fetal monitoring definition

Most guidelines state that hands-on listening should be done for at least 60 seconds at a time, at least every 15-30 minutes during the active phase of the first stage of labor and at least 5-15 minutes during the pushing phase of the second stage of labor (ACNM 2015). With hands-on listening, the care provider listens to the fetal heart rate for short periods of time at regular intervals. Also, if a hospital has not trained their nurses in hands-on listening, or does not have a written policy or protocol, it might be impossible for their nurses to provide this service. People assigned to EFM on admission were more likely to end up being put on continuous EFM for the rest of their labor. Continuous electronic fetal heart rate monitoring was introduced into hospitals in the 1970s without evidence from clinical trials, but with a strong marketing push from the monitoring industry (Obladen 2018). Several guidelines of hands-on listening protocols: The California Maternal Quality Care Collaborative includes model policies for fetal monitoring in their, This video (http://bit.ly/2FB2qzA) of a wireless, water resistant monitor, and these links to the Novii (http://bit.ly/2FAyDXA) and GE (http://bit.ly/2FAByzL) monitoring products. Hands-on listening alone is used with about 11% of mothers giving birth in U.S. hospitals (Declercq et al. They also note that handheld Dopplers are simple, affordable, and probably cause less discomfort than Pinard fetal stethoscopes. (2015), Whitburn, L. Y., Jones, L. E., Davey, M. A., et al. The clinical bulletin of the American College of Nurse Midwives (ACNM) states that hands-on listening—not electronic fetal monitoring—should be the preferred method of fetal monitoring in people at low risk for complications (ACNM 2015). Intermittent EFM was defined as wearing the sensors for the last 10 continuous minutes of every 30 minutes if the results were normal, or the last 10 continuous minutes of every 20 minutes if the results were abnormal. The growing evidence that EFM carries risks without clear benefits has probably influenced their views. The monitor is assessing the baseline fetal heart rate and how it changes with contractions. However, over time, fewer professionals reported that EFM leads to a good newborn health outcome. Alfirevic, Z., Devane, D. and Gyte, G.M. Today, as we mentioned earlier, the rate of EFM during labor is around 90%. The Cochrane review did not find a difference in the rate of cerebral palsy between the continuous EFM group and the group who received hands-on listening. Understandably, clinicians also want to protect themselves from expensive lawsuits. It was embraced by most obstetricians and nurses. Electronic fetal monitoring (EFM) involves the use of an electronic fetal heart rate (FHR) monitor to record the baby's heart rate. We also explore the history of fetal monitoring, barriers to evidence-based care, and ways to improve the current situation. One unexpected benefit of hands-on listening is that it requires caregivers to spend more time with the laboring mother—and their more frequent physical presence may actually lower pain and increase satisfaction for their patients (Hodnett 2002). (2017), Centers for Disease Control and Prevention (2018), Declercq, E. R., Sakala, C., Corry, M. P., et al. Mehr zum Thema. However, on the other hand, EFM may actually require more time than they realize (Smith et al. We would also like to thank Cristen Pascucci for her medical editing assistance. External fetal monitoring. The authors concluded that the use of a handheld Doppler device is a more reliable test for abnormal fetal heart rates than intermittent EFM or the use of a Pinard fetal stethoscope. Category II tracings, in particular, should be addressed first with preventive measures and scalp stimulation before deciding to perform a Cesarean. Laboring people may also feel less supported by their care providers if the providers pay more attention to the monitor than to the person wearing the monitor. Does the use of diagnostic technology reduce fetal mortality? According to the Listening to Mothers III national survey, 89% of mothers who experienced labor in a U.S. hospital in 2011-2012 used EFM at some point during labor (Declercq et al. Baseline Fetal Heart Rate (FHR): The baseline FHR is the heart rate during a 10 minute segment rounded to the nearest 5 beat per minute increment excluding periods of marked FHR variability, periodic or episodic changes, and segments of baseline that differ by more than 25 beats per minute. Medizin-Lexikon. One of the main reasons EFM is so common is that doctors, nurses, midwives, and hospitals think that it protects them from cerebral palsy lawsuits. Home > Fetal Monitoring > Late decelerations A deceleration is a decrease in the fetal heart rate below