The fetal monitor is one of the most basic pieces of obstetrical medical equipment that hospitals purchase when they offer a Women’s and Children’s Service Line of patient care. Thousands of dollars are spent yearly on fetal monitor equipment purchases by hospitals in Florida. A small portion of this amount, by comparison, is spent on education and training on how to use the fetal monitor, the equipment features and capabilities. It is often up to the Service Line unit educator to provide training, testing and supervision. Some hospitals lack a designated educator, and training and education becomes a duty for preceptors and charge nurses. Even when the teaching and education is of high quality, the learners may not learn. Supervision must accompany teaching, education, and testing of fetal heart rate interpretation skills and knowledge.
Training and education for the user is required before the electronic fetal monitor is actually used for direct patient care. Training and education varies between groups of caregivers and varies in scope and quality. This is particularly true regarding the use of the fetal monitor and interpretation of the fetal heart rate. For example, nurses are rarely educated in the same format or in the same room with physicians. Hospitals may require that nurses be “certified” but may not require the same for physicians or mid-levels. Residents may learn fetal monitoring interpretation from senior residents. Learning fetal monitoring interpretation may be reduced to on-line learning only, which may be a non critical- thinking exercise.
Fetal Monitor Interpretation Based on Categories Instead of Critical Thinking
An attempt to standardize fetal monitoring definitions in 1994 and in 2008 resulted in the creation of concepts called Categories. It was thought that if the concepts of fetal monitoring interpretation were simplified into only 3 categories, anyone could interpret monitor tracings and come to the correct conclusion regarding the fetal status. This perception was wrong.
Simplifying fetal monitoring concepts into categories that resemble that of some weather phenomenon, such as hurricanes, has not improved fetal well-being, has not shortened labor lengths and has not made fetuses who were malpositioned fit into funnel-shaped pelvises. Changing or re-wording terminology of fetal monitoring interpretation served little purpose except to confuse bedside caregivers about which features of the fetal heart rate belonged in Category I, Category II or Category III. Creating fetal monitoring categories did not change fetal anatomy and physiology. Using the Categories in the absence of critical thinking and without an underlying knowledge of fetal anatomy and physiology, did not and will not protect the unborn baby from harm.
Most users of the fetal monitor actually know a Category I tracing and may be able to define its properties accurately. However, beyond Category I, comprehension becomes sketchy and many users simply just use fetal heart rate variability as the defining characteristic of fetal-well being. Baseline variability reflects brainstem function. It does not reflect supratentorial brain function. This is the fatal flaw of many nurses, midwives and physicians and may lead to bad outcomes for the mother and her unborn baby.
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The 5 Failures of Fetal Monitoring Associated with Negligence
It is the standard of care to assess and monitor the fetal status on admission to the hospital and during labor and delivery. There can be many failures by the treatment team to meet the standard of care; however, there are approximately 5 failures that occur with frequency. The following are the fetal monitoring failures that contribute to cause the most devastating outcomes for the fetus that are associated with negligent care. This is a discussion of those 5 failures.
1. Failure to recognize closely-spaced contractions and act to decrease uterine activity even when the baseline variability is moderate.
Closely-spaced contractions are easily recognizable. When the interval or the resting time between the uterine contractions is less than 60 seconds, the uterus is contracting too frequently and oxygen delivery to the fetus is decreased. While some fetuses are able to re-oxygenate during short periods of time, prolonged and excessive uterine activity is not well tolerated by the fetus. The presence of moderate variability during excessive uterine activity fails to indicate an oxygenated fetal brain tissue. Moderate variability is an indicator of brain stem (medulla) oxygenation. Over-reliance on moderate variability alone in the presence of excessive uterine activity is a fatal flaw by fetal monitor users. It is better to rely on the presence of a stable baseline rate, the presence of accels, the absence of decels and the presence of moderate variability to determine fetal oxygenation.
When there are too many contractions, either spontaneously or from the administration of uterine stimulants, actions should be taken to decrease the uterine activity. There should be at least 60 seconds of resting time between contractions. Intrauterine resuscitation measures should be initiated and continued until the uterus is calmed and the fetus is re-oxygenated.
2. Failure to act to oxygenate the fetus when there is fetal tachycardia and/or a rising fetal heart rate baseline even when the baseline variability is moderate.
