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Using remote fetal monitoring to enhance labor and delivery
The NEST initiative at the University of Maryland Medical System uses remote fetal monitoring to improve patient safety and health equity in labor and delivery systemwide.
With millions of babies born each year, labor and delivery are common in the United States. However, given the potential complications, such as infections, postpartum hemorrhage and blood clots, and persistent maternal health disparities, the process is fraught with challenges. With the U.S. maternal mortality rates continuing to lag behind its peers, health systems are increasingly using virtual healthcare technology to make childbirth safer.
One example of virtual healthcare enhancing labor and delivery is the University of Maryland Medical System's (UMMS) NEST initiative. NEST, which stands for Neonatal outcomes impacted by Escalation Safety Telemetry, is a remote fetal monitoring initiative that aims to boost maternal health outcomes and equity.
"This initiative is to support our patients, provide equity in their care and higher quality [outcomes] and innovation in obstetrics, which doesn't typically happen," said Cristina Haas, M.S.N., NEST nurse manager at UMMS.
Though implementing NEST required the health system to overcome change management barriers and other challenges, the initiative appears to be achieving its goals and making a positive impact in UMMS' labor and delivery units.
How the NEST initiative works
The NEST initiative, launched in the summer of 2024, enables nurses to conduct continuous, real-time remote patient monitoring (RPM) of labor and delivery across UMMS hospitals. Led by a medical director, NEST includes a team of 16 nurses who have extensive experience at the bedside.
"I think what's really unique is that all of the NEST nurses practiced as bedside labor and delivery nurses for cumulative years of experience greater than 250 years," Haas said.
The NEST team uses PeriGen's fetal monitoring platform, which gathers fetal heart rate data and uterine contraction patterns of every labor taking place in UMMS' seven hospitals. The AI-based PeriGen technology also organizes the data by acuity and flags potential issues. Once flagged, the nurses verify the information and contact the hospital's clinical teams.
"The intent of the NEST operating procedure is to support timely intervention for ominous trends, if you will," Haas said. "And not every trend is necessarily ominous, but we don't want it to go down that path."
NEST nurses use their expertise to decide if contacting the hospital is necessary. For instance, in some cases, the technology may flag an abnormal pattern, but Hass explained that there may be an explanation for it in the clinical documentation. In other cases, the nurse may contact the onsite clinical care team, and they may decide to continue monitoring the patient instead of intervening.
"We are partners in care, and we are not [there] to dictate a plan," Haas said. "We are not calling to make recommendations to the doctor about what they should and shouldn't do. We're really kind of there to serve as a timekeeper, to understand the physician's plan, and to work together and sort of help collaborate with the physician team member who is developing the plan."
Implementing the NEST initiative
Change management is one of the critical aspects of technology implementation. To implement the NEST initiative, clinical staff members needed to change how they had done their jobs for the last few decades.
"Change is hard…There's the [feeling] of, 'Well, I've been doing this a long time, why now? And why do I need it?'" Haas said of the sentiment within clinical care teams at UMMS. "And my question to that is, why not? Why not now?"
To support change management efforts, Haas had numerous meetings with leadership teams across UMMS hospitals. The NEST nurses went to the hospitals to meet with the clinical teams in person and invited the hospital teams to visit the NEST center to foster a strong working relationship.
Haas noted that they try to collaborate with the bedside teams as much as possible to smooth over any potential hiccups and cultivate collaboration. For instance, the NEST teams send recognitions called 'NEST eggs' to the bedside teams that they work with, highlighting good work and positive patient outcomes each month.
Further, UMMS only allows experienced nurses to join the NEST team. This not only helps alleviate any concerns or mistrust between bedside teams and the virtual nurses but also makes the training process easier.
"You have to have a minimum of five years of current labor and delivery experience," Haas shared. "That's in our job description to be considered for being hired for the NEST. So our talent acquisition partners really kind of vet that through. And then they also have to be nationally certified in electronic fetal monitoring through the National Certification Corporation."
The health system has also worked closely with Lisa Miller, a midwife, lawyer and author of two textbooks on electronic fetal monitoring. According to Haas, Miller helped train the UMMS NEST team, and they continue to use Miller's approaches and resources for continuing education. NEST nurses are expected to stay up-to-date with relevant advances in electronic fetal monitoring.
Though UMMS does not yet have outcomes data to share, Haas detailed numerous wins linked to NEST.
For one, the collaboration between the NEST nurses and bedside clinicians has helped expedite deliveries and enabled new nurses to escalate clinical care issues within the chain of command, which, Haas noted, can be challenging for new nurses.
Additionally, NEST is helping address health equity gaps. Maternal health inequities are a trenchant problem in America, with CDC data showing that Black people are three times more likely to die from pregnancy and childbirth than their white peers. According to the data, in 2023, the maternal mortality rate for white women was 14.5 deaths per 100,000 live births versus 50.3 deaths per 100,000 live births for Black women.
Since the NEST program is supported by data that is not influenced by race or ethnicity information, nurses can intervene equitably across the system.
"It's a blinded program," Haas said. "We see fetal heart trends. We don't see people; we see the data."
Though UMMS still needs to collect outcomes data to validate these early wins, NEST leaders like Haas are enthusiastic about the initiative and its potential to enhance birthing outcomes.
"When we receive calls or when I get emails from fellow leaders, directors, managers that say, 'Hey, the NEST really helped make an impact in this delivery,' that is a great victory," she said.
Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.
