Listening to Baby During Labour

Edited and updated: August 2013

Intermittent auscultation (IA) is considered to be an important aspect of midwifery care for women during a ‘low risk’ labour. The expectation of surveillance of the baby is reflected in guidelines and hospital policies. The recommended frequency of IA is generally every 15-30 minutes during the first stage of labour and after every contraction (or more often if contractions are longer than 5mins apart) during the second stage. Of course this raises questions about the concept of ‘stages’ of labour, but that’s a whole other blog entry. There is an assumption that evidence based guidelines are based on research evidence. However there is NO research to date examining whether the practice of fetal heart rate auscultation is beneficial, or the optimal frequency of auscultation. There may be theoretical and experiential evidence to support the practice, but the timing seems to have been plucked out of the air and set in stone. Guidelines cite other guidelines as reference sources and I am yet to track down the actual research that supports the guidelines. You can read more about the history of auscultating the fetal heart rate in an article by Maude, Lawson and Foureur (2010).

This post is not going to discuss the technical ‘how to’ or ‘what to look for’ of IA. This is more of a reflection on the practice of IA and how it might be done in a more woman-centred way.

Some concerns about prescriptive IA

While hearing a normal fetal heart rate can be reassuring for both midwife and mother there are a number of issues associated with the practice – particularly the increased frequency while the woman is pushing her baby out:

  • It involves doing something to the birthing woman – anything you do may interfere with the physiology of birth (ie. stimulate the neocortex).
  • The woman may have to move from an instinctively perfect position so that you can ‘get in’ to listen.
  • It can create anxiety and concern if the heart rate is difficult to find or not ‘normal’. In the second stage of labour 75% of babies will have an ‘abnormal’ heart rate due to normal physiological processes such as head compression (Sheiner et al. 2001). Abnormal patterns in the second stage are only significant if there were abnormal patterns in the first stage of labour (Sheiner et al. 2001; Loghis et al. 1997; Wu, Chen & Wang 1996).

Suggestions

Before labour discuss IA with the woman:

  • Reinforce that she is the expert in her baby’s well-being. Encourage her to connect with her baby and trust her instincts regarding his/her health in pregnancy, labour and beyond.
  • Find out how often would she like you to listen to her baby, and if she would prefer you to use a doppler or a pinnard? Explain that she can change her mind at any time during labour about when and how you listen to her baby.
  • Explain that while she is pushing her baby out there will be some changes to the heart rate pattern (decelerations) and that this is normal.
  • Explain how you plan to listen to her baby (see below) and check that she is happy with this approach.

During labour:

  • Fit the timing of IA around the woman’s preferences and what is going on rather than set time intervals.
  • Avoid stimulating her neocortex by asking the question ‘can I listen in?’ Instead gently move towards her with the doppler/pinnard. Have a prior agreement that she can move away or push you away if she doesn’t want you to listen.
  • If the heart rate has been normal throughout the first stage, and there are no risk factors (eg. coached pushing) – there is no need to increase IA during the second stage.
  • When the head is crowning it can be incredibly difficult and uncomfortable to locate the fetal heart sounds due to the position of the baby in the pelvis. Instead observe the colour of the baby’s scalp to assess oxygenation – a nice pink scalp = a well oxygenated baby.

I am aware that my suggestions may be difficult for midwives caring for women they don’t know in a hospital setting. As usual I am being idealistic rather than prescriptive.

Further reading/resources

  • You can download a poster (literature review) about a number of routine midwifery practices carried out during birth here
  • My Phd thesis includes a literature review of fetal heart rate auscultation during birth

 

About midwifethinking

independent midwife, lecturer and student of all things birthy
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14 Responses to Listening to Baby During Labour

  1. Comments transferred from previous blog:

    Holly Meyer
    Thank you for posting this Rachel. I have often thought about this, as home vs hospital is so different. In the 2 homebirths of my own babes I didn’t want IA. My rationale for this was that I was concerned if I heard an abnormal heart rate/tone that it could send me into panic, pulling me out of my ‘birth space’ or ‘labour land’ and focussing on something that may or may not be of concern. Thus beginning a cascade of fear.
    Your suggestions for ways to offer IA to mothers enabling them to make informed choices backup my own feelings on the subject and will be very helpful in my practice.
    LOVING this blog, and I look forward to more entries!
    Tuesday, July 27, 2010 – 07:43 AM

