FOJP Optimal Outcomes

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FOJPThe timely and accurate interpretation of fetal heart rate tracings is as important for supporting risk management programs as it is for providing excellent patient care. Aimed at furthering both of these goals, the FOJP Optimal Outcomes program educates and evaluates physicians and nurses in fetal heart monitor tracing interpretation via its unique case-based online curriculum. The course content was developed in collaboration with clinicians at a number of academic medical centers. This course has also been used as part of a structured communications protocol for clinical staff on the labor and delivery floor to reinforce the NICHD criteria for fetal heart rate pattern interpretation.

Unique Interactivity

FOJPFOJP's Optimal Outcomes course offers clinicians a variety of multiple learning modalities, ranging from traditional text to highly interactive audio visual presentations. Testing materials and functionality are included in the basic program. Continuing education credit is provided for physicians and PAs (CMEs), nurses (CEU contact hours) and Certified Nurse Midwives (ACNM Specialty Credits). The course can be made available to organizations or groups at favorable terms. Contact Irene Kassel at 212.891.0865 or e-mail ikassel@fojp.com.

A Comprehensive Curriculum

An Introductory Module provides an overview of the language of fetal heart monitoring interpretation and introduces the standardized terminology and objective criteria to evaluate and categorize FHM tracings. This optional, ungraded learning activity can be accessed or printed, for reference, at any time.

FOJPThe Case Simulator is the heart of the Optimal Outcomes curriculum. A series of six cases are presented time point by time point. Course participants are challenged to interpret the tracings and make judgments based on the unfolding clinical story. Advisor’s Opinion tabs enable users to access an audio-video feature where specialists in obstetrics and maternal fetal medicine provide opinion and commentary relative to the topics covered in the various sections throughout the course. A "View References" tab can be accessed to expose users to evidence-based literature and resources that support the practice standards included in the course.

Didactic materials relevant to the principles and practice issues raised during the time points are provided in the context of the clinical story, seizing the most teachable moments at which to present this type of course material. The didactic content can be printed out for reference. Brief didactic quizzes test understanding of this material in each session.

FOJPThe Pattern Recognition Workshop is a visual learning experience well suited to the interactive online medium. It is designed to enhance and maintain clinicians’ visual skills at accurately identifying fetal heart rate tracing patterns according to the NICHD nomenclature.  Its Yardstick tools allow clinicians to objectively measure FHR tracing features, baseline, variability, accelerations and decelerations, and classify the tracing according to the NICHD Criteria. More than 40 patterns are provided for review in a setting that leads the clinician to the correct interpretation for each tracing.

Course Contents

Fetal Heart Rate Interpretation: An Introduction and Overview
This optional module presents an overview of the language of Fetal Heart Rate (FHR) monitoring incorporating the latest NICHD criteria and can be viewed at any time while taking the course. The material can be printed or saved as a PDF file for reference.

Case 1: FHR Variability and Clues to Assessing Fetal Well-Being
Interpreting the variability seen in fetal heart rate tracings is a key to gauging the oxygenation status of the fetus. This case highlights this tracing feature. Integrated into the case study is an overview of the three-tiered  classification of tracings. A discussion of fetal physiology within the context of FHR findings is introduced.

  • Variability: Introduction
  • Fetal Physiology: Introduction
  • Decelerations: Introduction
  • Fetal Heart Monitoring: Methods
  • Three-Tiered Classifications of FHR Tracings

Case 2: Trial of Labor After Cesarean (TOLAC)
This case addresses the special concerns clinicians must have when interpreting fetal heart rate monitor tracings in patients undergoing a trial of labor after Cesarean delivery (TOLAC). Discussion of the risks and benefits of TOLAC is presented within the conceptual framework of fetal heart monitoring. The parameters of baseline, accelerations and decelerations are detailed, and variability is further explored. The physiology of fetal acid base balance is addressed within the case’s clinical progression.

