21 Dec

Why EFM trends are important

The importance of longer EFM views

Inventor of PeriGen advanced fetal monitoringby Emily Hamilton, MD CM
Senior Vice President, Clinical Research

Labor and delivery clinicians use EFM to identify fetal intolerance to labor to guide intervention and prevent hypoxic fetal injury. This task requires not only assessing the past and current degree of tracing abnormality and but projecting what is likely to happen in the near future. There is good evidence that tracing abnormalities generally evolve over hours (1-3). In addition, intervention guidelines usually recommend evaluating fetal response to supportive interventions over 30 to 60 minutes before resorting to cesarean delivery (4, 5). Thus long term assessments are essential. Standard computerized displays provide views of only 8 -10 minutes of tracing. Short term “snapshot” views can contribute to a failure to appreciate duration of tracing abnormality and the likely evolution.

PeriCALM Checklist analyzes EFM tracings in a consistent fashion. Its displays show long term trends over several hours, color coding regions of abnormality according to the criteria set by the institution. Such displays help clinicians see if a problem is intermittent or persistent, improving or deteriorating, stable or changing rapidly. A view of EFM trends may assist with situational awareness and helps clinicians in acute care settings more accurately project what is likely to happen and institute appropriate care. Checklist techniques and methods are especially pertinent in acute care settings during night time work when large amounts of data must be processed by the care givers over many hours. (6,7)

1. Vintzileos AM, Smulian JC. Decelerations, tachycardia, and decreased variability: have we overlooked the significance of longitudinal fetal heart rate changes for detecting intrapartum fetal hypoxia? Am J Obstet Gynecol. 2016 Sep;215(3):261-4.
2. 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 Mar;202(3):258.
3. Clark SL, Hamilton EF, Garite TJ, Timmins A, Warrick PA, Smith S. The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. Am J Obstet Gynecol. 2016 Oct 14. pii: S0002-9378(16)30872-9. doi: 10.1016/j.ajog.2016.10.009. [Epub ahead of print]
4. Clark SL, Nageotte MP, Garite TJ, Freeman RK, Miller DA, Simpson KR, Belfort MA, Dildy GA, Parer JT, Berkowitz RL, D’Alton M, Rouse DJ, Gilstrap LC, Vintzileos AM, van Dorsten JP, Boehm FH, Miller LA, Hankins GD. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol. 2013 Aug;209(2):89-97.
5. 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 Jul;114(1):192-202.
6. Chapter 46. Fatigue, Sleepiness, and Medical Errors. AHRQ. (accessed December 2, 2016) https://archive.ahrq.gov/clinic/ptsafety/chap46a.htm
7. Fioratou E, Flin R, Glavin R, Patey R. Beyond monitoring: distributed situation awareness in anaesthesia. Br J Anaesth. 2010;105:83-90.

10 Nov

Impact of the laborist model on obstetric care

Research Summary:
Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes*

Inventor of PeriGen advanced fetal monitoringBy Emily Hamilton, MD CM, Senior Vice President of Clinical Research

This study, published in the August 13th issue of the American Journal of Obstetrics & Gynecology, examines outcomes before and after the introduction of a laborist model of care. Surprisingly, very few differences were noted when comparing changes over time in the hospitals with laborists to changes over the same period of time in the matched hospitals without laborists. This paper describes an interesting methodology to try and tease apart the effect of various factors on obstetrical outcomes. This is relevant because most quality improvement initiatives are studied in a before-and-after fashion and not in a prospective randomized trial.

The study is discharge summary data to NPIC between 1998 and 2011. Results from three hospitals where laborists were introduced were compared to six control hospitals matched for delivery volume, geographical area, teaching hospital status and level of neonatal nursery.

