CCM Technical Bulletin # 1 ~ Intermittent Auscultation

by faithgibson on August 18, 2018

Principles and “Best Practices” Associated with the
Physiologic Management of Pregnancy & Childbirth

Technical Bulletin No. 1 

Intermittent Auscultation for Community-based Midwifery


Continuous Electronic Fetal Monitoring (EFM) is directly associated with an increase in cesarean surgeries without any decrease in either fetal mortality or cerebral palsy. (citations provided at the end of this document). Unfortunately, Cesarean surgery is also associated with an increased rate of maternal mortality.

Preventing unnecessary cesarean surgeries prevents maternal mortality. Replacing Continuous EFM with intermittent auscultation (perhaps augmented with episodic EFM) prevents maternal mortality and morbidity and spares both mother and baby the interruption of bonding that accompanies cesarean surgery.

Prevention of medically-unnecessary reproductive surgeries increases opportunities for valuable maternal-child interaction during the postpartum, promotes family values and the rate of successful breastfeeding and reduces the cost of maternity care. Intermittent Auscultation should be the standard of care for healthy mothers experiencing normal pregnancies except in circumstances of evident medical need.

Principles & Practices of Intermittent Auscultation for Community-based Midwives

“It is unusual for a heart rate under normal nervous system control to be steady at any one consistent rate. Rather, there is considerable variation or short-term variability on a beat-to-beat basis, usually ranging from 3 to 8 bpm around an imaginary average heart rate. Fluctuation or long-term variability occurs as well, usually having a cyclicity of three to five cycles per minute (cpm). The presence of normal fetal heart rate variability is one of the best indicators of intact integration between the central nervous system and the heart of the fetus.” [Gabbe’s obstetrical text]

The chapter on EFM Intermittent Auscultation (IA) in Gabbe Obstetrical Text is a systematic method of listening to fetal heart tones with an acoustical device (fetascope) or a hand-held ultrasound (doptone), paying attention to rate, rhythm and variability for at least one full minute, most usually following a uterine contraction (UC), and timing with a watch or clock with a sweep second hand. The best type of timer for IA is a 7” (or larger) battery-operated analog clock with a quartz movement (available at most office supply stores) that stops briefly after each ‘tick’ of the second hand. That makes it easier to distinguish the beginning and ending of each of the 5-second sampling units.

This highly effective but low-tech method of monitoring fetal heart rate gathers both quantitative and qualitative information on the four critical characteristic of fetal wellbeing (a) baseline, (b) variability, (c) presence of accelerations and (d) absence of pathological decels (i.e. during second stage, most head compression decels are not pathologic). These numerical and qualitative findings are then charted or graphically represented to indicate the baseline rate, presence or absence of beat-to-beat variability, and presence or absence of accelerations, decelerations.

The purpose of graphically displaying this data is to assist the midwife or other practitioner to make logical, information-based decision during labor and birth that protect the well-being of the unborn baby without exposing the mother to the risks of unnecessary interventions.

According to a preponderance of scientific literature (well-conducted prospective and RCTs), the major advantage of using continuous Electronic Fetal Monitoring (EFM) for healthy laboring women with normal pregnancies is the ability to assure fetal wellbeing by documenting “re-assuring” FHR patterns. The essential element of “reassurance” comes from identifying long and short-term beat-to-beat variability, which is a manifestation of a neurologically-intact fetus. However, there is no clinically significant difference in fetal well-being between long and short-term variability. [1] Short-term variability refers to the time between any two beats. Long-term variability refers to the general variability seen in various blocks of time (5 seconds or longer) over several minutes.

This is a crucial point as only EFM can regularly detect short-term variability (the time between any two beats). However, Intermittent Auscultation (IA) does permit the listener to detect long-term variability (slight speeding up and slowing down of the baseline rate over a period of several seconds). As one becomes practiced at this skill, it is also possible to acoustically identify short-term variability (i.e., to hear the moment in which the FHR speeds up or slows down dramatically between two beats). The presence of a moderate level of variability (6-24 bpm) gives reasonable assurance of the well-being of the unborn baby at that point in time.

