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1.
BMC Pregnancy Childbirth ; 20(1): 78, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32024504

RESUMO

BACKGROUND: Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines. METHODS: A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process. RESULTS: A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2). CONCLUSIONS: Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.


Assuntos
Parto Obstétrico/normas , Prática Clínica Baseada em Evidências , Trabalho de Parto , Adulto , Canal Anal/lesões , Episiotomia/psicologia , Feminino , Monitorização Fetal/normas , Pessoal de Saúde/psicologia , Hospitais de Ensino , Humanos , Filipinas/epidemiologia , Gravidez , Centros de Atenção Terciária , Adulto Jovem
2.
Glob Health Action ; 13(1): 1711618, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31955672

RESUMO

Background: In Uganda, perinatal mortality is 38 per 1000 pregnancies. One-third of these deaths are due to birth asphyxia. Adequate fetal heart rate (FHR) monitoring during labor may detect birth asphyxia but little is known about monitoring practices in low resource settings.Objective: To explore FHR monitoring practices among health workers at a public hospital in Northern Uganda.Methods: A sequential explanatory mixed methods study was conducted by reviewing 251 maternal records and conducting 11 interviews and two focus group discussions with health workers complemented by observations of 42 women in labor until delivery. Quantitative data were summarized using frequencies and percentages. Content analysis was used for qualitative data.Results: FHR was assessed in 235/251 (93.6%) of records at admission. Health workers documented the FHR at least once in 175/228 (76.8%) of cases during the first stage of labor compared to observed 17/25 (68.0%) cases. Median intervals between FHR monitoring were 30 (IQR 30-120) minutes in patients' records versus 139 (IQR 87-662) minutes according to observations. Observations suggested no monitoring of FHR during the second stage of labor but records indicated monitoring in 3.2% of cases. Reported barriers to adequate FHR monitoring were inadequate number of staff and monitoring devices, institutional challenges such as few beds, documentation problems and perceived non-compliant women not reporting for repeated checks during the first stage of labor. Health workers demonstrated knowledge of national FHR monitoring guidelines and acknowledged that practice was different.Conclusions: When compared to national and international guidelines, FHR monitoring is sub-optimal in the studied setting. Approximately one in four women was not monitored during the first stage of labor. Barriers to appropriate FHR monitoring included shortage of staff and devices, institutional challenges and mother's negative attitudes. These barriers need to be addressed in order to reduce neonatal mortality.


Assuntos
Monitorização Fetal/normas , Mão de Obra em Saúde/estatística & dados numéricos , Frequência Cardíaca Fetal/fisiologia , Hospitais Públicos/estatística & dados numéricos , Trabalho de Parto/fisiologia , Feminino , Fidelidade a Diretrizes , Pessoal de Saúde , Humanos , Lactente , Recém-Nascido , Entrevistas como Assunto , Guias de Prática Clínica como Assunto , Gravidez , Uganda
3.
Acta Obstet Gynecol Scand ; 99(3): 413-422, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31792930

RESUMO

INTRODUCTION: Noninvasive fetal heart rate monitoring using transabdominal fetal electrocardiographic detection is now commercially available and has been demonstrated to be an effective alternative to traditional Doppler ultrasonographic techniques. Our objective in this study was to compare the results of computerized identification of fetal heart rate patterns generated by ultrasound-based and transabdominal fetal electrocardiogram-based techniques with simultaneously obtained fetal scalp electrode-derived heart rate information. MATERIAL AND METHODS: We applied an objective computer-based analysis for recognition of fetal heart rate patterns (Monica Decision Support) to data obtained simultaneously from a direct fetal scalp electrode, Doppler ultrasound, and the abdominal-fetal electrocardiogram techniques. This allowed us to compare over 145 hours of fetal heart rate patterns generated by the external devices with those derived from the scalp electrode in 30 term singleton uncomplicated pregnancies during labor. The direct fetal scalp electrode is considered to be the most accurate and reliable technique used in current clinical practice, and was, therefore, used as the standard for comparison. The program quantified the baseline heart rate, long- and short-term variability. It indicated when an acceleration or deceleration was present and whether it was large or small. RESULTS: Ultrasound was associated with significantly greater deviations from the fetal scalp electrode results than the abdominal fetal electrocardiogram technique in recognizing the correct baseline heart rate, its variability, and the presence of small and large accelerations and small decelerations. For large decelerations the two external methods were each not significantly different from the scalp electrode results. CONCLUSIONS: Noninvasive fetal heart rate monitoring using maternal abdominal wall electrodes to detect fetal cardiac activity more reliably reproduced the computerized analysis of heart rate patterns derived from a direct fetal scalp electrode than did traditional ultrasound-based monitoring. Abdominal-fetal electrocardiogram should, therefore, be considered a primary option for externally monitored patients.


