify potential sourcesof interrupted oxygenation (Table 2). Inaddition, a number of factors can influ-ence the appearance of the FHR tracingby mechanisms other than interruption offetal oxygenation. If the FHR changes arethought to be due to any cause not directlyrelated to fetal oxygenation (Table 3),individualized management is directed atthe specific cause. (B)Begin correctivemea-sures as indicated: At each point along theoxygen pathway, conservative correctivemeasures are initiated, if indicated, tooptimize oxygen delivery (Table 2). Initia-tion of corrective measures should beguided by individual clinical judgment.For example, amnioinfusion may be ap-propriate in the setting of variable decel-erations, but would not be expected toresult in resolution of late decelerations.A systematic approach does not mandatethat all of these measures are used. Itsimply helps to ensure that importantconservative corrective measures are con-sidered and decisions are made in a timelymanner.

Reevaluate the FHR TracingIf, on reevaluation, the FHR tracing re-turns to category I, continued surveillanceis appropriate. If the FHR tracing pro-gresses to category III, delivery usually is

TABLE 1. Three-tier FHR ClassificationSystem

Category IFHR tracings include all of the following:Baseline rate: 110-160 bpmBaseline FHR variability: moderateAccelerations: present or absentLate or variable decelerations absentEarly decelerations present or absent

Category IIIncludes all FHR tracings not categorizedas category I or category III

Category IIIFHR tracings includeAbsent baseline FHR variability and

Recurrent late decelerationsRecurrent variable decelerationsBradycardia

Sinusoidal pattern

Adapted with permission from Obstet Gynecol. 2008;112:661–666.

bpm indicates beats per minute; FHR, fetal heart rate.

24 Miller


expedited. Tracings that remain in cate-gory II warrant additional evaluation. If acategory II FHR tracing shows moderate

variability and/or accelerations withoutclinically significant decelerations, con-tinued surveillance is reasonable (Fig. 1).

TABLE 2. ABCD Fetal Heart Rate Management

A B C D

Assess OxygenPathway

Begin Corrective

Measures ifIndicated*

Clear Obstaclesto Rapid Delivery

Determine Decisionto Delivery Time

Lungs AirwayBreathing

Supplementaloxygen

Facility OR availabilityEquipment

Response time

Heart Heart rate andrhythmCardiacoutput

Staff Consider notifyingObstetricianSurgicalassistantAnesthesiologistNeonatologistPediatricianNursing staff

Consider staffAvailabilityTrainingExperience

Vasculature Blood pressureVolumestatus

IV fluid bolusMaternalpositionchangesCorrecthypotension

Mother Informed consentIV accessAnesthesiaoptionsLaboratory testsBlood productsUrinary catheter

Surgical considerations(prior abdominal ofuterine surgery)Medicalconsiderations(obesity,hypertension,diabetes)

Uterus ContractionstrengthContractionfrequencyBaselineuterine toneUterinerelaxationtimeExcludeuterinerupture

Stop or reducestimulantConsideruterine relaxant

Fetus ConfirmEstimated fetalweightGestational agePresentationPosition

ConsiderEstimated fetalweightGestational agePresentationPosition

Placenta PlacentalseparationVasa previa

Labor ConfirmAccuratemonitoringAdequateuterine activity

ConsiderArrest disorderProtracted laborRemote fromdeliveryPoor expulsiveefforts

Cord Vaginal examExclude cordprolapsed

Consideramniofusion

Examples of clinical factors to be considered in a systematic manner. Institutions may modify according to individualcircumstances.

*Conservative corrective measures should be guided by clinical circumstances. For example, amnioinfusion may be appropriatein the setting of variable decelerations but would not be expected to result in resolution of late decelerations.

IV indicates intravenous; OR, operating room.



Category II tracings that do not meetthese criteria require further measures. Ifthere is any question regarding the pre-sence of moderate variability, accelera-tions or the clinical significance of anydecelerations, the most reasonable ap-proach is to take the next step in theABCD management model. (C) Clearobstacles to rapid delivery: If conservativecorrective measures do not result in mod-erate variability (and/or accelerations)and resolution of clinically significant de-celerations, it is prudent to plan ahead forthe possible need for rapid delivery. Thisdoes not constitute a commitment to aparticular time or method of delivery.Instead, it provides a systematic reminderof factors involved in the decision process.A practical approach includes review ofthe individual characteristics (from largeto small) of the facility, staff, mother,fetus, and labor (Table 2). Standardizedintrapartum FHR management does notmandate that each of these measures arecarried out. It simply provides a systema-tic checklist of factors to consider in orderto minimizing potential errors and to en-courage timely decision making. (D) De-cision-to-delivery time: After appropriateconservative measures have been imple-mented, it is sensible to take a moment toestimate the time needed to accomplish

