NonStress Tests & Using Fetal Monitors in Midwifery...

NonStress Tests & Using Fetal

Monitors in Midwifery

Practice

KarenE.Hays,DNP,CNM,ARNP

MAWSConference

November9,2012

photosremoved

Objectives 1.  List6indicaEonsforperforminganonstress

test(NST),anddiscusshowtheNSTmight

provideimportantinformaEonforproviding

qualitymidwiferycare.

2.  State10minimaldocumentaEon

requirementswhencharEngtheresultsofan

NST,anddiscusswhytheyareimportant.

3.  IdenEfyNSTresultsthatindicatetheneedfor

consultaEon,co‐management,orreferral.

What are the goals of doing an NST?

1.  ToidenEfy…

____________________________

2.  Inordertoprevent…

____________________________


1.  ToidenEfyifthereispossiblestress

tofetaloxygenaEon&threatsto

acid‐base(pH)status. [Whichwecall“fetalwell‐being”.]

2.  Topreventintrauterineasphyxia

andfetal/neonatalorgandamage

ordeath.


1.  ToidenEfyifthereispossiblestress

tofetaloxygenaEon&threatsto

acid‐base(pH)status.

2.  Topreventintrauterineasphyxia

andfetal/neonatalorgandamageor

death.

Thejourneyfrom#1to#2canoccurslowly

orquickly,andiso;enunpredictable.

Fetal Physiology

SeeAfors,K.,&Chandraharan,E.(2011).Useof

conEnuouselectronicfetalmonitoringina

pretermfetus:Clinicaldilemmasand

recommendaEonsforpracEce.Journalof

Pregnancy,doi:10.1155/2011/848794

foranexcellentgraphexplainingfetal

physiologyandtheeffectsofstress

photosremoved

Fetal Physiology

• 

Aforsetal.,2011

Aspects of the NST •  Recognizingwhenitisindicated

–  Riskfactorforfetalwell‐beinghasbeenidenEfied

–  GestaEonalage>28weeks(somesay32weeks)

•  Appropriateinformedconsent

–  ClientunderstandswhattheNSTcan&cannottellus

•  Performingitcorrectly

–  TocoispresentandfuncEoning

–  FHR(notmaternalHR)istracingconEnuously

•  Interpre9ngitcorrectly

–  Understandingphysiology

–  Usingdefinedterminology

•  Takingappropriateac9on

–  DocumentaEon

–  ConsultaEonorreferralifindicated

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Indications for an NST in midwifery practice

Ariskfactor

hasbeen

iden@fied.

Whattypesof

clinicalsitua8ons

wouldinspirea

midwifetoorderor

performanNST?photoremoved

Indications for an NST in midwifery practice

Ariskfactor

hasbeen

iden@fied.

• Decreasedfetalmovement

• Imminentposhermorposherm

• Hxofobstetricalproblem

o SEllbirth

o LBW

o Others

• CurrentmedicalorOBproblem

o GDM

o HTN

o Almostanything!

• Reassurance

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Interpreting the NST: NICHD Terminology?

  WorkingGroupjointlysponsoredbytheNaEonal

InsEtuteofChildHealth&Development,ACOG,

&theSocietyforMaternal‐FetalMedicine

  Terminology:

  1stformalizedin1997

  >30yearsanertheEFMwasintroduced

  2008wasthenextupdate

  Evidencebased?

  Theyrecommendmoreresearchneedstobedone….

NICHD 2008 Categories

CATEGORYI

Normal

CATEGORYII

Indeterminate

CATEGORYIII

Abnormal


CATEGORYI

Normal

Baseline110‐160

andModerateVariability

andNoLateorVariableDecels

Accels&EarlyDecelspresentorabsent

CATEGORYII

Indeterminate

CATEGORYIII

Abnormal


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

CATEGORYIII

Abnormal


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

CATEGORYIII

Abnormal

AbsentVariability+Baseline<110

or

AbsentVariability+LateorVariableDecels


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

CATEGORYIII

Abnormal


or


PredicEveof

abnormalpH.

Ac9on:

Immediate

remedies


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

Baseline<110or>160

orVariabilityabsent,minimal,ormarked

orAccels–noneanersEmulaEon

oranyoftheseDecels:• Variablewithslowreturn,shoulders,orovershoots

• Variableswithminormodvariability

• Lateswithmoderatevariability

• Prolongeddecel>2min

CATEGORYIII

Abnormal


or


PredicEveof

abnormalpH.

Ac9on:

Immediate

remedies


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

Baseline<110or>160







NotpredicEveof

pHstatus.

Ac9ons:

1.Longer

surveillance+/‐

othertesEng

and

2.Re‐evaluaEon

CATEGORYIII

Abnormal


or


PredicEveof

abnormalpH.

