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September 28, 2020

Intermittant Auscultation

 

Intermittent Auscultation

Continuous EFM was introduced to reduce the incidence of perinatal death and cerebral palsy and as an alternative to the practice of intermittent auscultation. However, the widespread use of continuous EFM has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Low risk in this context has been variously defined but generally includes women who have no meconium staining, intrapartum bleeding, or abnormal or undetermined fetal test results before giving birth or at initial admission; no increased risk of developing fetal acidemia during labor (eg, congenital anomalies, intrauterine growth restriction); no maternal condition that may affect fetal well-being (eg, prior cesarean scar, diabetes, hypertensive disease); and no requirement for oxytocin induction or augmentation of labor. A Cochrane review of 13 RCTs included women with varying degrees of a priori risk of fetal acidemia at the onset of labor. This meta-analysis found that continuous EFM was associated with an increase in cesarean deliveries (RR, 1.63; 95% CI, 1.29–2.07; n=18,861, 11 RCTs) and an increase in instrumental vaginal birth rate (RR, 1.15; 95% CI, 1.01–1.33; n=18,615, 10 RCTs) when compared with intermittent auscultation. However, continuous EFM was associated with a halving of the rate of early neonatal seizures (RR, 0.50; 95% CI, 0.31–0.80, n=32,386, nine trials, 0.15% for EFM versus 0.29% for intermittent auscultation group), but the authors found no significant difference in the rates of perinatal death or cerebral palsy when compared with intermittent auscultation 22. In the largest RCT conducted, the group that had early onset seizures had a neonatal death similar to those allocated to EFM versus intermittent auscultation. Moreover, at 4 years of age, there was no difference in the rate of cerebral palsy (1.8 per 1,000 in the EFM group versus 1.5 per 1,000 in the intermittent auscultation group.

  • “Despite its widespread use, there is controversy about the efficacy of EFM, inter-observer and intra-observer variability, nomenclature, systems for interpretation, and management algorithms. Moreover, there is evidence that the use of EFM increases the rate of cesarean deliveries and operative vaginal deliveries.”

ACOG National Meeting July 2009

  • “IA is the preferred method of fetal surveillance for healthy low risk women in labor”

    SOGC (Society of Obstetricians and Gynecologists of Canada)

  •   “The FHR may be evaluated by auscultation or by EFM” ACOG PB 2009
  •   IA is an “appropriate and safe alternative to electronic fetal monitoring” ACOG PB, 2010.
  • The evidence against continuous electronic fetal monitoring is so clear that the U.S. Preventive Services Task Force issued a recommendation in 1996 saying that continuous electronic fetal monitoring should NOT be used in low risk women. (Guide to Clinical Preventative Services 1996)
  • “The frequency of observations required to monitor labor with IA facilitates other evidence-based labor support practices, and this method of monitoring the FHR should be the preferred method.”

 

CONTINUOUS FETAL MONITORING

Benefits
▶ Can identify early signs of developing hypoxia
▶ Allows closer monitoring of high risk patients
▶ Excellent predictor of a normally oxygenated fetus ▶ Records FHR and UCs simultaneously

Limitations


▶ High rate of false positives leading to increased

interventions…C/S, etc… without better outcomes

▶  Restricts maternal mobility unless Tele available

▶  No agreement regarding timing of intervention

▶  Expensive

▶  Poor reliability/validity

When: Frequency of IA

Professional Organization

1st Stage

2nd Stage

ACOG

q15 mins

q5 mins

ACNM

q15-30 mins

q5-15 mins

AWHONN

q15-30 mins

q5-15 mins

SCOG

q15-30mins

q5mins

NICE

q15mins

q5mins

To facilitate the option of intermittent auscultation,obstetric care providers and facilities should adopt protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor  In considering the relative merits of intermittent auscultation and continuous EFM, patients and obstetric care providers also should evaluate how the technical requirements of each approach may affect a woman’s experience in labor; intermittent auscultation can allow freedom of movement, which some women appreciate.

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