Garite_edit.qxp 8/8/08 12:29 Page 62
Maternal–Fetal Medicine
time and remove the nurse from the patient. A simple policy, called Where do we need to go now with EFM? Clearly, any technology with a
‘charting by exception,’ would create written definitions of what high sensitivity and poor specificity, such as EFM, should have a back-up
constitutes a reassuring tracing and ask the nurse to initial the tracing method. When the FHR is reassuring, care-givers are well trained, and the
every 15 minutes as long as the FHR fits these criteria. When the FHR does monitor is carefully watched, mistakes that can result in hypoxic damage
not meet these criteria, the physician should be notified and the nurse to the baby will rarely be made, since there will never be an oxygen
should perform the appropriate interventions and make a chart entry deficit with a reassuring FHR pattern. There are specific circumstances
describing what is seen and what was done. where FHR can accurately be relied upon to identify hypoxia and acidotic
fetuses. These include persistent late decelerations with absent
Fifth, a physician is required to review all non-reassuring and questionable variability, persistent severe variable decelerations with tachycardia and
patterns. This may be done in person or electronically, but there should absent variability, and persistent bradycardia with absent variability.
never be any argument; when the nurse has a concern, the physician should
review the strip. However, most non-reassuring FHR patterns do not meet these criteria,
and in these situations the fetus is more often not hypoxic. How can we
Sixth, a hospital should be able to achieve a 30-minute response time to be sure and do we want to take a chance on the baby’s outcome when
perform a Cesarean section whenever an FHR pattern indicates that such an we cannot be sure? The answer is of course no, and that is why there are
urgent intervention is required. Policies to ensure nursing, operating room, so many unnecessary but appropriate operative interventions. What we
anesthesia, and obstetric physician staff are available to accomplish this desperately need is a back-up method that has excellent specificity for
should be created. Many hospitals are now performing unexpected drills at hypoxia and/or acidosis.
random times to see whether this can be consistently performed.
Fetal scalp pH monitoring was the original method used, and is still in
The seventh recommendation concerns oxytocin problems, which are widespread use in parts of Europe, but it is infrequently used in the US
among the most consistently alleged issues of substandard care in the event because it is cumbersome and the volume of blood obtained does not
of a bad outcome. Clark
4
has made the following recommendations to allow the determination of partial pressure of carbon dioxide (pCO
2
) and
avoid this issue: ruling out a respiratory acidosis that is not significant. Continuous pH
monitoring using a glass electrode was attempted but never perfected.
• there should be checklists for oxytocin use—one for induction and one
for augmentation; There was great hope that fetal pulse oximetry would be the answer to
• a history and physical should be undertaken, and a physician must order this problem, but, for various reasons, including the fact that the
oxytocin. The physician’s note should include that the pelvis is clinically technology was rolled out before it was perfected, its popularity and
adequate, and indicate oxytocin; utilization (which had a brief flurry of success) waned and the product is
• an estimated fetal weight should be on the chart from within the no longer produced in the US. This technology is theoretically ideal, and
past week; will perhaps re-emerge at some point in the future.
• the physician should be readily or immediately available as defined
locally by hospital protocol; Currently, the only technology available that shows great promise to back
• one-on-one nursing should be provided whenever possible; up EFM is the STAN technology, which is a computer-based analysis of the
• EFM criteria for continuing oxytocin should be established. Suggestions EKG waveform and is apparently a more specific way of defining fetal
for such criteria include no late decelerations within the last 30 minutes, hypoxia. There are two very good prospective randomized trials in Europe
and no variable decelerations to <60bpm for >60 seconds within the last that suggest that this technology not only decreases the need for
30 minutes. A physician’s note should be required to continue oxytocin unnecessary operative intervention, but may even decrease the likelihood
for any exception to the above; of delivering a baby with severe metabolic acidosis.
5,6
Trials in the US are
• contraction criteria should be defined: adequate recording at the planning stage, and the machines are currently being used in
of contractions should be documented or monitored with several pilot hospitals.
intrauterine-pressure catheter (IUPC), uterine contractions (UCs) should
not exceed five to 10 minutes, and no two UCs should last >120 seconds Obstetrics is not unique in its quest for a technology that improves patient
in a 30-minute period. If IUPC is used, Montevideo Units should be <300 outcome. The labor and delivery unit is a true intensive care area, and
and resting tone <25; and dangerous and unexpected things can and do happen. The technology of
• a protocol should be established for the oxytocin dosing regimen. When EFM is imperfect in many ways, but it is what we have. Therefore, we are
an exception to this protocol is made, a written order and note obliged to understand it, to continually improve our expertise in its use,
explaining why should be required. and to apply it appropriately and carefully. ■
1. Freeman RK, Garite TJ, Nageotte MP, Fetal Heart Rate Monitoring, score, JAMA, 1972;219:1322. Obstet Gynecol, 1993;169:1151–60.
3rd Edition, Philadelphia: Lippincott, Williams & Wilkins, 2003. 4. Clark SL, Oxytocin, new perspectives on an old drug, Am J Obstet 6. Amer-Wåhlin I, Hellsten C, Noren H, et al., Cardiotography only
2. Joint publication of the American College of Obstetricians and Gynecol, 2008; in press. versus cardiotocography plus ST analysis of fetal
Gynecologists and the American Academy of Pediatrics, Neonatal 5. Westgate J, Harris M, Curnow JSH, Greene KR, Plymouth electrocardiogram for intrapartum fetal monitoring: a Swedish
Encephalopath and Cerebral Palsy, 2003. randomised trail of cardiotocogram only versus ST waveform plus randomised controlled trial, Lancet, 2001;358:534–8.
3. Shifrin BS, Dame L, Fetal heart rate pattern. Prediction of Apgar cardiotocogram for intrapartum monitoring, 2,400 cases, Am J
62 US OBSTETRICS & GYNECOLOGY
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100 |
Page 101 |
Page 102 |
Page 103 |
Page 104 |
Page 105 |
Page 106 |
Page 107 |
Page 108 |
Page 109 |
Page 110 |
Page 111 |
Page 112 |
Page 113 |
Page 114 |
Page 115 |
Page 116