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).
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.
- 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.
- 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