A revised nomenclature regarding electronic fetal heart rate monitoring was accepted at a National Institute of Child Health and Human Development consensus conference in 2008. At the heart of patient safety are communication strategies that enhance teamwork and collaboration between health care professionals. Communications is a complex 2-way process that involves more than transfer of factual information. P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations in Obstetrics is an acronym that helps facilitate this communication process in perinatal care. P.U.R.E. stands for purposeful, unambiguous, respectful, and effective. The P.U.R.E. Conversations approach involves refinement of the mental processes associated with delivering the message, delivery of the message with data, accuracy, and direct requests for action, attention to relationships and behaviors between the communicating parties, and real-time assessment of the effectiveness of the communication. When the new electronic monitoring nomenclature is combined with an effective communication tool, one could expect to see a reduction in communication failures that could lead to adverse perinatal outcomes.
“Late deceleration:
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Visually apparent usually symmetrical gradual decrease and return of the fetal heart rate (FHR) associated with a uterine contraction.
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A gradual FHR decrease is defined as from the onset to the FHR nadir of 30 seconds or more.
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The decrease in FHR is calculated from the onset to the nadir of the deceleration.
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The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.
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In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively.”
At the depositions: “She was having late decelerations and I really wanted him to come in.” “She really did not seem that concerned about the tracing. She never asked me to come to see the patient.”
This hypothetical scenario is the result of a communications failure that could occur despite the standardized terminology and suggested management regimens agreed on at a consensus conference sponsored by the National Institute of Child Health and Human Development (NICHD) in April of 2008. The terminology was accepted and endorsed by both the American College of Obstetrics and Gynecologists and Association of Women’s Health, Obstetric, and Neonatal Nurses.
Several commercial interests have initiated efforts to make these definitions and interpretations available to the perinatal community. There are, however, continuing concerns that this new approach will not necessarily result in improved teamwork, a collaborative approach to care, and improved responsiveness when intervention is needed.
Some organizations have recognized that even with mandatory certification of their medical and nursing staffs in the understanding of the new terminology, improved outcomes need to be associated with team training for all members of the perinatal team. So it can be said that although the standard definitions provided by the NICHD Consensus Conference provide a foundation for interpretation, it is the integration of all of the characteristics of the fetal tracing combined with the clinical picture of the patient that must be considered and discussed.
Despite the efforts of a few organizations’ attempts to improve teamwork and communication surrounding the interpretation of fetal heart tracings, this communications component of care has been largely unaddressed. The essential missing link centers on the process of effective communication between health care professionals that will eventually lead to a consensus-based management plan that results in the best outcome for the mother and her fetus. Recognition of patterns, the decision to call the patient’s provider, the nature of the call and the tenor of the conversation, reaching consensus of interpretation, and finally reaching a management plan are all part of the communication process that is necessary for appropriate care.
There have been some reasonable attempts to codify some components of this process by linking certain fetal heart patterns to the requirement that the physician is needed at the bedside. An additional relatively new layer of safety in obstetrical care, the introduction of the obstetric hospitalist or laborist, has made the need for accurate communication between multiple practitioners even more essential.
The purpose of this essay is to focus attention on the need to address this communication process between professionals associated with the NICHD terminology and to make recommendations of how individual labor and delivery units can implement, enculturate, and hardwire these communication strategies.
It is important to recognize that communication is a complex 2-way process, with a number of factors that can lead to miscommunication, or the lost-in-translation effect. Miscommunication can result from the choice of language made by the person sending the message and from the interpretation of the message by the receiver, both being steps in the communication process in which more than the words themselves (the facts) are attached to the actual material being transferred.
Said in another way, “Communication is often not simply about conveying factual information but often also contains components of self-revelation (an expression of the sender), the relationship between the sender and receiver , and an appeal aimed at influencing the receiver” (italics added).
P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations in obstetrics: a framework for enhancing communications on the perinatal unit
Structured communication as a way to improve the transfer of information between individuals is not new to health care and, in particular, perinatal medicine. One popular form of structured communication, situation, background, assessment, and recommendation (SBAR), has been widely introduced in the perinatal arena.
P.U.R.E. Conversations was developed as a tool to enhance structured communications between health care professionals in the perinatal unit. The principles of P.U.R.E. Conversations are meant to complement and enhance any other form of structured communication that might be in use. The P.U.R.E. Conversations approach to communication seeks to refine the mental process of determining a purpose for the conversation; delivering the message in an unabiguous manner; making sure that the interchange is respectful (safe, balanced, and nonintimidating); and measuring, in real time whether the conversation is effective in determining the plan of action.
As a complement to the SBAR technique of structured communication, P.U.R.E. Conversations takes into account relationships of the individuals as well as allowing for an ongoing evaluation of the progress and eventual success of the interaction. P.U.R.E. Conversations is a particularly useful tool to help prevent miscommunications regarding fetal monitoring interpretation, clearly one of the most frequent, high-risk conversations that occur in labor and delivery.
We advocate using the P.U.R.E. Conversations approach that incorporates NICHD definitions, terminology, and category determination. Many of the conversations about category I and III tracings will be straightforward with respect to management; it is the broad definition and varied approaches to category II tracings that will require the most effective communication practices.
P.U.R.E. Conversations addresses the nature and structure of the communication that must take place between members of the perinatal team, be it nurses, midwives, residents, obstetricians, family medicine physicians, or maternal-fetal medicine specialists. In most cases, the communication begins with the nurse at the bedside and is directed toward house staff or the patient’s attending physician or midwife. Even in situations in which the fetal heart tracing is available for viewing by all parties through a number of alternate technologies, the elements of interpretation and subsequent management still require consensus to be reached by the patient’s nurses and physicians. It is the success of this communication component that is necessary to gain consensus and subsequent action, if necessary, based on the appearance of the fetal monitoring strip and the clinical status of the mother.
Using the P.U.R.E. Conversations structure, a typical approach to the communication process regarding a given fetal heart tracing would entail the following factors:
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