Effect of a labor triage checklist and ultrasound on obstetric referral at three primary health centers in Eastern Uganda.

OBJECTIVE: To test whether introduction of a midwife-performed triage checklist and focused ultrasound improves diagnosis and referral for obstetric conditions, including multiple gestation, placenta previa, oligohydramnios, preterm birth, malpresentation, and abnormal fetal heart rate. METHODS: We implemented an intake log (Phase 1), a checklist (Phase 2), and a checklist plus ultrasound scan (Phase 3) at three primary health centers in Eastern Uganda for women presenting in labor. Intake diagnoses, referral status, and delivery outcomes were assessed, as well as sensitivity and positive predictive value (PPV). RESULTS: Between February 2018 and July 2019, 1155, 961, and 603 women were enrolled across the three phases (n=2719); 2339 had outcome data. Incidence of any outcome-confirmed condition was 8.8%, 7.9%, and 7.1% (P=0.526) for each phase, respectively. The proportion of referred women with a condition did not change between Phases 1 and 2 (7.8% versus 8.6%, P=0.855), but increased in Phase 3 (48.4%, P<0.001). Sensitivity improved with each intervention; PPV decreased with ultrasound. CONCLUSION: Use of ultrasound plus checklist increased referrals and sensitivity for high-risk conditions, with decreased PPV. The checklist alone improved correct diagnosis, but not referral. Further evaluation of these triage interventions to maximize diagnostic accuracy, referral decisions, and outcomes are warranted.

Midwife-performed checklist and ultrasound to identify obstetric conditions at labour triage in Uganda: A quasi-experimental study.

OBJECTIVE: The aim of this study was to evaluate the effect of a midwife-performed checklist and limited obstetric ultrasound on sensitivity and positive predictive value for a composite outcome comprising multiple gestation, placenta praevia, oligohydramnios, preterm birth, malpresentation, abnormal foetal heart rate. DESIGN: Quasi-experimental pre-post intervention study. SETTING: Maternity unit at a district hospital in Eastern Uganda. INTERVENTIONS: Interventions were implemented in a phased approach: standardised labour triage documentation (Phase 1), a triage checklist (Phase 2), and checklist plus limited obstetric ultrasound (Phase 3). PARTICIPANTS: Consenting women presenting to labour triage for admission after 28 weeks of gestation between February 2018 and June 2019 were eligible. Women not in labour or those requiring immediate care were excluded. 3,865 women and 3,937 newborns with similar sample sizes per phase were included in the analysis. MEASUREMENT AND FINDINGS: Outcome data after birth were used to determine true presence of a complication, while intake and checklist data were used to inform diagnosis before birth. Compared to Phase 1, Phase 2 and 3 interventions improved sensitivity (Phase 1: 47%, Phase 2: 68.8%, Phase 3: 73.5%; p ≤ 0.001) and reduced positive predictive value (65.9%, 55%, 48.7%, p ≤ 0.001) for the composite outcome. No phase differences in adverse maternal or foetal outcomes were observed. CONCLUSION: Both a triage checklist and a checklist plus limited obstetric ultrasound improved accurate identification of cases with some increase in false positive diagnosis. These interventions may be beneficial in a resource-limited maternity triage setting to improve midwives' diagnoses and clinical decision-making.