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Tuesday, 25 June 2013

Intermittent auscultation

Intermittent auscultation: the practice of listening to the baby's heartbeat at intervals either by a handheld ultrasonographic device (aka a Sonicaid) or a wooden or plastic fetal stethoscope known as a Pinard's stethoscope.  Current NICE guidelines state that this should be done EVERY 15 MINUTES during established labour.  The alternative is continuous monitoring of the baby's heart via a cardiotocograph (CTG machine).

A very interesting article by Ruth Martis in "Essentially MIDIRS" (Vol 4, no 5, May 2013) about the intrusiveness of intermittent auscultation and the lack of evidence regarding the efficacy of listening to baby's heartbeat in an otherwise normal labour/healthy woman.  A woman quoted describes the experience of intermittent auscultation as being intermittently "ripped away from my peaceful place".

The level of evidence for NICE's 15 minute guideline is C, effectively nothing more than personal opinion.  As obstetricians dominate the NICE maternity guidelines, this means obstetric opinion, and not scientific evidence.  It is actually as near to continuously monitoring as they could get without actually opting for continuous monitoring by CTG machine, undoubtedly their favoured option if not for the presence of lay members and midwifery representatives pointing out that the evidence pointed against that.  (Someone in the know told me this was the situation shortly after the intrapartum guideline was published.)

If some women (and of course many will want their midwife to listen to the baby's heart, whether at 15 minute or longer intervals) find it obtrusive, it also interferes with watchful midwifery.  Having to fiddle around with a sonicaid or Pinard every 15 minutes, changing the woman's position to get a clear reading, interfering with clothing, having to talk to or touch her, as well as the noise of the sonicaid which is intrusive even at low volume.  So called low-intervention care contains many interventions - pulse, blood pressure, palpations, FH auscultation, temperature-taking, asking questions, making records, noting times, offering drinks, massaging backs, even being in the same room ......they can all be intrusive and some women do not want or benefit from any of it.  Especially those who are using hypnobirthing techniques or who are most emotionally and therefore physiologically comfortable in private peace and quiet, who need a deeply mammalian experience and environment.  And there are far more women who need and want this than currently get it.

The Essentially MIDIRS article isn't available online but here is a link to Ruth Martis' proposal to undertake a review of auscultation and the frequency it may or may not be efficacious.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008680/full

and a link to her other work which includes the use of music during caesarean section:
http://scholar.google.com/citations?user=73RnpAEAAAAJ&hl=en

I am quite sure the questions Ruth is asking are important for women and midwives as she is asking questions about the nature of intervention itself in low-risk labour or where women do not want it regardless of risk.  Undercover Midwife looks forward to reading more when she and her colleagues publish their review.

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