February 2, 2024 • 53 mins
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.
Want to know more?
https://birthsmalltalk.com/
Kirsten has many fascinating blog posts to explore we touch on a couple of them here
https://birthsmalltalk.com/2023/05/24/keeping-up-with-physiology-research/
https://birthsmalltalk.com/2022/01/12/whats-the-deal-with-early-decelerations-and-head-compression/
She also runs online fetal monitoring courses for maternity professionals.
https://birthsmalltalk.com/courses/
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...
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife, maybe birth fascinates
you, or you're simply curiousabout what exactly an
obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
Episode 164, intermittentoscortation.
(00:53):
It's absolutely wonderful towelcome back Dr Kirsten Small
today.
We talked to her on episode 157, monitoring the fetus in labour
, and we're going to continue onwith that theme, but in a
slightly different direction,because we're going to discuss
(01:16):
intermittent oscortation, whichis still monitoring the fetus in
labour, but may not beconsidered that or considered
sufficiently that, which is someof what we're going to explore
today.
So perhaps we should start bydiscussing what is intermittent
(01:37):
oscortation and what do we meanby that.
Speaker 2 (01:41):
Oscortation means to listen to something.
So, as the name suggests, itrefers to intermittently
listening to the fetal heartrate during labour as a means of
telling whether things are okaywith the fetus or not.
It is typically done in mostparts of the high income
(02:04):
maternity care systems aroundthe world using Doppler
technology and they call thingslike sonic aids or dolptones,
depending on which part of theworld that you're in.
That uses ultrasound waves thatare bounced through the tissues
and sound waves are thenreflected back and if something
(02:24):
is moving as the sound wave hitsit, it produces then called the
Doppler shifts, so there's achange in the frequency of those
sound waves and so thosedevices then can pick up that
movement and then there's alittle mini computer in the
brain of it that turns it intoan audible sound that we can
hear.
Plus, most handheld machinesnow have the same technology CTG
(02:47):
machines have, which will alsocount the heart rate for you.
So you don't have to sit therewith your watch on your wrist or
you know the front of youruniform listening to and looking
at the hand on the clock andtrying to do maths to work out
how many beats per minute it is.
So those bits of the technologymake life so much easier.
(03:09):
Because the original on thevery first form of fetal heart
rate monitoring was to use athing called a pinard
stethoscope, which is just along cone shaped hollow device
made of wood or sometimes metalor sometimes plastic that then
has a flat area on one end tomake it comfortable to stick it
(03:31):
next to your ear.
And you put the wide end of thecone on the mother's abdomen
next to where the fetal heartsits.
You know kind of a feel and seewhich one around the baby's
pointing first, so that you'renot sticking it over its bum and
you can actually directly hearthe actual sound that the heart
is making.
And there are some theoreticaladvantages to actually hearing
(03:54):
the actual fetal heart sound andnot something that's computer
generated and slightly abstract.
But obviously they don'tcalculate the heart rate for you
.
You've got to do that and dothe maths and count the numbers
as you're going, which isrequires a little bit of
technical expertise and it kindof limits the positions that the
(04:15):
woman can get into and you knowthe care provider needs to work
around her in terms of beingable to physically do fetal
heart rate monitoring so youcan't stick your head into the
birth pool, use a pin hardunderneath the water, for
example.
You know you're going to haveto ask a woman to stand up so
(04:36):
that you can access that if youwant, if you wanted to use a pin
hard.
So you know a handheldwaterproof Doppler means that
you can work.
You know it's uncommon that youwould need to ask a woman to
really significantly adjust herposition in order to be able to
hear what's going on.
So hence the Dopplers havebecome so prolific in use and
(04:58):
it's now quite difficult to findcare providers who actually
have, you know, expertise interms of using a pin hard
stethoscope and using it well.
Speaker 1 (05:09):
Yeah, I think so.
I had not that long ago, awoman who didn't want Doppler,
who wanted a pin hard, and wehad exactly that conversation
about, well, that will be moredifficult for you to position
and if you want to use the pool,that will be more challenging.
Just what you'll have to standup or or get out, or we'll have
(05:31):
to adjust things.
Because listening with a pinhard which definitely I did
earlier on in my career is it'squite intimate.
You are quite close to thewoman's abdomen.
The pin hard is maybe sort ofsix or eight inches long, isn't
it?
Sorry, centimeters, 15centimeters or so.
So so you are, you are, you arequite close up, close and
(05:55):
personal, but there is somethingpretty amazing about hearing
directly the baby, I think.
Speaker 2 (06:04):
I feel it's a bit sad that we've lost that.
I think it is a bit sad thatwe've lost that.
We might pick up back on thisas we continue the conversation.
Many years ago I had a fabulousconversation with two midwives
from North America Oregon whohad an American midwifery
(06:24):
training system is verydifferent to your country and my
.
In Australia and the UK there'sthe option to do an
apprenticeship model where youtrain with a midwife who works
in the community, not in ahospital system.
At the end of multiple years,when you feel that you've
mastered the skill set, then youdo an exam that's managed
(06:48):
nationally.
They learn their skills fromother women serving women in
their communities and out ofhospital settings.
They've never used a CTGmachine and I don't even know if
they owned a Doppler.
I was fascinated.
How do you know whether thefetus is okay or not?
(07:11):
What are the things that you useto be able to say we're fine or
we need to transfer to hospitalor we need to just whatever
wiggle and jiggle and move orcut in the physiognomy tools
they've got in the out ofhospital setting to speed labour
up and because they were usingpinards and they talked about
the fact that the sound, thatthe heart rate makes changes
(07:36):
when you're getting up in asituation where there's fetal
compromise and I think now, manyyears later, having learned a
whole lot more about fetalphysiology and what's going on,
I think what they're hearing isfetal blood pressure dropping,
which is really interestingbecause it's not something we
can pick up with the CTG, andyet it's probably one of the few
(07:58):
reliable signs that you've gonefrom my oxygen levels low, but
I'm actually okay.
You don't need to do anything tomy oxygen levels low and I'm
not okay and you need to get meout of here.
Maybe we abandoned pinards tooearly, when there might have
been a way to capture thatinformation, but in a way that
(08:24):
still had all the advantages ofDoppler technology the
flexibility in terms of women'spositions and being able to be
waterproof and not having to bequite so physically intimate
with women to be able to do thejob and have a room that's
really quiet to be able to hear.
If we could have achieved thatwhilst listening to the actual
(08:47):
fetal heart and it's not toolate somebody could still invent
that technology for us today.
It might be a game of change.
Speaker 1 (08:55):
Yeah, yeah, it could be.
So if we're talking about awoman in labour and we're
discussing what sort ofmonitoring, we talked on our
previous episode about the lackof evidence for CTG and what we
(09:15):
were talking about was thecomparison between CTG
continuous cardiotochograph andthis method intermittent
oscultation.
So this is our sort of basiccomparative way of monitoring
the baby.
We weren't talking about notmonitoring the baby.
Speaker 2 (09:38):
Correct.
There's never been a studythat's compared to CTG use with
no form of fetal heart ratemonitoring and likewise, there's
never been a study that'scompared intermittent
oscultation with no form offetal heart rate monitoring.
All we've got is studies thatcompare one against the other.
Stethoscopes which resembledpinout stethoscopes when they
were first invented were, youknow that, the 1820s and by
(10:01):
1830s we see quite widespreaduse through France and the
English-speaking world ofintermittent oscultation in
labour.
The focus was more on is thisbaby alive or not, rather than
is it well or not, because theydidn't have safe caesarean
(10:23):
section, and so you know thedecision was about if this baby
is dead, it's pretty gruesome.
We can chop it up into littlepieces and pull it out through
the woman's vagina and save herlife in the process.
So you know it was a differentworld, different situation, and
(10:44):
you know, and our modernunderstanding of research didn't
exist and nobody ran around themost controlled trial in 1832
to see whether this was, youknow, useful technology or not.
Speaker 1 (10:55):
Yes.
Speaker 2 (10:57):
And then, over you know, 120 odd years, it kind of
evolved and people had a senseof the things that they were
listening for.
That helped them to feel likethings were okay or that things
weren't okay, and so it wasreally well established as being
the way that we do thingsaround here.
(11:17):
And then CTGs became the newkid on the block.
So that's why the two werecompared to one another.
That intermittent auscultationwas already really well
established by the time CTGscame and then very rapidly took
over in maternity care.
So you know, how does itcompare with CTGs in terms of
(11:39):
the outcomes?
This is basically the sameconversation that we had, but in
reverse.
Speaker 1 (11:44):
Yes.
Speaker 2 (11:45):
So you know CTGs compared to intermittent
auscultation.
Intermittent auscultation doesnot increase or decrease the
mortality rate, the deaths ofbabies during labor or in the
first week of life afterwards.
We see the same outcomesregardless of which approach to
fetal heart rate monitoring isused.
We see the same long-termoutcomes in terms of brain
(12:08):
injury as well, so cerebralpalsy.
The only area where we seeintermittent auscultation
doesn't appear to perform aswell is in terms of the neonatal
seizure rate.
So babies having fits not longafter their birth and, as we
talked about last time, you needto do quite a lot of CTG
(12:30):
monitoring, including RIM 1 babyfrom having a seizure done.
The effect size is quite smalland it's probably possibly maybe
confined only to women who arehaving their labors sped up with
an oxytocin infusion to maketheir contractions stronger.
Again, there's just these bigtruck-sized holes in the
(12:50):
research that just should havebeen done and never was done
before we started going oh, it'sokay, we'll use it this way.
That seems like a good idea.
Where intermittent auscultationreally shines is that it's
better for women, and so youdon't see the increase in
cesarean section rate and theincrease in instrumental birth,
(13:11):
but you do see a higherspontaneous vaginal birth rate,
where an intermittentauscultation is being used
rather than a CTG monitoring.
