August 23 2011
The Future of Electronic Fetal Monitoring
If you had a baby in a hospital within the last 25 years, most likely you had a fetal monitor applied at some point in your labor. Electronic fetal monitoring (EFM) has become rooted in the practice of obstetrics in the United States over the last generation or so, becoming the most common obstetric procedure in the U.S. In 1980, 45% of laboring women had EFM, and by 2002, CDC reported that it was used 85.4% of the time, impacting 3.2 million live births.
Why is EFM so valued in modern obstetrics? We know that an assessment of fetal heart rate (FHR) is an important indirect measure of fetal oxygenation in antepartum and intrapartum care, especially when combined with information about the mother's uterine contractions. EFM provides for the simultaneous measurement of FHR and uterine contractions, creating a visual waveform that can viewed by maternity clinicians, and it can be added to the patient's health record as a permanent document. It helps to tell the story of the mother and her fetus as they progress through the last stages of the pregnancy. To simplify it to my patients when I was a labor and delivery nurse, I would explain to them that the fetal monitor helps us to “watch” not only her, but that second little “invisible” patient that we are also responsible for. Being able to see a continuous reading of the baby's heartbeat allows us to intervene quickly if we see signs of concern. Of course, the EFM tracing does not tell us everything there is to know about the fetal condition, but it is a helpful tool that can be used for clinical decision support.
So, what did doctors and nurses do to assess the unborn baby before EFM's were invented? They started with an ear to the abdomen, and then progressed to various types of listening devices, in order to detect fetal heart tones during a woman's pregnancy and birth. These techniques, used in conjunction with palpation of the mother's abdomen to identify contractions, were the only means they had to evaluate fetal well-being.
We have come a long way from an ear to the abdomen to the sophisticated systems that are commonplace today. We can view, record, and alert on a continuous fetal monitor tracing in real time, and document our immediate actions taken in response to that tracing. And, the technology continues to evolve. We have moved away from paper tracings to electronic display and storage. We have integrated the fetal monitor tracing with the patient's lifetime health record, instead of keeping it in a separate system. And, we are moving into a more mobile workflow. For example, a few years ago, it was almost impossible for an OB physician to be able to view a patient tracing remotely, without an elaborate network configuration. Today, a physician can easily view a fetal monitor tracing from a commonly-used mobile device, such as an iPhone or iPad.
Another exciting new technology allows us to view, with certain types of fetal monitor devices, a fetal ECG tracing. The device can analyze the changes in the ST segment of the fetal ECG waveform and send an alert to clinician indicating the presence of fetal acidosis, which is a sign of fetal distress. These types of proprietary fetal monitor devices, known as STAN monitors (for ST Analysis), help reduce the ambiguity that is sometimes present when clinicians visually analyze the traditional FHR tracing. By pushing more specific information to the clinician, STAN monitors can help the OB physician determine a strategy for intervention. For example, the information can help determine whether continued observation is appropriate, or an expeditious surgical delivery is indicated.
The goal for obstetric care has always been to achieve the best outcomes possible for mother and baby. As a common obstetric procedure, electronic fetal monitoring plays in important role in helping realize that goal.
Jill Meier, RN, BSN, is a senior strategist with Cerner's Women's Health ABU. She has more than 20 years of experience as an RN in labor and delivery, and 10 years of experience as a hospital-based childbirth nurse educator. Meier assisted in the early design of Cerner's PowerChart Maternity and FetaLink solutions. She has also collaborated on the creation of prototypes for innovative women's health development, such as infant security, breast milk tracking a newborn screening tool and others.