Fetal tachycardia has been defined as a fetal heart rate baseline above 160 bpm. Fetal tachycardia is not benign and may reflect chronic hypoxia or a fetal arrhythmia. The presence of fetal tachycardia on the fetal monitor requires communication with the most experienced provider and a bedside assessment by the provider. Initially, when fetal tachycardia is accompanied by moderate variability, the fetus may be oxygenated. Over time, especially when the tachycardia worsens, the fetus will tire and the heart rate will begin to fall. Caregivers may see this fall in the fetal heart rate as a positive sign, however, it is not. A falling fetal heart baseline rate, especially when preceded by fetal tachycardia is an indicator of fetal compromise. Caregivers who lack education and understanding of fetal physiology may fail to act to re-oxygenate the fetus and just continue to monitor the fetal heart rate while the fetus decompensates. Continuing to monitor the fetal heart rate while the fetus decompensates is a fatal flaw by fetal monitor users.
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3. Failure to believe that the fetal heart rate bradycardia captured on the fetal monitor is accurate and failure to act to oxygenate the fetus and change the plan of care.
Fetal bradycardia has been defined as a fetal heart rate below 110 bpm for a term fetus and below 120 bpm when the fetus is pre-term. A bradycardic rate is a sustained rate over 10 or more minutes, however, caregivers should not wait 10 minutes to act to do the right thing. Heart rates lower than 80-90 bpm may not perfuse the fetus and are associated with ischemia, especially when the bradycardia continues without improvement and worsens. Watching the bradycardia worsen on the monitor, turning the mother side to side, performing multiple vaginal exams, and applying a scalp electrode to see just how low the heart rate really is, are time consuming. Although these actions may be correct in some situations, they are incomplete and opening the operating room, notifying the provider and moving the patient to the operating room must occur. Fetal bradycardia less than 80-90 bpm is a medical emergency for the fetus.
Failure to treat severe fetal bradycardia captured by the fetal monitor is a fatal flaw. When the vaginal delivery is imminent (fetal vertex and up to the level of the ears are birthed), there may be persistent bradycardia. Because precious fetal brain cells and brain tissue are not being perfused, the birth must occur immediately. A resuscitative team must be ready to receive a depressed or an asphyxiated infant.
It is a severe threat to fetal life when caregivers fail to believe the bradycardia and instead, continue watching the tracing on the monitor thinking it will resolve at any instant with conservative measures. A delay to deliver the fetus with bradycardia, hoping the heart rate will suddenly recover, is a fatal flaw.
4. Failure to recognize when the maternal heart rate is being monitored and not the fetal heart rate, especially during second stage.
Serious injury or even fetal death may occur when caregivers mix-up or confuse the maternal heart rate for the fetal heart rate. The manufacturers of fetal heart monitors warn users about the monitor’s capability of the conversion from the capture of the fetal heart valve opening and closure to the capture of maternal aortic pulsations, especially during pushing and when the mother is sitting up and curled around her pregnant abdomen.
Also, the fetal monitor is not a sound machine, no healthcare team members should rely on the sound that is being emitted from the fetal monitor. The fetal monitor does not detect heart sounds. The fetal monitor does create a sound, but that sound is artificial and is NOT the sound of fetal heart valves opening and closing. The fetal monitor does detect heart valve motion. The fetal monitor acts as a computer and uses high speed data processors to analyze each incoming nonrandom ultrasound signal generated by fetal mitral and tricuspid valve movement. When fetal heart valve movement is very slow or has ceased, the monitor uses automatic gain control to boost signal capture, and maternal aortic pulsations will be captured instead. This is especially true during the second stage of labor. The aortic pulsations are read by the data processors within the fetal monitor, calculated and printed on the heat sensitive paper and displayed on the LED screen on the front of the fetal monitor. The failure of caregivers to distinguish the maternal heart rate from the fetal heart rate is a fatal flaw.
5. Failure to timely act when there are fetal heart rate decelerations that decrease oxygen delivery to the fetus even when the baseline variability is moderate.
The presence of baseline fetal heart rate variability is important. Baseline variability, however, is not the sole predictor of fetal well-being. Variability in isolation should not be used to determine fetal health. It is critical that users understand fetal physiology and understand that the presence of a stable baseline rate, the presence of accelerations, the absence of decelerations and the presence of moderate variability are the best indicators of fetal well-being.
Variable decelerations, prolonged decelerations and late decelerations all rob the fetus of oxygen. While some fetuses tolerate intermittent decelerations, some do not. Decelerations that continue during labor and the second stage, decelerations that are deep, and decelerations that last a long time pose a threat to fetal life, especially when the uterine activity is excessive. The presence of moderate variability does not negate the threat. Over-reliance on moderate variability alone in the presence of fetal heart rate decelerations is a fatal flaw.
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