Following the exploration of thoughts and feelings, the Gibb. (1988) reflective cycle suggests an evaluation of the incident in order to uncover what was good and bad about the experience. Christine palpated Jo’s abdomen initially to facilitate in the locating of the fetal lie, which in turn would indicate where the fetal heart would be most audible. Johnson & Taylor (2003) suggest that the clearest sounds may be heard through the fetal shoulder and that the fetal presentation should be identified first in order to place equipment in the correct place. Initially, the midwife used a Pinards stethoscope which, according to Johnson & Taylor (2003) is good practice as this type of auscultation distinguishes between the maternal heart rate and that of the fetus. Fraser & Cooper suggest the featl heart should range between 110 – 160 beats per minute as opposed to the mother’s heart rate of approximately 70 beats per minute but unless a midwife listens in then this would not be detected. Following the use of the Pinards, Christine used a hand held Doppler or Sonicaid which enabled Jo to hear the sounds of her baby’s heart which in turn provided the reassurance and care which Jo had originally expected. The fundal height, lie, presentation, degree of engagement, position, fetal heart rate and movements were then recorded by Christine in the notes but according to Johnson & Taylor (2003) the type of equipment used to auscultate should also be documented and this was not done.
An advantage of using both Sonicaid and Pinards stethoscope is that Christine would have been maintaining her skills, which is recommended by NMC (2002). Henderson & Jones (1997) state that the fetal heart is always auscultatated on clinical examination and it would be extremely difficult to change habits if a midwife has been practising for years. However, the choice of listening in to the fetal heart rate meant that Christine did not follow the clinical guidelines which are, after all evidence-based and suggest that although auscultation of the fetal heart confirms that it is alive at that present moment it is unlikely to predict any outcomes, therefore recommending the termination of this routine practice at antenatal visits (NHS, 2003). This routine observation may also use up valuable time that might be spent on other midwifery duties but this could be at the expense of an unhappy and anxious expectant mother. Feeling anxious about her baby may have other implications upon the mother, as all pregnancies should be as stress free as possible.
Gibb, (1988) continues with an analysis of the incident in order to make sense of it. Christine chose to perform the antenatal check as she always had done and Jo expected this procedure. Unfortunately the NICE Guidelines (NHS. 2003) suggest that auscultation of the fetal heart should not be carried out routinely but The Pregnancy Book that is also provided by NHS. (2003) to all pregnant mothers in England and Wales informs expectant mothers that a doctor or midwife will listen to the baby’s heartbeat at antenatal checks. If this routine procedure is to be phased out, at what point should it be done? It seems that women who are used to hearing the heartbeat of their baby will expect this to continue. Perhaps all newly pregnant women should be informed that the procedure is being changed. There are also implications for midwives who also appear to be reassured by hearing the sound of the fetal heart. It may be that a date should be set where this practice is no longer carried out routinely but unless a woman is given evidence to show that hearing a heartbeat does not ensure the outcome of her pregnancy, then it is unlikely she will accept this suggestion with open arms.
The NHS (2003) does state that if a woman specifically requests the auscultation of her baby’s heartbeat, then it should be carried out to provide reassurance. These guidelines appear to contradict somewhat saying on the one hand that this practice will not provide any assurances of outcome and protocols should therefore be reviewed and implemented as rapidly as possible and yet in The Pregnancy Book (NHS. 2003) which is accessible to all pregnant women it implies that these sounds should reassure her. These guidelines are based on category IV evidence that considers expert committee reports or opinions and / or clinical experience of respected authorities. Randomised controlled trials or comparative, correlation or case studies are also taken into consideration when the guidelines are written which therefore suggest this information is solid. Conflicting views from Mattson & Smith (1993) state that the hand-held Doppler assesses the rate and any significant accelerations or decelerations that might be associated with fetal distress. A randomised trial in 1994 undertaken by Mahomed K et al involving 1255 women stated that the use of a hand held Doppler detected abnormalities more accurately than a Pinard stethoscope and was equally as efficient as electronic monitoring and was associated with lower neonatal morbidity and mortality. It must be remembered that this trial is somewhat dated and that more recent information was used to create the guidelines.
A conclusion can be drawn (Gibb, 1988) that if a midwife listening in to the fetal heart at antenatal checks can reassure a woman, then perhaps this should be the continuing course of action irrespective of guidelines. Expectant women appear to look forward to this part of the examination and there is also a space for the information to be recorded in the notes. If auscultating the fetal heart is to be abolished routinely then the guidelines need to be written in conjunction with the Pregnancy Book in order to avoid confusion. It appears that women need to be better informed about this practice; that hearing a heartbeat does not necessarily guarantee a safe outcome for the pregnancy. The maintenance of a midwife’s skills should be considered and if this practice is not upheld both the practice of midwifery in this particular area and the mother’s wishes will subsequently suffer. A student can only learn these skills if they are used in practice frequently and therefore the future of using these particular types of equipment is also being challenged.
Gibb (1988) rerflective cycle concludes with an action plan. As a student it is apparent that decisions and guidelines for midwives are not always clear-cut and may often conflict. There are dilemmas that midwife faces that place her in a difficult position regarding her role and her duties as such. Should she follow the guidelines or listen to what women want regardless of what the recommendations state? It appears there are no definite answers but happily the guidelines do give a little scope in the interpretation of the recommendations regarding fetal heart monitoring. The very fact that there is a clause which states that if a mother requests for her baby’s heart to be monitored suggests a recognition that this is still a reassuring feature in the antenatal check for the expectant mother and it would seem from this particular incident that it will remain so.