the fetal baseline heart rate. Subscribe to our podcast:  iTunes  |  Stitcher On today's podcast, we're going to talk with Nathalie Walton, CEO of the Expectful app, about coping with anxiety during pregnancy and postpartum— especially when you have a high-risk pregnancy.... Don't miss an episode! They do this to check how he's doing and see how he's tolerating your contractions. You would need about 12,000 people in each group in order to find a difference in the rate of uterine rupture between groups (Bujold et al. 2016). However, hands-on listening is still not easily available in most hospitals. Today, the use of continuous EFM machines is widespread, although, as you will see, it is still lacking evidence of benefits (Sartwelle et al. The authors concluded that there is no evidence of benefit for using EFM on admission in labor among low-risk women, and that hands-on listening is the preferred method. As the use of EFM during labor increased, so did the Cesarean rate, and it is possible that these two trends are connected. (2015), American College of Obstetricians and Gynecologists (2009), American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Caughey, A. They also reported that hospital legal concerns were sometimes prioritized over the benefits of hands-on listening. Even the price to purchase the 200-page report on the global fetal monitoring market is enormous—it costs $4,000 for a single user to read a report about this market. Dopplers can be audio-only or come with a digital display of the baby’s heartbeat. Interestingly, however, AWHONN practice guidelines recommend 1:1 staffing for people on Pitocin. 2015); (Cascade 2018). Because non-reassuring fetal heart tones can be a vague diagnosis, several professional organizations in the U.S. came together to decide upon a standard approach to interpreting and managing fetal heart rate tracings, with a goal of preventing unnecessary Cesareans. Wichtiger Hinweis zu diesem Artikel Diese Seite wurde zuletzt am 18. Overall, most nurses and physicians are much more comfortable using EFM rather than hands-on listening, since they have had more training and experience with EFM. 2017). In order to be considered a “good” screening test, the test must be able to tell the difference between people with a real problem and those without. The Cochrane reviewers estimate that more than 50,000 women would have to be randomly assigned to continuous EFM or hands-on listening in order to detect a difference in one death out of 1,000 births. In their 2009 practice bulletin, ACOG concludes that there is Level A evidence (based on good and consistent scientific evidence) that the false-positive rate of EFM for predicting cerebral palsy is greater than 99%. The paper listening tool was later made in wood to become the first wooden stethoscope. However, guidelines state “performance of these interventions without a subsequent change in fetal heart rate pattern is not necessarily an indication for cesarean delivery.” It’s important for care providers to consider the many clinical factors that can affect the fetal heart rate, such as medication use, quick progress in labor, cervical exams, maternal infection, maternal blood pressure, and maternal fever. There have only been two randomized trials on this topic: In one study, researchers in Sweden randomly assigned more than 4,000 low-risk participants to receive either continuous EFM or intermittent EFM (Herbst and Ingemarsson 1994). Birthing people in these studies reported that they like the mobility that they had with the wireless monitors. External fetal monitoring graph Your baby's heartbeat is recorded against a baseline measurement of 120 beats per minute. This means that there would be one additional Cesarean for every 11 women monitored by continuous EFM. The researchers found no differences between the continuous EFM group and the hands-on listening group in Apgar scores or cord blood gases, rates of low-oxygen brain damage, admission to the neonatal intensive care unit, or perinatal death. | Leer en Espanol. A simplified scheme of the fetal circulation. Originally published on July 17, 2012 and updated on May 21, 2018 by Rebecca Dekker, PhD, RN and Anna Bertone, MPH. Researchers in Australia conducted face-to-face interviews and written surveys to understand how people’s state of mind relates to how they experience labor pain (Whitburn et al. If this theory is correct, it means that what qualifies as normal fetal heart rate patterns during labor is broader than previously thought. In contrast, it appears that intermittent EFM alone (when not combined with other monitoring methods) is not based on research evidence. Monitors are also usually set to alarms, so staff are notified when the heart rate is abnormal or the monitor is not picking up the heart rate. fetal