Journal of Midwifery & Women’s Health

www.jmwh.org

Original Review

The Recognition and Management of Intrapartum Fetal Heart Rate Emergencies: Beyond Definitions and Classification

CEU

Jenifer O. Fahey, CNM, MSN, MPH

The ongoing and well-documented debate about the value of electronic fetal monitoring has focused primarily on the fact that most variant fetal heart rate (FHR) patterns are poor predictors of fetal acid–base status. Most recently, much of this attention has been focused on the implications for clinical management of FHR patterns that the National Institute of Child Health and Human Development has classified as indeterminate: neither normal nor abnormal. Given that a majority of fetuses will have an FHR pattern considered indeterminate at some point in labor, this is an important and worthwhile discussion. It is also important, however, for providers to be able to recognize those patterns that signal the presence of developing acidemia and those that signal the potential presence of an acute obstetric complication that can quickly lead to acidemia and fetal asphyxia, such as a placental abruption or uterine rupture. Early identification of these FHR patterns, and immediate intervention to improve oxygenation or expedite birth, may help improve neonatal outcomes. The first part of this article presents descriptions of theses FHR patterns. The route and timing of birth during these emergencies is then discussed. The last part of the article presents an overview of strategies for optimizing the efficiency of providers, particularly teams of providers, in responding to FHR emergencies. The use of simulation-based training is reviewed, with specific focus on its potential application in the context of preparing for these emergencies. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:616–623  Keywords: electronic fetal monitoring, fetal acidemia, fetal heart rate emergencies, obstetric emergencies, simulation, teamwork training

A related patient education handout can be found at the end of this issue and at www.sharewithwomen.org

identified. The use of simulation has emerged as an important strategy to achieve this efficient provider and team response. This article provides guidance on recognizing and responding to FHR emergencies.

INTRODUCTION

Use of continuous electronic fetal monitoring (EFM) has become the standard of care for intrapartum fetal monitoring in hospitals in the United States, despite a lack of clear evidence of efficacy in improving neonatal outcomes, and is likely to remain so for the foreseeable future. Continuous EFM is used by more than 80% of women in labor in the United States.1,2 Although there are multiple concerns related to the widespread adoption of continuous EFM during labor, particularly for women at low risk for fetal acidemia, the most significant concern is its association with an increased risk of cesarean birth. Approximately 27% of intrapartum cesarean births are conducted for variant fetal heart rate (FHR) patterns, making this the second most common indication for intrapartum cesarean birth.3 Providers of intrapartum care in settings where EFM is utilized are thus tasked with the challenge of using an imperfect technology to optimize outcomes while minimizing intervention. To best accomplish this goal, clinicians must apply knowledge that most variant FHR patterns are not associated with an increased risk of fetal acidemia while also recognizing those patterns that may warrant expedited birth. Additionally, optimizing outcomes depends on a well-coordinated and efficacious response once an intrapartum FHR emergency has been

Address correspondence to Jenifer O. Fahey, CNM, MSN, MPH, 326 Dewey Drive, Annapolis, MD 21401. E-mail: [email protected]

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1526-9523/09/$36.00 doi:10.1111/jmwh.12256

IDENTIFICATION OF FETAL HEART RATE EMERGENCIES

For the purposes of this article, FHR emergencies are defined as clinical scenarios in which the FHR pattern indicates an elevated risk of fetal acidemia sufficient to warrant immediate assessment and intervention, including preparations to expedite birth via operative vaginal birth or cesarean. These FHR emergencies are discussed in 2 separate sections. The first section describes those FHR patterns that are associated with abnormal acid–base status and thus signal an increased risk of fetal acidemia (irrespective of the source of compromised oxygenation). The second section includes FHR patterns that may herald the presence of an acute obstetric complication, such as a placental abruption, uterine rupture, cord prolapse, or acute maternal hypotension, which can lead to fetal acidemia. FETAL HEART RATE PATTERNS INDICATIVE OF IMPENDING OR EXISTING FETAL ACIDEMIA

