Failure to Monitor, Interpret or Respond to Atypical and Abnormal Fetal Health Surveillance (FHS) Patterns

Service: Risk Management
Subject: Care
Setting: Obstetrics

Assessment of the fetal heart rate response to uterine activity provides insight into the wellbeing of the fetus. The lack of proficiency in performing and interpreting intermittent auscultation (IA) and/or electronic fetal monitoring (EFM), in conjunction with high levels of intra/inter-observer disagreement surrounding EFM interpretation has contributed to adverse clinical outcomes including intrapartum morbidity and mortality.

In civil actions involving neurologically or physically compromised newborns (where it is alleged that the management of labour, delivery and/or resuscitation processes contributed to long term harm), the health record is considered the most reliable source of evidence of the care provided to the pregnant person (i.e. the records are frequently regarded as proof of the facts). Missing and inadequate documentation of fetal heart rate assessments makes defending medical-legal claims challenging.

Common claim themes

System

  • Inconsistent and ineffective means to ensure initial and ongoing team knowledge and insight in fetal health surveillance (e.g., clinical competence assumed versus demonstrated).
  • Perceived and actual tolerance of unprofessional, unsafe and/or disruptive behaviour as well as ongoing inter-/intra-professional conflicts.
  • Lack of a newborn and obstetrical emergency response code and evidence based procedures.
  • Resource and staffing challenges in responding to time sensitive and urgent obstetrical scenarios, including (but not limited to) lack of a practitioner skilled to perform or apply advanced.
    • Neonatal resuscitation such as  intubation and endotracheal tube management;
    • Fetal assessment including application of fetal scalp/spiral electrode (FSE).
  • Chaotic transfers to the operating room for an urgent and emergent C-sections.

Knowledge and judgement

  • Lack of compliance and/or awareness with hospital/facility FHS policies.
  • Labouring persons unattended for significant periods of time.
  • Staff practicing under the assumption that another practitioner is monitoring (double checking) the tracing at a centralized fetal surveillance monitoring station.
  • Fetal heart alarms and alerts ignored or bypassed due to alarm fatigue.
  • Misinterpretation of abnormal IA and atypical and abnormal EFM tracing patterns:
    • In the presence of IV oxytocin (induction and augmentation of labour);
    • During second stage of labour (both passive and active stages).
  • Normalizing and/or decreased vigilance over time towards atypical (IA and EFM) and abnormal (EFM) FHS findings.
  • Failure to properly perform IA and/or classify continuous EFM tracings resulting in interpretation difficulties, misdiagnoses and delays in identifying and responding to changes in fetal status.
  • Undetected and unremitting (constant) uterine tachysystole and its negative impact on fetal oxygen reserves.
  • Delays in:
    • Request for, or application of FSE when clinically indicated (e.g., challenges finding or  hearing fetal heart sounds, uninterpretable tracing);
    • Calling for assistance and notifying the MRP:
      • Due to misinterpretation of atypical or abnormal FHS;
      • Due to confusion between the pregnant person’s and fetal heart rates;
      • When abnormal FHS is encountered/persists (e.g., FHS pattern does not return to normal).
    • Calling a newborn and/or obstetrical emergency code (code pink and/or resuscitation team).
  • Failure to initiate timely intrauterine resuscitation measures due to misinterpretation of fetal status.
  • Failure to institute protective measures for cord prolapse during transfer to and/or awaiting C-section.
  • FHS not or inadequately performed once an urgent or emergent C-section is called including pregnant persons being prepped for and/or in the OR awaiting team arrival.

Communication and documentation

  • Hesitancy to escalate concerns about unsafe practitioners and practices, including practitioners in leadership roles (e.g., department chief, clinical educator, team lead).
  • Disagreement among the health care team as to when and whether the report and/or consultation for the atypical and/or abnormal FHS took place.
  • Inconsistent:
    • Charting-by-exception or focus charting practices (e.g., normal IA and EFM classification not recorded);
    • Documentation of:
      • Fetal assessments and interpretation during first and second stage of labour including presence or absence of accelerations and variable decelerations;
      • IA performed once the EFM is temporarily removed;
      • Uterine activity;
      • Fetal station and position; 
      • Justification for discontinuing continuous EFM;
      • Intrauterine resuscitation measures instituted in response to abnormal IA or atypical or abnormal EFM tracing findings.

Case Study 1

A pregnant person with a body mass index (BMI) > 50 kg/m2 presented to hospital in latent labour. The practitioners encountered difficulties with FHS monitoring throughout the labour. Ultimately, the pregnant person underwent an emergency C-section due to abnormal FHS. The infant was transferred to a tertiary care hospital and diagnosed with permanent brain damage. Expert review of the practitioners’ care and management indicated that the care provided was sub-optimal. In particular, the practitioners’ lack of awareness and compliance with the hospital policy on FHS, specifically related to the frequency of FHS monitoring, and interpretation of findings. In addition there was a delayed response to challenges in confirming the wellbeing of the fetus due to maternal body habitus. There was also an apparent lack of proactive care planning given the presence of risk factors (loss of situational awareness or ‘big picture’ thinking). Experts were also critical of the team surrounding the confusion on the degree of urgency in performing the C-section.

