Join me & my guest Dr. Kirsten Small as we build on our previous joint episode 157 Fetal heart monitoring in labour. This time we discuss the world of intermittent auscultation, you'll be enlightened by the evolution from the hands-on Pinard stethoscope to the advanced Doppler device. Dr. Small shares her expertise on the intimate connection care providers once had with this practice and how it's changing in today's clinical settings. We also examine the remarkable methods midwives employ in various care environments to monitor fetal well-being, revealing the depth and diversity of approaches.
Listen as we discuss cardiotocograph interpretation, the myths surrounding traditional CTG patterns and upend long-held beliefs about fetal distress. We discuss the need to re-evaluate our understanding of decelerations. This episode promises to arm you with knowledge and provoke reflection on the stories we've accepted without question.
We compare intermittent auscultation and continuous electronic fetal monitoring. We lay out the importance of considering the full spectrum of fetal heart rate information, dissecting the biases that can sway clinical judgment. Dr. Small's insights offer clarity on the practical application of guidelines required to ensure informed clinical decisions. This episode not only educates but also invites you to contribute to our ongoing conversation about the complexities of maternity care.
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider. If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth. Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small. Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor. If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
Join me & my guest Dr. Kirsten Small as we build on our previous joint episode 157 Fetal heart monitoring in labour. This time we discuss the world of intermittent auscultation, you'll be enlightened by the evolution from the hands-on Pinard stethoscope to the advanced Doppler device. Dr. Small shares her expertise on the intimate connection care providers once had with this practice and how it's changing in today's clinical settings. We also examine the remarkable methods midwives employ in various care environments to monitor fetal well-being, revealing the depth and diversity of approaches.
Listen as we discuss cardiotocograph interpretation, the myths surrounding traditional CTG patterns and upend long-held beliefs about fetal distress. We discuss the need to re-evaluate our understanding of decelerations. This episode promises to arm you with knowledge and provoke reflection on the stories we've accepted without question.
We compare intermittent auscultation and continuous electronic fetal monitoring. We lay out the importance of considering the full spectrum of fetal heart rate information, dissecting the biases that can sway clinical judgment. Dr. Small's insights offer clarity on the practical application of guidelines required to ensure informed clinical decisions. This episode not only educates but also invites you to contribute to our ongoing conversation about the complexities of maternity care.
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider. If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth. Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small. Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor. If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
Speaker 1:
Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you. Episode 164, intermittent oscortation. It's absolutely wonderful to welcome back Dr Kirsten Small today. We talked to her on episode 157, monitoring the fetus in labour, and we're going to continue on with that theme, but in a slightly different direction, because we're going to discuss intermittent oscortation, which is still monitoring the fetus in labour, but may not be considered that or considered sufficiently that, which is some of what we're going to explore today. So perhaps we should start by discussing what is intermittent oscortation and what do we mean by that.
Speaker 2:
Oscortation means to listen to something. So, as the name suggests, it refers to intermittently listening to the fetal heart rate during labour as a means of telling whether things are okay with the fetus or not. It is typically done in most parts of the high income maternity care systems around the world using Doppler technology and they call things like sonic aids or dolptones, depending on which part of the world that you're in. That uses ultrasound waves that are bounced through the tissues and sound waves are then reflected back and if something is moving as the sound wave hits it, it produces then called the Doppler shifts, so there's a change in the frequency of those sound waves and so those devices then can pick up that movement and then there's a little mini computer in the brain of it that turns it into an audible sound that we can hear. Plus, most handheld machines now have the same technology CTG machines have, which will also count the heart rate for you. So you don't have to sit there with your watch on your wrist or you know the front of your uniform listening to and looking at the hand on the clock and trying to do maths to work out how many beats per minute it is. So those bits of the technology make life so much easier. Because the original on the very first form of fetal heart rate monitoring was to use a thing called a pinard stethoscope, which is just a long cone shaped hollow device made of wood or sometimes metal or sometimes plastic that then has a flat area on one end to make it comfortable to stick it next to your ear. And you put the wide end of the cone on the mother's abdomen next to where the fetal heart sits. You know kind of a feel and see which one around the baby's pointing first, so that you're not sticking it over its bum and you can actually directly hear the actual sound that the heart is making.
Speaker 2:
And there are some theoretical advantages to actually hearing the actual fetal heart sound and not something that's computer generated and slightly abstract.
