OBG Management

Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.

The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.

Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.

Defendants' defense: The case was settled during trial.

Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.

Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.

Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.

Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.

Verdict: A $1.5 million Illinois settlement was reached.

What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.

Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.

Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.

At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.

Verdict: A California defense verdict was returned.

Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.

Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.

Hospital's Defense: The case was settled during trial.

Verdict: A $625,000 Illinois settlement was reached.

Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
 
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.

Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death. 

Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.

Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy. 

Verdict: An Illinois defense verdict was returned.

 

Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.

The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.

Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.

Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.

Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.

 

Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.

Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.

Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.

Verdict: An Alabama defense verdict was returned.

Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.

The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.

Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.

Defendants' defense: The case was settled during trial.

Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.

Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.

Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.

Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.

Verdict: A $1.5 million Illinois settlement was reached.

What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.

Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.

Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.

At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.

Verdict: A California defense verdict was returned.

Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.

Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.

Hospital's Defense: The case was settled during trial.

Verdict: A $625,000 Illinois settlement was reached.

Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
 
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.

Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death. 

Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.

Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy. 

Verdict: An Illinois defense verdict was returned.

 

Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.

The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.

Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.

Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.

Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.

 

Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.

Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.

Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.

Verdict: An Alabama defense verdict was returned.

Preeclampsia test cancelled: $5M settlement
A 35-year-old woman was pregnant with her first child. Prior to and during her pregnancy, she took medication for chronic hypertension. Although another ObGyn had ordered a 24-hour urinalysis to test for preeclampsia, the ObGyn who saw the mother in early May for a third trimester visit cancelled the test.

The mother delivered the child by cesarean delivery when the fetal heart-rate monitor indicated fetal distress. After birth, the child received a diagnosis of cerebral palsy, spastic quadriplegia, and dystonia.

Parents' claim: The decision by the second ObGyn to cancel the 24-hour urinalysis eliminated the opportunity to diagnose preeclampsia superimposed on chronic hypertension. Over time, preeclampsia impaired blood flow to the placenta and fetus. If the mother had been assessed in early May, the injury could have been prevented.

Defendants' defense: The case was settled during trial.

Verdict: A $5,000,000 Illinois settlement was reached through mediation with the hospital physicians’ group and 2 ObGyns.

Umbilical cord damaged at delivery: $1.5M settlement
A mother at full term presented to the hospital in labor. During delivery, the umbilical cord was severed during maneuvers to address shoulder dystocia. The fetus was stillborn.

Parents' claim: The patient told the nurses that shoulder dystocia had been encountered during a previous delivery. Shoulder dystocia maneuvers were not performed correctly. Cesarean delivery was never offered.

Hospital's Defense: The nurses called the certified nurse midwife who was managing labor and delivery to alert her of the patient’s history. The midwife denied receiving such a call. The case was settled during trial.

Verdict: A $1.5 million Illinois settlement was reached.

What caused sepsis after oophorectomy?
A woman had a cyst on her left ovary. The ObGyn began surgery laparoscopically but converted to open salpingo-oophorectomy because of extensive adhesions. Four days after surgery, the patient received a diagnosis of peritonitis and sepsis due to spillage from the sigmoid colon. She required a second surgery to repair the damage, followed by a long recovery.

Patient's claim: The ObGyn should not have attempted laparoscopic surgery; he knew of her extensive surgical history and should have anticipated the presence of adhesions. If the laparoscopic entry site had been examined properly intraoperatively, the injury could have been repaired immediately.

Physician's defense: The ObGyn had no reason to believe the patient would have adhesions in the umbilical area; prior surgeries occurred in the upper abdomen. Laparoscopic surgery with Veress needle access is an accepted method used by obstetric surgeons. The ObGyn carefully irrigated and inspected the abdomen before closing. Injury to the sigmoid colon is a known complication of left oophorectomy.

At the time of surgery, the patient was likely suffering from diverticulosis, a long-term condition that can lead to a leak in the large colon. The weakness in the patient’s colon caused a postsurgical leak; signs and symptoms did not appear until 4 days after surgery.

Verdict: A California defense verdict was returned.

Ectopic pregnancy misdiagnosed
A 39-year-old woman reported abdominal pain to her ObGyn. After ultrasonography (US), she was given a diagnosis of ectopic pregnancy. The ObGyn administered methotrexate to terminate the pregnancy. Five days later, repeat US showed a viable uterine pregnancy. Based on the risks posed by methotrexate, the patient terminated the pregnancy.

Patient's claim: The ObGyn misdiagnosed the pregnancy as ectopic.

Hospital's Defense: The case was settled during trial.

Verdict: A $625,000 Illinois settlement was reached.

Infant dies. was it fetal hydrops?
A woman was admitted to the hospital in full-term labor. She was cared for by a team of residents and nurses supervised by an attending ObGyn. During labor, the staff documented late, variable decelerations with periods of minimal or undetectable variability on the fetal heart-rate monitor. The fetal heart rate, however, was reported as being reassuring overall.
 
After 90 minutes, fetal heart-rate tracings became non-reassuring. Because the baby's head was crowning, the ObGyn used vacuum extraction for delivery. The infant was born without signs of life. A neonatologist thought the infant appeared hydropic with generalized edema, ascites, and pleural effusion. Efforts at resuscitation were unsuccessful until the neonatologist performed thoracentesis. The infant died several hours later. Cause of death has charted as hypoxic ischemic encephalopathy and multisystem organ failure.

Estate's claim: The hospital staff deviated from the standard of care by failing to appropriately communicate, failing to recognize fetal distress, and failing to perform a cesarean delivery when tracings were nonreassuring. An expert neonatologist claimed that failure to react to fetal distress caused the fetus to develop severe intrauterine hypoxic ischemia causing death. 

Defendants' defense: Overall, the fetal heart-rate tracings were reassuring. The team communicated appropriately and kept the attending ObGyn alerted to the status. Delivery was expedited when fetal distress was evident.

Fetal hydrops was the end result of a serious problem in utero that could not have developed during the hours of labor and delivery; it most likely arose days to weeks before delivery. Nothing that occurred during labor and delivery caused hypoxic ischemic encephalopathy. 

Verdict: An Illinois defense verdict was returned.

 

Child has permanent shoulder injury: $1M verdict
A mother was admitted to a hospital in full-term labor. During delivery, anterior shoulder dystocia was encountered.

The child received a diagnosis of a left brachial plexus injury and extracranial and intracranial bleeding. She underwent 3 surgeries to reattach nerve roots and move muscles and tendons in her shoulder and forearm in an effort to improve function in her left arm, wrist, and hand. She has undergone extensive physical and occupational therapy. Her left arm is smaller than her right arm and she has minimal strength, dexterity, and only 20% functionality of her left arm.

Parent's claim: The ObGyn exerted excessive traction when delivering the child. Alternate methods should have been used to manage shoulder dystocia. The hospital nurses should not have used fundal pressure.

Defendants' defense: The suit was brought against the ObGyn, his practice, and the hospital. The ObGyn claimed that he used several maneuvers to manage shoulder dystocia. The child’s injuries were a result of the maternal forces of labor and were not caused by negligence on the part of the ObGyn or nurses. The nurses denied using fundal pressure; they were trained to use suprapubic pressure.

Verdict: A $1,012,00 Illinois verdict was returned, finding the ObGyn’s practice 100% liable.

 

Parvovirus exposure: Fetal death
When a woman first saw an ObGyn, ultrasonography (US) indicated that her fetus was at 8 to 9 weeks’ gestation. One month later, she told the same ObGyn that she had been exposed to Fifth disease. Because blood work was positive for parvovirus B19, the ObGyn ordered the patient to undergo US every 2 weeks for the next 10 weeks. Two weeks later, the patient saw a second ObGyn at the same clinic. Although the first ObGyn had ordered US, none was performed; the patient’s next appointment was scheduled in 4 weeks. At that time, the patient saw a third ObGyn, who ordered US. He noted in her chart that the fetus had a nuchal fold, indicating Down syndrome. He told the patient to return in 2 weeks for a follow-up US. The results of that US showed that the fetus had died. Fetal cord blood tested positive for parvovirus B19.

Parent's claim: All 3 ObGyns failed to react properly to indications of parvovirus infection. Regular US should have been performed, as suggested by the first ObGyn. The mother should have been referred to a perinatologist or other maternal-fetal specialist when blood work was positive for parvovirus B19. A specialist could have provided treatment for the virus.

Physician's defense: The ObGyns denied any breach in the standard of care. They claimed that results would have been the same if they had referred the patient to a specialist.

Verdict: An Alabama defense verdict was returned.

Interpreting continuous fetal heart rate (FHR) monitoring is one of the most common tasks obstetricians perform during the course of intrapartum care. Notably, many providers do not seek ongoing training to optimize their ability to reliably and accurately interpret the FHR. Yet FHR interpretation is one of the most frequent causes of litigation in the modern obstetric practice. Failure to interpret continuous FHR monitoring appropriately is estimated to account for 75% of obstetric-related litigation.¹

Continuous FHR monitoring during labor was introduced to identify infants at risk for  developing hypoxic-ischemic encephalopathy (HIE). The rate of HIE has not declined, however, despite almost universal adoption of continuous FHR monitoring.² Numerous reasons account for this failure, including ad hoc interpretation of terminology, lack of standardized protocols for management and intervention, and the oftentimes challenging patterns that must be interpreted.³ The confusion about and dissatisfaction with the current state of FHR monitoring has led to attempts to enhance our ability to identify infants at risk with additional approaches (such as fetal pulse oximetry and fetal ST-segment evaluation), and some have called for a complete overhaul of our approach to interpreting the FHR. Clark and colleagues stated recently, "It is time to start over and establish some common language, standard interpretation, and reasonable management principles and guidelines."³

We must recognize that, as a stand-alone tool, continuous FHR monitoring is ineffective for avoiding preventable adverse outcomes. It is most likely to be effective when used in accordance with published standard guidelines by professionals skilled in interpretation and when timely, appropriate interventions are performed based on that interpretation. Optimal FHR monitoring requires a collaborative perinatal team that performs the monitoring correctly, interprets it appropriately, and communicates the findings effectively, and in a timely fashion, to all members of the care team when a high-risk pattern is detected.

In this article we review some common challenges that clinicians encounter during intrapartum FHR monitoring and we offer 10 simple tips to help overcome these challenges. The clinical scenarios described are derived from published reports in the medical literature, published malpractice claims, and from our personal experience working in a major health care system as part of a team charged with overseeing ongoing certification and training of labor and delivery nurses.

Challenge: Signal ambiguity
CASE 1  Young woman in labor with first pregnancy
A 19-year-old woman presents in spontaneous labor with her first pregnancy, which has been uncomplicated. During the course of her care, it is noted that the FHR changes to a lower baseline than previously recorded. Evaluation reveals that the external monitor is tracking the maternal heart rate and not the FHR (FIGURE 1). After the monitor is adjusted, both the fetal and maternal rates are documented for a short period. Ultimately, continuous monitoring of the maternal heart rate is discontinued. After delivery of the infant several hours later, it is noted that the FHR continues to register on the monitor, and it is determined that for the last few hours the maternal heart rate has been traced.

FIGURE 1 FHR tracing indicates signal ambiguity

As described in Case 1, the upper panel of this tracing demonstrates the maternal heart rate confused as the fetal heart rate, while the segment in the lower panel shows a clear distinction between the maternal and fetal heart rates.

TIP #10: Ensure the FHR monitor is tracking the fetal, not the maternal, heart rate
Confusing the maternal and the fetal heart rate with external cardiotocography is common. When the mix-up is noted and corrected expeditiously, it is unlikely to result in an adverse outcome. Signal ambiguity may arise from faulty Doppler equipment or the inability of the cardiotocograph to differentiate between maternal and fetal heart rates. It commonly occurs after repositioning the patient, after fetal movement, or during pushing in the second stage when the maternal heart rate may increase to a baseline that is similar to that of the fetus.

Signal ambiguity should be suspected when the FHR runs in the low-normal range or when FHR accelerations are noted with greater than 50% of contractions (especially when pushing).⁴ Signal ambiguity also should be ruled out when there is an apparent FHR deceleration to the maternal range that does not recover.

Evaluating for suspected signal ambiguity involves 2 key steps: (1) documentation and verification of the maternal heart rate and (2) definitive documentation of the true FHR. To document the maternal heart rate, manually count the radial pulse for 1 minute or use a pulse oximeter for continuous monitoring. Using a pulse oximeter is a less labor-intensive approach and has the advantage of allowing continuous assessment of the maternal heart rate for comparison. Recording the maternal pulse continuously on the same screen as the FHR enables ongoing differentiation of the mother and fetus in difficult cases, particularly if internal fetal monitoring is not an option (because of maternal infectious disease, low suspicion for an abnormal FHR pattern, or strong maternal preference against internal monitoring, for example).

When clinically appropriate, use of a fetal scalp electrode (FSE) can document the FHR. If intrauterine fetal death has occurred, however, the FSE may transmit the maternal heart rate.⁵ Using ultrasonography to confirm the FHR prior to placing the FSE is a reliable method of definitive differentiation. If a newly placed FSE shows a clear differentiation of 5 to 10 beats per minute from a continuously assessed maternal pulse rate, then this is also a reliable way to assure that the FHR monitoring represents the fetus, particularly if ultrasonography is not immediately available.

Ultimately, before intervening based on an abnormal FHR tracing, it is paramount to confirm that the data are adequate for interpretation and represent the actual FHR. If signal ambiguity is identified or suspected, correct it by using ultrasonography to locate the FHR and replace the external monitor until a rate that is at least 5 to 10 beats per minute different from the maternal rate is obtained. Alternatively, this is an indication for internal fetal monitoring with an FSE.

Challenge: Inadequate FHR tracing, poor communication, lack of clinical context
CASE 2  Woman with uncomplicated postdates pregnancy presents for induction
A 28-year-old woman (G3P2) at 41 weeks 0 days of gestation presents to labor and delivery for induction of labor for the indication of postdates. There have been no complications with the current pregnancy. The initial cervical exam reveals 1+ cm dilation, 90% effacement, and −3 station, and the patient is started on oxytocin per the hospital protocol. What is your interpretation of the continuous FHR tracing shown in FIGURE 2?

