Improvement Story

Increasing Use of
Intermittent Auscultation for
Low-Risk Laboring Women

Cathy Emeis, PhD, CNM
Assistant Professor & Assistant Program Director for
Nurse Midwifery, Oregon Health & Science University
School of Nursing, Portland Campus

What did you set out to change or improve?
To reduce the number of low-risk laboring women using the electronic fetal monitor (EFM) continuously during labor. To increase use of intermittent auscultation (IA) based on a new clinical guideline.

How did you change it?
We developed a clinical guideline for our hospital unit using the guidance from the ACNM Clinical Bulletin on Intermittent Auscultation for Intrapartum Fetal Heart Rate Surveillance.

Who was involved in making the change and what was each personís role?
One CNM took the lead on this project . She became enthusiastic about making this happen after attending a University of California at San Francisco Antepartum and Intrapartum Management conference. She and two nurses from the labor unit performed the groundwork on searching for evidence and then initiating the creation of an IA algorithm. This was presented to a multidisciplinary committee for approval by the midwifery practice manager.

How did you determine if the change worked?
Success would be defined as

  1. fewer women dependent on the EFM for their fetal surveillance during labor;

  2. no increase in poor neonatal outcome (poor neonatal outcome is reviewed routinely during faculty midwifery peer review process, and at department of OB/GYN quality executive committee (sometimes as weekly morbidity and mortality conferences)

  3. increasing competency (CNM, RN, SNM) and comfort with performing IA

What was the biggest barrier to making the change?
Coming to agreement on the guidelines with the Professional Practice Leader for Women and Children Services (a CNS) regarding specific parameters in the algorithm

How did you overcome that barrier?
We formed an interdisciplinary sub-committee to come to agreement on the algorithm.

If you have data or other evidence that your change was successful, please provide that data.
We anticipate the number of women who have continuous EFM has reduced. We will be analyzing this number for 2012 in the near future.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
Find a nurse leader in a position of authority to aid in co-development of such a guideline. This type of practice change is heavily dependent on nursing buy-in for success. We had buy-in from the nurse educators and nursing staff, but the nursing practice leader was most comfortable with continuous EFM.