12/3/2020 Fetal Assement Methods 1 up to 9% of exam 5 to 9 questions 13.00 Adjunct Fetal Surveillance Methods 10%) 13.01 Auscultation (Intermittent Auscultation- IA) 13.02 Fetal movement counting 13.03 Nonstress testing 13.04 Fetal acid base interpretation – will be covered in a separate section 13.05 Biophysical profile 13.06 Fetal Acoustic Stimulation 2 1 12/3/2020 HERE IS ONE FOR YOU!! AWW… Skin to Skin in the OR ☺ 3 Auscultation 4 2 12/3/2020 Benefits of Auscultation • Based on Random Control Trials, neonatal outcomes are comparable to those monitored with EFM • Lower CS rates • Technique is non-invasive • Widespread application is possible • Freedom of movement • Lower cost • Hands on Time and one to one support are facilitated 5 Limitation of Auscultation • Use of the Fetoscope may limit the ability to hear FHR ( obesity, amniotic fluid, pt. movement and uterine contractions) • Certain FHR patterns cannot be detected – variability and some decelerations • Some women may think IA is intrusive • Documentation is not automatic • Potential to increase staff for 1:1 monitoring • Education, practice and skill assessment of staff 6 3 12/3/2020 Auscultation • Non-electronic devices such as a Fetoscope or Stethoscope • No longer common practice in the United States though may be increasing due to patient demand • Allows listening to sounds associated with the opening and closing of ventricular valves via bone conduction • Can hear actual heart sounds 7 Auscultation Fetoscope • A Fetoscope can detect: • FHR baseline • FHR Rhythm • Detect accelerations and decelerations from the baseline • Verify an FHR irregular rhythm • Can clarify double or half counting of EFM • AWHONN, (2015), pp. 88 • AWHONN, (2018), pp. e4 8 4 12/3/2020 Examples of Fetoscopes Pinard Horn Leff Fetoscope Fetoscope 9 Auscultation – Doppler • Electronic devices such as a hand held Doppler: • Detects FHR baseline • Detects FHR rhythm • Detects increases and decreases from the baseline • An electronic Doppler device uses ultrasound technology to detect the motion of the heart walls or valves and then converts it to sound • AWHONN, (2015) pp. 87-88 10 5 12/3/2020 Auscultation – Doppler • When an irregular heartrate is audible by Doppler, assessment with a Fetoscope is warranted to rule out artifact. • A Doppler can not be used reliably to verify the presence of an irregular rhythm due to its technical limitations • It may half an SVT rate (Supraventricular Tachycardia) 11 Addressing the Elephant in the Room Using the EFM ultrasound device versus a hand held Doppler http://ab.pkimgs.com/pkimgs/ab/images/dp/wcm/201615/0007/baby-elephant-costume-c.jpg 12 6 12/3/2020 Auscultation – Using a Fetal Monitor • The external US may be used to listen to the FHR intermittently, however……. • Some systems archive data even when the paper tracing is turned off. Segments of the EFM may be retrievable but the data generated would be of too short a duration to be reliably interpreted. Using a hand held device would minimize these issues and the decision to use a certain device should be handled by institutional policies and procedures. • AWHONN (2015) p. 88 13 Auscultation • Both Fetoscope and a Hand Held Doppler without a recording device can not verify: • Variability • Sinusoidal Pattern • These are visual assessments and an EFM device is required 14 7 12/3/2020 REMEMBER Auscultation is an Auditory Assessment EFM is based on Visual Interpretation and includes the component of variability and decelerations! 15 DON’T Forget About the Uterine Activity Comparison Model for Palpation of Uterine Activity Palpation of Uterus Feels Like….. Contraction Intensity Easily indented Tip of the nose Mild Slightly indented Chin Moderate Cannot indent Forehead Strong 16 8 12/3/2020 Documentation • Using Categories with IA (Intermittent Auscultation) • Category I is considered NORMAL. By auscultation, a Category I tracing includes all of the following: • Normal FHR baseline – 110-160 • Regular rhythm • Presence or absence of FHR increases/accelerations from the baseline rate • Absence of FHR decreases/decelerations from the baseline • AWHONN (2015) p. 91 17 Documentation • Using Categories with IA • Category II is considered indeterminate and requires further investigation. By auscultation, a Category II tracing includes all of the following: • Irregular rhythm • Presence of FHR decreases/decelerations from the baseline • Tachycardia - baseline >160 bpm >10 minutes in duration • Bradycardia - baseline <110 bpm <10 minutes in duration • AWHONN (2015) p. 91 18 9 12/3/2020 Intermittent Auscultation (IA) Versus Continuous EFM • AWHONN (2015) Fetal Heart Monitoring Position Statement • Current research indicates that FHR auscultation, when provided with a 1:1 nurse-patient ratio, is comparable