Evidence Based

Guidelines for
Midwifery-Led Care in Labour

Intermittent
Auscultation (IA)
 Practice Points

Intermittent Auscultation (IA)

A discussion about fetal monitoring should take place antenatally between the woman and
her midwife (Thacker et al. 2004). If this has not taken place by the time the woman goes
into labour, it should form part of the initial discussion about the woman’s birth plan.

For women with no risk factors for fetal hypoxia in normal labour, intermittent auscultation
is the method of choice because of the increased level of intervention associated with
electronic fetal monitoring (Alfirevic et al. 2006; NICE 2007).

An abdominal palpation should be performed to determine the optimal area for listening
to the fetal heart.

A pinard or fetal stethoscope should be used at initial assessment to establish the real
sound of the fetal heart and to aid confirmation of presentation and position.

The maternal pulse should be palpated at the initial assessment, hourly throughout
labour and if an FHR abnormality is detected, to differentiate between the two heart
rates (NICE 2007).

Current evidence does not support the use of the admission CTG in low risk pregnancy
(Devane et al. 2012; NICE 2007; Blix et al. 2003; Impey et al. 2003; Mires et al. 2001).
Midwives should justify why this intervention has been undertaken.

Monitoring fetal well-being is a holistic process involving multiple clinical criteria included
in a full assessment which should be recorded and an action plan documented.

EFM should never be offered as a substitute for, or interfere with, continuous care and
support during labour (MIDIRS 2008).

If the auscultated fetal heart rate gives reason for concern, or if any intrapartum risk factors
develop, then a continuous record should be obtained using electronic fetal monitoring.

2 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Intermittent Auscultation (IA)

Intermittent Auscultation (IA)

The goal of intrapartum fetal monitoring is to validate the fetus’s ability to respond
positively to the stress of labour. Intermittent auscultation (IA) of the fetal heart was
the chosen method of fetal assessment during labour until the introduction of electronic
fetal monitoring (EFM) in the late 1960s. As a new technology EFM quickly gained
ground and in the next two decades several randomised controlled trials were conducted
comparing EFM to IA. These have suggested that there is no significant improvement in
outcome for the baby by using EFM during labour for low risk pregnancies (Mahomed
et al. 1994; McDonald et al. 1985; Kelso et al. 1978; Haverkamp et al.1976). This has been
supported more recently by a Cochrane systematic review comparing neonatal outcomes
following the use of EFM and intermittent auscultation (Alfirevic et al. 2006). Although
continuous electronic monitoring was linked to a reduction in neonatal seizures there was
no significant difference in overall infant mortality or other standard measures of neonatal
well-being and women who were in the intervention group were significantly more likely
to have an instrumental birth or a caesarean section. Pateman et al. (2008) discuss how
electronic fetal heart monitoring is not 100% sensitive or specific for diagnosing cerebral
palsy. This is supported by the study by Schiermeier et al. (2008) which showed 95%
sensitivity for ‘suspect’ pathology but very low specificity for fetal acidosis. The problem
of EFM as a poor predictor of fetal compromise is thus compounded by its low specificity
(the ability to identify those fetuses that are not distressed) and the consequent increase
in operative and assisted delivery rates, without showing a reduction in perinatal mortality,
or the incidence of cerebral palsy (Ayres-de-Campo 2010; Alfirevic 2006).

Because of the increased level of intervention attached to electronic fetal monitoring,

the recommendation for women with no risk factors for fetal hypoxia in normal labour
is intermittent auscultation (Alfirevic et al. 2006; NICE 2007).

As Thacker et al. stated in 2004, the decision about fetal monitoring should be made
in a joint discussion between the woman and her midwife in the antenatal period.
If this has not taken place by the time the woman goes into labour it should form part
of the discussion of the birth plan. The midwife must ensure that advice given is evidence
based (NMC 2009a). Following discussion, it is the woman who will make the decision
based upon her individual needs and preferences (NMC 2004). Electronic fetal monitoring
should never be offered as a substitute for, or interfere with, continuous care and support
during labour (MIDIRS 2008).

Current evidence does not support the use of the admission CTG in low risk pregnancy
(Devane et al. 2010; NICE 2007; Blix et al. 2003; Impey et al. 2003; Mires et al. 2001).
If the intervention is undertaken, midwives should justify and document the reason
(NMC 2010).