And that's true whether we'retalking about women who are
considered to be low risk orwomen who are considered to be
high risk.
And, interestingly, in terms ofthe beneficial effects of CTGs
(13:32):
for seizures, that seems toactually be strongest in women
who are considered to be lowrisk and it actually doesn't
read statistical significance inwomen who are considered to be
high risk, which is kind of theflip side of the one that we
actually do things in practice.
The group where we maybe havesome evidence that they'll do
(13:55):
better with CTG use we don'toffer CTGs.
We say you can just haveintermittent 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 weread them the riot act if they
dare think that they might haveintermittent auscultation
(14:16):
instead of CTG use.
Yes, yeah.
Speaker 1 (14:21):
I'm finding myself in increasingly weird
conversations where I'm havingto say to women I have to
recommend continuous CTG becausethat's the national guidance,
blah blah blah.
But actually the evidence isn'tthere and so if they want to do
or have intermittentauscultation, that's fine.
(14:43):
And then making them care plansto mean that it's okay for them
to make the choice that isobviously evidence says is okay,
but just because the guidancedoesn't say it's okay.
So it's kind of verycontradictory.
So if you are pregnantlistening to this, what would
(15:06):
you expect for intermittentauscultation in labour?
What would that actually mean?
Speaker 2 (15:11):
With intermittent auscultation.
Most guidelines recommend thatsomewhere between every 15
minutes to every 30 minutes inthe earlier stages of labour,
that someone listens to thefetal heart rate for at least 60
seconds one minute, and usuallymost guidelines say to listen
in between contractions, and I'mhoping we get to circle back
(15:33):
later and talk about why.
I think that's probably not agreat idea and you're basically
looking for the same informationthat you would get from the CTG
.
You know what's the baselineheart rate.
Are there accelerations?
Are there decelerations?
Is there variability?
Does the heart rate bounce upand down?
Just you know, not too much andnot you know more than not
(15:56):
enough so that you can then makea determination that this fetus
is fine, we can leave it aloneor I'm so happy about this one.
We need to pay more attentionand possibly take some action to
, you know, increase oxygensupply and if that can't be
achieved, then get the baby outwhere it can be, in room air or
(16:16):
additional oxygen, and be lookedafter.
Now, as labour progresses, thenusually as people move into the
pushing stage, the second stageof labour, the guidelines say to
increase how frequently it'sdone.
So it might be every fiveminutes or it might be after
every contraction or after everysecond contraction, that people
are listening and obviouslycommon sense would dictate if
(16:39):
there's a change in what's goingon.
You know if there's suddenlysome bleeding or the pain
changes or the woman's membranesrupture and there's mecanium
staining, you know if it's twominutes 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 youreassess the situation at that
(17:01):
stage again to get reassurancethat all is well before moving
on.
Speaker 1 (17:06):
Yeah, so we want to hear the baseline and
variability in accelerations anddecelerations and you mentioned
this idea of not listeningthrough a contraction and I'm
interested that you say thatbecause to me that sort of makes
sense.
But obviously I've got tounpick the fact that that
(17:28):
knowledge is coming from what Iknow happens on a CTG, which
we've already agreed isn'tnecessarily a good thing, but I
know that some decelerations arenormal during contractions and
it's more about the pace atwhich they recover and the
(17:50):
baseline afterwards and thevariability afterwards.
You know, is this baby gettingprogressively hypoxic?
Now that's my assumption fromsomeone that's working with CTG.
Speaker 2 (18:03):
I'm about to take your world upside down and tell
you that it's commonly taught.
If you go and read thephysiology research, there's no
proof whatsoever that you candistinguish between this kind of
(18:24):
deceleration, that kind ofdeceleration and the other kind
of deceleration, and these onesare okay and these ones are not.
All decelerations are due tofetal hypoxia and you and I
would thought, as we were juniorobstetricians, that early
decelerations when the heartrates flows at the same time as
the contraction and recovers bythe end of it they're due to
(18:47):
head compression and they'reharmless.
And in some situations I'veactually been taught that
they're a reassuring sign thatthe baby's neurological system
is intact.
Then there's things calledvariable decelerations that
start and finish at slightlydifferent times and they look
different on a CTG from onecontraction to the next and
(19:07):
they're due to the cord beingcompressed and dropping the
baby's blood pressure and thatproduces a particular response.
And then there's things calledlate decelerations and they're
the ones that are due to lowoxygen and they happen.
They start about halfwaythrough the contraction and they
take much longer to recover.
Yeah, so it's all nonsense.
Speaker 1 (19:27):
Okay, great.
So I'm in the world ofphysiological CTG.
I'm going to say invertedcommas there, so we now call
them baroreceptor decels andchemoreceptor decels, but it's
the same sort of principle, sowe educate me.
Speaker 2 (19:47):
If you look at the physiology, for starters, people
have done research wherethey've squeezed fetal heads,
either in animal models or inactual human fetuses, where
they've done things like puttingring pisseries inside women's
vaginas and forcibly pushing upagainst the fetal head with them
, and it doesn't reliablyproduce a deceleration at all.
(20:09):
So the whole head compressionthing just doesn't hold water
and I have a blog postspecifically about that that
goes through all of thatresearch.
Speaker 1 (20:18):
Amazing.
I need to go and read thatclearly.
Speaker 2 (20:22):
There's also been some research questioning
whether the baroreceptor reflexis the thing that's responsible
for the changes that we see inCTG patterns, and the answer is
it isn't that.
The only time that you start tosee a deceleration is when
hypoxia starts.
So if you've got a baby that'sdropped its blood pressure but
the fetus is adequatelyoxygenated, you don't get a
(20:45):
deceleration, you don't get adrop in the heart rate.
It's all low oxygen levels thatare doing the changes and I
think what's happened.
We are the species who can lieon our backs and look at the sky
and see clouds and decide thatthat one's a giraffe and that
one's a teacup.
We have brains that pick uppatterns and make stories out of
(21:07):
them, and I think that this isa situation where we've picked
up some patterns and we've madestories out of them and we've
done such a good job ofstorytelling it that we've all
believed them.
I remember, as a registrar,being in a CTG education session
when one of my fellowregistrars who liked a good joke
(21:29):
and it was back in the days ofoverhead projectors, before
PowerPoints existed, becausenone of us had personal
computers or mobile phones,because we're old and what he'd
done is he'd taken a blank pieceof CTG paper and had
photocopied it onto thisoverhead projector sheet and
then he'd gone and grabbed agraph of a stock exchange report
(21:51):
of the ups and downs of thestock exchange values of a share
of a company and superimposedone over the top of the other
and then drew on some more likecontractions across the bottom
of this and presented it to usas a CTG.
Everyone in that room, forabout 10 minutes, had a red hot
go at classifying that CTG andtrying to make it fit the
(22:15):
stories that we've been told,when in fact it was impossible
to do so because it wasn't afatal part that we were looking
at.
That's hilarious and I thinkand now I look in that now,
knowing what I now know, manyyears later, looking back on
that experience like it shouldhave taught me something at that
(22:35):
point in time that we are sodriven to look for patterns and
meanings in heart rates, thatyou know we've.
We have fallen in the trap ofseeing things and making nice
stories about them withoutactually really having good
research evidence to back thatup at all.
And it's really only been inthe last 10, 15 years that we've
(22:58):
started to get the researchevidence and that shows that all
decelerations are due to athing called the chemo receptor.
Reflex Oxygen levels fall.
There are receptors in some ofthe blood vessels in our body
that recognize that and theythen do a couple of things.
So they turn on the sympatheticnervous system and that
(23:21):
redistributes blood.
So it contracts blood vesselsin parts of the body that aren't
, frankly, that important andcan do without it right now.
So you know you left little toeand your earlobe, and it pushes
blood back into the centralpart of the body so that the
brain and the heart gets more ofit.
So they're protected, becausethat's a good thing to do.
(23:42):
You can't see that on a CTG, butit's going on.
The other thing that happens isthat, in order to protect the
heart, you want it to do lesswork, and so you turn on the
parasympathetic nervous systemvia the vagus nerve and you drop
the heart rate dramatically,because if it goes from beating
120 times a minute to 60 times aminute, it only needs half as
(24:05):
much oxygen, so it can get byliterally with half as much
oxygen and function exactly aswell.
So when people talk about fetaldistress, what we're actually
seeing is fetal coping.
It's not as sexy though,because, you know, pressing the
big button on the wall andrunning screaming up a corridor
to the operating theatre becauseyour fetus is coping just
(24:28):
doesn't make the same ring to it.
But you know we've gotten caughtup in this story that what
we're seeing is sign ofimpending doom for this child,
rather than a valid copingmechanism that's actually
designed to prevent damage fromlow oxygen levels.
The problem is that we don'thave a heart rate signal that
(24:50):
will tell us when we've gonefrom my oxygen levels low.
I've made all these adjustmentson brilliant now I'm great, I
can keep going and the fetusthat's made all of the
adjustments and they are notenough and there's now starting
to be damage to the brain or tothe heart.
The heart rate patterns lookthe same, and that's precisely
(25:14):
that we need something that cantell those two apart, for some
form of fetal monitoring to workin labour, because otherwise we
see what we see in clinicalpractice, and that is that we
end up doing lots of caesareansections and instrumental bursts
and telling people to pushharder and cutting of
physiotomies because we seepatterns on the heart rate.
The baby's completely fine,comes out yelling its lungs off
(25:37):
a few minutes later and sayswhat, what are you doing to that
poor?
I was okay, and yet we alsosometimes miss babies that would
have benefited from earlierbirth because we put them in
that they're probably okay, havea greedy when they're not, and
so I'm not really solving theproblem, which is why I think
(25:58):
the pinard and how the heartrate changes sound.
