Pinard Wisdom

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In my years as a lecturer, I was repeatedly asked by midwifery and medical students for a reference to an article that gives basic information on how to use a Pinard to listen to a baby’s heartbeat. Either to supplement learning in practice, or because they are not being taught this skill.

My inability to find much written about this led me to decide to write something myself.

Rather than share only my own experiences, I asked a number of colleagues to share their experiences, tip and tricks as well.

The original article containing our collated wisdom was first published in 2002. So bear in mind, as always, that this is experiential knowledge, and that things change over time and in different areas of the world.

But this is a really old ‘hand skill’ that doesn’t change with time, and people still search for information about how to learn it. So I have now updated and republished this online along with some new information at the bottom, because it turns out that this is still of interest, relevance and value.

I hope you’ll find it useful. 

Pinard Wisdom

It might be hard to imagine now, but some midwives trained in a time when Pinards were the only real option. When I was a student, we were expected to learn to use one, because it was sometimes the only way of listening to a baby. And many midwives told us that listening to a baby with our own ears could tell us things that the electronic monitors couldn’t.

They were right.

Over the past few years, though, this has become a skill in danger of being lost. Indeed, several of the midwives I talked with when I was researching this article had had to teach themselves to use Pinards.

And the one piece of advice that almost all of them shared?

“Keep doing it, keep practising”.

That’s because, like with some other practical skills, lots of midwives remember trying to use their Pinard for what seemed like months, without hearing anything, then suddenly it ‘clicked’.

These midwives understand it’s difficult for students:

“It needs lots of practice and in a busy clinic if you haven’t got a sympathetic midwife it’s hard to get started. It also involves lots of explanations to women about how you’ll quite likely not be able to hear anything!”  

But don’t give up.

So Why Use a Pinard?

These are some of the reasons that midwives give for wanting to learn, use, practise and pass on this skill.

  • To keep the skill so that when the batteries run out I can still function.
  • To give me a bit of warning if I can’t hear anything, and start framing the words I’m going to use.
  • To help confirm my palpation, especially hearing the OP [occopito posterior, when the baby’s back is next to the mum’s back, rather than at the front of her abdomen] baby centrally and also very clearly far round to the side, and hearing a breech baby higher up.
  • To show couples that you don’t need electronics, and go on to explain that a partner can hear the baby just by putting their ear over where the baby’s back is.
  • To be able to check a very fast or very slow heartbeat on a monitor and make sure it’s not being doubled or halved.
  • There’s a degree of satisfaction in finding the fetal heart with a Pinard.
  • When I worked on an antenatal ward, I used it regularly to reassure anxious women, or to listen in quickly when waiting for CTG’s to be free, and of course, locating the FH prior to attaching a monitor.
  • A Pinard is better than Doppler as you are listening to the sound, not an echo, so you can hear different tones.  You’re not just counting the beats of valves as they open and close.

When can you hear?

Although some of the midwives pointed out that you can sometimes hear the fetal heart before 28 weeks with a Pinard, especially on a slim woman, most said that you shouldn’t expect to hear it until around this time.

Some midwives remember not even thinking about listening to the fetal heart until the end of the second trimester, and being more reliant on signs such as quickening before the onset of routine Doppler use.

Which kind of Pinard is best?

There was quite a debate over whether wood, plastic or metal Pinards were better. Several midwives somewhat reluctantly suggested that plastic or metal Pinards were better to use to learn on, as wood can absorb some of the sound. However, almost everybody felt wood was the better material once you had the hang of things, as it was more attractive, softer and warmer for women.

Most of the midwives suggested you should own your own Pinard, so you could learn its resonance and idiosyncrasies and how it expresses different tones.

Five Steps to Pinard Success

  1. Palpate, palpate, palpate to ascertain the baby’s position. Ask the woman for her feelings on where the baby is too.  Generally, you are aiming to hear the FH through the fetal back (remember that the baby’s lungs are not inflated).
  2. Use your knowledge and experience (or the table below) to see where the fetal heart might be for the different positions the baby might be in – and choose your ‘target point’.
  3. Place the Pinard in your chosen spot, put your ear to the ‘O’, take your hand away from the Pinard, and listen – and keep listening.
  4. Feel the maternal pulse at the same time and if it coincides you have the uterine vessels.
  5. If after careful listening you really can’t hear anything, repeat the palpation and try the Pinard in another spot.

More Practical Pinard Tips

A few more suggestions for getting it right:

  • Make sure you’ve got your ear directly over the hole!
  • Don’t press too hard or too softly – be prepared to alter the pressure.
  • There needs to be gentle pressure indenting the abdomen – a bit less than a centimetre.

The midwives who shared their experience here concentrated more than anything on stressing that there is an art to hearing the fetal heart by Pinard. With a Pinard, you are of course hearing the ‘real’ fetal heart, rather than an electronic rendition of it. It sounds a bit different, but remember that what you’re hearing with the Pinard is the real thing!

