Mosby's® Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach

370 Pages·2021·33.419 MB·English

by  Lisa A. Miller CNM JD, David Miller, Rebecca L. Cypher

Quick Reference Guide
● ABCDs of intrapartum FHR management, 150
● Differential factors that may influence FHR, 108
● Evaluation of uterine activity during labor, 85
● Fetal oxygenation pathway, 11
● Fetal response to interrupted oxygenation, 11
● NICHD FHR categories, 106–107
● NICHD FHR definitions, 105–106
● Normal values for fetal cord blood gases, 164
● Sample FHR tracings with definitions and interpretation, 291–331
● Scientific levels of evidence, 108
● Standardized FHR interpretation, 140
● Standardized intrapartum FHR management algorithm, 148
MOSBY’S®
Fetal
POCKET
GUIDE TO

Monitoring
A MULTIDISCIPLINARY APPROACH
NINTH EDITION
LISA A. MILLER, CNM, JD
Founder, Perinatal Risk Management and Education Services
Portland, Oregon
DAVID A. MILLER, MD
Professor of Obstetrics, Gynecology, and Pediatrics
Keck School of Medicine
University of Southern California
Chief, Division of Maternal Fetal Medicine
Children’s Hospital Los Angeles
Director, CHLA-USC Fetal Maternal Center
Los Angeles, California
REBECCA L. CYPHER, MSN, PNNP
Perinatal Nurse Practitioner
Founder, Cypher Maternal Fetal Solutions LLC
Gig Harbor, Washington
3251 Riverport Lane
St. Louis, MO 63043
MOSBY’S® POCKET GUIDE TO FETAL MONITORING:
A MULTIDISCIPLINARY APPROACH, NINTH EDITION ISBN: 978-0-323-64260-6
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REVIEWERS
JANICE DENNY GIBBS, MSN, RNC-INPT OB, C-EFM
Louisville, Kentucky
ELISABETH HOWARD, PhD, CNM, FACNM
Associate Professor of Obstetrics and Gynecology, Clinician Educator
Director, Midwifery
Women and Infants Hospital
Department of Obstetrics and Gynecology
Warren Alpert Medical School
Brown University
Providence, Rhode Island
JAMES M. KELLEY, JD
Elk & Elk
Mayfield Heights, Ohio
PAULA WELLDE, MSN, RNC-OB, C-EFM
Perinatal Safety Nurse
Elliot Hospital
Manchester, New Hampshire
iii
ACKNOWLEDGMENTS
Clinical Computer Systems, Inc.
Elgin, Illinois
GE Medical Systems Information Technologies
Milwaukee, Wisconsin
Hill-Rom Company, Inc.
Batesville, Indiana
Huntleigh Healthcare Ltd.
Cardiff, United Kingdom
Philips Medizin Systemes
Böblingen, Germany
iv
PREFACE
We are proud to continue nursing, midwifery, and physician collab-
oration in this new ninth edition of Mosby’s® Pocket Guide to Fetal
Monitoring: A Multidisciplinary Approach, consistent with the inter-
and intradisciplinary approach all of us bring to teaching this subject
matter. Diligently revised, this new edition continues to emphasize
standardized terminology and an evidence-based approach to inter-
pretation and management. This text remains a key resource for the
most clinically useful information for clincians of all levels on every
aspect of fetal monitoring, including intermittent auscultation, assess-
ment and management of uterine activity, and the crucial role of both
communication and documentation in risk management related to fetal
monitoring. Whether your practice is office-based, in a birth center, in a
hospital serving the community, or in an academic tertiary care center,
this text provides a relevant and easily understood reference for daily
clinical practice as well as clinician orientation and ongoing education.
DESCRIPTION
Primarily an oxygen monitor, the electronic fetal monitor is a tool
used to prevent fetal injury resulting from interruption of fetal oxy-
genation, whether used during labor or in the antepartum period. Key
to this goal is standardization and simplification of clinical practices
related to interpretation and management of fetal monitoring. This
book provides clinicians with the tools needed to understand both
the strengths and the weaknesses of both electronic fetal monitoring
(EFM) and intermittent auscultation; as well as apply a collaborative
approach to clinical practice that is evidence- and consensus-based.
After a brief overview of the history of fetal monitoring, the text pro-
vides core clinical information on the physiologic basis for monitor-
ing, reviews the newest instrumentation for uterine and fetal heart
rate (FHR) monitoring, including the newer abdominal “patch”
technology, and identifies key factors in the evaluation of uterine
activity. In keeping with maintaining the legal standard of care in
the United States, the National Institute of Child Health and Human
Development (NICHD) definitions are presented and reviewed, and
a standardized approach to interpretation and management is clearly
outlined. The influence of gestational age on FHR is examined, along
with the evaluation of fetal status outside the obstetric unit and in
the antenatal setting. Documentation and risk management issues are
v
vi Preface
delineated, including issues of informed consent in choice of moni-
toring modality. An overview of fetal monitoring in Europe provides
clinicians with a look at fetal monitoring outside the United States.
Patient safety, communication, and clinical collaboration are the cor-
nerstones of each chapter, and suggestions for practice improvement
make this edition an invaluable resource for the busy clinician.
FEATURES
This book has a number of distinctive features:
n Content is organized in a manner that allows clinicians to build
on key fundamental concepts and progress logically to advanced
principles, making the text suitable for novices needing basic
information as well as experienced practitioners seeking greater
insight into clinical practice issues.
n Critical information is highlighted using illustrations, tables, and
illustrative fetal monitor tracings.
n FHR characteristics are explained and the supporting level of evi-
dence is provided, revealing a number of common myths regard-
ing fetal monitoring.
n Evidence levels are provided for information regarding various
FHR patterns, and several common obstetric myths are laid to rest.
n Appendices now include self-assessment questions as well as
fetal monitor tracings for practice in application of the NICHD
