Deviations in the baseline activity are classified as absent (no noticeable bpm variation), minimal (up to 5 bpm), moderate (variability ranges from 6 to 25 bpm), or marked (exceeding 25 bpm).( 6) The normal baseline activity of the fetal heart rate is dependent on adequate oxygenation to the brain if the fetal brain is receiving enough oxygen, then there is substantial heart rate variability. Electronic fetal monitoring was introduced in 1958 and was quickly adopted because it offered a continuous measure of FHR activity and was expected to reduce infant mortality.( 1-4) Both FHR activity and maternal contractions are recorded by transducers placed on the maternal abdomen and tracings can be displayed either on a paper strip or a computer screen.( 4,5) The baseline heart rate is measured in beats per minute (bpm) and measured over a 10-minute period.( 6) Normal mean values for FHR range from 110 to 160 bpm. The case presented above involves failure to recognize concerning fetal heart rate (FHR) tracings during labor. The responsible obstetrician was busy throughout the period of abnormal tracings with another complicated childbirth. When asked about the incident, they both replied that they "just didn't see the bad tracings" and commented how difficult it can be sometimes to identify abnormalities and to continuously watch all 16 small windows. Two nurses at the nursing station were assigned to watch the monitor at the time of the concerning abnormalities. On this screen, the individual fetal heart monitoring strips for the 16 rooms were displayed continuously in small windows. In this institution, continuous fetal heart monitoring of all of the women in labor was displayed centrally on a large 40-inch monitor at the nurses' station. These abnormalities, which likely would have prompted an urgent cesarean delivery, had not been recognized by any of the physicians or nursing staff. The fetal heart rate tracings had shown evidence of Category 2 and 3 abnormalities (moderate-to-severe fetal distress) for at least 90 minutes prior to the delivery. The fetus had been monitored using the standard fetal heart rate tracings throughout the time of labor. He is likely to be severely disabled for the remainder of his life.Ī root cause analysis of the case found that the mother had been appropriately monitored and had not shown any evidence of distress. He spent a month in the neonatal intensive care unit before being transferred to a neuro-rehabilitation 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. The infant required extensive resuscitation but survived and was transferred to the neonatal intensive care unit. An arterial blood gas at the time showed a pH of 6.70 (normal: 7.25–7.35), a profound acidosis. Unfortunately, when the infant was born, he was cyanotic and flaccid with very low Apgar scores. She pushed for approximately 2 hours without any difficulty or any sign of problems with the fetus. By the next morning, she had a completely dilated cervix and was ready to push. She progressed slowly over the first night. Appreciate the importance of safety culture on labor and delivery units.Ī 29-year-old woman had an uncomplicated pregnancy with a healthy fetus and presented to the hospital at term (40 weeks) in early labor.Describe the impact of increasing the number of displays that need to be monitored on overall vigilance and detection of critical signals.List the known hazards of centralized fetal heart rate monitoring.Describe the current state of evidence regarding fetal heart rate monitoring.
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