Routine antenatal fetal auscultation

During my first year as a student midwife, I have witnessed and carried out many

antenatal appointments. For every woman, at each appointment, (excluding the

booking appointment) I have auscultated the fetal heart. Women will always ask to

hear their baby’s heartbeat. For a lot of women, it was the main reason that they

attended the appointment. Whilst on community placement, my mentor and I

booked a lady who had previously had stillbirth at 25 weeks’ gestation. During her

booking appointment, we asked about her previous pregnancies. She explained that

when she stopped feeling movements during her last pregnancy, she went into

hospital for a check and when she arrived the fetal heart could not be heard. She

then went on to explain that she was told that even though she thought she was 25

weeks her baby was only measuring 22 weeks. She explained how upset she was

that she had been unaware that her baby had died a few weeks before she found

out about it. She asked us if it would be possible to have more regular appointments

to listen in to the fetal heartbeat during this pregnancy. We agreed that we could

make this possible for her reassurance and would therefore make quick, specific

appointments just to auscultate. For this lady, hearing her baby’s heartbeat was

extremely important and reassuring due to her previous stillbirth. However, if we

had followed the national guidelines she, and other women, would rarely hear their

baby’s heartbeat which I feel is detrimental.

The National guidelines laid out by the National Institute for Health Care and

Excellence (NICE) states that ‘auscultation of the fetal heart may confirm that the

fetus is alive but is unlikely to have any predictive value and routine listening is

therefore not recommended.’ (NICE, 2015) However, NICE does then go on to say

that if requested by the mother for reassurance, then the midwife can auscultate.

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The fetal heart can normally be heard towards the beginning of the second trimester

(Heazell, et al., 2011). If the midwife auscultates the fetal heart she is listening for a

several factors: Firstly, the fetal heart rate base line should be between 110-

160bpm (Foureur, Maude, Skinner, 2016). Secondly, the midwife should be able to

determine an acceleration of the heart rate, although if only listening for a short

period of time, this may not be heard (Foureur, Maude, Skinner, 2016). If the

midwife was to hear any decelerations antenatally, this may be a sign of fetal

distress, so the midwife would refer the woman to hospital for monitoring (Foureur,

Maude, Skinner, 2016).

There are several ways that the fetal heart can be heard. The first instrument used

was a stethoscope in 1821; further specialised into the Pinard stethoscope in 1876,

which is still used today (Harrison, 2008). Since 1968 an electronic monitor has also

been used for auscultation as well as portable Dopplers (Harrison, 2008). Whilst

there are many methods of auscultating the fetal heart, there is little evidence

regarding which is the most effective method. When considering the benefits of

some compared to others it is not always straightforward. For example, there is

much anecdotal evidence that the Pinard stethoscope offers the least medicalised

approach to auscultating the fetal heart and for this reason is commonly used, it also

cannot pick up the maternal heart rate so the midwife can be sure that what she

hears is fetal (North Surrey Midwives, 2015). However, by using a Pinard, a woman

cannot hear her baby’s heart rate; this may disappoint and sometimes upset her.

Also a Pinard isn’t very successful before 28 weeks’ gestation therefore if the woman

wants to have the heartbeat checked a Doppler is normally used (North Surrey

Midwives, 2015). When using a Pinard, the midwife must apply it to the abdomen

after palpation to locate the fetal back (Wickham, 2002), which means that the

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midwife is in very close proximity to the woman. Some women may find this

uncomfortable. However, there are many benefits of the Pinard some mentioned

above and another is if a fetal heard cannot be heard then it gives the midwife a

warning and time to prepare how she will tell the parents, (Wickham, 2002).

By comparison, when considering the portable electronic Doppler, close proximity to

the mother is not an issue and a woman is able to hear the fetal heartbeat.

However, a study in the RCM article, Auscultation: The Art of Listening, showed that

there was a higher risk of cesarean section in woman examined by Doppler

compared to those examined with the Pinard stethoscope group (Harrison, 2008).

However, this could be because the Doppler is more reliable at picking up

abnormalities therefore if an abnormality is heard the chance of caesarean may

increase (Harrison, 2008). This evidence isn’t conclusive as it was only one study

and therefore further evaluation is required.

Although Dopplers are available, midwives recommend that women do not buy their

own hand held Doppler. There have been anecdotal cases where women have

listened to the baby’s heart rate at home and misinterpreted their own heart rate as

the baby’s. This has led to women panicking for no reason. Also it has been noted

anecdotally by midwives that many women only attend antenatal appointments to

hear the baby’s heart rate. If women thought they could do this at home, they may

not attend as many appointments as they should, potentially leading to a

compromised mother and or fetus; the midwife would be unaware of any

complications occurring. For this reason, antenatal auscultation can be seen as very

important as it is an additional incentive for women to attend their appointments.

Given my experience and researching the topic, there is an assumption by midwives

and doctors that auscultation of the fetal heart is reassuring for women and their

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partners, as it comforts them to know that their baby is well; and even though NICE

guidelines do not recommend auscultation, it is worthwhile. However, although

evidence shows many women do feel this way, other research on women’s attitudes

towards auscultation during labour discovered that many women found the

abdominal pressure uncomfortable, meaning some women may actually prefer not

to hear the heartbeat as it causes them discomfort or even pain (PubMed Health,

2008). Health professionals cannot always assume that the woman wants the heart

to be auscultated, like any other procedure, consent must be given.

Nevertheless, I believe that midwives should offer an auscultation at every

appointment the woman attends. While the NICE guidelines state that auscultation

has no value other than to check the fetus is alive I disagree. Not only does it

reassure the mother that their baby is well and encourage them to attend their

appointments but, there have been a few occasions where I or my mentor have

heard a very obvious deceleration or a tachycardic episode. As a result, our referral

of these women to hospital for further monitoring, has actually lead to action being

taken for the health of the fetus. Therefore, I believe auscultation of the fetal heart

plays a vital role in antenatal care.

References:

Foureur, M., Maude, R., Skinner, J. 2016. Putting intelligent structured intermittent
auscultation into practice. Women and Birth. [e-journal]. 29(3) pp. 285-292.
https://doi.org/10.1016/j.wombi.2015.12.001

Harrison, J. 2008. Auscultation: the art of listening. [online]. Available at:

https://www.rcm.org.uk/news-views-and-analysis/analysis/auscultation-the-art-of-
listening [Accessed 5 July 2017].

Heazell, A., Hill, S., Melvin, C., Rowland, J. 2011. Auscultation of the fetal heart in
early pregnancy. [online] Available at:
https://www.ncbi.nlm.nih.gov/pubmed/20617441 [Accessed 7 July 2017].

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PubMed Health. 2008. Fetal Growth and Wellbeing. [online] Available at:
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0009600/ [Accessed 7 July 2017].

NICE. 2015. Antenatal Care for Uncomplicated Pregnancies. [online] Available at:
https://www.nice.org.uk/guidance/cg62/chapter/1-guidance [Accessed 5 July 2017].

North Surrey Midwives. 2015. Sharing the Skills: The Pinard [online] Available at:
http://northsurreymidwives.co.uk/sharing-the-skills-the-pinard/ [Accessed 7 August
2017].

Wickham, S. 2002. Pinard Wisdom – Tips and Tricks from Midwives. [online] Available at:
http://sarawickham.com/wp-content/uploads/2013/05/tpm6-pinard-wisdom1.pdf
[Accessed 7 August 2017].