There has been only one randomised controlled trial, which has included women’s
preferences of monitoring (Garcia et al. 1985). This reported that women were
more likely to feel that their movements were restricted by EFM but otherwise
showed little preferences. It must be noted that this trial took place in a hospital
where personal and continuous care from a midwife for all women was a key
feature of hospital policy. The report states, however, that even in that hospital
“there is a suggestion that women monitored with EFM were more likely to be left
alone for short periods”.

3 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Intermittent Auscultation (IA)
It has to be acknowledged that fetal monitoring has several components, being a process
based on an appropriate assessment pathway. A healthy term fetus will react normally to
the stress of labour and normal progress in labour will maintain this equilibrium. A holistic
approach to assessing fetal wellbeing in labour includes an understanding of the normal
physiology of fetal heart rate changes during labour and recognition of factors that
influence it (Chandraharan 2010). Continuous assessment should include consideration of
clinical factors such as progress in labour, maternal hydration, uterine stimulation, and the
use of opioids which have an effect on the fetal somatic system. Fetal activity is a positive
sign of fetal well-being, it is therefore appropriate to discuss fetal movements with the
mother and listen during periods of activity to detect accelerations.

NICE (2007) details a list of risk factors which indicate that a change to using EFM is
appropriate. However, it is recommended that the midwife is alert to all clinical factors
which may have an impact upon the ability of the fetus to cope during labour
(Chandraharan 2010).

NICE (2007) recommends that IA should consist of listening to the fetal heart after a
contraction for minimum of 60 seconds every 15 minutes in the first stage, every 5 minutes
in the second stage and the rate should be recorded as an average in a single figure.

There is a lack of clear evidence to guide the frequency of intermittent auscultation and this
remains a matter of on-going debate amongst the midwifery community. There does not
appear to be any good evidence from trials to recommend any particular frequency and
duration of IA. Therefore, it is more a ‘custom and practice’ than ‘evidence-based’ process
(Walsh 2008).

The Society of Obstetricians and Gynecologists of Canada recommend first stage

auscultation to be recorded every 15 to 30 minutes and every 5 minutes in second stage.
The American College of Obstetricians and Gynecologists and the Royal College of
Obstetricians and Gynaecologists (subsequently recommendations made by NICE) both
suggest 15 minute auscultations during the first stage and 5 minute auscultations during
the second stage (Liston et al. 2007). This timing is made through consensus of expert
opinion rather than as a result of evidence. Consequently some authors have challenged it
suggesting that every 15 minutes during the first stage is too disruptive for the labouring
woman and time consuming for the midwife (Sholapurkar 2010). This obstetrician argues
that prolonged bradycardia is rare, and in the scenario with no risk factors for fetal hypoxia,
an assessment every 30 minutes should not lead to a delay in recognition of abnormalities.
An alternative intensive assessment lasting 10 minutes every 30 minutes is suggested in
which the clinician listens to the fetal heart following 3 contractions during the 10 minute
period and during this time also assesses the frequency and strength of contractions.
However, NICE guidance is referenced within the clinical risk management standards and
currently informs local unit protocols (NHSLA 2011).

The recommendations from NICE (2007) also state that the auscultation should take place
following a contraction. This again is based upon expert consensus opinion rather than
high level evidence, although it is fair to say that increasing knowledge regarding the
physiology of the fetus during labour helps to guide opinion. Sholapurkar (2010) suggests
that listening following a contraction alone may allow for the misinterpretation of a
deceleration as a normal baseline. This is a hypothetical argument but offers a note of
caution. His recommendation is that the baseline should be assessed between contractions
and the on-going assessment should be based on this.

4 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Intermittent Auscultation (IA)
Goodwin (2000) suggests that auscultation can “easily” detect fetal tachycardia,
bradycardia and the impression of accelerations and decelerations. However, she states
that the technique does not give ample information to support the description of the
FHR pattern or the type of deceleration. Goodwin makes these recommendations based
upon a comprehensive review of the studies previously discussed.

None of the literature, either the few studies examining IA method or the guidance
produced by experts in the field, suggests that variability can be determined. Conclusions
are drawn that, due to the findings that randomised controlled trials have confirmed the
equivalence of IA to EFM in terms of neonatal outcome, it doesn’t appear significant that
variability and type of deceleration cannot be determined (ACNM 2010).