According to outcome studies, a normal baseline rate with good variability is the single best predictor of fetal well-being. Reduced variability or a “silent pattern” of less than 5 beats variability can represent a fetal rest or sleep cycle lasting from 5 to 40 minutes. If the baby previously demonstrated reassuring FHTs and circumstances are otherwise low risk for chronic hypoxia, it is customary for community-based midwives providing care under physiological standards to wait and recheck. Some authors caution that babies never “sleep” longer than 90 minutes, so be highly suspicious of a prolonged pattern of reduced variability.

Chronically developing hypoxia (causes other than acute placental or cord accident, maternal hemorrhage or seizure, etc.) takes over 100 minutes (usually 115 to 185 minutes) to produce respiratory or metabolic acidosis, so it is important to transfer care during this window of opportunity (akin to the “golden hour” recognized in trauma medicine).

In general, an age-appropriate fetus at term whose mother is healthy (by history and examination) and is displaying a “reassuring” fetal heart rate pattern confirms the presence of healthy fetus for the next 4 hours unless a placental or cord accident intervenes.

Death of a normally formed fetus within 4 hours of a normal cardiogram is a statistically rare event.

Reassuring markers of fetal health

  • Normal baseline rate & rhythm (regular rhythm between 110 >> 150)
  • Observable variability (between 5 and 25 beats)
  • Accelerations with fetal movement
  • Absence of decelerations, especially after the onset of UCs

Acceleration are the hallmark of fetal health so celebrate accelerations! But from the caregiver’s standpoint they can easily be missed if they occur between individual auscultation samplings. Sometimes it is helpful for the mother to verbally indicate when the baby is moving so you can listen again or at least chart her report of fetal activity.

Tachycardia hypoxic babies do not make normal fetal movements, so if the mother feels that the force and frequency of fetal movement is “normal” (for her baby), or you are able to hear accelerations and document normal variability, you can be reassured of the baby’s health (barring acute emergency events) for the next four hours.

Goals of IA:

The goal of IA is to determine baseline rate of the fetal heart and to detect FHR accelerations and variability and, when possible, periodic changes (early, late & variable decels during and immediately after uterine contractions UCs) in a community-based (OOH) setting (or other “low-tech” circumstances), without the expense and risks associated with the use of continuous electronic fetal monitoring. This has global application as many less affluent populations do not have access to continuous electronic fetal monitoring, especially in the rural areas.

Since auscultative monitoring requires the mother to remain immobile during strong uterine contractions for good FHT data to be obtained, it is not always feasible to monitor regularly for periodic changes. However, documenting the presence of good long-term (or cyclic) variability with an amplitude of 6 bpm indicates fetal wellbeing. An amplitude of 2 or less bpm (absence of variability) or greater than 25 bpm (saltatory pattern) is indicative of a compromised fetus.

Amplitude is the bandwidth of high and low impulses. For example, an amplitude of 6 bpm would be a variation of 3 above and 3 below the baseline, or 6 bpm above baseline. For a baseline of 144, the range would be from 141 to 147 bpm.


Intermittent Auscultation (IA) is the gold standard for community-based midwifery care. This low-tech evidence-based method is recognized as efficacious by ACOG, AWWOHN and other conventional obstetrical providers. Since it only requires a doptone and watch or clock with a sweep second hand (preferably with a quartz movement so it stops briefly with each “tick”), IA can be used in non- institutional setting and in the developing world.

The method is simple. Immediately following a uterine contraction (UC) the FHTs are listened to for one full minute, counting in twelve consecutive 5-second sets. The quantity and quality of fetal cardiac activity is then recorded. This method was originally described by Dr. Joseph DeLee in his 1924 obstetrical textbook “The Principles and Practice of Obstetrics“.

By listening for one full minute while counting in 5-second increments (i.e. twelve samplings per 60 seconds), it is possible with practice to hear rate, rhythm and variability (or lack of variability). It is helpful to occasionally listen during a UC if the mother is able and willing to remain adequately still. Typically, heart tones of a fetus with normal variability will `wander’ between 9-14 per 5-second unit. For example, when there is very good variability in the fetus, the midwife might hear 12, 12, 11, 10, 10, 09, 11, 12, 10, 13, 14, 12, etc. More typically for laboring woman, you will count a lot of 12s with a few 11s, and an occasional 10 or 13 thrown in from time to time.