The use of a standardized system of FHR interpretation has been repeatedly identified as a key patient safety goal to reduce adverse neonatal outcomes.4,5 In 2008, the National Institute of Child Health and Human Development (NICHD), in collaboration with the American College of Obstetricians and Gynecologists (ACOG) and the Society for MaternalFetal Medicine, convened an expert panel that developed and proposed a 3-tier classification scheme for interpreting FHR

 c 2014 by the American College of Nurse-Midwives

✦ Specific variant fetal heart rate (FHR) patterns that are associated with an increased risk of fetal acidemia, and those that are associated with acute obstetric complications such as placental abruption and uterine rupture, may require immediate intervention. ✦ Awareness of FHR signs of progression of fetal acidemia can help providers minimize unnecessary intervention and also allow for adequate preparation for cesarean to proceed in a controlled fashion when indicated. ✦ Failures in teamwork and communication have been identified as key contributing factors to adverse outcomes during root cause analysis of incidents of fetal injury or death that were preceded by variant FHR patterns. ✦ Teamwork training is most effective when it is context-specific and learned in an applied setting such as simulation scenarios. ✦ Simulation-based training has been demonstrated to be an effective strategy to identify pitfalls in the management of obstetric emergencies, improve individual provider knowledge and skill, and optimize team performance during obstetric emergencies. ✦ Successful simulation-based training can be accomplished without the use of expensive simulators. patterns.6 In this scheme, category I FHR patterns are those patterns that are strongly predictive of a normal acid–base balance at the time of observation, whereas category III FHR patterns are those that are predictive of an abnormal fetal acid–base status at the time of observation. Category III FHR patterns require prompt evaluation. All other FHR patterns fall into category II. Whereas a standardized system of FHR pattern classification is considered an important precursor to the standardization of clinical management of variant patterns, there is growing consensus that the 3-tier categorization system, as currently proposed by the NICHD, may be of limited use for the purposes of guiding clinical management.7–9 The main critique of this classification system is that the patterns in the indeterminate category II represent an overly broad heterogeneity of risk for fetal acidemia, precluding the possibility of standardized management recommendations for this category as a whole.9 This represents a significant limitation of this classification system because studies indicate that approximately 84% of fetuses will have an FHR pattern at some point in labor that falls into this category.10 Similarly, some experts argue that there are additional FHR patterns that, like those in category III, signal a high probability of fetal acidemia and warrant urgent evaluation.9,11,12 An alternative 5-tier classification system has been proposed by Parer and Ikeda.12 The 5 tiers represent a gradient of risk for fetal acidemia. The tiers are color-coded from green, which signals no risk of acidemia, to red, which signals the possibility of existing or impending damaging fetal acidemia. The red category in this system includes all those patterns that the NICHD has designated as category III; it also includes additional patterns that have been repeatedly associated with an increased risk of fetal and/or neonatal acidemia, as evidenced by an umbilical artery pH less than 7.2, a base deficit more than 12 mEq/L, or 5-minute Apgar scores less than 7.12,13 In recent studies, the 5-tier system has performed better than the 3-tier system in identifying fetuses with acidemia.7,8 In one of these studies, researchers found that when using the 5-tier system, 37% of all newborns with an umbilical artery pH less than 7.0 could be Journal of Midwifery & Women’s Health r www.jmwh.org