Once adjustment was made for several patient-related factors, no differences were observed in the odds ratio (OR) for any of the neonatal outcomes or for cesarean rates. The OR was reduced only for induction of labor (0.85 95%CI 0.71-0.99) and for Preterm Birth (0.83 95%CI 0.72-0.96). Although the OR for Preterm Birth was reduced this was not accompanied by a change in the OR for the birth of babies weighing

In short, the introduction of laborists was associated with a change in medical behavior (Induction of labor) and some change in actual outcome (preterm births), but not in low-birth-weight babies. A question that springs to mind immediately is the role of unmeasured factors such as policies to curtail elective induction of labor prior to 39 weeks that became common during this timeframe and were not adopted by all hospitals at the same time. Evidently the desire to improve is alive and well in many hospitals and there is no single solution for all.

*Srinivas SK, Small DS, Macheras M, Hsu JY, Caldwell D, Lorch S. Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes. Am J Obstet Gynecol. 2016 Aug 13. https://www.ncbi.nlm.nih.gov/pubmed/27530491

09 Nov

How L&D Teams Use Protocols

What do you think? Is that a late?It’s hard to believe it’s been nine years, almost ten, since Steven Clark et al published “Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes.” Their study found that the use of a checklist-based protocol for oxytocin administration could reduce maximum infusion rates without lengthening labor or increasing operative intervention. In fact, cesareans decreased as a result of the use of the protocol.

To understand how protocols are handled today, PeriGen has launched an ongoing research survey. So far, 129 clinicians have participated. Here is a summary of results so far:

  • 96.7% of respondents use protocols to improve patient safety
  • The top three most commonly used protocols are for obstetric hemorrhage (8.2%), induction/oxytocin (7.6%) and pre-eclampsia (6.8%).
  • Most protocols (56.06%) are managed via a combination of EHR forms, paper forms and separate electronic forms. Few (6.1%) are actually integrated with the EFM.
  • Despite published research indicating induction protocol compliance was 40%, the mean estimate for protocol compliance among respondents is 90%.
  • Most respondents (53.85%) indicate that their teams spend about 1-3 hours a month on training, including initial training, for the protocols they use.
  • Respondents (47.7%) also say they meet as needed to analyze and generate ideas about increasing the effectiveness of the protocols they use, although 21.5% schedule monthly meetings.

To view an infographic of the survey results, please click here. To participate, click here.

19 Nov

New AJOG Articles

PeriGen’s Clinical Research

Team Just Got the Good

News: Two New Research

Articles Published in AJOG

Inventor of PeriGen advanced fetal monitoringEmily Hamilton and the rest of the clinical research team are thrilled to hear that two of their research papers – one on assessing dilation & descent – have been accepted for publication by the much-respected American Journal of Obstetrics & Gynecology (AJOG).

Emily is reviewing the research done by the team on the first paper next month during a brief  lunchtime webinar on December 2nd titled “Rethinking the Labor Curve.”  To register, complete the form below today.

Traditional methods for measuring labor progress have relied only on dilation and descent over time. The PeriGen team, joined by Samuel Smith MD and Kathleen Collins RN, both of PeriCALM customer MedStar, have identified a more discriminating method, one that uses multifactorial analysis to measure labor progress more reliably to enable improved intervention decisions.

The two papers published online (soon to be included in the next paper issue) by the American Journal of Obstetrics & Gynecology (AJOG) are:

The mathematic model tested for the published research is the foundation of PeriGen’s integrated labor curve software, PeriCALM® Curve™.  Part of the PeriCALM suite of perinatal analysis software, Curve provides clinicians a graphical display of labor progress at the bedside or remotely.  This display includes a comparison to the expected range of dilation from a normal reference population.  The labor progress comparison is presented graphically and numerically via percentiles to provide a precise quantitative and personalized assessment of dilation.  At each examination the comparison is updated to adapt to current labor conditions.

PeriCALM Curve benefits include:

  • Consistent visualization and measurement of labor progress
  • Tracks the effect of interventions in real-time, at-a-glance
  • Automatic adjustments for nulliparity/multiparity status