The primary purpose for auscultating in sets of 5-second intervals is to be able to document “reassuring” FHT patterns (assuming they are present) without dependence on continuous electronic monitoring. This permits unfettered mobility for the mother and reduces unnecessary expense as well as the risk of unwarranted interventions (for example, CSs performed for fetal distress based on an ‘abnormal’ EFM tracing but resulting in a babies with Apgars of 9 & 10!).

For the caregiver IA techniques (as contrasted with random listening of FHR) provides many of the advantages of continuous EFM without the disadvantages. The use of IA (instead of random, unsystematic counting) gives the midwife more latitude in management and helps avoid unnecessary intervention (e.g. unnecessary episiotomy to hasten 2nd stage). IA also provides added confidence for community-based practitioners in the decision to either remain at home for the birth or to facilitate as well-timed transfer when warranted.

Timing & other protocols for Intermittent Auscultation:

The recommended schedule for IA is every:

  • Hour during latent labor,
  • 30 minutes during active labor
  • 15 minutes during second stage*

*NOTE ~ Auscultate more frequently — every other or every 3rd contraction — during a prolonged perineal stage, or if there are other issues of concern.

Active labor is defined as UC q 5′ x 60″(with an intensity of 3+ or greater) for one hour or longer. To avoid dilution or pollution of data, the highest & lowest numbers during a 60-second set should be heard two or more times during the set OR heard in 2 or more consecutive sets when this determination is central to management decisions. For instance, a single high or low may be an artifact of counting; the inclusion of random artifacts may reduce the clinical value of the system and should be avoided.

The use of a large (at least 7″) battery-powered clock with a quartz movement is recommended as the sweep second hand stops momentarily with each “tic”, making it easier to accurately determine each 5-second sampling unit. The larger clock face is also helpful. If possible, listen for a full 60+ seconds and chart the range (typically ranging between 10 to 14 bp5s^).

Another helpful method is to chart the specific numbers heard (ex — 11, 12, 13s) and then add a check over top of the number you heard most frequently, which will usually be the 12, or if it is about half and half, check both numbers. This allows you to more easily determine the baseline, which is reflective of the number heard with the most frequency.

The ACCM-CCM form for IA allows for charting a broad range from 5 bp5s^ to 15 bp5s^, providing for tracking of a baseline range from 60 bpm to 192 bpm. The line on the chart form for 12 bp5s^ (144 bpm) is darkened to assist reading the graph for the normal physiological baseline. Also the block of lines indicating 110 bpm/10 bp5s and 156 bpm (13 bp5s) are lightly shaded to establish the normal range of fetal variability.

{To-be-added later } Sample copy of the ACDM IA form to download and print

Normal Baseline Rate: IA can successfully assess the baseline FHR to determine whether it is within the normal range or displays an abnormally high or low rate. For the last 80 years the normal range has been defined as between 120 to 160 bpm, but newer evidence* sets the physiological range of normal for a term fetus between 110 to 150 bpm. [*Fetal Monitor in Practice, 2nd edition, by obstetricians Donald Gibb and S. Arulkumaran]

Baseline of under a 110 bpm is bradycardia. When the FHR is sustained between 150 bpm – 170 bpm it is considered to be mild tachycardia. FHR over 170 bpm is a clinically significant tachycardia. IA can also document acceleration and decelerations and access long-term variability (i.e. bandwidth of high and low phases excluding acceleration and decelerations).

Second stage is defined as spontaneous sustained pushing (Sustained Urges To Push or SUTP) after full (or in some multips, after 8-9 cm) of dilatation. Listen every 15 minutes, with additional monitoring (in sequential 5-second intervals) as indicated. It is not uncommon for a period of early decels, down to 1/2 of the baseline (the equivalent of mammalian diving reflex), to occur as the baby’s bi-parietals are first depressed by pressure of the mother’s ischial spines, causing head compression and triggering a vagal nerve reflex. For instance, a fetal baseline of 140 may go down to 70 bpm at the peak of the UC. This phenomenon is usually short-lived (10 minutes or so) and the baby continues to display variability, good recovery and return to a normal baseline rate. This pattern can also occur with a tight nuchal cord or a cord temporarily getting pinched between the fetal head and maternal bone.