monitoring continuous intrapartal monitoring of the fetal heart rate and uterine contractions for the purpose of reducing preventable fetal and neonatal death by more accurate diagnosis and correction of problems related to fetal distress during labor, such as compression of the umbilical cord or … The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) asserts that the availability of registered nurses (RNs) and other health care professionals who are skilled in fetal heart monitoring (FHM) techniques, including auscultation and electronic fetal monitoring (EFM), is essential to maternal and fetal well-being during antepartum care, labor, and birth. Every time I rolled over or tried to get comfortable, a nurse would come rushing in insisting that she’d lost the signal and that my baby could be in distress and I had to stop moving so much… It created a situation where I was a liability and a problem just for wanting to be the tiniest bit mobile.”. Some hospitals now offer wireless, water resistant continuous electronic monitors. For example, the time taken to maintain EFM equipment, adjust the monitoring belts, continuously watch the monitor, respond to alarms, and interpret the fetal heart strip, could take longer than the time required to use hands-on listening for 1-2 minutes every 15-30 minutes during active labor. This theory would help to explain why many babies are born healthy despite repeated brief decelerations during labor. The bottom line is that hands-on listening is an evidence-based option for mothers and babies. Don't miss an episode! There has only been one randomized, controlled trial that compared intermittent EFM alone with hands-on listening alone (Mahomed et al. 2017). US FDA Clears MindChild Medical's … As we mentioned, there are a variety of devices that can be used for hands-on listening during labor. Any decrease in the risk of stillbirth during labor would be very small, especially among low-risk births, while the known increase in Cesarean rates with continuous EFM is very large (Hornbuckle et al. Insight into the stresses on the fetus and its ability to tolerate those stresses. Researchers believe that when people labor and give birth in upright positions there is less risk of compressing the mother’s aorta, which means there is a better oxygen supply to the baby. In an earlier version of the Cochrane review, the researchers grouped the studies into those with a Cesarean rate of less than 10% and those with a Cesarean rate of greater than 10% (Alfirevic et al. The research overwhelmingly supports hands-on listening compared to EFM, and practice guidelines should state this clearly. Some nurses reported that hospital policies and a lack of support from care teams limit their use of hands-on listening. 2017). Standard of care means, how did this doctor practice compared to how other doctors are currently practicing? (2013), Gupta, J. K., Sood, A., Hofmeyr, G. J., et al. When the researchers removed the poorer quality trials from the analysis it did not change the overall findings. Research also shows that people who give birth in upright positions are 54% less likely to have abnormal fetal heart rate patterns (Gupta et al. The research midwives in the study used Huntleigh pocket Doppler ultrasound monitors to listen to the fetal heart rate during the last 10 minutes of every half hour, especially before and immediately after a contraction. According to the Global Fetal Monitoring Report by Allied Market Research, the global fetal monitoring market is expected to reach $3.6 billion by 2022. Fetal Monitoring. The first fetal electrocardiogram (EKG) recording took place in 1906 (Heelan 2013). In 1958, Dr. Hon from Yale University first identified fetal distress by monitoring the fetal heart rate continuously through the mother’s abdomen (Hon 1958). 2017). Subscribe to our podcast:  iTunes  |  Stitcher On today's podcast, we are talking with Jamie and Ryan English about their unexpectedly long but empowering hospital birth, as well as the effects of severe diastasis recti on the labor process.... Don't miss an episode! 2014). OpenSubtitles2018.v3. (2014), Devane, D., Lalor, J. G., Daly, S., et al. The rate of cerebral palsy has stayed the same over time, despite the widespread adoption of using EFM during labor. But it’s important to realize that less time spent with the mother comes at a price. Since the Cochrane analysis only included around 37,000 participants, there is a chance that continuous EFM has an effect on stillbirth that was not detected. A., Sprague, A. E., et al., (2017), Sartwelle, T. P., Johnston, J. C. and Arda, B. This information should not be considered complete, up to date, and is not intended to be used in place of a visit, consultation, or advice of a legal, medical, or any other professional. EFM was used among 45% of laboring women in 1980, 62% in 1988, 74% in 1992, and 85% in 2002 (ACOG 2009). 