By Sue Campbell, freelance healthcare writer and editor
Monitoring moms and babies during labor and delivery
In the world of labor and delivery (L&D), nurses and physicians rely on electronic fetal monitoring (EFM) to check how a mother and baby are doing. EFM continually records contractions and fetal heart rate and is interpreted frequently by the L&D care team. An EFM strip at category I means everyone’s fine; labor is progressing and there’s no cause for alarm. On the other end of the spectrum, category III, it’s clear there’s a complication requiring an immediate caesarian section (C-section).
Category II is the gray area. It’s where you ask, “What’s happening?” The baby’s not quite happy, but it’s not clear there needs to be a rush for a C-section,” says Tonyie Andrews-Johnson, DNP, BSN, RN, C-EFM, HN-BC, Director of Women’s Services at Sparrow Hospital in Lansing, Michigan.
It’s in that indeterminate phase, requiring interpretation of EFM strips, where the L&D care team may interpret the data differently and where a range of interventions may be required. The L&D team may need to rely on each other for interpretation and to determine what, if any, interventions are needed. Often , a nurse will decide to ask the physician to weigh in on the interpretation.
Varying interpretations in the EFM strip can lead to dire consequences
The consequences of some decisions or lack of a decision or action can be severe. The maternal mortality rate in the United States is three times higher than in other developed countries. Fetal injury is also a concern. Babies might suffer brain or neurological injuries that cause permanent damage.
Mistakes can also be costly for medical institutions. In an analysis of our malpractice claims, delay in recognition and treatment of fetal distress is the top obstetrical (OB) allegation in terms of both percent of claims and cost. Though OB claims make up only four percent of total claims, they rank third in total cost and have the highest average settlement payments.
Looking deeper into claim data, 49 percent of cases involved communication breakdowns among care teams as a contributing factor, along with improper assessment and monitoring.
One health system’s experience in improving outcomes
At Sparrow Hospital, Andrews-Johnson and her team had noted “outcomes that were disturbing,” she says, especially in category II EFM interpretation and shoulder dystocia, where the baby’s shoulder catches under the mother’s pelvic bone. They homed in on a lack of communication and collaboration between physicians and nurses as a factor, and strategized about how they could enhance processes and systems to improve outcomes.
“One idea we had was to have physicians and nurses train together, so everyone would learn together and speak the same language,” Andrews-Johnson says. Even before Andrews-Johnson came on board in 2020, Sparrow’s leadership had decided to use an online training program that offered testing, personalized assessments, training and learning tools like computer simulations.
First, they had to overcome some obstacles, including:
- Tiredness and burnout from the pandemic
- Time commitment and need to hold training outside of regular working hours
- Pushback from some physicians who questioned their involvement and necessity for additional education
It took strong leadership and a reminder about organizational values to overcome these barriers. Andrews-Johnson and her team used staff meetings to give presentations on team communication and collaboration, reminding everyone of Sparrow’s mission pyramid that puts patients at the very top:
“We were transparent and shared our data that clearly showed we had opportunity to improve and do our part to address maternal mortality and morbidity,” she says. “We talked about it as part of professional development – nurses earn continuing education credits. We advocated for the importance of learning together. It was stressed as us doing what is best for our patients. We ultimately won them over.”
Enhanced learning with joint education
Once they had everyone on board, Sparrow rolled out testing and training, focusing on a few key areas to begin: postpartum hemorrhage, shoulder dystocia and EFM. They could quickly see the benefits of the combined individual and group learning.
The online education modules were combined with collaborative in person educational sessions. The EFM segment of the software education suite provides examples of how effective this approach can be. It began with a review of material, followed by education sessions that had a game-like quality. The sessions included a friendly competition of jeopardy with real cases of EFM interpretation.
In one class, the instructor projected EFM strips on a screen, paired with information about lab work and other patient details. As the class studied the cases, Andrews-Johnson said it became clear there were different interpretations, and interpretations lead to the next clinical steps. The more team members talked, and in some cases shouted out answers, the easier it was to see how people could reach different conclusions and therefore next steps. Those “ah-ha” moments provided grace, allowing for deeper discussion of ways a care team might proceed in varying situations.
They also coalesced around terminology, using the same language to identify, describe and categorize fetal heart rates and maternal contraction patterns. Clarity of terms will help communication as the care teams move into real-life situations.
Training together also informed a new communication process
“When a L&D nurse has a concern with a strip, she can call a team huddle to bring everyone to the table,” Andrews-Johnson says. “We had this happen and the team developed a plan for the patient, and the baby had a good outcome.” In the end, mitigating risk and delivering the best outcomes—and healthy babies—are the true benefits of Sparrow’s education efforts.
Relias Fetal Heart Rate Monitoring education suite—targeted training to improve care
Constellation believes Relias education on Fetal Heart Rate Monitoring may reduce potential harm events and medical malpractice liability. The educational course begins with a proficiency assessment to analyze knowledge and judgment, followed by a personalized learning plan with targeted training to reduce the risk of adverse events and improve the quality of patient care. Past participants report significant improvements in clinical and risk outcomes after completing the course. Contact your designated Risk Consultant or email RiskTeam@ConstellationMutual.com to learn more about our obstetrical risk management resources.
Watch the webinar rewind, Reducing Obstetrical Harm With Electronic Fetal Monitoring Team Training, to learn more about mitigating obstetrical-related harm.
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Learn how Sparrow Hospital implemented collaborative clinician and care team training to make labor and delivery safer.
A review of our obstetrical (OB) claims reveals that the majority are related to recognizing and treating fetal distress and involve communication breakdowns among the OB team. Learn how we can help.
Informed consent goes far beyond a signature on a consent form; it is a process of ongoing conversations that are held at critical points in the care process. Learn how we can help.