Limitations of IA: Loss of FHT signal due to limitations caused by equipment or maternal movements. IA is also unable to detect a sinusoidal pattern caused by fetal anemia/bleeding and subtle late decels.   It may be necessary to use acoustical stimulation or scalp stim if you have a relatively flat variability and are suspicious of mild but persistent late decels.

Maternal Cooperation: Mothers need to be in a stable position that permits the midwife to listen for one full minute. Ideally, some proportion of these monitoring events should include listening during and following a UC, — not always easy during the strong painful contractions of transition labor and pushing stage.

Graphic Form for Intermittent Auscultation

Human being are better at (and much happier with) pattern recognition than they are computing. We can glance at a pattern and get instant information (and gratification!) — otherwise we must number, count and compute outcomes. One of the reasons EFM is so popular is that it does the math and prints out the pattern.

For midwives using IA, these same concepts are employed by writing down the audible variability you hear (numbers counted), thus making a visual pattern of bandwidth on a numbered graph, giving actionable information on each unit counted and also an overview pattern, thus creating a system to help identify relationships between the mother’s labor activity and signs of fetal wellbeing or lack therefor.

Design of LTV Graphic Form: 

The purpose of the form for IA is to systemize the data identified. It quantifies, qualifies and co-ordinates the recorded information about FHT variability, uterine forces, periodic changes if present, cervical effacement and dilatation, descent of presenting part (station) and expulsive stage (urges to push). It also notes several other aspects of the mother’s labor and wellbeing. But in most labors, where the baseline is normal and there is consistently good variability, simple charting of baseline and variability on standard labor notes/flow sheet is quite sufficient (i.e., you don’t need to use CCM form for graphing FHT when there is no question or concern of fetal wellbeing).

If fetal heart tone variability is absent or when a specific concern occurs in which it is clinically beneficial to document the relationship of fetal cardiac patterns to uterine activity, this formalized display of data by using the LTV graph can be very helpful in making timely management decisions.

Unlike the real time print-outs of continuous EFMs which result in reams of disassociated data, this FHT Long-term Variability (LTV) graph has the advantage of integrating data over many hours of time on a single sheet of paper so that meta-patterns can be discerned, allowing the practitioner to compare fetal heart activity at different stages of labor or under different circumstances. This appears to be a distinct advantage over the current method continuous of EFM.

Charting Criteria for IA Form:

Palpation and recording of Uterine Forces: UC are quantified on a 1 – 5 scale as follows: Uterine Contractions — #1) under 30 seconds; #2) 35″ to 50″; #3) 55″ to 65″; #4) 70″ to 85″; and #5) over 90″. You arrive at these time frames by palpating the length of the UC manually (i.e. the midwife’s hand resting lightly on the fundus of the uterus, with finger tips pressed slightly into the body of the uterus, between contractions to determine when the next contraction starts and during the entire length of the UC). If there are any questions about the efficiency of the labor, manually palpate contractions for at least 10 minutes.

Experienced midwives cautions against calculating the length and strength of UCs by asking the mother to tell you when they feel the contraction start and stop, or by using verbal clues (independent of manual confirmation). Visual and auditory clues or the mother’s report of when they start and stop is often misleading. By the sight and sound of things, it looks like long and/or strong contractions, giving a false impression of a good labor pattern.

However, when the uterus is manually palpated with each contraction over the course of 5, 10 or 15 minutes, the UCs turn out to be much less intensity and much shorter. Also replying on the mother’s report sometimes will cause you can miss forceful contractions because the mother-to-be has such excellent coping skills (and more often than not, is a multip!)

A second quality of uterine forces is ability to indent the uterine wall during the apex of the contraction. As UCs increase in length they also increase in strength so that the uterine wall become “board-like” or unable to be indented by palpation.

In UCs lasting 30 to 50 seconds (1+ or 2+), you can usually indent the uterus during the height of the contraction. In UCs lasting 55 to 90 seconds (3+, 4+ or 5+), it is usually not possible to indent the uterine wall. In instances in which the length of the contraction is great but the quality is poor, subtract 1 or more from the scale. For instance, a UC lasting 60 seconds but never becoming board-like would be charted as a 2+ instead of a 3+ and marked with an asterisk* and also noted in the progress notes as less forceful than expected.

