I would be interested to know what tool is being used in IA which epitomises
the listening and counting. Where I work we are used to hand held dopplers
which certainly don't show a constant rate, and therefore many (but not
all) would record a range (e.g. 147-159). I would have thought that such a
range would indicate the presence or absence of variability.
Deborah
Belinda Cox writes:
> Dear Robyn,
>
> Thank you so much for this! I was feeling really uncomfortable about the
> variability, Dr C Bravado and sticky labels issue around IA, but hadn't
> actually managed to think through why. You've done it for me, and actually
> this is what I teach on our fetal monitoring sessions. I can't wait to read
> more from you :-)
>
> Best wishes,
>
> Belinda
>
> Belinda
> -----Original Message-----
> From: A forum for discussion on midwifery and reproductive health research.
> [mailto:[log in to unmask]] On Behalf Of Robyn Maude [CCDHB]
> Sent: Monday, September 20, 2010 7:26 AM
> To: [log in to unmask]
> Subject: Re: Intermittent auscultation query
>
> Hi All
>
> I am a midwifery PhD candidate in New Zealand . I am doing my research
> on midwives' practices of fetal monitoring for low risk women, in
> particular intermittent auscultation. We have had some very interesting
> discussions on IA over the last couple of years and it seems there is
> still plenty to discuss. I started a thread on this back in 2007 which I
> have collated for my thesis work - it is very interesting looking at
> feedback from around the globe.
>
> I am doing a multi methods quasi experimental design using pre and post
> intervention assessment of practice - getting a snapshot of practice by
> reading notes and talking to midwives and then delivering an education
> package (the intervention) which incudes history, physiology, research
> and introducing midwives to a model I have developed for the conduct,
> interpretation of IA, this is followed by another snapshot of practice
> and focus groups to see whether there has been any change in practice
> following the intervention. I am looking for changes in the number of
> eligble woman who get IA, the way it is conducted i.e. frequency timing
> and duration and the birth outcomes when IA is used.
>
> My model for practice was presented in an oral presentation and a poster
> at the normal birth conference in Vancouver in July this year and
> provides a framework for the use of IA as an admission assessment and
> for ongoing FHR monitoring.
>
> Part of the work and model is around how we document our FHR monitoring
> using IA that demonstrates it is a robust evidence-based FHR modality
> that is reasurres us that the fetus is well but is alo capable of
> detecting FHR abnormalities so that the appropriate actions are taken -
> this is all it needs to do. The model and the documentation demonstrate
> critical thinking and the decision-making trail.
>
>
> Applying what we know about EFM is not useful. IA is a listening and
> counting method, factors such as variability are notions from EFM.
> Timing freqency and duration are set out in the guidelines are drawn
> from the protocols used RCTs comparing IA and EFM - so whilst they have
> not been subjected to robust testing they are at this pointin time the
> only protocols we have to guide practice that have been used in
> research. Looking at many guidelines they tend to have a range 15-30
> mins in active labour - but this is a whole further discussion
>
> I think how we talk about and document IA findings needs to be done
> carefully so we are not trying to emulate EFM. Therefore we talk about
> FHR increases (from a baseline previously determined) and FHR decreases
> which are not defined further (because they can't be with this method).
> I feel very strongly that we do not record the auscultated FHR as a
> range, which midwives believes shows variability (a notion from EFM) IA
> is a listening and counting method - we dont write a woman's pulse rate
> as a range! The FHR is auscultated after a contraction as tis is when we
> are more likely to hear a decrease if one is present. FHR decreases
> after a contraction are more problematic than those heard during a
> contraction, hence the timing. Arulkumaran has discussed multiple count
> methods - which I agree are very hard to do and commented on the fact
> that they can amplify the inaccuracy of the finding because of the
> difficulty.
>
> A comment on the use of Dr C BRAVADO and sticky labels emulating EFM
> characteristics - I have a real uncomfortable feeling about using these
> as I do not think they demonstrate IA/Normality/Low risk well enough and
> add to the confusion midwives experience when they attampt to use EFM
> tools to interpret IA. Feistein, Sprague and Trepanier, 2008 (AWHONN)
> have produced a good flow chart for IA recording. I have sought
> permission to adapt this flow chart as part of my PhD work as I think we
> need to incorporate other things that demonstrate maternal and fetal
> wellbeing.
>
> I am loving these discussions because it highlights again the need to
> research this method of fetal surveillance to get some credibilty for it
> and to introduce or reintroduce it back into practice.
>
> Look forward to more discussions
>
> Cheers, Robyn Maude
> [log in to unmask]
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