FIGURE 2 Inadequate, uninterpretable FHR tracing

This FHR tracing, from the patient described in Case 2, is unusable because of the absence of data.

TIP #9: Check that the monitors are providing useful data
The ability to accurately interpret a continuous FHR tracing depends on the quality of data recorded. Unfortunately, the absence of data makes interpretation impossible. This includes both FHR and tocometry data, since both pieces of information are required for appropriate interpretation of a continuous FHR tracing.

Prolonged periods of uninterpretable FHR and uterine activity tracings imply that no one was attending the mother and fetus.⁶ If it is difficult to obtain an interpretable FHR tracing, document in the medical record that you made ongoing efforts to maintain an adequate tracing, including the amount of time spent holding the external monitor, use of ultrasonography to document the FHR, and plans for potential internal monitoring.

CASE 2  Continued
After several hours, the patient requests an epidural for pain management and one is placed without difficulty. She reports adequate pain relief and is comfortable for the next 1 to 2 hours. Subsequently, the patient reports a sudden onset of increasing pain that does not respond to additional patient-administered doses of anesthesia over a 30-minute period. The labor and delivery nurse becomes concerned about the patient's pain level and contacts the attending physician to discuss her concerns. The physician, who is currently attending to patients in clinic, listens to the nurse and asks her to contact the anesthesia department with her concerns (FIGURE 3).

FIGURE 3 FHR tracing reveals recurrent variables in a patient with evolving clinical concerns

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #8: Clearly communicate an urgent situation to the care team
Poor communication underlies many preventable adverse outcomes in medicine.⁷ Effective communication requires an adequate description of the clinical scenario or problem. A root cause analysis of a series of intrapartum adverse events involving fetal death or injury showed that poor communication about a concerning FHR tracing played a role in 72% of cases.¹

In this clinical scenario, the nurse believed that the patient's pain level was unusual or more than anticipated. The person who is communicating his or her concern (the sender) must be sure that the person receiving the message (the responder) clearly understands the sender's level of concern. In this case, it would have been appropriate for the sender to state clearly that she felt the patient's pain was outside of normal expectations and to request that the attending physician come to evaluate the patient.

Clear and effective communication includes (1) an appropriate description of the urgency of the situation and (2) an indication by the sender as to the desired response to this information ("please come evaluate the patient").⁸ In all cases, both steps are necessary to elicit an appropriate response.

CASE 2  Continued
Over the next 2 hours, recurrent variable decelerations develop, and then sudden, prolonged fetal bradycardia leads to urgent cesarean delivery. At delivery, a uterine rupture is diagnosed and a fetal hand is observed protruding through a lower-uterine segment defect into the maternal abdomen.

TIP #7: Always consider the entire clinical scenario
In this case, the team caring for the patient was not aware that her previous pregnancy had ended with a low transverse cesarean delivery. How does this information change your interpretation of the clinical scenario? The importance of understanding the entire clinical context when interpreting individual characteristics of cardiotocography cannot be overstated. For example, the sudden onset of recurrent, significant variable decelerations is more concerning in the context of a prior cesarean delivery, and late decelerations are more concerning in a patient with placental abruption, fetal growth restriction, or poorly controlled maternal diabetes.

An estimated 70% of fetuses will have an indeterminate FHR pattern (category II) at some time during labor.⁹ To appropriately interpret the FHR tracing, it is crucial to know the a priori risk for fetal hypoxia and metabolic acidosis (the precursor of fetal injury) due to such identified clinical risk factors as placental insufficiency, medical comorbidities (hypertension, diabetes), or postdates gestational age.

It is well established that cardiotocography has a good negative predictive value for the absence of fetal metabolic acidosis when there is moderate variability and spontaneous or induced accelerations. When attempting to risk stratify the fetus with a category II (indeterminate) FHR tracing, consider these 3 important questions:

1. What are the risk factors for this particular patient and her fetus?
2. What is the state of the fetus right now, and when was the last time metabolic acidosis could be excluded reasonably (by the presence of moderate variability and accelerations)?
3. What is the risk that the fetus will develop acidemia prior to delivery?

The presence of decelerations indicates interruption of oxygen delivery to the fetus, and recurrent decelerations may indicate an evolving process of accumulated oxygen deprivation, hypoxia, and eventually, metabolic acidosis. Most authorities agree that, for the fetus with a previously normal FHR tracing, the onset of significant, recurrent decelerations with slowly cumulative oxygen deficit can lead to fetal acidemia over the course of approximately 1 hour.¹⁰ Of course, acidosis also can occur much more quickly with acute events, such as placental abruption or uterine rupture. In deciding whether or not to intervene based on an FHR tracing, the clinician must take into account the clinical context to determine if delivery is likely to occur before significant acidemia develops.

Challenge: Lack of situational awareness, failure to address nursing concerns, reluctance to initiate the chain of command
CASE 3  Spontaneous labor in a second pregnancy
A 28-year-old woman (G2P1) at 40 weeks' gestation presents in spontaneous labor. She has a history of a previous uncomplicated vaginal delivery. After 6 hours she reaches complete dilation with the fetus at −1 station and begins pushing. After 60 minutes, the patient has only progressed to +1 station. She is contracting every 1 to 2 minutes with recurrent variable decelerations (FIGURE 4).

FIGURE 4 FHR tracing shows time points for initiation and continuation of pushing

This tracing, from the patient described in Case 3, documents contraction frequency every 1-2 minutes for more than 60 minutes while the patient continues to push. The fetal heart rate demonstrates repetitive moderate variable decelerations with every push.

TIP #6: Maintain situational awareness
A state of situational awareness exists when caregivers have a clear understanding of all of the factors at play in a clinical situation.¹¹ This can be lost when caregivers focus too intensely on one aspect of care. It often happens when the patient is pushing in the second stage and the provider, focused on the progress of fetal descent, loses track of the amount of time that has passed without reassuring features (such as variability and induced or spontaneous accelerations) in the FHR tracing. The nurse, seeing the physician at the bedside, presumes he or she is aware of the tracing and is thus reluctant to point out the concerning features for fear of appearing insubordinate.

Situational awareness also may be lost at the time of patient hand off between providers wherein critical information, such as a history of previous cesarean delivery, is not communicated to the next care team. When receiving an intrapartum patient hand off, providers must have heightened vigilance to ensure they quickly reach situational awareness and are cognizant of the entire clinical context. Maintaining an environment in which all members of the care team, regardless of their training level, are encouraged to voice their concerns is another way to promote ongoing situational awareness.

CASE 3  Continued
The patient continues pushing for another 20 minutes without delivery, and the nurse raises a concern about the FHR tracing to the physician, who remains in the room but does not respond (FIGURE 5).

FIGURE 5 FHR tracing reveals ongoing repetitive variable decelerations

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #5: Acknowledge and respond to other caregivers' concerns
A team approach to patient care is essential in all areas of medicine, perhaps none more so than in obstetrics. Each member of the team is engaged in trying to provide optimal patient care and the concerns of every team member--regardless of title or level of training--must be acknowledged and addressed. Good communication requires creating a safe environment wherein each member of the team feels comfortable raising concerns without fear of reprisal. Rather than becoming angry or frustrated when questioned, providers should remain cognizant that these are ongoing efforts to maintain situational awareness and ensure the best possible outcome for mother and baby.

CASE 3  Continued
Pushing continues for another 30 minutes despite the nurse's repeated effort to express concern to the physician about the FHR tracing. After more than 2 hours of pushing, the infant is delivered; Apgar scores are 1, 5, and 7. No cord gas is obtained.

TIP #4: Initiate the chain of command when necessary
Any caregiver, regardless of job title, has a duty to initiate the institution's chain-of-command policy and procedure if he or she has a concern about patient well-being that is not being addressed adequately. It can be uncomfortable for a nurse, midwife, or resident physician to question an attending physician, particularly if that person responds in a dismissive, condescending, or angry manner. If a caregiver has made several attempts to engage the attending physician and feels the concerns are being inadequately addressed, then he or she must respectfully initiate the chain of command to seek additional objective review of the clinical situation.

Failure to follow oxytocin protocols, inadequate surveillance, poor documentation
CASE 4  Induction of an uncomplicated pregnancy due to postdates
A 20-year-old woman (G1P0) at 42 weeks' gestation with an otherwise uncomplicated first pregnancy presents for postdates induction with oxytocin. After 6 hours, she develops uterine tachysystole with recurrent variable decelerations but the oxytocin infusion is continued at the same rate (FIGURE 6).

FIGURE 6 FHR tracing indicates uterine tachysystole

The patient in Case 4 received oxytocin for induction of postdates pregnancy. The red arrow shown on the FHR tracing points out that oxytocin augmentation continues despite the presence of uterine contractions that are too frequent and initial changes, including subtle late decelerations in the FHR, that suggest early fetal compromise.

TIP #3: Manage oxytocin infusion according to protocol
Inappropriate use of oxytocin is common, including the improper management of oxytocin infusion in the setting of uterine tachysystole (defined as the presence of >5 contractions over a 10-minute period averaged over 30 minutes) and/or an abnormal FHR tracing. The mismanagement of uterine tachysystole is cited in more than two-thirds of obstetric malpractice cases.¹²

Uterine contractions alter blood flow through the spiral arteries and transiently reduce placental perfusion. Prolonged uterine tachysystole can lead to fetal oxygen debt and early signs of hypoxia, including the loss of spontaneous accelerations, tachycardia, and reduced variability. Continuing or increasing the oxytocin in the setting of such changes is hard to justify. One study found that the use of oxytocin in the setting of tachysystole was significantly associated with signs of fetal asphyxia (odds ratio [OR], 5.6).¹³ When the FHR pattern suggests significant interruption of fetal oxygen delivery and possible hypoxia, continuing or increasing an oxytocin infusion suggests a lack of understanding of the physiology that is the basis for FHR interpretation.

Appropriate management of tachysystole depends on the accompanying FHR.¹⁴ In the setting of a category I (normal) FHR tracing, tachysystole can be treated first with maternal repositioning (left or right lateral) and administration of a 500-cm3 maternal IV fluid bolus. If uterine activity does not return to normal after 10 to 15 minutes, decrease the oxytocin rate by at least half. If it does not return to normal after another 10 to 15 minutes, discontinue oxytocin until the tachysystole has resolved.

In the setting of a concerning category IIFHR tracing, discontinuation of oxytocin should be the first step along with maternal repositioning and administration of a fluid bolus. If these measures do not improve the FHR tracing and tachysystole persists, administration of an acute uterine relaxant, such as terbutaline, should be considered to slow contraction frequency.

If interventions result in normalization of the FHR tracing and resolution of tachysystole for 20 to 30 minutes, then oxytocin may be restarted if necessary for labor progress at no more than half the rate that produced tachysystole.

TIP #2: Recognize an abnormal FHR tracing--and what it means
Misinterpretation of the FHR tracing occurs when there is a failure to recognize characteristics that should raise concern about fetal well-being. Failure to recognize an abnormal FHR tracing occurred in 77% of sentinel cases involving intrapartum birth injury or death.^1,12,13 To limit misinterpretation of the FHR tracing, it is critical for nurses and physicians to use standardized terminology for clear, effective communication.

In 2008, the Eunice Kennedy Schriver National Institute of Child Health and Human Development (NICHD) published guidelines standardizing the terminology used to describe cardiotocography and to create consensus around its interpretation.15 Any description of an intrapartum FHR tracing should include a designation of category (I, II, or III). Fetal well-being is reasonably established with a category I FHR tracing.  A category III tracing indicates the high likelihood of fetal acidemia and the need for immediate intervention. A category II FHR tracing is considered indeterminate, and further characterization is required to reasonably exclude fetal metabolic acidosis and a risk of fetal injury.

The presence of moderate variability and fetal response to scalp stimulation are considered reassuring findings that reasonably exclude significant metabolic acidosis. In assessing variability, one pitfall is mistaking the appearance of "variability" within a deceleration (including during return to baseline) for baseline FHR variability. In the event of a persistent category II FHR tracing (>30 minutes), nursing staff should request direct physician review of the FHR tracing. In any case in which fetal well-being is uncertain, nursing staff should request direct physician evaluation of the mother in person and also the FHR tracing, with clear documentation of the findings, interpretation, and plan of care.¹⁶

TIP #1: Document, document, document
Nursing and physician documentation about the FHR tracing within the patient-specific clinical context is crucial for effective caregiver communication and patient safety. Thoughtful documentation also reduces liability exposure for providers by demonstrating maternal-fetal surveillance, early identification and treatment of an abnormal or indeterminate FHR tracing, and timely intervention on fetal behalf when necessary.

When the medical record aligns with the electronic FHR tracing and includes appropriate descriptions, interpretations, and interventions in line with national guidelines and institutional policy, the record demonstrates that the providers have a thorough understanding of the physiology behind cardiotocography and, more importantly, that they are able to apply that knowledge in clinical practice.⁶

Minimizing missteps
Several straightforward interventions can help clinicians overcome the most common pitfalls during FHR monitoring. These include accurate and high-quality cardiotocography, a collaborative team-based approach to patient care, and sustained situational awareness among providers. The consistent use of common language for the description and interpretation of FHR monitoring, adherence to hospital oxytocin protocols, and well-defined expectations for fetal surveillance and provider communication are critical to overcoming these challenges. Regularly scheduled nursing and physician education sessions and interdisciplinary case review can promote the adoption and sustained incorporation of these simple techniques into daily practice.³

Some have advocated for an "electronic fetal monitoring bundle," which would serve as a checklist of clinical evaluation steps that should occur every time a given process occurs.¹⁷ This approach would ensure that all providers on labor and delivery are qualified to read, accurately interpret, and respond to FHR tracings. It would require a credentialing process to confirm the competency of team members and reinforce the presence of a common language. It would also include an explicit escalation policy for rapid initiation of the chain of command in cases wherein there is a disagreement among team members about the FHR interpretation. Finally, each patient would be required to have, at all times, an identified responsible provider capable of a rapid response.