identified by the presence of one of the red FHR patterns, as opposed to 12.7% identified by the presence of an NICHD category III FHR pattern.7 Table 1 lists the FHR patterns predictive of fetal acidemia and an increased risk of asphyxia. This includes the highest risk categories in both the NICHD and the Parer and Ikeda 5-tier classification system (ie, red FHR patterns). The sum of the existing literature suggests that providers should consider the presence of any of the patterns included in Table 1 as an FHR emergency that requires immediate evaluation and intervention to improve fetal oxygenation. Although there is no evidence from randomized controlled trials that the use of intrauterine resuscitation measures collectively are associated with improved neonatal outcomes, these measures are recommended as part of the management of these FHR patterns based on physiology of fetal oxygenation and observational studies that suggest individual measures improve fetal oxygenation.14 For category III patterns, there currently is general consensus that these interventions should also include preparations for expedited birth via cesarean, with the following exceptions: 1) there is a maternal contraindication to surgery; 2) the birth can be achieved more expeditiously vaginally (spontaneously or operatively); or 3) the variant pattern is due to a reversible cause (eg, uterine tachysystole) and resolves with intrauterine resuscitation measures during preparations for birth.2,9,15 Some experts, however, also recommend proceeding with preparations for emergent birth for certain category II patterns that, if present following intrauterine resuscitation measures, cannot reliably rule out fetal acidemia.2,13 These category II patterns fall into the red category in the 5-tier system and are described in Table 1. FETAL HEART RATE PATTERNS ASSOCIATED WITH ACUTE OBSTETRIC COMPLICATIONS

A variant FHR pattern may be the initial presenting sign of an obstetric emergency, such as uterine rupture, umbilical cord prolapse, or placental abruption, which can quickly lead to fetal acidemia. These patterns can, therefore, be used to make a timely diagnosis of these complications. For example, 617

Table 1. FHR Patterns Associated with Increased Risk of Fetal Acidemia

Category III (NICHD Classification) “Predictive of abnormal fetal acid-base status at time of observation”6 Absent baseline FHR variability and any of the following: Recurrenta late decelerations Recurrenta variable decelerations Bradycardia

25% of placental surface) area associated with a 5-minute Apgar score greater than or equal to 7 and an umbilical cord pH greater than or equal to 7.1.24 In these marginal abruptions, a variant FHR pattern may not be present. A severe abruption of more than 50% of placental surface, however, is associated with an increased risk of fetal acidemia or demise.21 Fetal bradycardia is the most common variant FHR pattern associated with severe placental abruption and is also the pattern that correlates most highly with neonatal acidemia in women who had a confirmed abruption.24

Sinusoidal pattern Umbilical Cord Prolapse

Red Category (Parer and Ikeda 5-Tier Classification)12 12

“Evidence of actual or impending damaging fetal asphyxia” All category III patterns listed above Minimal variability with normal baseline and recurrenta

severe late decelerations (ࣙ45 bpm below baseline) and/or severe prolonged decelerations (⬍70 bpm)

Variable FHR decelerations and prolonged FHR decelerations are the most common FHR patterns associated with umbilical cord prolapse.25,26 An increased index of suspicion for umbilical cord prolapse (including occult cord prolapse) is warranted when one of these patterns described is present, particularly in a woman with the risk factors listed in Table 2.

Minimal variability with any degree of bradycardia and recurrent late, variable, or prolonged decelerations Minimal variability with tachycardia and recurrent severe late decelerations (ࣙ 45 bpm below baseline) Minimal variability with severe bradycardia (⬍70 bpm) Absent variability with tachycardia Abbreviations: bpm, beats per minute; FHR, fetal heart rate; NICHD, National Institute of Child Health and Human Development. a Occurring in ⬎50% of contractions in any 20-minute segment of strip. Source: Macones et al6 ; Parer & Ikeda.12

a variant FHR pattern is the most common (and sometimes the only) sign of uterine rupture.16–19 Similarly, variant FHR patterns are estimated to be a heralding sign in 80% of placental abruptions.20,21 Table 2 lists the FHR patterns, contraction patterns, and risk factors associated with uterine rupture, placental abruption, and cord prolapse. Uterine Rupture

