Fetal monitoring bundle.

In 2008, the Eunice Kennedy Shriver National Institute of Child Health and Human Development published guidelines for categorizing fetal heart rate patterns. However, even if universally adopted, they will fail to improve outcomes unless they are integrated into a "bundle" of activities. Bundles reduce risks by assuring that key steps in a process are always taken. A fetal monitoring bundle would have four components: credentialed staff, an escalation policy, a known responsible party, and the capability for rapid response. The first requirement would be that all providers are qualified to appropriately interpret and respond to fetal heart rate tracings. Education should be uniform across disciplines, and there should be a credentialing process. Second is an escalation policy: an algorithm for nurses to use when getting help. It would avoid delays that occur when a nurse requesting a check on a tracing is required to call a hierarchical series of residents who must all concur before the attending who can move the patient to the operating room is called. Third, there must be an identified responsible provider at all times, ie, an obstetrician who can be readily contacted in emergent circumstances. Finally, there must be the capability of a rapid response; whenever a patient is monitored, the institution must have the obstetric, anesthesia, and pediatric resources necessary to respond to deteriorating fetal status. This bundle is a key, but not sole, piece of the perinatal safety pie; perinatal safety is advanced through a multifaceted approach anchored in a culture that values and invests in safety.