Journal of Midwifery & Women’s Health

Clinical Rounds

Intermittent Auscultation of the Fetal Heart Rate During Labor: An Opportunity for Shared Decision Making


Sally Hersh, CNM, DNP, Michele Megregian, CNM, MSN, Cathy Emeis, CNM, PhD

Electronic fetal heart rate monitoring is the most common form of intrapartal fetal assessment in the United States. Intermittent auscultation of the fetal heart rate is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting. Several expert organizations have proposed the use of intermittent auscultation as a means of promoting physiologic childbirth. Within a shared decision-making model, the low-risk pregnant woman should be presented with current evidence about options for fetal heart rate assessment during labor. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:344–349  Keywords: cesarean birth, electronic fetal monitoring, ethics, intermittent auscultation, intrapartum care, physiologic birth, shared decision making


C.M. is a 33-year-old gravida 2 para 1001 who presents for a return prenatal visit at 35 weeks’ gestation. C.M. initiated care at 12 weeks’ gestation and has had an uncomplicated prenatal course. Her previous birth was with a nursemidwife in an out-of-hospital birth center. Because of insurance changes, she plans a hospital birth with her second child. She recently attended a prenatal class offered by the hospital as a way to learn more about her new birth environment. One of C.M.’s concerns is her ability to move about in labor. After attending the prenatal class, she is concerned that she and her fetus will be monitored continuously during labor. She states that she did not undergo continuous fetal heart rate monitoring during her previous birth experience. She is worried that continuous fetal heart-rate monitoring might limit her mobility and asks if intermittent auscultation is an option for her in this setting. C.M. has heard from friends that one intervention often leads to another and wants to know if she will have the ability to decline specific interventions. C.M.’s questions provide the midwife with an opportunity to review the evidence for assessment of the fetal heart rate during labor, discuss institutional policy, and explore C.M.’s preferences.

currently involves widespread use of some technologic interventions that do not have evidence to support their use.2 One of the most commonly used intrapartum interventions in the United States is continuous electronic fetal heart rate monitoring3 (EFM), despite expert opinion that intermittent auscultation (IA) of the fetal heart rate is recommended or acceptable.4,5 The purpose of this article is to briefly review the evidence for IA of the fetal heart rate in labor and implications of its use in low-risk laboring women. Using the consensus statement as a framework,1 the impact of the type of fetal heart rate monitoring on the mother, as well as the clinician, birth setting, and environment, will be explored. Ethical considerations and the implications of a shared decision-making model when discussing IA with women are presented. METHODS OF INTRAPARTUM FETAL HEART RATE ASSESSMENT

Address correspondence to Sally Hersh, CNM, DNP, Oregon Health & Science University, School of Nursing, Nurse-Midwifery Academic Program, Portland, OR 97239. E-mail: [email protected]

Fifty years ago, continuous EFM was introduced into clinical practice with the intent of reducing perinatal mortality and cerebral palsy.3,4,6 Currently, IA and continuous EFM are the 2 methods used to assess fetal well-being in labor. Intermittent auscultation consists of using a stethoscope or Doppler ultrasound to listen and count the fetal heart rate at specific intervals.7 Women may move about as desired between intervals of assessment. The Doppler device may be used underwater when the woman utilizes hydrotherapy. Investigators have recommended various regimens for counting, timing, and interpreting the auscultated fetal heart rate during labor.4,5 Electronic fetal heart rate monitoring uses a Doppler ultrasound transducer to continuously hear and record the fetal heart rate and a mechanical transducer to simultaneously record the frequency and duration of uterine contractions. Belts or an abdominal sheath keep the external transducers in place on the woman’s abdomen. Cords extend from the transducers to the monitor, limiting her mobility in labor. Some


 c 2014 by the American College of Nurse-Midwives


In 2012, the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America, and the National Association of Certified Professional Midwives released the landmark consensus statement, Supporting Healthy and Normal Physiologic Childbirth.1 The goal of this joint statement was to identify key benchmarks of safe, healthy, and normal physiologic childbirth within the context of contemporary obstetric environments. Intrapartum care in hospitals

1526-9523/09/$36.00 doi:10.1111/jmwh.12178

birth units have cordless telemetry units available. When internal monitoring is needed, a fetal scalp electrode and/or an intrauterine pressure catheter are affixed to the woman’s thigh and connected to cords to the monitor. A paper and/or electronic tracing provide a visual display that is used to read, interpret, and document the findings.7 Continuous EFM is considered to be the most common obstetric procedure in the United States.5 Among women participating in a national survey about their recent childbearing experiences, 80% of the sample (n = 1,027) were monitored either continuously (60%) or for most of the labor (20%), while 12% were monitored intermittently.8 INTERMITTENT AUSCULTATION

