Intrapartum fetal heart rate monitoring: do Swiss midwives implement evidence into practice?

OBJECTIVE: Evidence Based Medicine has shown that the results of continuous electronic fetal heart rate (FHR) monitoring are equivalent to those of intermittent auscultation. We were interested in the method midwives preferred to use to monitor FHR during labour and the factors which influenced their choice of method. STUDY DESIGN: A questionnaire with Likert scaled questions was sent to 500 German speaking Swiss midwives. Data analysis was performed by using SPSS for Windows. RESULTS: The majority of the midwives were confident monitoring FHR using intermittent auscultation as their main method during low risk delivery. The essential factors influencing the choice of method of FHR monitoring were their own personal experience and hospital guidelines. Less important were factors such as risk category, litigation, the mother's preferences, research results, time and staffing levels. CONCLUSIONS: Although the skills necessary to implement evidence into obstetrical practice are still available, evidence based research results do not seem to be of great importance, when midwives decide which method to use for intrapartum FHR monitoring. Hospital policies and the professional training received were more important factors. Programs designed to implement evidence in care should reflect the identification and use of these factors in order to facilitate the process of realisation.

Safety of term vaginal breech delivery.

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.