 And first of all, the first thing I wanted to say is we have to make a break 10 minutes before the next hour because we have some technical issues and so we have to start and we have to stop this session 10 minutes before the hour. So, but I'm very delighted to introduce to you the next speaker, Robin Maude. Robin is a senior lecturer and director of student research at the Graduate School of Nursing, Midwifery and Health at the Victoria University of Wellington, and she's a practice in LMC-Midwife, and she's a member of the Midwifery and Normal Birth Research Group and her interests are focused on activities that promote and protect normal birth through developing an awareness of knowledge translation and quality improvement and the effects on clinical material practice. And the focus of Robin's research was translating evidence into practice around the fundamental literary skills of intermittent escalation of the fetal heart rate for lower risk women. And she's continued, she continues to be interested in the use of water immersion for labor and birth from our master's research and is currently planning research in this area. So, Robin, welcome. She's speaking today from Hawaii and I'm very much looking forward to hear your presentation. Over to you. Oh, thank you, Michaela. And I hope you can hear me. Lovely to be involved. And yes, I did tick the other box and it because I'm sitting in a hotel room and Waikiki Beach at the moment. It's nine o'clock at night and I'm hungry. So I'm looking forward to doing this and then going to dinner. So, welcome everyone and lovely to see you on board here. So today I'm going to talk about intelligent structured intermittent escalation or I call it Isaiah. It's about fetal heart rate monitoring for low risk women and it was the subject of my PhD studies that I finished in 2012. And so today I really want to just introduce you to the model and talk a little bit about how it works. So here I am from New Zealand sitting all the way up here in Hawaii and it feels really weird to be talking to you all around the world and it's lovely to see so many people on board and all the countries that you come from. I was really excited to see that there are a couple of midwives from Switzerland on board at the moment. I've just recently had the Isaiah framework translated into German and published in the Swiss Federation of Midwives Journal. So lovely to see the Swiss midwives on board tonight. Here's a little map of Wellington for people who may not have been there. It's a particularly good looking picture on a sunny day. So I hope that anyone who's interested comes on down to Wellington in New Zealand at some stage if possible. We look forward to seeing you and welcoming you. So just quickly a little bit about my research project. It was a mixed method non-experimental pre and post intervention study done in three phases. And so for this particular piece of work, what I was interested in is why we are not using intermittent oscultation when the evidence for its use is very strong. And indeed all of the guidelines that you see around the world generally say that for low risk women it is recommended that intermittent oscultation should be offered. And so one of the conundrums for me was if we have this evidence, why are we not using it in practice? And so I set about to investigate why this was happening. I'm just going to move on to the next one here. So some of the assumptions I started with when I went into my research was that there are unanticipated effects associated with using CDG monitoring for low risk women. And the literature tells us that the rates of interventions and particularly things like epidural and augmentation and caesarean sections are higher when women who are low risk are essentially well and healthy and have uncomplicated pregnancies. When they are subjected to unnecessary interventions like CDG monitoring, it increases their risks without any significant benefits for the baby. And so although intermittent oscultation has been used for many, many years, with the introduction of CDG monitoring back in the late 60s, early 70s, this resulted in a really huge decrease in the use of intermittent oscultation for fetal heart monitoring. And it's a factor that affects whether or not intermittent oscultation is actually used in practice in many health settings. And as a result of this, we know that practitioners are becoming de-schooled in the skill of oscultation and palpation as well because they go together. So the knowledge that midwives were becoming more and more drawn into the cascade of intervention increased the urgency for me to undertake this research into fetal heart monitoring using intermittent oscultation. And it's my belief that the choice of monitoring modality is a decision that needs to be made in partnership with women, with well-informed women. And there's growing evidence that the form of fetal monitoring is an intervention that has possible consequences as I've mentioned. I thought it was very interesting to see the foreword in the fetal monitoring book by Gibbon, Aril Kumar in 2008, where they say that excessive technology should not be applied to those women who are manifestly at low risk. It may confer no benefit, can generate both medical and non medical anxiety, and through subtle effects may cause significant harm. And so I agree with that. And I agree that we need to have a look at the evidence, but also to find some ways to reestablish the basic fundamental school of intermittent oscultation for women during labor. So those are some of my assumptions. And one of the things that I did early back in about 2007 was to go out onto these midwifery lists here that I've got that I've got on my PowerPoint. These are email discussion lists that are made up of midwives all around the world, just like we are today. And it's a fabulous