Several major expert groups have noted that, for low-risk women in labor, IA is safe and as effective at detecting changes in fetal well-being as is continuous EFM. ACNM, the National Institute for Health and Clinical Excellence from Great Britain, and the Society of Obstetricians and Gynaecologists of Canada recommend the use of IA for low-risk women in labor.4,9,10 The American College of Obstetricians and Gynecologists states that either IA or continuous EFM is acceptable for the woman without complications.5 While a systematic review of IA for labor surveillance is in the protocol stage,11 neither the criteria that define low risk nor the methodology for conducting IA has been universally developed or accepted.4,12,13 During IA, the fetal heart rate is auscultated between contractions to establish the baseline rate. Periodic changes are assessed by auscultating the fetal heart rate over a period of time. Evidence-based clinical guidelines on IA provide bestpractice recommendations for the assessment of fetal heart rate baseline and periodic changes, frequency of observation, interpretation of findings that necessitate transition to electronic fetal heart rate monitoring, and documentation.4 Hospital birthing units are often challenged to provide one-toone nursing care, which is required for compliance with IA protocols.7,13 As with continuous EFM, education and ongoing training in IA are necessary for effective implementation. The continuous care associated with IA may have a positive synergistic effect with other care activities that support physiologic labor and birth.2,4 ELECTRONIC FETAL HEART RATE MONITORING

Continuous electronic fetal heart rate monitoring is the most utilized form of intrapartum fetal surveillance in the United States.5 During the early phases of adoption, continuous EFM was limited to women at high risk for fetal compromise. Over time, it gained in popularity as a tool for laboring women of any risk category.3,6 Continuous EFM was widely adopted in clinical practice prior to research evaluating its validity was performed.14 Cited reasons for the persistent use of continuous EFM in low-risk women include habit, liability concerns, adequacy of nursing staffing, resistance to evidencebased practice, convenience, and the inability to provide adequate consent to women in labor.15–17 With continuous EFM, the fetal heart rate is assessed relative to its baseline characteristics and response to contractions, and the fetal risk for acidemia is interpreted based on Journal of Midwifery & Women’s Health r

the specific fetal heart rate pattern.5 In 2008, an interdisciplinary expert panel from the National Institute of Child Health and Human Development published recommendations aimed at definitively establishing terminology and interpretation of electronic fetal heart rate monitoring.18 A recent meta-analysis of 13 randomized controlled trials (RCTs) compared neonatal and maternal outcomes in women who had undergone continuous EFM or IA during labor.7 Of the 13 trials representing 37,715 women, only 2 were considered to be high quality. Analysis of 11 trials (N = 33,513) found no significant difference in perinatal mortality (relative risk [RR], 0.86; 95% confidence interval [CI], 0.59-1.23), or rates of cerebral palsy in 2 of the trials (RR, 1.75; 95% CI, 0.84-3.63; N = 13,252). Women who had been monitored continuously were more likely to have a cesarean birth (RR, 1.63; 95% CI, 1.29-2.07; 11 trials; N = 18,861) as well as slightly more likely to have an instrumental vaginal birth (RR, 1.15; 95% CI, 1.01-1.33; 10 trials; N = 18,615). There was a 50% reduction in the incidence of neonatal seizures in the group monitored continuously with electronic fetal heart rate monitoring (RR, 0.50; 95% CI, 0.31-0.80; 9 trials; N = 32,386). A follow-up study at 4 years of age for the infants who had seizures revealed no difference in number of those who developed cerebral palsy when compared to the rate of cerebral palsy in the infants without seizures.19 Alfirevic et al7 concluded that professionals and patients should consider the evidence carefully when determining the method of fetal heart rate surveillance in labor, taking into account individualized risk–benefit assessment and preservation of the normality of labor. Grimes and Peipert20 contend that electronic fetal heart rate monitoring has failed as a public health screening program. They postulate that, as a screening tool, it should have been subjected to rigorous analysis as a public health strategy prior to its ubiquitous use. The authors conclude that electronic fetal heart rate monitoring should be reserved for women at risk of poor outcomes, since it will perform better as a screening test if the potential for adverse conditions in the screened population is high. The correlation between continuous EFM and elevated rates of cesarean birth has been highlighted recently as part of initiatives to lower the cesarean rate.12,13,21,22 Cesarean and operative vaginal births are known to increase the risk of maternal morbidity, particularly thromboembolic complications, bladder injury, and placenta accreta in subsequent pregnancies.4,12 While the review of literature on the ineffectiveness of electronic fetal heart rate monitoring to prevent neonatal morbidity is compelling, Devoe23 and King13 caution against generalizing the results of older RCTs on continuous EFM and the systematic reviews that have included them. Many of the RCTs were carried out decades ago when obstetric practices varied considerably from current practices, interpretation of fetal heart rate tracings was not standardized, and fetal heart rate variability was not considered. Additionally, fetal pH from scalp sampling was used in some studies, whereas its use in current practice is rare. Recent research on electronic fetal heart rate monitoring has focused on fine-tuning the art of fetal heart rate interpretation with the formation of multitier risk categories such as the 3-tier method and, more recently, the 5-tier method.12,13,24 345


