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.