way of being able to have discussions with people about practice issues. So I went out to these two lists in 2007 and asked them questions about intermittent oscultation. And some of the questions I asked were, you know, what do you do? What does your practice look like? How did you learn how to do that? Some specifics around how often would you listen to the baby's heartbeat during labor? And what is the normal practice in your area? And what are the things that are important about developing some notion about how we should do intermittent oscultation during labor? Some of the midwives came, well, I had a lot of midwives. I had midwives from 31 different countries around the world who gave me an enormous amount of response that really helped me to develop this ISIA project. Some of the things that were influencing their decision making were the evidence and the guidelines that exist around fetal surveillance. One of the issues that affected whether they would use intermittent oscultation was often the staffing levels within the maternity units. And this is one of the impacts that comes up, or one of the barriers to use that comes up repeatedly. And these are particularly in countries where the guidelines still say that you should be listening every 15 minutes. Many midwives came back on this list and said that they use electronic fetal monitoring, or the CTG, as a defensive practice. In other words, we put it on so that it has a printout of the fetal heart rate that provides evidence that I have been doing some fetal heart rate monitoring in the event of an adverse outcome. Others said that the use of fetal movement monitoring in a package of overall monitoring of fetal wellbeing is a very useful thing. So that led me to do some investigation into the role of fetal movement monitoring. Some people are concerned that listening to the baby's heartbeat with intermittent oscultation means that you are unable to determine variability. And of course, variability is a term that's associated with fetal heart rate monitoring. And I think with electronic fetal heart rate monitoring, and I think that we can touch on that a little bit later. And strongly it came out from midwives that coming from a position of using and understanding normal physiology gives us a lot of confidence to be able to monitor fetal wellbeing during labor without necessarily attaching the woman to a CTG machine. I'm just going to move on to the Isaiah framework. And the words that I used were very specific. And just looking at these definitions here. Intelligent was rational, logical, able, structured as an ordered or prearranged approach. And for me, the Isaiah framework enabled midwives to become more skilled and competent with this sort of logical and ordered approach to fetal assessment during labor. And going back, of course, to that fetal monitoring book by given Errol Coomer and they do state that this form of fetal monitoring is almost equivalent to using a CTG machine. So it's about having an organised and logical approach to what we're doing with our IA that gives us robust data to make some good decisions about the fetal monitoring that we are doing. So this Isaiah framework has been designed to be able to use as an admission assessment and also for ongoing fetal heart monitoring. So I'm going to move first of all to the admission assessment. Now I know that that's a little hard for you to see on there and I apologise for that. But I want to talk about each little section on its own and this work has been published and I'll show you where the publication is available in an open access journal in my final slide. So the admission assessment part of the Isaiah framework simply gives us a structured approach to how we will do an assessment when we first see that woman. And so that might be that we see her in a maternity unit for the first time. It might be that we are going to see her at a home or in a birthing unit. And in New Zealand the context for us is that at least 85% of all the women giving birth here have their own midwife, their own continuity of care midwife. So we know these women very well and that's a really huge advantage for women and midwives in New Zealand. But this framework I believe can be used if you're seeing the woman for the first time in labour in the hospital and they have never met her before and don't know anything about her history. So what this framework gives us is a flowchart or an algorithm to help us decide what kind of fetal monitoring is the best to use for any woman, low risk women. So you can see in the central component there is a risk assessment, abdominal palpation, assessment of fetal movements, uterine activity and assessing the fetal heart rate. So I'm going to have a look at these sections in a minute. And this is the second component of the Isaiah framework and this is the framework that guides us when we're doing, when we've finished our admission assessment and we've made a decision about which is the best form of fetal heart monitoring for this woman. And this is how we will then continue to do Isaiah throughout her labour. And I'll talk a bit about that as well. So coming on to the admission assessment or first contact in active labour, there are a couple of decision points that need to be made. And the first one is around reviewing the history, looking at the woman's care plan and to consider any social factors that might put the fetus at risk. And this supports the work that we're doing, anti-natal anyway. So the risk assessment begins by reviewing all of these pieces of work. It's supported by the, sorry, let me start again. The woman and the midwife share the information about how she's coping with labour and what supports she might need moving forward, as well as reviewing those care plans and also from the physical assessment that you're going to be doing. It's important