Purpose of the tool: This tool describes the key perinatal safety elements that support the use of electronic fetal monitoring (EFM). The key safety elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) unit staff responsible for assessment, interpretation, management, communication, and documentation of fetal heart rate patterns and uterine activity observed through EFM.
How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to determine how the elements will be implemented on your L&D unit. Consider any existing unit procedures, policies, or processes related to the use of EFM to support implementation. Consider existing policies, standing orders, or processes that refer to EFM findings that may need to be updated.
Key Perinatal Safety Elements
|Standardize When Possible (CUSP Science of Safety)|
|Key Perinatal Safety Elements||Examples|
|Use standard terminology to describe and document fetal heart rate (FHR) and uterine contraction pattern assessment for all patients who are receiving continuous EFM.||
|Use standard terminology to describe and document fetal heart rate (FHR) and uterine contraction pattern assessment for all patients who are receiving continuous EFM. (continued)||
|Use a standard, three-tier system for FHR interpretation for all patients who are receiving continuous EFM.||
The 2008 NICHD Workshop also proposed a three-tier system for interpreting FHR tracings. This system is a mechanism for linking observed FHR findings on the current fetal acid-base status and can suggest a general clinical management strategy.1,2
|Use a standard, three-tier system for FHR interpretation for all patients who are receiving continuous EFM. (continued)||Use of the standard three-tier system for interpreting and communicating FHR tracings provides a common language for use among providers and staff to decrease variation and provide accurate communication among caregivers.|
|Create Independent Checks (CUSP Science of Safety)|
|Provide cognitive aids for standard EFM terminology at the point of care.||Clinician pocket cards and bedside reference aids that describe the 2008 NICHD nomenclature and three-tier system for interpretation can be used to provide quick access for staff reference. A sample cognitive aid with NICHD nomenclature is provided in the Appendix of this tool.|
|Use uniform parameters for provider notification.||Use of uniform, unit-established parameters for provider notification of EFM findings ensures that signs of potential adverse effects or clinical deterioration are communicated for situational awareness and response if needed.|
|Use standing nurse orders and rapid response systems for some or all Category III FHR tracings.||Use of unit-established standing nurse orders Category III FHR tracings. Prompt recognition and action may prevent "failure to rescue." Standing orders for first response may include maternal oxygen, maternal repositioning, discontinuing labor-stimulating agents, and treatment of hypotension with IV fluids.1,2 Standing orders may also include activation of a rapid response when provider is not immediately available, or disagreement among staff regarding EFM interpretation exists. The rapid response may include—
|Learn From Defects (CUSP Module)|
|Debrief and analyze near misses and adverse events and the contribution of EFM use, EFM interpretation, and communication of EFM findings||
|Have a process in place to review severe maternal or neonatal morbidity and mortality events.||Unit can decide its approach to reviewing cases of severe maternal or neonatal morbidity or mortality. This might include an existing medical peer-review process or review by a perinatal safety or quality committee.
A sample process and forms for a committee review are available at the Council on Patient Safety in Women's Health Care.Select "Get SMM Forms" menu.
|Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning.||Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally.|
|Simulation (SPPC Program Pillar)|
|Teamwork Training (TeamSTEPPS®)|
|Have situational awareness during use of EFM.||Situational awareness refers to all staff caring for the patient—
|Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques.||Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of EFM, these techniques are particularly useful—
|Use a predetermined approach to call for additional rapid assistance.||Unit-established process for eliciting a rapid response for specific Category III EFM findings requiring immediate action.