Cervical changes, fetal decent and expulsion are noted traditionally (cx dilation 1-10 cms, effacement in percentages, descent in station -5 through +5). An additional notation of Urges to Push (UTP) is qualified in as: Variable/intermittent (V) Spontaneous/sustained (S) Irresistible/ uncontrollable (I). The perineal stage or incremental crowning may be indicate by the initials “IC”.

Intra-uterine resuscitation is designed to immediately reduce the stress on the unborn baby by instructing the mother NOT to push, use of anti-gravity positions, lying left side, bolus of IV fluids, etc. Administration of maternal 02 due to fetal bradycardia should also be noted on the FHT graph. Maternal O2 at 8 liter via tight fitting mask is recommended for evidence of fetal hypoxia. Midwives need to anticipate that intrauterine resuscitation will be followed by the need to perform neonatal resuscitation. Oxygen supplies should be adequate to meet the needs of both procedures. In that regard, it is useful for the second call midwife to also make available her own cylinder of oxygen as a backup.

Criteria for Long-term Variability (LTV):

  • Normal when over 6> bpm amplitude; “reassuring pattern” — represents a normally oxygenated fetus without evidence of asphxial distress
  • Decreased when less than <6 bpm — may indicate sleep cycle (which should never be longer than 90 minutes), CNS depression to drugs or mild to moderate hypoxia
  • Absent when less than <2 bpm — insufficient oxygen to preserve cerebral & myocardial tissue and represents uncompensated fetal acidosis
  • Saltatory patterns — when over 25> bpm — may indicate a brief or acute hypoxic event

Criteria for Periodic Changes: Transient slowing of the fetal heart rate with UCs is known as a deceleration, while a transient increase is known as an acceleration.

This data is collected during UCs. The type or category noted as — Accelerations (A), Decelerations — Early (E), Late (L) and Variables (V).

In early decels, the lowest point coincides with the peck of the UC in the shape of an inverted bell curve.

Late decels begin to dip as the contraction wanes and become most profound after the contraction has ceased. As graphed on EFM strip, the two lines (Toco & FHT) slide down together like parallel ski tracks. Recent ACOG literature is now grouping both early and late decels together and using the terms “reflex” and “non-reflex”, based on the presence or absence of variability to distinguish the clinical importance of this type of pattern.

It is considered a “reflex” late decels pattern when the drop in bpm is gradual and mirrors the UC (either during or following the UC) but still maintains long & short-term variability. It is considered to be a true “late” or non-reflex (ie., caused by hypoxia) decel when variability is absent.

For purposes of this technical bulletin, the distinction between early and late decels (with or without variability) has been maintained. This is consistent with the criteria used by Drs Gibbs and Arulkumaran in their very helpful book “Fetal Monitoring in Practice”, which was used as the basis for the technical bulletin on episodic EFM.

Variable decels are “V” shaped, in which the FHR falls and recovers suddenly and varies greatly in timing — that is, it is not predictably in relation to UCs. This is the most frequent type of “non-reassuring” pattern. They are variable in duration, shape and profundity and thought to be caused by a vagal nerve response. In that case, they would be considered to be “reflexive” in the ACOG categorization. In first stage labor variable decels are associated with umbilical cord compression; in second stage they can be caused by head compression. As long as variability is present, they are considered to be benign (reflexive).

The highest or lowest beats-per-minute (as calculated by the lowest or highest 5-second unit) and the length of the period are also noted when accelerations or decels are present.

Loss of Reassuring Patterns

Non-reassuring connotes a neutral rather than a negative or pathological condition indicating fetal stress or distress. However, like a yellow caution light, they require a higher level of attention on the part of the practitioner.

Pronounced Lack of Variability / Flat EFM Tracing: Profound and prolonged Lack of Variability (flat EFM tracing) or flat sound as detected by IA is quite distinct. The number of bpm (for example, baseline of 120 bpm equates to 10 beats per 5 second increment) will be incredibility precise and predictable, giving rise to a very mechanical quality of repetition.

This is a different set of circumstances than a heart rate with audible decels or arrhymia. As in the above example of 120 bpm baseline, you will hear the 10th beat will occur again and again and again at precisely the last “tick” of the 5-second unit for 12-18 times in a row – all without any variation.

