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HEALTH SERVICES

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NURSING PROCEDURE

TITLE: FETAL HEALTH SURVEILLANCE IN

LABOUR & BIRTH A. Intermittent Auscultation (IA) B. External (Indirect) Monitoring (EFM) C. Internal (Direct) Monitoring (EFM)

CATEGORY: RNSP: RN Procedure

PURPOSE

To ensure a systematic assessment and classification system in communicating and managing clinical data from fetal surveillance techniques.

To assess and interpret IA and EFM thus providing information from the fetal heart rate characteristics and patterns in response to stimuli in antepartum and intrapartum periods. The goal is to provide timely and effective interventions as needed to prevent fetal compromise.

To assess uterine contraction activity.

NURSING ALERT:

Only Registered Nurses who have received initial training and maintain yearly competency requirements in assessing all parameters of fetal well-being may carry out and assist with these procedures.

The Registered Nurse should be able to: accurately perform Leopold’s Maneuvers, palpate and assess uterine contractions, perform correct techniques of intermittent auscultation and electronic fetal monitoring, accurately interpret fetal heart rate patterns, recognize auditory changes in the fetal heart rate, and is able to appropriately provide interventions to respond to changes, and evaluate fetal well-being.

EQUIPMENT

1. Electronic Fetal Monitor (EFM) or Handheld Doppler

A. INTERMITTENT AUSCULTATION PURPOSE

Intermittent Auscultation (IA) is the recommended method of fetal assessment for healthy term pregnancies in the absence of intrapartum risk factors (<36 weeks and 41+3).

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For those over 41+3, IA is preferred when there has been a normal NST and when the amniotic fluid level has been assessed as normal.

NOTE: Advantages for using IA are that it is non-invasive which allows for position

changes and ambulation as desired. IA is associated with lower intervention rates without compromising neonatal outcome when compared to electronic fetal monitoring (EFM).

Disadvantages for IA is that IA does not allow for interpretation of baseline variability and type of decelerations.

EQUIPMENT 1. Ultrasonic gel 2. Hand held Doppler or ultrasound transducer portion of EFM 3. Cloth or tissue for wiping abdomen PROCEDURE 1. Explain procedure to patient, obtain informed consent and describe purpose along with

benefits, risks and limitations.

2. Ensure maternal vital signs are obtained according to stage of labour and intervention. Document vital signs onto appropriate forms.

3. Assist the patient into a comfortable position (for example: semi-fowler or lateral position).

4. Palpate abdomen using Leopold’s Maneuver to determine the fetal presentation and position.

5. Palpate and assess contractions for systemic interpretation including frequency in a 10 minute period, duration, strength and resting tone.

6. Turn on Doppler or ultrasound transducer of the EFM, apply it to the area of maximum intensity of heart sounds and listen following contraction for 60 seconds. Note mean baseline fetal heart rate, rhythm and presence or absence of accelerations or decelerations.

NOTE: Use of EFM, without indication, has been shown to increase

interventions. When using the ultrasound transducer portion of the EFM be sure that the monitor is not tracing.

7. Palpate the maternal pulse at the same time to ensure the maternal and FHR are

different.

8. Assess the fetal heart rate regularly after baseline is established by listening following a contraction for 30-60 seconds. Ensure to note rate, rhythm and presence or absence of accelerations or decelerations.

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NOTE: Additional common indications for assessment of the fetal heart by IA are:

Initiation of labour enhancing procedures (amniotomy).

Administration of medications or analgesia.

Transfer or discharge of the patient.

Change in uterine activity (tachysystole).

Untoward event in labour.

9. Continue monitoring, assessment, interpretation, evaluation and documentation as per current classification system. Refer to Appendix C.

10. Document accordingly. \

B. EXTERNAL (INDIRECT) FETAL MONITORING PURPOSE

In the presence of risk factors, refer to Appendix A and C. External fetal monitoring (EFM) provides a continuous assessment of the fetal heart rate and its characteristics. This fetal well-being assessment tool acts as a screening tool to evaluate fetal oxygenation and well-being to determine the potential for compromise to the fetus(s).