Clear ethical obligations exist regarding informed consent for fetal heart rate monitoring for women who are at low risk for fetal acidemia developing during labor. Bioethical principles are called upon to assist providers and patients in resolving clinical questions and to guide practice, specifically the principles of beneficence, nonmaleficence, autonomy, and justice. When examining the methods of fetal heart rate assessment in labor for low-risk women, continuous EFM has been described in several ways including: as a “cautionary tale of unintended consequences”25(p. 552) ; a “failure” that “could have, and should have, been predicted and thus avoided”20(p. 1397) as causing “more unnecessary interventions overall”26(p. 1189), ; and as “no better than tossing a coin in its ability to predict abnormal outcomes.”12(p. 380-381) Yet, despite evidence that continuous EFM is not superior to IA for low-risk women, it is generally accepted that continuous EFM will continue to be used in this manner.12,13 Intermittent auscultation is inadequately studied, and data regarding the benefit or burden to women are limited. Obstetric providers have an ethical obligation to both the pregnant woman and her fetus; thus, they have a duty to act in the best interests of both, which includes assessment of fetal well-being during labor. Beneficence describes actions of the provider, which promote well-being and are in the best interests of the patient.27 Continuous EFM fails to promote beneficence for the mother, and the benefits to the fetus/newborn are unclear.7 Intermittent auscultation may offer a benefit to the mother by promoting free movement and position changes in labor, which may be associated with increased patient satisfaction. Intermittent auscultation is also associated with a lower risk of operative birth when compared to continuous EFM, which may offer a benefit to both the mother and her fetus.6,21 Nonmaleficence describes the concept of do no harm; that is, providers will avoid interventions and recommendations that cause harm to their patients, be they physical, emotional, psychological, or spiritual harms.25 The use of continuous EFM has wrought some harm to women, as noted above. The maternal risks associated with IA are unclear. Research suggests that IA and continuous EFM have equivalent neonatal outcomes.4,5,7 Autonomy refers to the recognition of the individual’s right to have opinions, to make choices, and to take action that is based on personal values and beliefs and that is free from influence.27 Any procedure, intervention, or medical decision requires a form of patient consent. Informed consent requires that the woman understands the information regarding the intervention (including risks, benefits, alternative treatments, and risks associated with no intervention), appreciates how that information specifically applies to her, and voluntarily accedes to the intervention without coercion.27 The routine use of continuous EFM or IA, without discussion of the risks involved with the use and limitations of both methods of monitoring fetal well-being in labor, violates the low-risk laboring woman’s autonomy. The principle of justice includes the complex concepts of fairness, freedom from discrimination, the right to health, and the equal distribution of health care resources.27 Institutions such as hospitals and birth centers have an ethical obligation 346

to provide a sufficient quantity of qualified, trained staff to attend women in labor. The Association of Women’s Health, Obstetrics, and Neonatal Nurses recommends a 1:1 patient to nurse staffing ratio for women who are receiving IA in labor and for women choosing to labor with minimal or no pharmacologic pain relief.28 It can be argued that institutional obligations include the provision of staff trained in both IA and continuous EFM, as well as adequate number of staff to support the use of either method for women with low obstetric risk in labor. In the case of C.M., the use of continuous EFM in labor was perceived by her as an intervention that may have negative effects. Her previous experience in a birth center provided her with an alternative perspective of the birth environment. Her experiences and preferences informed her questions and concerns during her prenatal visit. After her experience with IA during the labor and birth of her healthy first newborn, her assumption was that this method of fetal heart rate assessment would be offered in the hospital along with continuous EFM. Applying the shared decision-making model, the midwife was able to reassure her that, in the hospital in which she was electing care, IA would be offered as long as her risk status did not change.