Speaker 1 (26:02):
Yeah.
Speaker 2 (26:02):
Because if you're not getting enough oxygen levels to
actually continue to have yourheart squeeze blood out hard,
even though it's dropped itsheart rate to protect itself,
that's a sign you shifted acrossthe line and you can hear that
if you know what you'relistening for with the pinard
step.
Speaker 1 (26:20):
Yes.
Speaker 2 (26:21):
The one bit of research that has started to
look hopeful is a thing calledthe total deceleration area or
total deceleration time, whichbasically adds up the amount of
time the baby's heart rate staysbelow the baseline, the average
heart rate.
So you can either have asmaller number of really long,
(26:47):
really deep decelerations thatthen add up to a much larger
number of really small shortdecelerations, and that would
give us the same information.
You know that those fetuses areboth in the same condition.
So therefore, given that almostall decelerations happen during
contractions, it becomes reallyimportant that we know what's
(27:11):
going on during contractions,because if you're having
consistent decelerations thatrecover by the time the
contractions finished, if theonly time that you're listening
with your intermittentoscultation is, you know, 10 or
15 seconds after the woman'sgone that was a big one, okay,
you can listen.
Now you won't know that thosedecelerations are happening, and
(27:36):
so you'll lose really vitalinformation, which I think
potentially becomes a selffulfilling prophecy there.
Because people go, well,intermittent oscultation doesn't
like it can't pick up the onesthat are.
That's because you're notlooking for the right
information.
You're ignoring the one time inthe contraction cycle when that
heart rate might actually beproviding you with the most
(27:59):
information I could.
It's jolly uncomfortable tolisten.
Have someone listen to thefield heart rate with a Doppler
during contractions and it doesmean that you know if you want
to sway and stomp and what haveyou.
You know, either you need anagile midwife who can follow you
around and sway and stomp anddo it at the same time, or you
(28:19):
have to be still whilesomebody's listening.
So it is a bit of a pest, but Ido think that paying more
attention during contractions issomething that we should
incorporate in our guidelinesand our thinking when we're
using intermittent oscultation.
Speaker 1 (28:38):
For that reason, so so I understand what you're
saying and you probably notblowing my mind quite as much as
you think, because, because wedo because we do.
we talk about gradually evolvinghypoxia.
So the baby's decelerating, butit's coming back to its normal
baseline and it's all good.
(29:00):
And what we're looking for isthat moment that you've
described, where actually it'snow shifting to it's not, it was
coping, it's coping, it'scoping and then actually this is
the point where it's going tostart to decompensate and not
cope as well.
And so I'm now going to say so.
(29:22):
We've listened in thecontractions, great, and we've
heard a deceleration, oh,decelerations.
And now what are we going to do?
Because the thing Immediatelythat was happened in my birth
centre would be we've heard adeceleration.
(29:42):
Let's put the CCG on.
So now we're.
Now we're back in that stickything, but the CCG doesn't make
a difference.
So I'm not stuck.
Speaker 2 (29:56):
There's not been a research trial where the only
entry criteria was women who hadan abnormal heart rate pattern
on oscultation.
And then we keep going withintimate noscultation or we keep
going with CTG, because thatyou know, even the days before
CTGs were invented, of course,people went and kept going with
intimate noscultation was theonly tool I had available.
(30:16):
So you know, there is a pointin history when that was done
and people found ways tocontinue to gather useful
information.
We do have the some of theso-called high risk trials that
are included in the Cochranereview, where women who had some
kind of risk factor wererandomized either to
(30:37):
intermittent oscultation or CTGmonitoring.
One of the criteria and almostall of those trials had multiple
criteria that you got youacross the line in terms of
being called high risk, but oneof the criteria was abnormal
heart rates on oscultation andyet they still randomized we
people to intermittentoscultation and still got
outcomes that were equivalent toCTG use.
(31:00):
Now, you know, it may be, itmight be that those women
actually did that.
Those women's fetuses did a lotworse, but the women who had
diabetes did so much better withintimate noscultation and
therefore they kind of cancelledeach other out.
You know, we just we haven'tgot that kind of fine grained
detailed in the research, butthere's certainly there's no
(31:23):
compelling research out therethat says that you have to put a
CTG on when you hear the heartrates Right.
And I think in real life, in areal clinical situation, I think
this is hugely contextdependent, depends on what the
clinical situation is, howrapidly it's unfolding, how many
sets of hands you've got ondeck where the equipment is and
(31:49):
you know what.
What really needs to happen isadequate assessment of the woman
and her fetus, of anappropriate decision making, and
you use the best set of toolsthat you have at your disposal
at the time to do that.
So if you're in a place wherethere's a CTG machine fixed to
the wall next to the bed and theequipment is in the top drawer
(32:12):
and it's always available, butyou're a bit short on staff and
when you press the buzzer no onecomes then putting the CTG on
to free up your hands so thatyou can then go on and do all
the other you know, do thevaginal examination and do the
maternal observations and thoseother things that need doing,
then that makes sense.
(32:33):
If you're in a situation wherethe CTG machine is in another
room and the straps are lockedup in the drug cupboard and the
midwife who's got the keys is onthe T break and there's three
of you that are in the bathroom,then it might actually make
sense just to keep going withreally frequent intermittent
oscillation, so basicallycontinuous oscillation, with
(32:54):
somebody holding the Doppler onand it's there just to continue
listening while all of thoseother things happen around you.
And it's more because of the waywe structure our maternity care
systems.
It's more common that we'll beshort on staff for heavy on
equipment, and so it makeslogical sense to go down that
let's put the CTG machine on.
(33:16):
But you know, I'm kind of hopepeople would think through that
rationally and not leave a womanalone and go and find the CTG
machine and then with wife, whenreally what needs to happen is
a rapid clinical assessment ofthe situation, because they
become rules based and the rulesays you have to put a CTG on
(33:37):
instead of thinking about what'sreally happening here and
what's the best way for me tosolve this problem.
Speaker 1 (33:44):
And I think that's a really good point, because I was
thinking about home birth orbirth center where a CTG machine
is not available and actuallyyou know if birth is imminent or
you know you can do thingssafely and continue monitoring
(34:05):
and make that full clinicalassessment.
It may be that you don't needto move.
You don't need to necessarilychange what you're doing.
You've just got an awarenessthat this baby may need some
assistance when it's born or mayneed something slightly
different doing to expeditebirth.
(34:26):
You know, changing the woman'sposition or whatever it is, or
but you don't.
You can make that clinicalassessment first and decide.
And that's what brings me to.
We sometimes have startedreferring to intermittent
auscultation as intelligentauscultation, and I think you
(34:46):
know yes, that's not quitecorrect, because you know it's
all about what you're describinglistening in but it is then
about engaging your brain andthinking what does this mean in
the context in which I'mlistening?
Speaker 2 (35:03):
The other thing that's worth reminding people of
is, if we go back to theconversation that we had last
time about the, the idea thatCTG monitoring is continuous
monitoring and I'm using airquotes while I'm saying that,
because in reality it's actuallyintermittent monitoring, but
continuous recording Peopledon't look at the machine.
(35:26):
They might vaguely be aware ofthe heart rate ticking away in
the background, but in terms ofactually stopping and engaging
with the CTG trace and activelyinterpreting it and making
meaning of it, that happensintermittently.
When you're doing intermittentascultation, that analysis and
interpretation is happening atthe same time that you are
(35:48):
actively listening to it.
And so if you're activelylistening over the space of one,
two or three minutes and going,I do not like what I'm hearing,
and then you need to stopbecause you've got to do the
blood pressure and you've got topress the buzzer and you've got
to do seven other things.
It's actually not dissimilar towhat's happening with CTG
monitoring and yet people tellthemselves this kind of story
(36:11):
that there's somehow morecontemporaneous oversight over
the heart rate when the CTG ison it.
It's not actually true.
What's happening is it'sretrospective analysis of it
after the event has alreadypassed.
When you look back at the last15 or 20 minutes while they've
been running around doing allthe things that needed doing to
sort out the clinical situation.
So they're not as diametricallyopposed as we might think that
(36:37):
they are.
In clinical practice theintelligent intermittent
ascultation starts interesting.
I haven't actually seen theinside of any of that.
It's UK based so it's notavailable to me here.
And the devil's in the detailswith these things.
So I would quite like to get ahandle on it.
(36:57):
But what used to happen when Iwas training and even in the
early years of my practice, wasthat people had listened
strictly.
Every 15 or 30 minutes or everyfive minutes or after,
depending on what the guidelinesin the hospital said for 60
seconds They'd calculate thebaseline heart rate and they'd
reduce it down to a singlenumber.
(37:18):
And then they'd go and find thepartogram where we'd record all
of the labour observations andthey'd put a little X so that it
sat at 125 at 10.30 am and thenat 11.00 am they'd put another
little X at 130 and that was it.
It's not enough.
(37:38):
It's not good enough to justrecord one single number every
half an hour.
And again, if you then compareit to CTG monitoring, well, of
course, that looks likecompletely deficient monitoring.
I think it sets up a situationwhere people are asking
themselves the wrong question.
They're asking what's the heartrate?
(37:59):
Not have I got enoughinformation right now about
what's going on for thesefeeders to tell me that it's
okay for me to leave it exactlythe way that it is and not do
anything different, and that'sit's a very different mindset
and that might require listeningfor a lot longer.
I'll listen through the nextcontraction, I'll give the woman
a bit of a break for the oneafter that and then I'll listen
(38:21):
again to the one after thatbecause I'm still not quite sure
what I'm hearing, to increasethe intensity of that until I
get to a point where I'm readyto make a decision that in fact,
this is okay and I can back offand wait another 15 minutes or
no, it's not okay and I've gotto call for help and we've got
to do something different aboutthe situation here.