delivery in the event of a sudden deteriora-tion of the FHR tracing. This can befacilitated by systematically consideringindividual characteristics of the facility,staff, mother, fetus, and labor (Table 2).The anticipated decision-to-delivery timemust be taken into consideration whenweighing the risks and benefits of contin-ued expectant management versus expe-ditious delivery.

TransitionManagement steps A, B, C, and D arelargely uncontroversial, are readily amen-able to standardization, and represent theoverwhelming majority of decisions thatmust bemade during labor.However, oncethey are exhausted, standardized intra-partum FHR management must transi-tion exclusively to individual clinicaljudgment.

DeliveryIf conservative measures are unsuccess-ful, the clinician must decide whether toawait spontaneous vaginal delivery or toexpedite delivery by other means. Thisdecision demands individual clinical judg-ment, weighing the estimated time untilvaginal delivery against the estimatedtime until the onset of metabolic acidemiaand potential injury. Information in theliterature is limited regarding the rate ofprogression of metabolic acidemia. Thetopic is reviewed in detail elsewhere in thissymposium. Retrospective data suggestthat, in the setting ofminimal-absent vari-ability and recurrent decelerations, meta-bolic acidemia can evolve over a periodof approximately 60 minutes, assumingthat the preceding tracing was normal.11

This process can occur much more ra-pidly, more slowly, or not at all, depend-ing on many factors, including thefrequency and duration of decelerations.Despite the paucity of data, a clinicaldecision must be made using the best

TABLE 3. Examples of Causes of FetalHeart Rate Changes Not DirectlyRelated to Fetal Oxygenation

MaternalFeverInfectionMedicationHyperthyroidism

FetalSleep cycleInfectionAnemiaArrhythmiaHeart blockCongenital anomalyPreexisting neurologic injuryExtreme prematurity

26 Miller


information available. The ultimate deci-sion may differ from case to case. How-ever, a standardized, systematic approachcan help ensure that management deci-sions are made in a timely manner and arebased, to the extent possible, on scientificevidence and consensus in the literature.The most important part of this step inFHRmanagement is to use discipline andindividual clinical judgment to make anddocument a plan.

ConclusionsRecent progress toward consensus inFHRmonitoringmakes it possible to con-struct a practical, standardized approachto FHR interpretation and management.The intrapartumFHRmanagementmod-el described in this article is not intendedto dictate actions that must be taken inresponse to specific FHR patterns. In-stead, it is intended to serve as a reminderof common sources of preventable errorand a reminder of actions that should beconsidered to ensure that managementdecisions are made in a timely manner.

References1. Electronic fetal heart rate monitoring:

research guidelines for interpretation.National Institute of Child Health andHuman Development Research PlanningWorkshop. Am J Obstet Gynecol. 1997;177:1385–1390.

2. American College of Obstetricians andGynecologists. Neonatal Encephalopathyand Cerebral Palsy: Defining the Patho-genesis andPathophysiology.Washington,DC: American College of Obstetriciansand Gynecologists; 2003.

3. MacLennan A. A template for defining acausal relation between acute intrapartumevents and cerebral palsy: international con-sensus statement.BMJ. 1999;319:1054–1059.

4. American College of Obstetricians andGynecologists. ACOG practice bulletin.Clinical management guidelines for ob-stetricians-gynecologists, number 70, De-cember 2005 (replaces practice bulletinnumber 62, May 2005). Intrapartum fetalheart rate monitoring. Obstet Gynecol.2005;106:1453–1461.

5. Association of Women’s Health, Obste-tric and Neonatal Nurses. Fetal HeartMonitoring: Principles and Practices. 3rded. Washington, DC: Association of Wo-men’s Health, Obstetric and NeonatalNurses; 2005.

6. Association of Women’s Health, Obste-tric and Neonatal Nurses. Fetal HeartMonitoring: Principles and Practices. 4thed. Washington, DC: Association of Wo-men’s Health, Obstetric and NeonatalNurses; 2009.

