Mismanagement of Intrapartum Fetal Monitoring

Assessment of the fetal heart rate (FHR) response to uterine activity provides insight into the wellbeing of the fetus. The lack of proficiency in performing and classifying intermittent auscultation (IA) and / or electronic fetal monitoring (EFM), in conjunction with high levels of intra- or inter-observer disagreement surrounding EFM classification 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). Inconsistencies and gaps in documentation of FHR assessments makes defending medical-legal claims challenging. 

Expected Outcomes

Adopt standardized evidence-based protocols to support early detection and response to atypical and abnormal FHR patterns.

Implement strategies to support a psychological safety workplace.

Implement formal strategies to provide targeted FHS education and training.

Definitions and Acronyms

• BMI – body mass index
• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• EFM – electronic fetal monitoring
• FHR – fetal heart rate
• FHS – fetal health surveillance
• FSE – fetal spiral electrode
• Human factors – “scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human wellbeing and overall system performance.” (International Ergonomics Association, n.d.)
• IA – intermittent auscultation
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician
• NICU – neonatal intensive care unit
• OR – operating room
• PRN – Latin abbreviation for “pro re nata” meaning “as needed” or “as necessary”
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning

Common Claim Themes and Contributing Factors

Organizational

• Perceived or actual systematic tolerance of unprofessional or unsafe behaviours.
• Intra- and inter-disciplinary conflicts.
• Lack of, unrealistic, or ambiguous:
  • Escalation and chain of command process;
  • Obstetrical emergency response and codes.
• Lack of clarity on how to activate the obstetrical emergency contingency plans when on-call team members fail to respond or attend.
• Insufficient mechanisms to support provider and team proficiency in FHS and awareness of applicable policies / protocols.
• Lack of systematic approach to perinatal-related harm incidents involving FHS during labour.
• Lack of a formal plan to respond to various types of staffing and resource challenges to ensure optimal care during labour and birth.
• Periodic and ongoing delayed attendance to urgent and emergency situations by on call, second on call / contingency practitioners, and surgical teams. 

Knowledge and Judgment 

• Misidentification of the pregnant person’s heart rate as the FHR.
• Failing to modify FHS practices (where clinically indicated) for pregnant persons with additional risks. 
• Inadequate response to unremitting uterine tachysystole.
• Infusing IV oxytocin for augmentation of labour in the absence of reliable, interpretable, and normal FHS. 
• Normalizing and decreased vigilance over time towards atypical and abnormal FHR findings.
• Assumptions that tracings at the centralized monitoring location was monitored by another practitioner.
• Lapse in team and practitioner situational awareness, contributing to delayed recognition of and response to pregnant person and / or fetal deterioration during labour.
• Inappropriate discharge following triage assessment (e.g., reduced fetal movements), atypical or abnormal non-stress test.
• Delays:
  • Requesting or applying fetal spiral electrode (FSE) when indicated (e.g., challenges finding or hearing fetal heart sounds; uninterpretable tracing);
  • Calling for assistance, notifying the most responsible practitioner (MRP) or requesting a physician consult where indicated;
  • Calling a newborn and / or obstetrical emergency code (code pink and / or resuscitation team).
• FHS not or inadequately performed once an urgent or emergent caesarean is called, including pregnant persons being prepped for and / or in the operating room (OR) awaiting team arrival.
• Improper or incomplete handovers for care transitions between providers, especially changes in MRP.

Pregnant Person

• Does not consent to assessments or recommendations for fetal and pregnant person monitoring, EFM, or obstetrician consult.
• Higher risk factor impacting routine FHS. 

Communication

• Hesitancy to escalate concerns about unsafe practitioners and practices, including:
  • Practitioners in leadership roles; 
  • Disagreements with leadership regarding further escalation of unresolved concerns.
• Disagreement among the team as to whether a report or consultation for ongoing atypical and / or abnormal FHS took place. 
• Significant delays notifying and requesting MRP attendance:
  • Following client arrival at obstetrical triage and / or admission to the labour / delivery unit;
  • Significant changes in health status of the pregnant person;
  • When abnormal FHS is encountered and / or persists (e.g., FHS pattern that does not return to normal) in obstetrical triage, in the labour / delivery suite, following the call for an emergency caesarean, and in the OR or caesarean ready room.