In a woman undergoing trial of labor after cesarean, the development of the FHR patterns described in Table 2 should trigger an evaluation for possible uterine rupture. The suspicion for uterine rupture should increase if the bradycardia is preceded or accompanied by recurrent late decelerations, uterine tachysystole, pain that seems more severe or different in quality or location than the pain of labor contractions, the need to re-dose an epidural more frequently than expected, inadequate pain relief from an epidural that was previously providing adequate pain management, a sudden change in uterine contraction pattern, or vaginal bleeding.22 Placental Abruption

A variant FHR pattern, vaginal bleeding, and uterine pain are considered the classic triad of diagnostic signs and symptoms associated with placental abruption.23 In addition to assisting in the diagnosis of a placental abruption, FHR characteristics may also be used to determine the severity of the abruption. Marginal placental abruption (less than 618

Impending Fetal Demise

Knowledge of FHR patterns that precede fetal demise (sometimes referred to as terminal FHR patterns) is primarily derived from literature that predated current nomenclature to describe FHR patterns. These reports refer to the loss of beat-to-beat variability and an unstable or rapidly changing baseline that is followed by a profound bradycardia as characteristic patterns found on the EFM tracing preceding fetal demise.27,28 In current nomenclature, these patterns would be described as an indeterminate baseline with absent variability (with or without recurrent decelerations) that is followed by severe fetal bradycardia (⬍70 beats per minute [bpm]). Prolonged tachycardia with minimal or absent variability has also been described as a finding prior to bradycardia and fetal demise.15 This tachycardia, as well as the loss of variability and loss of a discernible baseline, are attributed to central nervous system effects of profound acidemia, whereas bradycardia is believed to be due to direct myocardial depression also secondary to the acidemia. THE ROUTE AND TIMING OF BIRTH IN A FETAL HEART RATE EMERGENCY

A 30-minute decision-to-incision time frame for emergent cesarean related to variant FHR patterns was recommended by ACOG and the American Academy of Pediatrics in the 1989 Guidelines for Perinatal Care.29 This time frame became the standard goal for achieving emergent birth.30 This 30-minute rule, however, was based on consensus opinion and not on research evidence documenting improved neonatal outcomes.31 Studies examining whether neonatal outcomes are better when a cesarean birth is performed within this 30-minute timeline have produced conflicting results.32 Some recent studies have reported that outcomes were on average worse for those neonates born within 30 minutes of the decision to proceed with a cesarean.30,33 These results should be interpreted with caution. In several of these studies, the indication for expedited birth was not controlled for in the analysis. Because clinicians will commonly proceed with birth Volume 59, No. 6, November/December 2014

Table 2. Obstetric Emergencies: Associated FHR Patterns, Contraction Patterns, and Risk Factors

Associated FHR Complication

Pattern(s) 16–19

Uterine rupture

a

Recurrent late

Associated Uterine Contraction Patterna

Risk Factors

Uterine tachysystole

Previous cesarean or uterine surgery

decelerations

(especially with vertical incision)

Bradycardia

Fetal malpresentation Second-stage labor dystocia Use of prostaglandins for labor induction in a woman with a history of uterine surgery

Abruption20–24

Bradycardia Recurrent late decelerations Recurrent variable

Sudden increase in frequency of contractions

History of trauma History of smoking, alcohol, or illicit drug

Uterine hypertonicity

use (especially cocaine/crack)

High-frequency but low-amplitude

Hypertension/preeclampsia

decelerations

uterine contractions (sometimes

Fetus with growth restriction

Minimal or absent

imprecisely referred to as uterine

Chorioamnionitis

irritability)

Placenta previa

variability Sinusoidal pattern

Oligohydramnios/polyhydramnios Premature rupture of membranes (PROM)

Cord prolapse25,26

Variable

N/A

decelerations Prolonged decelerations

Rupture of membranes with high fetal presenting part Polyhydramnios Small fetus Grand multiparity Fetal malpresentation Multiple gestation