Although continuous FHR monitoring may not effectively reduce intrapartum fetal asphyxia, it is clearly here to stay. Recognizing--and addressing--the most common challenges encountered during intrapartum FHR monitoring may reduce unnecessary morbidity and potential liability for caregivers.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Interpreting continuous fetal heart rate (FHR) monitoring is one of the most common tasks obstetricians perform during the course of intrapartum care. Notably, many providers do not seek ongoing training to optimize their ability to reliably and accurately interpret the FHR. Yet FHR interpretation is one of the most frequent causes of litigation in the modern obstetric practice. Failure to interpret continuous FHR monitoring appropriately is estimated to account for 75% of obstetric-related litigation.¹

Continuous FHR monitoring during labor was introduced to identify infants at risk for  developing hypoxic-ischemic encephalopathy (HIE). The rate of HIE has not declined, however, despite almost universal adoption of continuous FHR monitoring.² Numerous reasons account for this failure, including ad hoc interpretation of terminology, lack of standardized protocols for management and intervention, and the oftentimes challenging patterns that must be interpreted.³ The confusion about and dissatisfaction with the current state of FHR monitoring has led to attempts to enhance our ability to identify infants at risk with additional approaches (such as fetal pulse oximetry and fetal ST-segment evaluation), and some have called for a complete overhaul of our approach to interpreting the FHR. Clark and colleagues stated recently, "It is time to start over and establish some common language, standard interpretation, and reasonable management principles and guidelines."³

We must recognize that, as a stand-alone tool, continuous FHR monitoring is ineffective for avoiding preventable adverse outcomes. It is most likely to be effective when used in accordance with published standard guidelines by professionals skilled in interpretation and when timely, appropriate interventions are performed based on that interpretation. Optimal FHR monitoring requires a collaborative perinatal team that performs the monitoring correctly, interprets it appropriately, and communicates the findings effectively, and in a timely fashion, to all members of the care team when a high-risk pattern is detected.

In this article we review some common challenges that clinicians encounter during intrapartum FHR monitoring and we offer 10 simple tips to help overcome these challenges. The clinical scenarios described are derived from published reports in the medical literature, published malpractice claims, and from our personal experience working in a major health care system as part of a team charged with overseeing ongoing certification and training of labor and delivery nurses.

Challenge: Signal ambiguity
CASE 1  Young woman in labor with first pregnancy
A 19-year-old woman presents in spontaneous labor with her first pregnancy, which has been uncomplicated. During the course of her care, it is noted that the FHR changes to a lower baseline than previously recorded. Evaluation reveals that the external monitor is tracking the maternal heart rate and not the FHR (FIGURE 1). After the monitor is adjusted, both the fetal and maternal rates are documented for a short period. Ultimately, continuous monitoring of the maternal heart rate is discontinued. After delivery of the infant several hours later, it is noted that the FHR continues to register on the monitor, and it is determined that for the last few hours the maternal heart rate has been traced.

FIGURE 1 FHR tracing indicates signal ambiguity

As described in Case 1, the upper panel of this tracing demonstrates the maternal heart rate confused as the fetal heart rate, while the segment in the lower panel shows a clear distinction between the maternal and fetal heart rates.

TIP #10: Ensure the FHR monitor is tracking the fetal, not the maternal, heart rate
Confusing the maternal and the fetal heart rate with external cardiotocography is common. When the mix-up is noted and corrected expeditiously, it is unlikely to result in an adverse outcome. Signal ambiguity may arise from faulty Doppler equipment or the inability of the cardiotocograph to differentiate between maternal and fetal heart rates. It commonly occurs after repositioning the patient, after fetal movement, or during pushing in the second stage when the maternal heart rate may increase to a baseline that is similar to that of the fetus.

Signal ambiguity should be suspected when the FHR runs in the low-normal range or when FHR accelerations are noted with greater than 50% of contractions (especially when pushing).⁴ Signal ambiguity also should be ruled out when there is an apparent FHR deceleration to the maternal range that does not recover.

Evaluating for suspected signal ambiguity involves 2 key steps: (1) documentation and verification of the maternal heart rate and (2) definitive documentation of the true FHR. To document the maternal heart rate, manually count the radial pulse for 1 minute or use a pulse oximeter for continuous monitoring. Using a pulse oximeter is a less labor-intensive approach and has the advantage of allowing continuous assessment of the maternal heart rate for comparison. Recording the maternal pulse continuously on the same screen as the FHR enables ongoing differentiation of the mother and fetus in difficult cases, particularly if internal fetal monitoring is not an option (because of maternal infectious disease, low suspicion for an abnormal FHR pattern, or strong maternal preference against internal monitoring, for example).

When clinically appropriate, use of a fetal scalp electrode (FSE) can document the FHR. If intrauterine fetal death has occurred, however, the FSE may transmit the maternal heart rate.⁵ Using ultrasonography to confirm the FHR prior to placing the FSE is a reliable method of definitive differentiation. If a newly placed FSE shows a clear differentiation of 5 to 10 beats per minute from a continuously assessed maternal pulse rate, then this is also a reliable way to assure that the FHR monitoring represents the fetus, particularly if ultrasonography is not immediately available.

Ultimately, before intervening based on an abnormal FHR tracing, it is paramount to confirm that the data are adequate for interpretation and represent the actual FHR. If signal ambiguity is identified or suspected, correct it by using ultrasonography to locate the FHR and replace the external monitor until a rate that is at least 5 to 10 beats per minute different from the maternal rate is obtained. Alternatively, this is an indication for internal fetal monitoring with an FSE.

Challenge: Inadequate FHR tracing, poor communication, lack of clinical context
CASE 2  Woman with uncomplicated postdates pregnancy presents for induction
A 28-year-old woman (G3P2) at 41 weeks 0 days of gestation presents to labor and delivery for induction of labor for the indication of postdates. There have been no complications with the current pregnancy. The initial cervical exam reveals 1+ cm dilation, 90% effacement, and −3 station, and the patient is started on oxytocin per the hospital protocol. What is your interpretation of the continuous FHR tracing shown in FIGURE 2?

FIGURE 2 Inadequate, uninterpretable FHR tracing

This FHR tracing, from the patient described in Case 2, is unusable because of the absence of data.

TIP #9: Check that the monitors are providing useful data
The ability to accurately interpret a continuous FHR tracing depends on the quality of data recorded. Unfortunately, the absence of data makes interpretation impossible. This includes both FHR and tocometry data, since both pieces of information are required for appropriate interpretation of a continuous FHR tracing.

Prolonged periods of uninterpretable FHR and uterine activity tracings imply that no one was attending the mother and fetus.⁶ If it is difficult to obtain an interpretable FHR tracing, document in the medical record that you made ongoing efforts to maintain an adequate tracing, including the amount of time spent holding the external monitor, use of ultrasonography to document the FHR, and plans for potential internal monitoring.

CASE 2  Continued
After several hours, the patient requests an epidural for pain management and one is placed without difficulty. She reports adequate pain relief and is comfortable for the next 1 to 2 hours. Subsequently, the patient reports a sudden onset of increasing pain that does not respond to additional patient-administered doses of anesthesia over a 30-minute period. The labor and delivery nurse becomes concerned about the patient's pain level and contacts the attending physician to discuss her concerns. The physician, who is currently attending to patients in clinic, listens to the nurse and asks her to contact the anesthesia department with her concerns (FIGURE 3).

FIGURE 3 FHR tracing reveals recurrent variables in a patient with evolving clinical concerns

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #8: Clearly communicate an urgent situation to the care team
Poor communication underlies many preventable adverse outcomes in medicine.⁷ Effective communication requires an adequate description of the clinical scenario or problem. A root cause analysis of a series of intrapartum adverse events involving fetal death or injury showed that poor communication about a concerning FHR tracing played a role in 72% of cases.¹

In this clinical scenario, the nurse believed that the patient's pain level was unusual or more than anticipated. The person who is communicating his or her concern (the sender) must be sure that the person receiving the message (the responder) clearly understands the sender's level of concern. In this case, it would have been appropriate for the sender to state clearly that she felt the patient's pain was outside of normal expectations and to request that the attending physician come to evaluate the patient.

Clear and effective communication includes (1) an appropriate description of the urgency of the situation and (2) an indication by the sender as to the desired response to this information ("please come evaluate the patient").⁸ In all cases, both steps are necessary to elicit an appropriate response.

CASE 2  Continued
Over the next 2 hours, recurrent variable decelerations develop, and then sudden, prolonged fetal bradycardia leads to urgent cesarean delivery. At delivery, a uterine rupture is diagnosed and a fetal hand is observed protruding through a lower-uterine segment defect into the maternal abdomen.

TIP #7: Always consider the entire clinical scenario
In this case, the team caring for the patient was not aware that her previous pregnancy had ended with a low transverse cesarean delivery. How does this information change your interpretation of the clinical scenario? The importance of understanding the entire clinical context when interpreting individual characteristics of cardiotocography cannot be overstated. For example, the sudden onset of recurrent, significant variable decelerations is more concerning in the context of a prior cesarean delivery, and late decelerations are more concerning in a patient with placental abruption, fetal growth restriction, or poorly controlled maternal diabetes.

An estimated 70% of fetuses will have an indeterminate FHR pattern (category II) at some time during labor.⁹ To appropriately interpret the FHR tracing, it is crucial to know the a priori risk for fetal hypoxia and metabolic acidosis (the precursor of fetal injury) due to such identified clinical risk factors as placental insufficiency, medical comorbidities (hypertension, diabetes), or postdates gestational age.

It is well established that cardiotocography has a good negative predictive value for the absence of fetal metabolic acidosis when there is moderate variability and spontaneous or induced accelerations. When attempting to risk stratify the fetus with a category II (indeterminate) FHR tracing, consider these 3 important questions:

1. What are the risk factors for this particular patient and her fetus?
2. What is the state of the fetus right now, and when was the last time metabolic acidosis could be excluded reasonably (by the presence of moderate variability and accelerations)?
3. What is the risk that the fetus will develop acidemia prior to delivery?

The presence of decelerations indicates interruption of oxygen delivery to the fetus, and recurrent decelerations may indicate an evolving process of accumulated oxygen deprivation, hypoxia, and eventually, metabolic acidosis. Most authorities agree that, for the fetus with a previously normal FHR tracing, the onset of significant, recurrent decelerations with slowly cumulative oxygen deficit can lead to fetal acidemia over the course of approximately 1 hour.¹⁰ Of course, acidosis also can occur much more quickly with acute events, such as placental abruption or uterine rupture. In deciding whether or not to intervene based on an FHR tracing, the clinician must take into account the clinical context to determine if delivery is likely to occur before significant acidemia develops.

Challenge: Lack of situational awareness, failure to address nursing concerns, reluctance to initiate the chain of command
CASE 3  Spontaneous labor in a second pregnancy
A 28-year-old woman (G2P1) at 40 weeks' gestation presents in spontaneous labor. She has a history of a previous uncomplicated vaginal delivery. After 6 hours she reaches complete dilation with the fetus at −1 station and begins pushing. After 60 minutes, the patient has only progressed to +1 station. She is contracting every 1 to 2 minutes with recurrent variable decelerations (FIGURE 4).

FIGURE 4 FHR tracing shows time points for initiation and continuation of pushing

This tracing, from the patient described in Case 3, documents contraction frequency every 1-2 minutes for more than 60 minutes while the patient continues to push. The fetal heart rate demonstrates repetitive moderate variable decelerations with every push.

TIP #6: Maintain situational awareness
A state of situational awareness exists when caregivers have a clear understanding of all of the factors at play in a clinical situation.¹¹ This can be lost when caregivers focus too intensely on one aspect of care. It often happens when the patient is pushing in the second stage and the provider, focused on the progress of fetal descent, loses track of the amount of time that has passed without reassuring features (such as variability and induced or spontaneous accelerations) in the FHR tracing. The nurse, seeing the physician at the bedside, presumes he or she is aware of the tracing and is thus reluctant to point out the concerning features for fear of appearing insubordinate.

Situational awareness also may be lost at the time of patient hand off between providers wherein critical information, such as a history of previous cesarean delivery, is not communicated to the next care team. When receiving an intrapartum patient hand off, providers must have heightened vigilance to ensure they quickly reach situational awareness and are cognizant of the entire clinical context. Maintaining an environment in which all members of the care team, regardless of their training level, are encouraged to voice their concerns is another way to promote ongoing situational awareness.

CASE 3  Continued
The patient continues pushing for another 20 minutes without delivery, and the nurse raises a concern about the FHR tracing to the physician, who remains in the room but does not respond (FIGURE 5).

FIGURE 5 FHR tracing reveals ongoing repetitive variable decelerations

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #5: Acknowledge and respond to other caregivers' concerns
A team approach to patient care is essential in all areas of medicine, perhaps none more so than in obstetrics. Each member of the team is engaged in trying to provide optimal patient care and the concerns of every team member--regardless of title or level of training--must be acknowledged and addressed. Good communication requires creating a safe environment wherein each member of the team feels comfortable raising concerns without fear of reprisal. Rather than becoming angry or frustrated when questioned, providers should remain cognizant that these are ongoing efforts to maintain situational awareness and ensure the best possible outcome for mother and baby.

CASE 3  Continued
Pushing continues for another 30 minutes despite the nurse's repeated effort to express concern to the physician about the FHR tracing. After more than 2 hours of pushing, the infant is delivered; Apgar scores are 1, 5, and 7. No cord gas is obtained.

TIP #4: Initiate the chain of command when necessary
Any caregiver, regardless of job title, has a duty to initiate the institution's chain-of-command policy and procedure if he or she has a concern about patient well-being that is not being addressed adequately. It can be uncomfortable for a nurse, midwife, or resident physician to question an attending physician, particularly if that person responds in a dismissive, condescending, or angry manner. If a caregiver has made several attempts to engage the attending physician and feels the concerns are being inadequately addressed, then he or she must respectfully initiate the chain of command to seek additional objective review of the clinical situation.

Failure to follow oxytocin protocols, inadequate surveillance, poor documentation
CASE 4  Induction of an uncomplicated pregnancy due to postdates
A 20-year-old woman (G1P0) at 42 weeks' gestation with an otherwise uncomplicated first pregnancy presents for postdates induction with oxytocin. After 6 hours, she develops uterine tachysystole with recurrent variable decelerations but the oxytocin infusion is continued at the same rate (FIGURE 6).