Documentation

• Gaps or inconsistencies in documentation related to:
  • Shared Decision Making (informed choice - informed consent) discussions;
  • FHS assessments;
  • Intrauterine resuscitation measures;
  • All methods and attempts to contact the MRP or consultant. 

Mitigation Strategies

Reliable Care Processes 

• Adopt a standardized evidence-based protocol to assist in the systematic classification of and response to abnormal IA and atypical and abnormal EFM tracing findings (Dore & Ehman, 2020); ensure the protocol includes considerations regarding access to appropriate resources and infrastructure (intrauterine pressure catheters and FSEs) when providers are challenged to adequately monitor uterine activity and / or FHR.

Psychological Safety

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Interprofessional collaboration and collegiality;
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation;
  • Assertive and respectful questioning and challenging of unsafe practices;
  • Early response to suspected and actual pregnant person and / or fetal deterioration, including seeking assistance from peers and other resources (e.g., rapid response teams where in place) (D'Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005) (Romijn, De Bruijne, Teunissen, Wagner, & De Groot, 2018).
• Adopt a standardized, formalized, and program-specific chain of command protocol for the rapid escalation of unresolved care concerns or disagreements related to orders and / or decisions related to FHS during labour (Provincial Council for Maternal and Child Health, 2022) (Agency for Healthcare Research and Quality, 2017).

Communication

• Implement formal strategies to enable access to interpreter services during the intrapartum period to facilitate shared decision making (informed choice - informed consent) conversations in all birth locations (Le Neveu, Berger, & Gross, 2020).
• Adopt a standardized and structured communication framework for team (intra- and inter-disciplinary) communication during the intrapartum and postpartum period (e.g., SBAR). 
• Implement formal strategies to discourage informal reports or consultations (e.g., hallway chats and heads up) with the MRP or physician consultant (Canadian Medical Protective Association, 2019).
• Implement strategies to facilitate timely communication to the MRP or physician consultant:
  • For pregnant persons enroute to the hospital from the community labour / birth setting;
  • Following pregnant person's presentation to the obstetrical triage and / or labour / delivery floor;
  • Following the pregnant person's presentation to the hospital from the community birth location due to ongoing and / or unresolved FHS abnormalities or pregnant person concerns;
  • When continuous EFM, where utilized or ordered, is discontinued;
  • Where fetal monitoring is challenging or unresolved inadequate quality or non-interpretable tracings;
  • When a pregnant person declines some or all fetal assessments during labour (including EFM where indicated by hospital/health region guidelines).
• Adopt a standardized and formalized on-call and second on-call / contingency protocol for the rapid response for when the MRP, physician consultant, resuscitation team, or surgical team does not respond or is unable to respond in a clinically appropriate timeframe; ensure the protocol is updated based on human health resource changes and challenges (Stirk & Kornelsen, 2019).
• Adopt a standardized and formalized communication process for handovers and transfer of accountability during the intrapartum period, including (but not limited to) handover and transfer of accountability between:
  • Triage and labour floor;
  • Labour floor and neonatal intensive care unit (NICU);
  • Practitioners (nurse to nurse during breaks or shift change, midwife to physician during transfer of care, etc.).
• Clarify, in practice and in protocol, the role of midwives after a transfer of primary clinical responsibility to a physician.

Equipment and Technology

• Implement formal strategies to ensure central monitoring is not used as replacement for bedside observations and assessments (where indicated).
• Implement formal strategies to:
  • Clarify the practice expectations for staff monitoring displays at the central monitoring location (e.g., offer collegial and timely support to the practitioners in the room versus assume they will ask for help if needed) (Small, Sidebotham, Fenwick, & Gamble, 2022) (Ona & Greenberg, 2018);
  • Reduce critical alarm and alert fatigue (Kern-Goldberger, Hamm, Raghuraman, & Srinivas, 2022) (Kern-Goldberger, Nicholls, Plastino, & Srinivas, 2023).
• Implement strategies to support adequate and appropriate fetal monitoring supplies such as intrauterine pressure catheters and FSEs.

Strategies for midwives and physicians

• Adopt a standardized request template for referrals / consultations during the antenatal and intrapartum period (College of Physicians and Surgeons of British Columbia, 2022) (College of Midwives of Manitoba, 2020).

