Intermittent Auscultation : I have no financial disclosures related - - PowerPoint PPT Presentation

6/8/2018 1

Intermittent Auscultation : Evidence vs. Expert Opinion

WHEN SHOULD WE, HOW SHOULD WE, AND ON WHOM SHOULD WE DO IT.

BY MELINDA FOWLER, CNM, MSN

Disclosures…

 I have no financial disclosures related to the content of

this presentation.

 Special thanks to Tekoa L. King, CNM, MPH for her help

with this presentation.

Objectives

 1. Define Intermittent Auscultation(IA)  2. Best candidate for IA  3. Methods of IA  4. How often should IA be done  5. Limitations

Purpose of Intrapartum Fetal Surveillance …

 Detect potential fetal decompensation  Allow for timely and effective intervention  Prevent perinatal/neonatal morbidity or mortality

6/8/2018 2

What is Intermittent Auscultation(IA)?

 ACNM defines IA as… ”a method of fetal

surveillance that listens and counts the fetal heart rate for a specified amount of time at specific intervals in relationship to uterine contractions.”



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.

So why use IA?

 The number one reason for IA is patient satisfaction.  It is the least invasive method for fetal surveillance.  Allows women to be mobile without feeling trapped by

the cords on the electronic fetal monitor(EFM) even if it’s telemetry.

 Makes it easier to find the FHR when the women is in an

unconventional position.

Who is a candidate for IA?

 Any LOW-RISK woman who comes in for labor.  ACNM defines this as…women without medical or

• bstetrical conditions that are associated with

uteroplacental insufficiency that could affect the umbilical artery pH.

3 Key Recommendation for IA

 Formal fetal risk assessment on admission into labor  Understanding the NICE guidelines of when to switch from IA to continuous

fetal monitoring

 Being alert to the quick transition between latent and active labor, and

active labor and second stage of labor

6/8/2018 3

Tools of the Trade

Electronic Fetal Monitor Fetoscope Wooden Pinard Horn Fetoscope Doppler

So how do you do IA?

1.

LEOPOLD’S

2.

ASSESS THE FREQUENCY AND DURATION OF CONTRACTIONS. AND ASSESS MATERNAL HEART RATE.

3.

OPTIMAL POSITION OF MOM.

4.

PUT FETOSCOPE OR DOPPLER OVER FETAL THORAX OR BACK.

5.

DETERMINE THE BASELINE.

6.

COUNT THE FHR STARTING AT THE PEAK OF THE CONTRACTION AND FOR A SHORT PERIOD OF TIME AFTER THE CONTRACTION ENDS.

Evaluation of Fetal Heart

Baseline Fetal Heart Rate

 Auscultate between contractions

when the fetus is not moving.

 At the same time, palpate the

mother’s radial pulse to ensure that the FHR auscultated is not maternal.

 After establishing the baseline, then

listen for 15 to 60 sec at the recommended intervals between contractions when the fetus is not moving to assess the baseline.

Periodic FHR Changes

 Using the multiple-count strategy,

which is counting the FHR during several 5 to 15 second increments.

 An increase would be consistent with

an acceleration and a decrease would be consistent with a deceleration.

 This information can be plotted on a

graph for a clear picture.

Experts…What do they say??

6/8/2018 4

Recommendation for Assessment and Documentation of Fetal Heart Rate in Labor

Latent phase (<4cm) Latent phase (4-5cm) Active phase (>6cm) Second stage (passive descent) Second stage (active pushing) American College

• f Nurse-Midwives

Q 15-30 min for 60 sec Q 5 min for 60 sec American College

• f Obstetricians

and Gynecologist Q 30 min for 60 sec Q 15 min for 60 sec Association of Women’s Health, Obstetric and Neonatal Nurses At least hourly for 60 sec Q 15-30 min for 60 sec Q 15-30 min for 60 sec Q 15 min Q 5-15 min for 60 sec

Royal College of Midwives

Q 15-30 min for 60 sec Q 5 min for 60 sec NICE Guidelines Q 15 min for 60 sec in 1st stage of labor Q 5 min after contraction for 60 sec

So what do the numbers mean?

Interpretation of IA

Category I includes…

 Normal FHR baseline 110-160 bpm  Regular rhythm  No decrease or decelerations in FHR

from baseline

Category II could be…

 Irregular rhythm  A decrease baseline or deceleration  Tachycardia (baseline >160 bpm >10

min in duration)

 Bradycardia (baseline <110 bpm >10

min in duration)

Reasons to move to continuous fetal monitoring

 Maternal HR 120 bpm on 2 occasions 20

min apart.

 Elevated B/P on two consecutive

• ccasions 30 min apart.

 37.5 C on two occasions 1 hr apart or 38.0

C on one occasion

 Vaginal bleeding different from show  Rupture of membranes more than 24hr

before the onset of established labor

Maternal

6/8/2018 5

Reasons to move to continuous fetal monitoring

 Presence of significant meconium  Pain different from labor pain  Any factors in history that may suggest

the need for continuous monitoring

 Confirmed delay in 1st or 2nd stages of

labor

 Regional anesthesia  Obstetric emergency

Maternal

Reason to move to continuous fetal monitoring

 Abnormal presentation  Decreased fetal movement in the last 24

hour noted by the mother

 Decelerations heard on IA  Suspected fetal growth restriction or

macrosomia

 Polyhydramnios or anhydramnios  Fetal heart rate below 110 or above 160

bpm

Fetal

So what are the limitations to IA?

Fetal Heart Rate Characteristics Determined via Auscultation vs. Electronic Monitor

FHR Characteristic Fetoscope Doppler without Paper Printout Electronic FHR Monitor

Variability No No Yes Baseline Rate Yes Yes Yes Accelerations Detects increases Detects increases Differentiates type of decelerations Decelerations Detects decreases Detects decreases Differentiates type of decelerations Rhythm Yes Yes Yes Double counting or half- counting FHR Can clarify May double count or half count May double count or half count Differentiation of maternal and fetal heart rate Yes May double count or half count May double count or half count

6/8/2018 6

Other Limitations

Nursing

One to one nursing necessary Unit acuity Education

Patients

By-in when low risk to IA By-in when there is a need for continuous monitoring

Future Research

Methods on timing of FHR and best tool Continued evaluations on when there is a need to move from one method to another

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. 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. Journal Nurse Midwifery. 1986; 31(2) 73-77. Liston R, Sawchuck D, Young D, Society of Obstetrics and Gynaecologists of Canada. British Columbia Perinatal Health

• Program. (2007) Fetal health surveillance: antepartum and intrapartum consensus guideline. Journal of Obstetrics

and Gynecology Canada 29(9s4): s3-56. Goodwin L. (2000) Intermittent auscultation of the fetal heart rate: a review of general principles. Journal of Perinatal and Neonatal Nursing 14 (3): 53-61. National Institute of Clinical Excellence (NICE) (2007) Intrapartum Care: care of healthy women and their babies. London: NMC

THANK YOU