Speaker 2:
But obviously they don't calculate the heart rate for you. You've got to do that and do the maths and count the numbers as you're going, which is requires a little bit of technical expertise and it kind of limits the positions that the woman can get into and you know the care provider needs to work around her in terms of being able to physically do fetal heart rate monitoring so you can't stick your head into the birth pool, use a pin hard underneath the water, for example. You know you're going to have to ask a woman to stand up so that you can access that if you want, if you wanted to use a pin hard. So you know a handheld waterproof Doppler means that you can work. You know it's uncommon that you would need to ask a woman to really significantly adjust her position in order to be able to hear what's going on. So hence the Dopplers have become so prolific in use and it's now quite difficult to find care providers who actually have, you know, expertise in terms of using a pin hard stethoscope and using it well.
Speaker 1:
Yeah, I think so. I had not that long ago, a woman who didn't want Doppler, who wanted a pin hard, and we had exactly that conversation about, well, that will be more difficult for you to position and if you want to use the pool, that will be more challenging. Just what you'll have to stand up or or get out, or we'll have to adjust things. Because listening with a pin hard which definitely I did earlier on in my career is it's quite intimate. You are quite close to the woman's abdomen. The pin hard is maybe sort of six or eight inches long, isn't it? Sorry, centimeters, 15 centimeters or so. So so you are, you are, you are quite close up, close and personal, but there is something pretty amazing about hearing directly the baby, I think.
Speaker 2:
I feel it's a bit sad that we've lost that.
Speaker 2:
I think it is a bit sad that we've lost that. We might pick up back on this as we continue the conversation. Many years ago I had a fabulous conversation with two midwives from North America Oregon who had an American midwifery training system is very different to your country and my. In Australia and the UK there's the option to do an apprenticeship model where you train with a midwife who works in the community, not in a hospital system. At the end of multiple years, when you feel that you've mastered the skill set, then you do an exam that's managed nationally. They learn their skills from other women serving women in their communities and out of hospital settings. They've never used a CTG machine and I don't even know if they owned a Doppler.
Speaker 2:
I was fascinated.
Speaker 2:
How do you know whether the fetus is okay or not?
Speaker 2:
What are the things that you use to be able to say we're fine or we need to transfer to hospital or we need to just whatever wiggle and jiggle and move or cut in the physiognomy tools they've got in the out of hospital setting to speed labour up and because they were using pinards and they talked about the fact that the sound, that the heart rate makes changes when you're getting up in a situation where there's fetal compromise and I think now, many years later, having learned a whole lot more about fetal physiology and what's going on, I think what they're hearing is fetal blood pressure dropping, which is really interesting because it's not something we can pick up with the CTG, and yet it's probably one of the few reliable signs that you've gone from my oxygen levels low, but I'm actually okay.
Speaker 2:
You don't need to do anything to my oxygen levels low and I'm not okay and you need to get me out of here. Maybe we abandoned pinards too early, when there might have been a way to capture that information, but in a way that still had all the advantages of Doppler technology the flexibility in terms of women's positions and being able to be waterproof and not having to be quite so physically intimate with women to be able to do the job and have a room that's really quiet to be able to hear. If we could have achieved that whilst listening to the actual fetal heart and it's not too late somebody could still invent that technology for us today. It might be a game of change.
Speaker 1:
Yeah, yeah, it could be. So if we're talking about a woman in labour and we're discussing what sort of monitoring, we talked on our previous episode about the lack of evidence for CTG and what we were talking about was the comparison between CTG continuous cardiotochograph and this method intermittent oscultation. So this is our sort of basic comparative way of monitoring the baby. We weren't talking about not monitoring the baby.
Speaker 2:
Correct. There's never been a study that's compared to CTG use with no form of fetal heart rate monitoring and likewise, there's never been a study that's compared intermittent oscultation with no form of fetal heart rate monitoring. All we've got is studies that compare one against the other. Stethoscopes which resembled pinout stethoscopes when they were first invented were, you know that, the 1820s and by 1830s we see quite widespread use through France and the English-speaking world of intermittent oscultation in labour. The focus was more on is this baby alive or not, rather than is it well or not, because they didn't have safe caesarean section, and so you know the decision was about if this baby is dead, it's pretty gruesome. We can chop it up into little pieces and pull it out through the woman's vagina and save her life in the process. So you know it was a different world, different situation, and you know, and our modern understanding of research didn't exist and nobody ran around the most controlled trial in 1832 to see whether this was, you know, useful technology or not.
Speaker 1:
Yes.
