Chapter 9. Monitoring fetal wellbeing during routine antenatal care
Introduction
A significant aspect of the midwife’s role in the antenatal period is to monitor the health of the woman and of her unborn child. This chapter focuses on the role of the midwife in monitoring the wellbeing of the developing fetus during routine antenatal care. As antenatal care usually takes place within the community setting in the United Kingdom this chapter will concentrate on the antenatal examination within this arena. The skill of abdominal palpation with regard to monitoring growth, activity and the fetal heart rate, will be described.
Background
Consideration for the wellbeing of the fetus should not be taken in isolation from the wellbeing of the mother, as they are both intrinsically interlinked. Pregnancy is a time of change for women and their families and the relationship she has with her unborn baby is complex. Many fear that the wellbeing of their baby may have been inadvertently compromised. In a large questionnaire-based survey it was shown that women commonly feared there was something wrong with their babies, particularly at the beginning and end of pregnancy (Statham et al 1997). Part of a midwife’s role is to enhance a woman’s wellbeing through reassurance that her baby is growing and developing at an appropriate rate, through appropriate monitoring techniques (NMC 2004).
National guidance
The NICE Guidelines for antenatal care (NICE 2008) provide guidance for caring for the woman and her fetus. They state that midwives should always treat women:
with kindness, respect and dignity…The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times…Women should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals
(NICE 2008:37)
The guidelines state that the number of appointments required: ‘in order to successfully monitor the baby should be dependent on the needs of the mother and baby.’ (NICE 2008:72). This means that the midwife should provide a flexible approach to care and using her professional judgment over the woman’s and baby’s needs.
Professional guidance
In the midwives rules of practice (NMC 2004) it states that the needs of the woman or baby should be the ‘primary focus’. In the EU activities of a midwife, one of the roles is:
To diagnose pregnancies and monitor normal pregnancies; to carry out examinations necessary for the monitoring of the development of normal pregnancies.
(NMC 2004)
Access the NICE antenatal guideline: http://www.nice.org.uk/guidance/index.jsp?action=download&o=40145 and look at section 4:7 What should happen at antenatal appointments?: the suggested patterns of care for nuilliparous and multiparous women.
Access http://www.nice.org.uk/guidance/index.jsp?action=download&o=40115 and look at section 1.10 on Fetal growth and wellbeing. Consider the midwife’s role in monitoring the growth of the baby.
Students are expected to learn skills of communication in the antenatal period, as well as to ‘assess and monitor women holistically’ through the whole pregnancy continuum ‘through the use of a range of assessment methods and reach valid, reliable and comprehensive conclusions’, further: ‘to carry out examinations necessary for the monitoring of the development of normal pregnancies.’ (NMC 2009)
Monitoring fetal wellbeing
Assessing fetal growth
During the antenatal examination, the midwife uses a range of methods to assess fetal growth, including sensitive use of discussion, palpation and measurement.
Discussion with the woman
Probably the most important gauge of fetal growth is the woman’s own estimation. She is the one who is living with her growing uterus and able to note the impact of her changing shape on her daily life. She may be finding it more difficult to bend over and pick dropped items from the floor as fundal height increases. Alternatively, earlier in pregnancy she might be concerned that she has not yet needed to buy any maternity clothes. A simple question such as, ‘How do you think your baby has grown since we last met?’ provides an opportunity for her to voice any concerns.
Women may worry about the growth of their baby at both ends of the scale. Fear that it is growing rapidly may raise doubts about her ability to have a vaginal birth. Worry that the baby is too small may cause concern about its development and health. Concern about fetal growth can also change over time, with women worrying that they are not growing enough in early pregnancy and then too much as pregnancy advances and thoughts of the birth become more prominent.
Verbal consent to palpate the woman’s abdomen should be gained at each examination. Although it will not be appropriate to launch into a full-blown explanation about what you are going to do each time you meet, if you have never met the woman before, or it is the first time she has attended the clinic, she needs to know what the palpation will involve. As a midwife, you will develop your own way of asking permission to undertake procedures, but avoid the use of statements such as, ‘I’m just going to…’ or ‘Just pop up on the couch’. Consent should not be assumed, and such language can come across as condescending. Where any language difficulties are anticipated, an interpreter should be used.
Having ensured that the woman does not have a full bladder, that she understands what you aim to do and that she agrees to it, ask her to sit on the couch. She should be asked to undo or loosen her clothing before you lower the headrest, so that she can see what she is doing. The headrest should not be totally flat. Her legs should be covered with a modesty sheet and her arms by her side. The equipment required for palpation is listed in Box 9.1.
