Listening to a foetus’ heart rate during labour is an important method of assessing the baby’s wellbeing. It is a form of screening which seeks to identify foetuses who may be affected by a reduction in oxygen and may benefit from intervention. A normal foetal heart rate can provide some reassurance to the woman, her family and the midwife that the foetus is well during labour (1) Identifying foetal heart rate anomalies can support the midwife to help identify babies which may be at risk of perinatal mortality or morbidity. These can occur due to foetal metabolic acidosis and or cerebral hypoxia although there are a variety of factors that may contribute to asphyxia during labour and or birth (2). Birth asphyxia may be due to incidents that have occurred during pregnancy and prior to birth rather than due to the labour and birth itself.
There are two ways of listening to the baby’s heart rate,
- Intermittent Auscultation (IA) using a pinard or fetoscope or Doppler ultrasound device.
- continuous electronic foetal monitoring (EFM) using a Cardiotocograph (CTG) machine via Doppler ultrasound or a foetal scalp electrode that continuously records the foetal heart rate and its response to the woman’s uterine contractions
In keeping with the basic premise that childbirth is usually a normal, physiological life-cycle event, midwives will use technology only when indicated, to enhance the well-being of mothers and babies and to improve outcomes (3). For women who are well and healthy and have a normal (physiological) labour midwives should assess foetal wellbeing using intermittent auscultation (IA).
The use of routine electronic foetal monitoring results in an increase in a number of interventions with no concomitant increase in positive neonatal outcomes. It is associated with a definite increase in caesarean section, instrumental vaginal births and other interventions with little significant improvement in perinatal mortality or morbidity outcomes other than a reduction in neonatal seizures when CTG is used (4) (5) (6). CTG monitoring reduces the woman’s ability to be active and to use a variety of positions during labour. Both of which are recognised as supporting healthy oxygenation for the baby during labour. Several meta-analysis and professional association guidelines support the use of intermittent auscultation for well healthy women (Low risk) in spontaneous term labour (7) (8) (9).
In keeping with the basic premise that childbirth is usually a normal, physiological life-cycle event and to enhance the well-being of mothers and babies and to improve outcomes ICM urges midwives to
- only use technology when indicated
- assess foetal wellbeing using intermittent auscultation (IA) for women who are well and healthy and have a normal (physiological) labour. Recommendations ICM encourages member associations to: • Recognise Intermittent Auscultation (IA) as a basic midwifery competency.
- Support education on the optimum method of Intermittent Auscultation.
- Encourage the use of Intermittent Auscultation with women who are well and healthy and in spontaneous labour regardless of birth setting.
Appropriate use of Intervention in Childbirth
For most women, childbirth is normal, life event. Midwives should only use interventions during childbirth when these are necessary. All women should have access to quality are, including options for lifesaving interventions when they are needed.
Bill of Rights for Women and Midwives
The Bill of Rights for Women and Midwives addresses the basic human rights of women and midwives that have been systematically denied and adds another framework to approach governments when demanding change to improve midwifery and maternity services.
Other Relevant Documents
- Consultation on the NICE Exceptional Review of Intrapartum Foetal Monitoring Recommendations: Addenum to intrapartum care. RCOG, 2017. at https://www.rcog.org.uk/en/about-us/nga/consultation-on-the-nice-exceptional-review-ofintrapartum-foetal-monitoring-recommendations/.)
- Devane D, Lalor JG, Daly S, McGuire W, Smith V. Cardiotocography versus intermittent auscultation of foetal heart on admission to labour ward for assessment of foetal wellbeing. Cochrane Database Syst Rev 2012: Cd005122.
- Lewis D, Downe S. FIGO consensus guidelines on intrapartum foetal monitoring: Intermittent auscultation. Int J Gynaecol Obstet 2015; 131:9-12.
- Martis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of foetal heart rate in labour for foetal well-being. Cochrane Database Syst Rev 2017 ;2 :CD008680.
- Maude RM, Skinner JP, Foureur MJ. Putting intelligent structured intermittent auscultation (ISIA) into practice. Women Birth 2016; 29:285-92.
- Nelson KB, Sartwelle TP, Rouse DJ. Electronic foetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence. BMJ 2016;355: i6405.
- Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum Foetal Surveillance Clinical Guidelines – Third Edition 2014. Victoria, Australia: RANZCOG; 2014.
Adopted at Toronto Council meeting, 2017
Due for next review 2023