FIGURE 6 FHR tracing indicates uterine tachysystole

The patient in Case 4 received oxytocin for induction of postdates pregnancy. The red arrow shown on the FHR tracing points out that oxytocin augmentation continues despite the presence of uterine contractions that are too frequent and initial changes, including subtle late decelerations in the FHR, that suggest early fetal compromise.

TIP #3: Manage oxytocin infusion according to protocol
Inappropriate use of oxytocin is common, including the improper management of oxytocin infusion in the setting of uterine tachysystole (defined as the presence of >5 contractions over a 10-minute period averaged over 30 minutes) and/or an abnormal FHR tracing. The mismanagement of uterine tachysystole is cited in more than two-thirds of obstetric malpractice cases.¹²

Uterine contractions alter blood flow through the spiral arteries and transiently reduce placental perfusion. Prolonged uterine tachysystole can lead to fetal oxygen debt and early signs of hypoxia, including the loss of spontaneous accelerations, tachycardia, and reduced variability. Continuing or increasing the oxytocin in the setting of such changes is hard to justify. One study found that the use of oxytocin in the setting of tachysystole was significantly associated with signs of fetal asphyxia (odds ratio [OR], 5.6).¹³ When the FHR pattern suggests significant interruption of fetal oxygen delivery and possible hypoxia, continuing or increasing an oxytocin infusion suggests a lack of understanding of the physiology that is the basis for FHR interpretation.

Appropriate management of tachysystole depends on the accompanying FHR.¹⁴ In the setting of a category I (normal) FHR tracing, tachysystole can be treated first with maternal repositioning (left or right lateral) and administration of a 500-cm3 maternal IV fluid bolus. If uterine activity does not return to normal after 10 to 15 minutes, decrease the oxytocin rate by at least half. If it does not return to normal after another 10 to 15 minutes, discontinue oxytocin until the tachysystole has resolved.

In the setting of a concerning category IIFHR tracing, discontinuation of oxytocin should be the first step along with maternal repositioning and administration of a fluid bolus. If these measures do not improve the FHR tracing and tachysystole persists, administration of an acute uterine relaxant, such as terbutaline, should be considered to slow contraction frequency.

If interventions result in normalization of the FHR tracing and resolution of tachysystole for 20 to 30 minutes, then oxytocin may be restarted if necessary for labor progress at no more than half the rate that produced tachysystole.

TIP #2: Recognize an abnormal FHR tracing--and what it means
Misinterpretation of the FHR tracing occurs when there is a failure to recognize characteristics that should raise concern about fetal well-being. Failure to recognize an abnormal FHR tracing occurred in 77% of sentinel cases involving intrapartum birth injury or death.^1,12,13 To limit misinterpretation of the FHR tracing, it is critical for nurses and physicians to use standardized terminology for clear, effective communication.

In 2008, the Eunice Kennedy Schriver National Institute of Child Health and Human Development (NICHD) published guidelines standardizing the terminology used to describe cardiotocography and to create consensus around its interpretation.15 Any description of an intrapartum FHR tracing should include a designation of category (I, II, or III). Fetal well-being is reasonably established with a category I FHR tracing.  A category III tracing indicates the high likelihood of fetal acidemia and the need for immediate intervention. A category II FHR tracing is considered indeterminate, and further characterization is required to reasonably exclude fetal metabolic acidosis and a risk of fetal injury.

The presence of moderate variability and fetal response to scalp stimulation are considered reassuring findings that reasonably exclude significant metabolic acidosis. In assessing variability, one pitfall is mistaking the appearance of "variability" within a deceleration (including during return to baseline) for baseline FHR variability. In the event of a persistent category II FHR tracing (>30 minutes), nursing staff should request direct physician review of the FHR tracing. In any case in which fetal well-being is uncertain, nursing staff should request direct physician evaluation of the mother in person and also the FHR tracing, with clear documentation of the findings, interpretation, and plan of care.¹⁶

TIP #1: Document, document, document
Nursing and physician documentation about the FHR tracing within the patient-specific clinical context is crucial for effective caregiver communication and patient safety. Thoughtful documentation also reduces liability exposure for providers by demonstrating maternal-fetal surveillance, early identification and treatment of an abnormal or indeterminate FHR tracing, and timely intervention on fetal behalf when necessary.

When the medical record aligns with the electronic FHR tracing and includes appropriate descriptions, interpretations, and interventions in line with national guidelines and institutional policy, the record demonstrates that the providers have a thorough understanding of the physiology behind cardiotocography and, more importantly, that they are able to apply that knowledge in clinical practice.⁶

Minimizing missteps
Several straightforward interventions can help clinicians overcome the most common pitfalls during FHR monitoring. These include accurate and high-quality cardiotocography, a collaborative team-based approach to patient care, and sustained situational awareness among providers. The consistent use of common language for the description and interpretation of FHR monitoring, adherence to hospital oxytocin protocols, and well-defined expectations for fetal surveillance and provider communication are critical to overcoming these challenges. Regularly scheduled nursing and physician education sessions and interdisciplinary case review can promote the adoption and sustained incorporation of these simple techniques into daily practice.³

Some have advocated for an "electronic fetal monitoring bundle," which would serve as a checklist of clinical evaluation steps that should occur every time a given process occurs.¹⁷ This approach would ensure that all providers on labor and delivery are qualified to read, accurately interpret, and respond to FHR tracings. It would require a credentialing process to confirm the competency of team members and reinforce the presence of a common language. It would also include an explicit escalation policy for rapid initiation of the chain of command in cases wherein there is a disagreement among team members about the FHR interpretation. Finally, each patient would be required to have, at all times, an identified responsible provider capable of a rapid response.

Although continuous FHR monitoring may not effectively reduce intrapartum fetal asphyxia, it is clearly here to stay. Recognizing--and addressing--the most common challenges encountered during intrapartum FHR monitoring may reduce unnecessary morbidity and potential liability for caregivers.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Interpreting continuous fetal heart rate (FHR) monitoring is one of the most common tasks obstetricians perform during the course of intrapartum care. Notably, many providers do not seek ongoing training to optimize their ability to reliably and accurately interpret the FHR. Yet FHR interpretation is one of the most frequent causes of litigation in the modern obstetric practice. Failure to interpret continuous FHR monitoring appropriately is estimated to account for 75% of obstetric-related litigation.¹

Continuous FHR monitoring during labor was introduced to identify infants at risk for  developing hypoxic-ischemic encephalopathy (HIE). The rate of HIE has not declined, however, despite almost universal adoption of continuous FHR monitoring.² Numerous reasons account for this failure, including ad hoc interpretation of terminology, lack of standardized protocols for management and intervention, and the oftentimes challenging patterns that must be interpreted.³ The confusion about and dissatisfaction with the current state of FHR monitoring has led to attempts to enhance our ability to identify infants at risk with additional approaches (such as fetal pulse oximetry and fetal ST-segment evaluation), and some have called for a complete overhaul of our approach to interpreting the FHR. Clark and colleagues stated recently, "It is time to start over and establish some common language, standard interpretation, and reasonable management principles and guidelines."³

We must recognize that, as a stand-alone tool, continuous FHR monitoring is ineffective for avoiding preventable adverse outcomes. It is most likely to be effective when used in accordance with published standard guidelines by professionals skilled in interpretation and when timely, appropriate interventions are performed based on that interpretation. Optimal FHR monitoring requires a collaborative perinatal team that performs the monitoring correctly, interprets it appropriately, and communicates the findings effectively, and in a timely fashion, to all members of the care team when a high-risk pattern is detected.

In this article we review some common challenges that clinicians encounter during intrapartum FHR monitoring and we offer 10 simple tips to help overcome these challenges. The clinical scenarios described are derived from published reports in the medical literature, published malpractice claims, and from our personal experience working in a major health care system as part of a team charged with overseeing ongoing certification and training of labor and delivery nurses.

Challenge: Signal ambiguity
CASE 1  Young woman in labor with first pregnancy
A 19-year-old woman presents in spontaneous labor with her first pregnancy, which has been uncomplicated. During the course of her care, it is noted that the FHR changes to a lower baseline than previously recorded. Evaluation reveals that the external monitor is tracking the maternal heart rate and not the FHR (FIGURE 1). After the monitor is adjusted, both the fetal and maternal rates are documented for a short period. Ultimately, continuous monitoring of the maternal heart rate is discontinued. After delivery of the infant several hours later, it is noted that the FHR continues to register on the monitor, and it is determined that for the last few hours the maternal heart rate has been traced.

FIGURE 1 FHR tracing indicates signal ambiguity

As described in Case 1, the upper panel of this tracing demonstrates the maternal heart rate confused as the fetal heart rate, while the segment in the lower panel shows a clear distinction between the maternal and fetal heart rates.

TIP #10: Ensure the FHR monitor is tracking the fetal, not the maternal, heart rate
Confusing the maternal and the fetal heart rate with external cardiotocography is common. When the mix-up is noted and corrected expeditiously, it is unlikely to result in an adverse outcome. Signal ambiguity may arise from faulty Doppler equipment or the inability of the cardiotocograph to differentiate between maternal and fetal heart rates. It commonly occurs after repositioning the patient, after fetal movement, or during pushing in the second stage when the maternal heart rate may increase to a baseline that is similar to that of the fetus.

Signal ambiguity should be suspected when the FHR runs in the low-normal range or when FHR accelerations are noted with greater than 50% of contractions (especially when pushing).⁴ Signal ambiguity also should be ruled out when there is an apparent FHR deceleration to the maternal range that does not recover.

Evaluating for suspected signal ambiguity involves 2 key steps: (1) documentation and verification of the maternal heart rate and (2) definitive documentation of the true FHR. To document the maternal heart rate, manually count the radial pulse for 1 minute or use a pulse oximeter for continuous monitoring. Using a pulse oximeter is a less labor-intensive approach and has the advantage of allowing continuous assessment of the maternal heart rate for comparison. Recording the maternal pulse continuously on the same screen as the FHR enables ongoing differentiation of the mother and fetus in difficult cases, particularly if internal fetal monitoring is not an option (because of maternal infectious disease, low suspicion for an abnormal FHR pattern, or strong maternal preference against internal monitoring, for example).

When clinically appropriate, use of a fetal scalp electrode (FSE) can document the FHR. If intrauterine fetal death has occurred, however, the FSE may transmit the maternal heart rate.⁵ Using ultrasonography to confirm the FHR prior to placing the FSE is a reliable method of definitive differentiation. If a newly placed FSE shows a clear differentiation of 5 to 10 beats per minute from a continuously assessed maternal pulse rate, then this is also a reliable way to assure that the FHR monitoring represents the fetus, particularly if ultrasonography is not immediately available.

Ultimately, before intervening based on an abnormal FHR tracing, it is paramount to confirm that the data are adequate for interpretation and represent the actual FHR. If signal ambiguity is identified or suspected, correct it by using ultrasonography to locate the FHR and replace the external monitor until a rate that is at least 5 to 10 beats per minute different from the maternal rate is obtained. Alternatively, this is an indication for internal fetal monitoring with an FSE.

Challenge: Inadequate FHR tracing, poor communication, lack of clinical context
CASE 2  Woman with uncomplicated postdates pregnancy presents for induction
A 28-year-old woman (G3P2) at 41 weeks 0 days of gestation presents to labor and delivery for induction of labor for the indication of postdates. There have been no complications with the current pregnancy. The initial cervical exam reveals 1+ cm dilation, 90% effacement, and −3 station, and the patient is started on oxytocin per the hospital protocol. What is your interpretation of the continuous FHR tracing shown in FIGURE 2?

FIGURE 2 Inadequate, uninterpretable FHR tracing

This FHR tracing, from the patient described in Case 2, is unusable because of the absence of data.

TIP #9: Check that the monitors are providing useful data
The ability to accurately interpret a continuous FHR tracing depends on the quality of data recorded. Unfortunately, the absence of data makes interpretation impossible. This includes both FHR and tocometry data, since both pieces of information are required for appropriate interpretation of a continuous FHR tracing.

Prolonged periods of uninterpretable FHR and uterine activity tracings imply that no one was attending the mother and fetus.⁶ If it is difficult to obtain an interpretable FHR tracing, document in the medical record that you made ongoing efforts to maintain an adequate tracing, including the amount of time spent holding the external monitor, use of ultrasonography to document the FHR, and plans for potential internal monitoring.

CASE 2  Continued
After several hours, the patient requests an epidural for pain management and one is placed without difficulty. She reports adequate pain relief and is comfortable for the next 1 to 2 hours. Subsequently, the patient reports a sudden onset of increasing pain that does not respond to additional patient-administered doses of anesthesia over a 30-minute period. The labor and delivery nurse becomes concerned about the patient's pain level and contacts the attending physician to discuss her concerns. The physician, who is currently attending to patients in clinic, listens to the nurse and asks her to contact the anesthesia department with her concerns (FIGURE 3).

FIGURE 3 FHR tracing reveals recurrent variables in a patient with evolving clinical concerns

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #8: Clearly communicate an urgent situation to the care team
Poor communication underlies many preventable adverse outcomes in medicine.⁷ Effective communication requires an adequate description of the clinical scenario or problem. A root cause analysis of a series of intrapartum adverse events involving fetal death or injury showed that poor communication about a concerning FHR tracing played a role in 72% of cases.¹

In this clinical scenario, the nurse believed that the patient's pain level was unusual or more than anticipated. The person who is communicating his or her concern (the sender) must be sure that the person receiving the message (the responder) clearly understands the sender's level of concern. In this case, it would have been appropriate for the sender to state clearly that she felt the patient's pain was outside of normal expectations and to request that the attending physician come to evaluate the patient.

Clear and effective communication includes (1) an appropriate description of the urgency of the situation and (2) an indication by the sender as to the desired response to this information ("please come evaluate the patient").⁸ In all cases, both steps are necessary to elicit an appropriate response.

CASE 2  Continued
Over the next 2 hours, recurrent variable decelerations develop, and then sudden, prolonged fetal bradycardia leads to urgent cesarean delivery. At delivery, a uterine rupture is diagnosed and a fetal hand is observed protruding through a lower-uterine segment defect into the maternal abdomen.