Speaker 2:
And then, over you know, 120 odd years, it kind of evolved and people had a sense of the things that they were listening for. That helped them to feel like things were okay or that things weren't okay, and so it was really well established as being the way that we do things around here. And then CTGs became the new kid on the block. So that's why the two were compared to one another. That intermittent auscultation was already really well established by the time CTGs came and then very rapidly took over in maternity care. So you know, how does it compare with CTGs in terms of the outcomes? This is basically the same conversation that we had, but in reverse.
Speaker 1:
Yes.
Speaker 2:
So you know CTGs compared to intermittent auscultation. Intermittent auscultation does not increase or decrease the mortality rate, the deaths of babies during labor or in the first week of life afterwards. We see the same outcomes regardless of which approach to fetal heart rate monitoring is used. We see the same long-term outcomes in terms of brain injury as well, so cerebral palsy. The only area where we see intermittent auscultation doesn't appear to perform as well is in terms of the neonatal seizure rate. So babies having fits not long after their birth and, as we talked about last time, you need to do quite a lot of CTG monitoring, including RIM 1 baby from having a seizure done. The effect size is quite small and it's probably possibly maybe confined only to women who are having their labors sped up with an oxytocin infusion to make their contractions stronger. Again, there's just these big truck-sized holes in the research that just should have been done and never was done before we started going oh, it's okay, we'll use it this way. That seems like a good idea.
Speaker 2:
Where intermittent auscultation really shines is that it's better for women, and so you don't see the increase in cesarean section rate and the increase in instrumental birth, but you do see a higher spontaneous vaginal birth rate, where an intermittent auscultation is being used rather than a CTG monitoring.
Speaker 2:
And that's true whether we're talking about women who are considered to be low risk or women who are considered to be high risk. And, interestingly, in terms of the beneficial effects of CTGs for seizures, that seems to actually be strongest in women who are considered to be low risk and it actually doesn't read statistical significance in women who are considered to be high risk, which is kind of the flip side of the one that we actually do things in practice. The group where we maybe have some evidence that they'll do better with CTG use we don't offer CTGs. We say you can just have intermittent auscultation, you'll be fine. And the group with this really, really no evidence that CTG is going to make anything better. The high risk population we read them the riot act if they dare think that they might have intermittent auscultation instead of CTG use. Yes, yeah.
Speaker 1:
I'm finding myself in increasingly weird conversations where I'm having to say to women I have to recommend continuous CTG because that's the national guidance, blah blah blah. But actually the evidence isn't there and so if they want to do or have intermittent auscultation, that's fine. And then making them care plans to mean that it's okay for them to make the choice that is obviously evidence says is okay, but just because the guidance doesn't say it's okay. So it's kind of very contradictory. So if you are pregnant listening to this, what would you expect for intermittent auscultation in labour? What would that actually mean?
Speaker 2:
With intermittent auscultation. Most guidelines recommend that somewhere between every 15 minutes to every 30 minutes in the earlier stages of labour, that someone listens to the fetal heart rate for at least 60 seconds one minute, and usually most guidelines say to listen in between contractions, and I'm hoping we get to circle back later and talk about why. I think that's probably not a great idea and you're basically looking for the same information that you would get from the CTG. You know what's the baseline heart rate. Are there accelerations? Are there decelerations? Is there variability? Does the heart rate bounce up and down? Just you know, not too much and not you know more than not enough so that you can then make a determination that this fetus is fine, we can leave it alone or I'm so happy about this one. We need to pay more attention and possibly take some action to, you know, increase oxygen supply and if that can't be achieved, then get the baby out where it can be, in room air or additional oxygen, and be looked after.
Speaker 2:
Now, as labour progresses, then usually as people move into the pushing stage, the second stage of labour, the guidelines say to increase how frequently it's done. So it might be every five minutes or it might be after every contraction or after every second contraction, that people are listening and obviously common sense would dictate if there's a change in what's going on. You know if there's suddenly some bleeding or the pain changes or the woman's membranes rupture and there's mecanium staining, you know if it's two minutes after you just listened you're not going to go. Oh, I'll wait for 28 minutes, I'll be good. You know you step in and you reassess the situation at that stage again to get reassurance that all is well before moving on.
Speaker 1:
Yeah, so we want to hear the baseline and variability in accelerations and decelerations and you mentioned this idea of not listening through a contraction and I'm interested that you say that because to me that sort of makes sense. But obviously I've got to unpick the fact that that knowledge is coming from what I know happens on a CTG, which we've already agreed isn't necessarily a good thing, but I know that some decelerations are normal during contractions and it's more about the pace at which they recover and the baseline afterwards and the variability afterwards. You know, is this baby getting progressively hypoxic? Now that's my assumption from someone that's working with CTG.