Assuntos
Eletrocardiografia , Monitorização Fetal/normas , Frequência Cardíaca Fetal , Primeira Fase do Trabalho de Parto , Trabalho de Parto , Ultrassonografia Pré-Natal , Adulto , Feminino , Monitorização Fetal/instrumentação , Humanos , Processamento de Imagem Assistida por Computador , Gravidez , Ultrassonografia Doppler
4.
Int J Gynaecol Obstet ; 146(1): 8-16, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30582153

RESUMO

OBJECTIVE: To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low-resource settings. METHODS: Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low-resource settings scored the importance of intrapartum fetal monitoring methods. RESULTS: 71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low-risk pregnancies during the first stage of labor and after every contraction for high-risk pregnancies in the second stage, (4) contraction monitoring hourly for low-risk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high-risk women in the first stage or low-risk women in the second stage of labor. CONCLUSION: There is a gap between international recommendations and what is physically possible in many labor wards in low-resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low-resource settings.


Assuntos
Monitorização Fetal/normas , Frequência Cardíaca Fetal , Adulto , Consenso , Técnica Delfos , Feminino , Humanos , Primeira Fase do Trabalho de Parto , Segunda Fase do Trabalho de Parto , Pobreza , Gravidez , Inquéritos e Questionários , Ultrassonografia Doppler
5.
Indian J Med Res ; 148(3): 309-316, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30425221

RESUMO

Background & objectives: India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India. Methods: A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets. Results: A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases. Interpretation & conclusions: The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.


Assuntos
Centros de Assistência à Gravidez e ao Parto/normas , Parto Obstétrico , Monitorização Fetal , Monitorização Fisiológica , Complicações do Trabalho de Parto , Qualidade da Assistência à Saúde/normas , Adulto , Competência Clínica/estatística & dados numéricos , Estudos Transversais , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Monitorização Fetal/métodos , Monitorização Fetal/normas , Humanos , Índia/epidemiologia , Trabalho de Parto/fisiologia , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/prevenção & controle , Gravidez , Melhoria de Qualidade
6.
J Gynecol Obstet Hum Reprod ; 47(9): 455-459, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30144558

RESUMO

BACKGROUND: Continuous fetal monitoring is commonly used during pregnancy and labor to assess fetal wellbeing. The most often used technology is cardiotocography (CTG), but this technique has major drawbacks in clinical use. OBJECTIVES: Our aim is to test a non-invasive multimodal technique of fetal monitoring using phonocardiography (PCG) and electrocardiography (ECG) and to evaluate its feasibility in clinical practice, by comparison with CTG. METHODS: This prospective open label study took place in a French university hospital. PCG and ECG signals were recorded using abdominal and thoracic sensors from antepartum women during the second half of pregnancy, simultaneously with CTG recording. Signals were then processed to extract fetal PCG and ECG and estimate fetal heart rate (FHR). RESULTS: A total of 9 sets of recordings were evaluated. Very accurate fetal ECG and fetal PCG signals were recorded, enabling us to obtain FHR for several subjects. The FHR calculated from ECG was highly correlated with the FHR from the CTG reference (from 74% to 84% of correlation). CONCLUSION: This work with preliminary signal processing algorithms proves the feasibility of the approach and constitutes the beginnings of a unique database that is needed to improve and validate the signal processing algorithms.


Assuntos
Eletrocardiografia/normas , Monitorização Fetal/normas , Frequência Cardíaca Fetal/fisiologia , Fonocardiografia/normas , Adulto , Cardiotocografia/métodos , Cardiotocografia/normas , Eletrocardiografia/métodos , Estudos de Viabilidade , Feminino , Monitorização Fetal/métodos , Humanos , Fonocardiografia/métodos , Gravidez , Estudos Prospectivos
7.
J Obstet Gynaecol Res ; 44(12): 2127-2134, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30084196