Abbreviations: FHR, fetal heart rate; N/A, not applicable; PROM, premature rupture of membranes. a These FHR and contraction patterns are not specific to these obstetric complications and may occur in the absence of these complications. Similarly, the referenced obstetric complications may be present in the absence of these specific variant FHR patterns or of any variant FHR pattern. Source: Sheiner et al,16 Ridgeway et al,17 Ayres et al,18 Kieser and Baskett,19 Tikkanen et al,20 Oyelese and Ananth,21 Kieser and Baskett,22 Tikkanen,23 Usui et al,24 Levy et al,25 and Koonings et al.26

more quickly if the fetus is believed to be in acute danger, a disproportionate number of the neonates most likely to have poorer outcomes will be in the less than 30-minute decisionto-birth group, thus skewing the results.32 In studies that have looked specifically at the time from bradycardia to birth during acute emergencies, outcomes are better for those fetuses who are born quickly.32 For example, in a retrospective study of 33 women with placental abruption, Kamoshita et al found a significant improvement in fetal outcome in those neonates born within 20 minutes of the decision to proceed with birth compared with those born later.34 It is estimated that the risk of fetal neuronal damage or death starts at approximately 10 minutes following the complete cessation of oxygen delivery, such as can occur during a placental abruption or uterine rupture.35 It may be impossible, therefore, even with immediate and efficacious intervention, to achieve birth quickly enough to prevent fetal central nervous system injury or fetal death in many of these acute events. In contrast, acidemia develops over a longer period of time when the fetus is exposed to intermittent decreases in oxygen delivery. In a fetus whose FHR pattern is category I before recurrent decelerations develop during labor (ie, baseline FHR of 110-160 bpm; moderate variability and no deceleraJournal of Midwifery & Women’s Health r www.jmwh.org

tions), potentially hazardous acidemia is believed to develop over a period of approximately one hour.13 Collectively, these studies suggest that a 30-minute time frame may be too long in situations when there is complete or near complete obliteration of blood flow to the fetus and too short for the management of nonacute, progressive hypoxemia for which intrauterine resuscitation measures such as maternal oxygen administration, intravenous fluids, maternal positional changes, and discontinuation of uterine stimulation may prevent the need for surgical intervention. If a decision has been made to proceed with cesarean, however, preparations should not be unduly delayed in order to implement these measures.11 When determining how expeditiously to proceed with achieving the birth, providers should take into account maternal and institution-specific factors that will determine the ability to proceed with surgery, such as whether the woman is obese or the availability of operating room staff.36,37

IMPROVING THE CLINCIAL RESPONSE TO FETAL HEART RATE EMERGENCIES

In 2004, The Joint Commission issued a sentinel event alert that analyzed incidents of fetal death or permanent 619

disability.38 The majority (77%) involved variant FHR patterns, whereas 16% involved either uterine rupture or placental abruption. In the cause analysis of these incidents, poor communication and failure to function as a team were identified as key contributing factors to poor outcomes. The top 2 recommendations issued by The Joint Commission in response to these findings were for hospitals to conduct teamwork and communication training as well as to perform emergency drills to help staff prepare for emergent, high-risk events that include emergency cesarean. This call for improvements in teamwork and communication by The Joint Commission echoed a similar recommendation for interdisciplinary team training put forth by the Institute of Medicine following their 1999 landmark report on preventable medical error: “To Err is Human: Building a Safer Health System.”39 Health care organizations have attempted to use the experiences of high-reliability organizations in other high-stakes industries such as aviation, nuclear power, and the military to create team training programs to improve patient safety, enhance team performance, and reduce adverse events.40 Despite its relatively wide adoption, studies that have assessed the effect of team training in the field of obstetrics have not found a significant difference in knowledge, clinical performance, or team behavior attributable to training on teamwork theory alone.41 Recent studies signal that team training may be more effective when it is context-specific, such as when it is embedded in simulated clinical scenarios.42 Simulation-Based Training

