2016 Fetal Monitoring Lunch & Learn Series

Beyond the Basics: The Art and Science of Tracing Interpretation Session 1: March 8, 2016

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Wisconsin Association for Perinatal Care (WAPC)

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Faculty Jeanne Rosendale, MSN, RNC-Inpatient OB, C-EFM Level 4 RN, Family Birthplace Mayo Clinic Health System – Franciscan Healthcare La Crosse, WI

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Notice of disclosures • Notice of requirements for successful completion – Registrants must attend full session and complete evaluation to receive contact hours

• Conflicts of Interest – None to report

• Financial Disclosures – None

• Sponsorship or commercial support – None

• Non-endorsement of products – The speaker does not endorse the use of any particular medications or products as part of this educational session

• Off-label use – The speaker may discuss the off-label use of misoprostol and terbutaline as they relate to labor and delivery.

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Before we begin… • Listen-only mode • Questions – please ask, please answer! – Raise your hand – Type into the Question Pane – Out of time? Email [email protected] • Technical problems: Email Barb Wienholtz at [email protected] or call at 608-285-5858, ext. 201 5

Before we begin… The content presented today is a case study. Components of this case were chosen based on their applicability to achieve learning objectives for this presentation. Do not assume the patient featured in the case was cared for by the instructor or at the facility at which the instructor is employed. The discussion will focus on interpretation of the electronic fetal monitoring (EFM) tracings for the purpose of education. At times, the discussion may lead to the care decisions made based on EFM interpretation. IF the instructor shares details regarding actual or potential care decisions, please note those decisions do not necessarily reflect the opinions of the instructor, a particular provider, the standard of care for any particular institution or facility, or of WAPC. 6

Objectives At the conclusion of the session, participants will be able to: 1.

Systematically review the fetal monitoring data to identify the fetal heart rate pattern classification (category).

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Identify the physiology and pathophysiology related to the tracing patterns.

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Discuss interventions/management of the fetal heart rate patterns.

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2008 NICHD Report The 2008 National Institute of Child Health and Human Development (NICHD) Report of Fetal Heart Rate Monitoring • Defined standard fetal heart rate nomenclature • Identified three categories for fetal heart rate interpretation • Proposed future research 8

2008 NICHD Report • Report endorsed by: – ACOG (2009) Practice Bulletin #106 "Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation and General Management Principles”

– AWHONN-endorsed and incorporated in fetal monitoring curriculum – American College of Nurse Midwives

– American Academy of Family Practice

American College of Obstetricians and Gynecologists (2009, July). ACOG Practice Bulletin #106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Washington, D.C.: Author

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ACOG Practice Bulletin #116 (2010) "Management of Intrapartum Fetal Heart Rate Tracings" •

Reviewed: – Nomenclature – Fetal Heart Rate Interpretation (categories)

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Provided framework for evaluation and management of intrapartum patterns based on categories

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Assessment algorithm for fetal heart rate patterns

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Intrapartum resuscitative measures

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Management of uterine tachysystole

American College of Obstetricians and Gynecologists (2009, July). ACOG Practice Bulletin #106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Washington, D.C.: Author

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Systematic Review of Case Studies The following questions are used to evaluate every tracing, followed by specific questions: 1. 2. 3. 4. 5. 6.

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What is the contraction pattern? (interval, duration, resting tone if appropriate) What is the baseline fetal heart rate? What is the baseline variability? Are there any periodic changes present? Are there any episodic changes present? What are the probable causes of the changes present? When was the last reassuring sign of fetal well-being?

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Strip Review Discussion • Interpretation • Interventions/Communication • Documentation in chart

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Intervention/Communication • SBAR – Situation – Background – Assessment – Recommendation

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Case #1 - History • 24 year old, Gravida 1 Para 0 EDD 3/7/2016 • Admitted on a Monday for induction of labor at 37 weeks because of Gestational Hypertension and Gestational Diabetes Mellitus on Insulin. • History of Depression/Anxiety. • BMI of 38. • Labs were all normal, urine protein was negative, P/C - .1 • Cervical exam = 0/10/-3 Cervical ripening started with vaginal Cytotec 14

Tracing 1

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Tracing 2

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Tracing 3

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Tracing 4

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Tracing 5

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Tracing 6

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Tracing 7

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Tracing 8

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Tracing 9

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Tracing 10

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Tracing 11

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Tracing 12

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Outcome • Delivered by Primary Cesarean on Thursday at 0957 • Boy weighing 2.715 Kg, length 46.8 cm • Apgars 1 min – 1 5 min – 6 10 min – 8 • Cord gases Arterial pH – 7.294 Venous pH – 7.314 • Magnesium level – 5.1mg/dL (range = 1.6-2.6) • Glucose – 56 27

Case 2 - History • 20 year old; Gravida 1 Para 0 • Scheduled for induction at 41+3 weeks, Admitted in labor at 41+2 weeks at 0720. Was 3/80/-2 • GBS negative, Smoker (3-4/day) • Scoliosis; Migraine headaches

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Tracing 1

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Tracing 2

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Tracing 3

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Outcome • 2201; Boy; 3.79 Kg; 51 cm • Apgars 7/9 • No gases done

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References • ACOG Practice Bulletin 106. (2009). Intrapartum fetal heart rate monitoring: Nomenclature, interpretation, and general management principles. • ACOG Practice Bulletin 116. (2013). Management of intrapartum fetal heart rate tracings.

Discussion Questions? Comments?

Remember • Fax or email attendance list to WAPC – fax: 608-285-5004 – email: [email protected]

• Evaluation will be sent via email from WAPC. Please complete to receive Continuing Education Credit. • Continuing Education Certificate will be sent via email upon completion of evaluation. • Archived version • Become a member of WAPC! Join online: https://www.perinatalweb.org/n-pay/membership.asp • Register for the 2016 WAPC Annual Perinatal Conference April 24-26, 2016, at the Osthoff Resort, Elkhart Lake: http://www.wapcperinatalconference.org/ EARLY BIRD REGISTRATION DEADLINE IS MARCH 12!

Thank-you