Speaker 2:
I'm about to take your world upside down and tell you that it's commonly taught.
Speaker 2:
If you go and read the physiology research, there's no proof whatsoever that you can distinguish between this kind of deceleration, that kind of deceleration and the other kind of deceleration, and these ones are okay and these ones are not. All decelerations are due to fetal hypoxia and you and I would thought, as we were junior obstetricians, that early decelerations when the heart rates flows at the same time as the contraction and recovers by the end of it they're due to head compression and they're harmless. And in some situations I've actually been taught that they're a reassuring sign that the baby's neurological system is intact. Then there's things called variable decelerations that start and finish at slightly different times and they look different on a CTG from one contraction to the next and they're due to the cord being compressed and dropping the baby's blood pressure and that produces a particular response. And then there's things called late decelerations and they're the ones that are due to low oxygen and they happen. They start about halfway through the contraction and they take much longer to recover.
Speaker 2:
Yeah, so it's all nonsense.
Speaker 1:
Okay, great. So I'm in the world of physiological CTG. I'm going to say inverted commas there, so we now call them baroreceptor decels and chemoreceptor decels, but it's the same sort of principle, so we educate me.
Speaker 2:
If you look at the physiology, for starters, people have done research where they've squeezed fetal heads, either in animal models or in actual human fetuses, where they've done things like putting ring pisseries inside women's vaginas and forcibly pushing up against the fetal head with them, and it doesn't reliably produce a deceleration at all. So the whole head compression thing just doesn't hold water and I have a blog post specifically about that that goes through all of that research.
Speaker 1:
Amazing. I need to go and read that clearly.
Speaker 2:
There's also been some research questioning whether the baroreceptor reflex is the thing that's responsible for the changes that we see in CTG patterns, and the answer is it isn't that. The only time that you start to see a deceleration is when hypoxia starts. So if you've got a baby that's dropped its blood pressure but the fetus is adequately oxygenated, you don't get a deceleration, you don't get a drop in the heart rate. It's all low oxygen levels that are doing the changes and I think what's happened. We are the species who can lie on our backs and look at the sky and see clouds and decide that that one's a giraffe and that one's a teacup.
Speaker 2:
We have brains that pick up patterns and make stories out of them, and I think that this is a situation where we've picked up some patterns and we've made stories out of them and we've done such a good job of storytelling it that we've all believed them. I remember, as a registrar, being in a CTG education session when one of my fellow registrars who liked a good joke and it was back in the days of overhead projectors, before PowerPoints existed, because none of us had personal computers or mobile phones, because we're old and what he'd done is he'd taken a blank piece of CTG paper and had photocopied it onto this overhead projector sheet and then he'd gone and grabbed a graph of a stock exchange report of the ups and downs of the stock exchange values of a share of a company and superimposed one over the top of the other and then drew on some more like contractions across the bottom of this and presented it to us as a CTG. Everyone in that room, for about 10 minutes, had a red hot go at classifying that CTG and trying to make it fit the stories that we've been told, when in fact it was impossible to do so because it wasn't a fatal part that we were looking at. That's hilarious and I think and now I look in that now, knowing what I now know, many years later, looking back on that experience like it should have taught me something at that point in time that we are so driven to look for patterns and meanings in heart rates, that you know we've. We have fallen in the trap of seeing things and making nice stories about them without actually really having good research evidence to back that up at all. And it's really only been in the last 10, 15 years that we've started to get the research evidence and that shows that all decelerations are due to a thing called the chemo receptor.
Speaker 2:
Reflex Oxygen levels fall. There are receptors in some of the blood vessels in our body that recognize that and they then do a couple of things. So they turn on the sympathetic nervous system and that redistributes blood. So it contracts blood vessels in parts of the body that aren't, frankly, that important and can do without it right now. So you know you left little toe and your earlobe, and it pushes blood back into the central part of the body so that the brain and the heart gets more of it. So they're protected, because that's a good thing to do.
Speaker 2:
You can't see that on a CTG, but it's going on. The other thing that happens is that, in order to protect the heart, you want it to do less work, and so you turn on the parasympathetic nervous system via the vagus nerve and you drop the heart rate dramatically, because if it goes from beating 120 times a minute to 60 times a minute, it only needs half as much oxygen, so it can get by literally with half as much oxygen and function exactly as well. So when people talk about fetal distress, what we're actually seeing is fetal coping. It's not as sexy though, because, you know, pressing the big button on the wall and running screaming up a corridor to the operating theatre because your fetus is coping just doesn't make the same ring to it.