7. American College of Nurse-Midwives.Position Statement: Standardized Nomen-clature for Electronic Fetal Monitoring.Silver Spring MD: American College ofNurse-Midwives; 2006.

8. Macones GA, Hankins GD, Spong CY,et al. The 2008National Institute of ChildHealth and Human Development work-shop report on electronic fetal monitor-ing: update on definitions, interpretation,and research guidelines. Obstet Gynecol.2008;112:661–666.

9. American College of Obstetricians andGynecologists. ACOG Practice Bulletinnumber 106: intrapartum fetal heart ratemonitoring: nomenclature, interpretation,andgeneralmanagementprinciples.ObstetGynecol. 2009;114:192–202.

10. American Academy of Pediatrics. Amer-ican College of Obstetricians and Gynecol-ogists: Guidelines for Perinatal Care. 6thed.Washington,DC:AmericanAcademyof Pediatrics; 2007.

11. Parer JT, King T, Flanders S, et al. Fetalacidemia and electronic fetal heart ratepatterns: is there evidence of an associa-tion? JMatern Fetal Neonatal Med. 2006;19:289–294.



J Perinat Neonat Nurs � Volume 27 Number 2, 126–133 � Copyright C© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

DOI: 10.1097/JPN.0b013e31828ee7fe

A Collaborative Interdisciplinary Approachto Electronic Fetal Monitoring

Report of a Statewide Initiative

Lisa A. Miller, CNM, JD; David A. Miller, MD

ABSTRACTIntrapartum electronic fetal monitoring (EFM) is one of themost common procedures in obstetrics. Current consensusstatements provide clinicians with a common language forEFM as well as provide a basis for a simplified approachto interpretation and management. This article presents asummary of the content and implementation of a statewideinitiative in interdisciplinary EFM education and training de-signed to give clinicians of all backgrounds a shared mentalmodel in EFM. Challenges to implementation at individualinstitutions may include physician and nursing engagementas well as time and cost constraints.Key Words: education, electronic fetal monitoring, nurse-physician communication, patient safety

Implementation of perinatal patient safety initiativeshave resulted in improved outcomes, as evidencedby decreased incidence of obstetric adverse events

and improvements in safety culture1,2 as well as sig-nificant decreases in malpractice litigation.3−5 A fre-quent component of obstetric safety programs is train-ing in electronic fetal monitoring (EFM).6 Institutionalinterdisciplinary education in EFM has been shown toimprove teamwork and collaboration.7 Although therehave been a number of successful EFM education pro-

Author Affiliations: Perinatal Risk Management and EducationServices, Portland, Oregon (Ms Miller); and University of SouthernCalifornia Keck School of Medicine, Maternal Fetal Medicine Children’sHospital Los Angeles, CHLA-USC Institute for Maternal Fetal Health,Los Angeles, California (Dr Miller).

Disclosure: The authors have disclosed that they have no significantrelationships with, or financial interest in, any commercial companiespertaining to this article.

Corresponding Author: Lisa A. Miller, CNM, JD, Perinatal RiskManagement and Education Services, 2393 SW Park Place, Ste 310,Portland, OR 97205 ([email protected]).

Submitted for publication: January 28, 2013; accepted for publication:February 23, 2013.

grams instituted as part of patient safety initiativesfor various hospital systems, the focus of the pro-grams has primarily been training in standardized EFMdefinitions.1−5,7 This article reviews the developmentand implementation of a unique statewide collabora-tion to provide interdisciplinary training in a standard-ized approach to EFM definitions, interpretation, andmanagement. It focuses on 2 primary aspects: to show-case an exemplary model of EFM collaborative educa-tion that includes team interpretation/management andto share information on the implementation process.

BACKGROUND AND DEVELOPMENTNew York State’s Obstetric Safety Initiative: Providing Ex-cellence in Electronic Fetal Monitoring (Initiative) wasa statewide program of education, training, and follow-up that took place from December 2008 through March2011. The Initiative was the result of collaboration be-tween the American Congress of Obstetricians and Gy-necologists (ACOG) District II, the Healthcare Associa-tion of New York State, and the New York State Depart-ment of Health. It was funded by a grant from the NewYork State Health Foundation. The purpose of the Ini-tiative was to provide training and materials to interdis-ciplinary hospital teams on standardized EFM nomen-clature, interpretation, and management. These teams,once trained, were expected to return to their respectiveinstitutions and provide the standardized training to allobstetric clinicians—nurses, midwives, and physicians.For a full calendar year following the “train-the-trainer”sessions, participant trainers were provided with a vari-ety of support tools, including Web conferences, techni-cal assistance, email access to instructors for questions,and incentives in the form of funding for participationin the certification examination in EFM available fromthe National Certification Corporation (NCC).8



