Putting intelligent structured intermittent auscultation (ISIA) into practice.

BACKGROUND: Fetal monitoring guidelines recommend intermittent auscultation for the monitoring of fetal wellbeing during labour for low-risk women. However, these guidelines are not being translated into practice and low-risk women birthing in institutional maternity units are increasingly exposed to continuous cardiotocographic monitoring, both on admission to hospital and during labour. When continuous fetal monitoring becomes routinised, midwives and obstetricians lose practical skills around intermittent auscultation. To support clinical practice and decision-making around auscultation modality, the intelligent structured intermittent auscultation (ISIA) framework was developed. AIM: The purpose of this discussion paper is to describe the application of intelligent structured intermittent auscultation in practice. DISCUSSION: The intelligent structured intermittent auscultation decision-making framework is a knowledge translation tool that supports the implementation of evidence into practice around the use of intermittent auscultation for fetal heart monitoring for low-risk women during labour. An understanding of the physiology of the materno-utero-placental unit and control of the fetal heart underpin the development of the framework. CONCLUSION: Intelligent structured intermittent auscultation provides midwives with a robust means of demonstrating their critical thinking and clinical reasoning and supports their understanding of normal physiological birth.

Intelligent Structured Intermittent Auscultation (ISIA): evaluation of a decision-making framework for fetal heart monitoring of low-risk women.

BACKGROUND: Research-informed fetal monitoring guidelines recommend intermittent auscultation (IA) for fetal heart monitoring for low-risk women. However, the use of cardiotocography (CTG) continues to dominate many institutional maternity settings. METHODS: A mixed methods intervention study with before and after measurement was undertaken in one secondary level health service to facilitate the implementation of an initiative to encourage the use of IA. The intervention initiative was a decision-making framework called Intelligent Structured Intermittent Auscultation (ISIA) introduced through an education session. RESULTS: Following the intervention, medical records review revealed an increase in the use of IA during labour represented by a relative change of 12%, with improved documentation of clinical findings from assessments, and a significant reduction in the risk of receiving an admission CTG (RR 0.75, 95% CI, 0.60-0.95, p = 0.016). CONCLUSION: The ISIA informed decision-making framework transformed the practice of IA and provided a mechanism for knowledge translation that enabled midwives to implement evidence-based fetal heart monitoring for low risk women.

Publicly-funded homebirth models in Australia.

BACKGROUND: Publicly-funded homebirth programs in Australia have been developed in the past decade mostly in isolation from each other and with limited published evaluations. There is also distinct lack of publicly available information about the development and characteristics of these programs. We instigated the National Publicly-funded Homebirth Consortium and conducted a preliminary survey of publicly-funded homebirth providers. AIM: To outline the development of publicly-funded homebirth models in Australia. METHODS: Providers of publicly-funded homebirth programs in Australia were surveyed using an on-line survey in December 2010. Questions were about their development, use of policy and general operational issues. A descriptive analysis of the quantitative data and content analysis of the qualitative data was undertaken. FINDINGS: In total, 12 programs were identified and 10 contributed data to this paper. The service providers reported extensive multidisciplinary consultation and careful planning during development. There was a lack of consistency in data collection throughout the publicly-funded homebirth programs due to different databases, definitions and the use of different guidelines. DISCUSSION: Publicly-funded homebirth services followed different routes during their development, but essentially had safety and collaboration with stakeholders, including women and obstetricians, as central to their process. CONCLUSION: The National Publicly-funded Homebirth Consortium has facilitated a sharing of resources, processes of development and a linkage of homebirth services around the country. This analysis has provided information to assist future planning and developments in models of midwifery care. It is important that births of women booked to these programs are clearly identified when their data is incorporated into existing perinatal datasets.

A survey of folic acid use in primigravid women.

A convenience sample of 320 consecutive primigravid women attending the antenatal clinic of a large Sydney tertiary referral hospital were invited to take part in a survey of folic acid use in pregnancy. The aim of the survey was to determine the number of primigravid women who commenced taking folic acid supplementation at least 1 month prior to conception. In addition the survey sought information on women's source of knowledge about the need for folic acid in pregnancy and whether their pregnancy was planned or unplanned. 295 women qualified to be included in the survey. While 88.1% of women took folic acid at some time prior to and/or during the first trimester, only 23.4% were found to have taken folic acid at least 1 month prior to conception. Of women with a planned birth only 34.5% commenced folic acid prior to conception. This survey adds further weight to the decision of the Australian Government to mandate for fortification of bread-making flour with folic acid, due to commence in September 2009. However, even with folic acid fortified food, health professionals need to continue to advise women to take supplements prior to conception and for at least 12 weeks into their pregnancy to prevent neural tube defects.