Editor’s Note: Jan Tritten, Midwifery Today’s mother and editor, often posts questions of interest for discussion by midwives on Facebook. We decided to share the thoughts on these topics in our magazine each quarter (sans emojis). Some of it may be controversial, but we hope that these conversations will inspire even further discussion and learning on the subjects we cover. To join the discussion: facebook.com/jan.tritten
Conversations from Facebook
If you use a fetoscope (obstetric stethoscope) during labor, how do you use it in your practice? If not, why not? If you do use a fetoscope, which one do you like best?
I don’t use it in labor because it’s quite difficult to get someone in active labor to stay still and quiet enough for it to be effective, not to mention [the impact of] room noise. It’s quite different from a prenatal visit. I need to be sure of what I’m hearing and be as unobtrusive as possible to the laboring client. (I almost never need to ask someone to change positions with a Doppler; I can make it work in any tight spot or in the shower.)
I have used a fetoscope during labor if that’s the mother’s preference. I prefer to use a Doppler during labor because it’s important to me to have a very clear idea of how baby’s heart is responding to contractions and a variety of positions and because I feel it’s unfair to ask a laboring mom to lie down on her back and be quiet through contractions. (If that’s her preference, I will do my best to support that—but I make it clear from the beginning that in order to be in my care, she must be okay with a Doppler if I feel like I can’t get a good reading on heart tones with the fetoscope.)
We liked our old Leff scopes. The nice thing is that you can give the earpiece to mom and/or family to listen once you find the heartbeat. The other thing I like about it is that it helped locate the position of the baby because it didn’t reverberate all over!
A fetoscope can work in almost any position. I have gotten FHT with mom on hands and knees many times.
I have no doubt that other midwives can get heart tones with positions/tools I can’t. But given my expertise and hearing, I know it doesn’t work well for me to use a fetoscope in labor. Honestly, I really hate to disturb a laboring mom and I know of no way for me to listen to heart tones without a Doppler without disturbing her. But, if that is her preference, I will do my level best.
I am an old woman who never had a Doppler and had to borrow one once when the mom had severe fat necrosis in abdomen. I strongly believe that every midwifery student should learn how to use fetoscope first and well, including in labor. Doppler is ultrasound and is cumulative. Does no one read the research anymore? My job is to provide the lowest intervention possible, bringing in more sophisticated equipment as needed. With proper training, a midwife does not have to have the mother lie down.
—Mary Ann Hall
I just love the sound and feel of listening with my ear. It really connects me to the baby. I haven’t done it in labor, but love teaching the dad and siblings to do it themselves.
Most of our clients labor in the tub. In order to not drown myself, I use a Doppler.
—Chrisje J Servranckx Vermeersch
I agree that we should listen to the baby. The timing of heart tone protocols should be based on evidence, though. Why is the World Health Organization schedule and method so different from ACOG’s? And why are so many midwife statutes based on the ACOG-suggested “high-risk schedule” when we are only supposed to be doing low risk at home?
I am convinced that we must listen, and I teach the subject “monitoring heart tones/detecting fetal distress in labor.” It is essential. However, we should not be trying to emulate the electronic fetal monitor which has caused so many problems and unneeded c-sections for false declaration of fetal distress.
Out of the box … training oneself to feel the heart tones with the palm of the hand also works just fine … although I used an Allen ten. Even for a waterbirth, to keep the paperwork tight.
—Miriam Medicine Prayer
I listen every hour if I am there in early labor. I listen every 30 minutes during active labor and every 15 minutes during pushing. I listen through and after a contraction at least once an hour, and then during pushing I listen during and through more contractions than not. I am not trying to copy EFM; I am trying to make sure baby is coping with contraction and that I am not hearing late decelerations.
Hourly, half-hour, and fifteen minutes is ACOG low-risk schedule and makes sense. WHO is similar. The difference is the length of time we listen and timing to contractions rather than the clock.
I have often said that FHTs are the only way a baby can tell us how it is doing. It’s the only way to talk to us. And we’d better be listening.
I like a Doppler for the last few hours of labor … especially in water. It is easy on the mom and not invasive, as long as I hear good recovery I listen every 15 minutes, but if I’m concerned with recovery, I will suggest changes and listen more often. In early labor I use a fetoscope following the WHO protocol … FHTs are the baby’s voice in labor.
It is important to listen though the contraction—you are listening for recovery. ncbi.nlm.nih.gov/m/pubmed/18191915.
For years in the beginning of my practice all I used was my Delee-Hillis. I loved it.
I [have been] retired from practice for 10 years and only used an Allen-type fetoscope unless I couldn’t hear due to positioning. I rarely needed a Doppler even with waterbirths and had excellent outcomes. Is it political pressure to use Dopplers so much? Or CYA? Or are midwives now convinced that Dopplers are harmless?
Our ears are unique and we will likely find a scope that works for us best. I could not use the Delee-Hillis and hated how it felt when used on me. The Leff worked well for many years, as does a good, high-quality Sprague-Rappaport stethoscope, but I really like my pinard best. I can feel the heart on my ears.
I have a very hard time hearing through others’ fetoscopes. But I put extra ear buds from a Littman stethoscope on my fetoscope—and they squish really well to seal in my ear.
I love the fetoscope in prenatals. I don’t know why I don’t use in labor; I guess I think it would be harder to accommodate mom’s position changes and to hear very well when mom is moaning and making noises.
I prefer the Leff; at times the Allen is easier.
I had homebirths with my midwives using a fetoscope—I hated how I had to lie still only on my back for FHT.
I like to use my ear … pressed firmly, for me, it works better than the fetoscope. Then the partner or family members can listen in the same place … it’s very exciting for them and they feel empowered.
Fetoscope all throughout pregnancy and Doppler at birth unless otherwise requested. I feel that there is added merit for the parents to hear the baby in labor.
—Chavah Meira BenZion
I love my fetoscope and use it regularly prenatally (not the Doppler unless early or if parents want, which is rare). I use the Doppler for labor as I want to get FHT without moving mama. I bought an expensive Allen after using a $15 fetoscope that was a gift and went back to the $15 one. It works great and actually better than the Allen for me.
I use a Pinard first, then Doppler. I also ensure that students know how to use it and what a fetal heart sounds like, how to count without the display.
The fetoscope is my preferred method of listening to heart tones during prenatal visits for many reasons: it takes time, patience, and attentive listening. All are valuable attributes of midwives and mothers. The acoustic sound of the baby’s heartbeat is more pure to its original nature. The fetoscope requires you to be more specific and helps to accurately determine position. Plus there is no cellular disruption from the use of ultrasound and batteries are not required.
However in labor, I don’t want to make mom lie on her back for long periods of time while I listen before, during, and after contractions while I press the fetoscope into her abdomen. The Doppler is faster, waterproof, and everyone can hear the heartbeat at the same time.
I have had moms request zero non-emergency Doppler use. I have several cheap stethoscope-style fetoscopes scattered around—in my office, in my truck, in my birth bags. I have no luck with pinards and they require the mom to be in an accessible position. With this type, the mom can be in almost any position, and I have even gotten great results underwater in the birth tub; as long as there is not a lot of noise and water movement I can hear just fine. Afterwards I just throw the fetoscope in a bowl of alcohol to clean it up, and send a large pipe cleaner through the tubing. Dopplers are nice, but they can fail for many and various reasons, so I think keeping this low-tech skill polished is important.
I always start with my Allen prenatally. During labor, especially with a waterbirth, I like my Doppler. Although I never had one for the first 30 years of practice, heart tones are critical.