This process may include—
|Communicate during transitions of care.||Use of transition communication techniques assures a shared mental model of plan of care and perceived risks between shifts or between units. This may include bedside review by nursing team of patient’s recent EFM strip, interpretation, and any further evaluation or treatment in response to the strip.|
|Have high-reliability teams.
|Patient and Family Engagement (CUSP Module)|
|Engage patient in decisions to use continuous EFM versus intermittent auscultation in appropriate candidates.||Some units may elect to offer appropriate patients the option of selecting between continuous EFM or intermittent auscultation (IA), or another approach to monitoring. A unit-established process should:
|Communicate with patient and family during episode involving possible fetal deterioration per EFM.||
|Disclose any unintended outcomes.||Unit-established process for disclosing unintended outcomes. This may include the following:
- Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. J Obstet Gynecol Neonatal Nurs. 2008 Sep-Oct;37(5):510-5. PMID: 18761565.
- Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008 Sep;112(3):661-6. PMID: 18757666.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009 Jul;114(1):192-202. PMID: 19546798. [Reaffirmed 2015]
- Heelan L. Fetal monitoring: creating a culture of safety with informed choice. J Perinat Educ. 2013 Summer;22(3):156-65. PMID: 24868127.
Every effort was made to ensure the accuracy and completeness of this resource. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
Sample Cognitive Aid for Electronic Fetal Monitoring Nomenclature
Based on 2008 National Institute for Child Health and Human Development Workshop Report1
Tachysystole: 6 or more contractions/10 min averaged over a 30-min window, either spontaneous or stimulated (do not use “hyperstimulation” or “hypercontractility”).
Normal: 5 or fewer contractions/10 min averaged over a 30-min window.
Baseline FHR: mean FHR rounded to increments of 5 bpm. Must have 2 min of identifiable baseline segments (not necessarily contiguous) in any 10-min window; otherwise, the baseline is indeterminate.
Normal baseline 110-160; Bradycardia < 110 bpm; Tachycardia > 160 bpm.
FHR variability: determine in a 10-minute window, excluding accelerations and decelerations; absent is undetectable, minimalis detectable but ≤ 5 bpm, moderate 6-25 bpm, marked > 25 bpm.
Acceleration: onset to the peak in < 30 seconds, and must last ≥ 15 seconds and be ≥ 15 bpm; before 32 weeks, use peak ≥ 10 bpm lasting ≥10 seconds.
Prolonged acceleration: ≥ 2 min but < 10 min in duration.
Baseline change: accelerations or decelerations lasting ≥ 10 min.
Prolonged deceleration: decreased FHR ≥ 15 bpm, lasting ≥ 2 min, but < 10 min long.
Recurrent decelerations: occur with ≥ 50% contractions in any 20-min window.
Intermittent decelerations: occur with < 50% contractions in any 20-min window.
Periodic decelerations: associated with uterine contractions.
Episodic decelerations: not associated with uterine contractions.
Appearance: abrupt decrease in FHR with beginning to nadir of < 30 seconds, ≥ 15 bpm, lasting ≥ 15 seconds, and < 2 min in duration.
Timing: may occur with or without contractions.
Appearance: symmetrical, gradual (≥ 30 seconds) decrease to nadir and return associated with a uterine contraction.
Timing: In most cases, the onset, nadir, and recovery occur after the beginning, peak, and ending of the contraction.
Appearance: identical to late decelerations.
Timing: In most cases the onset, nadir, and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction.
(Note: early decelerations are not common and are often confused with late decelerations.)
Category I: no specific action is required.
Baseline 110-160 bpm; variability is moderate; accelerations are present or absent; late or variable decelerations are absent; early decelerations may be present or absent.
Category II: indeterminate, requires reevaluation and continued surveillance.
Includes all FHR tracings not categorized as Category I or Category III.
(Note: Category II is very common at some point during labor.)
Category III: abnormal, requires prompt evaluation, maternal oxygen, change in maternal position, discontinuation of labor stimulation, treatment of maternal hypotension.
(Note: may require emergency CS.)
Includes absent baseline FHR variability and any of the following: recurrent late decelerations, recurrent variable decelerations, or bradycardia.
Also includes sinusoidal patterns (sine-wave-like pattern with frequency of 3-5/min that persists ≥ 20 min).