    Rachel
    Thanks Holly!
    I find IA difficult. On the one hand we are saying to the mother ‘trust your body and your instincts’ then the next moment we are checking that her body is working and the baby is safe.
    Most of the women I care for choose ‘occasional’ IA that fits around them. Some want more regular IA – especially those who have been fed fear during pregnancy (eg. VBAC).
    As a midwife I do like to hear a normal FH. But then as you said – if there is a transient change eg. tachy due to dehydration/heat I stress (on the inside only I hope) until it returns to normal. I am also aware that prescriptive IA is the standard legally regardless of evidence.
    Anyway, I’m pleased you like the blog. I plan to post at least once a week and keep focussed on midwifery practice rather than the depressing politics.
    Rx
    Tuesday, July 27, 2010 – 08:46 AM

    Anna Robins
    Loved your suggestions, which really hand the power back to the woman and recognise her right to making an informed decision regarding her labour. Also, lovely pinard !!
    Wednesday, July 28, 2010 – 10:58 PM

  2. This is a lovely post! I have shared it with my facebook world! Information coming to me this year is letting me look at those OP babies as another variation of normal. Reframing this in the context of the birth is helpful to all! thanks for writing this so well!

    Sharon

  3. Great post! I shared it on the CNY Doula Connection facebook page.

  4. Andie B says:

    I’ve just found your blog and love it. Thank you.
    My partner and I did a hypnobirthing course before the birth of my daughter last year but chose to deliver in hospital as it was our first baby. Our birth plan (aka ‘leave us alone’) was, on the whole, followed well by hospital staff and the membranes were intact for all except the last 30 minutes of labour. At this point I was in the birthing pool and felt them burst with a contraction. The midwife listened to the baby’s heartbeat immediately afterwards and because it ‘dropped’, told me I had to get out of the pool. I gave birth to Brianna on my side on a hospital bed.
    Although I was happy with the ‘natural’ birth I had, I can’t help wondering if I could have stayed in the pool. My thoughts/instincts are that anyone’s heart rate would drop if the environment they’d been in for 9 months suddenly blew up around them! Do you think there’s a chance the heart rate would have recovered? It wasn’t really given a chance to. The reason I ask is that I’m due to give birth again at Christmas and am planning a home birth with birthing pool. The videos you’ve provided links to have been so inspirational, I would LOVE to give birth in water. I know I will have more choice this time but would like to feel confident that the hospital midwives were being over-cautious when they hauled me out of that pool!
    Even if you don’t get the chance to respond, I’d like to say how much confidence reading your blog and watching the videos have given me to birth at home. I haven’t yet decided whether to hire an independent midwife but this is an option we are considering.
    Warmest regards,
    Andie B (UK)

    • Hi Andie
      Your thoughts and instincts are probably right. Often when the waters break and the baby descends quickly into the pelvis you will hear a deceleration – this is a normal response and will usually recover once the baby adjusts. Let me know how your waterbirth goes.
      Rx

  5. Annette says:

    I am a Brit who has had four sons between 1986 and 1990 the last as a home birth and I am absolutely convinced that audible foetal heart monitoring in hospital is causing increased anxiety and increased interventions in what should be a quiet, labouring-mother led process. The foetal heart rate is approx 140 bpm compared with 70-80 bpm adult resting rate – the baby’s heart therefore sounds like its racing and in a panic which makes everyone hyperviigilent and anxious.This means that any and every slight fluctuation is over analysed and leads to defensive interventions which are unnecessary and intrusive. I suggested to our National Childbirth Trust that they sponsor some research into this so I am very interested in Robyn’s research- Keep up the good work!

  6. Patsy says:

    I know of a Mom who had a boy #5 pregnancy that had his cord completely knotted tightly….the doctors could not believe it…he is a healthy young man today !

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  8. Tina says:

    If the frequency of measuring the fatal heart rate is hospital policy, can a women refuse to be monitored at that frequency? or at all? Or is it compulsory in a hospital setting?

  9. I visited multiple sites except the audio quality for audio songs current at this website is actually wonderful.

  10. nabila fowles-gutierrez says:

    I totally and utterly agree with this. I am currently planning my own birth no3 and this will be on my request list. In fact if I can find a technology that allows a “contactless” IA to take place then I will use it. I don’t want voices and hands touching me without need and just to fit into a neat protocol.

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