NOTE: Advantages for use of EFM are as stated above and that it is a non-invasive

means of continuous fetal monitoring that does not require the cervix to be dilated or membranes to be ruptured for placement.

Disadvantages for use may be that EFM (indirect or direct) is associated with more intrapartum interventions. EFM requires adjustment and repositioning with position change which may be restrictive for the patient. It may record the maternal pulse.

NOTE: If EFM has been initiated because of decelerations while doing IA and the EFM

findings are NORMAL, EFM may be discontinued. Resume IA.

NURSING ALERT: Recommended assessment of fetal heart rate: Latent Phase – every hour, Active Phase

and Second Stage without pushing – every 15-30 minutes and Active Second Stage (pushing) – every 5 minutes.

Intermittent Auscultation is the appropriate means of fetal monitoring with epidural use in the absence of risk factors. Epidural use alone is not an indication for the initiation of Electronic Fetal Monitoring (EFM). Rationale: The solution used in the continuous epidural infusion is diluted for the obstetrical population to decrease the risk of hypotension and promote ambulation in labour.

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EQUIPMENT 1. Ultrasonic gel 2. Securing belts 3. Electronic Fetal Monitor 4. Ultrasound transducer(s) 5. Tocotransducer

PROCEDURE 1. Explain the procedure to the patient obtaining informed consent and describe the purpose

along with the benefits, risks and limitations.

2. Turn the electronic fetal monitor machine on. Press the Test Button. This may delay use by approximately 2 minutes but helps to ensure accuracy of the monitor.

3. Ensure that all necessary equipment is working (transducers, paper feed and belts). If there are any breaks in printed lines, replace the monitor and send for repair. Otherwise, print yes and keep as part of record.

4. Check time on the electronic fetal monitor to ensure accurate time with electronic synchronized wall clock.

5. Assist the patient into a comfortable position (for example left lateral or semi-fowler).

6. Ensure maternal vital signs are obtained according to the stage of labour and intervention. Document vital signs onto appropriate forms.

7. Palpate abdomen using Leopold’s Maneuver to determine the fetal presentation and position.

8. Palpate and assess contractions for frequency in a 10 minute period, duration and resting tone.

9. Apply ultrasonic gel to the ultrasound (US) transducer. Place the US transducer over the area where the maximum intensity of heart sounds is heard. Adjust the US transducer position until fetal heart can be heard clearly. Ensure FECG is being recorded on monitor. Secure the transducer with elastic belts. NOTE: Electronic fetal monitors may pick up maternal signals or artifact and

interpret them as fetal cardiac activity. The computer may halve or double the fetal heart rate if it is outside of the normal range. Take the maternal pulse to ensure that maternal and FHR are different. Manual fetal heart rate auscultation may be necessary to confirm fetal heart activity and rate if the maternal and fetal rates are similar. Maternal ECG monitoring may be required to differentiate rates. Refer to the Corometrics Operator Manual for MECG monitoring.

With external monitoring, the contraction amplitude displayed on the tracing has no relationship to the intensity of the contractions.

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10. Place the external uterine pressure transducer (TOCO) over the uterine fundus. Secure the transducer with elastic belts. Press the fundus to determine resting tone. Once resting tone is noted, press the Uterine Adjustment (UA) Reference button on the front of the monitor to “zero” the tracing at 20 mmHg baseline. NOTE: Although the manufacturer and instructions identify the tocotransducer

buttons on the machine as “zero” buttons, the baseline for RQHR is set at 20 mmHg atmospheric pressure on the external tocotransducer.

11. Listen to fetal heart pattern and palpate the maternal pulse to differentiate following

application of US transducer.

12. Turn on the paper feed and commence recording of the fetal heart rate and contractions.

13. Adjust ultrasound and tocotransducer as needed to obtain a technically satisfactory tracing.

14. Continue monitoring, assessment, interpretation, evaluation and documentation as per current classification system. NOTE: Do not use while patient is in the tub as it is an electrical shock hazard.

15. Document accordingly. Press the mark button on the front of the monitor and initial on the monitor strip at times of observation.