Simulation is emerging as a key technique for provider education and team training in the management of obstetric emergencies.43,44 Simulation-based training allows providers to practice the management of various clinical situations in a setting that is safe, reproducible, and standardized using mannequins or standardized patients in realistic scenarios. These simulation scenarios can be written for almost any imaginable clinical situation. Teamwork and communication elements can be fluidly incorporated into the training along with clinical decision making and technical elements. Most simulation training programs include an opportunity for debriefing of the simulated scenario, during which participants are able to discuss what happened during the scenario and identify opportunities for improvement. In addition to providing a technique to build and improve team performance, simulation-based training has also been used to identify deficiencies and errors in the management of obstetric emergencies such as latent or system errors, which occur due to system or routine designs that predispose clinicians to make errors.45–48 Maslovitz et al identified a delay in getting to the operating room as one of the most common pitfalls in the management of simulated emergencies.45 Such a delay can be due to the provider’s failure to recognize the emergency or the need for expedited birth, but it can also be due to nonprovider-dependent barriers such as obstacles that hamper quickly moving a bed or stretcher from a labor room into the operating room or transferring the woman off the labor bed or wheelchair and onto the operating table. Deering et al also used simulation to identify errors and deficiencies in the management of obstetric hemorrhage. 620

This team found that almost one-half of 40 residents from 3 obstetrics-gynecology residency programs made an error in the dose or route of medications during a postpartum hemorrhage (PPH) simulation.49 Thus, simulation is used to identify and address management pitfalls before they affect the care of a real laboring woman by improving individual technical skills,50,51 provider knowledge and confidence,52 efficiency of interventions,53 accuracy and timeliness of medication administration, and accuracy and completeness of documentation.53 A recent longitudinal intervention study in community hospitals in Oregon demonstrated that simulation-based training consisting of a simulated birth and PPH led to significantly improved response times in the management of PPH, including the recognition of PPH, time to administer first medication, performance of uterine massage, time to administer second medication, and use of 3 indicated medications improved after training (P = .01).54 This study supports the findings of other research that the use of simulation can improve the management of various simulated emergencies such as eclampsia,46,47 shoulder dystocia,55 maternal cardiac arrest,46 and umbilical cord prolapse.56 Table 3 includes factors that have emerged as components of a successful simulation-based training program. Although most of the published studies on simulation in obstetrics have focused on the use of simulation for the training of providers already in clinical practice or clinical training, pilot studies suggest that simulation can be used to teach procedural, behavioral, and clinical decision-making skills to students—including midwifery students—during the preclinical portion of their education.57,58 Simulation may become a key technique to help students more successfully and efficaciously transition from the classroom to clinical practice, as well as a method to determine students’ preparedness to enter into clinical practice. The experience of established centers such as the Uniformed Services University of the Health Sciences and the Center for Medical Simulation of Harvard Medical School shows that simulation can be incorporated into nearly all components of the curriculum across specialties and disciplines.59 Evidence that the knowledge and skills gained during simulation training can be transferred into real clinical practice and translated into improvement in perinatal outcomes is still limited, but promising. A study from a team in England provides the most relevant and most compelling evidence that simulation-based team training may be able to produce improvements in the management of real-life obstetric emergencies.55 In this retrospective cohort study, the researchers found that the incidence of hypoxic-ischemic encephalopathy decreased significantly from 27.3 to 13.6 per 100,000 births following a one-day training course for midwives, obstetricians, and anesthesiologists (P = .032). The course was conducted using several formats including traditional lecture, EFM tracing review, and small groupcase discussion. The educational component on interpretation of FHR patterns was followed by a series of 6 simulations that addressed various intrapartum emergencies. The marked improvement in perinatal outcomes documented in the study may have resulted because the training led to better recognition of intrapartum problems requiring preventive Volume 59, No. 6, November/December 2014

