Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy

Abstract

Background Intermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps. Methods We conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook , and we performed an overall assessment of the summary of evidence using the GRADE approach. Results The searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29–2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult. Conclusion Although IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We foun...

Intermittent auscultation (surveillance) of fetal heart rate in labour: A progressive evidence-backed approach with aim to improve methodology, convenience, reliability and patient safety.

“…); and failing that unnecessarily switching over to CTG. 7 But, the absence of FHR accelerations (especially in low risk cases) is not in itself pathological even on CTG and hence doesn't warrant commencing CTG in the first place. [1][2][3][4] Thus, one can safely await detection of late decelerations on IA.…”

“…1,2,9,10 Any challenge to this retrogressive advice is further countered by an argument that there is no evidence to recommend Doppler-device instead of Pinard stethoscope, a mistaken simplistic interpretation in systematic reviews and guidelines. 1,2,7 It is far more reliable and accurate to carefully observe the temporal FHR numerical readouts on the Doppler-device and then select an approximate single figure representing the average baseline. 6,18 FHR baseline in reality is not a single figure but could be written as such.…”

“…Indeed, a systematic scoping review of many aspects of IA was unhelpful for practice improvement but highlighted only one conclusion namely "there was no evidence to recommend Doppler-device instead of Pinard". 7 But is this sole conclusion valid? Is the evidence judiciously interpreted and then appropriately applied?…”

“…8,19 There are four RCTs of "Doppler vs Pinard" including 8436 women, all from African countries. 7,[20][21][22][23] In three studies the facility of CTG was not available/used at all. [20][21][22] In contrast, CTG is the recommended recourse after abnormal IA in developed countries to optimise perinatal outcome.…”

“…A recent comprehensive systematic review of 26 studies and 11 guidelines concluded that the optimal regime of IA (frequency, duration, method) remains unproven. 7 Similarly, many other systematic analyses have failed to provide practical suggestions for improvement. 6 Empiricism remains at the heart of science and statistics is said to be its grammar.…”