If this mechanical quality is heard, listen continuously or listen again after every contraction until the condition corrects itself or your steps to correct it are effective. If present more than 10 minutes, the practitioner may choose to stimulate the fetus through the “earth shake” maneuver (slow external shaking or jostling through abdominal wall), acoustical stimulation or vaginally rubbing the baby’s scalp. If that doesn’t resolve the problem, do a vaginal exam to check for possible occult cord prolapse (some midwives also push the baby’s head up a bit as a diagnostic activity to see if that changes the FHR pattern).

Try maternal position/activity change, O2, IV bolus, physician consult or transfer of care to medical management unless delivery is imminent, the condition corrects itself or there are other reasonable explanations for this occurrence.



Useful Information/Quotes from Gabbe’s Obstetrical Textbook ~ Obstetrics: Normal and Problem Pregnancies, 1991 edition

“Perhaps the most reliable indicator of fetal well-being available to the  obstetrician is the finding of normal beat-to-beat variability.”

“It is unusual for a heart rate under normal nervous system control to be steady at any one consistent rate. Rather, there is considerable variation or short-term variability on a beat-to-beat basis, usually ranging from 3 to 8 bpm around an imaginary average heart rate. Fluctuation or long-term variability occurs as well, usually having a cyclicity of three to five cycles per minute (cpm). The presence of normal fetal heart rate variability is one of the best indicators of intact integration between the central nervous system and the heart of the fetus.”

“The clinical significance of short-term variability or beat-to-beat variability has been assessed for a number of years. To date, no clinical significant difference between long-term and short-term variability is uniformly apparent or clinically significant. Wherever there is good beat-to-beat variability present on a heart rate tracing without other indicators of loss of fetal well-being, the likelihood of delivering a significantly-jeopardized fetus is exceedingly low. Even when other parameters suggest fetal distress, the presence of good beat-to-beat variability is generally a reassuring finding.” [26]

“Exaggerated or increased fetal heart rate variability ( >>25 bpm) may be representative of a shifting PO2 and PCO2 relationship…”p.466

Periodic Changes — “Transient slowing of the fetal heart rate with UC is known as a deceleration, while a transient increase is known as an acceleration. The four patterns of clinical significance are accelerations and early, variable and late decelerations.” p. 469

“It was soon appreciated that the fetal heart rate counted over a period of time and expressed as a mean (e.g. 150 bpm averaged over 4 to 5 minutes) was an inadequate measurement. Seasoned clinicians, using stethoscopically derived fetal heart rate data, were wrong at least one-third of the time…” (NOTE: They were correct 2/3 of the time)

“Accordingly, investigators began to plot by hand fetal heart rate in a beat-by-beat manner. Subsequently, an electronic system, the current fetal heart rate monitor, was developed to do this function automatically.”

“…heart rate auscultated by the human ear must be averaged over a given number of beats in seconds or minutes, and this averaging destroys the physiologic detail.” p. 461 [emphasis added]

“Fetal heart rate variability can only be appreciated when it is continuously and instantaneously calculated and recorded on a beat-by-beat basis.”

“However, in prospective, randomized studies, the incidence of neuralgic damage and perinatal death associated with the use of electronic fetal monitoring is not significantly lower than documented with older methods of fetal surveillance, including intermittent fetal rate auscultation by stethoscope or Doppler.” p. 457

” …has been demonstrated that electronic fetal heart rate monitoring is associated with an increased incidence of delivery by cesarean section without demonstrable improvement in perinatal outcome…” p. 457

“…the outstanding value of fetal heart rate monitoring during the intrapartum period is the reasonable sensitive ability of the technique to confirm fetal well-being and to permit labor to continue without unnecessary intervention. Unfortunately, this method of surveillance is less able to identify if the fetus is clearly in distress. Accordingly, in utilizing fetal heart rate monitoring alone, a large number of fetuses that are in good condition and that show no clinical evidence of morbidity may be delivered by “emergency” measures.” p. 484

“Most of the criticism of EFM has been aroused by this deficiency. Banta and Thacker [47] reviewed the world literature and could find no statistical evidence that fetal heart rate surveillance reduced perinatal morbidity or mortality. p. 484

“A few large prospective investigations have recently failed to demonstrate that continuous EFM is associated with an improved outcome.”