An interdisciplinary advisory committee and taskforce worked with hospitals throughout New York Stateto provide information about the Initiative and to ar-range locations and support services for 6 educationsessions in a variety of locations across the state. Thetrain-the-trainer sessions were 1.5 days in length andwere taught by an interdisciplinary team composed ofa perinatologist and a certified nurse-midwife. The ses-sions were all held in June and July of 2009, and alleducational follow-ups were completed by December2010. Close to 400 participants from 86 hospitals com-pleted the training sessions, more than half of whomwere nurses or nurse-midwives (see Figure 1). To par-ticipate, each hospital was asked to identify at least1 physician and 1 nurse trainer; most hospitals sent in-terdisciplinary teams averaging 4 clinicians. These clin-icians were selected specifically for the role of trainer,and these interdisciplinary teams were then responsiblefor the implementation of training at their home insti-tutions. This responsibility included both developmentand execution of educational plans designed to reachall clinicians within their particular hospital culture. The86 hospitals represented a majority of hospitals provid-ing obstetric care in the state of New York and werediverse geographically, in volume of annual deliver-ies, and in provider staffing (academic/nonacademic,laborists, midwifery, etc).8

COURSE STRUCTURE AND CONTENTCourse materials were developed by the faculty and re-viewed by the designated clinical advisors from the task

force. EFM education was based on the deconstructionof EFM evaluation into 3 simple, yet crucial, questionsfor every EFM tracing viewed by every clinician, regard-less of clinical background:

1. What do I call it? (definitions or nomenclature)2. What does it mean? (interpretation)3. What do I do about it? (management)

On the first day of training, the participants answereda series of multiple-choice questions using an anony-mous, interactive audience response system (ARS). Theparticipants were able to immediately see the correctanswer as well as the percentage of correct answersgiven by their peers in training. Figure 2 is a sample testquestion with answer data from one of the locations;a sample of self-assessment questions with correct an-swers highlighted is provided in the Appendix.

Surprising for most participants, there were few ARSquestions where even a simple majority chose the cor-rect answer, and the variation among incorrect answersmade it obvious that there was a significant knowledgedeficit. The mean percent of correct responses to allquestions was 49%.8 Following a discussion of the self-assessment results and a review of the common cogni-tive biases associated with both error and adult learning,participants reviewed the standardized definitions fromthe 2008 National Institute of Child Health and HumanDevelopment (NICHD) workshop report.9 The remain-der of the morning on day 1 of each training sessionfocused on a standardized approach to intrapartum EFMinterpretation and management.10

Figure 1. Distribution of participant trainers by discipline. Although each trainingsession had nurse-midwives as participants, not all participating hospitals hadnurse-midwives on staff, which accounts for the significantly lower percentage.



Figure 2. Sample audience response system self-assessment question. Correct answer is 4—“undetectable”.

Intrapartum EFM interpretation and management

The principles of EFM interpretation presented are il-lustrated in Figure 3 and are based on a standard-ized approach to EFM interpretation that recognizesthe relationship between late, variable, and/or pro-longed decelerations of the fetal heart rate (FHR) andinterruption of oxygenation. (see Figure 3, principle1). When interrupted oxygenation progresses, hypox-

Figure 3. Three principles of fetal heart rate inter-pretation. Standardized interpretation based onfetal oxygenation, fetal response to interruptedoxygenation, and fetal heart rate components.Figure provided courtesy of David A. Miller, MD.

emia can progress and eventually metabolic acidemiacan result. Although EFM has limited value in identify-ing the presence of fetal metabolic acidemia, there are2 characteristics of the FHR which, when present, serveto exclude the possibility of fetal metabolic acidemiaat the time they are seen—moderate variability and/orFHR accelerations9 (see Figure 3, principle 2). The abil-ity to exclude metabolic acidemia is significant becausemetabolic acidemia at birth is one of the essential cri-teria that links intrapartum fetal hypoxia with potentialhypoxic neurologic injury11 (see Figure 3, principle 3).For FHR tracing interpretation, these principles allowclinicians to answer 2 important questions: (1) Doesthe FHR tracing show evidence of interruption of theoxygen pathway? and (2) Can you rule out the pos-sibility of fetal metabolic acidemia? This standardizedapproach to FHR tracings allows clinicians of all dis-ciplines to approach EFM interpretation with a sharedmental model for interpretation.

