Intermittent Auscultation & Fetal Physiology
» The primary purpose of the NHS is to deliver high quality care to all, free at the point of need. High quality care encompasses care that is safe, clinically effective, and results in as positive an experience for patients as possible. » Delivering care puts individuals, teams and organisations under pressure » Decisions have to be made in unpredictable circumstances (National Quality Board, 2013)
» Heuristics and biases ˃ The rule of thumb ˃ Stereotyping ˃ Profiling » Recognise and manage ‘low validity’ situations by ˃ Standardised decision making (protocols and guidelines) ˃ Using cognitive aids (check lists, bundles, stickers) ˃ Train in ‘low validity’ environment (simulation) » Train for collective competence ˃ Team based learning ˃ Cognitive sharing
» When do we listen during pregnancy? ˃ Auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value and routine listening is therefore not recommended. However, when requested by the mother, auscultation of the fetal heart may provide reassurance. (NICE, 2017) ˃ Auscultation of the fetal heart is a common event in antenatal care, in early pregnancy it may be associated with false negative results, which require ultrasound scan to confirm fetal viability. (Rowland et al, 2011)
» Nervous systems ˃ Autonomic ▪ Sympathetic ▪ Parasympathetic ˃ Somatic
» What is normal?
» What are we looking for? » Beat-to-beat fluctuations in fetal heart rate within one minute without accelerations or decelerations ˃ Normal 5-25 ˃ Increased >25 ˃ Reduced 3-5 ˃ Absent <3
» What are accelerations? » What do they signify? » There should be heightened suspicion if accelerations are regularly heard immediately following a contraction as these may indicate overshoot, which is an abnormal feature
» Different type of decelerations ˃ Early ˃ Variable ˃ Late ˃ Prolonged ˃ Bradycardia -over 10 minutes » What do they signify?
» Baroreceptor response ˃ Head compression ˃ Cord compression » Chemoreceptor response ˃ Catecholamines(adrenaline)
» Labour is stressful time for the baby » The goal of intra partum fetal monitoring is to validate the fetus’s ability to respond positively to the stress of labour.
❖ The initial assessment of fetal wellbeing at first contact/admission should involve a holistic and thorough assessment. ❖ A detailed risk assessment should be undertaken including immediate indicators of risk, such as fetal movements and maternal observations, as well as existing risk factors An abdominal palpation should ascertain the optimal position for auscultation ❖ The baseline of the fetal heart should be assessed by listening for at least a minute between contractions, when the fetus is at rest, using a hand-held sonicaid or Pinard stethoscope. ❖ A single figure should be documented
» Intermittent auscultation is recommended for low-risk women in labour as a screening tool for fetal hypoxia. It is a fundamental skill that midwives should feel confident in carrying out
» If no risks identified, intermittent auscultation should be offered » During the first stage of labour, fetal heart should be auscultated every 15 min for at least one minute immediately after a contraction. FH should be recorded as a single number » In the second stage of labour the fetal heart should be auscultated immediately after every contraction for at least 1 minute or at least every 5 minutes, whichever is more frequent » Maternal pulse should be palpated hourly and documented in the partogram » If FH abnormality is detected, maternal pulse should be palpated to differentiate between the maternal pulse and FH » In second stage-palpate the woman's pulse every 15 minutes to differentiate between the two heart rates
❖ Fetal growth restriction ❖ Oligohydramnios/ polyhydramnios ❖ Abnormal uterine artery dopplers ❖ Multiple pregnancy ❖ Significant meconium stained liquor ❖ Malpresentation – i.e. breech ❖ Previous IUD/ stillbirth ❖ Reduced or absent fetal movements ❖ Placenta praevia ❖ Known congenital disease/ malformation
❖ Previous caesarean section or uterine scar ❖ Pre-eclampsia / hypertensive disorders ❖ Post term pregnancy > 42/40 ❖ Preterm labour ≥28/40 and <37/40, if <28/40 – discuss with SpR prior to CTG ❖ Prolonged rupture of membranes >24 hours ❖ Induction of labour(excluding if spontaneous after OPIOL) ❖ Pre-existing diabetes or gestational diabetes on Insulin ❖ Poorly controlled diabetes or if macrosomia is suspected ❖ Significant antepartum haemorrhage ❖ Substance misuse ❖ Pyrexia ❖ Tachycardia ❖ Other Medical disease
» Risk assessment should be continually performed and the type of monitoring indicated may change depending on the maternal and fetal condition. » Women should be offered the same level of care regardless of type of intra partum monitoring » Use of the new Barts Health Intra partum care bundle as a guide. » Fresh ears-2hrly » Escalate to CEFM if concerned (document reason), discontinue after 20 minutes if trace is normal. If the woman is in a Birth Centre will need to be transferred to Obstetric Unit (if safe to do so).
❖ Significant meconium stained liquor ❖ Abnormal FH is detected during intermittent auscultation# ❖ Any difficulty of listening to FH for one minute after contraction ❖ Maternal pyrexia (≥38.0˚C once or ≥37.5˚C on two occasions two hours apart) ❖ Fresh bleeding during labour ❖ Raised blood pressure during labour ❖ Persistent maternal tachycardia ❖ Oxytocin use for augmentation ❖ Diagnosed delay in first or second stage of labour ❖ Epidural analgesia ❖ Women’s request ❖ Non significant meconium in the presence of other risk factors
» It is the responsibility of midwives caring for the women to provide clinical care as described in the guideline » All personnel who have undertaken specific training or programmes of education are able to perform fetal observations and are accountable for their practice and must ensure they maintain their competence in this skill. A registered practitioner remains accountable for delegation of this skill to an unregistered practitioner
» The initial assessment should be documented within the clinical notes and include reference to a discussion with the mother and recommendations for IA » Ongoing documentation should include the baseline plotted as a single number on the partogram and comments within the clinical notes about the presence/absence of decelerations and accelerations and a recognition of developing risk factors. » IA doesn’t have to be complicated. Initial reassurance that the baby is well (and therefore it is the appropriate form of surveillance) and on going intelligent auscultation is all that is required to ensure mother and baby are cared for safely.
» Antenatal care for uncomplicated pregnancies Clinical guideline [CG62] Published date: March 2008 Last updated: January 2017 » Human Factors in Healthcare: A Concordat from the National Quality Board November 2013 » Intermittent fetal heart auscultation in labour in all care settings Published date: September 2016 » Rowland, J., Heazell, A., Melvin, C. et al. Arch Gynecol Obstet (2011) 283(Suppl 1): 9. doi:10.1007/s00404-010-1563-5
Thank You for listening
Recommend
More recommend
