From the Editor
Transfer to the hospital for women planning a home birth: A high-risk obstetrics problem
Do you have a written clinical guideline for pregnant women planning a home birth who are transferred to your hospital?
When clinically appropriate, use of a fetal scalp electrode (FSE) can document the FHR. If intrauterine fetal death has occurred, however, the FSE may transmit the maternal heart rate.5 Using ultrasonography to confirm the FHR prior to placing the FSE is a reliable method of definitive differentiation. If a newly placed FSE shows a clear differentiation of 5 to 10 beats per minute from a continuously assessed maternal pulse rate, then this is also a reliable way to assure that the FHR monitoring represents the fetus, particularly if ultrasonography is not immediately available.
Ultimately, before intervening based on an abnormal FHR tracing, it is paramount to confirm that the data are adequate for interpretation and represent the actual FHR. If signal ambiguity is identified or suspected, correct it by using ultrasonography to locate the FHR and replace the external monitor until a rate that is at least 5 to 10 beats per minute different from the maternal rate is obtained. Alternatively, this is an indication for internal fetal monitoring with an FSE.
Challenge: Inadequate FHR tracing, poor communication, lack of clinical context
CASE 2 Woman with uncomplicated postdates pregnancy presents for induction
A 28-year-old woman (G3P2) at 41 weeks 0 days of gestation presents to labor and delivery for induction of labor for the indication of postdates. There have been no complications with the current pregnancy. The initial cervical exam reveals 1+ cm dilation, 90% effacement, and −3 station, and the patient is started on oxytocin per the hospital protocol. What is your interpretation of the continuous FHR tracing shown in FIGURE 2?
| FIGURE 2 Inadequate, uninterpretable FHR tracing | ||
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This FHR tracing, from the patient described in Case 2, is unusable because of the absence of data. | ||
TIP #9: Check that the monitors are providing useful data
The ability to accurately interpret a continuous FHR tracing depends on the quality of data recorded. Unfortunately, the absence of data makes interpretation impossible. This includes both FHR and tocometry data, since both pieces of information are required for appropriate interpretation of a continuous FHR tracing.
Prolonged periods of uninterpretable FHR and uterine activity tracings imply that no one was attending the mother and fetus.6 If it is difficult to obtain an interpretable FHR tracing, document in the medical record that you made ongoing efforts to maintain an adequate tracing, including the amount of time spent holding the external monitor, use of ultrasonography to document the FHR, and plans for potential internal monitoring.
CASE 2 Continued
After several hours, the patient requests an epidural for pain management and one is placed without difficulty. She reports adequate pain relief and is comfortable for the next 1 to 2 hours. Subsequently, the patient reports a sudden onset of increasing pain that does not respond to additional patient-administered doses of anesthesia over a 30-minute period. The labor and delivery nurse becomes concerned about the patient's pain level and contacts the attending physician to discuss her concerns. The physician, who is currently attending to patients in clinic, listens to the nurse and asks her to contact the anesthesia department with her concerns (FIGURE 3).
| FIGURE 3 FHR tracing reveals recurrent variables in a patient with evolving clinical concerns | ||
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This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers. | ||
TIP #8: Clearly communicate an urgent situation to the care team
Poor communication underlies many preventable adverse outcomes in medicine.7 Effective communication requires an adequate description of the clinical scenario or problem. A root cause analysis of a series of intrapartum adverse events involving fetal death or injury showed that poor communication about a concerning FHR tracing played a role in 72% of cases.1
In this clinical scenario, the nurse believed that the patient's pain level was unusual or more than anticipated. The person who is communicating his or her concern (the sender) must be sure that the person receiving the message (the responder) clearly understands the sender's level of concern. In this case, it would have been appropriate for the sender to state clearly that she felt the patient's pain was outside of normal expectations and to request that the attending physician come to evaluate the patient.
Clear and effective communication includes (1) an appropriate description of the urgency of the situation and (2) an indication by the sender as to the desired response to this information ("please come evaluate the patient").8 In all cases, both steps are necessary to elicit an appropriate response.