The standardized management algorithm is illus-trated by Figures 4 and 5. Participant trainers weretaught to apply a simple series of questions and assess-ments based on the 3-tiered category system for FHRtracing classification from the NICHD. (see Figure 4)Category I tracings are managed with routine or height-ened surveillance (tracing review). Risk-based surveil-lance recommendations were based on the guidelinesfor perinatal care published by ACOG and the AmericanAcademy of Pediatrics12 and consisted of tracing reviewevery 30, 15, or 5 minutes depending on both stageof labor and patient risk profile (see Figure 4). Initialevaluation of tracings outside category I is facilitated bya checklist approach designed to (“A”) assess potentialcauses of interrupted oxygenation. Suspected interrup-tion of oxygenation was managed initially by (“B”) be-ginning conservative corrective measures as indicated.If conservative corrective measures failed to achieve thedesired results, the next steps included (“C”) clearingobstacles to delivery and (“D”) deciding on the timingof delivery13 (see Figure 5).

While the ultimate decision on delivery will likelyrest with the physician with surgical privileges, all par-ticipating trainers were educated regarding the nature ofdelivery decisions and the importance of a clear courseof action, whether that be continued surveillance orexpedited delivery.

Following the morning session, trainers worked insmall, randomized interdisciplinary groups to applythe standardized approach to definitions and interpre-tation with actual FHR tracings. Randomization wasachieved by assigning each participant a number thatcorresponded to a work group. This resulted in clin-icians of different backgrounds and from different in-stitutions working together without prior collaborative



Figure 4. Intrapartum FHR management decision model. Figure provided courtesy of David A. Miller, MD. FHRindicates fetal heart rate.

experience and thus reduced the possibility of biasor deference to opinion that may result from previ-ous work experience. The tracings were then reviewedand discussed by the entire group, and participants hadtime to ask questions and discuss variations in answers.Day 1 continued with a review of EFM documenta-tion issues including flow sheet and narrative charting,use of summary terms such as categories, and differ-ences between assessment, communication, and docu-mentation. Concluding day 1 was an interactive reviewin which trainers applied the principles of interpreta-tion as well as the management model to an actualEFM case.

Day 2: Training

The second day of training began with a repeat of theARS quiz that had been given on day 1. In all 6 loca-tions throughout New York State, participants on day2 performed significantly better than day 1, demonstrat-ing retention of content from day 1. The difference wasdramatic, with the average correct response to ques-tions on day 2 being 85%.8 The ARS assessment wasfollowed by a mock deposition session to illustrate the

importance of clinicians being comfortable with artic-ulating definitions, interpretation, and management ofEFM when questions regarding an obstetric team’s carearise. The remainder of the half-day program on day2 was a working session for the facility teams to re-view the training materials and strategize implementa-tion approaches with the help of faculty. All partici-pants received a copy of the course reference book,Mosby’s Pocket Guide to Fetal Monitoring: A Multidisci-plinary Approach, 6th edition; a ruler and pocket cardset designed to assist clinicians in applying the NICHDdefinitions and a laminated poster of the managementmodel. They were also provided with a USB drive witha faculty guide and PowerPoint modules trainers coulduse to teach standardized EFM at their home institu-tions. The faculty guide provided explanations of eachPowerPoint module with suggestions for use and imple-mentation. Participants were given a designated e-mailaddress for sending questions to the faculty. Facultysupport for trainers continued formally throughout thecalendar year following the final training session andin some cases has continued informally even after thecompletion of the project.



Figure 5. ABCD checklist for fetal heart rate management. Figure provided courtesy of David A. Miller, MD. ORindicates operating room; IUPC, Intrauterine Pressure Catheter.