Speaker 2:
But you know we've gotten caught up in this story that what we're seeing is sign of impending doom for this child, rather than a valid coping mechanism that's actually designed to prevent damage from low oxygen levels.
Speaker 2:
The problem is that we don't have a heart rate signal that will tell us when we've gone from my oxygen levels low.
Speaker 2:
I've made all these adjustments on brilliant now I'm great, I can keep going and the fetus that's made all of the adjustments and they are not enough and there's now starting to be damage to the brain or to the heart. The heart rate patterns look the same, and that's precisely that we need something that can tell those two apart, for some form of fetal monitoring to work in labour, because otherwise we see what we see in clinical practice, and that is that we end up doing lots of caesarean sections and instrumental bursts and telling people to push harder and cutting of physiotomies because we see patterns on the heart rate. The baby's completely fine, comes out yelling its lungs off a few minutes later and says what, what are you doing to that poor? I was okay, and yet we also sometimes miss babies that would have benefited from earlier birth because we put them in that they're probably okay, have a greedy when they're not, and so I'm not really solving the problem, which is why I think the pinard and how the heart rate changes sound.
Speaker 1:
Yeah.
Speaker 2:
Because if you're not getting enough oxygen levels to actually continue to have your heart squeeze blood out hard, even though it's dropped its heart rate to protect itself, that's a sign you shifted across the line and you can hear that if you know what you're listening for with the pinard step.
Speaker 1:
Yes.
Speaker 2:
The one bit of research that has started to look hopeful is a thing called the total deceleration area or total deceleration time, which basically adds up the amount of time the baby's heart rate stays below the baseline, the average heart rate. So you can either have a smaller number of really long, really deep decelerations that then add up to a much larger number of really small short decelerations, and that would give us the same information. You know that those fetuses are both in the same condition. So therefore, given that almost all decelerations happen during contractions, it becomes really important that we know what's going on during contractions, because if you're having consistent decelerations that recover by the time the contractions finished, if the only time that you're listening with your intermittent oscultation is, you know, 10 or 15 seconds after the woman's gone that was a big one, okay, you can listen. Now you won't know that those decelerations are happening, and so you'll lose really vital information, which I think potentially becomes a self fulfilling prophecy there.
Speaker 2:
Because people go, well, intermittent oscultation doesn't like it can't pick up the ones that are. That's because you're not looking for the right information. You're ignoring the one time in the contraction cycle when that heart rate might actually be providing you with the most information I could. It's jolly uncomfortable to listen. Have someone listen to the field heart rate with a Doppler during contractions and it does mean that you know if you want to sway and stomp and what have you. You know, either you need an agile midwife who can follow you around and sway and stomp and do it at the same time, or you have to be still while somebody's listening. So it is a bit of a pest, but I do think that paying more attention during contractions is something that we should incorporate in our guidelines and our thinking when we're using intermittent oscultation.
Speaker 1:
For that reason, so so I understand what you're saying and you probably not blowing my mind quite as much as you think, because, because we do because we do.
Speaker 1:
we talk about gradually evolving hypoxia. So the baby's decelerating, but it's coming back to its normal baseline and it's all good. And what we're looking for is that moment that you've described, where actually it's now shifting to it's not, it was coping, it's coping, it's coping and then actually this is the point where it's going to start to decompensate and not cope as well. And so I'm now going to say so. We've listened in the contractions, great, and we've heard a deceleration, oh, decelerations. And now what are we going to do? Because the thing Immediately that was happened in my birth centre would be we've heard a deceleration.
Speaker 1:
Let's put the CCG on. So now we're. Now we're back in that sticky thing, but the CCG doesn't make a difference. So I'm not stuck.
Speaker 2:
There's not been a research trial where the only entry criteria was women who had an abnormal heart rate pattern on oscultation. And then we keep going with intimate noscultation or we keep going with CTG, because that you know, even the days before CTGs were invented, of course, people went and kept going with intimate noscultation was the only tool I had available. So you know, there is a point in history when that was done and people found ways to continue to gather useful information. We do have the some of the so-called high risk trials that are included in the Cochrane review, where women who had some kind of risk factor were randomized either to intermittent oscultation or CTG monitoring. One of the criteria and almost all of those trials had multiple criteria that you got you across the line in terms of being called high risk, but one of the criteria was abnormal heart rates on oscultation and yet they still randomized we people to intermittent oscultation and still got outcomes that were equivalent to CTG use. Now, you know, it may be, it might be that those women actually did that. Those women's fetuses did a lot worse, but the women who had diabetes did so much better with intimate noscultation and therefore they kind of cancelled each other out. You know, we just we haven't got that kind of fine grained detailed in the research, but there's certainly there's no compelling research out there that says that you have to put a CTG on when you hear the heart rates Right.
