Shared learning database

Royal Berkshire NHS Foundation Trust
Published date:
November 2014

The goal of intrapartum fetal surveillance is to detect potential fetal decompensation and to allow timely and effective intervention to prevent perinatal/neonatal morbidity or mortality. Intermittent auscultation (IA) of the fetal heart was the chosen method of fetal assessment during labour following the development of the fetoscope in the early 1900s.

Following the introduction of electronic fetal monitoring (EFM) in the late 1960s IA steadily declined and EFM became the form of monitoring of choice. Between 1975 and 2008 several randomised controlled trials and a review of trials were conducted comparing EFM and IA. These suggested there was no significant improvement in outcome for the baby by using EFM for low-risk pregnancies. It is now recognised in the evidence and NICE intrapartum care guideline recommendations that, for women with no risk factors for fetal acidosis, IA should once again be the method of monitoring that is used.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

There were 2 main objectives to the training programme:
1) to confirm when IA is appropriate to use as a screening tool for fetal wellbeing in labour by encouraging midwives to undertake a thorough risk assessment and determine that the baby is well at the onset of the episode of care. This is done by listening to the fetal heart in between contractions to determine the baseline, immediately after a contraction to exclude decelerations and during episodes of fetal movements (or after a vaginal assessment or palpation) to determine the presence of accelerations. IA is not a reliable tool for assessing fetal wellbeing if the fetus is already compromised.

2) to move away from recording the fetal heart rate as a range (in an attempt to record variability) and to record it as a single rate which reflects the baseline. With an understanding of fetal physiology midwives should recognise that this is the parameter that is significant in understanding how fetal hypoxia develops and is the only parameter that can be quantified during IA.

Reasons for implementing your project

When working in a previous role in 2011, Christine noticed that lack of or poor quality IA was a theme within investigations following poor neonatal outcome and that midwives hadn't recognised fetal compromise and therefore taken appropriate action. There was a need to increase competence and confidence in auscultation and to address variation in practice. There was some evidence to suggest that midwife auscultation skills were not very good and that current practice was to possibly revert to using CTG unnecessarily. To establish this context a survey of midwifery practice and knowledge was carried out, sets of notes were reviewed and incidents audited. The findings of this review included:
- confusion in what midwives felt they could hear
- variations in practice
- The fetal heart rate being recorded as a range meaning that the baseline could not be determined
- midwives were focusing on variability of the fetal heart despite this being a late sign of fetal hypoxia
- there being no evidence that IA can be used to quantify it
- Lack of knowledge of fetal physiology and no intelligence in what was listened for.

How did you implement the project

A literature review was undertaken to explore the evidence upon which to base the training. Time was also spent with published experts in the field of fetal monitoring to ensure that the training was accurate. Mandatory training sessions were organised for all midwives within the organisation which was supported by the Trust and delivered alongside training on EFM. A case study approach enhanced the learning opportunities as well as simple and clear information on fetal physiology. Posters and pocket guides were developed and printed professionally and distributed within the Trust. The training was discussed at regional and national meetings and conferences and as a result the training package has been delivered to multiple trusts and posters and pocket guides sold. In order to spread the teaching further a 'How To' article in a midwives journal was published as well as a chapter on IA in a book about fetal surveillance.

There were no costs incurred by the trust during this project. Christine's trainee role came with a bursary which was used to produce the posters and pocket guides for the home trust. Orders for these resources were made by 7 trusts and 1 university within the region at the cost of production plus 20% bringing in a total of £1905.00 which included a profit of £444. This money was used to purchase books and training equipment for the practice development midwife to further enhance midwifery knowledge and skills.

Key findings

Evaluation of the initial training package locally demonstrated that midwives had a clearer understanding of fetal physiology and greater confidence in their skills of IA. During the review stage of the project a survey was undertaken amongst midwives within one Trust and a notes audit was undertaken. These were repeated during the evaluation stage. Before the teaching it was identified that 55% of midwives documented the fetal heart as a range in the first stage of labour and 64% in the second stage. During the evaluation stage the audit demonstrated these figures had increased to 82% and 91% respectively. The audit also demonstrated a significant increase in the numbers of midwives who were recording the maternal pulse hourly from 58% before the teaching to 96% after. Thus there had been a dramatic shift towards compliance with NICE guidance concerning recording the fetal heart as a single figure and recording the maternal pulse hourly.

Intelligence in IA was evidenced within clinical patient records with midwives demonstrating a justification for using IA through a thorough risk assessment and fetal wellbeing assessment and comments received within the surveys confirmed that midwives felt that they had a greater understanding of how to carry out IA intelligently.

The following are examples of comments received:
"The addition of auscultating an acceleration during the initial assessment makes perfect sense but was something I hadn?t thought about doing before, rather it was good fortune if I happened to hear one. This makes me feel more confident about confirming fetal wellbeing"

"I am confident that I know how IA should be carried out, what needs documenting and more importantly the rationale"

"My practice has changed as I no longer listen routinely before, during and after contractions and I recognise that I don't need to"

"I am much more aware of how/why/when IA is appropriate and how to perform it correctly and safely"

Further formal evaluation of the initiative has not been undertaken as Christine's job changed and her focus has been taken elsewhere. However she recognises that further evaluation is needed.

Key learning points

The implementation of this initiative has been very simple and without major challenge owing to the commitment of service providers to improve and develop initiatives that improve fetal monitoring. Training specifically on IA has always been lacking with the onus on the complexity of EFM and therefore midwives have welcomed this guidance on IA. The pocket guides and posters were very successful and evaluated positively by those who purchased them. This was enhanced due to the fact that they were produced professionally and therefore were eye catching and durable.

Contact details

Christine Harding
Clinical Lead Midwife
Royal Berkshire NHS Foundation Trust

Primary care
Is the example industry-sponsored in any way?