Difficulties with intrapartum fetal heart monitoring have been identified as a key area of preventable harm (Lame et al, 2023). This often includes the use of the high-alert medication oxytocin, used to induce or augment labor, and is a complex topic for many reasons. Differences in opinions around fetal heart monitoring interpretation and the management of oxytocin practices are not uncommon in labor units. Electronic fetal monitoring (EFM) interpretation is affected by both individual and system factors: people, duties, equipment, technology (electronic medical record), and clinical competency. Individual influences include human factors such as fatigue and cognitive overload. Teamwork and communication process of care reflect system factors and involve escalation and team mobilization. (Lame et al, 2023). As a solution, the literature supports a multi-faceted approach to improving patient safety around fetal heart monitoring interpretation and team communication.
This article describes four key interventions to aid in these challenges: standardized EFM education and certification to ensure a shared mental model, use of an oxytocin checklist, a Category II algorithm to guide interventions and management, and a TeamSTEPPS program to establish and maintain psychological safety and 200% accountability to using any established processes.
Clinical Vignette
The following story demonstrates the complexity and variation that may occur involving EFM interpretation and communication from a new nurse perspective, in a setting lacking effective structures in place.
Jenny is a labor and delivery nurse with a year of experience and it’s a few hours into her shift. She is caring for a full-term laboring patient and encounters a fetal heart tracing that she is not entirely comfortable with. Given her limited experience in fetal monitoring, her concerns center around minimal variability and what appear to be late decelerations. She immediately thinks to seek out a second opinion from a colleague. As she considers her next steps, she realizes the outcome of this situation is dependent on the team she is working with- the charge nurse, senior mentors, the physician involved- and the ability for effective team communication to occur with establishment of a clear plan in moving forward.
Communication is impacted by education, relationships with colleagues, history, peer receptivity to having a conversation, and in this instance with a newer nurse, the presence of nurse colleagues who can help navigate the situation. Ultimately, the ability of this nurse to successfully navigate this situation will “depend” on several factors, which speaks to variation. Safety science has shown that variation is associated with unwanted and adverse outcomes. Furthermore, cultures in which a response “depends” on who the team members are, sets us up for failure. Implementing a structured, evidence-based program provides a solution to this long-standing problem.
Standardized fetal heart monitoring education and certification
Standardizing EFM education ensures that all staff are practicing from the same mental model and using a shared language. Practices that organizations have employed successfully include requiring fetal monitoring education alone or in combination with EFM certification for all staff responsible for interpreting fetal heart monitoring. This strategy, as part of a comprehensive perinatal patient safety program, has been demonstrated to significantly reduce liability claims and payments, and improve patient outcomes and safety culture (Pettker et al., 2009; Pettker et al., 2014; Wagner et al., 2012; Wiley et al., 2016).
Helpful tips:
Integrating this into mandatory requirements for all staff (ex. provider credentialing)
Providing review courses and evidence-based articles to help support staff through the certification process
Integrating standardized EFM education into onboarding for new staff (ex. AWHONN Intermediate Fetal Heart Monitoring Course), including the expected timeline to become certified
Ensuring standardized language is integrated into the electronic medical record system and policies/guidelines
Once we have folks speaking the same language around fetal heart monitoring, providing safe parameters for oxytocin use is another high-risk area to address.
Oxytocin Checklist
A standardized oxytocin checklist, described by Clark et al (2007, 2015) established guardrails for maternal and fetal safety. It was implemented by the Hospital Corporation of America and associated with a decreased cesarean delivery rate and improved newborn outcomes in singleton, vertex fetuses (gestational age > 37 weeks) in women with a history of an unscarred uterus and undergoing an induction of labor with oxytocin. The checklist sets parameters for adequate fetal oxygenation, normal uterine activity, and acceptable interruptions in fetal oxygenation (decelerations) prior to and during oxytocin initiation.
Central to checklist implementation is proper education for all staff, memorializing it into a guideline, creating electronic order sets, and ensuring checklist parameters are easily accessible- either in the electronic medical record, or in laminated templates easily accessible for frontline staff. Successful rollout involves sharing all available evidence supporting the protocol, integrating education into onboarding of new staff, and continued monitoring of protocol use. Ongoing communication and documentation between physicians and nurses is critical when oxytocin requires adjustment due to parameters not being met. Along with safe parameters for oxytocin use, is the integration of a standardized structure to follow when abnormalities occur in the fetal heart tracing. One such structure is a Category 2 (CAT 2) algorithm.
CAT 2 Algorithm paired with a Team Huddle
The CAT 2 algorithm described by Shields et al (2018) guides the management of fetal heart tracings based on variability, the presence of significant decelerations, phase of labor and progress, and time parameters around re-evaluation and delivery.
It offers the opportunity to initiate intrauterine resuscitation measures to correct any abnormalities, communicate with the care providers, and reassess in a timely manner. Use of this algorithm with recurrent significant decelerations has been shown to reduce infants born with Apgar scores of <7 at 5 minutes and severe unexpected newborn complications.
A common theme in patient adverse events is a lack of communication and situational awareness among all team members. Employing a team huddle to review the fetal heart tracing and the CAT 2 algorithm allows everyone to have a clear picture of the fetal heart tracing including changes over time, any intrauterine resuscitation measures employed, and ensures a plan is established for re-evaluation. Establishing parameters for the huddle is essential:
What are the criteria for huddle initiation?
