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.
Aims and objectives
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
- 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
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.
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.