  • TOLAC: Risks and Benefits
  • Variability: Further Exploration
  • Baseline
  • Decelerations: Early, Variable, Late, Prolonged
  • Decelerations: Intermittent and Recurrent
  • Fetal Physiology: Correlation with  FHR parameters
  • Fetal Acid-Base Balance

Case 3: FHR Decelerations: Interpretation and Management
Decelerations can be indications of very different degrees of fetal well-being, and accurate interpretation of decelerations in FHM tracings is crucial. A further understanding of fetal heart decelerations, with emphasis on the physiology and clinical implications of variable decelerations is advanced in this case study. The methodology and interpretation of fetal assessment for acidemia are addressed.

  • Variable Decelerations: Causes, Significance, Interventions
  • Scalp Stimulation  and Fetal Scalp PH
  • Interpretation of Findings  and Clinical Decisions

Case 4: The Progress of Labor
As patients progress through the labor process, various considerations in the interpretation of FHM tracings arise at different points along the way. The physiology of the first and second stage of labor provides the basis of a discussion of anticipated and unanticipated FHR findings as illustrated in this case study. Clinical considerations of regional anesthesia and FHR changes are explored. The principles for an expeditious delivery are introduced.

  • Stages of Labor: First and Second
  • Frequency of Assessment
  • Regional Anesthesia
  • Labor Dystocia
  • Expeditious Delivery
  • Episiotomy
  • Apgar Score

Case 5: Rapid Response
Fetal heart rate monitoring plays a key role in assessing when expedited delivery is indicated. The clinical scenario in this case demonstrates the clinical correlation between evolving findings in the FHM tracings and a quickly changing clinical picture with placental abruption. An understanding of the physiological processes affecting the FHM tracings promotes anticipation of the next step. Teamwork and effective communication provide the platform for action.  

  • Hypertension in Pregnancy
  • Group B Strep
  • Placental Abruption
  • Prolonged Decelerations
  • New Onset Bradycardia
  • Rapid Assessment Protocol
  • Teamwork / Communication
  • Neonatal Encephalopathy and Cerebral Palsy

Case 6: Multi-Parity
This case focuses on the variations in the interpretation of FHM tracings arising from a patient's multiparous status and how they affect clinical management decisions. The hemodynamic response to placental insufficiency and hypoperfusion are explored. An integrated discussion of the features of Category II Indeterminate tracings with the unfolding clinical picture advances understanding of these frequently observed FHM tracings.

  • Breech Presentation and External Cephalic Version
  • Chronic Hypertension
  • Placental Insufficiency and  Uteroplacental Hyoperfusion
  • Category II Indeterminate Tracings

After completion of the six case studies, the didactic quizzes and pattern recognition workshop, the 25 question final exam is released for the user. An overall average grade of 70% across all elements is required. All exam questions are chosen at random from a larger question pool to insure variety in the test questions for different users.

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Course Contributors

Thomas Kerenyi, MD, FACOG
Course Director

Associate Clinical Professor
Mount Sinai School of Medicine

Loraine O’Neill, RN, MPH
Performance Improvement Coordinator
The Office of Excellence in Patient Care
The Mount Sinai Medical Center

Nathan Fox, MD, FACOG
Clinical Content Director

Assistant Clinical Professor
Mount Sinai School of Medicine 

Lucille Nassery, RNC
Clinical Nurse Manager
Labor and Delivery
The Mount Sinai Medical Center

Peter Bernstein, MD, FACOG
Director, Institute for Women’s Health
Montefiore Medical Center

Irene Kassel, BSN, RN
Operations Project Coordinator
FOJP Service Corporation

Charles Lockwood, MD, FACOG
Chairman, Department of Obstetrics and Gynecology
Yale School of Medicine

Robert Stanyon, MS, RN
Vice President Risk Management
FOJP Service Corporation

Joanne Stone, MD, FACOG
Division Director, Maternal-Fetal Medicine
Mount Sinai School of Medicine

John Glenn
Creative and Technical Director
Ceribrio/Optimal Outcomes

Erin DuPree, MD, FACOG
Deputy Chief Medical Officer
Vice President for Patient Safety
Vice Chair of Quality, OB/GYN and Reproductive Services
Mount Sinai Medical Center

Rachel Kondon, MPH
Clinical Content Coordinator
Cerebrio/Optimal Outcomes

Mark Callahan, MD
Senior Vice President and
Chief Medical Officer
FOJP Service Corporation