department of family medicine special thanks to dr. gary viner, dr. dave millar, dr. kristine...
TRANSCRIPT
Electronic Fetal Monitoring
Department of Family Medicinespecial thanks toDr. Gary Viner, Dr. Dave Millar, Dr. Kristine Whitehead, Nursing Care Facilitators & Champlain Maternal Newborn Regional ProgramJuly 2015
Family Medicine Obstetrics Orientation1FM Maternity Care - Resourceshttp://youtu.be/nizKRUv37lsHuman Labor and Birth, Oxorn - Foote, Sixth Edition Dr. Glenn Posner et al.SOGC Clinical Practice Guidelines, sogc.orgmyHospital -> Policies and Procedures -> Obstetrics, Gynecology and Newborn CareCmnrp.ca, Champlain Maternal Newborn Regional ProgramV-driveDFM Website UptodateOngoing teaching in the Units and at Academic DayLow Risk ObstetricsSession 1: Role in Obstetrical Triage & Birthing RoomTechnical SkillsFetal Health Surveillance Triage assessments
Session 2: Management of LaborHospital-based Postpartum Care
Session 3:OBS emergencies
Perineal repair: July 17, 2015 Academic Day
3ObjectivesDescribe FM residents role in intrapartum maternity care Review expected competencies and e-fieldnotesReview important skills & protocolsIntroduce Fetal Health Surveillance (FHS)Prepare for triage assessments
NB. this information is available on DFM website, including Mat and NB fieldnote
NEW in 2014 FIRST SHIFTS ARE WITH R2, BU walk through with Care Facilitator Day 14Intra-partum CompetenciesDiagnose SROMPerform accurate cervical assessmentManage labour / fetal surveillanceScalp electrode placementManage amniotomy & labour augmentationManage spontaneous vaginal deliveryManage obstetrical emergenciesParticipate in assisted vaginal deliveryPerform uncomplicated perineal repairCommunicate/collaborate effectively (patient,family, team)66
77
Mandatory RequirementsDemonstrate sufficient competency on the Maternity and Newborn Field Note (FN) from across the different pregnancy stages antenatal, intra-partum and post-partum skills.Effective 2014 - 2015:PGY1s: must demonstrate exposure to 80% of intrapartum, antenatal and postpartum competenciesPGY2s: must demonstrate attainment of 80% of intrapartum, antenatal and postpartum competenciesCompleted FNs should be completed electronically (eFN) or faxed immediately (fax no. bottom right corner of form)FM Resident OB SupervisorsMaternity & Newborn Field Note - can be completed by:Family Physicians Staff Obstetrician Senior OB/Gyn ResidentsObstetrical Nurses9New DFM Evaluation Policy:when no designated/continuous preceptorMaternity & Newborn Field notes (FNs): 1/day expectedRN &/or Ob-Gyn residents (>PGY2)60% of FNs must be staff MD (FMOB or OBGyn)name, role & PGY level (if resident) of evaluator MUST be clear or FN WILL BE DISCARDEDInitiated by Resident or assessor
FM Resident Role in ObstetricsSenior for FM-OB but Junior for OB serviceEnvironment provides opportunity to work with manySpecial role of OB Nurseappreciate different approachesWatch, Listen, Learn and Do!!
Communicate status of each patient to:Staff (OB, FM-OB) or Senior (OB resident)- on admission, prior to d/c or any significant intervention - q2-4h in labour- q1h when pushing11
At the start of each shift
Identify yourself to Care Facilitator (CF) or Team Leader (TL) Introduce yourself to RNs, staff OB, OB resident Write contact info on white board & link to your patients (white board at Nursing station and in patient room)
FM Resident to FM Resident handover 0700 weekdays and 0800 on Sat/Sun/holidays vitally important skill
Attend interdisciplinary rounds with team in AM and PM variable time, around 0745 and 1700Staff OB, OB ResidentCare Facilitator / Team Leader and NursingSometimes: med student, anesthesia, MFM
Meet your patients - review history & plan prior to entering the room, introduce yourself to patient and RN Name on whiteboard If patient is Family Practice patient/low risk, ask RN to call you for ALL assessments At OGH Interdisciplinary handover is 0745 at the CF desk Mon, Tue, Thurs and Friday. 0830 on Wednesdays and 0845 on Sat. and Sun. Evening handover is 1700 Mon-Fri and 2000 Sat/SunAt OCH Interdisciplinary handover is 0745 Mon, Tue, Friday and 0845 Wed and Thurs. Handover is 0800 on weekends. Evening handover is 1715 Mon to Thurs, 1615 on Friday and 2000 on weekends
Family Practice patients 1st priority: responsible for all assessments management of labor attendance at deliveries & newborn assessments involve staff FM-OB, NOT OB resident in plan of care
Also follow LOW RISK, term OB patients Include OB resident in plan of care (keeping them updated of changes) any concerns -> speak to OB resident first, then on-call staff Obstetrician prn
Keep CF/TL & census (white) board up to date
Check In with your patients progress at least Q2 hourly -write note after each assessment
Update the CF and supervising staff after each patient assessment. Discuss any concerns with the Family Physician or OBS resident. (i.e. slow progress, abnormal FHS, meconium etc.)