Additional Considerations

Examples of elements to address during intrapartum referrals and consults:

• Pregnant person’s name, personal health number, and preferred and current contact details;
• Reason for consultation;
• Diagnosis;
• History of complaint;
• Medical history and social information;
• Clinical concerns;
• Special considerations;
• Copies of or summary of significant laboratory investigations, imagings, or other consultant reports;
• Urgency of referral;
• Type of consultation (medical opinion only, treatment, transfer of care, etc.).

• Adopt a standardized process for the follow-up of laboratory, imaging, or consultation results (Canadian Medical Protective Association, 2021a) (Canadian Medical Protective Association, 2020) (Canadian Medical Protective Association, 2021b).

Team Training and Education

• Implement formal strategies to support and enhance the team’s (i.e., nurses, midwives and physicians) clinical knowledge, skills (technical and non-technical), and practical experience surrounding FHS during labour including (but not limited to) scheduled interprofessional and cross-department skill drills, simulations, and FHS certification (Canadian Association of Perinatal and Women's Health Nurses, 2018) (Dore & Ehman, 2020).
• Ensure the scheduled interprofessional and cross-department team training and education strategies address or involve: 
  • Knowledge, skills, and practical experience required for both hospital and community birth locations;
  • Team and practitioner situational awareness (‘helicopter view’) and human factors;
  • Program areas or sites with limited practical experience with FHS such as low birth volume sites, rural sites, and emergency departments;
  • Unregulated care providers (where utilized), locums, travel, agency, contracted care providers, community birth partners in addition to regulated health professionals (NHS London, 2019) (Healthcare Safety Investigation Branch, 2020).

Documentation 

Strategies for Nurses, Midwives and Physicians

• Implement strategies to ensure contemporaneous and comprehensive documentation of all scheduled and as required FHS assessments in all phases of labour in all labour and birth settings (HIROC, 2017).

Additional Considerations

Examples of elements to document related EFM (all stages of labour, all birth locations):

• Baseline FHR;
• Indicators for initiating EFM;
• Align timing with time on the monitor clock (unless otherwise specified by local policy);
• Description of uterine activity;
• Description of resting tone;
• Description of the contraction;
• Duration of the contractions from beginning to the end;
• Description of variability;
• Presence or absence of acceleration;
• Present and type of decelerations;
• Description of the tracing classification;
• Shared decision making (informed choice - informed consent) regarding method of fetal monitoring;
• Actions taken in response to atypical or abnormal assessment, and the pregnant person's and fetal response to interventions.

Examples of elements to document related to IA (all stages of labour, all birth locations):

• Numerically defined terms (tachycardia, bradycardia);
• Baseline FHR;
• Description of FHR rhythm;
• Description of uterine activity:
  • Resting tone; 
  • Contraction intensity; 
  • Duration of the contractions from beginning to the end; 
• Presence or absence of accelerations or decelerations;
• Classification as normal or abnormal;
• Actions take in response to abnormal assessment, and the pregnant person's and fetal response to interventions;
• Indications for switching from IA to EFM;
• Rationale for not switching to EFM where ordered or indicated by local hospital / health region policy.

• Implement strategies to ensure contemporaneous and comprehensive documentation of the shared decision making (informed choice - informed consent) discussions surrounding method of fetal monitoring, including (but not limited to) where the pregnant person declines:
  • Scheduled and PRN fetal monitoring assessments (some or all of the assessments);
  • EFM where recommended by the MRP or indicated by local hospital / health region policy.

Monitoring and Measurement

(Stirk & Kornelsen, 2019)

• Implement formal strategies to monitor and measure practitioner and team attendance at labours / births (patterns, influences on attendances including when teams are called in from off site, etc.) and resources for intrapartum consults and attendance at birth. 
• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving FHS monitoring, classification, and related team communication resulting in client harm or death (Machen, 2023); incorporate system thinking and human factors concepts into the review process.
• Adopt standardized quality indicators for FHS during labour and collaborative care (Calder, et al., 2019) (Health Quality Ontario, n.d.).
• Incorporate learning from local, provincial, and national perinatal related safety reviews and data related to FHS and intrapartum care into local protocols as well as staff and client education and training. 