definitions and principles of standardized interpretation.
ORGANIZATION
Chapter 1 traces the history of fetal monitoring from the use of aus-
cultation in the 17th century to present-day practice and includes
a discussion of the resurgence of intermittent auscultation for fetal
monitoring in low-risk women.
Chapter 2 provides a review of the physiologic basis for monitor-
ing. The oxygen pathway is discussed, as well as the fetal response
to interrupted oxygenation. These core physiologic concepts provide
clinicians with the fundamentals of fetal oxygenation that serve as
the basis for current practice.
Chapter 3 offers a detailed look at instrumentation for both inter-
mittent auscultation and EFM, including newer approaches such as
abdominal electrocardiogram and new display options for dopplers
used in intermittent auscultation. Both external and internal moni-
toring devices and their application are covered in depth, including
artifact detection, telemetry, and troubleshooting tips.
Preface vii
Chapter 4, on uterine activity, provides crucial information includ-
ing a detailed discussion of normal versus excessive uterine activity
and the limitations of the summary term tachysystole. Consensus
guidelines for the diagnosis of active labor are presented, and the link
between excessive uterine activity and fetal acidemia is elucidated.
Evidence-based tips for managing uterine activity in clinical practice
are offered, and oxytocin use is also addressed.
Chapter 5 breaks down clinical practice in fetal monitoring to
its three core elements: definitions, interpretation, and management.
This chapter includes the NICHD definitions with illustrations to
aid in recognition and application. The role of NICHD categories is
examined, and evidence- and consensus-based principles of interpre-
tation are explained.
Chapter 6 presents the management of FHR tracings using a sys-
tematic approach based on principles of fetal oxygenation. This com-
prehensive model is based on EFM’s value as a screening tool (rather
than a diagnostic tool). The management algorithm uses NICHD
categories and a structured approach based on the oxygen pathway.
Evidence-based corrective measures for hypoxemia are provided in
a checklist format. An adapted model specific to the management of
Category 2 FHR tracings with significant decelerations is included,
with evidence supporting this approach. Chapter 6 elucidates the
primary objective of intrapartum FHR monitoring: to prevent fetal
injury that might result from the progression of hypoxemia during
the intrapartum period.
Chapter 7 reviews FHR characteristics in the preterm, late-term,
and postterm fetus, including implications for management in both
antepartum and intrapartum settings. The chapter includes informa-
tion on a variety of medications and clinical factors that can affect
FHR at various gestational ages.
Chapter 8 explores non-obstetric settings and FHR evaluation,
focusing on the importance of collaboration. Settings such as the
emergency department, surgical suite, or intensive care unit are
discussed with key points for clinical care and FHR assessment.
Obstetric triage is reviewed, including the impact of the Emergency
Medical Transport and Labor Act (EMTALA).
Chapter 9 focuses on antepartum testing, including the nonstress
test, the contraction stress test, vibroacoustic stimulation, ultrasound,
and the biophysical profile. Information regarding indication, fre-
quency, and type of antepartum test based on the results of the most
recent NICHD panel are provided in a clinically relevant manner.
Chapter 10 focuses on documentation and risk management.
Clinical tips for improving documentation are a highlight of this
viii Preface
new edition. Intermittent auscultation, EFM, and informed consent
are discussed, with suggestions for inter- and intradisciplinary dis-
cussion points and patient education. Actual deposition testimony
related to documentation reveals the importance of knowing both
nomenclature and physiology in detail.
Chapter 11 provides a glimpse of FHR monitoring in select
European countries, where paper speed is frequently 1 cm/minute ver-
sus the typical 3 cm/minute seen in the United States. Variations in
obstetric care models and sample illustrations of a variety of fetal mon-
itor tracings from our European colleagues are provided for review.
Appendix A reflects current practice regarding amnioinfusion,
indicated as a potential corrective measure for variable decelerations.
Appendix B has been updated and includes 10 new fetal monitor-
ing tracings, bringing the total number of FHR tracings in the appen-
dix to 40. This appendix provides ample opportunities for education,
review, and preparation for certification or credentialing exams.
Clinicians can use the tracings to practice application of the NICHD
definitions, as well as the principles of standardized interpretation,
and an answer key allows clinicians to evaluate their skills.
Appendix C offers a self-assessment consisting of multiple-
choice questions related to the content of the textbook. Helpful for
reinforcement of information presented herein, it can also be used to
study for certification or credentialing examinations or to develop
internal competency assessment tools for clinical practice.
Mosby’s® Pocket Guide to Fetal Monitoring: A Multidisciplinary
Approach continues to be written by clinicians, for clinicians. Nurses,
nurse-midwives, medical students, physicians, resident physicians,
clinical specialists, educators, and risk management and medical-
legal professionals will gain a clear perspective on modalities of
fetal monitoring, the role of standardization, as well as the keys to
successful collaboration. Meticulously researched and revised, the
ninth edition is the most portable and practical reference available for
daily clinical practice, education, test prep, and habituation of both
knowledge and skills. We are thrilled to be able to offer this valuable
tool to all clinicians, in all practice settings.
LISA A. MILLER
DAVID A. MILLER
REBECCA L. CYPHER