Shared decision making is a collaborative process between provider and patient to make health care decisions. Shared decision making emerged from the expansion and coalescing of medical quality-improvement initiatives29 and the legal doctrine of informed consent.30 It takes into account patient values and preferences; the best available scientific evidence; potential benefits and harms of all treatment options (including no treatment); and provider experience, bias, and expertise.31 Decisional priority rests with the patient. Providers empower patients to reflect on the choices available to them and to make independent decisions regarding their medical care.32 Shared decision making works optimally when decisions are preference-sensitive. That is, from a medical standpoint, the outcomes of various treatment options are equal or similar; thus, the best option is the one that best suits the patient’s preferences.33 In these situations, shared decision making is concentrated in the provision of information; and it has been demonstrated to promote patient satisfaction, decrease decisional conflict, and improve adherence, which may then improve outcomes.30 Shared decision making also offers the opportunity for the provider and woman to participate together in an exploration of uncertainty in decision making.30 Situations in which there are multiple clinical choices, clinical ambiguity, and lowquality or equivocal evidence evoke medical uncertainty. A clinical case in which there is obligation, yet uncertainty—as in C.M.’s case—requires a commitment of time, agency, and accountability from both provider and woman. Women’s satisfaction with their birth experience is directly linked to the quality of support and relationship with caregivers and to their involvement in decision making.34 Ideally, conversations regarding the expert recommendations for the use of IA for low-risk women in labor and Volume 59, No. 3, May/June 2014

Table 1. Woman-Centered Decision-Making Pathway for Fetal Monitoring

Table 2. Factors that Influence the Type of Fetal Monitoring and the Promotion of Normal Physiologic Childbirth


For the Woman

Identify what is important to

Steps Discussion about:

Autonomy and self-determination in childbirth

the woman and her family


Fully informed, shared decision making

regarding fetal monitoring

Worries about risk

Access to health care systems, settings, and providers

during labor

Impact on comfort measures

Gather baseline information

Review of medical record, labor

Undertake an individualized

Analysis of baseline

events, and progress assessment Formulate an evidence-based care plan

information Review of clinical practice guidelines and policy documents Consideration of the woman’s feelings and expectations

Talk it through

Review of the evidence with the woman Review of options, alternatives, consequences

Implement the agreed care plan for fetal monitoring

feelings, and consequences

care practices For the Clinician Education, knowledge, competence, skill, and confidence in supporting physiologic labor and birth Commitment to shared decision making Working within an infrastructure supportive of normal physiologic birth For the Birth Setting and the Environment Adequate time for shared decision making with freedom from coercion Freedom of movement in labor and women’s choice of birth positions Intermittent auscultation of fetal heart tones during labor,

Informed choice by the woman

unless continuous electronic monitoring is clinically

Put plan into action, based on


evidence-based practice and informed choice

Reflect together on outcomes,

supportive of and skilled in normal, physiologic childbirth

Source: American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives.1

Open and honest discussion between the midwife and the woman, incorporating

tum or intrapartum, about the mode of fetal heart rate monitoring in labor is unknown.

reflective practice Source: Rattray et al.15


the appropriate use of continuous EFM should take place prenatally. Rattray15 developed a 7-step “Woman Centred Decision-Making Pathway for Foetal Monitoring.” The first step involves an exploration of values, expectations, and the impact of continuous EFM in labor (Table 1). While this pathway was developed for use in labor, it may be implemented prenatally. The low-risk woman should also be presented with current evidence about IA, criteria for low-risk status, the importance of the continuous presence of a midwife or nurse, and the protocol and rationale for switching to continuous EFM. It is important to recognize that any discussion that involves true choice for women will also involve the choice of no intervention, accompanied by acceptance of the potential harms and benefits of this option. The percentage of women who choose, or might consider choosing, no fetal monitoring in labor is unknown. Midwifery practice represents a way of being with women. As with the shared decision-making model, the midwifery philosophy of care emphasizes patient-centered care, exploration of values, individualized risk assessment, and a commitment to collaborative care. The degree to which midwives have detailed discussions with their patients, either antepar-