References

• Agency for Healthcare Research and Quality. (2017). Safe Medication Administration: Oxytocin. Retrieved from https://www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
• Calder, L. A., Bowman, C. L., Yang, Q., Gondocz, T., Young, C., Zhang, C., . . . G., L. (2019). A quality indicator framework for high-risk areas in obstetrical care. Canadian Medical Protective Association.
• Canadian Association of Perinatal and Women's Health Nurses. (2018, 2). CAPWHN Position Statement - Fetal Health Surveillance Education for Nurses. Retrieved from Canadian Association of Perinatal and Women's Health Nurses: https://capwhn.ca/wp-content/uploads/2019/10/FHS_Position_Statement_Approved21.2.18_Final.pdf
• Canadian Medical Protective Association. (2019). If a colleague relies on your professional opinion, you may have a duty of care. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2019/if-a-colleague-relies-on-your-professional-opinion-you-may-have-a-duty-of-care
• Canadian Medical Protective Association. (2020). Results and expectations: Test follow-up and the office-based family physician. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2020/results-and-expectations-test-follow-up-and-the-office-based-family-physician
• Canadian Medical Protective Association. (2021a). Test results follow-up. Retrieved from https://www.cmpa-acpm.ca/en/education-events/good-practices/physician-patient/test-results-follow-up
• Canadian Medical Protective Association. (2021b). Continuity of care: Helping patients avoid falling through the cracks. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/continuity-of-care-helping-patients-avoid-falling-through-the-cracks
• College of Midwives of Manitoba. (2020). Standard for consultation and transfer of care. 
• College of Physicians and Surgeons of British Columbia. (2022). Referral-consultation process. 
• D'Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., & Beaulieu, M.-D. (2005, 5). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, 19(sup1), 116-131.
• Dore, S., & Ehman, W. (2020). No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline. J Obstet Gynaecol Can, 42(3), P316-348.E9. doi:10.1016/j.jogc.2019.05.007
• Health Quality Ontario. (n.d.). Vaginal birth after caesarean (VBAC). Retrieved from https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Vaginal-Birth-After-Caesarean-VBAC/Quality-Statement-8-Induction-and-Augmentation-of-Labour
• Healthcare Safety Investigation Branch. (2020). Delays to intrapartum intervention once fetal compromise is suspected. Retrieved from https://www.hsib.org.uk/investigations-and-reports/delays-to-intrapartum-intervention-once-fetal-compromise-is-suspected/delays-to-intrapartum-intervention-once-fetal-compromise-is-suspected/
• HIROC. (2017). Strategies for improving documentation: Lessons learned from medical-legal claims. Toronto, ON.
• International Ergonomics Association. (n.d.). What Is ergonomics (HFE)? Retrieved from https://iea.cc/about/what-is-ergonomics/
• Kern-Goldberger, A., Hamm, R., Raghuraman, N., & Srinivas, S. (2022, 4). Reducing Alarm Fatigue in Maternal Monitoring on Labor and Delivery: A Commentary on Deimplementation in Obstetrics. American journal of perinatology.
• Kern-Goldberger, A., Nicholls, E., Plastino, N., & Srinivas, S. (2023, 5). The impact of an intervention to improve intrapartum maternal vital sign monitoring and reduce alarm fatigue. American Journal of Obstetrics & Gynecology MFM, 5(5), 100893.
• Le Neveu, M., Berger, Z., & Gross, M. (2020, 9). Lost in Translation: The Role of Interpreters on Labor and Delivery. Health Equity, 4(1), 406-409.
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• NHS London. (2019). Intrapartum fetal monitoring: Training and competency assessments best practice sources. 
• Ona, S., & Greenberg, J. (2018, 5). Responses to Fetal Heart Rate Alarms on a Busy Tertiary Labor and Delivery Unit [12R]. Obstetrics & Gynecology, 131(1), 197S-198S.
• Provincial Council for Maternal and Child Health. (2022). Safe administration of oxytocin. 
• Romijn, A., De Bruijne, M., Teunissen, P., Wagner, C., & De Groot, C. (2018, 10). Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? International Journal of Integrated Care, 18(s2), 228.
• Small, K., Sidebotham, M., Fenwick, J., & Gamble, J. (2022, 3). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women and Birth, 35(2), 193-200.
• Stirk, L., & Kornelsen, J. (2019, 5). No. 379-Attendance at and Resources for Delivery of Optimal Maternity Care. Journal of Obstetrics and Gynaecology Canada, 41(5), 688-696.e4.