Download PDF
Am J Perinatol 2016; 33(07): 688-695
DOI: 10.1055/s-0036-1571325
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Easy as ABC: A System to Stratify Category II Fetal Heart Rate Tracings

Christina A. Penfield
1   Department of Obstetrics and Gynecology, University of California Irvine, Orange, California
2   Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
,
Connie Hong
2   Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
,
Samia El Haj Ibrahim
2   Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
,
Sarah J. Kilpatrick
2   Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
,
Kimberly D. Gregory
2   Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
› Author Affiliations
Further Information

Publication History

01 September 2015

03 December 2015

Publication Date:
12 February 2016 (online)

    Permissions and Reprints

Abstract

Objective To evaluate whether a subcategory system for category II tracings can improve team communication and perinatal outcomes.

Study Design We collected data prospectively for 15 months, first using the NICHD system, followed by the ABC system, which divides category II tracings into subcategories A, B, and C, each representing increased risk for metabolic acidemia. We surveyed providers about communication effectiveness and agreement on tracing interpretation for each system. In cases where the communication system was used to alert an off-site physician about a category II tracing, we compared arrival to L&D and NICU admissions.

Results The ABC system was preferred (69%, n = 152) and considered a more effective tool for communicating concerning fetal status (80% vs. 43%, p < 0.01). Participants also reported greater agreement on tracing interpretation (79% for ABC vs. 64% for NICHD, p = 0.046). When an off-site physician was contacted about a category II tracing (n = 95), they were more likely to arrive to L&D (44% vs. 20%, p < 0.01) and have fewer NICU admissions (0% vs. 6%, p < 0.01) with the ABC system.

Conclusion The ABC system resulted in improved team communication, increased physician response, and decreased NICU admissions. Using standardized communication may offer a useful strategy for identifying and expediting care.

Keywords

category II fetal heart rate tracings - electronic fetal monitoring - team communication - intrapartum fetal assessment

The findings of this study were presented at the 35th Annual Meeting for the Society for Maternal Fetal Medicine, February 2–7, 2015 in San Diego, CA.


 