16. Ensure appropriate interventions based on classification and need for intrauterine resuscitation needs of the fetus.

17. Encourage frequent position changes. NOTE: The patient in labour undergoing EFM may have intermittent periods of

no greater than 30 minutes off the monitor when the EFM is normal and oxytocin is at a stable rate.

NOTE: Using Remote Telemetry for establishing and continuation of EFM is

appropriate when available for use. It is recommended that the remote telemetry kit be checked prior to initiating EFM. Ensure that batteries are working, all cables are present and channels be set as per guidelines on the kit.

NURSING ALERT:

EFM cables are waterproof. Patient may sit in tub/shower as desired with EFM cables attached to telemetry kit.

Be sure telemetry kit is secured outside of tub/shower.

Monitoring guidelines remain the same.

Document use of telemetry device in nursing notes.

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NOTE: Uninterruptable or Technically Poor Tracing: For several reasons, the monitor strip may be of inadequate or unsatisfactory quality for assessment and interpretation of the FHR and /or contractions. Reasons for unsatisfactory quality may include fetal positioning, maternal obesity, excess maternal or fetal movement, polyhydramnios, machine or transducer malfunction or fetal cardiac arrhythmias or intrauterine fetal death. The nurse should try to identify and correct the reasons for the unsatisfactory quality. Refer to Appendix H. If correction is not successful, contact the Most Responsible Practitioner (MRP).

C. INTERNAL (DIRECT) FETAL HEART RATE MONITORING PURPOSE

Internal Fetal Monitoring (IFM) is used to obtain a more accurate assessment of fetal well-being when the external monitor strip is inadequate for interpretation. IFM may be used in conjunction with an intrauterine pressure catheter (IUPC).

NOTE: Advantages for use may be that it is beneficial when fetal monitor strip is

inadequate for interpretation. Examples can be in obese patients, fetal arrhythmias or when patient is pushing.

Disadvantages may include that it is invasive requiring cervical dilatation and membranes to be ruptured. IFM requires proper placement by trained person using sterile technique. IFM can be associated with greater risk for infection than other means of fetal monitoring.

NURSING ALERT: Contraindications for internal monitoring may include placenta previa, face or unknown

presentation, HIV positive, active genital herpes, Hepatitis infection and intrauterine infection.

There is no evidence to support IFM’s routine use and should be used at the MRPs discretion with informed consent.

EQUIPMENT 1. Scalp or spiral electrode 2. Disposable conductive adhesive leg plate 3. Intrauterine pressure catheter package 4. Transducer cables 5. Sterile gloves and lubricant 6. Securing belt 7. Tocotransducer

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NOTE: Either or both fetal heart rate and contractions may be monitored internally but the MRP may opt to monitor one parameter internally and the other externally. Refer to Nursing Procedure for Intrauterine Pressure Catheter assisting with insertion and amnioinfusion. http://rhdintranet/np/public/procedures/I.12.pdf

PROCEDURE 1. Explain the procedure to the patient obtaining informed consent and describe the purpose

including benefits, risks and limitations. 2. Ensure that all necessary equipment is present and functional.

3. Assist the patient into a comfortable position, a modified lithotomy position (legs flexed

at hips and knees and hips abducted) may be necessary to application of the scalp electrode.

4. Provide perineal care as needed.

5. Scalp Electrode: 5.1 Open scalp electrode package and sterile lubricant. Give to physician/midwife

performing the procedure.

5.2 Reassure the patient during the procedure.

5.3 Connect the wires to the leg plate firmly after scalp electrode is attached to the fetal

scalp and the guide has been removed. 5.4 Attach the leg plate to the patient’s leg with the accompanying adhesive pad.

5.5 Plug the leg plate cord into the FECG connector on the front of the monitor and ensure adequate tracing.

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6. Remove the external ultrasound transducer and belt from the patient’s abdomen. 7. Continue monitoring, assessment, interpretation, evaluation and documentation as per

current classification system (Appendix B/Appendix C). Document. 8. Removal: Twist the spiral electrode counter clockwise until free from the fetal head to remove

it when it is no longer needed. Ensure that this is accounted for and documented in the patient’s chart on the Labour 2.

