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

2. Two methods of technology for IA

3. 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

4. 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.

5. 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)

6. 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)

7. 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:

8. 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)

9. 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

10. 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 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)

11. 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 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

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

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

14. 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

15. Documentation differencesIA
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)

16. 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.

17. #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)

18. 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

19. References AAP, ACOG (2012). Guidelines for perinatal care (7th ed.).
ACNM (2016). Health Birth Initiative. Reducing primary cesareans. Bundle Name: Intermittent auscultation. Retrieved from
ACNM (2015). ACNM clinical bulletin #60: Intermittent auscultation for intrapartum fetal heart rate surveillance. Journal of Midwifery & Women’s Health, 60(5). doi: /jmwh.12372
AWHONN (2015). AWHONN position statement: Fetal heart monitoring. JOGNN, 44, doi: /
Fairview (2014). Fetal monitoring policy. Retrieved from
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: /JPN
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: /j.jigo
ACOG Practice Bulletin (reaffirmed 2015). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. No. 106.

20. Now lets practice!

21. Case #1

22. Case #2

23. Case #3

24. Case #4

25. Case #5

26. Case #6

27. Case #7

28. Case #8

29. Case #9

30. Case #10

31. Case #11

32. Case #12