Who can initiate the huddle?
Who participates in the huddle?
How is the huddle announced?
What information is reviewed at the huddle?
What does communication look like if the provider is not in-house?
What does this look like in the second stage of labor?
It is critical to engage frontline staff in a workgroup to develop this process. Explain the call to action and determine huddle parameters above together, with input from the people doing the work. This helps to create a process that is realistic, gives staff an opportunity to weigh in on workflows that impact their practice, and most importantly engages buy-in. Employing an evidence-based algorithm and building the huddle process with frontline staff are effective when team members hold themselves and each other accountable to using it. This is where a TeamSTEPPS program helps to build psychological safety, empower folks to speak up, and holds individuals and teams accountable to following established processes. A TeamSTEPPS program helps to pave the way for a supportive, structured team approach in this area.
TeamSTEPPS
A Joint Commission review of sentinel events from 2004-2015 revealed that human factors and communication were root causes for maternal events resulting in death or permanent loss of function (Joint Commission, n.d.). The same was true for perinatal events involving full-term infants 2500g and greater, and the absence of obvious congenital abnormalities, resulting in death or permanent loss of function. Human factors are defined as the following variables: staffing, orientation, education, competency process, supervision, processes for medical staff credentialing/privileging and peer review, and factors such as rushing, fatigue, and distraction. Communication breakdowns included all forms (written, verbal, electronic) and among all care providers and family (Joint Commission, n.d.).
TeamSTEPPS is an evidence-based program aimed at improving teamwork and communication among healthcare providers. It was originally developed from a joint effort by the Department of Defense and the Agency for Healthcare Research and Quality, and has been in place for several decades. TeamSTEPPS provides a set of structured communication tools and events to foster patient safety (Kelly et al, 2018). When incorporated into the day-to-day unit workflow, these tools promote real time patient safety awareness, and effective information exchange for handoff, critical events, and advocacy. Within the perinatal space, TeamSTEPPS has been described as a key strategy of a comprehensive obstetric patient safety program (Pettker et al 2014).
Advocacy tools include using a CUS tool for concerning situations. It represents the phrase “I’m Concerned, I’m Uncomfortable, this is a Safety issue.” If speaking up in this manner does not resolve the problem, this program also includes establishing a clear chain of command for staff to follow when clinical concerns are not being heard and addressed.
Central to this program is the concept of 200% accountability, meaning individuals are 100% accountable to monitor their own performance and 100% accountable to monitor others performance to ensure that appropriate care processes are being followed. This reinforces a team approach to fetal monitoring surveillance. All colleagues are expected to speak up regarding any concerning fetal heart tracing (beyond one’s own patient care assignment), and reinforce the use of processes such as the CAT 2 algorithm, huddle, and oxytocin checklist.
TeamSTEPPS also serves as a foundation for a comprehensive perinatal patient safety program and level-sets expectations for all staff to speak up when concerned, and for folks on the receiving end to, at minimum, listen and be receptive to the conversation.
While this article does not include all strategies to improve patient safety around fetal heart monitoring, what has been described are several key, evidence-based interventions.
*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide
Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS
References:
Clark, S., Belfort, M., Saade, G., et al. (2007). Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. American Journal of Obstetrics and Gynecology, 197, 480.e1-480.e5.
Clark, SL., Meyers, JA., Frye, DK., et al. (2015). Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. American Journal of Obstetrics and Gynecology, 212, 494.e1-6.
Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to Quality and Safety Education for Nurses: Core Competencies for Nursing Leadership and Management. Springer Publishing Company.
Lamé, G., Liberati, EG., Canham, A., Burt, J., Hinton, L., Draycott, T., Winter, C., Dakin, FH., Richards, N., Miller, L., Willars, J., & Dixon-Woods, M. (2023). Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ ergonomics and social science analysis. BMJ Quality Safety; 0:1–11. doi:10.1136/bmjqs-2023-016144 doi:10.1136
The Joint Commission (n.d.) Sentinel Event Data Root Causes by Event Type 2004 – 2015. Retrieved from https://hcupdate.wordpress.com/wp-content/uploads/2016/02/2016-02-se-root-causes-by-event-type-2004-2015.pdf
Pettker, C.M., Thung, S.F., Norwitz, E.R., Buhimschi, C.S., Raab, CA., Copel, JA., Kuczynski, E., Lockwood, CJ., & Funai, EF. (2009). Impact of a comprehensive patient safety strategy on obstetric events. American Journal of Obstetrics and Gynecology, 200, 492.e1-492.e8.
Pettker, CM., Thung, SF., Lipkind, HS., Illuzzi, JL., Buhimschi, CS., Raab, CA., Copel, JA., Lockwood, CJ., & Funai, EF. (2014). A comprehensive obstetric patient safety program reduces liability claims and payments. American Journal of Obstetrics and Gynecology, 211 (4), 319-325.
Shields, LE., Wiesner, SW., Klein, C., Pelletreau B., and Hedriana, HL. (2018). A standardized approach for category II fetal heart rate with significant decelerations: maternal and neonatal outcomes. American Journal of Perinatology, 35: 1405-1410. DOI https://doi.org/ 10.1055/s-0038-1660459
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Wiley R., Begun JW., Meredith L., Miller KK., Connolly K., Price R., Muri JH., McCullough M., & Davis S. (2016). Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback. Health Services Research, 51 (6), 2431-2452.
DOI: 10.1111/1475-6773.12592