Ac9on:

Immediate

remedies

NICHD Categories & Physiology

CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

Baseline<110or>160







NotpredicEveof

pHstatus.

Ac9ons:

1.Longer

surveillance+/‐

othertesEng

and

2.Re‐evaluaEon

CATEGORYIII

Abnormal


or


PredicEveof

abnormalpH.

Ac9on:

Immediate

remedies


Do the NICHD

Categories apply to

Antepartum EFM

or only to Intrapartum EFM?


CATEGORYI

Normal

Baseline110‐160




PredicEveof

normalpH.

Ac9on:

RouEnecare

CATEGORYII

Indeterminate

Baseline<110or>160







NotpredicEveof

pHstatus.

Ac9ons:

1.Longer

surveillance+/‐

othertesEng

and

2.Re‐evaluaEon

CATEGORYIII

Abnormal


or


PredicEveof

abnormalpH.

Ac9on:

Immediate

remedies

TheNICHDC

ategoriesar

enotappro

priate

forantepart

umsurveillance

(NSTs).

Butthephysiologicalconcepts&otherterminologyarerelevant.

Terminology for NSTs

•  “Accelerations” o 15x15

o 10x10forpreterm<32weeks

•  ‘NST’isinappropriatefor<28weeks

• Baseline, variability, decels, … o Sameterminology,withknowledgeoftermvs.

pretermphysiologyinformingyourAssessment.

o SomedecelscanonlybedefinedwithcontracEons

present,soknowthephysiology&theproperuse

oftheterms.

Accelerations (“Accels”)

ThiswebsitehasexcellentpicturesandEFMstrips,many

thatyoucanclicktowatchscrollonthescreen.

CenterforExperienEalLearning,QuillenCollegeof

Medicine,EastTennesseeStateUniversityuElis.net/wm/

photoremoved

Nonperiodic Accelerations (donotoccurinapahernwithcontracEons)

What’sthephy

siology?

Well‐oxygenate

dheart,brain

,&adrenals.

photoremoved

.Periodic Accelerations (occurregularlywithcontracEons)

What’sthep

hysiology?

Cordcompression

–theseare‘ups

idedownvariab

les’.

Alihlesqueeze

oftheumbilicalve

incausesanacc

el,

whileastronger

squeezeoftheu

mbilicalvein+arte

rycausesadece

l.

photoremoved

Accelerations? Theseriseoffthebaselinebutdonotmeetthecriteriaof15beatsabovebaselineat

theacmeeventhoughtheyaremorethan15secondsatthebase.

What’sthephysiology?

Fetus<32weeks?Sleepingfetusundernormalstress?CompensaEonduetosomestress?(cordcompression,oligohydramnios,smoking,drugs,…)Somethingelse?

photoremoved

Are there accelerations?

What’sthephysiology?

Fetus>32wksor<32wks?

Baseline120‐125,modvariability,nodecels.

Need2accelstoreach>135‐140.

NotreacEveatthispoint–butcannotsayif

fetusisundernormalstressornot.

MightconsidersEmulaEonto‘wakebabyup’

photoremoved

Stimulation for Accelerations

SomeEmes30‐60minuteshavepassed,allelselooks

okay,butno15x15accelshavebeenidenEfied.

•  Techniquestotryto“wake”thebabyup:

– Massagingor‘jiggling’thematernalabdomen

–  ChangematernalposiEon

–  Juiceorothercold/glucosefooditems

– Noise(clapping,music,vibroacousEcsEmulaEon)

–  Light(halogenispopular)

–  RubpresenEngpartinvagina(‘scalpsEm’)

– Others?

88decibelsBetweena

garbage

disposal&

apower

mower.

photoremoved

photoremoved

NST Assessment Terminology “Reactive” 2accelswithin20minofeachother

“Nonreactive” doesnotmeetreacEvecriteria

‘Reaffirmed’in2

012withoutc

hanges.

NST Assessment Terminology “Reactive” 2accelswithin20minofeachother

“Nonreactive” doesnotmeetreacEvecriteria

Othertermsonenusedbutarenotstandardized:

– Equivocal

– Unsatisfactory

– Suspicious

– Indeterminate

– Abnormal

What can the midwife conclude from an NST?

Remember our Goals:

1.  Toiden9fyifthereispossiblestressto

fetaloxygena9on&threatstoacid‐

base(pH)status.

‘Reac9veNST’withanormalbaseline+moderate

variability+nodecelsindicatesthatfetalwell‐

beingispresent.

Anythingelseisnotinterpretablewithoutfurther

surveillance–babymayormaynotbeina

situaEonwhereoxygenaEoniscompromised.