The direct contradiction between the philosophy of care espoused by midwives—that of supporting birth with an evidence-based, physiologic, low-intervention approach— and the continued reliance on continuous EFM was examined in a qualitative study evaluating midwives’ attitudes and experiences with this mode of fetal heart rate assessment in the United Kingdom.35 This study found that midwives have positive attitudes toward IA and negative attitudes about the routine use of continuous EFM and its potential effect on womancentered approach to care. Midwives must examine their strengths as experts in normal birth in settings where interventions during labor and birth have become standard practice.1 The birth setting and environment are influential factors in midwives’ abilities to offer and promote IA as an option for low-risk laboring women. Table 2 summarizes the factors that influence the choice of fetal heart rate monitoring modality. In out-of-hospital birth settings, IA is the primary means of fetal surveillance during labor, yet a minority of women who reside in the United States receive IA in the hospital setting.8 It may be difficult to employ a shared decision-making process and offer IA when the likelihood that women will receive IA is low. Numerous barriers to implementing IA in the hospital setting, outlined previously in this article, have prevented its widespread

Journal of Midwifery & Women’s Health r


adoption as an alternative for low-risk laboring women. Introduction of policies to support care practices that promote normal physiologic childbirth can provide a framework for implementation of IA in hospital settings.1 Modeling of IA and other evidence-based maternity care practices, such as continuous labor support, is important in the training of current and novice maternity nurses; a lack of core childbearing knowledge has been noted to be a barrier to the implementation of evidence-based maternity care.2 Opportunities exist for midwives to lead in development of evidence-based policies, procedures, and training of staff in performing IA. In addition to promoting normal physiologic childbirth, advancing IA in institutions where midwifery students are trained ensures that future midwives will be competent and confident using IA for low-risk laboring women in hospital settings. It is unknown whether midwifery students receive adequate opportunities to develop this skill set in US hospitals—the primary training environment for certified nurse-midwives and certified midwives. Competency-based, interdisciplinary education programming for all maternity health care clinicians and students is needed to provide IA and other care practices supportive of physiologic birth.1


Intermittent auscultation is an acceptable modality for evaluating fetal well-being during the labor of women who are at low risk for developing fetal acidemia. Despite this, continuous EFM remains one of the most common interventions in labor. Within a shared decision-making model, the low-risk woman should be presented with current evidence about IA and continuous EFM. Midwifery and nursing students should be educated in the practice of both of these modalities. As experts in normal physiologic childbirth, midwives have an obligation to champion the introduction and refinement of institutional and staff development processes for IA in the hospital setting. Comprehensive examination of birth care practices, dissemination of evidence, as well as the development of a future research agenda on the short-term and longterm effects of normal physiologic birth are recommended.1 Research that examines facilitators of promotion and barriers to normal physiologic childbirth should address patient, provider, and system factors that facilitate the use of IA in lowrisk laboring women in the hospital setting.


Sally Hersh, CNM, DNP, is Clinical Assistant Professor in the Oregon Health & Science University (OHSU), School of Nursing, Nurse-Midwifery Academic Program. She is the OHSU nurse-midwifery practice manager. Michele Megregian, CNM, MSN, is Clinical Assistant Professor in the Oregon Health & Science University, School of Nursing, Nurse-Midwifery Academic Program. She completed a fellowship in interprofessional health care ethics at the Center for Ethics in Health Care at Oregon Health & Sci348

ence University and has a certificate in medical ethics from Portland State University. Cathy Emeis, CNM, PhD, is Assistant Professor in the Oregon Health & Science University, School of Nursing, NurseMidwifery Academic Program. She is the Assistant Director of the Nurse-Midwifery Program. CONFLICTS OF INTEREST