What are you listening for?

  • It is more like listening for a ‘vibration’ than a sound. 
  • At first I found it hard to hear but then I got the hang of it and appreciated that it felt to me rather more like “feeling” the heartbeat through my ear than “hearing” it.
  • It’s a sound like listening to a blood pressure – your ear needs time to tune to the sound.
  • You need to know what sounds you’re listening for – try closing your ear off with one finger and tapping that finger with another finger.
  • You are listening for a sound that is in the distance and sounds like a watch ticking under a pillow, but of course faster than a ticking watch. If you have an old fashioned watch that ticks (borrow one from your grandpa), then try it. 
  • If you hear a slow schooching noise you a probably hearing the maternal vessels supplying the uterus.  
  • I often close my eyes when listening (I tell the woman that I am going to do this first). I find it really helps to shut down one of my senses. I sometimes do the same thing for the same reason when I am palpating – I find that I can hear and feel much better when I can’t see. Weird but true!
  • Sounds daft, but if you are really having problems, think about getting your hearing checked.  I know I am somewhat deaf in my left ear, so can’t hear an FH on that side – I have to use my right ear. 

To count the fetal heart, use a digital watch, or one with a decent second hand. Wait till the second hand (or readout) is at one of the quarters and start counting. Count for 15 seconds and multiply the number of beats heard by four. For instance, 35 beats in 15 seconds equates to a fetal heart of 140 bpm. To calculate an average fetal heart, listen to four different 15-second intervals, not necessarily consecutively, and take the average.

If you can’t find the heartbeat first time:

  • Try slightly realigning the Pinard – but pick it up and put it back down somewhere else, don’t rotate it like a Sonicaid.
  • Sometimes the fetal heart will be heard much more laterally than you expect.
  • Sometimes I still find it hard to locate the heartbeat with my Pinard and I calmly resort to listening with the doppler so as not to worry the mother.
  • If you can’t find it in a reasonably short time the woman will think something is wrong so use a Sonicaid or ask for help.
  • If the woman doesn’t mind, you can listen with a Sonicaid first in different places until you hear the “lub dub” sound when the heart valves open and close – then put your Pinard on that spot.

Interestingly, most of the midwives focused on using Pinards during pregnancy rather than in labour. Those that did talk about using a Pinard in labour mentioned that, although it was difficult to hear anything through a contraction with a Pinard, they weren’t sure that listening through contractions was fair to women anyway, even with a sonicaid, being both distracting and uncomfortable. Certainly some midwives find that the American-style fetoscopes (a Pinard on stethoscope ‘ears’) are easier in labour, especially when women are in all-fours or standing positions.

More Pinard Skills

There are all sorts of things you can do with your Pinard once you master the skill.

  • I have a personal caseload and am able to ‘learn’ what individual babies sound like. It’s something I’m really trying to consolidate at the moment.
  • You can hear different sounds and tones at different gestations, and you can sometimes work out the baby’s sex because of the difference in tone. 
  • To measure variability, count the number of beats heard in a series of intervals of 5 seconds; the number of beats should differ, which will confirm variability. If the numbers of beats are consistently the same, the baby is probably asleep; try listening again in 15 minutes. 

The midwives here felt that sharing the experience with women was important, although their experience of what women wanted differed.

While one midwife said that about 19 in 20 women still wanted to hear the fetal heart with the Sonicaid as well, another said that many of the women she worked with were happy with the Pinard alone, especially as she offered to tap the rhythm of the fetal heart on the woman’s leg as she heard it through the Pinard.

At least two midwives commented that some women didn’t want to take on the potential risks of using Doppler ultrasound, and several said they reinforced to women that the most important way of knowing that the baby is well is for the mother to develop awareness of her baby’s well-being and movement pattern.

Using a Pinard is one of the most basic midwifery skills, yet it is one which is in danger of being lost as our reliance on technology grows. Hopefully, the sharing of these tips will help midwives retain this skill, and go on to develop it further. As these midwives highlight, there are some things we can do – and tell – with a Pinard that no amount of technology is able to do better!

More information

In 2022, researchers in Norway also talked to midwives about this topic, with the same aim as I had: “to illuminate the knowledge before it is lost.” Here is their article: Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

 

A version of this article was first published as: Wickham S (2002). Pinard Wisdom (part 1). TPM 5(9):21 and Wickham S (2002). Pinard Wisdom (part 2). TPM 5(10):35.

With many thanks to the following midwives who contributed to the original article on which this post is based: Lynn Walcott, Jean Sutton, Mary Stewart, Jane Munro, Ishbel Karger, Elizabeth Jeffery, Jo Hindley, Jane Evans, Lorna Davies, Mary Cronk, Penny Champion and Christine Andrew.

 

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