Intermittent Auscultation: Supporting Physiologic Labor Becky Gams, MS, APRN, CNP Nanette Vogel, MS, RN,C-OB, EFM

Two methods of technology for IA

Objectives Select the least invasive and most appropriate method of monitoring for the fetal heart rate and uterine activity. Demonstrate the correct method and timing for determining the fetal heart rate and uterine activity according to standards and guidelines. Describe 3 benefits to utilizing intermittent auscultation

Introduction “In general, the least invasive method of monitoring is preferred in order to promote physiologic labor and birth” AWHONN, 2015 “Clinicians must understand that IA is not simply EFM without a tracing” (Miller, 2013). This is an auditory skill.

Why do we care? U.S. using more continuous fetal monitoring than other developed countries with no improvement in birth outcomes Cochrane Database Meta-analysis Compared IA to CEFM N=37,000 births More Cesarean births and operative births with CEFM No difference in perinatal mortality or rates of cerebral palsy Cochrane Database Met-analysis reviewed 13 RCTs (n=37,000) comparing EFM with IA. Continuous EFM Group More cesarean births More operative vaginal births No difference in perinatal mortality or rates of cerebral palsy 50% decrease in newborn seizures with continuous EFM, however, in the follow-up study in the group with seizures at 4 years of age, there were an equal number of children in each group with CP. ACNM (2015)

Benefits & Limitations IA Neonatal outcomes comparable ↓ Cesarean birth Noninvasive Widespread application Freedom of movement Less expensive Care provider presence Clarifies double counting or half counting Limitations Can’t determine variability, types of decels No ability to archive or perform surveillance Time intensive Takes practice Epic documentation supports EFM and not IA at this time Lyndon & Usher Ali (2015)

Patient Selection for Intermittent Auscultation Term pregnancy greater than or equal 37 weeks gestation Category 1 on initial tracing per fetal monitoring policy Normal baseline Moderate variability Accelerations present or not present Early decelerations ok No variable, late or prolonged decelerations And then assess for:

Patient Selection for IA Antepartum & Intrapartum Maternal Factors Antepartum & Intrapartum Fetal Factors Spontaneous labor and normal frequency of contractions (No oxytocin) No serious maternal health conditions such as maternal diabetes or preeclampsia Rupture of membranes < 24 hours Absence of antenatal vaginal hemorrhage No previous uterine scar (TOLAC) Afebrile, < 38C, absence of chorio or intrauterine infection No regional analgesia No postdates  42 weeks Absence of trauma Absence of morbid obesity Singleton, term, vertex Normal fetal heart rate range Normal fetal growth, amniotic fluid and doppler Normal fetal movements Clearly audible heart rate sounds in the normal range Clear amniotic fluid (no meconium)

Quiz Time: Timing of IA in relation to UA How long do you auscultate? How frequently should you auscultate? When do you auscultate in relation to contractions (before, during, after)? How many contractions do you have to listen through, if any? Fairview, 2014

Second stage (passive fetal descent) Second stage When Using Intermittent Auscultation Latent Phase (<4 cm) Latent phase (4-5 cm) Active phase (≥ 6 cm) Second stage (passive fetal descent) Second stage (active pushing) Low-risk without oxytocin At least hourly Every 15-30 minutes Every 15 minutes Every 5-15 minutes When Using Electronic Fetal Monitoring Latent Phase (<4 cm) Latent phase (4-5 cm) Active phase (≥ 6 cm) Second stage (passive fetal descent) Second stage (active pushing) Low-risk without oxytocin At least hourly Every 30 minutes Every 15 minutes With oxytocin or risk factors Every 15 minutes with oxytocin; every 30 minutes without Every 5 minutes Note: Frequency of assessment should always take into consideration maternal-fetal condition and at times will need to occur more often based on maternal-fetal clinical needs, for example a temporary or on-going change in maternal or fetal status. During the active phase of the first stage of labor, the fetal heart rate should be determined, evaluated, and recorded at least every 15 minutes, preferably before, during, and after a uterine contraction, when intermittent auscultation is used. If continuous electronic fetal heart rate monitoring is used, the heart rate tracing should be evaluated at least 3very 15 minutes. During the second stage of labor, the fetal heart rate should be determined, evaluated and recorded at least every 5 minutes if auscultation is used. If continuous electronic fetal heart rate monitoring is used, the tracing should be evaluated at least every 5 minutes (AAP, ACOG, 2014) The use of the terms category I and category II should not be used with IA because one of the key factors in determining both categories is the presence or absence of moderate baseline variability which of course cannot be determined with IA (Miller, 2015) AWHONN (2015)

