In 1999, a highly publicized report from the Institute of Medicine identified major deficiencies in the United States health care system, which fueled the rapid growth of the modern patient safety movement. One of the greatest risks to patient safety in obstetrics is poor communication of electronic fetal heart rate monitoring findings. Standardization and elimination of unnecessary complexity are 2 of the cornerstones of improved patient safety. This article describes a standardized, simplified approach to the definition, interpretation, and management of electronic fetal heart rate monitoring that is evidence-based and reflects consensus in the literature.
More than 10 years ago, the Institute of Medicine Committee on Quality of Health Care in America identified standardization as an essential element of effective patient safety initiatives. A growing body of scientific evidence suggests that standardization and elimination of unnecessary complexity can yield statistically significant reductions in adverse outcomes and decrease malpractice claims. Electronic fetal heart rate monitoring (EFM) is only one of many issues to compete for the attention of busy obstetric care providers, yet it consumes a disproportionate amount of time and energy. As one of the most common procedures in obstetrics, EFM has the potential to influence the incidence of preventable life-long brain damage or death. Consequently, it is a common focus for litigation and an obvious choice for standardization and process simplification.
Over the last decade, a number of publications have evaluated and summarized the best available evidence regarding the capabilities and limitations of the technology. Together, these publications provide consensus and make it possible to create a multidisciplinary approach to EFM that eliminates unnecessary complexity and minimizes preventable error.
The primary goal of obstetric care is to optimize outcomes for the mother and the newborn infant. An important secondary goal is to minimize medical and legal risks. Both goals require clinicians to practice according to the standard of care , which is defined as care that is reasonable. Reasonableness requires factual accuracy and the ability to articulate a rational plan. This article addresses factual accuracy by encouraging the systematic use of standardized fetal heart rate (FHR) definitions and simplified, evidence-based interpretation. In addition, it provides a simple framework for clinicians at all levels of experience to articulate a rational plan of management. A simplified, standardized approach to EFM begins by deconstructing it into 3 components: definition, interpretation, and management.
Standardized definitions
In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop proposed standardized, unambiguous definitions for FHR tracings that subsequently were endorsed by the American College of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses, and the American College of Nurse Midwives. In 2008, a second NICHD Research Planning Workshop reaffirmed the original definitions, which are summarized in Table 1 , and introduced standard nomenclature for normal and abnormal uterine contraction frequency. Normal contraction frequency was defined as ≤5 contractions in a 10-minute window, averaged over 30 minutes. Contraction frequency in excess of this threshold is termed tachysystole . Although the clinical response may differ, these definitions apply to both spontaneous and stimulated contractions. The terms hyperstimulation and hypercontractility are defined inconsistently in the literature. Therefore, the consensus report recommended that the terms be abandoned. In the management model given in this article, uterine activity is evaluated and managed in relation to FHR changes as part of clinical assessment of the oxygen pathway. The NICHD Workshop also recommended classifying FHR tracings as category I, II, or III according to the criteria that are summarized in Table 2 . Defining FHR patterns accurately and consistently with standardized nomenclature helps to ensure factual accuracy, an essential element of reasonableness, and the standard of care.
| Pattern | Definition |
|---|---|
| Baseline |
|
| Tachycardia | Baseline FHR >160 beats per min |
| Bradycardia | Baseline FHR <110 beats per min |
| Baseline variability |
|
| Acceleration |
|
| Early deceleration |
|
| Late deceleration |
|
| Variable deceleration |
|
| Prolonged deceleration | Visually apparent decrease in the FHR at least 15 beats/min below the baseline lasting at least 2 min but <10 min from onset to return to baseline |
| Periodic deceleration | Accompanies a uterine contraction |
| Episodic deceleration | Does not accompany a uterine contraction |
| Sinusoidal pattern | Visually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 per min which persists for ≥20 min |
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