The authors have no conflicts of interest to report. REFERENCES 1.American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. J Midwifery Women’s Health. 2012;57(5):529-532. 2.Sakala, C, Corry, M. Evidence-Based Maternity Care: What It Is and What It Can Achieve. New York, NY: The Milbank Memorial Fund; 2008. 3.Stout MJ, Cahill AG. Electronic fetal monitoring: Past, present, and future. Clin Perinatol. 2011;38(1):127-142. 4.American College of Nurse-Midwives. Intermittent auscultation for intrapartum fetal heart rate surveillance (replaces ACNM Clinical Bulletin #9, March 2007). J Midwifery Women’s Health. 2010;55(4):397403. 5.American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: Nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009;114(1):192-202. 6.Gourounti K, Sandall J. Admission cardiotocography versus intermittent auscultation of fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumental delivery—A systematic review. Int J Nurs Stud. 2007;44(6):10291035. 7.Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2013;5:CD006066. doi: 10.1002/14651858.CD006066.pub2. 8.Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers SM III: Pregnancy and Birth. New York, NY: Childbirth Connection, 2013. /listeningtomothers. Accessed September 1, 2013. 9.National Institute for Health and Care Excellence. Clinical guideline 55. 2007. Accessed 9/14/2013. 10.Liston R, Sawchuck D, Young D. Fetal health surveillance: Antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can. 2007;29(suppl 4):S3-S56. 11.Martis R, Emilia O, Nurdiati DS. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being (Protocol). Cochrane Database of Syst Rev. 2010;9:CD008680. DOI: 10.1002/14651858. CD008680. 12.Costantine MM, Saade GR. The first cesarean: Role of “fetal distress” diagnosis. Semin Perinatol. 2012;36(5):379-383. 13.King TL. Preventing primary cesarean sections: Intrapartum care. Semin Perinatol. 2012;36(5):357-364. 14.Haverkamp AD, Orleans M, Langendoerfer S. A controlled trial of differential effects of intrapartum monitoring. Am J Obstet Gynecol. 1979;134:399-412. 15.Rattray J, Flowers K, Miles S, Clarke J. Foetal monitoring: A womancentred decision-making pathway. Women and Birth. 2011;24(2):6571. Volume 59, No. 3, May/June 2014

16.Tillett J. Intermittent auscultation of the fetal heartbeat: Can nurses change the culture of technology? J Perinat & Neonatal Nurs. 2007;21(2):80-82. 17.Altaf S, Oppenheimer C, Shaw R, Waugh J, Dixon-Woods M. Practices and views on fetal heart monitoring: A structured observation and interview study. BJOG. 2006;113(4):409-418. 18.Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development Research workshop report on electronic fetal heart rate monitoring. Obstet Gynecol 2008;112:661-666. 19.Grant A, Joy MT, O’Brian N, Hennessey E, MacDonald D. Cerebral palsy among children born during the Dublin randomized trial of intrapartum monitoring. Lancet. 1989;2(8674):1233-1236. 20.Grimes D, Peipert J. Electronic fetal monitoring as a public health screening program: The arithmetic of failure. Obstet Gynecol. 2010;116(6):1397-1400. 21.Rossignol M, Moutquin JM, Boughrassa F, et al. Preventable obstetrical interventions: How many caesarean sections can be prevented in Canada? J Obstet Gynaecol Can. 2013;35(5):434443. 22.Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011;118(1):29-38. 23.Devoe LD. Electronic fetal monitoring: Does it really lead to better outcomes? Am J Obstet Gynecol. 2011;204(6):455-456. 24.DiTommaso M, Seavealli V, Cordisco A, Consorti G, Mecacci F, Rizzello F. Comparison of five classification systems for interpreting electronic fetal monitoring in predicting neonatal status at birth. J Matern Fetal Neonatal Med. 2013;26(5):487-490. 25.Freeman J. Beware: The misuse of technology and the law of unintended consequences. Neurotherapeutics. 2007;4(3):549-554. 26.Spong C, Berghella V, Wenstrom K, Mercer B, Saade G. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver

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National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists workshop. Obstet Gynecol. 2012;120(5):11811193. 27.Beauchamp T, Childress J. Principles of Biomedical Ethics. New York, NY: Oxford University Press; 2008. 28.Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN). Guidelines for Professional Nurse Staffing for Perinatal Units. Washington, DC:AWHONN; 2010. 29.Barry M, Edgman-Levitan S. Shared decision making—The pinnacle of patient-centered care. NEJM. 2012;366(9):780-781. 30.Braddock III C. Supporting shared decision making when clinical evidence is low. Med Care Res Rev. 2013;70(suppl 1):129S-140S. 31.Gee R, Corry M. Patient engagement and shared decision making in maternity care. Obstet Gynecol. 2012;120(5):995-997. 32.McNutt RA. Shared medical decision making: Problems, process, progress. JAMA. 2004;292(20):2516-2518. 33.Politi M, Lewis C, Frosch D. Supporting shared decisions when clinical evidence is low. Med Care Res Rev. 2013;70(suppl 1):113S-128S. 34.Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet and Gynecol. 2002;186(suppl 5):S160-S172. 35.Hindley C, Hinsliff SW, Thomson AM. English midwives’ views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: Conflicts and compromises. J Midwifery Women’s Health. 2006;51(5):354-360.

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Intermittent auscultation of the fetal heart rate during labor: an opportunity for shared decision making.

Electronic fetal heart rate monitoring is the most common form of intrapartal fetal assessment in the United States. Intermittent auscultation of the ...
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