Speaker 2:
And I think in real life, in a real clinical situation, I think this is hugely context dependent, depends on what the clinical situation is, how rapidly it's unfolding, how many sets of hands you've got on deck where the equipment is and you know what.
Speaker 2:
What really needs to happen is adequate assessment of the woman and her fetus, of an appropriate decision making, and you use the best set of tools that you have at your disposal at the time to do that.
Speaker 2:
So if you're in a place where there's a CTG machine fixed to the wall next to the bed and the equipment is in the top drawer and it's always available, but you're a bit short on staff and when you press the buzzer no one comes then putting the CTG on to free up your hands so that you can then go on and do all the other you know, do the vaginal examination and do the maternal observations and those other things that need doing, then that makes sense.
Speaker 2:
If you're in a situation where the CTG machine is in another room and the straps are locked up in the drug cupboard and the midwife who's got the keys is on the T break and there's three of you that are in the bathroom, then it might actually make sense just to keep going with really frequent intermittent oscillation, so basically continuous oscillation, with somebody holding the Doppler on and it's there just to continue listening while all of those other things happen around you.
Speaker 2:
And it's more because of the way we structure our maternity care systems. It's more common that we'll be short on staff for heavy on equipment, and so it makes logical sense to go down that let's put the CTG machine on. But you know, I'm kind of hope people would think through that rationally and not leave a woman alone and go and find the CTG machine and then with wife, when really what needs to happen is a rapid clinical assessment of the situation, because they become rules based and the rule says you have to put a CTG on instead of thinking about what's really happening here and what's the best way for me to solve this problem.
Speaker 1:
And I think that's a really good point, because I was thinking about home birth or birth center where a CTG machine is not available and actually you know if birth is imminent or you know you can do things safely and continue monitoring and make that full clinical assessment. It may be that you don't need to move. You don't need to necessarily change what you're doing. You've just got an awareness that this baby may need some assistance when it's born or may need something slightly different doing to expedite birth. You know, changing the woman's position or whatever it is, or but you don't. You can make that clinical assessment first and decide. And that's what brings me to. We sometimes have started referring to intermittent auscultation as intelligent auscultation, and I think you know yes, that's not quite correct, because you know it's all about what you're describing listening in but it is then about engaging your brain and thinking what does this mean in the context in which I'm listening?
Speaker 2:
The other thing that's worth reminding people of is, if we go back to the conversation that we had last time about the, the idea that CTG monitoring is continuous monitoring and I'm using air quotes while I'm saying that, because in reality it's actually intermittent monitoring, but continuous recording People don't look at the machine. They might vaguely be aware of the heart rate ticking away in the background, but in terms of actually stopping and engaging with the CTG trace and actively interpreting it and making meaning of it, that happens intermittently. When you're doing intermittent ascultation, that analysis and interpretation is happening at the same time that you are actively listening to it. And so if you're actively listening over the space of one, two or three minutes and going, I do not like what I'm hearing, and then you need to stop because you've got to do the blood pressure and you've got to press the buzzer and you've got to do seven other things. It's actually not dissimilar to what's happening with CTG monitoring and yet people tell themselves this kind of story that there's somehow more contemporaneous oversight over the heart rate when the CTG is on it. It's not actually true. What's happening is it's retrospective analysis of it after the event has already passed. When you look back at the last 15 or 20 minutes while they've been running around doing all the things that needed doing to sort out the clinical situation. So they're not as diametrically opposed as we might think that they are.
Speaker 2:
In clinical practice the intelligent intermittent ascultation starts interesting. I haven't actually seen the inside of any of that. It's UK based so it's not available to me here. And the devil's in the details with these things. So I would quite like to get a handle on it.
Speaker 2:
But what used to happen when I was training and even in the early years of my practice, was that people had listened strictly. Every 15 or 30 minutes or every five minutes or after, depending on what the guidelines in the hospital said for 60 seconds They'd calculate the baseline heart rate and they'd reduce it down to a single number. And then they'd go and find the partogram where we'd record all of the labour observations and they'd put a little X so that it sat at 125 at 10.30 am and then at 11.00 am they'd put another little X at 130 and that was it. It's not enough. It's not good enough to just record one single number every half an hour. And again, if you then compare it to CTG monitoring, well, of course, that looks like completely deficient monitoring.
Speaker 2:
I think it sets up a situation where people are asking themselves the wrong question.