Fetal heart sounds can be heard using a fetal or Pinard stethoscope or a hand held
Doppler device. The Pinard stethoscope allows the clinician to hear the actual heart sounds.
Auscultation with the hand held Doppler uses ultrasound to detect motion of the fetal
heart valves or walls and converts this information into a sound that is heard or displayed
as a representation of the fetal cardiac cycle. There continues to be debate concerning
the use of the Pinard stethoscope within today’s modern practice and it would appear that
its use is a dying skill despite the fact that it is specifically included within the standards for
pre-registration midwifery education (NMC 2009b, p44). Discussion published by the
Association of Radical Midwives demonstrates that some midwives firmly believe that the
Pinard is a tool that is vital in the assessment of fetal wellbeing despite the fact that it can
be difficult to use depending upon the position of the mother and that it does not give
the mother the reassurance that is gained from hearing the heart beat (ARM 2000).
It is also recognised that as the Doppler converts movement of the heart into sound there
is potential for this to be inaccurate and misinterpreted. It is currently recommended that
the Pinard stethoscope should be used in the first instance to determine that there is a fetal
heart before applying a CTG or when any concern arises (MHRA 2010). Most importantly,
the maternal pulse must be palpated to differentiate between the sounds.

The importance of record keeping and regular re-assesssment of action plans is set by
the Midwives Professional Standards (NMC 2010; NMC 2004). It needs to be clear if an
escalation of monitoring the fetal heart is required and why this decision has been made.

5 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 References

Intermittent Auscultation (IA)

Alfirevic Z, Devane D, Gyte G (2006) Continuous cardiotocography (CTG) as a form of electronic
fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews,
Issue 3. Chichester: John Wiley & Sons

American College of Nurse-Midwives (ACNM) (2010) Intermittent Auscultation for Intrapartum Fetal
Heart Rate Surveillance. Clinical Bulletin Number 11. Journal of Midwifery and Women’s Health.
55(4): 397-403

Association of Radical Midwives (ARM) (2000) Hearing variability. Midwifery Matters. 84 [online]
available athttp://www.midwifery.org.uk/index.php?option=com_content&view=article&id=151:heari
ng-variability&catid=80:magazine-spring-2000&Itemid=102 accessed 21st December 2011.

Ayres-de-Campos D, Bernades J (2010) Twenty-five years after the FIGO guidelines for the use of
fetal monitoring: Time for simplified approach?. International Journal of Obstetrics and Gynaecology
110: 1-6

Blix E, Sviggum O, Koss K et al. (2003) Inter-observer variation in assessment of 845 labour
admission tests: comparison between midwives and obstetricians in the clinical setting and two
experts. British Journal of Obstetrics and Gynaecology 110: 1-5

Chandraharan E (2010) Rational approach to electronic fetal monitoring during labour in ‘all’
resource settings. Sri Lanka Journal of Obstetrics and Gynaecology 32: 77-84

Devane D, Lalor JG, Daly S et al. (2012) Cardiotocography versus intermittent auscultation of fetal
heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of
Systematic Reviews, Issue 2. Chichester: John Wiley & Sons

Garcia J, Corry M, Macdonald D, Elbourne D et al. (1985) Mothers’ views of continuous electronic
fetal heart monitoring and intermittent auscultation in a randomised controlled trial. Birth 12: 79-86

Goodwin L (2000) Intermittent Auscultation of the Fetal heart rate: A Review of General Principles.
Journal of Perinatal and Neonatal Nursing. 14(3): 53-61

Haverkamp AD, Thompson HE, McFee JC, et al. (1976) The evaluation of continuous fetal heart rate
monitoring in high-risk pregnancy. American Journal of Obstetrics and Gynecology. 125: 310-20

Impey L, Reynolds M, Macquillan K et al. (2003) Admission cardiotocography: a randomised

controlled trial. The Lancet 361: 465-70

Kelso IA, Parsons RJ, Lawrence GF et al. (1978) An assessment of continuous fetal heart rate
monitoring in labor: A randomized trial. American Journal of Obstetrics and Gynecology.
131: 526-32

Liston R, Sawchuck D, Young D (2007) Intrapartum Fetal Surveillance. Fetal Health Surveillance:
Antepartum and Intrapartum Consensus Guideline. Journal of Obstetrics and Gynecology Canada.
29(9): 25-54

Macdonald D, Grant A, Sheridan-Pereira M et al. (1985) The Dublin randomised controlled trial of
intrapartum fetal heart rate monitoring. American Journal of Obstetrics and Gynecology 152:
524-39

