Fetal Heart Monitoring

Cindy Balvastro, Sharon Concepcion, Erika Hawkins,

Yvette Meza, Natasha Ramirez

Case Study
A 29-year-old woman had an uncomplicated pregnancy with a healthy fetus and presented to
the hospital at term (40 weeks) in early labor. She progressed slowly over the first night. By the next
morning, she had a completely dilated cervix and was ready to push. She pushed for approximately 2
hours without any difficulty or any sign of problems with the fetus. Unfortunately, when the infant
was born, he was cyanotic and flaccid with very low Apgar scores. An arterial blood gas at the time
showed a pH of 6.70 (normal: 7.257.35), a profound acidosis. The infant required extensive
resuscitation but survived and was transferred to the neonatal intensive care unit. The infant
subsequently had multiple seizures typical of hypoxic-ischemic encephalopathy (brain injury from
inadequate oxygenation of the brain that occurred during childbirth) and other problems related to
the complicated delivery. He spent a month in the neonatal intensive care unit before being
transferred to a neuro-rehabilitation unit. He is likely to be severely disabled for the remainder of his
life.

QSEN: Areas of Focus

Teamwork and Collaboration

Function effectively within nursing and
interprofessional teams, fostering open
communication, mutual respect, and shared
decision-making to achieve quality patient care.
Quality Improvement
Use data to monitor the outcomes of care
processed and use improvement methods to
design and test changes to continuously improve
the quality and safety of health care system.
Safety
Minimize risk of harm to patients and providers
through both system effectiveness and individual
performance.

Problems

Inadequate monitoring of fetal heart rate that leads to poor outcomes in baby
Individual fetal heart monitoring was displayed centrally on a large 40-inch
monitor at the nurses station; FHR for the 16 rooms were displayed
continuously in small windows.
Two nurses are assigned to monitor FHR for all rooms.
The responsible obstetrician was busy throughout the period of abnormal
tracings with another complicated childbirth

Significance of Problems

Case Study:

Baby was cyanotic, flaccid, had low Apgar scores

ABG: pH = 6.70 (normal: 7.25 -7.35)
Required extensive resuscitation
Baby had multiple seizures of hypoxic-ischemic encephalopathy
Baby was in NICU for one month
Transferred to a neuro-rehabilitation unit
Likely to be disabled for the remainder of his life

Family is affected
Punitive damages
Fetal mortality
Maternal mortality

FISHBONE
Environment
-Understaffed:
Physicians/Nurses
-High Census
-Busy

-Too many, small

windows
-Alarms not
activated

Equipment

People
-Not following protocol
-Not reading the monitor correctly
-Occupied w/other tasks
-Monitor fatigue

-Lack of training
-Centralized
Monitoring

Methods

Inadequate
fetal heart rate
monitoring that
leads to poor
outcomes in
baby

Factors to Enhance Achievement

Training of staff
Better supervision by leadership
Clear communication and reporting
Having more staff available to monitor fetal heart
activity
Alarm activation on fetal monitor
Centralized and bedside fetal heart rate monitoring

Factors to Detract from

Achievement

Lack of money for training

Lack of leadership/support
Nurse fatigue and stress
Alarm activation could lead to staff over
trusting the equipment, decrease the nurses
ability to detect abnormalities, and reduce the
amount of time spent with the patient

Development of a Solution
GOAL: Building a safer system and safety culture

Communication between healthcare teams

CUSsing
Electronic Fetal Heart Rate Monitoring: Applying
Principles of Patient Safety
Continuous education and training to help staff
identify subtle fetal heart rate abnormalities
ST-segment analysis in conjunction with fetal
heart monitor
Care Bundle

Communication

Resource Time: Ongoing evaluation

Fiscal Resources: Presentation supplies,
Nurse educator, unit leadership, quality
improvement team, physician, and staff
nurse salaries
Resource of people: Unit leadership,
nurse educator, staff nurses, physicians,
quality improvement team
Marketing Strategies: Lunch & learn,
Poster Presentations, Huddles
Leadership & Management Concepts:
CUSsing