TIP #7: Always consider the entire clinical scenario
In this case, the team caring for the patient was not aware that her previous pregnancy had ended with a low transverse cesarean delivery. How does this information change your interpretation of the clinical scenario? The importance of understanding the entire clinical context when interpreting individual characteristics of cardiotocography cannot be overstated. For example, the sudden onset of recurrent, significant variable decelerations is more concerning in the context of a prior cesarean delivery, and late decelerations are more concerning in a patient with placental abruption, fetal growth restriction, or poorly controlled maternal diabetes.

An estimated 70% of fetuses will have an indeterminate FHR pattern (category II) at some time during labor.⁹ To appropriately interpret the FHR tracing, it is crucial to know the a priori risk for fetal hypoxia and metabolic acidosis (the precursor of fetal injury) due to such identified clinical risk factors as placental insufficiency, medical comorbidities (hypertension, diabetes), or postdates gestational age.

It is well established that cardiotocography has a good negative predictive value for the absence of fetal metabolic acidosis when there is moderate variability and spontaneous or induced accelerations. When attempting to risk stratify the fetus with a category II (indeterminate) FHR tracing, consider these 3 important questions:

1. What are the risk factors for this particular patient and her fetus?
2. What is the state of the fetus right now, and when was the last time metabolic acidosis could be excluded reasonably (by the presence of moderate variability and accelerations)?
3. What is the risk that the fetus will develop acidemia prior to delivery?

The presence of decelerations indicates interruption of oxygen delivery to the fetus, and recurrent decelerations may indicate an evolving process of accumulated oxygen deprivation, hypoxia, and eventually, metabolic acidosis. Most authorities agree that, for the fetus with a previously normal FHR tracing, the onset of significant, recurrent decelerations with slowly cumulative oxygen deficit can lead to fetal acidemia over the course of approximately 1 hour.¹⁰ Of course, acidosis also can occur much more quickly with acute events, such as placental abruption or uterine rupture. In deciding whether or not to intervene based on an FHR tracing, the clinician must take into account the clinical context to determine if delivery is likely to occur before significant acidemia develops.

Challenge: Lack of situational awareness, failure to address nursing concerns, reluctance to initiate the chain of command
CASE 3  Spontaneous labor in a second pregnancy
A 28-year-old woman (G2P1) at 40 weeks' gestation presents in spontaneous labor. She has a history of a previous uncomplicated vaginal delivery. After 6 hours she reaches complete dilation with the fetus at −1 station and begins pushing. After 60 minutes, the patient has only progressed to +1 station. She is contracting every 1 to 2 minutes with recurrent variable decelerations (FIGURE 4).

FIGURE 4 FHR tracing shows time points for initiation and continuation of pushing

This tracing, from the patient described in Case 3, documents contraction frequency every 1-2 minutes for more than 60 minutes while the patient continues to push. The fetal heart rate demonstrates repetitive moderate variable decelerations with every push.

TIP #6: Maintain situational awareness
A state of situational awareness exists when caregivers have a clear understanding of all of the factors at play in a clinical situation.¹¹ This can be lost when caregivers focus too intensely on one aspect of care. It often happens when the patient is pushing in the second stage and the provider, focused on the progress of fetal descent, loses track of the amount of time that has passed without reassuring features (such as variability and induced or spontaneous accelerations) in the FHR tracing. The nurse, seeing the physician at the bedside, presumes he or she is aware of the tracing and is thus reluctant to point out the concerning features for fear of appearing insubordinate.

Situational awareness also may be lost at the time of patient hand off between providers wherein critical information, such as a history of previous cesarean delivery, is not communicated to the next care team. When receiving an intrapartum patient hand off, providers must have heightened vigilance to ensure they quickly reach situational awareness and are cognizant of the entire clinical context. Maintaining an environment in which all members of the care team, regardless of their training level, are encouraged to voice their concerns is another way to promote ongoing situational awareness.

CASE 3  Continued
The patient continues pushing for another 20 minutes without delivery, and the nurse raises a concern about the FHR tracing to the physician, who remains in the room but does not respond (FIGURE 5).

FIGURE 5 FHR tracing reveals ongoing repetitive variable decelerations

This tracing, from the patient described in Case 2, shows variables in the FHR while the patient experiences increasing discomfort. Each of the red arrows indicates documentation by the nurse of increasing pain reported by the patient. The black bars are used to cover names of caregivers.

TIP #5: Acknowledge and respond to other caregivers' concerns
A team approach to patient care is essential in all areas of medicine, perhaps none more so than in obstetrics. Each member of the team is engaged in trying to provide optimal patient care and the concerns of every team member--regardless of title or level of training--must be acknowledged and addressed. Good communication requires creating a safe environment wherein each member of the team feels comfortable raising concerns without fear of reprisal. Rather than becoming angry or frustrated when questioned, providers should remain cognizant that these are ongoing efforts to maintain situational awareness and ensure the best possible outcome for mother and baby.

CASE 3  Continued
Pushing continues for another 30 minutes despite the nurse's repeated effort to express concern to the physician about the FHR tracing. After more than 2 hours of pushing, the infant is delivered; Apgar scores are 1, 5, and 7. No cord gas is obtained.

TIP #4: Initiate the chain of command when necessary
Any caregiver, regardless of job title, has a duty to initiate the institution's chain-of-command policy and procedure if he or she has a concern about patient well-being that is not being addressed adequately. It can be uncomfortable for a nurse, midwife, or resident physician to question an attending physician, particularly if that person responds in a dismissive, condescending, or angry manner. If a caregiver has made several attempts to engage the attending physician and feels the concerns are being inadequately addressed, then he or she must respectfully initiate the chain of command to seek additional objective review of the clinical situation.

Failure to follow oxytocin protocols, inadequate surveillance, poor documentation
CASE 4  Induction of an uncomplicated pregnancy due to postdates
A 20-year-old woman (G1P0) at 42 weeks' gestation with an otherwise uncomplicated first pregnancy presents for postdates induction with oxytocin. After 6 hours, she develops uterine tachysystole with recurrent variable decelerations but the oxytocin infusion is continued at the same rate (FIGURE 6).

FIGURE 6 FHR tracing indicates uterine tachysystole

The patient in Case 4 received oxytocin for induction of postdates pregnancy. The red arrow shown on the FHR tracing points out that oxytocin augmentation continues despite the presence of uterine contractions that are too frequent and initial changes, including subtle late decelerations in the FHR, that suggest early fetal compromise.

TIP #3: Manage oxytocin infusion according to protocol
Inappropriate use of oxytocin is common, including the improper management of oxytocin infusion in the setting of uterine tachysystole (defined as the presence of >5 contractions over a 10-minute period averaged over 30 minutes) and/or an abnormal FHR tracing. The mismanagement of uterine tachysystole is cited in more than two-thirds of obstetric malpractice cases.¹²

Uterine contractions alter blood flow through the spiral arteries and transiently reduce placental perfusion. Prolonged uterine tachysystole can lead to fetal oxygen debt and early signs of hypoxia, including the loss of spontaneous accelerations, tachycardia, and reduced variability. Continuing or increasing the oxytocin in the setting of such changes is hard to justify. One study found that the use of oxytocin in the setting of tachysystole was significantly associated with signs of fetal asphyxia (odds ratio [OR], 5.6).¹³ When the FHR pattern suggests significant interruption of fetal oxygen delivery and possible hypoxia, continuing or increasing an oxytocin infusion suggests a lack of understanding of the physiology that is the basis for FHR interpretation.

Appropriate management of tachysystole depends on the accompanying FHR.¹⁴ In the setting of a category I (normal) FHR tracing, tachysystole can be treated first with maternal repositioning (left or right lateral) and administration of a 500-cm3 maternal IV fluid bolus. If uterine activity does not return to normal after 10 to 15 minutes, decrease the oxytocin rate by at least half. If it does not return to normal after another 10 to 15 minutes, discontinue oxytocin until the tachysystole has resolved.

In the setting of a concerning category IIFHR tracing, discontinuation of oxytocin should be the first step along with maternal repositioning and administration of a fluid bolus. If these measures do not improve the FHR tracing and tachysystole persists, administration of an acute uterine relaxant, such as terbutaline, should be considered to slow contraction frequency.

If interventions result in normalization of the FHR tracing and resolution of tachysystole for 20 to 30 minutes, then oxytocin may be restarted if necessary for labor progress at no more than half the rate that produced tachysystole.

TIP #2: Recognize an abnormal FHR tracing--and what it means
Misinterpretation of the FHR tracing occurs when there is a failure to recognize characteristics that should raise concern about fetal well-being. Failure to recognize an abnormal FHR tracing occurred in 77% of sentinel cases involving intrapartum birth injury or death.^1,12,13 To limit misinterpretation of the FHR tracing, it is critical for nurses and physicians to use standardized terminology for clear, effective communication.

In 2008, the Eunice Kennedy Schriver National Institute of Child Health and Human Development (NICHD) published guidelines standardizing the terminology used to describe cardiotocography and to create consensus around its interpretation.15 Any description of an intrapartum FHR tracing should include a designation of category (I, II, or III). Fetal well-being is reasonably established with a category I FHR tracing.  A category III tracing indicates the high likelihood of fetal acidemia and the need for immediate intervention. A category II FHR tracing is considered indeterminate, and further characterization is required to reasonably exclude fetal metabolic acidosis and a risk of fetal injury.

The presence of moderate variability and fetal response to scalp stimulation are considered reassuring findings that reasonably exclude significant metabolic acidosis. In assessing variability, one pitfall is mistaking the appearance of "variability" within a deceleration (including during return to baseline) for baseline FHR variability. In the event of a persistent category II FHR tracing (>30 minutes), nursing staff should request direct physician review of the FHR tracing. In any case in which fetal well-being is uncertain, nursing staff should request direct physician evaluation of the mother in person and also the FHR tracing, with clear documentation of the findings, interpretation, and plan of care.¹⁶

TIP #1: Document, document, document
Nursing and physician documentation about the FHR tracing within the patient-specific clinical context is crucial for effective caregiver communication and patient safety. Thoughtful documentation also reduces liability exposure for providers by demonstrating maternal-fetal surveillance, early identification and treatment of an abnormal or indeterminate FHR tracing, and timely intervention on fetal behalf when necessary.

When the medical record aligns with the electronic FHR tracing and includes appropriate descriptions, interpretations, and interventions in line with national guidelines and institutional policy, the record demonstrates that the providers have a thorough understanding of the physiology behind cardiotocography and, more importantly, that they are able to apply that knowledge in clinical practice.⁶

Minimizing missteps
Several straightforward interventions can help clinicians overcome the most common pitfalls during FHR monitoring. These include accurate and high-quality cardiotocography, a collaborative team-based approach to patient care, and sustained situational awareness among providers. The consistent use of common language for the description and interpretation of FHR monitoring, adherence to hospital oxytocin protocols, and well-defined expectations for fetal surveillance and provider communication are critical to overcoming these challenges. Regularly scheduled nursing and physician education sessions and interdisciplinary case review can promote the adoption and sustained incorporation of these simple techniques into daily practice.³

Some have advocated for an "electronic fetal monitoring bundle," which would serve as a checklist of clinical evaluation steps that should occur every time a given process occurs.¹⁷ This approach would ensure that all providers on labor and delivery are qualified to read, accurately interpret, and respond to FHR tracings. It would require a credentialing process to confirm the competency of team members and reinforce the presence of a common language. It would also include an explicit escalation policy for rapid initiation of the chain of command in cases wherein there is a disagreement among team members about the FHR interpretation. Finally, each patient would be required to have, at all times, an identified responsible provider capable of a rapid response.

Although continuous FHR monitoring may not effectively reduce intrapartum fetal asphyxia, it is clearly here to stay. Recognizing--and addressing--the most common challenges encountered during intrapartum FHR monitoring may reduce unnecessary morbidity and potential liability for caregivers.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Obstetricians work diligently to anticipate, diagnose, and treat preeclampsia because the maternal and perinatal health burden of the disease is enormous. Many meta-analyses have reported that aspirin treatment of women at high risk for preeclampsia reduces the risk of developing the disease by about 10% to 23%.^1–5 In addition, for women at high risk for preeclampsia, aspirin treatment reduces the risk of preterm birth and intrauterine growth restriction (IUGR). In your practice you should start offering aspirin to pregnant women at high risk for preeclampsia.

Aspirin reduces the risk of preeclampsia, preterm birth, and IUGRBased on the results of multiple meta-analyses of clinical trials involving more than 35,000 women, investigators consistently have concluded that aspirin treatment reduces the risk of preeclampsia in women at high risk for the disease.^1–5 The magnitude of the effect is difficult to define with precision, but the risk reduction is likely in the range of 10% to 23%.¹

In addition to reducing the risk of preeclampsia, aspirin also reduces the risk of 2 associated problems: preterm birth and IUGR. For preterm birth, the risk reduction is estimated to be in the range of 11% to 31%. For IUGR, the estimation for risk reduction is in the range of 7% to 24%.¹ Although these benefits are modest, the burden of maternal and perinatal morbidity associated with preeclampsia is great, making even a modest benefit clinically significant.

Potential harms of aspirin treatmentIn the most recent meta-analysis from the US Preventive Services Task Force (USPSTF),¹ low-dose aspirin treatment was associated with no significant perinatal or maternal harms, but rare harms could not be ruled out. A small increase in the risk of placental abruption was noted, but this increase did not reach significance (relative risk [RR], 1.17; 95% confidence interval [CI], 0.93–1.48).¹ There was no increased risk of maternal postpartum hemorrhage or blood loss at delivery.¹ In one meta-analysis, aspirin treatment did not increase the risk of newborn intracranial hemorrhage.¹

Other potential adverse effects of aspirin treatment include maternal gastrointestinal bleeding and exacerbation of respiratory disorders such as asthma, but these effects have not been reported as significant associations in clinical trials of preeclampsia prevention.