RESUMO

AIM: Although several studies reported the measurement of fetal oxygen saturation using fetal pulse oximetry (FPO) for evaluation of the fetal intrapartum condition, a systematic review of the seven randomized controlled trials (RCTs) provided no evidence to support FPO for intrapartum fetal monitoring. In the present review, we re-evaluate an overview for the use of FPO and seven RCTs of FPO. METHODS: We reviewed numerous previous reports on FPO and seven RCTs of intrapartum FPO. RCTs were conducted with the main outcome measure being a reduction in the cesarean section rate. RESULTS: The largest trial with 5341 entries failed to show any reduction. The negative result from this RCT may be explained by the use of a different cutoff value for fetal oxygen saturation compared to the other RCT; in addition, there were differences in the indications for cesarean section due to dystocia and in the definition of non-reassuring fetal status (NRFS). An abnormal FPO value, defined as the fetal oxygen saturation value <30% for at least 10 min, is useful for making a diagnosis of fetal acidosis. A newly developed device, an examiner's finger-mounted tissue oximetry, accurately measures tissue oxygen saturation while overcoming the drawbacks of FPO, such as infection risk and slipping off of the sensor during descent of the fetal head. CONCLUSION: FPO (including the new device) with fetal heart rate monitoring in selected cases of NRFS may reduce the cesarean section rate.


Assuntos
Parto Obstétrico/normas , Monitorização Fetal/normas , Complicações do Trabalho de Parto/prevenção & controle , Oximetria/normas , Parto Obstétrico/métodos , Feminino , Monitorização Fetal/métodos , Humanos , Oximetria/métodos , Gravidez
8.
Am J Perinatol ; 35(14): 1405-1410, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29895077

RESUMO

OBJECTIVE: To determine if a standardized intervention process for Category II fetal heart rates (FHRs) with significant decels (SigDecels) would improve neonatal outcome and to determine the impact on mode of delivery rates. STUDY DESIGN: Patients with Category II FHRs from six hospitals were prospectively managed using a standardized approach based on the presence of recurrent SigDecels. Maternal and neonatal outcomes were compared between pre- (6 months) and post-(11 months) implementation. Neonatal outcomes were: 5-minute APGAR scores of <7, <5, <3, and severe unexpected newborn complications (UNC). Maternal outcomes included primary cesarean and operative vaginal birth rates of eligible deliveries. RESULTS: Post implementation there were 8,515 eligible deliveries, 3,799 (44.6%) were screened, and 361 (9.5%) met criteria for recurrent SigDecels. Compliance with the algorithm was 97.8%. The algorithm recommended delivery in 68.0% of cases. Relative to pre-implementation, 5-minute APGAR score of <7 were reduced by 24.6% (p < 0.05) and severe UNC by -26.6%, p = < .05. The rate of primary cesarean decreased (19.8 vs 18.3%, p < 0.05), while there were nonsignificant increases in vaginal (74.6 vs 75.8%, p = 0.13) and operative vaginal births (5.7 vs 5.9%, p = 0.6). CONCLUSION: Standardized management of recurrent SigDecels reduced the rate of 5-minute APGAR scores of < 7 and severe UNC.


Assuntos
Cesárea/estatística & dados numéricos , Desaceleração , Monitorização Fetal/normas , Frequência Cardíaca Fetal , Índice de Apgar , Feminino , Humanos , Recém-Nascido , Trabalho de Parto , Gravidez
9.
Acta Obstet Gynecol Scand ; 97(10): 1206-1211, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29806955

RESUMO

INTRODUCTION: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities. MATERIAL AND METHODS: We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided. RESULTS: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable. CONCLUSIONS: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.


Assuntos
Traumatismos do Nascimento/mortalidade , Mortalidade Infantil , Imperícia/estatística & dados numéricos , Erros Médicos/mortalidade , Obstetrícia/normas , Traumatismos do Nascimento/epidemiologia , Competência Clínica , Feminino , Monitorização Fetal/normas , Humanos , Lactente , Recém-Nascido , Relações Interprofissionais , Erros Médicos/estatística & dados numéricos , Noruega , Unidade Hospitalar de Ginecologia e Obstetrícia/normas , Gravidez , Papel Profissional
10.
J Obstet Gynaecol Can ; 40(4): e251-e271, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29680082

RESUMO

OBJECTIVE: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum care in Canada. OPTIONS: Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: FETAL MOVEMENT COUNTING: RECOMMENDATION 2: NON-STRESS TEST: RECOMMENDATION 3: CONTRACTION STRESS TEST: RECOMMENDATION 4: BIOPHYSICAL PROFILE: RECOMMENDATION 5: UTERINE ARTERY DOPPLER: RECOMMENDATION 6: UMBILICAL ARTERY DOPPLER.