Continuous Education & Training

ST-segment Analysis (STAN) in conjunction with fetal heart monitoring
Resource Time: Ongoing evaluation
Fiscal Resources:
The STAN is cost effective alternative to Cardiotocography (CTG) alone
Vijgen et al. (2011) found that the additional costs of monitoring by ST analysis is not
significantly higher.
Staff development is a cost-effective method of strengthening productivity
Resource of people:

nurse managers, multidisciplinary team leaders, quality improvement

leaders.
Marketing Strategies:

Unit staff nurses, nurse educator, physicians, advanced practice nurses,

PowerPoint teaching presentation, Competency Day, poster presentations,

assessment of outcomes.
Leadership & Management Concepts:
STAN training course - develop an educational program

Continuous Education & Training (cont.)

Care Bundle

Resource Time: Ongoing

Fiscal Resources:
Include the bundle in the charting program
Takes less than 2 minutes to complete the form (Garrod et al., 2010)
Resource of people:

Midwives, unit staff nurses, nurse educator, physicians, advanced practice nurses, nurse
managers, multidisciplinary team leaders, quality improvement leaders.
Marketing Strategies:

PowerPoint teaching presentation, Competency Day, poster presentations, assessment of

outcomes.
Leadership & Management Concepts:
Training on when and how to complete the care bundle form.

Project Summary: Communication

Implementation:

Structured process by which information is clearly and accurately exchanged among team
members

Constraints Experienced

Physicians are too busy to collaborate with the nursing staff

Use CUS for safety concerns and DESC for managing and resolving conflict
Abnormalities are not reported during handoff
Have both nurses review FHR strip during change of shift
Nomenclature - use of different terms
Training for new hires

Project Summary:
Continuous Education & Training

Implementation

STAN training - ST-segment Analysis in conjunction with fetal heart monitoring

Constraints Experienced

Cost
Implement training into the department budget
Schedule availability
Scheduling the course during the nurses shift

Project Summary: Continuous Education & Training (cont.)

Implementation: Electronic fetal monitoring care bundle

Identify fetal heart rate changes during labor and detect fetal hypoxia before it leads to
complications and long-term neurological adverse outcomes for the baby.

Constraints Experienced

Lack of understanding of what the care bundle is about

Nurse educators to provide training on how to fill out the form
Falsification of care bundles
Co-signer - a second nurse can sign off (to quickly review) what is being filled out on the
form
Time to fill out forms
Filling out at bedside while the nurse is assessing mother and fetal vital signs
Implementing the form within the charting process

Evaluation of Consequences
Evaluation of project effectiveness

Communication Initiative - Monitoring dialogue, discussion at a future staff meeting or huddle

Education Initiative - Knowledge checks, competency validation

What facilitated change?

A preventable event where brain injury occurred during childbirth and other problems related to
the complicated delivery.

What inhibited change?

Unit culture, time constraints, funding availability

Alternative approaches for future use

Eliminating central monitoring personnel and give primary responsibility to the nurse and doctor
Provide visual or audio alerts to specific conditions (e.g. tachycardia, bradycardia, abnormal
variability, FHR decelerations)

Results Discussion for STAN

91.7% improvement was

correlated with significantly
better quality of care interpretation of tracings and
timely action
There was a reduction of cord
metabolic acidosis 0.72% to
0.06%

Results for Communication

Reduces stress, improves productivity, and contributes to a
healthy workforce
Maxfield et al. (2011) found that nurses today are voicing their
concerns nearly three times more often than they did just five
years ago.
Simpson & Knox (2000) found the chances of
miscommunication between care providers, especially during
telephone conversations about fetal status, are decreased when
everyone is speaking the same language about EFM (p. 43).

Results for Care Bundle

Overall data completion was very poor, with a large majority of the fields
having incomplete data.
20 of the 828 babies were admitted to the NICU (6 of the admissions were for
preexisting fetal conditions or prematurity).
Spontaneous vaginal delivery was the most common mode of delivery recorded
in the care bundle.

References
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