It concerns me when peoplewrite these guidelines that say
(38:45):
they shall listen every Xseconds, but every so many
minutes at this point in life,and it's easy to follow the
rules and lose sight of thereason why they exist in the
first place.
Speaker 1 (38:58):
Yes, I think that's very true, and I've had some
conversations with our FECLmonitoring midwife about how you
do this and listening for aminute or do you listen in
blocks of 15 seconds.
She was talking about thisOxford method that's being
described, where you listen for15 second, blocks for 90 seconds
(39:21):
, and then you've got to docomplex maths in your head.
What I see in the notes muchmore is the single number yeah
on the pateogram or written inthe notes, the single number,
which is interesting because inthe anti-natal clinic these days
we tend to write down a rangeor if, for example, it's
(39:47):
somewhere in going aroundbetween 140 and 150, we will
write down it's in the 140s,that's that baby's normal
baseline, but we won't writedown just 140.
142.
Yeah, exactly, or 142.
Speaker 2 (40:04):
Which, as you know it's really tricky to actually
arrive at that now, because ifyou're using one of the modern
Dopplers that has the littlescreen on it and the computer
brain in it that gives you anumber, it doesn't sit at 140 or
142 for 60 seconds.
It's like that for threeseconds and then another couple
of heartbeats later it's 148,and then it's 152, and then it's
(40:27):
136.
So you just have a bit of wildguess to try and arrive at that
baseline number.
Speaker 1 (40:36):
Which is where your brain comes in again, isn't it?
Because?
Are we unconsciously selectingthe numbers that we like?
It's a bit like I'm going offtrack now, but blood pressure
machines.
So when we did blood pressurewith a Sphig, it was much more
likely that you're going to pickthe blood pressure numbers that
(40:58):
are an even number, aren't they?
Speaker 2 (41:00):
So it's always going to be, because that's where the
lines are.
Speaker 1 (41:05):
Whereas now, if you take it on an electronic machine
, it might be 103 on 57 and youwould never, ever have made that
someone's blood pressure whenyou're doing it manually.
So I feel like this could be abit the same.
Do we pick numbers that wethink are okay out of the
numbers that are flashing beforeus, and how are we thinking
(41:28):
about that?
And then also, the numbers, aswe've said, are computer
generated anyway.
So lots to think about.
But definitely in the notes Isee people have written a single
number.
And then I also see if we'redoing a review of care, because
maybe there's been a riskincident which may or may not be
to do with the baby.
(41:50):
I'll see mid-wise criticisedbecause, well, they didn't do
every 15 minutes.
Well, actually all it is isthey didn't write it down every
15 minutes.
Maybe this one was 10 minutesapart, this one was 17 minutes
apart, this one was 8 minutesapart, this one was 20 minutes
apart.
Well, again, it's back to thatsort of rules thing.
(42:12):
Yes, we want good practice, butgetting back to the, is this
baby okay at this point in timewith what's happening to it?
That's the key.
Speaker 2 (42:24):
Yeah, I would like to see something that looks a bit
like this when a woman firstpresents for professional care
in labour, that there'ssomething kind of like what
happens with an admission CTG,but you're using intermittent
oscultation instead.
So you ask the one is your babymoving at the moment?
(42:45):
If the answer is no, then youhave a listen in between
contractions Long enough for youto get an idea of what the
baseline is, because for abaseline it needs to be in
between contractions and whenthere's no active fetal movement
there's no acceleration inprogress.
And you work out your baselineand you look at the, as I just
said, you look at the numbers onthe screen and if it's going
(43:05):
from 132 to 142 and anywhere inbetween, well, that's 10 bits of
variability.
So you've got normalvariability going on.
So you can record that in thesame way that you would if you
were interpreting CTG.
And then you say to the womanlook, tell me the next time your
baby moves.
And so she says, oh, it'shaving a kick.
And you have a listen and it's168.
(43:26):
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, andthere is no deceleration, and so
that might require you tolisten, for you know, a five
minute period across a 15 minuteperiod, starting and stopping,
(43:48):
to get the same kind ofinformation that you would get
with a CTG.
It's very different to just,you know, 60 seconds in between
contractions and we're done andwe're not going to listen now
for another half an hour.
And because if you've then gotthat robust and you can like you
can stand up and say you're onin a court of law.
This is exactly what I did toensure that this fetus was in
(44:09):
good health at the time that Iinitiated professional care for
this woman.
Then you know, no one's reallygoing to have too much room to
criticize that.
And then if that's well and theclinical situation is really
stable and it's early labor,nothing much is going to change.
So if you don't listen for 45minutes, probably no great big
(44:34):
deal.
But you know, if the womanruptures the membranes and
starts making a different noise,then you don't want to sit
there looking at your clockgoing.
I've got 15 minutes.
You know that's the time when,again, you step up and you
listen more intently and youmight do, you know, four periods
of intermittent oscultationback to back over the course of
(44:56):
five contractions, listening atdifferent times, until you can
reassure yourself once againthat this is okay and I'm happy
to you know now we'll wait 15minutes before the next time we
have a listen.
Yeah, and it's difficult totranslate into guidelines
because guideline writers likesimple rules and you know you
(45:17):
can do what you said then in thereviews afterwards.
Well, it was 12 minutes, not 15.
Yeah, it was, you know, 16minutes and 52 seconds, not 15.
But you know yeah doesn'tnecessarily constitute poor care
.
Speaker 1 (45:32):
No, exactly, but I really like that approach that
you just outlined.
I think that would be a reallygood way forward and I think I'm
hoping that you know women thatlistening to this that gives
them confidence that it's okayto choose intermittent
(45:54):
oscultation.
And I think women sometimesprobably from us as
professionals get this idea thatit's not monitoring, as we
discussed when we spoke lasttime.
And actually it is monitoring,it is assessing how your baby is
doing.
Speaker 2 (46:15):
It's the same fetal heart.
Yeah, it's the same set offetal heart rate patterns.
If you're comparing a handheldDoppler with a Doppler based CTG
, it's literally the sametechnology that's being used to
provide you with the information.
So, ego, it is actually not allthat surprising when you sit
down and think about it that wesee very little difference in
(46:36):
outcomes between the two of themBecause and as I said, it might
be continuous recording it'sstill intermittent monitoring.
When you're using a CTG, you'restill only interrogating and
interpreting and making adecision about the quality and
the meaning of that traceintermittently, the same as
you're doing when you'relistening intermittently with a
(46:57):
Doppler through contraction.
So it's actually not thatsurprising that the two of them
rank really similarly in theresearch.
So I think the take homemessages I would have for women
who are accessing maternity careis that it's actually okay to
question the idea that you haveto have a CTG because, in a
(47:19):
certain respect, to hear you'rehaving a feedback, you're having
twins, you're a bit overdue,whatever and obviously that
needs to be an individualiseddiscussion that you should have
with your care provider, becausesome situations are really
pretty scary and would make evenmy eyelids twitch at the
thought of not accessing CTGmonitoring, particularly when
(47:44):
people are using oxytocininfusions.
That would kind of feel veryuncomfortable about not having
CTG monitoring on, and that'smore for the T-bit of the CTG
making able to tell what'shappening with contraction
patterns and that if it is doneintelligently well by somebody
(48:05):
who's asking the right questions, then you should expect exactly
the same outcomes that we seewith CTG use, apart from the
fact that in the research we seehigh spontaneous vaginal birth
rates and I think that's morecomplicated than it's just
(48:26):
because we're not seeing a wholepile of scary things on the CTG
.
We just don't have access toinformation that would trigger a
response.
That's part of it, but I thinkit's more complicated than that.
There's something materiallydifferent about the intimacy of
the care that's involved inlaying hands on on a regular
(48:49):
basis.
A midwife has to be in the room.
They have to have laid hands onthat woman's abdomen to have a
rough idea of where that fetusis lying, to know where to
listen, and it will changeduring the course of the labor.
So they'll need to get hands onagain with the woman.
You are up close with people.
(49:09):
You can smell when they startgetting ketotic because they're
a bit dehydrated and haven't hadanything you know, a jelly bean
in the last seven hours.
You can feel that they're hotbefore you think to do a set of
observations and find out thatthey've got a fever.
If you've waked the CTG on andyou've wandered out to the
central monitoring station tohave your cup of tea on your
(49:33):
meal break and the woman's alonein the room, you miss all the
rest of that information at thesame time.
I think you know that thereassuring human presence of
somebody who's not stressedhelps to regulate your heart
rate and that probably helpsregulate the fetal heart rate.
And there's some safetyinformation that's also being
(49:56):
picked up by the activeinvolvement of the midwife or
obstetric nurse, depending onwhich country you're in who's
doing the endometriosisquotation.
That's missed, particularlywhen you've got central fetal
monitoring systems and peopleare absent from the room.
Speaker 1 (50:13):
I think that's sort of perfect message really, both
for women and those of usworking in maternity, and it
would be really great if havinghad this conversation spurred
people on to use intermittentoscultation in some of the ways
we've discussed and get a bitmore thoughtful about whether
(50:38):
actually they do need a CTG ornot and that kind of overall
clinical picture and being youknow, with women.
Speaker 2 (50:52):
Seems like a good point to end a podcast on.
Speaker 1 (50:54):
It does, does it?
Thank you so much.
Thank you very, very much forjoining me again.
It's been an absolute pleasureand, just like last time, I've
really enjoyed ourthought-provoking conversation.
So, yeah, thank you very much.
Speaker 2 (51:13):
Thanks for having me back to finish off the second
half of the conversation.
Speaker 1 (51:18):
I very much hope you found this episode of the OBS
pod interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review on whatever platform youfind your podcast, as well as
recommending the OBS pod toanyone you think might find it
(51:38):
interesting.