2017). In this article, we cover the evidence for the different types of fetal monitoring and their pros and cons. An early deceleration is defined as a waveform with a gradual decrease and return to baseline with time from onset of the deceleration to the lowest point of … 2015), who invented the stethoscope. (2017), Smith, H., Peterson, N., Lagrew, D., et al. (2017), American College of Nurse-Midwives. En Español | Spanish Translations, Click Here, earn a certification in continuous electronic fetal monitoring, You CAN say no to the fetal monitor, but you’ll need to bring your own Doppler—and nurse. Grab our one-page handout on Fetal Monitoring to take to your next appointment! Set up a fetal monitor. AWHONN (2017) Intermediate Course Instructor Resource Manual, 6th edition. However, if the baby has a bad health outcome, failure to produce an EFM strip as “proof” for the court can be seen as failure to meet the standard of care. In the United States, the American College of Obstetricians and Gynecologists (ACOG) has endorsed hands-on listening as an “appropriate and safe alternative” to electronic fetal monitoring for laboring people without complications (ACOG 2009). People have asked us if there is any evidence that “putting someone on the monitor” for a set time (e.g., 20 minutes of every hour) is any better than continuous EFM. ACOG states that hands-on listening may not be appropriate for people at increased risk of complications such as those with meconium staining, bleeding during labor, suspected fetal growth restriction, preeclampsia, prior Cesarean, type 1 diabetes, or receiving Pitocin. (2015), American College of Obstetricians and Gynecologists (2017), Association of Women’s Health, Obstetric and Neonatal Nurses (Revised 2015), Boatin, A. https://medical-dictionary.thefreedictionary.com/fetal+monitoring. EBB 160 – Introducing Mystique Hargrove: EBB Featured Instructor and Podcast Coordinator, Everyone in the room can hear the fetal heart beat, Can be used in many different laboring positions, Does not require wearing uncomfortable belts, May calculate and display fetal heart rate values, Pros: Inexpensive and available in most countries, Cons: May be uncomfortable for the mother, difficult to use in some laboring positions, and allows for listening with only one ear at a time, Pros: Inexpensive and allows for listening with both ears, Cons: May be uncomfortable for the mother and difficult to use in some laboring positions, Pros: Inexpensive, allows for listening with both ears, and comes with the option of extra long tubing so that the mother can also listen to the fetal heart rate, Pros: Best sound quality of the different fetoscopes, allows for listening with both ears, can be used underwater, and possible to use in many different laboring positions, Cons: More expensive than the other fetoscopes and may be uncomfortable for the mother, Category I = This is normal and does not require intervention. Our legal system needs to be updated to allow clinicians to provide evidence-based, hands-on listening without violating the “standard of care.”. The limitation with randomized trials, however, is that a rare outcome like stillbirth requires a very large sample size to detect a difference between groups. Rates of intrapartum death (stillbirth) were already falling when continuous electronic monitoring was introduced in the 1970s (Hornbuckle et al. 2014). In the meta-analysis, the absolute risk of Cesarean was 3.6% for people receiving hands-on listening and 5.9% for those receiving continuous EFM. Not all types of continuous EFM restrict mothers from movement. If the person giving birth has risk factors, then assessment and charting of the EFM tracings may be done as frequently as every 5-15 minutes. Februar 2009 um 22:01 Uhr bearbeitet. The story goes that he was too embarrassed to place an ear on a young woman’s chest to hear her heart beat. Electronic fetal monitoring also usually means that the mother loses the option of water immersion in a birth pool for pain management. So, in other words, the intermittent EFM group also had hands-on listening. Fetal monitoring fetal monitoring. If you read our article “Evidence on Birthing Positions,” you know that most people in hospital settings give birth in a lying or semi-sitting position. EFM can be utilized either externally or internally in the womb. 2000). The features of the fetal Doppler include: The drawbacks of the fetal Doppler are that it is costlier to purchase and maintain than some of the other options listed below, the probe is very sensitive to damage, and sometimes the Doppler may display the maternal heart rate instead of the baby’s, which can cause confusion.

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