Dueling recommendations: Restrictive or liberal use of aspirin?The American College of Obstetricians and Gynecologists (ACOG) recommends use of aspirin to prevent preeclampsia in women who have a personal history of early-onset preeclampsia with delivery before 34 weeks of gestation and in women with preeclampsia in 2 or more prior pregnancies.⁶ The restrictive ACOG guideline recommends aspirin treatment for a very small group of women. In one analysis, using the ACOG guideline, only 0.35% of all pregnant women would be eligible for treatment with aspirin to prevent preeclampsia.⁷

The USPSTF recommends that all pregnant women with one major risk factor for preeclampsia—including multifetal gestation, chronic hypertension, type 1 or 2 pregestational diabetes, renal disease, autoimmune disease, or prior personal history of preeclampsia—receive treatment with aspirin to prevent preeclampsia.⁸ The Task Force also recommends that women with multiple moderate risk factors for preeclampsia, such as nulliparity, body mass index greater than 30 kg/m², family history of preeclampsia in a mother or sister, age 35 years or older, and certain sociodemographic risk factors (African American race, low socioeconomic status) also be offered aspirin treatment.

The USPSTF guideline advises aspirin treatment for many women. According to one analysis, the USPSTFguideline would result in approximately 24% of all pregnant women being offered aspirin treatment.⁷

The USPSTF guideline would result in 67 times more pregnant women being treated with aspirin than the ACOG guideline. The narrowly focused ACOG recommendation is problematic because it recommends against aspirin treatment in women who are at very high risk for developing preeclampsia, for example, a 41-year-old woman in her first pregnancy with twins and pregestational diabetes. In addition, the ACOG recommendation is not consistent with the recommendations of most other major health organizations.

The World Health Organization,⁹ the United Kingdom’s National Institute for Health and Care Excellence (NICE),¹⁰ and the Society of Obstetricians and Gynaecologists of Canada¹¹ all recommend aspirin treatment to prevent preeclampsia in pregnant women at high risk for the disease and utilize an expanded definition of “high risk” (TABLE). Some experts have observed that, in actual clinical practice, it is often difficult to consistently implement a prevention plan based on a complex assessment of clinical risk factors.⁷

An alternative to guidelines that use clinical risk factors to identify women at high risk is universal treatment. With universal treatment all pregnant women are prescribed aspirin, thereby maximizing the clinical benefit but unnecessarily treating many women with aspirin.⁷ Universal treatment of pregnant women with aspirin appears to be cost-effective and would be associated with annual health care savings of $365 million.⁷

Timing of aspirin initiationIn one meta-analysis, initiating aspirin before 16 weeks’ gestation resulted in a greater reduction in preeclampsia than starting aspirin after 16 weeks.¹² The USPSTF cautions that meta-analysis of the available data is not well suited for identifying the optimal time to initiate aspirin therapy.¹³ ACOG, USPSTF, and NICE recommend initiating aspirin therapy at approximately 12 weeks’ gestation—the end of the first trimester.

Ideal aspirin doseThe optimal dose of aspirin to prevent preeclampsia is not precisely defined. Aspirin doses ranging from 50 mg to 162 mg have been proposed for the prevention of preeclampsia. Most authorities recommend a daily dose between 80 mg and less than 300 mg to prevent preeclampsia.¹⁴ ACOG and USPSTF recommend aspirin at a dose of 81 mg daily,^6,8 because this dose is widely available in the United States.

Let’s close the gap between current and optimal practiceAccording to the USPSTF guidelines, approximately 24% of the pregnant women in our practices have risk factors that would justify the initiation of aspirin treatment for the prevention of preeclampsia.⁸ This approach would modestly reduce the rate of preeclampsia and the associated problems of preterm birth and IUGR with little cost and few adverse effects. Yet relatively few pregnant women in the United States are currently receiving aspirin therapy. We could close this clinical gap between current and optimal practice by reflecting on the USPSTF recommendations and implementing them in our practices, as appropriate.

Tell us…What are your thoughts about the use of aspirin in pregnant women who are at high risk for preeclampsia?

Send your letter to the editor to rbarbieri@frontlinemedcom.com. Please include the city and state in which you practice.

Obstetricians work diligently to anticipate, diagnose, and treat preeclampsia because the maternal and perinatal health burden of the disease is enormous. Many meta-analyses have reported that aspirin treatment of women at high risk for preeclampsia reduces the risk of developing the disease by about 10% to 23%.^1–5 In addition, for women at high risk for preeclampsia, aspirin treatment reduces the risk of preterm birth and intrauterine growth restriction (IUGR). In your practice you should start offering aspirin to pregnant women at high risk for preeclampsia.

Aspirin reduces the risk of preeclampsia, preterm birth, and IUGRBased on the results of multiple meta-analyses of clinical trials involving more than 35,000 women, investigators consistently have concluded that aspirin treatment reduces the risk of preeclampsia in women at high risk for the disease.^1–5 The magnitude of the effect is difficult to define with precision, but the risk reduction is likely in the range of 10% to 23%.¹

In addition to reducing the risk of preeclampsia, aspirin also reduces the risk of 2 associated problems: preterm birth and IUGR. For preterm birth, the risk reduction is estimated to be in the range of 11% to 31%. For IUGR, the estimation for risk reduction is in the range of 7% to 24%.¹ Although these benefits are modest, the burden of maternal and perinatal morbidity associated with preeclampsia is great, making even a modest benefit clinically significant.

Potential harms of aspirin treatmentIn the most recent meta-analysis from the US Preventive Services Task Force (USPSTF),¹ low-dose aspirin treatment was associated with no significant perinatal or maternal harms, but rare harms could not be ruled out. A small increase in the risk of placental abruption was noted, but this increase did not reach significance (relative risk [RR], 1.17; 95% confidence interval [CI], 0.93–1.48).¹ There was no increased risk of maternal postpartum hemorrhage or blood loss at delivery.¹ In one meta-analysis, aspirin treatment did not increase the risk of newborn intracranial hemorrhage.¹

Other potential adverse effects of aspirin treatment include maternal gastrointestinal bleeding and exacerbation of respiratory disorders such as asthma, but these effects have not been reported as significant associations in clinical trials of preeclampsia prevention.

Dueling recommendations: Restrictive or liberal use of aspirin?The American College of Obstetricians and Gynecologists (ACOG) recommends use of aspirin to prevent preeclampsia in women who have a personal history of early-onset preeclampsia with delivery before 34 weeks of gestation and in women with preeclampsia in 2 or more prior pregnancies.⁶ The restrictive ACOG guideline recommends aspirin treatment for a very small group of women. In one analysis, using the ACOG guideline, only 0.35% of all pregnant women would be eligible for treatment with aspirin to prevent preeclampsia.⁷

The USPSTF recommends that all pregnant women with one major risk factor for preeclampsia—including multifetal gestation, chronic hypertension, type 1 or 2 pregestational diabetes, renal disease, autoimmune disease, or prior personal history of preeclampsia—receive treatment with aspirin to prevent preeclampsia.⁸ The Task Force also recommends that women with multiple moderate risk factors for preeclampsia, such as nulliparity, body mass index greater than 30 kg/m², family history of preeclampsia in a mother or sister, age 35 years or older, and certain sociodemographic risk factors (African American race, low socioeconomic status) also be offered aspirin treatment.

The USPSTF guideline advises aspirin treatment for many women. According to one analysis, the USPSTFguideline would result in approximately 24% of all pregnant women being offered aspirin treatment.⁷

The USPSTF guideline would result in 67 times more pregnant women being treated with aspirin than the ACOG guideline. The narrowly focused ACOG recommendation is problematic because it recommends against aspirin treatment in women who are at very high risk for developing preeclampsia, for example, a 41-year-old woman in her first pregnancy with twins and pregestational diabetes. In addition, the ACOG recommendation is not consistent with the recommendations of most other major health organizations.

The World Health Organization,⁹ the United Kingdom’s National Institute for Health and Care Excellence (NICE),¹⁰ and the Society of Obstetricians and Gynaecologists of Canada¹¹ all recommend aspirin treatment to prevent preeclampsia in pregnant women at high risk for the disease and utilize an expanded definition of “high risk” (TABLE). Some experts have observed that, in actual clinical practice, it is often difficult to consistently implement a prevention plan based on a complex assessment of clinical risk factors.⁷

An alternative to guidelines that use clinical risk factors to identify women at high risk is universal treatment. With universal treatment all pregnant women are prescribed aspirin, thereby maximizing the clinical benefit but unnecessarily treating many women with aspirin.⁷ Universal treatment of pregnant women with aspirin appears to be cost-effective and would be associated with annual health care savings of $365 million.⁷

Timing of aspirin initiationIn one meta-analysis, initiating aspirin before 16 weeks’ gestation resulted in a greater reduction in preeclampsia than starting aspirin after 16 weeks.¹² The USPSTF cautions that meta-analysis of the available data is not well suited for identifying the optimal time to initiate aspirin therapy.¹³ ACOG, USPSTF, and NICE recommend initiating aspirin therapy at approximately 12 weeks’ gestation—the end of the first trimester.

Ideal aspirin doseThe optimal dose of aspirin to prevent preeclampsia is not precisely defined. Aspirin doses ranging from 50 mg to 162 mg have been proposed for the prevention of preeclampsia. Most authorities recommend a daily dose between 80 mg and less than 300 mg to prevent preeclampsia.¹⁴ ACOG and USPSTF recommend aspirin at a dose of 81 mg daily,^6,8 because this dose is widely available in the United States.

Let’s close the gap between current and optimal practiceAccording to the USPSTF guidelines, approximately 24% of the pregnant women in our practices have risk factors that would justify the initiation of aspirin treatment for the prevention of preeclampsia.⁸ This approach would modestly reduce the rate of preeclampsia and the associated problems of preterm birth and IUGR with little cost and few adverse effects. Yet relatively few pregnant women in the United States are currently receiving aspirin therapy. We could close this clinical gap between current and optimal practice by reflecting on the USPSTF recommendations and implementing them in our practices, as appropriate.

Tell us…What are your thoughts about the use of aspirin in pregnant women who are at high risk for preeclampsia?

Send your letter to the editor to rbarbieri@frontlinemedcom.com. Please include the city and state in which you practice.

Obstetricians work diligently to anticipate, diagnose, and treat preeclampsia because the maternal and perinatal health burden of the disease is enormous. Many meta-analyses have reported that aspirin treatment of women at high risk for preeclampsia reduces the risk of developing the disease by about 10% to 23%.^1–5 In addition, for women at high risk for preeclampsia, aspirin treatment reduces the risk of preterm birth and intrauterine growth restriction (IUGR). In your practice you should start offering aspirin to pregnant women at high risk for preeclampsia.

Aspirin reduces the risk of preeclampsia, preterm birth, and IUGRBased on the results of multiple meta-analyses of clinical trials involving more than 35,000 women, investigators consistently have concluded that aspirin treatment reduces the risk of preeclampsia in women at high risk for the disease.^1–5 The magnitude of the effect is difficult to define with precision, but the risk reduction is likely in the range of 10% to 23%.¹

In addition to reducing the risk of preeclampsia, aspirin also reduces the risk of 2 associated problems: preterm birth and IUGR. For preterm birth, the risk reduction is estimated to be in the range of 11% to 31%. For IUGR, the estimation for risk reduction is in the range of 7% to 24%.¹ Although these benefits are modest, the burden of maternal and perinatal morbidity associated with preeclampsia is great, making even a modest benefit clinically significant.

Potential harms of aspirin treatmentIn the most recent meta-analysis from the US Preventive Services Task Force (USPSTF),¹ low-dose aspirin treatment was associated with no significant perinatal or maternal harms, but rare harms could not be ruled out. A small increase in the risk of placental abruption was noted, but this increase did not reach significance (relative risk [RR], 1.17; 95% confidence interval [CI], 0.93–1.48).¹ There was no increased risk of maternal postpartum hemorrhage or blood loss at delivery.¹ In one meta-analysis, aspirin treatment did not increase the risk of newborn intracranial hemorrhage.¹

Other potential adverse effects of aspirin treatment include maternal gastrointestinal bleeding and exacerbation of respiratory disorders such as asthma, but these effects have not been reported as significant associations in clinical trials of preeclampsia prevention.

Dueling recommendations: Restrictive or liberal use of aspirin?The American College of Obstetricians and Gynecologists (ACOG) recommends use of aspirin to prevent preeclampsia in women who have a personal history of early-onset preeclampsia with delivery before 34 weeks of gestation and in women with preeclampsia in 2 or more prior pregnancies.⁶ The restrictive ACOG guideline recommends aspirin treatment for a very small group of women. In one analysis, using the ACOG guideline, only 0.35% of all pregnant women would be eligible for treatment with aspirin to prevent preeclampsia.⁷

The USPSTF recommends that all pregnant women with one major risk factor for preeclampsia—including multifetal gestation, chronic hypertension, type 1 or 2 pregestational diabetes, renal disease, autoimmune disease, or prior personal history of preeclampsia—receive treatment with aspirin to prevent preeclampsia.⁸ The Task Force also recommends that women with multiple moderate risk factors for preeclampsia, such as nulliparity, body mass index greater than 30 kg/m², family history of preeclampsia in a mother or sister, age 35 years or older, and certain sociodemographic risk factors (African American race, low socioeconomic status) also be offered aspirin treatment.

The USPSTF guideline advises aspirin treatment for many women. According to one analysis, the USPSTFguideline would result in approximately 24% of all pregnant women being offered aspirin treatment.⁷

The USPSTF guideline would result in 67 times more pregnant women being treated with aspirin than the ACOG guideline. The narrowly focused ACOG recommendation is problematic because it recommends against aspirin treatment in women who are at very high risk for developing preeclampsia, for example, a 41-year-old woman in her first pregnancy with twins and pregestational diabetes. In addition, the ACOG recommendation is not consistent with the recommendations of most other major health organizations.