There's also tons of episodesto explore in my back catalogue,
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(52:03):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(52:27):
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
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(52:47):
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So if you've enjoyed myepisodes and, by chance, you do
(53:09):
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Don't feel under any obligation, but if you'd like to
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Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife, maybe birth fascinates
you, or you're simply curiousabout what exactly an
obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
Episode 164, intermittentoscortation.
(00:53):
It's absolutely wonderful towelcome back Dr Kirsten Small
today.
We talked to her on episode 157, monitoring the fetus in labour
, and we're going to continue onwith that theme, but in a
slightly different direction,because we're going to discuss
(01:16):
intermittent oscortation, whichis still monitoring the fetus in
labour, but may not beconsidered that or considered
sufficiently that, which is someof what we're going to explore
today.
So perhaps we should start bydiscussing what is intermittent
(01:37):
oscortation and what do we meanby that.
Speaker 2 (01:41):
Oscortation means to listen to something.
So, as the name suggests, itrefers to intermittently
listening to the fetal heartrate during labour as a means of
telling whether things are okaywith the fetus or not.
It is typically done in mostparts of the high income
(02:04):
maternity care systems aroundthe world using Doppler
technology and they call thingslike sonic aids or dolptones,
depending on which part of theworld that you're in.
That uses ultrasound waves thatare bounced through the tissues
and sound waves are thenreflected back and if something
(02:24):
is moving as the sound wave hitsit, it produces then called the
Doppler shifts, so there's achange in the frequency of those
sound waves and so thosedevices then can pick up that
movement and then there's alittle mini computer in the
brain of it that turns it intoan audible sound that we can
hear.
Plus, most handheld machinesnow have the same technology CTG
(02:47):
machines have, which will alsocount the heart rate for you.
So you don't have to sit therewith your watch on your wrist or
you know the front of youruniform listening to and looking
at the hand on the clock andtrying to do maths to work out
how many beats per minute it is.
So those bits of the technologymake life so much easier.
(03:09):
Because the original on thevery first form of fetal heart
rate monitoring was to use athing called a pinard
stethoscope, which is just along cone shaped hollow device
made of wood or sometimes metalor sometimes plastic that then
has a flat area on one end tomake it comfortable to stick it
(03:31):
next to your ear.
And you put the wide end of thecone on the mother's abdomen
next to where the fetal heartsits.
You know kind of a feel and seewhich one around the baby's
pointing first, so that you'renot sticking it over its bum and
you can actually directly hearthe actual sound that the heart
is making.
And there are some theoreticaladvantages to actually hearing
(03:54):
the actual fetal heart sound andnot something that's computer
generated and slightly abstract.
But obviously they don'tcalculate the heart rate for you
.
You've got to do that and dothe maths and count the numbers
as you're going, which isrequires a little bit of
technical expertise and it kindof limits the positions that the
(04:15):
woman can get into and you knowthe care provider needs to work
around her in terms of beingable to physically do fetal
heart rate monitoring so youcan't stick your head into the
birth pool, use a pin hardunderneath the water, for
example.
You know you're going to haveto ask a woman to stand up so
(04:36):
that you can access that if youwant, if you wanted to use a pin
hard.
So you know a handheldwaterproof Doppler means that
you can work.
You know it's uncommon that youwould need to ask a woman to
really significantly adjust herposition in order to be able to
hear what's going on.
So hence the Dopplers havebecome so prolific in use and
(04:58):
it's now quite difficult to findcare providers who actually
have, you know, expertise interms of using a pin hard
stethoscope and using it well.
Speaker 1 (05:09):
Yeah, I think so.
I had not that long ago, awoman who didn't want Doppler,
who wanted a pin hard, and wehad exactly that conversation
about, well, that will be moredifficult for you to position
and if you want to use the pool,that will be more challenging.
Just what you'll have to standup or or get out, or we'll have
(05:31):
to adjust things.
Because listening with a pinhard which definitely I did
earlier on in my career is it'squite intimate.
You are quite close to thewoman's abdomen.
The pin hard is maybe sort ofsix or eight inches long, isn't
it?
Sorry, centimeters, 15centimeters or so.
So so you are, you are, you arequite close up, close and
(05:55):
personal, but there is somethingpretty amazing about hearing
directly the baby, I think.
Speaker 2 (06:04):
I feel it's a bit sad that we've lost that.
I think it is a bit sad thatwe've lost that.
We might pick up back on thisas we continue the conversation.
Many years ago I had a fabulousconversation with two midwives
from North America Oregon whohad an American midwifery
(06:24):
training system is verydifferent to your country and my
.
In Australia and the UK there'sthe option to do an
apprenticeship model where youtrain with a midwife who works
in the community, not in ahospital system.
At the end of multiple years,when you feel that you've
mastered the skill set, then youdo an exam that's managed
(06:48):
nationally.
They learn their skills fromother women serving women in
their communities and out ofhospital settings.
They've never used a CTGmachine and I don't even know if
they owned a Doppler.
I was fascinated.
How do you know whether thefetus is okay or not?
(07:11):
What are the things that you useto be able to say we're fine or
we need to transfer to hospitalor we need to just whatever
wiggle and jiggle and move orcut in the physiognomy tools
they've got in the out ofhospital setting to speed labour
up and because they were usingpinards and they talked about
the fact that the sound, thatthe heart rate makes changes
(07:36):
when you're getting up in asituation where there's fetal
compromise and I think now, manyyears later, having learned a
whole lot more about fetalphysiology and what's going on,
I think what they're hearing isfetal blood pressure dropping,
which is really interestingbecause it's not something we
can pick up with the CTG, andyet it's probably one of the few
(07:58):
reliable signs that you've gonefrom my oxygen levels low, but
I'm actually okay.
You don't need to do anything tomy oxygen levels low and I'm
not okay and you need to get meout of here.
Maybe we abandoned pinards tooearly, when there might have
been a way to capture thatinformation, but in a way that
(08:24):
still had all the advantages ofDoppler technology the
flexibility in terms of women'spositions and being able to be
waterproof and not having to bequite so physically intimate
with women to be able to do thejob and have a room that's
really quiet to be able to hear.
If we could have achieved thatwhilst listening to the actual
(08:47):
fetal heart and it's not toolate somebody could still invent
that technology for us today.
It might be a game of change.
Speaker 1 (08:55):
Yeah, yeah, it could be.
So if we're talking about awoman in labour and we're
discussing what sort ofmonitoring, we talked on our
previous episode about the lackof evidence for CTG and what we
(09:15):
were talking about was thecomparison between CTG
continuous cardiotochograph andthis method intermittent
oscultation.
So this is our sort of basiccomparative way of monitoring
the baby.
We weren't talking about notmonitoring the baby.
Speaker 2 (09:38):
Correct.
There's never been a studythat's compared to CTG use with
no form of fetal heart ratemonitoring and likewise, there's
never been a study that'scompared intermittent
oscultation with no form offetal heart rate monitoring.
All we've got is studies thatcompare one against the other.
Stethoscopes which resembledpinout stethoscopes when they
were first invented were, youknow that, the 1820s and by
(10:01):
1830s we see quite widespreaduse through France and the
English-speaking world ofintermittent oscultation in
labour.
The focus was more on is thisbaby alive or not, rather than
is it well or not, because theydidn't have safe caesarean
(10:23):
section, and so you know thedecision was about if this baby
is dead, it's pretty gruesome.
We can chop it up into littlepieces and pull it out through
the woman's vagina and save herlife in the process.
So you know it was a differentworld, different situation, and
(10:44):
you know, and our modernunderstanding of research didn't
exist and nobody ran around themost controlled trial in 1832
to see whether this was, youknow, useful technology or not.
Speaker 1 (10:55):
Yes.
Speaker 2 (10:57):
And then, over you know, 120 odd years, it kind of
evolved and people had a senseof the things that they were
listening for.
That helped them to feel likethings were okay or that things
weren't okay, and so it wasreally well established as being
the way that we do thingsaround here.
(11:17):
And then CTGs became the newkid on the block.
So that's why the two werecompared to one another.
That intermittent auscultationwas already really well
established by the time CTGscame and then very rapidly took
over in maternity care.
So you know, how does itcompare with CTGs in terms of
(11:39):
the outcomes?
This is basically the sameconversation that we had, but in
reverse.
Speaker 1 (11:44):
Yes.
Speaker 2 (11:45):
So you know CTGs compared to intermittent
auscultation.
Intermittent auscultation doesnot increase or decrease the
mortality rate, the deaths ofbabies during labor or in the
first week of life afterwards.
We see the same outcomesregardless of which approach to
fetal heart rate monitoring isused.
We see the same long-termoutcomes in terms of brain
(12:08):
injury as well, so cerebralpalsy.
The only area where we seeintermittent auscultation
doesn't appear to perform aswell is in terms of the neonatal
seizure rate.
So babies having fits not longafter their birth and, as we
talked about last time, you needto do quite a lot of CTG
(12:30):
monitoring, including RIM 1 babyfrom having a seizure done.
The effect size is quite smalland it's probably possibly maybe
confined only to women who arehaving their labors sped up with
an oxytocin infusion to maketheir contractions stronger.
Again, there's just these bigtruck-sized holes in the
(12:50):
research that just should havebeen done and never was done
before we started going oh, it'sokay, we'll use it this way.
That seems like a good idea.
Where intermittent auscultationreally shines is that it's
better for women, and so youdon't see the increase in
cesarean section rate and theincrease in instrumental birth,
(13:11):
but you do see a higherspontaneous vaginal birth rate,
where an intermittentauscultation is being used
rather than a CTG monitoring.
And that's true whether we'retalking about women who are
considered to be low risk orwomen who are considered to be
high risk.