“In total, 16, or almost 80% of the 22 cases of cerebral palsy had not shown clinical evidence suggestive of intrapartal asphyxia. The incidence of cerebral palsy was nearly identical for both groups, 1.8:1,000 for EFM and 1.5:1,000 for the intermittent auscultation. The authors concluded that, compared with intermittent auscultation, EFM had little if any, protective effect against cerebral palsy. Overall, it appears that no more than 20% of cases of CP are associated with intrapartal events.” [54]

“Recent studies have also failed to demonstrate improved outcomes in pre-term infants followed with continuous EFM as compared with periodic auscultation.” [55]

“It is the opinion of ACOG, as reported in its technical bulletins [59,60], that continuous EFM with acid-base support and appropriate intermittent monitoring by auscultation or Doppler ultrasound are of equal value for the monitoring of the fetus. Some investigators have emphasized that, on a statistical basis, there is little advantage to continuous EFM for the normal fetus.” “It must be emphasized that in most studies comparing EFM to auscultation, auscultation has been carried out by a single nurse at the bedside. Such staffing is not possible in most institutions. [61] p.485 (emphasis added)

[Note: midwifery care naturally provides this auscultative model of one-on-one care at the mother’s side]

Informed Refusal Protocol according to Gabbe’s Obstetrical Textbook (1991)

“An occasional patient simply refuses any form of fetal surveillance. When appropriate explanations have been given and the patient still declines the process, it is generally advisable to have two independent observers document in the chart that the patient refuses “usual and customary forms of intrapartum fetal surveillance” in order to establish the facts that (1) the surveillance was offered, (2) the reasons for its use were explained, and (3) the complications that can arise from not using these forms of monitoring were known to the patient and fully understood at the time of the refusal.” p. 489

ACOG Antepartum & Intrapartum Management June 8-10, 1995

Material published by the 1995 ACOG conference states that: “Fetal Heart Rate Monitoring was introduced into clinical practice … without trials of its effectiveness and now trials are unable to show efficacy in clinical usage.”

“Despite lack of efficacy, FHRM is widely used in North America, with no apparent decrease in usage since publications of its lack of efficacy. This extensive usage continues despite possible deleterious effects (e.g., increased cesarean section rate) [p. 157]

“In several randomized trials … there is no evidence of any meaningful decrease in asphyxial damage in babies who were continually monitored. There is a significant increase in cesarean sections in monitored cases.” [p. 159]

In regard to reducing cerebral palsy through obstetrical management, it notes that: “…there is no evidence for the widespread belief that intrapartum care commonly influences the risk of cerebral palsy…”

“… the vast majority of cases of cerebral palsy are exceedingly unlikely to be preventable by more intensive forms of intrapartum care”. [p. 152, ]


Statistical data from “Obstetrical Myths Versus Research Realities” **page 25

by Henci Goer:

Mortality rates for Women of childbearing age per 100,000 — a comparison of vaginal birth, cesarean section and auto accidents

Vaginal Birth: 6 deaths per 100,000 // or ratio 1 death out of 16,666 vaginal deliveries

Auto Accidents women ages 14-40: 20 deaths per 100,000 // or ratio of 1 death for every 5,000 women in that age bracket

Cesarean Section: 31 per 100,000 // or ratio of 1 death out of 3225 surgeries


Continuous Electronic Fetal Monitoring is directly associated with an increase in cesarean surgeries without any decrease in either fetal mortality or cerebral palsy. Cesarean surgeries are directly associated with increased rates of maternal mortality.

Preventing unnecessary cesarean surgeries prevents maternal mortality. Replacing Continuous EFM with intermittent auscultation (or occassionally augmented with episodic EFM) prevents maternal deaths and spares both mother and baby the interruption of bonding that accompanies cesarean surgery.

Prevention of medically-unnecessary reproductive surgeries increases opportunities for valuable maternal-child interaction during the postpartum, promotes family values and the rate of successful breastfeeding and reduces the cost of maternity care.

Intermittent Auscultation should be the standard of care except in circumstances of evident medical need.

Characteristics of Clinical Competency
associated with 
Maternity Care Systems