Fetal Heart Rate Research Paper

Key words: high reliability, electronic fetal monitor (EFM), category II fetal heart rate (FHR)

Huddle Up for Fetal Safety: Strategies to Improve Outcomes In the mid-1990s, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) sponsored a series of workshops to standardize definitions of electronic fetal monitoring (EFM) fetal heart rate (FHR) characteristics. The common language they developed to describe fetal heart rate tracing patterns, which provide important information on the acid-base status of the fetus at the current point in time, was widely adopted by professional women's health organizations in the United States. Thereafter, in 2008, the NICHD, American College of Obstetricians and Gynecologists (ACOG), and the
Society for Maternal-Fetal Medicine convened another workshop to update the standard terminology for uterine contraction descriptions and FHR pattern categories from the prior NICHD workshops and to recommend a classification system for FHR tracing interpretation (Macones, Hankins, Spong, Hauth, & Moore, 2008). Per the resulting NICHD 3-tiered FHR interpretation system in common use since 2008, Category I FHR tracings reflect normal acid-base status of the fetus and Category III tracings are predictive of abnormal fetal acid-base status (Macones et al., 2008).
Category II FHR tracings are indeterminate, not reflective of abnormal acid-base status, but requiring continued evaluation, surveillance, and reevaluation, with increased risk for fetal hypoxia/ acidemia (Macones et al., 2008). [Table 1: 3-Tier FHR Interpretation System] Category II FHR tracings are less clearly defined than Category I and III and can be challenging to manage, as they make up a large category with many combinations of features. Although Category II FHR tracings sometimes develop into Category III, they are not often indicative of fetal complications that result in bad outcomes, making it easy for all members of the surveillance team to become complacent (Cahill, Roehl, Odibo, & Macones, 2012). During labor, 84% of FHR tracings exhibit category II features (Jackson, Holmgren, Esplin, Henry, & Warner, 2011) and in the last 30 minutes of second stage, 97% of FHR tracings are Category II (Cahil et al., 2012). In collaboration with obstetric (OB) residents, certified nurse-midwives (CNMs), and physician providers, RNs
are responsible for evaluating, managing, and reevaluating continuous FHR tracings in order to contribute their expertise to the most prudent ongoing plan of care. As such, nurses can find it challenging to remain vigilant when most FHR tracings exhibit Category II features, yet the outcomes are routinely good. [SUGGESTED Figure 1: Category II Tracing(s)] In February 2016, labor and delivery (L&D) nurses, CNMs, residents, and physician providers of a busy Colorado inner-city hospital implemented best practices to improve term neonatal outcomes. To develop the best practices, the nurse leadership team combined clinical high-risk L&D skills and their passion to provide high-quality patient care with a review of the best applicable clinical evidence (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). RNs, CNMs, residents, and physicians incorporated the resulting best practices into their care of women in labor, resulting in an improvement in prompt and appropriate responses to worrisome Category II FHR tracings. The L&D clinicians who worked together to accomplish the fetal safety initiative applied the operational principles of high reliability by demonstrating their commitment to continuous quality improvement, interdisciplinary collaboration, and safe perinatal care founded on standardization (Knox & Rice, 2011). After education for nurses and providers alike, the entire team of L&D nurses, midwives, and physicians began assembling for FHR tracing reviews on the unit, regularly scheduled around the clock. In March 2017, integration of an evidence-based Category II FHR algorithm augmented the regular EFM tracing huddles. Following, in the month of April, the L&D clinical team implemented a rapid response code to assemble all available team members emergently between scheduled tracing reviews when a worrisome FHR tracing required immediate group input. These combined improvements to FHR assessments and care planning resulted in a significant improvement in term neonatal outcomes.
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