to consider any social factors such as smoking, obesity, socioeconomic deprivation and high parity because these things will possibly contribute to an increased risk. Now sometimes it's added to the admission that many health care providers in maternity still consider that an admission CDG should be put on. And indeed many doctors and midwives are still using this technology despite the evidence strongly discouraging its use. Our research suggests that intelligent auscultation such as ISIA can be regarded equivalent to an admission CDG in low risk women and should be considered rather than the application of a CDG. So the ISIA framework provides an alternative means of assessing fetal wellbeing on admission or at first contact in labour and it supports the clinical decision making of the maternity provider in any model of care or any maternity setting. So the second decision point comes at the end of having done that full assessment that includes the palpation, the fetal movement, the uterine activity and listening to the fetal heart rate. And once you can see that all of those parameters are in the normal range, it is safe to say that this woman is suitable for intermittent auscultation moving forward. Looking at that admission assessment and by the way that woman here, this midwife, she was a third year student midwife who was out in practice with me as a lead maternity carer and she is getting married on the 5th of May in Hawaii, which is why I'm here. I've come over for her wedding. This was a student midwife who worked with me in practice and we've had a very close contact ever since. So it's really exciting to be coming over here to her wedding. So the admission assessment draws on the basic skills of auscultation and palpation as a means by which the midwife gains information about the well-being of the woman and her baby. So the essential midwifery skills of touching, feeling, sensing, hearing, seeing and knowing are employed. Reviewing the care plan, reviewing the history and the examination are supported by abdominal palpation that determines fetal lie, presentation and position, but it also helps the midwife identify the best place on the abdomen to put the device on for listening to the fetal heart. And it also helps us to determine the descent of the presenting part, and we can feel fetal movements. Measuring the fundal height to give us a clinical assessment also of the growth and light core volume. And this will indicate to us that the baby is well grown and likely to be healthy. And we can also palpate uterine activity at this point. So if there's optimal fetal position, optimal fetal growth and optimal light core volume, those things are all in line for the woman to be suitable for intermittent auscultation. Admission assessment, again fetal movements. So fetal movements during pregnancy we know indicate that well-being, fetal well-being because they are evidence of the integrity of both the central nervous system and the musculoskeletal system in the fetus. And we know that when we're looking after women antinatally during their pregnancies, we ask them to tell us about their baby's usual pattern of movement. And we know that we advise women if their fetal movements are reduced then they should be seen by their caregiver and assessed. Contrary to the understanding of some women and maternity care providers, the frequency of fetal movements does not diminish in the third trimester. And that's a myth that still is existing out there in the world and probably needs to be put to bed. Fetal movements should be assessed by subjective maternal perception and women are encouraged to be aware of their fetal movement pattern. This gives them some credibility about knowledge about their babies and themselves. So it's with that understanding in mind it seems appropriate for us to include a question of usual fetal movement patterns during the admission assessment. It should be reviewed, it should be seen as additional information. So determining the baby's movement patterns on admission, we ask the woman to tell us about her the usual pattern in recent time. So leading up to this assessment, what have the usual patterns been like? And we'll record those in the notes. But we'll also ask her to tell us each time she feels a baby's movement. Listening to the baby's heart rate during the time that it is moving is also the best time to determine any increases above the fetal heart rate average rate that we've already determined and I'll come to that in a minute. In the literature this is called the oscultated acceleration. I'm calling it increases above the fetal heart rate baseline or average base average. So you ask about the normal patterns, power paedophetal movement with the woman and listen to the fetal heart rate during a movement. And remember this is the most important thing. Fetal movement is a confirmation of fetal well-being. So the admission assessment, uterine activity, this is this is basic midwifery. We know how to do this. Uterine power patient by gentle touch throughout a series of contractions will determine the duration, frequency and strength of contraction. We can also assess if there's any uterine irritability or any tenderness and to determine what the resting time is like between contraction. Power patient of contractions enables the midwife to accurately time when to listen to the fetal heart. Fetal heart should be listened to at the end of the contraction. Assessing the fetal heart rate. Oscultation of the fetal heart rate will enable an average rate and rhythm to be determined along with the presence of fetal heart rate increases and the absence of fetal heart rate decreases. Oscultation according to Goodwin who wrote a wonderful piece of work back in 2000 she said, Oscultation requires extremely focused listening and counting of each fetal heartbeat as it's heard. Using