PROTOCOL: Active Management of Labor
Expect to be called for triage assessments maintain a high profile around the Nursing stationObstetrical AreasOAU Obstetrical Assessment Unit (Triage)Birthing Unit (BU/Case Room)Postpartum ward A4 OCH, 8E OGH1. Obstetrical Assessment Unit (OAU) = TriageAssess outpatientsPatient documentation required:History & Physical (RN supervised)AssessmentPlanReview with FMOB staff/OB senior or OB staffAll vaginal exams confirmed by RN initially
prior to OAU discharge of FM patient you must ALWAYS contact attending FM or OB resident/staff
Notify FM staff or OB resident of all admissions to the Birthing Unit 2. Birthing Unit Expectations Attend all low risk deliveries assist with clean up (discard sharps, count instruments) Complete L & D documentation and Birth Record Complete PP orders Sign Medication Reconciliation form Complete newborn exam (& documentation) and orders for FM babies
3. Postpartum CarePost Partum RoundsAfter birthing unit rounds ~08:30Patient lists from Ward Clerk on A4/8E both PP and newbornsSee, assess & 1st call for FM moms & babiesCommunicate with FM-OB Staff review concerns and before all dischargesMay assist with OB PP roundsReinforce newborn need for F/U 2 days after discharge PP care review/expectations in teaching session #2 and in-unit20Learning Opportunities! 1. Follow your patients through labor & birth (including C/S, if available) 2. Postpartum rounds/Newborn care 3. OB/gyn rounds Wednesday mornings 0730 4. Gyne (floor and ER) sometimes, as per OB resident 5. Medical students learn with them and teach them 6. Participate in MORE OB skills drills 7. Review TOH protocols/procedures on myHospital
Technical SkillsClinical Assessment:Abdominal Exam (Leopolds Maneuvers)Cervical Exam - confirmed by RN initiallyAssessment of SROM, vag/cx swabs prn, FFN prnARM amniotomyInduction -> Cervidil, foley catheterScalp ElectrodeAttend spontaneous vaginal deliveryPerform uncomplicated perineal repairApproach to assisted vaginal delivery and management of OBS emergencies221. Clinical assessment every patient (triage and BU)Introduce yourself to patient & supportsReview the antenatal recordsDevelop relationship, project secure/safe environmentCommunicate directly with patient and with RNDiscuss all patients with Senior OB resident, OB staff or FM staffNever discharge a patient without reviewing with staff
231. a) Leopolds Maneuvers
FirstSecondThirdFourthMartin, 2002Fundal GripUmbilical Grip fetal backPawlicks Grip presenting partPelvic Grip fetal browFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009241.b) Vaginal examWith RN supervision, with consent. Gently, avoid clitoris/urethra anteriorly1) CervixLocation of cervix vs. presenting part: posterior, mid-position or anteriorConsistencyEffacement/Length (avoid % - use cm)DilatationMembranes - ? bulging
251.b) Vaginal exam 2) Presenting PartVertex / breech / other?position261.b) Vaginal exam
Posterior fontanel: smaller fontanel - intersection of sagittal two lambdoid sutures.Anterior fontanel: larger fontanel - intersection of sagittal, frontal & two coronal sutures.