And, interestingly, in terms ofthe beneficial effects of CTGs
(13:32):
for seizures, that seems toactually be strongest in women
who are considered to be lowrisk and it actually doesn't
read statistical significance inwomen who are considered to be
high risk, which is kind of theflip side of the one that we
actually do things in practice.
The group where we maybe havesome evidence that they'll do
(13:55):
better with CTG use we don'toffer CTGs.
We say you can just haveintermittent 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 weread them the riot act if they
dare think that they might haveintermittent auscultation
(14:16):
instead of CTG use.
Yes, yeah.
Speaker 1 (14:21):
I'm finding myself in increasingly weird
conversations where I'm havingto say to women I have to
recommend continuous CTG becausethat's the national guidance,
blah blah blah.
But actually the evidence isn'tthere and so if they want to do
or have intermittentauscultation, that's fine.
(14:43):
And then making them care plansto mean that it's okay for them
to make the choice that isobviously evidence says is okay,
but just because the guidancedoesn't say it's okay.
So it's kind of verycontradictory.
So if you are pregnantlistening to this, what would
(15:06):
you expect for intermittentauscultation in labour?
What would that actually mean?
Speaker 2 (15:11):
With intermittent auscultation.
Most guidelines recommend thatsomewhere between every 15
minutes to every 30 minutes inthe earlier stages of labour,
that someone listens to thefetal heart rate for at least 60
seconds one minute, and usuallymost guidelines say to listen
in between contractions, and I'mhoping we get to circle back
(15:33):
later and talk about why.
I think that's probably not agreat idea and you're basically
looking for the same informationthat you would get from the CTG
.
You know what's the baselineheart rate.
Are there accelerations?
Are there decelerations?
Is there variability?
Does the heart rate bounce upand down?
Just you know, not too much andnot you know more than not
(15:56):
enough so that you can then makea determination that this fetus
is fine, we can leave it aloneor I'm so happy about this one.
We need to pay more attentionand possibly take some action to
, you know, increase oxygensupply and if that can't be
achieved, then get the baby outwhere it can be, in room air or
(16:16):
additional oxygen, and be lookedafter.
Now, as labour progresses, thenusually as people move into the
pushing stage, the second stageof labour, the guidelines say to
increase how frequently it'sdone.
So it might be every fiveminutes or it might be after
every contraction or after everysecond contraction, that people
are listening and obviouslycommon sense would dictate if
(16:39):
there's a change in what's goingon.
You know if there's suddenlysome bleeding or the pain
changes or the woman's membranesrupture and there's mecanium
staining, you know if it's twominutes 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 youreassess the situation at that
(17:01):
stage again to get reassurancethat all is well before moving
on.
Speaker 1 (17:06):
Yeah, so we want to hear the baseline and
variability in accelerations anddecelerations and you mentioned
this idea of not listeningthrough a contraction and I'm
interested that you say thatbecause to me that sort of makes
sense.
But obviously I've got tounpick the fact that that
(17:28):
knowledge is coming from what Iknow happens on a CTG, which
we've already agreed isn'tnecessarily a good thing, but I
know that some decelerations arenormal during contractions and
it's more about the pace atwhich they recover and the
(17:50):
baseline afterwards and thevariability afterwards.
You know, is this baby gettingprogressively hypoxic?
Now that's my assumption fromsomeone that's working with CTG.
Speaker 2 (18:03):
I'm about to take your world upside down and tell
you that it's commonly taught.
If you go and read thephysiology research, there's no
proof whatsoever that you candistinguish between this kind of
(18:24):
deceleration, that kind ofdeceleration and the other kind
of deceleration, and these onesare okay and these ones are not.
All decelerations are due tofetal hypoxia and you and I
would thought, as we were juniorobstetricians, that early
decelerations when the heartrates flows at the same time as
the contraction and recovers bythe end of it they're due to
(18:47):
head compression and they'reharmless.
And in some situations I'veactually been taught that
they're a reassuring sign thatthe baby's neurological system
is intact.
Then there's things calledvariable decelerations that
start and finish at slightlydifferent times and they look
different on a CTG from onecontraction to the next and
(19:07):
they're due to the cord beingcompressed and dropping the
baby's blood pressure and thatproduces a particular response.
And then there's things calledlate decelerations and they're
the ones that are due to lowoxygen and they happen.
They start about halfwaythrough the contraction and they
take much longer to recover.
Yeah, so it's all nonsense.
Speaker 1 (19:27):
Okay, great.
So I'm in the world ofphysiological CTG.
I'm going to say invertedcommas there, so we now call
them baroreceptor decels andchemoreceptor decels, but it's
the same sort of principle, sowe educate me.
Speaker 2 (19:47):
If you look at the physiology, for starters, people
have done research wherethey've squeezed fetal heads,
either in animal models or inactual human fetuses, where
they've done things like puttingring pisseries inside women's
vaginas and forcibly pushing upagainst the fetal head with them
, and it doesn't reliablyproduce a deceleration at all.
(20:09):
So the whole head compressionthing just doesn't hold water
and I have a blog postspecifically about that that
goes through all of thatresearch.
Speaker 1 (20:18):
Amazing.
I need to go and read thatclearly.
Speaker 2 (20:22):
There's also been some research questioning
whether the baroreceptor reflexis the thing that's responsible
for the changes that we see inCTG patterns, and the answer is
it isn't that.
The only time that you start tosee a deceleration is when
hypoxia starts.
So if you've got a baby that'sdropped its blood pressure but
the fetus is adequatelyoxygenated, you don't get a
(20:45):
deceleration, you don't get adrop in the heart rate.
It's all low oxygen levels thatare doing the changes and I
think what's happened.
We are the species who can lieon our backs and look at the sky
and see clouds and decide thatthat one's a giraffe and that
one's a teacup.
We have brains that pick uppatterns and make stories out of
(21:07):
them, and I think that this isa situation where we've picked
up some patterns and we've madestories out of them and we've
done such a good job ofstorytelling it that we've all
believed them.
I remember, as a registrar,being in a CTG education session
when one of my fellowregistrars who liked a good joke
(21:29):
and it was back in the days ofoverhead projectors, before
PowerPoints existed, becausenone of us had personal
computers or mobile phones,because we're old and what he'd
done is he'd taken a blank pieceof CTG paper and had
photocopied it onto thisoverhead projector sheet and
then he'd gone and grabbed agraph of a stock exchange report
(21:51):
of the ups and downs of thestock exchange values of a share
of a company and superimposedone over the top of the other
and then drew on some more likecontractions across the bottom
of this and presented it to usas a CTG.
Everyone in that room, forabout 10 minutes, had a red hot
go at classifying that CTG andtrying to make it fit the
(22:15):
stories that we've been told,when in fact it was impossible
to do so because it wasn't afatal part that we were looking
at.
That's hilarious and I thinkand now I look in that now,
knowing what I now know, manyyears later, looking back on
that experience like it shouldhave taught me something at that
(22:35):
point in time that we are sodriven to look for patterns and
meanings in heart rates, thatyou know we've.
We have fallen in the trap ofseeing things and making nice
stories about them withoutactually really having good
research evidence to back thatup at all.
And it's really only been inthe last 10, 15 years that we've
(22:58):
started to get the researchevidence and that shows that all
decelerations are due to athing called the chemo receptor.
Reflex Oxygen levels fall.
There are receptors in some ofthe blood vessels in our body
that recognize that and theythen do a couple of things.
So they turn on the sympatheticnervous system and that
(23:21):
redistributes blood.
So it contracts blood vesselsin parts of the body that aren't
, frankly, that important andcan do without it right now.
So you know you left little toeand your earlobe, and it pushes
blood back into the centralpart of the body so that the
brain and the heart gets more ofit.
So they're protected, becausethat's a good thing to do.
(23:42):
You can't see that on a CTG, butit's going on.
The other thing that happens isthat, in order to protect the
heart, you want it to do lesswork, and so you turn on the
parasympathetic nervous systemvia the vagus nerve and you drop
the heart rate dramatically,because if it goes from beating
120 times a minute to 60 times aminute, it only needs half as
(24:05):
much oxygen, so it can get byliterally with half as much
oxygen and function exactly aswell.
So when people talk about fetaldistress, what we're actually
seeing is fetal coping.
It's not as sexy though,because, you know, pressing the
big button on the wall andrunning screaming up a corridor
to the operating theatre becauseyour fetus is coping just
(24:28):
doesn't make the same ring to it.
But you know we've gotten caughtup in this story that what
we're seeing is sign ofimpending doom for this child,
rather than a valid copingmechanism that's actually
designed to prevent damage fromlow oxygen levels.
The problem is that we don'thave a heart rate signal that
(24:50):
will tell us when we've gonefrom my oxygen levels low.
I've made all these adjustmentson brilliant now I'm great, I
can keep going and the fetusthat's made all of the
adjustments and they are notenough and there's now starting
to be damage to the brain or tothe heart.
The heart rate patterns lookthe same, and that's precisely
(25:14):
that we need something that cantell those two apart, for some
form of fetal monitoring to workin labour, because otherwise we
see what we see in clinicalpractice, and that is that we
end up doing lots of caesareansections and instrumental bursts
and telling people to pushharder and cutting of
physiotomies because we seepatterns on the heart rate.
The baby's completely fine,comes out yelling its lungs off
(25:37):
a few minutes later and sayswhat, what are you doing to that
poor?
I was okay, and yet we alsosometimes miss babies that would
have benefited from earlierbirth because we put them in
that they're probably okay, havea greedy when they're not, and
so I'm not really solving theproblem, which is why I think
(25:58):
the pinard and how the heartrate changes sound.
Speaker 1 (26:02):
Yeah.