Auscultation Procedure Explain procedure Perform Leopold’s maneuvers Assess uterine contractions Position device on fetal back Palpate maternal pulse Listen during contraction and for at least 60 seconds after (Fairview, 2014) Listen through 2 contractions and 2 resting periods (Fairview, 2014) Promote maternal comfort and fetal oxygenation If no digital readout Count 30-60 seconds If clarification needed, recount for multiple, consecutive brief periods of 6-10 seconds Count rather than listen if you do not have a doptone with a digital readout Fairveiw, 2014; Lyndon & Usher Ali, 2015; Miller et al., 2015

Fetal Monitoring Decision Tree Lyndon & Usher Ali (2015, p. 95)

When do we convert to EFM? Lyndon & Usher Ali (2015, p. 95)

What about Categories with IA?? At this time there is not overwhelming acceptance for the use of categories with IA. This is being discussed in the literature. It is appropriate to document whether the baby is having a normal or abnormal response. Ask: Does the fetus baseline in the normal range? Does the fetus have a regular rhythm? Does the fetus have increases in the rate? Does the fetus have decreases in the rate in relation to contractions? If yes, or if no to the other questions, then consider increasing frequency of IA or converting to EFM and institute interventions to increase maternal comfort and fetal oxygenation

Documentation differences IA Baseline rate Rhythm Unable to determine variability Decreases (in relation to contractions) Increases (in relation to contractions EFM Baseline rate Rhythm not routinely documented Variability Decelerations (early, late, variable, prolonged) Accelerations (periodic, nonperiodic) Lyndon & Usher Ali (2015)

Documentation Examples Given what we have learned about documentation for EFM and IA, which is the example of IA and which is the example of EFM? When doppler is selected, IA documentation rows will appear.

#intermittentauscultationgoals Educate perinatal professionals on evidence-based approaches to FHR including intermittent auscultation Establish a unit culture that supports the evidence-based use of IA as the preferred method of FHR monitoring for women who are not at risk Identify inclusion and exclusion criteria for IA and criteria for changing modality if necessary Provide equipment and qualified professionals to perform IA Ensure sufficient staffing Promote shared decision making on modality ACNM (2016)

Conclusion “Intermittent auscultation is a skill that is not simple; it is a rightfully complex and time-consuming and must be performed with care and precision, no different from the appropriate use of EFM.” Miller, 2015

References AAP, ACOG (2012). Guidelines for perinatal care (7th ed.). ACNM (2016). Health Birth Initiative. Reducing primary cesareans. Bundle Name: Intermittent auscultation. Retrieved from http://birthtools.org/birthtools/files/BirthToolFiles/FILENAME/000000000089/Bundle-Intermittent-Ausculation-v2.pdf ACNM (2015). ACNM clinical bulletin #60: Intermittent auscultation for intrapartum fetal heart rate surveillance. Journal of Midwifery & Women’s Health, 60(5). doi: 10.1111/jmwh.12372 AWHONN (2015). AWHONN position statement: Fetal heart monitoring. JOGNN, 44, 683-686. doi: 10.1111/1552-6909.12743 Fairview (2014). Fetal monitoring policy. Retrieved from http://intranet.fairview.org/Policies/Category/PatientCareClinicalGuidelines/ClinicalGuidelines/Perinatal/S_069242 Lyndon, A. & Usher Ali L. (2015) Fetal heart monitoring: Principles and practices (5th ed.). Kendall Hunt, Washington, DC. Miller, L. (2015). Listen carefully: Implementing intermittent auscultation into routine practice. The Journal of Perinatal & Neonatal Nursing. Doi: 10.1097/JPN.0000000000000117 Miller, L., Miller, D., & Tucker, S. (2013). Mosby’s pocket guide to fetal monitoring: A multidisciplinary approach (7th ed.). Elsevier: St. Louis, MO. Lewis, D., & Downe, S. (2015). FIGO consensus on intrapartum monitoring: intermittent auscultation. Intern Jnl of Gyn and Obstetrics. Doi:10.1016/j.jigo.2015.06.019 ACOG Practice Bulletin (reaffirmed 2015). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. No. 106.

Now lets practice!

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