Occiput anterior positionsROALOAOA1.b) Vaginal exam
Occiput posterior position1.b) Vaginal exam
Occiput transverse positionsROTLOT1.b) Vaginal exam3) StationStation of presenting part should be positively determinedPelvis is divided into 5ths -5 to +5 (fetal head visible at the introitus)0station or spines usually represents engagement of the fetal head ( i.e. biparietal plane of the fetal head has passed through the pelvic inlet)
30
Assessing descent by vaginal examination -2 station: - leading bony edge of presenting part is 2cm above ischial spines 0 station: - head is engaged
1.b) Vaginal exam4) Pelvic ArchitectureAssess ischial spines, pelvic sidewalls & sacrum for adequacy
5) Amniotic Fluid AssessmentFerningNitrazine Clear or meconium?
321.b) Vaginal exam
NormalBacterial vaginosisPregnant woman with premature rupture of membranes. pH of vaginal discharge using nitrazine paperFalse + from blood, semen, urine, infection1.b) Vaginal exam
FerningPreferred test2. Technical Skills - ARMpractice
Amniohook354. Technical skills - Scalp electrode1) ensure continuous EFM is indicated
2) consider method of EFM: external vs. internalFetal vs. Maternal considerations
Technique practice this to be prepared!! (see session 2)
365.Technical skills Perineal RepairAcademic Day July 17, 2015Foam model simulation
6. Technical Skills - AVDAssisted vaginal deliveryIn hands-on workshops: session 3 (OBS emergencies)
39
FETAL HEALTH SURVEILLANCE
Fundamentals Workshop2009
Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009402009 PPPESO41Systematic Approach to InterpretationCHECK: Tracing quality, paper speed, graph range, internal vs. externalINTERPRET:Uterine Activity PatternBaseline FHRBaseline VariabilityPresence of Accelerations & DecelerationsCorrelate findings with clinical situation: Normal, Atypical, Abnormal (Reassuring or non-reassuring?)Document Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200941Highlight importance of methodological approach to interpretation.2009 PPPESO42
Paper speed - 3 cm/minFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009422009 PPPESO43Uterine Activity Assessment (contractions)Frequency (in minutes)Duration (in seconds)Intensity (mild, moderate, strong) by history and by palpationResting tone (soft, firm) by palpationFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200943RN can help resident learn how to palpate the uterine fundus2009 PPPESO44Baseline FHRDefinition: approximate mean FHR rounded to 5 bpm increments in a 10-minute segment, excluding:periodic & episodic changesperiods of marked FHR variability (> 25 bpm)Must be present 2 minutes or is indeterminate110-160 normal> 160 tachycardia< 110 bradycardiaFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009442009 PPPESO45FHR VariabilityDefinition: Fluctuations in baseline FHR 2 cycles per minuteIrregular amplitude and frequencyVisually quantitated as the amplitude of the peak-to-trough in bpm 1201501809012015018090Presence of variability is a crude indicator of fetal oxygenation as it reflects an intact CNSFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009452009 PPPESO46FHR VariabilityABSENT
MINIMAL
MODERATE
MARKEDAmplitude range undetectable
Amplitude range detectable but 5 bpm
Amplitude range 6-25 bpm
Amplitude range > 25 bpmFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009462009 PPPESO47FHR VariabilityMINIMAL VARIABILITY: 3-5 bpm
ABSENT VARIABILITY : 0-2 bpm
No distinction is made any longer between short-term variability (or beat-to-beat or R-R wave period differences in ECG) and long-term variability Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009472009 PPPESO48FHR VariabilityMODERATE VARIABILITY: 6-25 bpm
MARKED VARIABILITY: > 25 bpmFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009482009 PPPESO49AccelerationDefinition: Abrupt increase in FHR (onset to peak in < 30 seconds) 15 bpm above baseline lasting 15 sec.Before 32 weeks: 10 bpm for 10 sec.Prolonged acceleration is 2 minutesAcceleration 10 minutes is a baseline changeNORMAL finding
Accelerations are a sympathetic response indicating an intact, oxygenated CNSFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009492009 PPPESO50Early DecelerationDefinition: Gradual decrease in FHR (onset to peak in 30 seconds) associated with a uterine contractionOnset, nadir and recovery coincide with contractionNORMAL ie. reassuring120150180901201501809010025507501002550750Reflex vagal response associated withhead compressionFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200950Remind participants that these are uncommon, despite the fact that every babys head obviously gets compressed coming through the pelvis. Why dont we see these more often? Perhaps they are more common when the head is de-flexed, asynclitic or otherwise malpositioned. Not a lot of research into this
No acid-base complications UNLESS associated with nonreassuring baseline features