the index finger to tap the beat being heard may increase accuracy of the oscultation findings when the rate is rhythm, when the rate is rapid. The tapped beat may be counted by the second observer so that the person oscultating can be fully focused on hearing the rapid heart sound. And so that's what I tried to demonstrate in this picture. That the midwife is listening to the heart rate, she's also tapping out the beat of the baby's heart on the woman's leg there. And then another photo that I haven't put on here, she's also palpating the woman's radial pulse at the same time and is able to differentiate between the mother's pulse and the baby's heart boot. And that's a really important thing that we need to be doing when we're doing oscultation or in fact any fetal heart rate monitoring is to be differentiating between the maternal and the fetal heart rate. So the average fetal heart rate is determined by counting the fetal heart rate beats for 60 seconds between contractions or fetal movements over a period of about 10 minutes so that we can obtain an average rate. A watch with a second hand or a stopwatch function on a mobile phone can be used to count the fetal heart rate for the recommended period. The average fetal heart rate is expressed as a single number in beats per minute. That is 130 beats per minute if that's what you count. And this is the same as recording a maternal pulse. The notion here is that an oscultated fetal heart rate should not be written as a range of numbers which I have seen frequently in medical records when I review them. Quite often you'll see a fetal heart 136 to 148 which is trying to demonstrate a range and I believe that midwives are probably thinking that they're demonstrating fetal heart rate variability and that brings us back to that question of listening for variability that is not what we're doing in intermittent oscultation. So we're writing as a single number. We're listening and counting for a minute and writing as a single number. In terms of the fetal heart rate rhythm it's not very well defined in the literature or nor is it significant known. However it is possible to hear when the fetal heart beats are regular or irregular. If the fetal heart beat is irregular further assessment is required to determine what that dysrhythmia is about. So an irregular fetal heart beat is very often benign and requires no intervention. Normally would frequently revert to normal after the birth. But it may be an indication for you wanting to put the CTG machine on. Fetal heart increases is when the fetal heart rate is at least about 15 beats higher than that average rate that you've already determined. It may be heard with or without a fetal movement. So fetal heart increases are considered a good sign of fetal health and that means the fetus is responding to stimuli and displaying integrity of the mechanisms controlling the heart. An abrupt or gradual decrease in the fetal heart may be detected by listening to the fetal heart rate immediately after the end of a contraction and that's considered to be an abnormal finding. The complete clinical situation of the woman and the fetus should be reviewed in the presence of any fetal heart rate decreases after a contraction and measures taken to detect or correct any causes. So the normal fetal heart is seen there on the right hand side and the abnormal is seen below that. Just moving on now. I know this is also very hard to see and I apologize. This is just an example of the documentation we use once we get through all of those assessments and the key thing for me is that it's really important to make a statement like I've written here at the bottom that you've gone through this assessment and that you've made a clear statement that the woman's well and healthy and everything you've found about her so far as within the normal and that therefore she is suitable for intermittent auscultation moving forward. So the documentation I feel is incredibly important. One of the things I do is do review medical records when there's been an adverse outcome and I think it's probably the truth true for everywhere around the world that communication and documentation are two of the most important things in how we deliver our care and I really think that we need to be clear about our documentation and how well we do it which is why I've included this because I think it's important for educators to be telling and telling this message to all of our midwife colleagues. So in terms of intermittent auscultation as I move into doing that in ongoing we I refer you back to that original framework which was about doing an ongoing risk assessment. So when we're looking after women throughout Labor we're constantly assessing as we go along is there anything that's arising that might make it more prudent for me to move from intermittent auscultation to using a CTG machine and so some of the constant things that come up will come up for us that make it necessary for us to change our outlines in our fetal heart rate, fetal heart surveillance guidelines and they might include things like the use of oxytocin or if the auscultation becomes abnormal or having an epidural for analgesia or any sort of abnormal bleeding or maternal temperature blood-stained like war and those things are all within the guidelines but they're also within the framework that I put up frequently. So continuous assessments throughout Labor is very very important. It's also recommended that the fetal heart rate be assessed before and after any labor enhancing procedures such as artificial rupture of the membrane or admission of administration of medications or analgesia or even after spontaneous rupture of membrane, vaginal examinations or any abnormal uterine activity pattern or any untoward event that might happen during labor such as a sudden hypertension or such. So the