Case Study 2

A pregnant person presented to the hospital in labour at 41w+3d (post dates). The FHS was done via IA and remained normal up to full dilation. The FHS was switched over from IA to continuous EFM due to repetitive abnormal FHS findings. The EFM tracing was abnormal for over an hour with minimal variability and no evidence of accelerations or decelerations. The on call obstetrician was consulted an hour later. A decision was made to expedite delivery by a vacuum extraction. The infant was delivered unresponsive, with low Apgar scores, poor umbilical cord pH gases and was admitted to a tertiary paediatric facility. Expert review of the case considered the practitioners’ care and decision making to be indefensible, in particular their failure to institute typical intrauterine resuscitation interventions and the one hour delay in consulting with the obstetrician once the abnormal fetal health rate (FHR) patterns were identified.

Mitigation strategies

Reliable Care Processes

  • Adopt a standardized current evidence-based interdisciplinary decision tree or algorithm(s) to assist in the systematic interpretation of and response to:
    • Abnormal IA and atypical and abnormal EFM tracing findings;
    • Uninterpretable and poor quality tracings (e.g., use of FSE where available, repositioning, hand held doppler, etc.).
  • Adopt the current Canadian recommendations for the frequency of FHS during labour (i.e., SOGC guidelines).
  • Implement formal strategies to ensure the clinical skill, knowledge and experience associated with the application of FSE is available for all births.
  • Adopt a standardized speed (3cm/minute) for all EFM devices.
  • Adopt a standardized current evidence-based interdisciplinary intrauterine resuscitation protocols.

Strategies specific to nurses, midwives, obstetricians, family practitioners and anesthesiologists

  • Adopt best practice and methodology for performing IA (avoid abbreviated means of counting the fetal heart rate to minimize missing significant fetal findings, listening for a full minute whenever possible and palpating the pregnant person’s pulse to differentiate between the pregnant person’s and fetal heart rate).
  • Be familiar with the hospital’s/health region’s: 
    • On-call and second on-call contingency plan (e.g., specific action to be taken when the on-call does not respond or is unable to respond in an appropriate timeframe); 
    • Obstetrical program’s chain of command (‘escalation’ process), including the names, titles and current phone numbers of the obstetrical team members in the line of authority.

Documentation and Communication

Strategies specific to nurses, midwives, obstetri¬cians, family practitioners and anesthesiologists

  • Ensure complete, timely and judicious documentation of the reasons for:
    • Not performing scheduled fetal and maternal assessments;
    • Not utilizing and/or switching to continuous EFM where suggested by professional and/or hospital/health region guidelines;
    • Not immediately requesting physician attendance or consult in the presence of a non-responsive abnormal fetal status;
    • Disagreement with perinatal surveillance software alerts, alarms, interpretation and/or recommendations (including overrides and bypasses);
    • Discontinuing continuous EFM where utilized;
    • Care-related differences with the MRP and implementation of chain of command or escalation protocol.
  • Ensure complete and timely documentation of informed declines, in particular declined fetal monitoring, vaginal exams or continuous EFM where indicated; 
    • Ensure to document the pregnant person’s informed understanding that choosing to decline conflicts with applicable obstetrical, midwifery, and hospital, health region or birth centre guidelines (where a conflict exists).

Equipment

  • Implement formal strategies to:
    • Reduce fetal heart rate alarm and alert fatique (e.g., customizing alerts settings where available, reviewing alert indicators, adequate staffing to respond to alerts, noise control facility design, sharing alert data reports with units, surveying staff attitude/concerns towards alerts );
    • Improve the effectiveness and efficacy of centralized fetal heart rate monitoring (e.g., having more than one person monitor the tracings, limiting the duration of the monitoring shift, etc.).

Education

  • Implement formal multifaceted and targeted safety strategy to support and enhance the ongoing timely and consistent FHS interpretation and communication by nurses, midwives and physicians (e.g., participation in MOREOB, Canadian Fetal Health Surveillance Program, interdisciplinary workshops, in-situ simulations and emergency skill drills; sharing of learnings and trends from periodic chart audits and extracts, analysis of reported incidents or events, and medical-legal matters); 
    • Ensure the FHS education utilize Canadian guidelines and educational materials.

Monitoring and Measuring

  • Implement formal strategies to monitor and measure fetal health surveillance documentation practices across all teams and practitioners, including (but not limited to):
    • IA assessments, for example:
      • uterine activity: frequency, duration, intensity and relaxation between contraction
      • FHR: baseline, rhythm and gradual/abrupt decelerations or accelerations, and
      • practitioner interpretation;
    • IA performed when the pregnant person is discontinued from continuous EFM (e.g., ambulation, shower, labouring in water, preparation for and/or transport to OR);
    • EFM assessments (e.g., uterine activity [frequency, duration, intensity and relaxation between contractions], FHR [baseline, variability, presence and absence of accelerations, presence and type of decelerations, changes in trends over time] and practitioner interpretation).
  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and interdisciplinary adherence to fetal health surveillance guidelines, protocols and algorithms, including:
    • Adoption of formal quality measure and indicators (e.g., adherence to local FHS guidelines, evidence of delayed physician notification/consultation by any team member, missing EFM assessments once C-Section is called, cord gases with pH 7.0);
    • Sharing of learnings from perinatal harm incidents involving FHS with the interdisciplinary team(s) (e.g., learnings from chart audits, trigger tools, incident reports, team debriefs, critical incident, quality of care and quality improvement committee reviews, data from provincial birth and perinatal registries as well as maternal and perinatal networks, medical legal claims, coroner reports and recommendations).
       

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