What can the midwife conclude from an NST?

Remember our Goals:

1.  Toiden9fyifthereispossiblestressto

fetaloxygena9on&threatstoacid‐

base(pH)status.

‘Reac9veNST’withanormalbaseline+moderate

variability+nodecelsindicatesthatfetalwell‐

beingispresent.

Anythingelseisnotinterpretablewithoutfurther

surveillance–babymayormaynotbeina

situaEonwhereoxygenaEoniscompromised.

The NST is a

SCREENING test

,

not a DIAGNOSTIC te

st.

What can the Midwife predict from an NST?

Remember our Goals:

2.Topreventintrauterineasphyxiaand

fetal/neonatalorgandamageordeath.Althoughcontrolledresearchstudiesarefewand

‘evidence’basedonresearchisweak,anecdotal

experienceand‘expertopinion’perpetuateastrong

beliefintheNSTasascreeningtest.

ReacEveNST‐predicEveinthemomentandnearfuture.

NonreacEveNSTorotherconcerns‐youdon’tknowand

youcan’tpredictanything.

Commonlyreportedsta9s9cs:

Reac9veNST=fetaldeathrateof<5/1000

Nonreac9veNST=fetaldeathrateof40/1000

Cochrane Systematic Review Grivell et al., 2010

•  6studies,N=2105women

•  Studieswerenothighquality,

allfromthe1980s&1990s

•  AntepartumNSTwithEFM(“CTG”)vs.noEFM

•  Results:

– PerinatalMortality:nostaEsEcallysignificantdifference,n=1627

– Cesarean:nostaEsEcallysignificantdifference,n=1279

•  Conclusion–norecentorhighqualityexperimental

researchevidencetosupporttheuseofNSTs.

Ithasbeendifficulttodemonstratethat

EFMisindicatedorsuperiortootherforms

offetalsurveillancewithRCTs.

Butitis‘thestandardofcare’inmany

clinicalsitua9ons,somidwivesmust

understandit&iftheyuseit,todoso

wisely.

Interpretations & Actions •  Reac9veNST(normal,reassuring):

–  AcEons:

»  FetalmovementeducaEoninlaherhalfofpregnancy

»  Informwhentoreturnfornextvisit

•  Indeterminate–atemporaryassessment,notafinalassessment.

Needmoreinfobeforedeciding.Timelimit:2hours.

•  Nonreac9ve&/orOtherNonemergentConcerns (fetuscompensaEngforsomekindofstress):

–  AcEons:

»  Consultwithphysician,probablyreferforfurtherassessment.

»  PosiEonchange,hydraEon?

»  Extendedmonitoring+/‐US(BPP)

•  Nonreac9ve&/orEmergentConcerns(fetusdecompensaEng):

–  AcEons:

»  ImmediateposiEonchange,hydraEon,O2

»  ImmediatereferraltoL&Dhospital

NST Documentation 1.  Maternalname,age,G/P

2.  GestaEonalAge

3.  Maternalriskfactorsrelevanttofetalcompromise

4.  Fetalriskfactorsrelevanttofetalcompromise

5.  Maternalvitalsigns(minimum:BP&*Pulse*)

6.  CharacterisEcsof‘thestrip’

ContracEons–regularity,maternalpercepEon,strength

FHR–baseline,variability,accels,decels,anythingunusual

7.  InterpretaEon/Assessment

ReacEveorNonreacEve(urgency)

8.  AcEons&Plan–followsfromassessment&riskfactoreval

Date/Time S: Pam called this a.m. to report decreased FM x2h. Baby is ‘usually

active in the morning’. She reclined, drank juice, counted 4 ‘small’ movements over the next hour. No ctxs, back ache, bldg, LOF, pain, fever, or other s/sx. Was asked to come to clinic now for eval.

O: 29 yo G1P0 GA 372 based on LNMP & 12 wk US. No pg risk factors except Rh- & GBS+. NKDA.

BP 128/72 P 86 T 98.2 FH 37.5 cm Abd NT. Cephalic by Leopold’s, FM noted w/ abd exam. NST: BL 130-135, mod variability, 3 accels >15x15 in 18 min, no

decels. 1 mild nonpainful ctx recorded.

A: IUP at 37+ wks, c/o decreased FM, no other risk factors Reactive NST

P: Reassurance given. Will cont to monitor FM & call if concerned. RTC for next reg scheduled PNV in 4 days.

~Signature

Date/0845 S: Pam called this a.m. to report decreased FM x2h. …Was asked to

come to clinic now for eval.