Assuntos
Monitorização Fetal/normas , Assistência Perinatal/normas , Feminino , Monitorização Fetal/métodos , Movimento Fetal , Humanos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Ultrassonografia Pré-Natal
12.
J Obstet Gynaecol Can ; 40(4): e298-e322, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29680084

RESUMO

OBJECTIVE: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada. OPTIONS: Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: LABOUR SUPPORT DURING ACTIVE LABOUR: RECOMMENDATION 2: PROFESSIONAL ONE-TO ONE CARE AND INTRAPARTUM FETAL SURVEILLANCE: RECOMMENDATION 3: INTERMITTENT AUSCULTATION IN LABOUR: RECOMMENDATION 4: ADMISSION FETAL HEART TEST: RECOMMENDATION 5: INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME: When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). RECOMMENDATION 6: DIGITAL FETAL SCALP STIMULATION: RECOMMENDATION 7: FETAL SCALP BLOOD SAMPLING: RECOMMENDATION 8: UMBILICAL CORD BLOOD GASES: RECOMMENDATION 9: FETAL PULSE OXIMETRY: RECOMMENDATION 10: ST WAVEFORM ANALYSIS: RECOMMENDATION 11: INTRAPARTUM FETAL SCALP LACTATE TESTING.


Assuntos
Monitorização Fetal/normas , Trabalho de Parto , Assistência Perinatal/normas , Feminino , Doenças Fetais/etiologia , Monitorização Fetal/métodos , Humanos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
13.
Artigo em Inglês | MEDLINE | ID: mdl-29550180

RESUMO

Abnormal fetal growth significantly increases neonatal mortality and the risk of stillbirth. This creates the need for accurately monitoring fetal growth in all pregnancies regardless of the risk status. Several methods used in clinical practice include abdominal palpation, symphysio-fundal height measurements, and obstetric ultrasound. Of these, obstetric ultrasound remains the most reliable and objective way to monitor fetal growth. However, in most low-resource areas, access to obstetric ultrasound remains poor and this leaves the two as the only options available. This not only has effect on fetal growth monitoring but more importantly on the accuracy of pregnancy dating. To improve the current situation, we propose strategies for training of health workers, educating the public on importance of obstetric ultrasound, and improving access to basic equipment. However, interim solutions have to be implemented hand in hand with other strategies to ensure universal access to ultrasound technology for fetal growth monitoring.


Assuntos
Desenvolvimento Fetal , Monitorização Fetal/métodos , Idade Gestacional , Acesso aos Serviços de Saúde/normas , Ultrassonografia Pré-Natal/métodos , Feminino , Monitorização Fetal/normas , Saúde Global , Humanos , Obstetrícia/educação , Pobreza , Gravidez , Cuidado Pré-Natal/normas , Ultrassonografia Pré-Natal/normas
14.
Reprod Health ; 15(1): 14, 2018 Jan 27.
Artigo em Inglês | MEDLINE | ID: mdl-29374486

RESUMO

BACKGROUND: Making use of good, evidence based routines, for management of normal childbirth is essential to ensure quality of care and prevent, identify and manage complications if they occur. Two essential routine care interventions as defined by the World Health Organization are the use of the Partograph and Active Management of the Third Stage of Labour. Both interventions have been evaluated for their ability to assist health providers to detect and deal with complications. There is however little research about the quality of such interventions for routine care. Qualitative studies can help to understand how such complex interventions are implemented. This paper reports on findings from an observation study on maternity wards in Tanzania. METHODS: The study took place in the Lake Zone in Tanzania. Between 2014 and 2016 the first author observed and participated in the care for women on maternity wards in four rural and semi-urban health facilities. The data is a result of approximately 1300 hours of observations, systematically recorded primarily in observation notes and notes of informal conversations with health providers, women and their families. Detailed description of care processes were analysed using an ethnographic analysis approach focused on the sequential relationship of the 'stages of labour'. Themes were identified through identification of recurrent patterns. RESULTS: Three themes were identified: 1) Women's movement between rooms during birth, 2) health providers' assumptions and hope for a 'normal' birth, 3) fear of poor outcomes that stimulates intervention during birth. Women move between different rooms during childbirth which influences the care they receive. Few women were monitored during their first stage of labour. Routine birth monitoring appeared absent due to health providers 'assumptions and hope for good outcomes. This was rooted in a general belief that most women eventually give birth without problems and the partograph did not correspond with health providers' experience of the birth process. Contextual circumstances also limited health worker ability to act in case of complications. At the same time, fear for being held personally responsible for outcomes triggered active intervention in second stage of labour, even if there was no indication to intervene. CONCLUSIONS: Insufficient monitoring leads to poor preparedness of health providers both for normal birth and in case of complications. As a result both underuse and overuse of interventions contribute to poor quality of care. Risk and complication management have for many years been prioritized at the expense of routine care for all women. Complex evaluations are needed to understand the current implementation gaps and find ways for improving quality of care for all women.