Speaker 2:
They're asking what's the heart rate?
Speaker 2:
Not have I got enough information right now about what's going on for these feeders to tell me that it's okay for me to leave it exactly the way that it is and not do anything different, and that's it's a very different mindset and that might require listening for a lot longer. I'll listen through the next contraction, I'll give the woman a bit of a break for the one after that and then I'll listen again to the one after that because I'm still not quite sure what I'm hearing, to increase the intensity of that until I get to a point where I'm ready to make a decision that in fact, this is okay and I can back off and wait another 15 minutes or no, it's not okay and I've got to call for help and we've got to do something different about the situation here. It concerns me when people write these guidelines that say they shall listen every X seconds, but every so many minutes at this point in life, and it's easy to follow the rules and lose sight of the reason why they exist in the first place.
Speaker 1:
Yes, I think that's very true, and I've had some conversations with our FECL monitoring midwife about how you do this and listening for a minute or do you listen in blocks of 15 seconds. She was talking about this Oxford method that's being described, where you listen for 15 second, blocks for 90 seconds, and then you've got to do complex maths in your head. What I see in the notes much more is the single number yeah on the pateogram or written in the notes, the single number, which is interesting because in the anti-natal clinic these days we tend to write down a range or if, for example, it's somewhere in going around between 140 and 150, we will write down it's in the 140s, that's that baby's normal baseline, but we won't write down just 140. 142. Yeah, exactly, or 142.
Speaker 2:
Which, as you know it's really tricky to actually arrive at that now, because if you're using one of the modern Dopplers that has the little screen on it and the computer brain in it that gives you a number, it doesn't sit at 140 or 142 for 60 seconds. It's like that for three seconds and then another couple of heartbeats later it's 148, and then it's 152, and then it's 136. So you just have a bit of wild guess to try and arrive at that baseline number.
Speaker 1:
Which is where your brain comes in again, isn't it? Because? Are we unconsciously selecting the numbers that we like? It's a bit like I'm going off track now, but blood pressure machines. So when we did blood pressure with a Sphig, it was much more likely that you're going to pick the blood pressure numbers that are an even number, aren't they?
Speaker 2:
So it's always going to be, because that's where the lines are.
Speaker 1:
Whereas now, if you take it on an electronic machine, it might be 103 on 57 and you would never, ever have made that someone's blood pressure when you're doing it manually. So I feel like this could be a bit the same. Do we pick numbers that we think are okay out of the numbers that are flashing before us, and how are we thinking about that? And then also, the numbers, as we've said, are computer generated anyway. So lots to think about. But definitely in the notes I see people have written a single number. And then I also see if we're doing a review of care, because maybe there's been a risk incident which may or may not be to do with the baby.
Speaker 1:
I'll see mid-wise criticised because, well, they didn't do every 15 minutes. Well, actually all it is is they didn't write it down every 15 minutes. Maybe this one was 10 minutes apart, this one was 17 minutes apart, this one was 8 minutes apart, this one was 20 minutes apart. Well, again, it's back to that sort of rules thing. Yes, we want good practice, but getting back to the, is this baby okay at this point in time with what's happening to it? That's the key.
Speaker 2:
Yeah, I would like to see something that looks a bit like this when a woman first presents for professional care in labour, that there's something kind of like what happens with an admission CTG, but you're using intermittent oscultation instead. So you ask the one is your baby moving at the moment? If the answer is no, then you have a listen in between contractions Long enough for you to get an idea of what the baseline is, because for a baseline it needs to be in between contractions and when there's no active fetal movement there's no acceleration in progress. And you work out your baseline and you look at the, as I just said, you look at the numbers on the screen and if it's going from 132 to 142 and anywhere in between, well, that's 10 bits of variability. So you've got normal variability going on. So you can record that in the same way that you would if you were interpreting CTG. And then you say to the woman look, tell me the next time your baby moves. And so she says, oh, it's having a kick. And you have a listen and it's 168.
Speaker 2:
So there's your acceleration, and then you have a listen through the next contraction, all the way through beginning end and out the other end, and there is no deceleration, and so that might require you to listen, for you know, a five minute period across a 15 minute period, starting and stopping, to get the same kind of information that you would get with a CTG. It's very different to just, you know, 60 seconds in between contractions and we're done and we're not going to listen now for another half an hour. And because if you've then got that robust and you can like you can stand up and say you're on in a court of law. This is exactly what I did to ensure that this fetus was in good health at the time that I initiated professional care for this woman. Then you know, no one's really going to have too much room to criticize that. And then if that's well and the clinical situation is really stable and it's early labor, nothing much is going to change. So if you don't listen for 45 minutes, probably no great big deal. But you know, if the woman ruptures the membranes and starts making a different noise, then you don't want to sit there looking at your clock going.