O: 29 yo G1P0 GA 372 based on LNMP & 12 wk US. No pg risk factors except Rh- & GBS+. NKDA. BP 128/72 P 86 T 98.2

FH 37.5 cm Abd NT. Cephalic by Leopold’s, FM not noted w/ exam. NST: BL 130-135, mod variability, no 15x15 accels in 60 min, 2

variable decels lasting 20-30 sec to nadir 90-100. 1 mild nonpainful ctx recorded. Position change from reclining to sidelying. Abd massage did not elicit an accel.

A: IUP at 37+ wks, c/o decreased FM, no other risk factors NonReactive NST + 2 variable decels

P: Reviewed nonreac NST results & concept of screening test-need for further evaluation. Pam states understanding, called partner Chris.

T.C. consult w/ Dr Smith – advises monitoring at Mercy Hosp L&D. I’ll call Pam &/or hosp in 1-2 hr to f/u.

Pam left for hosp at 10:15. ~Signature

Reducing Errors with EFM

EFMis“effec8veonlywhenusedin

accordancewithpublishedstandardsand

guidelinesbyprofessionalsskilledin

correctinterpreta8onandwhen

appropriate8melyinterven8onisbased

onthatinterpreta8on.”Simpson&Knox(2000)

photoremoved

Reducing Errors with EFM EFMis“effec8veonlywhenusedinaccordance

withpublishedstandardsandguidelinesby

professionalsskilledincorrectinterpreta@on

andwhenappropriate8melyinterven8onis

basedonthatinterpreta8on.”Simpson&Knox(2000)

Overthepast40years,EFMeduca8onhas

evolvedfroman‘on‐the‐job’RN‐onlytraining

approachtorequiringbothproviders&staff

todemonstrateformaleduca8onand

ongoingcompetency(similartoNRP).

EFM Certification •  CerEficaEon

– coursesareusually1‐2dayswithanexam

– maintenanceeitherrequiresCEUsorexamretake

•  BecomingarequirementacrossthenaEon

–  Interdisciplinary(physicians,nurses,midwives)

•  ineducaEonalprograms(CNMs)

•  forhiring

•  conEnuedcerEficaEon(every2‐3years)

•  PublishedreportsareappearingthatdescribeEFM

educaEon/cerEficaEonasamandatoryriskmanagement

acEvity.SomereportsarelinkingthiseducaEonto

improvedoutcomes.

photoremoved

EFM Certification ‘CerEficaEon’course

In‐person,notonline,is

bestfor1stEme

SomeonlyletMDs,RNs,

CNMstakeexam

NST Informed Consent Please share your informed consent discussion

•  Verbal?

•  Wrihen?

•  Signed?

•  Differentinfofor

recommendingor

advisingtheNSTvs.

performingtheNST?

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Writing Practice GuidelinesIndica9onsforNST

IniEaEon,frequency

InformedConsent

CriteriaforAssessment

Defineyourterms!

‐ReacEve

‐NonreacEve

‐Others(‘indeterminate’)

CriteriaforDocumenta9on

Indica9onsforConsultaEon,Co‐management,Referral

•  Decreasedfetalmovement•  Imminentposhermorposherm•  Hxofobstetricalproblem

o  SEllbirth

o  LBW

o  Others•  CurrentmedicalorOBproblem

o  GDM

o  HTN

o  Almostanything!•  Reassurance

photoremoved

NST Practice Guidelines •  DecreasedFetalMovement

–  IniEaEon–samedayasthereportofdecreasedFM(ifnoFM

anertheusualeffortsoflyingdowndrinkjuicecountlonger)

– Frequency–once,intheabsenceofotherriskfactors

•  PendingPos`erm

–  IniEaEon–41wkscompletedgestaEon(somestartat40½)

– Frequency–q3‐4daysunElbirth

•  MedicalorOBRiskFactors(hxorcurrent)

–  IniEaEon–perconsultaEonwithMD,usuallysomeEme

between32‐36weeks

– Frequency–perconsultaEon,usuallyweekly

Strip Review

Reactive? NonReactive?

Strip Review •  CenterforExperienEalLearning,QuillenCollege

ofMedicine,EastTennesseeStateUniversity

uElis.net/wm/hasexcellentpicturesandEFMstrips,

manythatyoucanclicktowatchscrollonthe

screen.

Take Home Messages •  KnowwhenanNSTisindicated:maternal/fetal

physiology&riskfactors.

•  Demonstrateappropriatetrainingbefore

performing&interpreEngNSTs.

•  InformedConsent:NSTsareforscreeningonly.

•  DeveloppracEceguidelinesthatreflectthe

recogniEonofthescreeningnatureofNSTs,and

theconsultaEon&referralindicators&resources

ofyourparEcularpracEce.

•  Documentthoroughly,withaplanthatreflectsthe

normalcyorurgencyoftheAssessment.

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