Intermittent auscultation of the fetal heart rate during labor: an opportunity for shared decision making

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Birth Care Gaps in the Childbirth Options, Information, and Person-Centered Explanation (CHOICEs) Measure

PURPOSE

The objective of this study was to revise and improve the intrapartum items of the shared decision-making (SDM) measure, CH ildbirth O ptions, I nformation and person- C entered E xplanation (CHOICEs).

STUDY DESIGN AND METHODS

Methodological sequential triangulation was used to select a purposive sample of 29 people who gave birth in the United States between August 2019 and June 2021. A qualitative descriptive approach was used to analyze and interpret the data. We used an interview guide with questions related to the nine intrapartum items in CHOICEs to address the question: How did decision-making occur during your most recent birth?

RESULTS

Four major themes were identified: provider told me what to do ; communication about interventions during labor and birth ; preferences overlooked ; multiple team members . Under the theme of provider told me what to do , there was one sub-theme of induction of labor .

CLINICAL IMPLICATIONS

Participants noted lack of shared decision-making, poor communication, and obstetric violence. We found the need for perinatal providers to improve communication with birthing people on topics such as fetal monitoring, induction of labor, and multiple team members who may participate in their care. Revisions of CHOICEs will include seven new items to further address birth preferences, feeling heard, and multiple team members.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Implementing an Evidence-Based Bundle to Reduce Early Labor Admissions and Increase Adherence to Labor Arrest Guidelines: A Quality Improvement Initiative

BACKGROUND

At many hospitals, the cesarean birth rate among nulliparous term singleton vertex (NTSV) pregnancies is higher than World Health Organization benchmarks. Reducing NTSV cesarean birth is a national quality imperative. The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth.

METHODS

Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks.

RESULTS

The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

CONCLUSIONS

Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

IMPLICATIONS FOR NURSING

Implementation of evidence-based bundles has the potential to achieve meaningful quality improvements in maternity care.

I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth

Background

No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended.

Methods

In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations.

Results

More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences.

Conclusions

Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.

Healthy Birth Practice #4: Avoid Interventions Unless They Are Medically Necessary

Maternity care in the United States continues to be intervention intensive. The routine use of intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, epidural analgesia, and augmentation of labor characterize most U.S. births. The use of episiotomy has decreased but is still higher than it should be. These interventions disturb the normal physiology of labor and birth and restrict women's ability to cope with labor. The result is a cascade of interventions that increase risk, including the risk of cesarean surgery, for women and babies. This paper describes the use and effect of routine interventions on the physiologic process of labor and birth and identifies the unintended consequences resulting from the routine use of these interventions in labor and birth.

Fetal Heart Rate Auscultation, 3rd edition

The use of intermittent auscultation (IA) for fetal surveillance during labor decreased with the introduction of electronic fetal monitoring (EFM). The increased use of EFM is associated with an increase in cesarean births. IA is an evidence-based method of fetal surveillance during labor for women with low risk pregnancies and considered one component of comprehensive efforts to reduce the primary cesarean rate and promote vaginal birth. Many clinicians are not familiar with IA practice. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues, and strategies to promote implementation of IA into practice.

Use of the partogram in a private hospital in South Africa

OBJECTIVE

to explore and describe the use of the partogram in private hospitals in South Africa.

DESIGN

an explanatory mixed method design. In-depth interviews were conducted with the midwives and midwife specialists to explicate the significance of the initial quantitative questionnaires.

SETTING

a private maternity hospital in Gauteng Province, South Africa.

PARTICIPANTS

11 midwives and 3 advanced midwives working in the labour unit of the private maternity hospital.

FINDINGS

although all the midwives and midwife specialists knew the purpose of the partogram, where to find the recommendations on the use of the partogram and the signs of true labour, not all were sure when the partogram had to be completed and who is accountable for plotting the findings. Fetal heart rate monitoring during the active phase of labour remains a concern.

KEY CONCLUSION

the findings revealed that the midwives understood the importance of the partogram but are not using it within the parameters for which it was intended. The obstetricians intervened during labour with no or little use of the partogram.

IMPLICATIONS FOR PRACTICE

the study identified the knowledge strengths and deficits of midwives working in a private hospital on partogram use that would benefit from training interventions and professional development. Evidence suggests a culture where the partogram is not central to care as obstetricians are not using the partogram. The purpose of the partogram in the private sector needs to be reviewed.

Clinical suspicion, management and outcome of intrapartum foetal distress in a public hospital with limited advanced foetal surveillance

OBJECTIVES

To determine the basis for the clinical suspicion of foetal distress, the instituted managements and delivery outcome in a tertiary hospital in sub-Saharan Africa with limited capability for advanced foetal monitoring.

METHODS

It is a 3-year retrospective analysis of all the obstetrics cases with intrapartum foetal distress.

RESULTS

There were 301 cases reviewed. The birth asphyxia incidence rate was 233/1000 live births and the perinatal death rate was 47/1000 live births. Suspicion of foetal distress was premised on the presence of persistent tachycardia or bradycardia during intermittent auscultation. Main resuscitative measures were left lateral repositioning of patient, fast saline infusion, intranasal oxygen administration and discontinuation of oxytocin infusion, if any. Only 124 (41.2%) of all the cases had delivery achieved within 2 h of diagnosis. Mean decision-delivery interval by caesarean section was 2.93 ± 2.05 h. Socio-demographic factors (p= 0.001) and pregnancy risk category (p = 0.002) influenced incidence of birth asphyxia.

CONCLUSION

To reduce subsisting high perinatal morbidity and mortality in sub-Saharan Africa, it is best that at the least referral hospitals should have advanced facilities for foetal monitoring and shortened surgical intervention time.

Healthy birth practice #4: avoid interventions unless they are medically necessary

Maternity care in the United States is intervention intensive. The routine use of intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, epidural analgesia, and augmentation of labor characterize most U.S. births. The use of episiotomy is far from restrictive. These interventions disturb the normal physiology of labor and birth and restrict women's ability to cope with labor. The result is a cascade of interventions that increase risk, including the risk of cesarean surgery, for women and babies. This article is an updated evidence-based review of the "Lamaze International Care Practices That Promote Normal Birth, Care Practice #4: No Routine Interventions," published in The Journal of Perinatal Education, 16(3), 2007.