ongoing assessment is very important. Looking at the ISR protocol and I struggle with this one because I know that there's a difference in the frequency in particular in different fetal monitoring guidelines throughout the world. There's a number in I mean in the UK it's recommended that every 15 minutes in the US they're a little bit easier. They say 15 to 30. The RANSCOG guidelines says 15 to 30. The reality is that there's never been any robust research especially randomized controlled trials that have actually tested these frequencies and so they really are based on opinion, expert opinion. What we do know is that these frequencies were used in a lot of the randomized controlled trials that were done in the 80s and 90s and so they again as I say they were based on expert opinion and they've been the only protocols for frequency that have actually been subjected to any kind of rigorous testing. There's never been a trial to see whether 15 minutes is better than 30 minutes and so maybe that's something that we will look at in the future. For me I guess the bottom line was that we needed to pick a number that fitted well with practice and thinking back to that discussion I had with the midwires on the email list. People were saying and certainly midwires in my studies said that they were very concerned about disrupting the normal patterns of labor and so rather than being bound by a strict rule that you did it every 15 minutes or every 15 to 30 minutes they would take, they did what they called opportunistic monitoring and so they would take the opportunity to have a listen to the fetal heart when the woman herself made some sort of change so it might be that she was deeply concentrating on her contractions and then stopped to say something or like you know wow that was really big one or something and so the midwife would take the opportunity to say I'll have a listen to the fetal heart now but one of the things I saw in my study was because I did a retrospective medical record review so I could actually see how often the midwives were documenting how the frequency of listening was that it ranged from 15 minutes to 30 minutes with probably the biggest number of doing it around 20 minutes so it seems that in practice we are doing it within this 15 to 30 minute time frame and so as I say until such time we've had some robust research comparing those frequencies that's what I stuck with for my frame work and that can certainly be up to debate the literature is relatively is a guidelines and literature are relatively clear about listening immediately after a contraction although I do know that Rand's cogs say start before the contraction has ended and go for a little bit of time afterwards it's interesting to have a look at some of our historical textbooks I was looking at the Maggie Miles 1953 book that said that the fetal heart rate should never be auscultated during a contraction since oxygen to the fetus would be reduced at this time and so this would not be a true reading of the fetal heart rate so the rationale for auscultation of the fetal heart after contraction is two-fold firstly the decelerations that return to the average fetal heart rate before the contraction is unlikely to be harmful to the fetus in addition it's irritating to the woman to have the fetal stethoscope or docla used during a contraction thickening of the myometrium during a contraction always also reduces the ability to hear the fetal heart rate clearly most of the harmful fetal heart rate decelerations are late atypical variable or prolonged decelerations and these can be identified by auscultation immediately after a contraction so as in the admission assessment component the presence of fetal movement is documented throughout labor and these are an ongoing indicator of fetal well-being and so we've touched on before we've touched on the maternal pulse and you can see in this picture how the midwife is auscultating and feeling the radial pulse and also tapping the beat so another person can count as well and that is not a hard thing to do which is which is good to know so one of the things that we need to consider is what happens if we've got concerns or have an abnormal fetal heart rate and during our auscultation and what should we do with it so normal fetal heart rate findings include a rise above the of the average above 160 beats per minute or a decrease in the average below 110 or gradual or abrupt decelerations or an absence of any increases and some of the things that we consider that may cause these are some of the things that are raised on the slide and one of the one of the most significant things we can do is change maternal position because we know that that will considerably help if there's any umbilical cord compression or cord occlusion so if there is any abnormal fetal heart rate findings it's really pertinent to go through some of these some of these questions here to see if there's a cause for any one of them looking now at the management if there's a non reassuring audible fetal heart rate during auscultation one of the things that's very important is continuous care or one to one one to one care and continuous support and labor but because we know that when women become anxious it's um it can it can actually lead to fetal distress and when we talk about the fear cascade theory we know that increased catamacolamines constrict blood vessels and decreases uterine blood flow and reduces placental perfusion which in turn decreases fetal oxygenation and as a consequence it can increase fetal distress so staying with the woman is probably one of the key things and certainly when you're doing auscultation during labor you need to have one to one care to be able to meet those requirements for frequency but because that's what we think is an important thing to do so consideration must be given to other management