  • References

  • 1 Chen HY, Chauhan SP, Ananth CV, Vintzileos AM, Abuhamad AZ. Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States. Am J Obstet Gynecol 2011; 204 (6) 491.e1-491.e10
    CrossrefPubMedGoogle Scholar
  • 2 Ananth CV, Chauhan SP, Chen HY, D'Alton ME, Vintzileos AM. Electronic fetal monitoring in the United States: temporal trends and adverse perinatal outcomes. Obstet Gynecol 2013; 121 (5) 927-933
    CrossrefPubMedGoogle Scholar
  • 3 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; 114 (1) 192-202
    CrossrefPubMedGoogle Scholar
  • 4 Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2013; 5: CD006066
    PubMedGoogle Scholar
  • 5 Belfort MA, Saade GR, Thom E , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. A randomized trial of intrapartum fetal ECG ST-segment analysis. N Engl J Med 2015; 373 (7) 632-641
    CrossrefPubMedGoogle Scholar
  • 6 Clark SL, Meyers JA, Frye DK, Garthwaite T, Lee AJ, Perlin JB. Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol 2015; 212 (4) 494.e1-494.e6
    CrossrefPubMedGoogle Scholar
  • 7 Blackwell SC, Grobman WA, Antoniewicz L, Hutchinson M, Gyamfi Bannerman C. Interobserver and intraobserver reliability of the NICHD 3-tier fetal heart rate interpretation system. Am J Obstet Gynecol 2011; 205 (4) 378.e1-378.e5
    CrossrefPubMedGoogle Scholar
  • 8 Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. 2008:661–666
    PubMedGoogle Scholar
  • 9 Coletta J, Murphy E, Rubeo Z, Gyamfi-Bannerman C. The 5-tier system of assessing fetal heart rate tracings is superior to the 3-tier system in identifying fetal acidemia. Am J Obstet Gynecol 2012; 206 (3) 226.e1-226.e5
    CrossrefPubMedGoogle Scholar
  • 10 Jackson M, Holmgren CM, Esplin MS, Henry E, Varner MW. Frequency of fetal heart rate categories and short-term neonatal outcome. Obstet Gynecol 2011; 118 (4) 803-808
    CrossrefPubMedGoogle Scholar
  • 11 Preventing infant death and injury during delivery. Sentinel Event Alert 2004; (30) 1-3
    PubMedGoogle Scholar
  • 12 Parer JT, Ikeda T. A framework for standardized management of intrapartum fetal heart rate patterns. Am J Obstet Gynecol 2007; 197 (1) 26.e1-26.e6
    CrossrefPubMedGoogle Scholar
  • 13 Elliott C, Warrick PA, Graham E, Hamilton EF. Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity. Am J Obstet Gynecol 2010; 202 (3) 258.e1-258.e8
    CrossrefPubMedGoogle Scholar
  • 14 Chauhan SP, Klauser CK, Woodring TC, Sanderson M, Magann EF, Morrison JC. Intrapartum nonreassuring fetal heart rate tracing and prediction of adverse outcomes: interobserver variability. Am J Obstet Gynecol 2008; 199 (6) 623.e1-623.e5
    CrossrefPubMedGoogle Scholar
  • 15 Palomäki O, Luukkaala T, Luoto R, Tuimala R. Intrapartum cardiotocography—the dilemma of interpretational variation. J Perinat Med 2006; 34 (4) 298-302
    CrossrefPubMedGoogle Scholar
  • 16 Parer JT, Ikeda T, King TL. The 2008 National Institute of Child Health and Human Development report on fetal heart rate monitoring. Obstet Gynecol 2009; 114 (1) 136-138
    CrossrefPubMedGoogle Scholar
  • 17 Clark SL, Nageotte MP, Garite TJ , et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013; 209 (2) 89-97
    CrossrefPubMedGoogle Scholar
  • 18 Frey HA, Tuuli MG, Shanks AL, Macones GA, Cahill AG. Interpreting category II fetal heart rate tracings: does meconium matter?. Am J Obstet Gynecol 2014; 211 (6) 644.e1-644.e8
    CrossrefPubMedGoogle Scholar
  • 19 Gyamfi Bannerman C, Grobman WA, Antoniewicz L, Hutchinson M, Blackwell S. Assessment of the concordance among 2-tier, 3-tier, and 5-tier fetal heart rate classification systems. Am J Obstet Gynecol 2011; 205 (3) 288.e1-288.e4
    CrossrefPubMedGoogle Scholar
  • 20 Ross MG, Jessie M, Amaya K , et al. Correlation of arterial fetal base deficit and lactate changes with severity of variable heart rate decelerations in the near-term ovine fetus. Am J Obstet Gynecol 2013; 208 (4) 285.e1-285.e6
    CrossrefPubMedGoogle Scholar
  • 21 Akagi K, Okamura K, Endo C , et al. The slope of fetal heart rate deceleration is predictive of fetal condition during repeated umbilical cord compression in sheep. Am J Obstet Gynecol 1988; 159 (2) 516-522
    CrossrefPubMedGoogle Scholar
  • 22 Hamilton E, Warrick P, O'Keeffe D. Variable decelerations: do size and shape matter?. J Matern Fetal Neonatal Med 2012; 25 (6) 648-653
    CrossrefPubMedGoogle Scholar
  • 23 Cahill AG, Roehl KA, Odibo AO, Macones GA. Association and prediction of neonatal acidemia. Am J Obstet Gynecol 2012; 207 (3) 206.e1-206.e8
    CrossrefPubMedGoogle Scholar
  • 24 Berwick DM. A user's manual for the IOM's ‘Quality Chasm’ report. Health Aff (Millwood) 2002; 21 (3) 80-90
    CrossrefPubMedGoogle Scholar
  • 25 Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000
    Google Scholar
  • 26 Berkowitz RL. Of parachutes and patient care: a call to action. Am J Obstet Gynecol 2011; 205 (1) 7-9
    CrossrefPubMedGoogle Scholar
  • 27 Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006; 32 (3) 167-175
    PubMedGoogle Scholar
  • 28 Mickan S, Atherton H, Roberts NW, Heneghan C, Tilson JK. Use of handheld computers in clinical practice: a systematic review. BMC Med Inform Decis Mak 2014; 14 (1) 56
    CrossrefPubMedGoogle Scholar
  • 29 Mosa ASM, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak 2012; 12 (1) 67
    CrossrefPubMedGoogle Scholar