Hi Robyn, this is very interesting, but more than that, you offer a very
important point for clinicians. If, indeed, it is not the range of FH, and
therefore an indication of variability, being detected when the recording on
a hand held doppler fluctuates ( which I have always thought to be
reassuring) then is it possible to ascertain what the FH is at all, with a
Doppler. I would be very grateful for your evidence, as I am also due to
teach this topic, but also, to share with practice development.
Robyn Maude [CCDHB] writes:
> Hi Deborah
>
> You have raised another interesting fact about how what we know from the
> technology of today is applied to the FHR monitoring methods from the
> past.
>
> Traditionally, the FHR was listened to using a Pinard and was counted.
> The counted rate - if between 110 and 160 bpm - was considered a normal
> FHR (in fact in my training in 1975 the normal rate was defined as
> 120-160). It is the actual heart sounds i.e the opening and closing of
> the vales that are heard via auscultation with a Pinard
>
> The Doppler uses ultrasound technology that detects movement and
> converts it to sound, averages out 3-4 beats and displays this on the
> screen as a number. You can see the number chaanging frequency - this is
> not necessarily demonstrating variability but often just an indication
> of loss of contact as the process of converting the movement to sound to
> a display relies on a dircet line of the ultrasound beam remaining in
> contact with the movement within the fetal heart (and we know from CTG
> how difficlut this can be at times when we are monitoring babies). So
> what is seen on the Doppler display is not necessarily the correct and
> indeed is distracting - I am sure you have seen the Doppler display
> saying 90 when you can clearly 'hear' it is around 130 or the reverse
> when the display shows 200 [probably a doubling effect] when what you
> hear is more like 90.
>
> So when applying the technology of today i.e a Doppler device to perform
> a method of FHR monitoring that has been around for a long time, is
> evidence-based as appropriate for well women with uncomplicated
> pregnancies, I try not to mix my methodologies.I teach and practice
> ingnoring what we see on the display, listening and counting the FH even
> when using a Doppler and recoding the FHR as a single number.
>
>
> Regards Robyn Maude
>
> -----Original Message-----
> From: A forum for discussion on midwifery and reproductive health
> research. [mailto:[log in to unmask]] On Behalf Of
> Deborah Caine
> Sent: Tuesday, 21 September 2010 10:45
> To: [log in to unmask]
> Subject: Re: Intermittent auscultation query
>
> 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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