Speaker 2 (26:02):
Because if you're not getting enough oxygen levels to
actually continue to have yourheart squeeze blood out hard,
even though it's dropped itsheart rate to protect itself,
that's a sign you shifted acrossthe line and you can hear that
if you know what you'relistening for with the pinard
step.
Speaker 1 (26:20):
Yes.
Speaker 2 (26:21):
The one bit of research that has started to
look hopeful is a thing calledthe total deceleration area or
total deceleration time, whichbasically adds up the amount of
time the baby's heart rate staysbelow the baseline, the average
heart rate.
So you can either have asmaller number of really long,
(26:47):
really deep decelerations thatthen add up to a much larger
number of really small shortdecelerations, and that would
give us the same information.
You know that those fetuses areboth in the same condition.
So therefore, given that almostall decelerations happen during
contractions, it becomes reallyimportant that we know what's
(27:11):
going on during contractions,because if you're having
consistent decelerations thatrecover by the time the
contractions finished, if theonly time that you're listening
with your intermittentoscultation is, you know, 10 or
15 seconds after the woman'sgone that was a big one, okay,
you can listen.
Now you won't know that thosedecelerations are happening, and
(27:36):
so you'll lose really vitalinformation, which I think
potentially becomes a selffulfilling prophecy there.
Because people go, well,intermittent oscultation doesn't
like it can't pick up the onesthat are.
That's because you're notlooking for the right
information.
You're ignoring the one time inthe contraction cycle when that
heart rate might actually beproviding you with the most
(27:59):
information I could.
It's jolly uncomfortable tolisten.
Have someone listen to thefield heart rate with a Doppler
during contractions and it doesmean that you know if you want
to sway and stomp and what haveyou.
You know, either you need anagile midwife who can follow you
around and sway and stomp anddo it at the same time, or you
(28:19):
have to be still whilesomebody's listening.
So it is a bit of a pest, but Ido think that paying more
attention during contractions issomething that we should
incorporate in our guidelinesand our thinking when we're
using intermittent oscultation.
Speaker 1 (28:38):
For that reason, so so I understand what you're
saying and you probably notblowing my mind quite as much as
you think, because, because wedo because we do.
we talk about gradually evolvinghypoxia.
So the baby's decelerating, butit's coming back to its normal
baseline and it's all good.
(29:00):
And what we're looking for isthat moment that you've
described, where actually it'snow shifting to it's not, it was
coping, it's coping, it'scoping and then actually this is
the point where it's going tostart to decompensate and not
cope as well.
And so I'm now going to say so.
(29:22):
We've listened in thecontractions, great, and we've
heard a deceleration, oh,decelerations.
And now what are we going to do?
Because the thing Immediatelythat was happened in my birth
centre would be we've heard adeceleration.
(29:42):
Let's put the CCG on.
So now we're.
Now we're back in that stickything, but the CCG doesn't make
a difference.
So I'm not stuck.
Speaker 2 (29:56):
There's not been a research trial where the only
entry criteria was women who hadan abnormal heart rate pattern
on oscultation.
And then we keep going withintimate noscultation or we keep
going with CTG, because thatyou know, even the days before
CTGs were invented, of course,people went and kept going with
intimate noscultation was theonly tool I had available.
(30:16):
So you know, there is a pointin history when that was done
and people found ways tocontinue to gather useful
information.
We do have the some of theso-called high risk trials that
are included in the Cochranereview, where women who had some
kind of risk factor wererandomized either to
(30:37):
intermittent oscultation or CTGmonitoring.
One of the criteria and almostall of those trials had multiple
criteria that you got youacross the line in terms of
being called high risk, but oneof the criteria was abnormal
heart rates on oscultation andyet they still randomized we
people to intermittentoscultation and still got
outcomes that were equivalent toCTG use.
(31:00):
Now, you know, it may be, itmight be that those women
actually did that.
Those women's fetuses did a lotworse, but the women who had
diabetes did so much better withintimate noscultation and
therefore they kind of cancelledeach other out.
You know, we just we haven'tgot that kind of fine grained
detailed in the research, butthere's certainly there's no
(31:23):
compelling research out therethat says that you have to put a
CTG on when you hear the heartrates Right.
And I think in real life, in areal clinical situation, I think
this is hugely contextdependent, depends on what the
clinical situation is, howrapidly it's unfolding, how many
sets of hands you've got ondeck where the equipment is and
(31:49):
you know what.
What really needs to happen isadequate assessment of the woman
and her fetus, of anappropriate decision making, and
you use the best set of toolsthat you have at your disposal
at the time to do that.
So if you're in a place wherethere's a CTG machine fixed to
the wall next to the bed and theequipment is in the top drawer
(32:12):
and it's always available, butyou're a bit short on staff and
when you press the buzzer no onecomes then putting the CTG on
to free up your hands so thatyou can then go on and do all
the other you know, do thevaginal examination and do the
maternal observations and thoseother things that need doing,
then that makes sense.
(32:33):
If you're in a situation wherethe CTG machine is in another
room and the straps are lockedup in the drug cupboard and the
midwife who's got the keys is onthe T break and there's three
of you that are in the bathroom,then it might actually make
sense just to keep going withreally frequent intermittent
oscillation, so basicallycontinuous oscillation, with
(32:54):
somebody holding the Doppler onand it's there just to continue
listening while all of thoseother things happen around you.
And it's more because of the waywe structure our maternity care
systems.
It's more common that we'll beshort on staff for heavy on
equipment, and so it makeslogical sense to go down that
let's put the CTG machine on.
(33:16):
But you know, I'm kind of hopepeople would think through that
rationally and not leave a womanalone and go and find the CTG
machine and then with wife, whenreally what needs to happen is
a rapid clinical assessment ofthe situation, because they
become rules based and the rulesays you have to put a CTG on
(33:37):
instead of thinking about what'sreally happening here and
what's the best way for me tosolve this problem.
Speaker 1 (33:44):
And I think that's a really good point, because I was
thinking about home birth orbirth center where a CTG machine
is not available and actuallyyou know if birth is imminent or
you know you can do thingssafely and continue monitoring
(34:05):
and make that full clinicalassessment.
It may be that you don't needto move.
You don't need to necessarilychange what you're doing.
You've just got an awarenessthat this baby may need some
assistance when it's born or mayneed something slightly
different doing to expeditebirth.
(34:26):
You know, changing the woman'sposition or whatever it is, or
but you don't.
You can make that clinicalassessment first and decide.
And that's what brings me to.
We sometimes have startedreferring to intermittent
auscultation as intelligentauscultation, and I think you
(34:46):
know yes, that's not quitecorrect, because you know it's
all about what you're describinglistening in but it is then
about engaging your brain andthinking what does this mean in
the context in which I'mlistening?
Speaker 2 (35:03):
The other thing that's worth reminding people of
is, if we go back to theconversation that we had last
time about the, the idea thatCTG monitoring is continuous
monitoring and I'm using airquotes while I'm saying that,
because in reality it's actuallyintermittent monitoring, but
continuous recording Peopledon't look at the machine.
(35:26):
They might vaguely be aware ofthe heart rate ticking away in
the background, but in terms ofactually stopping and engaging
with the CTG trace and activelyinterpreting it and making
meaning of it, that happensintermittently.
When you're doing intermittentascultation, that analysis and
interpretation is happening atthe same time that you are
(35:48):
actively listening to it.
And so if you're activelylistening over the space of one,
two or three minutes and going,I do not like what I'm hearing,
and then you need to stopbecause you've got to do the
blood pressure and you've got topress the buzzer and you've got
to do seven other things.
It's actually not dissimilar towhat's happening with CTG
monitoring and yet people tellthemselves this kind of story
(36:11):
that there's somehow morecontemporaneous oversight over
the heart rate when the CTG ison it.
It's not actually true.
What's happening is it'sretrospective analysis of it
after the event has alreadypassed.
When you look back at the last15 or 20 minutes while they've
been running around doing allthe things that needed doing to
sort out the clinical situation.
So they're not as diametricallyopposed as we might think that
(36:37):
they are.
In clinical practice theintelligent intermittent
ascultation starts interesting.
I haven't actually seen theinside of any of that.
It's UK based so it's notavailable to me here.
And the devil's in the detailswith these things.
So I would quite like to get ahandle on it.
(36:57):
But what used to happen when Iwas training and even in the
early years of my practice, wasthat people had listened
strictly.
Every 15 or 30 minutes or everyfive minutes or after,
depending on what the guidelinesin the hospital said for 60
seconds They'd calculate thebaseline heart rate and they'd
reduce it down to a singlenumber.
(37:18):
And then they'd go and find thepartogram where we'd record all
of the labour observations andthey'd put a little X so that it
sat at 125 at 10.30 am and thenat 11.00 am they'd put another
little X at 130 and that was it.
It's not enough.
(37:38):
It's not good enough to justrecord one single number every
half an hour.
And again, if you then compareit to CTG monitoring, well, of
course, that looks likecompletely deficient monitoring.
I think it sets up a situationwhere people are asking
themselves the wrong question.
They're asking what's the heartrate?
(37:59):
Not have I got enoughinformation right now about
what's going on for thesefeeders to tell me that it's
okay for me to leave it exactlythe way that it is and not do
anything different, and that'sit's a very different mindset
and that might require listeningfor a lot longer.
I'll listen through the nextcontraction, I'll give the woman
a bit of a break for the oneafter that and then I'll listen
(38:21):
again to the one after thatbecause I'm still not quite sure
what I'm hearing, to increasethe intensity of that until I
get to a point where I'm readyto make a decision that in fact,
this is okay and I can back offand wait another 15 minutes or
no, it's not okay and I've gotto call for help and we've got
to do something different aboutthe situation here.
It concerns me when peoplewrite these guidelines that say
(38:45):
they shall listen every Xseconds, but every so many
minutes at this point in life,and it's easy to follow the
rules and lose sight of thereason why they exist in the
first place.
