Resources by experienced OB &
MFM physicians and L&D Nurses.

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Early Warning Systems

The Institute for Healthcare Improvement calls them “scorecards that save lives.”  Originally created in answer to research finding that 40-50% of maternal deaths are potentially preventable, early warning systems seek to standardize clinical assessment and to facilitate recognition of maternity patients who have or are developing critical illness.  Non-obstetric early warning systems have been use in Europe, especially Great Britain, for over twenty years.  Systems adapted to obstetrics have started to gain traction in the US relatively recently.

There are two types of early warning systems.  Single parameter systems rely on carefully defined threholds.  Multiple parameters systems, often using weighted algorithms, result in a composite score that triggers protocol activities.  Because most systems are manual, the type used is often a balance between practicality and clinical impact.

(See how PeriWatch Vigilance® provides easy-to-use, easy-to-implement way to leverage the impact of early warning systems.)

Following are links to published information on the design and use of obstetric early warning systems:

Other Reading:

This collection of resources provides guidance to L&D unit leads on providing consistent standards of care:

Use these resources to learn how organizations use best practices and benchmarking to improve performance.

The following resources are helpful for those looking to incorporate unit and care management strategies others are using to improve key obstetric benchmarks.

The Category II Management App, a free web-based app (not-downloadable) offered exclusively by PeriGen, is based on published research and designed for US usage to help support the management of patients with FHR tracings in category II (present in over 80% of labors).

Only 4-8 clicks get you the suggested outcome and the app takes seconds to use.

  • Answer a few questions about the tracing and labor status
  • The application processes the data through the algorithm and presents its conclusion along with the publication’s original image.

This online app (not for download) can be used as often as needed on any computer or mobile device.

Register for the Category II Management App
(Before launching the web tool please read this important information.)

Any questions or feedback, email

A Message from Thomas Garite, MD
Chief Medical Officer:

“Category II fetal heart rate tracings are common and cover a wide spectrum ranging from relatively minor findings to more significant combinations that require very different clinical management. This app based on a researched algorthm represents a practical set of management guidelines for clinicians to consider as they care for women in labor. The algorithm was designed in accordance with a fundamental premise in patient safety circles – that standardization and simplification of critical care processes promote better outcomes. Please do read the full publication that describes a number of important concepts that clinicians must also include in their clinical reasoning. No simple algorithm can handle every unusual circumstances or rapid change in the tracing. We look forward to your feedback and hope it will be a useful tool for clinicians to access on their smart phones when managing patients whose tracings are in Category II.”

“We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.”

Reference Publication:
Intrapartum management of category II fetal heart rate tracings: towards standardization of care. 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. Am J Obstet Gynecol. 2013 Aug;209(2):89-97. doi: 10.1016/j.ajog.2013.04.030. Epub 2013 Apr 27

When asked about their greatest challenges with existing EFM systems, labor & delivery clinicians consistently cite integration with their EHR.  In keeping with Stephen Covey’s (Seven Habits of Highly Effective People) rule of “seek first to understand,” following are resources for understanding the mechanics and practices for integrating electronic fetal monitoring systems with major EHRs.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) indicate that inadequate communications between providers or between providers and patients/families is the root cause of 60% to 70% of investigated sentinel events in medicine.  When 47 perinatal deaths were investigated by JCAHO, poor communication was identified as the root cause in 72% of these adverse events.

One of the most common challenges experienced by labor & deliver management is maintaining efficient communications between team members, while consolidating a wide range of skill sets and personalities into a cohesive, effective unit.  Here are a few information resources that may help you meet this challenge.  Please feel free to suggest more.

Team-Building Tools & Tips

The following information resources provide educational information on assessing labor progress, as well as the latest research on labor curves:

The following is a compilation of information resources providing practical, actionable strategies for fine-tuning your patient safety initiatives:

The Institute of Medicine defines protocols, or clinical guidelines, as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical situations.”  The following information resources aim to help labor & delivery unit directors, chair people, and risk managers understand, leverage, and improve protocol compliance.

Shoulder Dystocia

Shoulder dystocia is typically defined as a vaginal birth where the baby’s shoulders get “stuck,” requiring extraordinary maneuvers to delivery the fetus. The incidence of shoulder dystocia varies based on fetal weight, maternal weight, and the presence of diabetes. Complications associated with shoulder dystocia include postpartum hemorrhage, maternal lacerations, and brachial plexus palsies.

The electronic fetal monitoring (EFM) resources below have been compiled from a review of materials readily available on the Internet.  Although PeriGen is not responsible for the creation of this content — or for its continued availability and quality — they provide a comprehensive curriculum for clinicians seeking to gain a basic understanding of EFM.  In addition to these EFM training resources, we’ve found several general, free online training resources of use:

Electronic fetal monitoring definition: 

Electronic fetal monitoring or EFM is the practice of measuring and displaying fetal heart rate and contraction rate during labor.  Traditionally, the output of EFM takes the form of tracings — a visual display of the fetal heart rate on top and the contraction rate on the bottom.

PeriGen's Cues offers cutting-edge L&D strip analysis

Screenshot of an EFM tracing with feature analysis generated by the PeriWatch system

Like much technology, electronic fetal monitoring has progressed rapidly.  The latest EFM software offers  specialized displays so a detailed view of the tracing can be seen simultaneously with a longer term overview for trend analysis, pattern recognition, and color-coded notifications when specific combinations of EFM patterns are present. All of these advances help labor & delivery clinicians to spend less time on manual calculations, support improved care decisions, and better manage multiple patients.

This technology adds statistical analysis to the traditional EFM display to highlight abnormal patterns, yield meaningful summary information, and display the meaningful interaction between contractions and fetal heart rate via color-coded visual cues.

Figure 2. PeriCALM Patterns display showing the analysis related to uterine tachysystole.

Figure 2. PeriWatch Cues display showing the analysis related to uterine tachysystole.

Some of the most recent technology adds an even greater depth of statistical interpretation to labor progress, comparing a single patient’s measurements to a large population of others sharing similar characteristics.

EFM Education: PeriCALM Curve Labor Progress Analsysis Software

PeriCALM Curve offers labor progress analysis

*PeriGen is approved by the California Board of Registered Nursing, Provider Number CEP16729. Video completion via a single computer/device per user is required for credit achievement.  Once video completed, a web link is provided for completion of a mandatory course evaluation.  Once evaluation is finished, an online certificate of completion is provided for printing and retention.

Workflow is defined as a set of tasks and resources need to accomplish to meet a goal.  Defining and conforming to a set of processes enables a team to consistently achieve organizational objectives.  Typical workflows in a labor & delivery unit include admission, documentation, and filling laboratory orders.  Following are information resources on defining and optimizing workflows for labor & delivery teams.

Following are items of broad interest to labor & delivery clinicians:

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