No interventions required for the early decels, however, look at the total clinical picture for lack of progress which might explain the difficulty of the head in maneuvering through the pelvis2009 PPPESO51Variable DecelerationDefinition: Abrupt decrease in FHR (onset to peak in < 30 seconds) that is 15 bpm below the baseline for 15 sec., and < 2 minutes from onset to return to baselineWhen periodic, their onset, depth and duration commonly vary with successive contractionsCan be NORMAL, ATYPICAL or ABNORMAL 120150180901201501809010025507501002550750Reflex response tocord compression during or between contractionsFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009512009 PPPESO52Variable Deceleration
Shoulders Overshoots NORMAL (REASSURING)ABNORMAL (NON-REASSURING)Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009522009 PPPESO53
Complicated Variable DecelerationsDeceleration 60 sec.Loss of variability of baseline and in the troughBiphasic decelerationOvershoot (20 bpm increase by 20 secondsSlow return to baselineContinuation of baseline rate at a lower level than prior to the decelerationPresence of tachycardia or bradycardia
Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200953532009 PPPESO54Late DecelerationDefinition: Gradual decrease in the FHR (onset to peak in 30 seconds) associated with a contractionOnset, nadir & recovery occur after the beginning, peak & end of contractionATYPICAL or ABNORMAL ie. Non-reassuring120150180901201501809010025507501002550750Chemoreceptor & vagal response toutero-placental insufficiency , reflecting marginal fetal oxygenationFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200954Stress to participants that late decels might be either reflex (and therefore probably correctable) and occasional or related to some sort of chronic problem (poor placenta, or hypertension affecting placental blood flow) that are repetitive and not likely correctable. This doesnt get documented, but helps care providers think about the likely success of their interventions.
For example, late decelerations associated with a healthy woman who happens to be positioned on her back are probably correctable. 2009 PPPESO55Prolonged DecelerationVisually apparent decrease in FHR below baseline, > 15 bpm, lasting > 3 minutes, but < 10 minutes from onset to return to baselineDecrease calculated from the most recently determined portion of baselineProlonged deceleration > 10 min is a baseline changeABNORMAL (Nonreassuring)
Chemoreceptor, baroreceptor & CNS responses toprofound changes in fetal environment Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009552009 PPPESO56Rare FHR changes
Sinusoidal pattern differs from variability in that it has a smooth, sine wave-like pattern of regular frequency and amplitude, and is excluded in the definition of FHR variabilityAssociated with fetal anemiaFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200956Is classified as an ABNORMAL findingIntermittent Auscultation (IA)Appropriate for low risk labor
Classification of NON STRESS TEST (NST)58Classification of EFM tracings
2009 PPPESO60Factors to consider wheninterpreting FHR characteristics Gestational age Fetal behavioral state External factors / influences Cause of decreased oxygen delivery Duration of precipitating causeThe overall clinical picture!Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200960Review each of these factors:QUESTIONS:What is the reason that we should consider each of the above stated factors?
2009 PPPESO61Responses to Atypical and Abnormal FHRConsider total clinical pictureFurther assessments to identify potential causes (maternal, fetal, placental) and to assess fetal well-beingFetal scalp stimulationFetal scalp samplingClinical actions to:remove aggravating condition(s)institute intrauterine resuscitation techniquesFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009612009 PPPESO62RECOMMENDATION:Digital Fetal Scalp Stimulation Recommended with atypical EFMGentle digital pressure over the parietal bonesMax 15 seconds between contractions and between decelsAcceleration usually = pH > 7.19 ( Murray, 2007)When a acceleratory response is absent: fetal scalp blood sampling where available (IIB)when unable to perform fetal scalp sampling, consider prompt delivery (IIIC)Fetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009622009 PPPESO63GOALS:Improve uterine blood flowImprove umbilical circulationImprove oxygen saturationReduce uterine activityINTERVENTIONS:Change positionGive O2 per mask ?Decrease/discontinue oxytocinTemporarily increase IV rateSupport woman / familyCommunicate / DocumentIntrauterine ResuscitationFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 2009632009 PPPESO64Documentation contentAssessments, interventions, evaluations Subjective (statements/feedback from client in " ")Objective (observed/measured, actions, etc)Communication with care providers:Who was called, and time of callInformation reported and request(s) madeCare providers responseAgreed-upon plans of actionOutcomesThird-party information (family member, etc)Clients non-compliant or risk-taking behaviourFetal Health Surveillance - Instructor Notes PPPESO, 2009Copyright PPPESO, 200964