The World Health Organization,⁹ the United Kingdom’s National Institute for Health and Care Excellence (NICE),¹⁰ and the Society of Obstetricians and Gynaecologists of Canada¹¹ all recommend aspirin treatment to prevent preeclampsia in pregnant women at high risk for the disease and utilize an expanded definition of “high risk” (TABLE). Some experts have observed that, in actual clinical practice, it is often difficult to consistently implement a prevention plan based on a complex assessment of clinical risk factors.⁷

An alternative to guidelines that use clinical risk factors to identify women at high risk is universal treatment. With universal treatment all pregnant women are prescribed aspirin, thereby maximizing the clinical benefit but unnecessarily treating many women with aspirin.⁷ Universal treatment of pregnant women with aspirin appears to be cost-effective and would be associated with annual health care savings of $365 million.⁷

Timing of aspirin initiationIn one meta-analysis, initiating aspirin before 16 weeks’ gestation resulted in a greater reduction in preeclampsia than starting aspirin after 16 weeks.¹² The USPSTF cautions that meta-analysis of the available data is not well suited for identifying the optimal time to initiate aspirin therapy.¹³ ACOG, USPSTF, and NICE recommend initiating aspirin therapy at approximately 12 weeks’ gestation—the end of the first trimester.

Ideal aspirin doseThe optimal dose of aspirin to prevent preeclampsia is not precisely defined. Aspirin doses ranging from 50 mg to 162 mg have been proposed for the prevention of preeclampsia. Most authorities recommend a daily dose between 80 mg and less than 300 mg to prevent preeclampsia.¹⁴ ACOG and USPSTF recommend aspirin at a dose of 81 mg daily,^6,8 because this dose is widely available in the United States.

Let’s close the gap between current and optimal practiceAccording to the USPSTF guidelines, approximately 24% of the pregnant women in our practices have risk factors that would justify the initiation of aspirin treatment for the prevention of preeclampsia.⁸ This approach would modestly reduce the rate of preeclampsia and the associated problems of preterm birth and IUGR with little cost and few adverse effects. Yet relatively few pregnant women in the United States are currently receiving aspirin therapy. We could close this clinical gap between current and optimal practice by reflecting on the USPSTF recommendations and implementing them in our practices, as appropriate.

Tell us…What are your thoughts about the use of aspirin in pregnant women who are at high risk for preeclampsia?

Send your letter to the editor to rbarbieri@frontlinemedcom.com. Please include the city and state in which you practice.

Expert Commentary The unintended pregnancy rate has hovered around 50% for at least 20 years despite vigorous efforts to educate both the public and health care providers on the importance of using effective contraceptive methods. During that time, new contraceptives were developed and older methods were improved to reduce risk and adverse effects. Despite these efforts, however, an estimated 48% of all unintended pregnancies in the United States occurred among contraceptive users.¹ Results of the study by Finer and Zolna on the recent decline in unintended pregnancies suggest there may be some light at the end of the tunnel.

Details of the studyThe study authors used data from the National Survey of Family Growth (NSFG) and other sources to calculate rates of pregnancy in the United States for 2008 and 2011, including rates based on pregnancy intentions and outcome. About 45% of pregnancies in 2011 were unintended, compared with 51% in 2008. The rate in 2011 represents the lowest rate of unintended pregnancy in more than 3 decades.

Rates reduced in many population subgroupsThe percentage of unintended pregnancies ending in abortion remained stable at 40% in 2008 and 42% in 2011. The largest changes in rate of unintended pregnancy from 2008 to 2011 occurred in women aged 15 to 17 years (−44%), women cohabiting (−29%), those with incomes at 100% to 199% of the federal poverty level (−32%), women who were not high school graduates (−28%), and Hispanic women (−26%). Other population subgroups also showed improvement but to a lesser extent than those described here.

The study authors concede that some of the reduction in unintended pregnancies can be attributed to the economic recession that occurred during the study time frame, when many women intentionally reduced or delayed childbearing. The more likely explanation, they point out, is the increased use of long-acting reversible contraception (LARC), particularly the intrauterine device (IUD). Notably, among US women using contraception, the rates of IUD use increased from 4% in 2007 to 12% in 2012.²

Nevertheless, while the unintended pregnancy rate has shown improvement, the rate in the United States still lags considerably behind that of other industrialized nations. In Western Europe, for example, the unintended pregnancy rate was 34% in 2012.³

What this evidence means for practiceAs the study data suggest, use of contraceptive methods that do not rely on a frequent activity by the user, such as LARC methods, is associated with improved adherence. Consequently, all LARC methods, including the IUD, are associated with a pregnancy rate of about 1% or less; this rate is equal to or better than the rates seen with many forms of tubal sterilization, and it is superior to that seen with other methods, such as oral contraceptives, which have a contraceptive failure rate of about 9%.⁴

Finally, to correct disparities noted in this study that may be related particularly to access to contraceptive methods, the Affordable Care Act contains provisions that should lead to greater availability of contraceptive services in the United States.

—Ronald T. Burkman, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Expert Commentary The unintended pregnancy rate has hovered around 50% for at least 20 years despite vigorous efforts to educate both the public and health care providers on the importance of using effective contraceptive methods. During that time, new contraceptives were developed and older methods were improved to reduce risk and adverse effects. Despite these efforts, however, an estimated 48% of all unintended pregnancies in the United States occurred among contraceptive users.¹ Results of the study by Finer and Zolna on the recent decline in unintended pregnancies suggest there may be some light at the end of the tunnel.

Details of the studyThe study authors used data from the National Survey of Family Growth (NSFG) and other sources to calculate rates of pregnancy in the United States for 2008 and 2011, including rates based on pregnancy intentions and outcome. About 45% of pregnancies in 2011 were unintended, compared with 51% in 2008. The rate in 2011 represents the lowest rate of unintended pregnancy in more than 3 decades.

Rates reduced in many population subgroupsThe percentage of unintended pregnancies ending in abortion remained stable at 40% in 2008 and 42% in 2011. The largest changes in rate of unintended pregnancy from 2008 to 2011 occurred in women aged 15 to 17 years (−44%), women cohabiting (−29%), those with incomes at 100% to 199% of the federal poverty level (−32%), women who were not high school graduates (−28%), and Hispanic women (−26%). Other population subgroups also showed improvement but to a lesser extent than those described here.

The study authors concede that some of the reduction in unintended pregnancies can be attributed to the economic recession that occurred during the study time frame, when many women intentionally reduced or delayed childbearing. The more likely explanation, they point out, is the increased use of long-acting reversible contraception (LARC), particularly the intrauterine device (IUD). Notably, among US women using contraception, the rates of IUD use increased from 4% in 2007 to 12% in 2012.²

Nevertheless, while the unintended pregnancy rate has shown improvement, the rate in the United States still lags considerably behind that of other industrialized nations. In Western Europe, for example, the unintended pregnancy rate was 34% in 2012.³

What this evidence means for practiceAs the study data suggest, use of contraceptive methods that do not rely on a frequent activity by the user, such as LARC methods, is associated with improved adherence. Consequently, all LARC methods, including the IUD, are associated with a pregnancy rate of about 1% or less; this rate is equal to or better than the rates seen with many forms of tubal sterilization, and it is superior to that seen with other methods, such as oral contraceptives, which have a contraceptive failure rate of about 9%.⁴

Finally, to correct disparities noted in this study that may be related particularly to access to contraceptive methods, the Affordable Care Act contains provisions that should lead to greater availability of contraceptive services in the United States.

—Ronald T. Burkman, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Expert Commentary The unintended pregnancy rate has hovered around 50% for at least 20 years despite vigorous efforts to educate both the public and health care providers on the importance of using effective contraceptive methods. During that time, new contraceptives were developed and older methods were improved to reduce risk and adverse effects. Despite these efforts, however, an estimated 48% of all unintended pregnancies in the United States occurred among contraceptive users.¹ Results of the study by Finer and Zolna on the recent decline in unintended pregnancies suggest there may be some light at the end of the tunnel.

Details of the studyThe study authors used data from the National Survey of Family Growth (NSFG) and other sources to calculate rates of pregnancy in the United States for 2008 and 2011, including rates based on pregnancy intentions and outcome. About 45% of pregnancies in 2011 were unintended, compared with 51% in 2008. The rate in 2011 represents the lowest rate of unintended pregnancy in more than 3 decades.

Rates reduced in many population subgroupsThe percentage of unintended pregnancies ending in abortion remained stable at 40% in 2008 and 42% in 2011. The largest changes in rate of unintended pregnancy from 2008 to 2011 occurred in women aged 15 to 17 years (−44%), women cohabiting (−29%), those with incomes at 100% to 199% of the federal poverty level (−32%), women who were not high school graduates (−28%), and Hispanic women (−26%). Other population subgroups also showed improvement but to a lesser extent than those described here.

The study authors concede that some of the reduction in unintended pregnancies can be attributed to the economic recession that occurred during the study time frame, when many women intentionally reduced or delayed childbearing. The more likely explanation, they point out, is the increased use of long-acting reversible contraception (LARC), particularly the intrauterine device (IUD). Notably, among US women using contraception, the rates of IUD use increased from 4% in 2007 to 12% in 2012.²

Nevertheless, while the unintended pregnancy rate has shown improvement, the rate in the United States still lags considerably behind that of other industrialized nations. In Western Europe, for example, the unintended pregnancy rate was 34% in 2012.³

What this evidence means for practiceAs the study data suggest, use of contraceptive methods that do not rely on a frequent activity by the user, such as LARC methods, is associated with improved adherence. Consequently, all LARC methods, including the IUD, are associated with a pregnancy rate of about 1% or less; this rate is equal to or better than the rates seen with many forms of tubal sterilization, and it is superior to that seen with other methods, such as oral contraceptives, which have a contraceptive failure rate of about 9%.⁴

Finally, to correct disparities noted in this study that may be related particularly to access to contraceptive methods, the Affordable Care Act contains provisions that should lead to greater availability of contraceptive services in the United States.

—Ronald T. Burkman, MD

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

“READER REACTIONS TO THE PROBLEM OF INADEQUATE CONTRACEPTION FOR HIGH-RISK WOMEN”(COMMENT & CONTROVERSY; APRIL 2016)

Focus on decreasing unintended pregnanciesI found the letters in response to Dr. Barbieri’s Editorial on inadequate contraception to be much overwrought. Dr. Will’s suggestion to have “automatic contraception … for all reproductive-age women including ‘children’ who are … menstruating” is excessive. Shouldn’t parents have the final decision making in their minor children’s health care?

An anonymous clinician ex-presses frustration with a Catholichealth care system for not allowing prescription of contraceptives, which does actually stay true to the religious beliefs of the institution, and proposes decreased reimbursements to these facilities across the board as a form of financial punishment for these practices. Not only would that be illegal and unconstitutional but it also demonstrates a lack of understanding of our First Amendment protections.

Overall, these letters and Dr. Barbieri’s response show a very narrow understanding of the issues involved. I think we can and should be focused on decreasing unintended pregnancies while also respecting the rights of all without resorting to Draconian and totalitarian solutions.

Myles Dotto, MD
Oradell, New Jersey

Dr. Barbieri respondsI share Dr. Dotto’s concern that government mandates regarding health care are potentially very dangerous. It is better for communities of clinicians and patients to develop optimal approaches to health care, without government interference.

“THE CRUSHING OF INNOVATION FOR TREATING FEMALE PELVIC FLOOR DISORDERS: A STORY OF ‘LEAD OR BE LED’”ANDREW CASSIDENTI, MD (GUEST EDITORIAL; APRIL 2016)Stand up for research benefiting our patientsI salute Dr. Cassidenti’s courage to call surgeons and the respective professional organizations to step up to defend the research and expose inappropriate expert testimony. We should be ashamed to be scattered like dogs because of fear and lack of courage to be advocates for what is in the best interest of our patients. Please continue the campaign to encourage physicians and surgeons to stand up.

Cleve Waters, MD
Chattanooga, Tennessee

Caving to class action litigation is a mistakeIn his Guest Editorial Dr. Cassidenti clarifies the importance of looking forward regarding mesh devices for pelvic organ prolapse (POP) treatment. As an advocate for women with POP and Founder/Executive Director of the Association for Pelvic Organ Prolapse Support—a US-based 501(c)(3)advocacy agency with global arms focused on generating awareness of POP and providing guidance and support to women navigating POP treatment—I found Endo International’s decision to close its Astora Women’s Health division extremely unsettling.

The nature of medicine is to continually advance, and that includes learning from experience and recognizing paths to evolution. Caving to class action litigation is a mistake. Research findings frequently indicate that up to half of the female population will experience POP and/or comorbid conditions.¹ It is imperative that health care, industry, research, academia, policy, and advocacy agencies continue to shine a light on this much needed field in women’s health.

Sherrie Palm
Milwaukee, Wisconsin

Reference

“INTRACTABLE SHOULDER DYSTOCIA: A POSTERIOR AXILLA MANEUVER MAY SAVE THE DAY”ROBERT L. BARBIERI, MD (APRIL 2016)

Avoidance: the greatest tool to address shoulder dystociaAlthough avoiding endometrial injury at cesarean delivery, including the possibility of later pathologic implantation, can be attained with vaginal delivery, vaginal birth at all cost leads to a dangerous situation. The emergency environment of shoulder dystocia is not a preferable or safer stratagem.

It is granted that shoulder dystocia will happen at some point but avoidance, by employing cesarean delivery when it is indicated, is the greatest tool for addressing this very dangerous problem.

J. Michael Arnold, MD
Oconto Falls, Wisconsin

Another suggestion for shoulder dystociaMy senior partner taught me a technique that works well, although I do not know its name. After suprapubic and McRoberts maneuvers fail and the shoulders do not deliver with gentle downward guidance in one direction, I rotate the head 180° and try again. Usually this works. I have taught this technique to several midwives, and they swear by it.

Annette Fineberg, MD
Davis, California

Dr. Barbieri respondsI thank Drs. Arnold and Fineberg for sharing their perspective and experience with our readers. Dr. Arnold notes that recommending cesarean delivery in high-risk situations such as cases in which the mother has diabetes and the fetus is macrosomic would surely reduce the frequency of shoulder dystocia. I respect Dr. Fineberg’s recommendation, based on extensive clinical experience, that by rotating the fetal head the shoulder dystocia may be resolved. My concern with this technique is that the torque transmitted to the neck might cause fetal damage. I think that rotating the shoulders (Rubin or Wood maneuver) would be less likely to result in fetal injury.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

“READER REACTIONS TO THE PROBLEM OF INADEQUATE CONTRACEPTION FOR HIGH-RISK WOMEN”(COMMENT & CONTROVERSY; APRIL 2016)

Focus on decreasing unintended pregnanciesI found the letters in response to Dr. Barbieri’s Editorial on inadequate contraception to be much overwrought. Dr. Will’s suggestion to have “automatic contraception … for all reproductive-age women including ‘children’ who are … menstruating” is excessive. Shouldn’t parents have the final decision making in their minor children’s health care?