NOTE: See Appendix B for Documentation of Fetal Health Surveillance

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REFERENCES Canadian Fundamentals of Fetal Health Surveillance Self Learning On-Line Manual

(December 11, 2013). Modules 405-413. Retrieved January 2017 from Centre for Excellence for Simulation Education and Innovation at: http://www.cesei.org/education/courses/index.php

Corometrics 250 Series Maternal/Fetal Monitor Operator Manuals 2020550-001 Rev. A &

154577AA Rev C. 2005. GE Medical Systems. Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield

JS. eds. (2014) Chapter 24. Intrapartum Assessment. Williams Obstetrics.(24th Edition). New York, NY: McGraw-Hill. Retrieved March 13, 2017 at: http://accessmedicine.mhmedical.com/content.aspx?sectionid=59789164&bookid=1057&jumpsectionID=59793339&Resultclick=2

Evans, R.J., Evans, M.K., Brown, Y.M.R., & Orshan, S.A., (2010) Canadian Maternity,

Newborn, & Women’s Health Nursing. Chapter 15 Labour and Childbirth. (pp. 592-606). Philadelphia, PA: Lippincott Williams & Wilkins.

Fundamentals of Fetal Health Surveillance: A Self-Learning Manual. (2009) Chapters 1-8

(pp. 1-351). (4th Edition). Vancouver, BC: The British Columbia Perinatal Health Program.

Gabbe, S.G., Neibyl, J.R., Simpson, J.L., Landon, M.B., Galan, H.L., Janiaux, E.R.M.,

Grobman, W.A., (2017). Obstetrics Normal and Problem Pregnancies. Chapter 12 Normal Labour and Delivery. (pp. 249) & Chapter 15 Intrapartum Fetal Evaluation(pp. 308-311) (7th Edition). Philadelphia, PA: Elsevier.

Leduc, D., Biringer, A., Lee, L., & Dy, J. (September 2013). Clinical Practice Guidelines.

Induction of Labour. Volume 35, Issue 9, (Pp.840–857). Society of Obstetricians and Gynecologists. Journal of Obstetrics and Gynecology. Retrieved Dec 12, 2016: http://www.jogc.com/article/S1701-2163(15)30842-2/fulltext. Elsevier.

Liston, R, Sawchuk, D, & Young, D. (September 2007). Fetal Health Surveillance:

Antipartum & Intrapartum Consensus Guidelines. Volume 29, (pp 1-60). Society of Obstetricians and Gynecologists. Journal of Obstetrics and Gynecology. Elsevier.

Miller, L.A., Miller, D.A., & Cypher, R. (Eds). (2017). Mosby’s Pocket Guide to Fetal

Monitoring: A Multidisciplinary Approach. Chapter 4 Uterine Activity Evaluation and Management. (pp. 95- 99) (8th Edition). St. Louis MO: Elsevier.

MoreOB Program (Sept 27, 2016) Module 1: Fetal Wellbeing during Labour. (15th Edition).

Retrieved January 3, 2017 from moreob.com.

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REFERENCES (Continued): Schub, E., & Hurst, A,. (October 23, 2015). Fetal Monitoring, Electronic, in Labor and

Delivery. CINAHL Nursing Practice & Skill. EBSCO Publishing. Retrieved January 3, 2017 from: http://web.a.ebscohost.com/nup/detail/detail?vid=4&sid=b5337769-ac94-47ef-b2e2-f7fc2f101a2e%40sessionmgr4008&hid=4207&bdata=JnNpdGU9bnVwLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=T704206&db=nup

Revised by: G. Weisshaar, CDE, Labor & Birth Unit Date: August, 2008 Revised by: A. Dornstauder, RN, Labour & Birth Unit; F. CarteriBitz, CDE Labour &

Birth Unit; J. Hanowski, CDE Labour & Birth Unit; L. Thorp, RN Coordinator Perinatal Outreach Education Program.