Speaker 1 (38:58):
Yes, I think that's very true, and I've had some
conversations with our FECLmonitoring midwife about how you
do this and listening for aminute or do you listen in
blocks of 15 seconds.
She was talking about thisOxford method that's being
described, where you listen for15 second, blocks for 90 seconds
(39:21):
, and then you've got to docomplex maths in your head.
What I see in the notes muchmore is the single number yeah
on the pateogram or written inthe notes, the single number,
which is interesting because inthe anti-natal clinic these days
we tend to write down a rangeor if, for example, it's
(39:47):
somewhere in going aroundbetween 140 and 150, we will
write down it's in the 140s,that's that baby's normal
baseline, but we won't writedown just 140.
142.
Yeah, exactly, or 142.
Speaker 2 (40:04):
Which, as you know it's really tricky to actually
arrive at that now, because ifyou're using one of the modern
Dopplers that has the littlescreen on it and the computer
brain in it that gives you anumber, it doesn't sit at 140 or
142 for 60 seconds.
It's like that for threeseconds and then another couple
of heartbeats later it's 148,and then it's 152, and then it's
(40:27):
136.
So you just have a bit of wildguess to try and arrive at that
baseline number.
Speaker 1 (40:36):
Which is where your brain comes in again, isn't it?
Because?
Are we unconsciously selectingthe numbers that we like?
It's a bit like I'm going offtrack now, but blood pressure
machines.
So when we did blood pressurewith a Sphig, it was much more
likely that you're going to pickthe blood pressure numbers that
(40:58):
are an even number, aren't they?
Speaker 2 (41:00):
So it's always going to be, because that's where the
lines are.
Speaker 1 (41:05):
Whereas now, if you take it on an electronic machine
, it might be 103 on 57 and youwould never, ever have made that
someone's blood pressure whenyou're doing it manually.
So I feel like this could be abit the same.
Do we pick numbers that wethink are okay out of the
numbers that are flashing beforeus, and how are we thinking
(41:28):
about that?
And then also, the numbers, aswe've said, are computer
generated anyway.
So lots to think about.
But definitely in the notes Isee people have written a single
number.
And then I also see if we'redoing a review of care, because
maybe there's been a riskincident which may or may not be
to do with the baby.
(41:50):
I'll see mid-wise criticisedbecause, well, they didn't do
every 15 minutes.
Well, actually all it is isthey didn't write it down every
15 minutes.
Maybe this one was 10 minutesapart, this one was 17 minutes
apart, this one was 8 minutesapart, this one was 20 minutes
apart.
Well, again, it's back to thatsort of rules thing.
(42:12):
Yes, we want good practice, butgetting back to the, is this
baby okay at this point in timewith what's happening to it?
That's the key.
Speaker 2 (42:24):
Yeah, I would like to see something that looks a bit
like this when a woman firstpresents for professional care
in labour, that there'ssomething kind of like what
happens with an admission CTG,but you're using intermittent
oscultation instead.
So you ask the one is your babymoving at the moment?
(42:45):
If the answer is no, then youhave a listen in between
contractions Long enough for youto get an idea of what the
baseline is, because for abaseline it needs to be in
between contractions and whenthere's no active fetal movement
there's no acceleration inprogress.
And you work out your baselineand you look at the, as I just
said, you look at the numbers onthe screen and if it's going
(43:05):
from 132 to 142 and anywhere inbetween, well, that's 10 bits of
variability.
So you've got normalvariability going on.
So you can record that in thesame way that you would if you
were interpreting CTG.
And then you say to the womanlook, tell me the next time your
baby moves.
And so she says, oh, it'shaving a kick.
And you have a listen and it's168.
(43:26):
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, andthere is no deceleration, and so
that might require you tolisten, for you know, a five
minute period across a 15 minuteperiod, starting and stopping,
(43:48):
to get the same kind ofinformation that you would get
with a CTG.
It's very different to just,you know, 60 seconds in between
contractions and we're done andwe're not going to listen now
for another half an hour.
And because if you've then gotthat robust and you can like you
can stand up and say you're onin a court of law.
This is exactly what I did toensure that this fetus was in
(44:09):
good health at the time that Iinitiated professional care for
this woman.
Then you know, no one's reallygoing to have too much room to
criticize that.
And then if that's well and theclinical situation is really
stable and it's early labor,nothing much is going to change.
So if you don't listen for 45minutes, probably no great big
(44:34):
deal.
But you know, if the womanruptures the membranes and
starts making a different noise,then you don't want to sit
there looking at your clockgoing.
I've got 15 minutes.
You know that's the time when,again, you step up and you
listen more intently and youmight do, you know, four periods
of intermittent oscultationback to back over the course of
(44:56):
five contractions, listening atdifferent times, until you can
reassure yourself once againthat this is okay and I'm happy
to you know now we'll wait 15minutes before the next time we
have a listen.
Yeah, and it's difficult totranslate into guidelines
because guideline writers likesimple rules and you know you
(45:17):
can do what you said then in thereviews afterwards.
Well, it was 12 minutes, not 15.
Yeah, it was, you know, 16minutes and 52 seconds, not 15.
But you know yeah doesn'tnecessarily constitute poor care
.
Speaker 1 (45:32):
No, exactly, but I really like that approach that
you just outlined.
I think that would be a reallygood way forward and I think I'm
hoping that you know women thatlistening to this that gives
them confidence that it's okayto choose intermittent
(45:54):
oscultation.
And I think women sometimesprobably from us as
professionals get this idea thatit's not monitoring, as we
discussed when we spoke lasttime.
And actually it is monitoring,it is assessing how your baby is
doing.
Speaker 2 (46:15):
It's the same fetal heart.
Yeah, it's the same set offetal heart rate patterns.
If you're comparing a handheldDoppler with a Doppler based CTG
, it's literally the sametechnology that's being used to
provide you with the information.
So, ego, it is actually not allthat surprising when you sit
down and think about it that wesee very little difference in
(46:36):
outcomes between the two of themBecause and as I said, it might
be continuous recording it'sstill intermittent monitoring.
When you're using a CTG, you'restill only interrogating and
interpreting and making adecision about the quality and
the meaning of that traceintermittently, the same as
you're doing when you'relistening intermittently with a
(46:57):
Doppler through contraction.
So it's actually not thatsurprising that the two of them
rank really similarly in theresearch.
So I think the take homemessages I would have for women
who are accessing maternity careis that it's actually okay to
question the idea that you haveto have a CTG because, in a
(47:19):
certain respect, to hear you'rehaving a feedback, you're having
twins, you're a bit overdue,whatever and obviously that
needs to be an individualiseddiscussion that you should have
with your care provider, becausesome situations are really
pretty scary and would make evenmy eyelids twitch at the
thought of not accessing CTGmonitoring, particularly when
(47:44):
people are using oxytocininfusions.
That would kind of feel veryuncomfortable about not having
CTG monitoring on, and that'smore for the T-bit of the CTG
making able to tell what'shappening with contraction
patterns and that if it is doneintelligently well by somebody
(48:05):
who's asking the right questions, then you should expect exactly
the same outcomes that we seewith CTG use, apart from the
fact that in the research we seehigh spontaneous vaginal birth
rates and I think that's morecomplicated than it's just
(48:26):
because we're not seeing a wholepile of scary things on the CTG
.
We just don't have access toinformation that would trigger a
response.
That's part of it, but I thinkit's more complicated than that.
There's something materiallydifferent about the intimacy of
the care that's involved inlaying hands on on a regular
(48:49):
basis.
A midwife has to be in the room.
They have to have laid hands onthat woman's abdomen to have a
rough idea of where that fetusis lying, to know where to
listen, and it will changeduring the course of the labor.
So they'll need to get hands onagain with the woman.
You are up close with people.
(49:09):
You can smell when they startgetting ketotic because they're
a bit dehydrated and haven't hadanything you know, a jelly bean
in the last seven hours.
You can feel that they're hotbefore you think to do a set of
observations and find out thatthey've got a fever.
If you've waked the CTG on andyou've wandered out to the
central monitoring station tohave your cup of tea on your
(49:33):
meal break and the woman's alonein the room, you miss all the
rest of that information at thesame time.
I think you know that thereassuring human presence of
somebody who's not stressedhelps to regulate your heart
rate and that probably helpsregulate the fetal heart rate.
And there's some safetyinformation that's also being
(49:56):
picked up by the activeinvolvement of the midwife or
obstetric nurse, depending onwhich country you're in who's
doing the endometriosisquotation.
That's missed, particularlywhen you've got central fetal
monitoring systems and peopleare absent from the room.
Speaker 1 (50:13):
I think that's sort of perfect message really, both
for women and those of usworking in maternity, and it
would be really great if havinghad this conversation spurred
people on to use intermittentoscultation in some of the ways
we've discussed and get a bitmore thoughtful about whether
(50:38):
actually they do need a CTG ornot and that kind of overall
clinical picture and being youknow, with women.
Speaker 2 (50:52):
Seems like a good point to end a podcast on.
Speaker 1 (50:54):
It does, does it?
Thank you so much.
Thank you very, very much forjoining me again.
It's been an absolute pleasureand, just like last time, I've
really enjoyed ourthought-provoking conversation.
So, yeah, thank you very much.
Speaker 2 (51:13):
Thanks for having me back to finish off the second
half of the conversation.
Speaker 1 (51:18):
I very much hope you found this episode of the OBS
pod interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review on whatever platform youfind your podcast, as well as
recommending the OBS pod toanyone you think might find it
(51:38):
interesting.
There's also tons of episodesto explore in my back catalogue,
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(52:03):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(52:27):
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email metheobspod at gmailcom.
(52:47):
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
(53:09):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it free,via my link to buy me a coffee.
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
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