options where there's an abnormal fetal heart and those will include as I say repositioning the woman and considering some of these other options and checking maternal pulse and blood pressure very important but doing a vaginal exam examination to rule out any cord and continue to auscultate and do it more frequently consider consider using a CTG or doing fetal blood sampling and obviously doing some consultation and Robin just a quick just a second and as we have to stop actually 10 minutes or so could you maybe get your conclusions and yeah super because we have to also have the audience asking questions thank you I'm ready to stop and I'm just going to with pass that documentation because that that's again just what I was talking about before and here's my conclusion which is the use of our desire for fetal heart rate monitoring of low risk women on admission and inactive labor is supported by the midwives scope of practice and midwifery model of care that includes partnership continuity of care and informed choice and consent ethics and research and the knowledge that intermittent auscultation of the fetal heart is a monitoring modality for low risk women as well supported and should be reassuring for midwives in practice and the final slide is just to show the reference for the journal article that was published in 2014 that contains that framework and I'm currently working on another one that I hope to publish in the next month or two that will explain the use and implementation of the ISR framework and so that's my final slide listening and if there's any questions we can do a couple now thank you Robin that was really good very interesting um there was already a common question from the audience earlier on the fetal movement and on fetal movement guidelines and they said they changed drastically from 10 movements and 24 hours to expecting 10 movements in two hours is that can you comment on that do you do you know anything about that that were like the Randolph guidelines and how does it it's interesting it is interesting about the fetal movement counting um I mean they one of one of my students Billy Bradford is also published in 2014 in BMC pregnancy and childbirth on fetal movements and in her literature review she could see very clearly that the the jury's been out for a very long time about counting fetal movements and moving strongly towards an understanding of women's perception of their fetal movements is being way more important than asking them to count a number and so there is quite a good body of literature that talks about women's perceptions of fetal movements and it seems to fit quite nicely I think with the the green top guideline from the UK from RCOG and so for me I think that the question was around counting and and I've moved away from the notion of counting and then and moving way into the realms of listening to what women say is their baby's normal pattern and I'm much more concerned if they tell me that there's a change in the baby's pattern rather than if the baby has kicked a certain number of kicks I hope that helps Is there anything any other questions before we wrap up? I can see another question here there were there was a new policy on fetal monitoring released just recently I think that's New South Wales and Australia and how they are different from the last guidelines I'm not sure probably if you if you are aware of them Is that Leanne Gill's question? Yes and was that a new policy on fetal or the latest RANDCOG guidelines? Yeah yeah I know the I know the latest RANDCOG guidelines for fetal monitoring and some of us in New Zealand did have the opportunity to give some important on to those there are there are there are some issues around those guidelines in terms of you know being relevant to the model of care and so one of the things I'd be really happy to see is if we could do some more research using Isaiah as the as the intervention and move to have a little bit more freedom in how we talk about intermittent ascultation in our fetal monitoring guidelines mean they have the protocol in the RANDCOG guidelines but as I said earlier on and there's very little evidence for the use of that protocol and what I what I believe about Isaiah is that if we use it logically and in a structured process we're probably getting more information than what you would get if you're simply doing a protocol that says you listen every 15 to 30 minutes because I think it would be really important for us to consider the physiology that's happening here as well yeah I agree with you Leanne it is and it's particularly hard when you don't have the ability to give one to one but again you know we start from the position that this is normal it's normal for a woman to have continuous care we know that continuous care has been researched at length and we know that the findings support that there's a reduction in intervention if women have one to one care so I guess we've got to get a little bit more political about that and go out there and talk to the people who make the decisions about funding and models of care and try and convince them that this model of care that I'm talking about will help us to reduce interventions that actually increase morbidity and don't necessarily improve so it's a bit of a um a bit of a political one there I think I think I have we have to stop here now um there was another question but I guess maybe you can write directly to Robin a private message yes I can who was that from Shailia pan a bit on determining variability by escalation alone so maybe if you could just um continue in a private chat because we want to wrap up so I will um first of all thank you Robin that was really good and I think we had some good comments um in in the chat and um yeah I hope to hear more about your research and read about your publication so I will turn off the record