Speaker 2:
I've got 15 minutes. You know that's the time when, again, you step up and you listen more intently and you might do, you know, four periods of intermittent oscultation back to back over the course of five contractions, listening at different times, until you can reassure yourself once again that this is okay and I'm happy to you know now we'll wait 15 minutes before the next time we have a listen. Yeah, and it's difficult to translate into guidelines because guideline writers like simple rules and you know you can do what you said then in the reviews afterwards. Well, it was 12 minutes, not 15. Yeah, it was, you know, 16 minutes and 52 seconds, not 15.
Speaker 2:
But you know yeah doesn't necessarily constitute poor care.
Speaker 1:
No, exactly, but I really like that approach that you just outlined. I think that would be a really good way forward and I think I'm hoping that you know women that listening to this that gives them confidence that it's okay to choose intermittent oscultation. And I think women sometimes probably from us as professionals get this idea that it's not monitoring, as we discussed when we spoke last time. And actually it is monitoring, it is assessing how your baby is doing.
Speaker 2:
It's the same fetal heart. Yeah, it's the same set of fetal heart rate patterns. If you're comparing a handheld Doppler with a Doppler based CTG, it's literally the same technology that's being used to provide you with the information. So, ego, it is actually not all that surprising when you sit down and think about it that we see very little difference in outcomes between the two of them Because and as I said, it might be continuous recording it's still intermittent monitoring. When you're using a CTG, you're still only interrogating and interpreting and making a decision about the quality and the meaning of that trace intermittently, the same as you're doing when you're listening intermittently with a Doppler through contraction. So it's actually not that surprising that the two of them rank really similarly in the research. So I think the take home messages I would have for women who are accessing maternity care is that it's actually okay to question the idea that you have to have a CTG because, in a certain respect, to hear you're having a feedback, you're having twins, you're a bit overdue, whatever and obviously that needs to be an individualised discussion that you should have with your care provider, because some situations are really pretty scary and would make even my eyelids twitch at the thought of not accessing CTG monitoring, particularly when people are using oxytocin infusions. That would kind of feel very uncomfortable about not having CTG monitoring on, and that's more for the T-bit of the CTG making able to tell what's happening with contraction patterns and that if it is done intelligently well by somebody who's asking the right questions, then you should expect exactly the same outcomes that we see with CTG use, apart from the fact that in the research we see high spontaneous vaginal birth rates and I think that's more complicated than it's just because we're not seeing a whole pile of scary things on the CTG. We just don't have access to information that would trigger a response. That's part of it, but I think it's more complicated than that.
Speaker 2:
There's something materially different about the intimacy of the care that's involved in laying hands on on a regular basis. A midwife has to be in the room. They have to have laid hands on that woman's abdomen to have a rough idea of where that fetus is lying, to know where to listen, and it will change during the course of the labor. So they'll need to get hands on again with the woman. You are up close with people.
Speaker 2:
You can smell when they start getting ketotic because they're a bit dehydrated and haven't had anything you know, a jelly bean in the last seven hours. You can feel that they're hot before you think to do a set of observations and find out that they've got a fever. If you've waked the CTG on and you've wandered out to the central monitoring station to have your cup of tea on your meal break and the woman's alone in the room, you miss all the rest of that information at the same time. I think you know that the reassuring human presence of somebody who's not stressed helps to regulate your heart rate and that probably helps regulate the fetal heart rate. And there's some safety information that's also being picked up by the active involvement of the midwife or obstetric nurse, depending on which country you're in who's doing the endometriosis quotation. That's missed, particularly when you've got central fetal monitoring systems and people are absent from the room.
Speaker 1:
I think that's sort of perfect message really, both for women and those of us working in maternity, and it would be really great if having had this conversation spurred people on to use intermittent oscultation in some of the ways we've discussed and get a bit more thoughtful about whether actually they do need a CTG or not and that kind of overall clinical picture and being you know, with women.
Speaker 2:
Seems like a good point to end a podcast on.
Speaker 1:
It does, does it? Thank you so much. Thank you very, very much for joining me again. It's been an absolute pleasure and, just like last time, I've really enjoyed our thought-provoking conversation. So, yeah, thank you very much.
Speaker 2:
Thanks for having me back to finish off the second half of the conversation.
Speaker 1:
I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcast, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue, from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.
Speaker 1:
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