An anonymous clinician ex-presses frustration with a Catholichealth care system for not allowing prescription of contraceptives, which does actually stay true to the religious beliefs of the institution, and proposes decreased reimbursements to these facilities across the board as a form of financial punishment for these practices. Not only would that be illegal and unconstitutional but it also demonstrates a lack of understanding of our First Amendment protections.

Overall, these letters and Dr. Barbieri’s response show a very narrow understanding of the issues involved. I think we can and should be focused on decreasing unintended pregnancies while also respecting the rights of all without resorting to Draconian and totalitarian solutions.

Myles Dotto, MD
Oradell, New Jersey

Dr. Barbieri respondsI share Dr. Dotto’s concern that government mandates regarding health care are potentially very dangerous. It is better for communities of clinicians and patients to develop optimal approaches to health care, without government interference.

“THE CRUSHING OF INNOVATION FOR TREATING FEMALE PELVIC FLOOR DISORDERS: A STORY OF ‘LEAD OR BE LED’”ANDREW CASSIDENTI, MD (GUEST EDITORIAL; APRIL 2016)Stand up for research benefiting our patientsI salute Dr. Cassidenti’s courage to call surgeons and the respective professional organizations to step up to defend the research and expose inappropriate expert testimony. We should be ashamed to be scattered like dogs because of fear and lack of courage to be advocates for what is in the best interest of our patients. Please continue the campaign to encourage physicians and surgeons to stand up.

Cleve Waters, MD
Chattanooga, Tennessee

Caving to class action litigation is a mistakeIn his Guest Editorial Dr. Cassidenti clarifies the importance of looking forward regarding mesh devices for pelvic organ prolapse (POP) treatment. As an advocate for women with POP and Founder/Executive Director of the Association for Pelvic Organ Prolapse Support—a US-based 501(c)(3)advocacy agency with global arms focused on generating awareness of POP and providing guidance and support to women navigating POP treatment—I found Endo International’s decision to close its Astora Women’s Health division extremely unsettling.

The nature of medicine is to continually advance, and that includes learning from experience and recognizing paths to evolution. Caving to class action litigation is a mistake. Research findings frequently indicate that up to half of the female population will experience POP and/or comorbid conditions.¹ It is imperative that health care, industry, research, academia, policy, and advocacy agencies continue to shine a light on this much needed field in women’s health.

Sherrie Palm
Milwaukee, Wisconsin

Reference

“INTRACTABLE SHOULDER DYSTOCIA: A POSTERIOR AXILLA MANEUVER MAY SAVE THE DAY”ROBERT L. BARBIERI, MD (APRIL 2016)

Avoidance: the greatest tool to address shoulder dystociaAlthough avoiding endometrial injury at cesarean delivery, including the possibility of later pathologic implantation, can be attained with vaginal delivery, vaginal birth at all cost leads to a dangerous situation. The emergency environment of shoulder dystocia is not a preferable or safer stratagem.

It is granted that shoulder dystocia will happen at some point but avoidance, by employing cesarean delivery when it is indicated, is the greatest tool for addressing this very dangerous problem.

J. Michael Arnold, MD
Oconto Falls, Wisconsin

Another suggestion for shoulder dystociaMy senior partner taught me a technique that works well, although I do not know its name. After suprapubic and McRoberts maneuvers fail and the shoulders do not deliver with gentle downward guidance in one direction, I rotate the head 180° and try again. Usually this works. I have taught this technique to several midwives, and they swear by it.

Annette Fineberg, MD
Davis, California

Dr. Barbieri respondsI thank Drs. Arnold and Fineberg for sharing their perspective and experience with our readers. Dr. Arnold notes that recommending cesarean delivery in high-risk situations such as cases in which the mother has diabetes and the fetus is macrosomic would surely reduce the frequency of shoulder dystocia. I respect Dr. Fineberg’s recommendation, based on extensive clinical experience, that by rotating the fetal head the shoulder dystocia may be resolved. My concern with this technique is that the torque transmitted to the neck might cause fetal damage. I think that rotating the shoulders (Rubin or Wood maneuver) would be less likely to result in fetal injury.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

“READER REACTIONS TO THE PROBLEM OF INADEQUATE CONTRACEPTION FOR HIGH-RISK WOMEN”(COMMENT & CONTROVERSY; APRIL 2016)

Focus on decreasing unintended pregnanciesI found the letters in response to Dr. Barbieri’s Editorial on inadequate contraception to be much overwrought. Dr. Will’s suggestion to have “automatic contraception … for all reproductive-age women including ‘children’ who are … menstruating” is excessive. Shouldn’t parents have the final decision making in their minor children’s health care?

An anonymous clinician ex-presses frustration with a Catholichealth care system for not allowing prescription of contraceptives, which does actually stay true to the religious beliefs of the institution, and proposes decreased reimbursements to these facilities across the board as a form of financial punishment for these practices. Not only would that be illegal and unconstitutional but it also demonstrates a lack of understanding of our First Amendment protections.

Overall, these letters and Dr. Barbieri’s response show a very narrow understanding of the issues involved. I think we can and should be focused on decreasing unintended pregnancies while also respecting the rights of all without resorting to Draconian and totalitarian solutions.

Myles Dotto, MD
Oradell, New Jersey

Dr. Barbieri respondsI share Dr. Dotto’s concern that government mandates regarding health care are potentially very dangerous. It is better for communities of clinicians and patients to develop optimal approaches to health care, without government interference.

“THE CRUSHING OF INNOVATION FOR TREATING FEMALE PELVIC FLOOR DISORDERS: A STORY OF ‘LEAD OR BE LED’”ANDREW CASSIDENTI, MD (GUEST EDITORIAL; APRIL 2016)Stand up for research benefiting our patientsI salute Dr. Cassidenti’s courage to call surgeons and the respective professional organizations to step up to defend the research and expose inappropriate expert testimony. We should be ashamed to be scattered like dogs because of fear and lack of courage to be advocates for what is in the best interest of our patients. Please continue the campaign to encourage physicians and surgeons to stand up.

Cleve Waters, MD
Chattanooga, Tennessee

Caving to class action litigation is a mistakeIn his Guest Editorial Dr. Cassidenti clarifies the importance of looking forward regarding mesh devices for pelvic organ prolapse (POP) treatment. As an advocate for women with POP and Founder/Executive Director of the Association for Pelvic Organ Prolapse Support—a US-based 501(c)(3)advocacy agency with global arms focused on generating awareness of POP and providing guidance and support to women navigating POP treatment—I found Endo International’s decision to close its Astora Women’s Health division extremely unsettling.

The nature of medicine is to continually advance, and that includes learning from experience and recognizing paths to evolution. Caving to class action litigation is a mistake. Research findings frequently indicate that up to half of the female population will experience POP and/or comorbid conditions.¹ It is imperative that health care, industry, research, academia, policy, and advocacy agencies continue to shine a light on this much needed field in women’s health.

Sherrie Palm
Milwaukee, Wisconsin

Reference

“INTRACTABLE SHOULDER DYSTOCIA: A POSTERIOR AXILLA MANEUVER MAY SAVE THE DAY”ROBERT L. BARBIERI, MD (APRIL 2016)

Avoidance: the greatest tool to address shoulder dystociaAlthough avoiding endometrial injury at cesarean delivery, including the possibility of later pathologic implantation, can be attained with vaginal delivery, vaginal birth at all cost leads to a dangerous situation. The emergency environment of shoulder dystocia is not a preferable or safer stratagem.

It is granted that shoulder dystocia will happen at some point but avoidance, by employing cesarean delivery when it is indicated, is the greatest tool for addressing this very dangerous problem.

J. Michael Arnold, MD
Oconto Falls, Wisconsin

Another suggestion for shoulder dystociaMy senior partner taught me a technique that works well, although I do not know its name. After suprapubic and McRoberts maneuvers fail and the shoulders do not deliver with gentle downward guidance in one direction, I rotate the head 180° and try again. Usually this works. I have taught this technique to several midwives, and they swear by it.

Annette Fineberg, MD
Davis, California

Dr. Barbieri respondsI thank Drs. Arnold and Fineberg for sharing their perspective and experience with our readers. Dr. Arnold notes that recommending cesarean delivery in high-risk situations such as cases in which the mother has diabetes and the fetus is macrosomic would surely reduce the frequency of shoulder dystocia. I respect Dr. Fineberg’s recommendation, based on extensive clinical experience, that by rotating the fetal head the shoulder dystocia may be resolved. My concern with this technique is that the torque transmitted to the neck might cause fetal damage. I think that rotating the shoulders (Rubin or Wood maneuver) would be less likely to result in fetal injury.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Click here to download the PDF.

Female sterilization is the most widely used form of permanent birth control around the world, and for more than 3 decades, laparoscopic procedures have been the preferred intervention. This supplement covers a hysteroscopic sterilization option, which first became available in 2002.

Cindy M. Basinski, MD
Basinski and Juran, MDs, LLC
Newburgh, Indiana

Linda D. Bradley, MD
Cleveland Clinic
Cleveland, Ohio
 

Click here to download the PDF.

Female sterilization is the most widely used form of permanent birth control around the world, and for more than 3 decades, laparoscopic procedures have been the preferred intervention. This supplement covers a hysteroscopic sterilization option, which first became available in 2002.

Cindy M. Basinski, MD
Basinski and Juran, MDs, LLC
Newburgh, Indiana

Linda D. Bradley, MD
Cleveland Clinic
Cleveland, Ohio
 

Click here to download the PDF.

Female sterilization is the most widely used form of permanent birth control around the world, and for more than 3 decades, laparoscopic procedures have been the preferred intervention. This supplement covers a hysteroscopic sterilization option, which first became available in 2002.

Cindy M. Basinski, MD
Basinski and Juran, MDs, LLC
Newburgh, Indiana

Linda D. Bradley, MD
Cleveland Clinic
Cleveland, Ohio
 

Guest Editor
Andrew M. Kaunitz, MD

Authors
Sheryl Kingsberg, PhD; Michael Krychman, MD; Juliana M. Kling, MD, MPH; JoAnn E. Manson, MD, DrPH; James H. Liu, MD; Gretchen Collins, MD; Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC

The object of this special issue is to enhance how you respond to and manage patients' menopausal and sexuality symptom concerns. The articles aim to alert women's health professionals to:

• the effects of sexual dysfunction, genitourinary syndrome of menopause in particular, on women emotionally and physically, and the available treatment options
• current nonhormonal treatment for hot flashes
• latest data on SERMs' role in managing menopausal symptoms, considering matching patients' symptoms to agents
• recommendations for intimacy counseling.

Articles included:

Image

Not enough women are receiving treatment for bothersome menopausal symptoms
Andrew M. Kaunitz, MD
Mitigating the impact of genitourinary syndrome of menopause on sexuality
Sheryl Kingsberg, PhD, and Michael Krychman, MD
Nonhormonal treatment options for vasomotor symptoms of menopause
Juliana M. Kling, MD, MPH, and JoAnn E. Manson, MD, DrPH
SERMs in menopause: Matching agents to patients' symptoms and attributes
James H. Liu, MD, and Gretchen Collins, MD

Tips for counseling women about intimacy after menopause
Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC

Guest Editor
Andrew M. Kaunitz, MD

Authors
Sheryl Kingsberg, PhD; Michael Krychman, MD; Juliana M. Kling, MD, MPH; JoAnn E. Manson, MD, DrPH; James H. Liu, MD; Gretchen Collins, MD; Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC

The object of this special issue is to enhance how you respond to and manage patients' menopausal and sexuality symptom concerns. The articles aim to alert women's health professionals to:

• the effects of sexual dysfunction, genitourinary syndrome of menopause in particular, on women emotionally and physically, and the available treatment options
• current nonhormonal treatment for hot flashes
• latest data on SERMs' role in managing menopausal symptoms, considering matching patients' symptoms to agents
• recommendations for intimacy counseling.

Articles included:

Image

Not enough women are receiving treatment for bothersome menopausal symptoms
Andrew M. Kaunitz, MD
Mitigating the impact of genitourinary syndrome of menopause on sexuality
Sheryl Kingsberg, PhD, and Michael Krychman, MD
Nonhormonal treatment options for vasomotor symptoms of menopause
Juliana M. Kling, MD, MPH, and JoAnn E. Manson, MD, DrPH
SERMs in menopause: Matching agents to patients' symptoms and attributes
James H. Liu, MD, and Gretchen Collins, MD

Tips for counseling women about intimacy after menopause
Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC

Guest Editor
Andrew M. Kaunitz, MD

Authors
Sheryl Kingsberg, PhD; Michael Krychman, MD; Juliana M. Kling, MD, MPH; JoAnn E. Manson, MD, DrPH; James H. Liu, MD; Gretchen Collins, MD; Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC

The object of this special issue is to enhance how you respond to and manage patients' menopausal and sexuality symptom concerns. The articles aim to alert women's health professionals to:

• the effects of sexual dysfunction, genitourinary syndrome of menopause in particular, on women emotionally and physically, and the available treatment options
• current nonhormonal treatment for hot flashes
• latest data on SERMs' role in managing menopausal symptoms, considering matching patients' symptoms to agents
• recommendations for intimacy counseling.

Articles included:

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Not enough women are receiving treatment for bothersome menopausal symptoms
Andrew M. Kaunitz, MD
Mitigating the impact of genitourinary syndrome of menopause on sexuality
Sheryl Kingsberg, PhD, and Michael Krychman, MD
Nonhormonal treatment options for vasomotor symptoms of menopause
Juliana M. Kling, MD, MPH, and JoAnn E. Manson, MD, DrPH
SERMs in menopause: Matching agents to patients' symptoms and attributes
James H. Liu, MD, and Gretchen Collins, MD

Tips for counseling women about intimacy after menopause
Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSC