Intermittent auscultation (IA) is a fetal surveillance method using manual palpation to assess uterine contractions and a handheld auscultation device to evaluate fetal heart rate (FHR) characteristics. Offering women a choice of the fetal monitoring method used in labor supports the principles of shared decision-making and patient-centered care. Although one-to-one nursing care is the recommended standard when using IA and is often cited as a barrier to its use, nurses might consider the increased time spent responding to and adjusting EFM equipment, especially in women who prefer mobility and upright or alternative labor positions. The high-touch nature of IA may help nurses connect to their patients and to the essence of nursing practice while alleviating issues such as alarm fatigue.

Intermittent Auscultation Method

Evaluate Uterine Activity

Abdominal palpation is used to evaluate uterine resting tone and contraction characteristics (frequency, duration, and intensity). It is best to use the more sensitive fingertip pads rather than palms to palpate the uterus when assessing contraction characteristics (Feinstein, Sprague, & Trepanier, 2008).

1. Assess uterine resting tone by palpating the fundus between contractions and document as soft or firm.

2. Determine contraction frequency in minutes, and duration in seconds. Once the contraction pattern has been established, maternal perception and feedback regarding contractions may be used to supplement the clinician's assessment.

3. Palpate the fundus throughout a contraction to determine intensity. Mild contractions are easily indented (like the tip of the nose), moderate contractions can be slightly indented (like the chin), and strong contractions cannot be indented (like the forehead).

Evaluate FHR

1. Assess FHR baseline between contractions when the fetus is not moving. Different counting methods are recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (Feinstein et al., 2008) and the American College of Nurse-Midwives (ACNM, 2010). When changes from baseline are detected, a multiple count strategy is suggested to investigate the nature of the periodic or episodic changes (ACNM, 2010; Feinstein et al., 2008).

2. Assess maternal pulse to differentiate maternal from FHR. For follow-up evaluation of FHR baseline, listen for 15 to 60 seconds at recommended intervals to evaluate baseline changes (ACNM, 2010). The FHR should be documented as regular or irregular. When using a Doppler, an irregular rhythm requires further evaluation to distinguish it from artifact. As variability is visually determined, it is not evaluated using IA.

3. Evaluate changes from baseline FHR before, during, and after contractions. The presence or absence of increases/decreases (Feinstein et al., 2008) or accelerations/decelerations (ACNM, 2010) and whether they are abrupt or gradual should be assessed and documented. As classification of decelerations requires visual interpretation, they cannot be categorized as early, late, variable, or prolonged. Additional documentation should include whether decelerations are intermittent or recurrent, the nadir rate, and any interventions initiated in response (ACNM, 2010).

4. For low-risk women, FHR and contraction characteristics should be assessed every 15 to 30 minutes in active labor and every 5 to 15 minutes while pushing, as well as before or after vaginal exams, membrane rupture, medication administration, and ambulation (Feinstein et al., 2008).

Conclusion

Nurses are uniquely positioned to influence the monitoring method used in labor by offering IA to low-risk women, and requesting orders from providers that include it as an option. Likewise, leaders of perinatal units can influence and encourage its use by ensuring that policies and procedures, order sets, and protocols contain language addressing both IA and EFM.

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