[CG] Intermittent auscultation in low risk labour (Green pathway) - midwifery guidance

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The goal of Intrapartum fetal monitoring is to detect and prevent the ill-effects of fetal hypoxia. There are currently two methods of monitoring fetal wellbeing in labour:

  • Intermittent auscultation (IA) using a Pinard or handheld Doppler
  • Continuous cardiotocography (CTG)

The method adopted is dependent on risk assessment and maternal choice. Women should be given evidence-based advice about fetal monitoring antenatally and should be involved in the decision making process (NHS Litigation Authority 2004).

Clinical practice guidelines only recommend continuous CTG for high-risk women (NICE 2014) and current evidence does not support the use of the admission CTG in low risk pregnancy (RCM 2012). Therefore, intermittent auscultation of the FH should be offered to low-risk women in established labour in all birth settings (NICE 2014).

Procedure for Intermittent Auscultation in labour

Intermittent auscultation involves listening to the fetal heartbeat periodically and recording a single measure of the fetal heart rate at a time (Martis et al. 2010).

  • Palpate the maternal abdomen to ascertain fetal position (FHR is usually best heard over the fetal back/anterior shoulder) (Martis et al. 2010).
  • A Pinard or Doppler ultrasound (NICE 2017) should be used at initial assessment to establish the real sound of the fetal heart and to aid confirmation of presentation and position (RCM 2012).

NICE (2014) recommend:

  • The maternal pulse should be palpated at the initial assessment, hourly throughout the first stage of labour, every 15 minutes in the second stage of labour and if a fetal heart rate abnormality is detected to differentiate between the two heart rates. Maternal heart rate should be documented on the partogram.
  • Auscultate the fetal heart for a minimum of 1 minute immediately after a contraction at least every 15 minutes in the first stage of labour and record as a single figure. This should be documented on the partogram.
  • Auscultate the fetal heart for a minimum of 1 minute immediately following a contraction at least every 5 minutes in the second stage of labour and record as a single figure. This should be documented on the NHS GG&C ‘Fetal heart – auscultation record’. This record card is completed every 5 minutes in conjunction with the partogram and is signed and filed in the labour ward booklet after the birth.
  • Record accelerations and decelerations if heard
  • Palpate the maternal pulse to differentiate between the maternal and fetal heartbeats (NICE 2017)

Both intermittent auscultation and continuous CTG provide information on the baseline heart rate (usually between 110 and 160 beats per minute in the term fetus), accelerations (transient increases in the FHR) and
decelerations (transient decreases in the FHR). It is known that some aspects of labour will cause natural alterations in FHR patterns. Some of these changes are subtle and can only be detected by continuous CTG, e.g. baseline variability, temporal shape of decelerations.

Take the following into account when assessing baseline FH rate:

  • this will usually be between 110 and 160 beats/minute – clear and regular on auscultation (NHSQIS 2009)
  • Be aware of a rising or changing baseline as an indicator of potential fetal compromise (NHSQIS 2009)

Ongoing risk assessment

Be aware that risk factors can change at any point during labour and may necessitate the move to continuous CTG (RCM 2012). According to NICE (2014) indications for continuous CTG include:

  • Significant meconium
  • Fetal heart rate abnormality
  • Suspected chorioamnionitis or sepsis (see NHS GG&C Sepsis guideline), or a temperature of 38 C or above
  • Fresh PV bleeding developing in labour
  • Oxytocin use
  • Severe hypertension (160/110 mmHg)

Other indications include:

  • Maternal request – woman should be informed that continuous CTG may restrict her mobility
  • Epidural analgesia
  • NOTE: Amniotomy alone for suspected delay in established labour should not be regarded as an indication to commence continuous CTG (NICE 2014)

Women at low risk of complications who have CTG commenced because of concern arising from intermittent auscultation should have the cardiotocograph removed if the trace is normal for 20 minutes, unless the woman asks to stay on continuous cardiotocography (NICE 2017).

Documentation

It is currently recommended that the Pinard should be used in the first instance to determine that there are fetal heart sounds before intermittent auscultation is carried out using a dopplar. Contemporaneous documentation is essential as there is no print out containing a record of the fetal heart rate.

Appendix: Fetal heart auscultation record

References

Alfirevic Z, Devane D, Gyte G (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, Issue 3. Chichester: John Wiley & Sons

Devane, D., Lalor, J. G., Daly, S., McGuire, W., Smith, V. (2012) Cardiotocography verus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing (Review). Cochrane Database of Systematic Reviews , Issue 2. Chichester: John Wiley & Sons

Martis, R., Emilia, O., Nurdiati, D. S. (2010) Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database of Systematic Reviews, Issue 9. Chichester: John Wiley & Sons

Medicines and Healthcare products Regulatory Agency (MHRA) (2010) Medical Device Alert. Fetal Monitor/Cardiotocograph. Ref MDA/2010/054 [online]

NHS Quality Improvement Scotland (2009) Pathways for Maternity Care

NICE (2014) Intrapartum care for healthy women and babies: Clinical guideline [online] Updated ~February 2017  https://www.nice.org.uk/guidance/cg190/resources/intrapartum-care-for-healthy-women-and-babies-35109866447557 {accessed 22/03/2017}

NICE (2015a) Fetal monitoring during labour [online] http://pathways.nice.org.uk/pathways/intrapartum-care/fetal-monitoring-during-labour {accessed 12/09/16}

NICE (2015b) Intrapartum care: Quality Standard [online] https://www.nice.org.uk/guidance/qs105/resources/intrapartum-care-75545239323589 {accessed 12/09/16}

The Royal College of Midwives (RCM) (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Intermittent Auscultation (IA) [online]https://www.rcm.org.uk/sites/default/files/Intermittent%20Auscultation%20(IA)_0.pdf {accessed 12/09/16}

Last reviewed: 18 April 2017

Next review: 01 April 2022

Author(s): Pauline Boyle, Practice Development Support Midwife PRM on behalf of GGC OGG

Approved By: Obstetric Governance Group