Mosby's® Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach PDF
Preview Mosby's® Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach
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 Copyright © 2022 Elsevier Inc. All Rights Reserved. Previous editions copyrighted 2017, 2013, 2009, 2004, 2000, 1996, 1992, 1988. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Control Number: 2020949257 Senior Content Strategist: Sandy Clark Director, Content Development: Ellen Wurm-Cutter Senior Content Development Specialist: Kathleen Nahm Publishing Services Manager: Shereen Jameel Senior Project Manager: Kamatchi Madhavan Design Direction: Ryan Cook/Bridget Hoette Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1 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
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