Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy

BackgroundIntermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps.MethodsWe conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach.ResultsThe searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29–2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult.ConclusionAlthough IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa.

**背景** 间歇性听诊（Intermittent auscultation, IA）指在活跃产程中短时段听诊并计数胎儿心率（fetal heart rate, FHR）的技术，而持续胎心监护（continuous cardiotocography, CTC）则指长时段的胎儿心率监测。尽管现有证据表明，对于并发症风险较低的健康孕妇，IA是最佳的监测方式，但目前尚无科学证据能明确IA的理想设备、监测时机、频率与时长。本研究旨在对该领域进行全面综述，明确并描述实施IA的方法与操作规范，梳理不同IA方法的相关证据与准确性，并识别当前的研究空白。

**方法** 本研究遵循乔安娜·布里格斯（Joanna Briggs）方法学开展系统性范围综述。检索了截至2019年1月的Medline、EMBASE、护理及联合健康文献累积索引（Cinahl）、母婴护理数据库、考克兰图书馆（Cochrane Library）、SveMed+、科学引文索引网络版（Web of Science）、斯高帕斯数据库（Scopus）、拉丁美洲与加勒比健康科学文献数据库（Lilacs）以及非洲在线期刊库（African Journals Online）。同时对相关文献及数据库进行了手工检索。纳入了所有国家的研究，以及丹麦、英国、美国、新西兰、澳大利亚、荷兰、瑞典、丹麦、挪威的国际指南与国家指南。采用AGREEMENT工具对纳入的指南进行质量评价。本研究参照《考克兰手册》（The Cochrane Handbook）中的方法，开展了针对多普勒设备（Doppler device）与Pinard听诊器（Pinard device）用于IA的效果的Meta分析，并采用GRADE方法对证据总结进行整体评价。

**结果** 本次检索共获得6408条检索结果，最终纳入26项研究与11篇指南。纳入的研究对IA的实施技术描述略有差异，部分研究未提供详细的操作说明。仅有少数研究详细描述了IA的正常与异常结果特征。全部11篇指南均推荐对低风险孕妇采用IA，但在IA的监测频率、时机、时长以及需观察的FHR特征方面，各指南的推荐略有差异。纳入的研究中有4项为随机对照试验，共涵盖8436对母婴，旨在比较多普勒设备与Pinard听诊器用于IA的效果。与使用Pinard听诊器相比，采用多普勒设备可更频繁地检测到异常FHR（风险比=1.77；95%置信区间：1.29~2.43）。其余所有孕产妇或新生儿结局均无显著差异。另有4项研究评估了IA结果的准确性。正常FHR最易于准确识别，而识别减速、跳跃型等周期性FHR模式则难度更高。

**结论** 尽管IA是推荐的监测方法，但目前尚无已发表的研究对IA的操作规范进行评价。亦无研究评估IA结果解读的组间一致性，且仅有极少数研究探讨了临床医师对IA检测到的FHR模式的描述能力。本研究未发现证据支持在IA中优先选用多普勒设备而非Pinard听诊器，反之亦然。