IMPLEMENTATION APPROACHES ANDCHALLENGESHospitals and hospital systems were encouraged to en-gage in a variety of education and training approachesthat were suited to their particular environment, includ-ing online educational resources. Because the trainerscame from a wide variety of institutions, both academicand nonacademic, trainer teams worked together to de-termine the best strategies for their particular environ-ment. While Table 1 outlines the variety of teachingstrategies utilized, the majority of participating institu-tions (75%) offered classes on EFM using the teachingmodules provided by the course faculty. Many of theinstitutions used more than 1 approach to implementa-tion, and ACOG District II created an easily accessibleonline EFM eToolkit based on materials presented in thetraining sessions.14 The Initiative stressed the value ofinterdisciplinary EFM training as an avenue to improvecommunication15 and ensure a shared mental model,and more than half of the institutions (56%) followedthat recommendation.8

Implementation was not without challenges. Table 2provides a synopsis of the common issues reported

with program implementation. The 2 most frequentlycited challenges were physician engagement (56%) andtime constraints for training (40%). Interestingly, hos-pitals choosing to have nurses and physicians traintogether had less of a challenge with physician en-gagement than those training nurses and physiciansseparately. Although physician engagement was lessproblematic with interdisciplinary training, cost and

Table 1. Implementation approaches for

electronic fetal monitoring educationa

Implementation approaches %

Electronic fetal monitoring classes offered 75Presentations at nursing staff meetings 59Presentations at obstetric department meetings 52Provided resource packet for self-education 38Required nurses to take an online course 27Required physicians to take an online course 25Grand rounds presentation 23

aNote that many institutions used more than 1 of these strategies. FromHealthcare Association of New York State, American Congress of Obstetri-cians and Gynecologists, New York State Department of Health.8



Table 2. Reported implementation

challengesa

Reported implementation challenges %

Engagement of physicians 56Time constraints 40Staffing issues 29Costs of training 20Engagement of nursing staff 13

aHospitals seeking to implement standardized electronic fetal monitoring ed-ucation programs should be ready to deal with these common issues. FromHealthcare Association of New York State, American Congress of Obstetri-cians and Gynecologists, New York State Department of Health.8

time constraint issues were reported more frequently,as well as the issue of nursing engagement.8 Whilereasons for higher cost and time constraint issueswith joint nurse-physician training are fairly obvious(scheduling, educational space, etc), the reasons forincreased challenges with nursing engagement in theinterdisciplinary approach are not clear. Factors suchas nurse’s organizational status and the individual in-stitution’s organizational culture16 or institutional issueswith nurse-physician communication, including defer-ence to hierarchy,17 may provide some explanation; itis certainly a finding that deserves further exploration.

RESULTS AND LESSONS LEARNEDSeveral surveys and opportunities for follow-up test-ing were completed over the course of the Initiative,including EFM posttesting and use of an online safetysurvey, the Agency for Healthcare Research and Qual-ity Hospital Survey (AHRQ Survey). There were 3 EFMposttests administered to the participating trainers. Thefirst posttest occurred on day 2 of the educationaltraining programs, and the mean percent of correctresponses was 85% (100% response rate). Additionalfollow-up testing of trainers was voluntary and per-formed using an online survey at 6 and 18 monthsposteducation. At 6 months, the mean percentage ofcorrect responses was 80% (42% response rate). At18 months, the mean percentage of correct responseswas 84% (30% response rate).8 The posttesting defi-nitely showed both improvements in knowledge andretention of knowledge in the respondents participat-ing. The Initiative was limited by its voluntary nature,trainers were not required to participate in follow-up,and the response rate at 18 months was low, at 30%.To improve retention posteducation, individual hospi-tals undertaking standardization of EFM education maywant to mandate participation in follow-up testing ordevelop programs of annual EFM competency evalua-tion to ensure knowledge retention.

In addition to positive posttest results, there was asignificant increase in the number of participating hos-pitals that mandated EFM education and competencyassessment as a condition for clinical privileging andrecredentialing of providers from 23% in 2010 to 38%at the conclusion of the Initiative in March 2011.8 Al-though completion of the NCC certification examinationwas not mandated by the Initiative, it was presented asan option for competency assessment, and it appearsthat the Initiative increased EFM certification throughthe NCC. At least 510 clinicians of all backgroundscompleted the examination following the initial train-ing programs, with funding for 169 hospital-selectedindividuals provided by the Initiative. Among these,382 (75%) passed the examination,8 which is consis-tent with the mean national pass rate of 74% for 2009-2011.18

Sixty of the 86 participating hospitals utilized theAHRQ Hospital Survey to evaluate safety culture twiceduring the course of the Initiative, and althoughthe time frame between surveys was insufficient todemonstrate significant changes or trends, respon-dents overwhelmingly agreed on 2 points: the cul-ture of safety was enhanced by participation in theInitiative (96%) and interdisciplinary interactions andteamwork in EFM were enriched (95%). In addition,94% of participants surveyed reported practice im-provements as a result of participation in the Initia-tive, including better staff communication, use of theNICHD nomenclature during nurse-physician commu-nication, physician use of NICHD nomenclature fordocumentation, incorporation of cord-blood gas analy-sis, and implementation of the standardized interpreta-tion and management model presented during training.Only 6% of respondents reported no noticed practicechange.8

