Sarah had planned a home birth for her second baby; the birth of her first baby had taken place at the local primary unit and all went well. Sarah had commented antenatally that she would rather have this baby at home as she felt the constant interruptions at the primary unit made her labour so much longer. Sarah was well throughout her pregnancy and went into labour in the early hours one Sunday morning. She called me when her contractions were coming about every five minutes. Her partner, Bryce, had filled the pool and Sarah enjoyed the relaxing effect of the water, which enabled her to go into herself to a place where nobody could touch her. She closed her eyes and quietly went about her labour. The room was darkened and a small lamp in the back of the room provided some light. When I arrived I was mindful of the relaxed and quiet atmosphere. I put my equipment down in the next room and silently went about organising baby clothes and putting towels into the oven to warm up. I did not want to disturb the serenity of Sarah’s labour — she was coping so well.
However, that is where my dilemma started. I have a professional obligation to assess Sarah’s and her baby’s well-being. How do I do that when she clearly does not want to be disturbed?
I observed how she was coping, and the length and frequency of the contractions. I had looked into the pool water to see if I could ascertain if her membranes had ruptured. But, according to the NICE guidelines National Institute for Health and Clinical Excellence (NICE) 2007) and consensus statement of the New Zealand College of Midwives (NZCOM) (NZCOM 2005), I needed to listen intermittently to Sarah’s baby’s heartbeat, as well as taking other observations (Martis et al 2010). When is the right time to do that? While I endeavour to provide care in the context of the woman and her situation and not adhere to routines that are prescribed without contextual input, I am also guided by best practice. According to the NICE guidelines (NICE 2007) I need to listen intermittently to the baby for one minute every 15 minutes in a normal first stage of labour. The American College of Obstetricians and Gynecologists (ACOG 2009) has refined its recommendation to 30 minutes of intermittent auscultation for a normal first stage of labour.
Could it possibly be that listening to the baby’s heartbeat is actually an intervention which could potentially be harmful in normal labour? I spoke to Sarah quietly and asked if I could listen to her baby and do some baseline observations including an abdominal palpation. She opened her eyes and it was obvious that she had been in ‘her own place’. As soon as she was back in ‘reality’ her contractions felt so much stronger, although they were actually slowing down. Sarah indicated the contractions were so much harder to cope with. In fact, she grew restless when I asked her to lean slightly backward so I could get the Pinard onto her abdomen to listen to her baby. She became quite agitated, as I found it difficult to listen to the fetal heart this way. Sarah stepped out of the pool, walked around the room in a circle rubbing her abdomen, and articulated how uncomfortable she was.
I had to stop her from walking to try and listen to the baby’s heartbeat again. This time I used the Doppler sonicaid, having checked with Sarah first. The fetal heartbeat, like all other observations, was within normal range. Sarah looked tense and unhappy, quite a change from when I had arrived earlier. I encouraged her to get back into the pool and find a position that was comfortable for her. However, it took her quite a while to get back to the place where she had been before I had interrupted her. This happened every time I tried to listen to the baby’s heartbeat. In fact, Sarah became frustrated with me wanting to listen to the baby’s heartbeat intermittently and, in the end, refused to have the auscultations done.
This is when I started questioning the use of intermittent auscultation in normal labour. How many babies are born before arrival at the place where they were supposed to be born and had anyone listened to their heartbeats? When I was working in South East Asia the majority of places did not have any auscultation tools. I wondered how many babies born every day in the world had not had anyone listening to their heartbeats during labour, despite otherwise good midwifery care. This does not make it right or wrong to listen intermittently to the baby’s heartbeat, but midwives might need to ask if there could be other indicators or observations of the baby’s well-being that can be made without interrupting the normal birth process?
When Sarah birthed her baby boy in the water I was glad that I had followed her cues. Later, over a hot cup of tea, she described the initial regular intermittent listening to her baby’s heartbeat as being regularly ‘ripped away from my peaceful place’.
Many authors (Katz Rothman 1982, Odent 1999, Gaskin 2002, Kitzinger 2002, Buckley 2003, Davis 2004) argue strongly that any disturbance in the normal birth process can adversely affect the labour and birth outcome. Buckley (2005) discusses that in order for a normal birth to proceed optimally the neocortex (or the rational brain) must be disengaged. Dim lighting, a quiet and warm environment, and being supported by people she can trust, will enable a woman to intuitively choose movements, sounds, breathing and positions that will help her birth the baby most easily. This will ensure that her oxytocin levels are high enough to create good contractions and ensure a feeling of well-being and love towards her baby. Catecholamines, which are mainly adrenaline-based hormones, are needed for the ejection reflex for the baby to be pushed out in second stage. However, adrenaline induced earlier will inhibit oxytocin production, slowing down labour and lessening the strength of the contractions (Moberg 2011). After the birth of the baby the mother still receives high doses of oxytocin up to 30-60 minutes after the birth (Eliot et al1980, Nissen et al 1995). Skin-to-skin and eye-to-eye contact between the mother and the baby optimises oxytocin release which will assist with uterine contraction and breastfeeding (Leake et al 1981, Moberg 2011). A number of studies have found that a malfunction of the oxytocin system have been implicated in conditions such as schizophrenia, autism, cardiovascular disease and drug dependency (Sarnyai & Kovacs 1994, Insel et al 1999, Gutkowska et al 2000).
Six years ago I was privileged to visit with helots (traditional midwives) in the Philippines on the island of Mindanao. I discovered that there is no fetal auscultation equipment available to listen to the baby’s heartbeat, although sometimes a stethoscope was used. However, the helot would often observe the woman’s abdomen and watch how the baby was moving during the labour or ask the woman how they felt the baby move. Through an interpreter they explained that distressed babies kick vigorously during a contraction when there is hypoxia present and are very quiet between contractions, and that a healthy baby kicks mostly inbetween contractions. There is no evidence about this observation in the literature and it indicates strongly that further research is needed. As I recall my time with the helots, I think there is a place for constructive discussion if routine intermittent fetal monitoring belongs in normal labour surveillance. Anecdotally, as with Sarah’s story, it suggests that intermittent auscultation can interfere with the normal labour process through reduction of oxytocin and an increase of catecholamines if the mother feels disturbed by it. Ina May Gaskin (2010) articulates that we need to take lessons from the animal kingdom and explore how the human mind can interfere with the birth process. She further argues that without understanding how often a single intervention is the sole reason for birth and labour complications to follow, the intervention rate will not stop. Midwives and women need to debate: does intermittent auscultation actually have an impact on the outcome of normal labour? Are there any other observations that would indicate a baby might need continuous monitoring as the labour starts to deviate from normal? Are regular strong contractions, normal blood pressure readings, clear liquor and an oxytocin ‘spaced out’ mother clear indications of fetal well-being? There is little evidence in the literature about the effects of intermittent auscultation. It is timely that midwives and women debate the place of intermittent auscultation for normal labour and encourage and support further research.
First Appeared in Essentially MIDIRS May 2013 Volume 4 Number 5 Reproduced with Permission.