6/8/2018 Disclosures… Intermittent Auscultation : I have no financial disclosures related to the content of this presentation. Evidence vs. Expert Opinion Special thanks to Tekoa L. King, CNM, MPH for her help with this presentation. WHEN SHOULD WE, HOW SHOULD WE, AND ON WHOM SHOULD WE DO IT. BY MELINDA FOWLER, CNM, MSN Objectives Purpose of Intrapartum Fetal Surveillance … 1. Define Intermittent Auscultation(IA) Detect potential fetal decompensation 2. Best candidate for IA Allow for timely and effective intervention 3. Methods of IA 4. How often should IA be done Prevent perinatal/neonatal morbidity or mortality 5. Limitations 1
6/8/2018 What is Intermittent Auscultation(IA)? So why use IA? ACNM defines IA as… ”a method of fetal The number one reason for IA is patient satisfaction . surveillance that listens and counts the fetal It is the least invasive method for fetal surveillance. heart rate for a specified amount of time at Allows women to be mobile without feeling trapped by specific intervals in relationship to uterine the cords on the electronic fetal monitor(EFM) even if contractions.” it’s telemetry. Makes it easier to find the FHR when the women is in an unconventional position . Journal of Midwifery &Women’s Health vol. 60 No. 5, September/October 2015, Clinical Bulletin no.11, September/October. Replaces ACNM Clinical Bulletin Number 11 March 2010. Who is a candidate for IA? 3 Key Recommendation for IA Any LOW-RISK woman who comes in for labor. Formal fetal risk assessment on admission into labor Understanding the NICE guidelines of when to switch from IA to continuous ACNM defines this as…women without medical or fetal monitoring obstetrical conditions that are associated with uteroplacental insufficiency that could affect the Being alert to the quick transition between latent and active labor, and active labor and second stage of labor umbilical artery pH. 2
6/8/2018 Tools of the Trade LEOPOLD’S 1. ASSESS THE FREQUENCY AND DURATION 2. OF CONTRACTIONS. AND ASSESS MATERNAL HEART RATE. OPTIMAL POSITION OF MOM. 3. PUT FETOSCOPE OR DOPPLER OVER 4. FETAL THORAX OR BACK. So how do you DETERMINE THE BASELINE. Fetoscope 5. Wooden Pinard do IA? COUNT THE FHR STARTING AT THE PEAK Horn Fetoscope 6. OF THE CONTRACTION AND FOR A SHORT PERIOD OF TIME AFTER THE CONTRACTION ENDS. Electronic Fetal Monitor Doppler Evaluation of Fetal Heart Experts…What do they say?? Baseline Fetal Heart Rate Periodic FHR Changes Auscultate between contractions Using the multiple-count strategy, when the fetus is not moving. which is counting the FHR during several 5 to 15 second increments. At the same time, palpate the mother’s radial pulse to ensure that An increase would be consistent with the FHR auscultated is not maternal. an acceleration and a decrease would be consistent with a After establishing the baseline, then deceleration. listen for 15 to 60 sec at the recommended intervals between This information can be plotted on a contractions when the fetus is not graph for a clear picture. moving to assess the baseline. 3
6/8/2018 Recommendation for Assessment and Documentation of Fetal Heart Rate in Labor Latent phase Latent phase Active phase Second stage Second stage (<4cm) (4-5cm) (>6cm) (passive descent) (active pushing) American College Q 15-30 min Q 5 min for of Nurse-Midwives for 60 sec 60 sec So what do the numbers mean? American College Q 30 min for Q 15 min for of Obstetricians 60 sec 60 sec and Gynecologist Association of At least hourly Q 15-30 min for Q 15-30 min for Q 15 min Q 5-15 min for Women’s Health, for 60 sec 60 sec 60 sec 60 sec Obstetric and Neonatal Nurses Royal College of Q 15-30 min for Q 5 min for 60 sec 60 sec Midwives NICE Guidelines Q 15 min for 60 sec Q 5 min after in 1 st stage of labor contraction for 60 sec Interpretation of IA Reasons to move to continuous Maternal HR 120 bpm on 2 occasions 20 fetal monitoring min apart. Category I includes… Category II could be… Elevated B/P on two consecutive Maternal occasions 30 min apart. Normal FHR baseline 110-160 bpm Irregular rhythm 37.5 C on two occasions 1 hr apart or 38.0 Regular rhythm A decrease baseline or deceleration C on one occasion No decrease or decelerations in FHR Tachycardia (baseline >160 bpm >10 Vaginal bleeding different from show from baseline min in duration) Bradycardia (baseline <110 bpm >10 Rupture of membranes more than 24hr before the onset of established labor min in duration) 4
6/8/2018 Reasons to move Reason to move to continuous to continuous Abnormal presentation Presence of significant meconium fetal monitoring fetal monitoring Decreased fetal movement in the last 24 Pain different from labor pain hour noted by the mother Any factors in history that may suggest Maternal Fetal Decelerations heard on IA the need for continuous monitoring Suspected fetal growth restriction or Confirmed delay in 1 st or 2 nd stages of macrosomia labor Polyhydramnios or anhydramnios Regional anesthesia Fetal heart rate below 110 or above 160 Obstetric emergency bpm Fetal Heart Rate Characteristics Determined via Auscultation vs. Electronic Monitor FHR Characteristic Fetoscope Doppler without Paper Electronic FHR Monitor Printout Variability No No Yes So what are the Baseline Rate Yes Yes Yes Accelerations Detects increases Detects increases Differentiates type of limitations to IA? decelerations Decelerations Detects decreases Detects decreases Differentiates type of decelerations Rhythm Yes Yes Yes Double counting or half- Can clarify May double count or half May double count or half counting FHR count count Differentiation of maternal Yes May double count or half May double count or half and fetal heart rate count count 5
6/8/2018 Other Limitations References Journal of Midwifery &Women’s Health vol. 60 No. 5, September/October 2015, Clinical Bulletin no.11, September/October. Replaces ACNM Clinical Bulletin Number 11 March 2010. Paine LL, Payton RG, Johnson TR. Auscultated fetal heart rate accelerations. Part I. Accuracy and documentation. Nursing Patients Future Research Journal Nurse Midwifery. 1986; 31(2):68-72. Paine LL, Payton RG, Johnson TR. Auscultated fetal heart accelerations. Part II. An alternative to the nonstress test. One to one nursing By-in when low risk to IA Methods on timing of FHR Journal Nurse Midwifery. 1986; 31(2) 73-77. necessary and best tool By-in when there is a need Liston R, Sawchuck D, Young D, Society of Obstetrics and Gynaecologists of Canada. British Columbia Perinatal Health for continuous monitoring Continued evaluations on Program. (2007) Fetal health surveillance: antepartum and intrapartum consensus guideline. Journal of Obstetrics when there is a need to and Gynecology Canada 29(9s4) : s3-56. Unit acuity move from one method to Goodwin L. (2000) Intermittent auscultation of the fetal heart rate: a review of general principles. Journal of Perinatal and another Neonatal Nursing 14 (3) : 53-61. Education National Institute of Clinical Excellence (NICE) (2007) Intrapartum Care: care of healthy women and their babies. London: NMC THANK YOU 6
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