Intelligent Structured Intermittent Auscultation (ISIA): A Mixed Methods Evaluation of an Informed Decision-Making Framework for Fetal Heart Rate Monitoring

Intermittent Auscultation (IA) of the fetal heart (FH) is a screening tool for the assessment of fetal well-being during labour; the detection of changes in the FH rate and rhythm may signal fetal compromise. While the evidence reveals that IA is as effective as continuous cardiotocography (CTG) for FH monitoring for low-risk women, current practitioners favour the use of continuous CTG despite the risk of significantly increased maternal and fetal morbidity. Translating the knowledge of the effectiveness of IA into practice became the primary aim of this study. While auscultation and palpation are essential midwifery skills, the teaching of IA does not go beyond simply outlining the protocol for frequency, duration, and timing and less is understood about the underlying physiology associated with what is heard and the reassurance of fetal wellbeing that this provides. A knowledge translation intervention, in the form of an evidence-based informed decision-making framework for Intelligent Structured Intermittent Auscultation (ISIA) and a comprehensive educational intervention were developed to enhance midwives‘ knowledge and awareness of IA and to influence decision-making and practice for FH monitoring for low-risk women. A mixed methods non-experimental pre- and post - intervention study design was used to evaluate the knowledge intervention. Pre measures included a retrospective review of 511 medical records to assess existing FH monitoring practices, and focus groups with 14 midwives explored barriers and facilitators to the use of IA. The intervention was then delivered to a mix of 33 midwives and doctors three months later, followed by a second review of 422 medical records and focus groups with seven midwives to determine any changes in practice and to evaluate outcomes. The findings revealed a statistically significant increase in the use of ISIA with improved documentation, and a relative decrease of 14% in the use an admission CTG for low risk women. The ISIA framework has wide applicability in all maternity settings. This research has illuminated the effects of culture, organisation and the socio-political context on the ability for midwives to utilise their fundamental midwifery skills to promote, facilitate and protect normal physiological birth in the institutional maternity care setting. Engagement with a Knowledge Translation project and the introduction of the ISIA framework for FHR monitoring for low risk women has given midwives voice to generate change.