Mahomed K, Nyoni R, Mulambo T et al. (1994) Randomised controlled trial of intrapartum fetal
heart rate monitoring. British Medical Journal. 308(6927): 497-503

Medicines and Healthcare products Regulatory Agency (MHRA) (2010) Medical Device Alert. Fetal
Monitor/Cardiotocograph. Ref MDA/2010/054 [online] available at http://www.mhra.gov.uk/home/
groups/dts-bs/documents/medicaldevicealert/con085077.pdf accessed 21st December 2010

Mires G, Willliams F, Howie P (2001) Randomised controlled trial of cardiotocography versus Doppler
auscultation of the fetal heart at admission in labour in low risk obstetric population. British Medical
Journal 322: 1457-1462

6 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Intermittent Auscultation (IA)
NHS Litigation Authority (2009) Study of stillbirth claims. London: NHS Litigation Authority

National Institute of Clinical Excellence (NIICE) (2007) Intrapartum Care: care of healthy women
and their babies. London: NICE

Nursing and Midwifery Council (NMC) (2010) Recordkeeping: Guidance for Nurses and Midwives.
London: NMC

Nursing and Midwifery Council (NMC) (2009a) Modern Supervision in action. London: NMC

Nursing and Midwifery Council (NMC) (2009b) Standards for pre-registration midwifery education.
NMC London

Nursing and Midwifery Council (NMC) (2004) Midwives rules and standards. NMC London

Pateman K, Khalil A, O’Brien P (2008) Electronic fetal heart rate monitoring: help or hindrance?
British Journal of Midwifery 16(7): 454-7

Schiermeier S, Pildner von Steinburg S, Thieme A et al. (2008) Sensitivity and specificity of intrpartum
computerised FIGO criteria for cardiotocography and fetal scalp pH during labour: multicentre
observational study. British Journal of Obstetrics and Gynaecology 115: 1557-63

Sholapurkar SL (2010) Intermittent auscultation of fetal heart rate during labour – a widely accepted
technique for low risk pregnancies: But are the current national guidelines robust and practical?
Journal of Obstetrics and Gynaecology. 30(6): 537-40

Thacker S (1997) Lessons in Technology Diffusion: The Electronic Fetal Monitoring Experience.
Birth 24: 58-60

Walsh D (2008) CTG use in intrapartum care: assessing the evidence. British Journal of Midwifery
16(6): 367-69

7 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Intermittent Auscultation (IA)
This updated guideline was authored by:

Jane Munro, Quality and Audit Development Advisor, RCM, Mervi Jokinen,
Practice and Standards Development Advisor, RCM

And peer reviewed by:

Dr Tracey Cooper, Consultant Midwife – Normal Midwifery, Lancashire Teaching

Hospitals NHS Foundation Trust.

Dr Fiona Fairlie, Consultant Obstetrician and Gynaecologist, Sheffield Teaching

Hospitals NHS Foundation Trust.

Anne-Marie Henshaw, Lecturer (Midwifery and Women’s Health)/ Supervisor of

Midwives, University of Leeds

Helen Shallow, Consultant Midwife & Head of Midwifery, Calderdale & Huddersfield
NHS Foundation Trust.

The guidelines have been developed under the auspices of the RCM Guideline
Advisory Group with final approval by the Director of Learning Research and Practice
Development, Professional Midwifery Lead.

The guideline review process will commence in 2016 unless evidence requires
earlier review.

© The Royal College of Midwives Trust 2012

8 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012
 Appendix A

Intermittent Auscultation (IA)

Sources

The following electronic databases were searched: The Cochrane Database of Systematic
Reviews, MEDLINE, Embase and MIDIRS. As this document is an update of research
previously carried out, the publication time period was restricted to 2008 to March 2011.
The search was undertaken by Mary Dharmachandran, Project Librarian (RCM Collection),
The Royal College of Obstetricians and Gynaecologists.

Search Terms

Separate search strategies were developed for each section of the review. Initial search
terms for each discrete area were identified by the authors. For each search, a combination
of MeSH and keyword (free text) terms was used.

Journals hand-searched by the authors were as follows:

• Birth

• British Journal of Midwifery

• Midwifery

• Practising Midwife

• Evidence-based Midwifery

9 Evidence Based Guidelines for Midwifery-Led Care in Labour ©The Royal College of Midwives 2012