Box 9.1
Equipment required for abdominal palpation
• Pinard’s stethoscope
Rationale To locate the fetal heart
• Doppler
Rationale To enable the woman/partner/children to hear the fetal heart
• Aqueous jelly
Rationale To facilitate contact with the Doppler transducer and maternal abdomen
• Tissues
Rationale To remove excess jelly from the woman’s abdomen
• Disposable or washable tape measure
Rationale To measure the symphysis–fundal height tape measure
• Modesty sheet
Rationale To cover woman’s legs
Inspection
The first observation that the midwife makes, before she lays her hands on the woman, is to inspect the abdomen for shape, scars, skin and size (the four S’s):
Shape
The uterus of the primigravida is ovoid in shape compared with the more rounded shape of multigravida. The abdomen should be inspected for curves and dips that might give clues regarding the fetal position. If the fetus has adopted an anterior position it may be possible to detect the curve of the fetal back. A fetus in the posterior position might give the abdomen a dip or hollow (best observed by looking at the abdomen at eye level).
Scars
Abdominal scars should be noted and should correspond with the ‘previous medical history’ taken at the booking visit. Women may need reassurance that a scar will not burst open, but that the skin will gradually stretch to accommodate the growing fetus.
Skin
Find out what potential fetal anomalies are associated with polyhydramnios and oligohydramnios.
Make sure you know what the woman might complain of when there is excess amniotic fluid.
Make yourself aware of the clinical significance of acute and/or chronic polyhydramnios.
Size
The first estimation of fetal growth is made by the midwife when she observes the abdomen. However, this is only part of the picture and one that can be entirely misleading, depending on the tone of the abdominal musculature, the amount of amniotic fluid, the accumulation of subcutaneous fat and fetal position. Further clinical assessments are required before fetal size can be more accurately judged, although clinical estimation of fetal weight is notoriously inaccurate (Enkin et al 2000).
Palpation
This essential practical skill takes time to develop and, like all skills, improves with practice. The hands of a midwife become her most powerful tools, with which she can convey care as well as detect both maternal and fetal wellbeing.
Before the procedure, the woman should be encouraged to empty her bladder. She might be advised to go to the toilet when she arrives at the antenatal clinic rather than during the consultation, but her comfort should be reassessed prior to the palpation. If she is trying to hold on to a full bladder, her abdominal muscles may be tense and palpation uncomfortable. A full bladder can significantly affect fundal height (Engstrom et al 1989) and lead to undue concern about fetal growth.
Maintaining privacy and dignity throughout the palpation is essential. If possible, the examination couch should be arranged so that the woman’s feet are away from the door and that her left-hand side (if the midwife is right-handed) is against a wall. There should be a fold-out step to enable the woman to reach the couch with ease and an adjustable headrest should be made use of. A sheet should be used to cover the woman’s legs, even if she still has trousers on. This conveys the message that you understand that she is exposing her body and that you will continue to take steps to minimize this exposure.
The woman must feel safe and the focus of the midwife’s attention at all times. Of course, this should be so during all points of contact between the woman and the midwife, but it is especially important when the woman is lying down and the midwife is standing up. This physical dominance must not be transferred into a superiority that prevents or spoils meaningful communication.
Estimation of gestational age
The next part of the palpation involves estimation of gestational age and size. The midwife, usually standing with the woman’s head to her left, uses her warm, clean hands to locate the uterine fundus. First, she applies the pads of the fingers of the left hand to the abdomen, just below the woman’s xiphisternum. Using a gentle pressing movement, the midwife works her way down the abdomen until she feels the resistance of the fundus.
The midwife uses three landmarks when assessing gestational age by palpation: the xiphisternum, the umbilicus and the symphysis pubis. She estimates that, at approximately 12 weeks of pregnancy, the fundus is palpable above the symphysis pubis. It rises approximately a centimetre each week thereafter, being between the pubis and the umbilicus at 16 weeks and at the umbilicus by about 22–24 weeks. By 32 weeks the fundus is midway between the umbilicus and xiphisternum. At 36 weeks the gravid uterus has reached the xiphisternum and in subsequent weeks, as the presenting part enters the pelvis, the fundal height descends slightly (‘lightening’). The overall size of the uterus must be taken into account, however, as fundal height will vary depending on the fetal lie.
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