Date: June 2018 Approved by: Date:

Regina Qu’Appelle Health Region Health Services

Nursing Procedure Committee

3Oct18

Keyword(s): EFM, IA

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APPENDIX A

DEFINITIONS FOR ASSESSMENT PARAMETERS Contractions: Frequency: The number of contractions in a 10-minute window, averaged over 30 minutes. Normal is ≤ 5 contractions in 10 minutes. Tachysystole is > contractions in 10 minutes. Duration: Measures from the beginning to the end of the contraction and record in seconds. Normal is < 90 seconds. Intensity: Intensity evaluation may be estimated by palpation (described as mild, moderate or strong). Resting Tone: The uterine tone is described as soft or firm between contractions by palptation for a minimum of 30 seconds. Baseline Fetal Heart Rate: IA: The baseline FHR is determined by listening and counting for 60 seconds between

contractions. EFM: The approximate mean FHR during a 10 minute segment of monitoring, rounded to 5 beats per minute (bpm) increments, excluding periodic and episodic changes or periods of marked variability.

Normal baseline rate is 110-160 bpm; Bradycardia is defined as a rate < 110 bpm for > 10 minutes

Tachycardia is defined as a rate > 160 bpm for > 10 minutes

Baseline Variability for EFM: Variability is the fluctuations within the baseline FHR. It is determined by choosing one minute of a 10 minute section of the FHR tracing this free from accelerations and decelerations and contains at least vertical amplitude cycles (normal is two or greater cycles.) The difference between the highest and lowest rate is the range/amplitude of variability. Range/Amplitude for EFM Terminology for Documentation Undetectable ≤ 2 bpm Absent ≤ 5 bpm Minimal 6-25 bpm Moderate > 25 bpm Marked Rhythm: While listening to the heart sounds, note the rhythm. It is either regular or irregular. Accelerations: An acceleration is a visually and or audibly apparent abrupt increase in FHR above the baseline (abrupt is defined as onset to peak of acceleration in < 30 seconds): 1) At > 32 weeks gestation: The acme/peak is ≥15 bpm above the baseline, the acceleration

lasts ≥15 seconds and ≤ 2 minutes from onset to return to baseline.

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2) At < 32 weeks gestation: The acme is ≥10 bpm above the baseline, the accelerations last ≥10 seconds and ≤ 2 minutes from onset to return to baseline.

NOTE: Prolonged accelerations last >2 minutes but <10 minutes. Accelerations that

last >10 minutes are considered a baseline change. Accelerations are considered normal.

Decelerations: Decelerations are classified as early, late, variable and prolonged decelerations. 1. Early Decelerations are defined as a visually apparent gradual decrease in the fetal heart rate and return to baseline associated with a contraction (gradual is defined as onset of deceleration to nadir of ≥ 30 seconds). The onset, nadir and recovery of the decelerations coincide with the start, peak and end of the contraction, respectively.

NOTE: Early decelerations are generally considered to be normal.

2. Late Decelerations are defined as visually apparent gradual decrease in the FHR and return to baseline. (Gradual is defined as the onset of the deceleration to the nadir of ≥ 30 seconds.) They occur in relation to contractions. The onset, nadir and recovery of the deceleration occur after the start, peak and end of the contraction, respectively.

NOTE: Consistent late decelerations (>50% of contractions) are considered abnormal. 3. Variable Decelerations may be divided into two groups:

i. Uncomplicated variable decelerations consistent of an initial acceleration, rapid deceleration of the FHR to the nadir, followed by the rapid return to baseline FHR with a secondary acceleration following the deceleration.

ii. Complicated variable decelerations exhibit any of the following features: o Decelerations to < 70 bpm lasting > 60 seconds o Loss of variability in the baseline FHR or the trough of the deceleration o Biphasic deceleration o Prolonged secondary acceleration (post deceleration smooth overshoot of more

than 20 bpm increase and/or lasting more than 20 seconds) o Slow return to baseline o Continuation of the baseline rate at lower rate than prior to the deceleration o Presence of baseline tachycardia or bradycardia

NOTE: Variable decelerations may be considered to be normal, atypical or abnormal

and must be interpreted within the clinical context. Refer to appropriate appendices.

