Clinical Practice Guideline
TITLE: Fetal Doppler
APPROVED BY: Healthy Sexuality and Harm Reduction Working Group
Date
 Population and Public Health
7, Dec, ‘11
Date
TARGET
REVIEW
DATE
PAGE
1 of 4
2013
Purpose:
1.0 Public Health Nurse (PHN) engagement and support of street-involved pregnant women with
the intention of referral/connection to services such as Primary Care, Families First and other
support services.
Scope and Goal:
2.0 This guideline is intended for use by PHNs who provide outreach through Street Connections’.
2.1. Street Connections nurses may provide fetal doppler auscultation to vulnerable,
marginalized pregnant women in order to engage clients and refer to appropriate services
such as Prenatal Care, Primary Care, Healthy Parenting and Early Childhood Development
and other support services.
Definitions:
3.0 Leopold’s maneuver: gentle palpation of the lateral, upper, and lower borders of the uterus to
determine the position of the fetus (Appendix A).
Background:
4.0 Street Connections is sometimes the only formal helping system involved with clients during the
prenatal timeframe. The incidence of infant mortality, drug and alcohol addicted/affected babies
is associated with a lack of prenatal care for the pregnant woman. Some women who have
already used drugs or alcohol while pregnant may be reluctant to receive help because of
shame or fear of negative consequences. Others may not attend because they face challenges
accessing services. Street Connections can bridge the gap to prenatal health care programs.
Procedure:
5.0 Fetal heart rate monitoring by doppler can be offered to pregnant women of at least 12 weeks
gestation. Priority clients include street involved women who have not established or attended
regular pre-natal care.
5.1. Offer and explain the procedure. As appropriate, client should be encouraged to empty
bladder and lay supine in a comfortable position. Ensure that client has privacy to expose
enough of her abdomen for the procedure. The client may need to lower her pants slightly.
5.2. If client >34 weeks gestation, consider determining fetal position via Leopold’s maneuver
before applying the doppler (Appendix A). Palpation and measurement of the fundal height
can help estimate gestation if the client is unsure (Appendix B).
5.2.1. Note that Leopold’s maneuver is contraindicated in the presence of unexplained vaginal
bleeding or signs of pre-term labor such as > 5 contractions/cramps per hour, bright red
Clinical Practice Guideline
TITLE: Fetal Doppler
APPROVED BY: Healthy Sexuality and Harm Reduction Working Group
Date
 Population and Public Health
7, Dec, ‘11
Date
TARGET
REVIEW
DATE
PAGE
2 of 4
2013
blood from the vagina, sudden gush of clear, watery fluid from the vagina, low, dull
backache or intense pelvic pressure. If any of these contraindications are present the
client should be advised (or be taken) to the nearest obstetrical centre ASAP.
5.2.2. If contraindications are not present and client provides informed consent, perform
Leopold’s maneuver to determine fetal position.
5.3. The fetal doppler should only be used on intact skin. Turn the doppler device on and apply
enough coupling gel to cover the probe face (about a nickel sized drop). For early gestation
(12-24 weeks) women, begin at the pubic bone moving back and forth from midline and up
toward umbilicus. In women 24-33 weeks, auscultation can begin below the umbilicus and
move down toward the pubic bone while checking back and forth across midline. For
women who are greater than 33 weeks if the position of the fetal back has been
determined by Leopold’s maneuvers, begin auscultation over this area as the fetal
heartbeat is best detected over the fetus’ upper back. Otherwise begin auscultation on one
of the lower quadrants of the abdomen, moving the Doppler towards the midline and up
towards the fundus as needed.
5.3.1. Identify fetal heart rate (FHR). Normal FHR is between 110- 160 bpm. Explain this to
the client as the rate can sound alarmingly fast. The FHR may be faster than 160 in
early pregnancy and during periods of fetal movement. Sustained FHR of >160 for a
period of more than 20 minutes in a fetus >25 weeks needs to be investigated further
at the nearest obstetrical centre. The fetal heart beat is usually a low frequency
“galloping” sound. Vascular blood flow tends to be higher frequency and sounds more
like “swishing”. The vascular rate may be lower than the heart rate. Accelerations are
a normal and reassuring finding that are associated with fetal movement.
5.3.2. If decelerations of the FHR are heard or FHR is <110 check maternal HR to ensure
auscultation of FHR and not maternal HR. If heart rate is fetal and fetus is >25
weeks, the client should be encouraged to attend (or transported if they provide
informed consent) to hospital triage ASAP.
5.3.3. If no FHR is auscultated, encourage the client to attend (or transported if they
provide informed consent) to their care provider or to hospital triage. If no FHR is
auscultated and the patient is in early pregnancy consider the possibility of unsure
dates. Reassure the client that they may be too early in their pregnancy to hear the
FHR but encourage follow up regarding same at a regular prenatal appointment to
rule out missed abortion.
5.4. Discuss prenatal care options with the client as well as community resources and assist in
facilitation of prenatal care and appropriate referral.
Clinical Practice Guideline
TITLE: Fetal Doppler
APPROVED BY: Healthy Sexuality and Harm Reduction Working Group
Date
 Population and Public Health
7, Dec, ‘11
APPENDIX A:
Leopold’s Maneuver
Date
TARGET
REVIEW
DATE
2013
PAGE
3 of 4
Clinical Practice Guideline
TITLE: Fetal Doppler
APPROVED BY: Healthy Sexuality and Harm Reduction Working Group
Date
 Population and Public Health
Date
7, Dec, ‘11
TARGET
REVIEW
DATE
PAGE
4 of 4
2013
Appendix B
Approximate Measurements of Fundal Height*
Weeks of
Gestation
Fundal Height (cm)
Fundal Height (as Measured with
Fingers)
8
Not palpable in abdomen (still in Size of a small grapefruit (bimanual
pelvis)
examination)
12
Variable
At symphysis
16
Variable
Halfway between symphysis and
umbilicus
20
20
At umbilicus
24
24
3 or 4 fingers above umbilicus
28
28
Halfway between umbilicus and
xyphoid process
32
34
3 or 4 fingers below xyphoid
36
36
At xyphoid process
38-40
Variable
2 fingers below xyphoid
*Measurements differ between primigravida and multigravida.