Table 3. Components of Successful Simulation-Based Training Programs

Training is championed by institutional leadership. Training is conducted at low cost or no cost to the participants and is scheduled in a way that facilitates participation for all shifts (eg, nighttime trainings in addition to daytime trainings). Training is conducted in a safe, threat-free environment where learners are able to make mistakes without ridicule or repercussion. Training is conducted in-house, making it cheaper and more accessible to participants. Simulation scenarios are conducted in situ (in actual work areas where emergencies would take place). This allows for increased realism and identification of site-specific barriers to emergency response. Training involves a sufficient proportion of staff to allow for improvements to institutional culture and sustained improvement in team response. Trainings are repeated on a regular basis to maintain provider and team proficiency and to ensure that new team members receive training. Simulation scenarios include, when possible and appropriate, an actress playing the part of a patient to increase realism and integrate the patient perspective. Training includes all members of the multiprofessional (eg, nurses, midwives, physicians) and multidisciplinary (eg, anesthesiology, obstetrics, pediatrics) teams who are involved in the care of laboring women as well as neonates. Training includes a constructive debriefing component during which participants are able to discuss the simulated scenario and create an action plan to improve individual or team response or to make system changes that will improve care of laboring women as well as neonates. Source: Siassakos et al,60 Meri´en,43 and Robertson et al.44

birth, and the training as a team led to improved chain-ofaction from the decision to proceed with immediate birth to the actual birth.43 Another research team also led by Draycott found improved management of umbilical cord prolapse following simulation-based training, including a significant decrease in the diagnosis-to-birth interval from 25 to 14.5 minutes (P ⬍ .001).56 Preliminary results from a separate research team conducting emergency management of obstetric complications trainings in international settings also indicate that simulation-based training has improved neonatal outcomes.52 This training program, which was designed for implementation in low-resource settings, demonstrated that effective, high-fidelity simulation can be conducted without the use of expensive, computerized mannequins. Few of the current research reports have described the incorporation of EFM tracings into simulation scenarios, and none have specifically examined whether scenario-based simulation training impacts the ability of individual providers or provider teams to interpret FHR patterns and make management decisions using the information provided by the EFM tracing. Research is needed on this topic. Additional research is also needed to confirm that the skills and knowledge obtained during simulation-based training are transferred into clinical practice in a way that consistently produces improved outcomes during real emergencies.

Additional Interventions That Improve the Clinical Response to Fetal Heart Rate Emergencies

Additional factors that improve recognition and response to FHR pattern emergencies include multidisciplinary training in interpretation of FHR patterns,61,62 the presence of a dedicated operating room ready at all times for an emergent cesarean, the continuous availability of anesthesia,63 and the implementation of simplified workflows and alarm/code sysJournal of Midwifery & Women’s Health r www.jmwh.org

tems that quickly alert the necessary team members of an obstetric emergency.64 There are also promising innovations in individual provider education programs that focus on improving clinical judgment in the management of variant FHR patterns, including approaches that provide adaptive, individualized content. Evidence documenting their effectiveness in improving clinical outcomes, however, is currently unavailable. CONCLUSION

Research over the last few decades has provided an improved understanding of which FHR patterns are most likely to be associated with fetal acidemia, as well as which FHR patterns are associated with specific obstetric emergencies. These FHR patterns are comparatively rare, especially in women at term who are in labor. When they do occur, however, there is evidence that immediate intervention to optimize fetal oxygenation and achieve expedited birth can help prevent fetal neurologic injury or death. Timely recognition of those patterns signaling the presence of potentially damaging acidemia, therefore, is critical to the management of these emergencies. The decision of whether to proceed with emergent birth depends on a variety of factors, including the availability of human and material resources, the etiology of compromised oxygenation, and the duration of an abnormal FHR pattern. Multiprofessional, multidisciplinary simulation-based training has been demonstrated to be well received by participants and associated with sustained improvements in confidence, knowledge, and clinical management of emergency situations.45,46 AUTHOR

Jenifer O. Fahey, CNM, MSN, MPH, is Assistant Professor at the University of Maryland School of Medicine in Baltimore, Maryland. 621

CONFLICT OF INTEREST

The author has no conflicts of interest to disclose.

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