Recommendations and conclusions
The case selection criteria for IA and actions on abnormal IA have been
well described in most guidelines.1-4 However, the
advice on the method of IA has potential to be improved to avoid serious
mistakes.6,25 IA should now be regarded as
‘intermittent FHR surveillance’ and best not necessitate actual
counting.
1. When only Pinard stethoscope is available for IA (e.g. in
resource-poor countries), the ‘multiple-count’ strategy4 is more accurate to detect FHR changes. If this is
impractical then a single count monitoring could be practiced. With
unavailability of CTG and much higher burden / importance of maternal,
neonatal and infant care, intrapartum fetal monitoring (IA) has a
different/lower priority in in many resource-poor settings.
2. Actually counting the fetal heart tones with a
Doppler-device1,9,10 seems an unnecessary, unsafe and
retrograde step.6 Guidelines should now recommend
preferential use of Doppler-device (when available) for IA, starting
auscultation i.e. observation of numerical FHR display in the later part
of the contraction and continuing up to the onset of next contraction
rather than just 1 minute. The baseline FHR and decelerations can be
best inferred from the instantaneous FHR read-outs on the Doppler-device
rather than actually counting the fetal heart tones. The maternal pulse
should be briefly felt to differentiate from FHR.
3. Specific guidance would be valuable regarding judgement of FHR
baseline (approximate single figure) especially when accelerations and
decelerations noted on Doppler display as described in this article. The
pitfall of missing a recovering late deceleration during the early phase
of auscultation6 needs to be highlighted in the
British and other guidelines to enhance patient safety.
4. Simple time-line analysis reveals that it is practically
near-impossible to perform IA every 15 minutes in first stage without
fail. But, failure to do so can be considered negligent practice. About
5-10 minutes would be required every time for IA and some more for
documentation and reflection. Guidelines should stipulate IA every 15-30
minutes during first stage and every 5-10 minutes in second
stage.2,25
5. It could only be briefly mentioned that the findings of IA need to be
interpreted in the context of clinical picture as IA is being practiced
mostly in low risk clinical picture. Any persistent abnormalities on IA
despite conservative measures need escalation to CTG monitoring.
Acknowledgements: The author is grateful to the midwives in his
institute and other hospitals who have always showed keen interest and
willingness to share their wisdom and experience in intermittent
auscultation and CTG.
Declaration of interest: The author has no conflict of interest
or funding to declare. The article is based on author’s hands-on
experience of IA for 8 years, followed by supervisory role for IA
(Pinard / Doppler) and CTG experience for 25 years.
Contribution to Authorship: The author conceived the review,
performed the literature search and wrote the contents.
Funding Statement: No funding was received for this manuscript.