to EFM for fetal assessment of the laboring woman. • Woman’s preference should be taken into account when possible 19 (IA) versus Continuous EFM • ACOG • IA versus continuous EFM should be based upon risk factors, patient and obtetric preference, and departmental policy • ACOG & AAP (2017) P. 240 20 10 12/3/2020 Intermittent Auscultation • Studies showing no difference in outcome were based upon one-to-one nursing care • Allows for more mobility for the patient • Studies show good results done by trained personnel 21 Intermittent Auscultation • Inconsistency in guidelines from ACOG, AWHONN, SOGC and ACNM regarding frequency of auscultation • No clinical trials have examined methods of fetal assessment during the latent phase of labor – frequency is at the discretion of the midwife or physician • AWHONN (2018) p. e8 • Feinstein et al (2008, p. 22) citing SOGC, 2007 22 11 12/3/2020 Frequency of Auscultation • AWHONN • Insufficient evidence to make a recommendation. Frequency at the discretion of the midwife or physician – < 4cm • Every 15-30 minutes in Active phase of labor Latent phase (4-5 cm) • Every 15-30 minutes in Active phase of labor > 6 cm • Every 15 minutes Second Stage (passive decent) • Every 5 - 15 minutes in the Second stage (active pushing) • AWHONN (2018) p. e8 23 AWHONN PRACTICE BULLETIN – IA - 2018 24 12 12/3/2020 Frequency of Auscultation • ACOG – No Risk Factors • Active phase of labor – 6cm should be the considered the threshold for the active phase of most women in labor • Determined, evaluated and recorded at a minimum of 30 minutes; preferably before, during and after a uterine contraction • Second stage - should be determined, evaluated and recorded at a minimum of 15 minutes • ACOG & AAP (2017) P. 240 25 Frequency of Auscultation • ACOG – if Risk Factors are identified….. • First stage - Active phase of labor – should be determined, evaluated and recorded at a minimum of 15 minutes; preferably before, during and after a uterine contraction • Second stage - should be determined, evaluated and recorded at a minimum of 5 minutes • ACOG & AAP (2017) P. 240 26 13 12/3/2020 Auscultation Procedure • Review • Miller, Miller, and Tucker (2013) text regarding procedure • Page 30 • Miller, Miller, and Cypher (2017) text regarding procedure • Page 29 27 Screening Devices for Fetal Well-Being For the exam read Miller, Miller & Tucker (2013) or the latest version is Miller, Miller and Cypher (2017) or one of the medical texts on the exam resource list…. 28 14 12/3/2020 Goals of Antenatal Fetal Assessment • To identify fetuses that are well oxygenated or those who may be at risk for hypoxia • To enable appropriate interventions to prevent or reduce perinatal morbidity and mortality 29 Antenatal Fetal Testing • Any fetal testing is a screening tool to rule out fetal hypoxemia and acidosis • Creasy and Resnik (2019) pg. 549 30 15 12/3/2020 For the test to show value it must: • Have a wide range and be flexible • Detect fetal peril in enough time to allow intervention • Have a low false positive rate due to the consequences of delivering a preterm infant • High sensitivity for modest degrees of compromise to facilitate early interventions • Have a high negative value to prevent stillbirth and fetal injury • Incorporate multiple variables • Detect fetal compromise from a variety of sources • Be applicable in the inpatient and outpatient settings • Have measurable benefits for the high risk populations • Creasy and Resnik (2019) pg. 549 31 A few facts to keep in mind: Fetal Assessment Methods are best when combined • A change in fetal behavior implies a change in fetal status • Maternal kick counts, NST and BPP • Doppler and Ultrasound are more useful to track both short- and long-term growth/development 32 16 12/3/2020 A few facts to keep in mind: • *As the fetus grows the parasympathetic nervous system dominates which decreases the fetal heart rate and is responsible for an increase in variability • *The response to acute change in fetal status is more immediate as the fetus matures • The presence of normal fetal tone and gross body movements and breathing reliably predict the absence of fetal hypoxemia and academia at the time it is observed 33 Key Measures of Effectiveness of Screening • False-negative • Fetal death that occurs within one week of a normal antepartum test • Rates range from 0.4 to 6 per 1000 with current testing methods • False-positive • Abnormal test that prompts delivery but is not associated with acute or chronic disruption of fetal oxygenation • Rates range from 30 to 90% with current testing methods Miller, Miller & Cypher (2017), pp.210-211 34 17 12/3/2020 Antepartal Screening • Primarily used for patients considered to be at increased risk for disrupted fetal oxygenation (Miller