Are we seeing the end of an era? - the death of the Pinard. Why do I say this? in the latest clinical guidelines for Intrapartum Fetal surveillance (2006) The Royal Australian and New Zealand College of Obstetricians an Gynaecologists (RANZCOG)have sounded the death knock for the pinard. Guideline 7 "intermittent auscultation should be performed using Doppler ultrasound rather than a Pinard stethocope" Guideline 8 "auscultation should occur with Doppler signal on speaker mode". Since the publication of these guidelines, I have seen the disapearance of all the pinard on our labour and birth suite, which has promted me to ask the question? are we loosing the art and skill of using the pinard?
It is interesting to note that in the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI)2005, this report recommended training for midwives and junior doctors in CTG interpretation, because errors were being made which had a detrimental effects for both woman and baby. The question is asked what about senior doctors? who monitors them? CTG monitoring is technology spreading without justifed research.
It is a well know fact that CTG monitoring is not an exact science, however in the current litigatous climate it is the best we have and clinicans are inclined to feel protected by using this technology, even though you can have several clinicans disagreeing on the interpretation of the CTG.
Mahomed et al. (1994, pp 497-500) conducted a randomised controlled trial on the effectiveness of differnet methods of intrapartum monitoring. They found that the doppler sonicad compared with the pinard stethoscope was better at detecting abnormalities in the fetal heart rate. They also found that the pinard was more uncomfortable for the woman.
The doppler sonicad is the electronic equivalent of the pinard and has the advantage of the woman being able to hear the babys heart rate, and further protecting the midwife against litgation (Seymoour, 1995, p 47).
So is there still a place for the pinard stethoscope?
I would like to see midwives teaching students how to use the pinard again in conjuction with the doppler, so that we maintain the midwifery skill, you never know if technology fails we are still able to monitor the fetal heart.
References:
Ayres-de-Campos D, et al. Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision, Br J Obs Gyn, 1999: 106; 1307-1310.
RANZCOG Intrapartum Fetal Survellance Clincial Guidelins. 2nd edition. 2006
Seymour, J. (1995). Fetal monitoring.
9 comments:
I absolutely agree with your comments and feel its vital that midwives maintain their skills using pinards. But... having said all that, I now mostly use sonocaid, especially in labour, because it is easier to use when women are in 'awkward' positions and on water.
In order to get a true picture of comparative effectiveness, when conducting a randomised trial of Pinards or Doppler, it would be important that the practitioners using these tools were equally comfortable and confident in the use of each of them . Sadly many are losing skill with Pinards. Many of the students I work with struggle to get opportunities to use a pinard but I encourage them to do so as often as they can in order to familiarise themselves with hearing a fetal heart for real.
No matter how good the electronic tool is the sound we hear is still an electronic simulation of the fetal heart. The only way to actually directly hear the fetal heart beating is to use a pinard or stethoscope.
In my practice I have often used a pinard to hear the fetal heart and then offered the woman the option of listening through the stethoscope. Do we offer women an informed choice when it comes to using a dopler to hear the fetal heart. As you know fetal doplers and CTG machines use ultrasound waves, similar to an ultrasound scan. These tools have been introduced into obstetric care without ever having been properly evaluated regarding their safety and efficacy . Although they might appear reasonably safe we really do not know what the long term effects of this technology might be. It is still a trial awaiting longterm outcomes. When I had my children in the early 1980s routine scanning and use of dopler was becoming more common. This is still a relatively short time in our history. Are we monitoring the effects of these tools adequately?
Most of the women I have cared for in recent years have requested that I listen to the fetal heart with a dopler during pregnancy. I have to say that in labour I do often find it easier to use a dopler for intermittent monitoring, particularly if the woman is in water. It saves her having to move around so that I can check the fetal heart.
Now we can hear the fetal heart with a dopler we can hear it much earlier, around 10 weeks often. In the past we would not have been able to hear the fetal heart until after the woman had already started to feel fetal movements. Somehow I think that we take something from women by hearing the fetal heart beating so early. Although we all find this to be an exciting moment in the pregnancy it is taking some of the personal experience and knowledge of the mother for her unborn child away, and making it public knowledge. I also think it begins a dependence on technology to ensure the safety of mother and child rather than the mothers own knowledge.
Although evidence does not generally demonstrate benefits in the use of CTG monitoring for ascertaining fetal well being in later pregnancy in low risk pregnancy. There is evidence supporting the mothers record of her babies movements as being a good indication of fetal wellbeing or compromise. Perhaps less use of these technologies in pregnancy and getting back to basics with tools such as pinards would support women to feel comfortable in their own knowledge of their unborn child's wellbeing.
doppler = ultrasound. Recent evidence suggests that overuse of ultrasound causes subtle brain damage .If a midwife follows the guidelines that suggest 15 minutely auscultation in active first stage and 5 minutely in 2nd stage, for at least 1 minute periods, that is a lot of ultrasound for the baby to deal with in labour. We have socialized women and midwives to believe that Dopplers are benign and more desirable than Pinards. I too use the Doppler when women are labouring in water, but I have when requested used the pinards. It means the woman has to stand up or roll over every 15 minutes and then every 5 minutes, which may be useful to keep the woman flexible. (Think about the action needed to stand up, wonderful way to move the baby through the pelvis). However I have to admit that I too find the Doppler very convenient.
Doppler = ultrasound. Recent evidence shows that overuse of U/S causes subtle brain damage. Considering that midwives are required to listen to the baby's heartbeat every 15 minutes in active labour and 5 minutes in 2nd stage, that is a lot of exposure to ultrasound on the 2Mhtz wavelength. Women and midwives have been socialized into believing ultrasound is benign. We continue to believe this at our own peril. Regardless of midwives or women's preference, we need to consider that this is the baby's brain we are messing with. the child will be dealing with the consequences for the rest of its life. I know how difficult it is to avoid the use of Doppler's in water births, but it can be done.(I did it when doing water births in the 80's) Women can be encouraged to stand up or roll over as much as possible. It is great for encouraging the baby to move through the pelvis. If we really need to hear the heartbeat and the woman is reluctant to move as often as we want her to, we can use the Doppler then. At least we have avoided a lot of exposure. Convenience for us adults doesn't mean we can blithely ignore the welfare of the baby.
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As a recently trained midwife I found it difficult to even find a Pinard's in the LBS where I work. I did track one down eventually and had a go with it, but I would like to gain confidence with it by using one more frequently.
I actually bought one (a turned wooden one), which I intend to carry with me when I enter community practice, so as not to be dependent on power sources of any kind.
I too am aware of the fact that Dopplers are ultrasounds, and I respect that some people would prefer they not be used.
The use of a Pinard is a skill that midwives should not lose.
Yes pinards are hard to find in the clinical area. However there is nothing stopping you from using a pinard in you current practice, together with the doppler, that way you are increasing your skill in the use of a pinard and following current guidelines. This way, by the time you enter the community you will be proficient in the use of a pinard, and you will be able to pass this skill onto the next generation of midwife.
I agree that it is really sad that we are seeing the demise of the pinard's. It can assist with confirmation of findings of abdominal palpation as we know it is loudest over the shoulder of the fetus. We cannot hear the maternal pulse with a pinard's yet we know that we can monitor the maternal pulse with a CTG and clearly hear it with the doppler - many FDIU's have been missed due to this.
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