4. Prolonged decelerations are decelerations that last > 2 minutes but < 10 minutes (> 10 minutes is a baseline change). Prolonged decelerations are considered to be atypical or abnormal but have many causes and have to be interpreted within the clinical context.

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APPENDIX B

DOCUMENTATION FOR FETAL HEALTH SURVEILLANCE

1. FHR data and interpretation should be documented in the patient’s chart at least hourly in

latent labor, every 15-30 minutes in active labor, at least every 15 minutes during oxytocin infusions and every 5 minutes in active second stage labor.

2. Documentation on the EFM tracing should include patient identifiers such as name, date and

Medical Record Number. Maternal data may be written on the EFM tracing but must be accurately matched in time on the patient’s chart.

3. Refer to appropriate Appendices. Documentation should include:

3.1 Method of fetal health surveillance. 3.2 Uterine characteristics such as frequency, duration, intensity, and resting tone. 3.3 Interpretation of Intermittent Auscultation including:

o baseline fetal heart rate, o rhythm, o presence and/or absence of accelerations and decelerations.

4. Assessment and indication of additional risk factors, Refer to Appendix A. The reason for

initiating EFM and method (US, indirect or external; scalp electrode, internal or direct, Tocotransducer or IUPC).

5. Interpretation of EFM including:

5.1 Baseline rate. 5.2 Baseline variability. 5.3 Presence or absence of accelerations. 5.4 Presence and type of decelerations.

6. Classification of the IA as normal or abnormal and the EFM as normal, atypical or abnormal. 7. Specific actions taken when interpretation and intrauterine resuscitation performed if the IA is

abnormal or the EFM as atypical or abnormal. 8. Communications with the MRP. 9. Maternal and fetal responses to interventions.

10. Other maternal observations and assessments.

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APPENDIX C

ANTEPARTUM CLASSIFICATION: NON-STRESS TEST

MOREOB

(Sept, 2016)

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APPENDIX D

ANTEPARTUM & INTRAPARTUM RISK FACTORS FOR ADDITIONAL MONITORING

ANTENATAL

MATERNAL:

Hypertensive disorders of pregnancy

Pre-existing diabetes mellitus/gestational diabetes

Antepartum hemorrhage

Maternal medical disease (cardiac, anemia <100, hyperthyroidism, vascular disease, renal disease, smoking)

Maternal MVA/trauma (EFM recommended for a minimum period of 4–6 hrs)

Morbid obesity (BMI>40)

Maternal perception of reduced or absent fetal movement

FETAL:

Intrauterine growth restriction

Prematurity (< 36 weeks)

Oligohydramnios

Polyhydramnios

Abnormal umbilical artery Doppler velocimetry

Isoimmunization

Multiple pregnancy

Breech Presentation significant congenital anomaly

Single umbilical artery or more nuchal loops

INTRAPARTUM

MATERNAL:

Vaginal bleeding in labor

Intrauterine infection/Chorioamnionitis

Previous cesarean section

Prolonged rupture of membranes (> 24 hours at term)

Induced labor

Augmented labor

Hypertonic uterus

Preterm labor

Post-term pregnancy (>42 weeks)

FETAL:

Meconium staining of the amniotic fluid

Abnormal FHR on auscultation

MORE

OB (Sept, 2016)

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APPENDIX E

PARAMETERS AND CLASSIFICATION OF INTERMITTENT AUSCULTATION

MOREOB

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APPENDIX F

CLASSIFICATION OF INTRAPARTUM ELECTRONIC FETAL HEART RATE MONITORING

MOREOB

(Sept, 2016)

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APPENDIX G

MONITORING TWINS

1. Use same maneuvers for placement of transducers and electrodes as listed in Section B.

NURSING ALERT: Use caution when changing ports or methods of monitoring. Adjust interpretation

accordingly for the changing tracing features as follows: Boldness of Tracing: When using US transducers to monitor twins, US signals from the first transducer will print in

plain black with US as the identification (typically Twin A). The secondary US transducer signal prints in bold, labeled as US2 (typically Twin B).