During follow-up Web conferences, participantswere encouraged to plan initiatives for ongoing qualityimprovement specific to EFM. The majority of surveyrespondents reported application of at least 1 processto evaluate and maintain EFM competency. Thesemethods included scheduled chart reviews, EFM trac-ing reviews at departmental meetings or during clinicalrounds, ongoing EFM posttesting, and the developmentof quality assurance and peer review related to EFM. Insupport of these efforts, ACOG District II developed anonline EFM eToolkit14 that offers educational materials,tutorials, and evaluation tools for EFM educationand training. In an effort to promote open access totools for quality improvement and education in EFM,these materials are available not just to participantsin the Initiative and ACOG District II members butthey are available to all clinicians who access theWeb site.



SUMMARYMore than 40 years ago, EFM was introduced into clin-ical practice without consensus regarding standard def-initions, interpretation, or management. Today, severalhighly publicized consensus statements make it pos-sible for clinicians to speak a common language andapproach EFM interpretation and management with ashared mental model. The statewide Initiative describedin this manuscript introduced a standardized approachto EFM that emphasized the central role of simplic-ity in improved communication, knowledge retention,and patient safety. It is crucial to recognize and ac-knowledge the fact that intrapartum EFM is an inter-disciplinary team endeavor involving nurses, midwives,and physicians with highly variable levels of experi-ence and expertise. As a team endeavor, intrapartumEFM requires dedicated, interdisciplinary team trainingto achieve optimal outcomes for the mothers and in-fants in our care.

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a comprehensive patient safety strategy on obstetric ad-verse events. Am J Obstet Gynecol. 2009;200:492.e1–492.e8.

2. Pettker CM, Thung SF, Raab CA, et al. A comprehensive ob-stetrics patient safety program improves safety climate andculture. Am J Obstet Gynecol. 2011;204(3):216.e1–216.e6.

3. Clark SL, Belfort MA, Dildy GA. Reducing obstetric litiga-tion through alterations in practice patterns. Obstet Gynecol.2008;112(6):1279–1283.

4. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Im-proved outcomes, fewer cesarean deliveries, and reducedlitigation: results of a new paradigm in patient safety. Am JObstet Gynecol. 2008;199:105.e1–105.e7.

5. Clark SL, Meyers JA, Frye DK, Perlin JA. Patient safety inobstetrics: the Hospital Corporation of America experience.Am J Obstet Gynecol. 2011;204(4):283–287.

6. Collins D. Multidisciplinary teamwork approach in labor anddelivery and electronic fetal monitoring. J Perinat NeonatalNurs. 2008;22:125–132.

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8. Healthcare Association of New York State, AmericanCongress of Obstetricians and Gynecologists, New YorkState Department of Health. Best practices in EFM def-inition, interpretation, and management—a statewidecampaign to standardize electronic fetal monitoring ed-ucation. Final report. May 2011. http://www.hanys.org/quality/clinical_operational_initiatives/obstetrics/docs/2011-05-17_elec_fetal_monitoring_grant_final_report.pdf. Ac-cessed January 25, 2013.

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18. NCC statistics for 2009–2011. http://www.nccwebsite.org/Certification/Statistics.aspx. Accessed January 25, 2013.



APPENDIX: Self-assessment questions withcorrect answers italicized

FHR

1. Absent variability is defined as . . .0-2 bpm< 0-3 bpm< 5 bpmUndetectable0

2. Parasympathetic stimulation . . .Causes marked variabilityCauses a decrease in FHRCauses an increase in FHRHas no effect on FHRResults in marked variability

3. Moderate variability is associated most specificallywith the absence ofAcute fetal hypoxemiaRespiratory acidemiaFetal metabolic acidemiaFetal hypoxiaFetal anemia

4. Late decelerations are an ominous signTrueFalse

5. Scalp stimulation is used to . . .Assess acid-base statusResolve FHR decelerationsBoth 1 and 2

6. Moderate FHR variability is defined as a range of6-15 bpm5-25 bpm> 10 bpm6-25 bpm

Abbreviation: FHR, fetal heart rate.



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