Again, this is really interesting stuff, as well as evidence for feeling 
confident about the efficacy of midwifery practice. I look forward to a 
further publications. 


Deborah Caine 

Robyn Maude [CCDHB] writes: 

> Hi Sheila 
> 
> It is an interesting question that you ask and of interest to me in my
> PhD studies. I agree with the feedback from Rachel, Pamela, Mary Doyle
> and Mary Kathleen Longworth. 
> 
> The only refernce I have found in my reading of the use of Pinard as
> part of a full fetal heart rate monitoring package (although not linked
> to any specific research study) comes in Gibb and Arulkumaran (2008)
> Fetal Monitoring in Practice. 3rd edition. Oxford: Elsevier (pages
> 12-15). It comes in the context of admission asessment and risk
> assessment and they say: 
> 
> "The importance of clinical sense cannot be over emphasized. Figure 2.4
> [a picture of a CTG machine with a tape measure and Pinard]shows the
> 'complete' CTG machine including an accompanying tape measure and fetal
> stethoscope. Why the fetal stethoscope? The CTG shown in figue 2.5
> [picture of a CTG with FHR looking OK with good variability] was
> undertaken in a mother admitted complaining of reduced fetal movements.
> The fetal stethoscope was not used and the ultrasound transducer was
> applied directly to the maternal abdomen.The mother was reassured that
> the baby was healthy; however a macerated stillbirth occurred 1 hour
> later. The heart rate picked up was the maternal pulse from a majot
> vessel with the ultrasound beam having passed through the dead
> fetus...The stethoscope must always be used to establish a fetal puls
> different from the maternal pulse". 
> 
> This excerpt below, from my recent publication explains a bit more about
> what is heard when using a Pinard or Ultrasound device: 
> 
> The technique of IA, sometimes referred to as periodic listening,
> generates information by listening to and counting the foetal heart
> sounds through the maternal abdomen, for a specified number of seconds
> at a specified time, in relation to uterine contractions. IA is
> conducted with either a foetal stethoscope (fetoscope) or a hand-held
> ultrasound device. Non-electronic auscultation, such as the application
> of a Pinard's fetoscope  to the maternal abdomen for periods of up to
> one minute or more, allows practitioners to hear the sounds associated
> with the opening and closing of the ventricular valves in the foetal
> heart, via bone conduction, with each foetal cardiac cycle. With this
> type of device, the midwife can hear the actual fetal heart sounds,
> including any abnormal heart beat rhythms.  Electronic devices such as
> the hand held Doppler applied to the maternal abdomen use ultrasound
> technology to listen to the reflected and amplified sounds of the motion
> within the fetal heart, such as the moving heart walls or valves. The
> information received by the Doppler device is converted into a sound
> that is heard and displayed as a representation of the foetal cardiac
> cycle11 
> 
> So this, I think, helps to provide a rationale for the use of Pinard
> before CTG.  
> 
> 
> I must say though that I fully agree with Mary Doyles comments below:
>  
> "The fundamental issue is the need to retain the skills of listening
> with a pinard and giving credit to this as a viable means of identifying
> and auscultating a fetal heart in addition to the use of other
> technologies as appropriate". 
> 
> This is really the crux of my thesis. I beleive Intermittent
> Auscultation (IA) of the fetal heart rate is a fundamnetal midwifery
> skill which is underpinned by the Keeping Birth Normal message. Midwives
> have/are becoming deskilled in the art and science of IA due to many
> reasons [increased use of technology, medico-legal fears, lack of 1 to 1
> care etc] but I think we need to return to  the basic skills of using
> our hands, ears and eyes (and other senses). This is what I am doing in
> my study by way of an education package and a model for intelligent,
> structured IA. 
> 
> 
> Cheers, Robyn Maude 
> 
>  
> 
> -----Original Message-----
> From: A forum for discussion on midwifery and reproductive health
> research. [mailto:[log in to unmask]] On Behalf Of Sheila
> Stewart
> Sent: Monday, 26 April 2010 08:27
> To: [log in to unmask]
> Subject: ascultation of FHR prior to attaching CTG 
> 
> Hi,
> I am trying to find evidence of why the FHR should be ascultated by a
> hand held doppler/sonicaid or pinnards before applying the ultrasound
> transducer when attaching a fetal monitor.  Why is asculating with an
> ultrasound doppler/sonicaid so different from ascultating with the U/S
> transducer of a EFM? It is the policy on the unit I work on to take the
> maternal pulse and doucment it when attaching EFM to differentiate FHR
> from maternal pulse.  I would appreciate any information on this.
> Thanks
> Sheila
> (midwife, North Wales)