If internal monitoring is used for the presenting twin, the FECG tracing prints in plain black and is labeled FECG on the tracing; Twin B will trace in bold and be annotated with US or US2 depending upon which port the cable is plugged into to. Twin B tracing will change to plain black once Twin A delivers.

Clearly identify which tracing corresponds to Twin A and which tracing corresponds to Twin B on the monitor strip and communicate this information to relief caregivers.

2. Press the Mark [Offset] button on the monitor front for 3 seconds to activate fetal heart rate

offset feature for twins. The shifted tracing should automatically revert to normal after 10 minutes with a dashed line to indicate the shift.

3. Press the Mark [Offset] button on the monitor front for 3 seconds to de-activate fetal heart rate offset feature sooner than 10 minutes.

NURSING ALERT: Fetal Heart Rate Offset Mode:

This feature may be activated to assist in interpretation of overlapping tracings. This mode may be used with dual US channels or US and FECG channels.

When using dual US channels, the US2 tracing shifts + 20 bpm and the tracing will read US2+20.

If using the US and FECG channels, the US trace shifts + 20 bpm and the US2 symbol prints on the strip.

A vertical dashed line prints to draw the shifted trend.

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APPENDIX G (Continued)

NURSING ALERT: Heartbeat Coincidence: Coincidence signals may exhibit when, in addition to the primary fetus, you are either

monitoring the mother or a second fetus by using any two monitoring channels (FECG, US, US2, MECG, MSpO2). This feature alerts the nurse to the possibility that the same stimuli is producing a duplicate signal. This feature prints two overlapping hearts on the monitor strip whenever the heart beats for the two channels coincide for 60% of the time during a one minute period. Once the heart beats do not coincide for > 40% for 7 seconds, two separate hearts (♥ ♥) will print out on the monitor. Adjustments of the US transducer position or auscultation may be needed to confirm the presence of fetal heart tones when the heartbeat coincidence signal appears.

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APPENDIX H

CORRECTIVE ACTIONS FOR A TECHNICALLY POOR MONITOR STRIP 1. Ensure that equipment is working properly by checking connections and pressing test

button on front of monitor.

2. If external monitor, reapply ultrasonic gel as necessary to US transducer and reposition to obtain clear continuous signal. It may be necessary to hold the US transducer if placing bands does not supply sufficient pressure to the abdomen for accurate recording.

3. Confirm uterine activity pattern and uterine resting tone by abdominal palpation.

4. Anticipate need for internal monitoring, if unable to obtain a technically adequate tracing despite corrective interventions for external monitoring.

5. With internal monitoring, confirm presence of FHR sounds by auscultation and note the FHR. Check the cord connections at the leg plate and machine. Have the physician check placement of electrode on the fetuses head if issues persist.

6. If there are any breaks in printed lines, replace the monitor and send for repair.

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APPENDIX I

CORRECTIVE ACTIONS FOR MONITORING WITH FETAL ARRHYTHMIAS

1. Refer to Appendix G: Corrective Actions and ensure that monitor is functioning properly. To turn on or off FECG Artifact Elimination (logic) on the Corometrics 250 series Electronic Fetal Monitor: 2. Identify that the fetus has a fetal arrhythmia. Confirm with MRP. 3. Access the toggle switch. 4. Scroll through to access and highlight “Set-up”, push toggle in. 5. Scroll through to access and highlight “Service”, push toggle in. 6. Scroll up to the Access Code, enter in the current date Day/Month. NOTE: Once the correct current date is entered in the screen it will automatically

switch and provide access to the service area. 7. Scroll through to access and highlight “Next Page”. 8. Scroll up to access and highlight “FECG Artifact Elimination on/off area”.

NOTE: The Corometrics 250 series monitors should always have FECG Artifact Elimination set to off. If there is a fetal arrhythmia this should be changed to on.

9. Set to the hospital default at bottom of screen when artifact elimination is no longer

needed. 10. Scroll through the options after selecting on/off to “Restart”.

NOTE: The Corometrics machine will restart after a few seconds and resume the electronic fetal monitoring. Ensure that it is tracing.