Assuntos
Parto Obstétrico/normas , Serviços de Saúde Materna/normas , Parto , Qualidade da Assistência à Saúde , Adulto , Parto Obstétrico/psicologia , Parto Obstétrico/estatística & dados numéricos , Feminino , Monitorização Fetal/normas , Monitorização Fetal/estatística & dados numéricos , Humanos , Trabalho de Parto/psicologia , Serviços de Saúde Materna/estatística & dados numéricos , Determinação de Necessidades de Cuidados de Saúde , Parto/psicologia , Gravidez , Melhoria de Qualidade , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/normas , Tanzânia/epidemiologia , Adulto Jovem
15.
Acta Obstet Gynecol Scand ; 97(2): 219-228, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29215160

RESUMO

INTRODUCTION: The updated intrapartum cardiotocography (CTG) classification system by FIGO in 2015 (FIGO2015) and the FIGO2015-approached classification by the Swedish Society of Obstetricians and Gynecologist in 2017 (SSOG2017) are not harmonized with the fetal ECG ST analysis (STAN) algorithm from 2007 (STAN2007). The study aimed to reveal homogeneity and agreement between the systems in classifying CTG and ST events, and relate them to maternal and perinatal outcomes. MATERIAL AND METHODS: Among CTG traces with ST events, 100 traces originally classified as normal, 100 as suspicious and 100 as pathological were randomly selected from a STAN database and classified by two experts in consensus. Homogeneity and agreement statistics between the CTG classifications were performed. Maternal and perinatal outcomes were evaluated in cases with clinically hidden ST data (n = 151). A two-tailed p < 0.05 was regarded as significant. RESULTS: For CTG classes, the heterogeneity was significant between the old and new systems, and agreements were moderate to strong (proportion of agreement, kappa index 0.70-0.86). Between the new classifications, heterogeneity was significant and agreements strong (0.90, 0.92). For significant ST events, heterogeneities were significant and agreements moderate to almost perfect (STAN2007 vs. FIGO2015 0.86, 0.72; STAN2007 vs. SSOG2017 0.92, 0.84; FIGO2015 vs. SSOG2017 0.94, 0.87). Significant ST events occurred more often combined with STAN2007 than with FIGO2015 classification, but not with SSOG2017; correct identification of adverse outcomes was not significantly different between the systems. CONCLUSION: There are discrepancies in the classification of CTG patterns and significant ST events between the old and new systems. The clinical relevance of the findings remains to be shown.


Assuntos
Algoritmos , Cardiotocografia/normas , Eletrocardiografia/normas , Hipóxia Fetal/diagnóstico , Monitorização Fetal/normas , Frequência Cardíaca Fetal/fisiologia , Adulto , Gasometria/normas , Cardiotocografia/métodos , Eletrocardiografia/métodos , Feminino , Monitorização Fetal/métodos , Humanos , Gravidez , Suécia , Adulto Jovem
16.
Pediatr Res ; 83(5): 961-968, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29281617

RESUMO

BackgroundA newly developed fetal movement acceleration measurement recorder has made it possible to count gross movements for hours. The purpose of this study was to determine the normal reference values for such movements.MethodsOne hundred and six pregnant women recorded fetal movements by themselves when they slept at home weekly from 28 weeks to term. The normal reference values were determined based on the data that could be recorded for more than 4 h per night.ResultsA total of 2,458 h of data from 385 recordings from 64 women was available. The median ratio of 10-s periods in which fetal movements occurred to the total time interval was 17% at 28 gestational weeks, decreasing to ∼6% at term. The number of fetal movements was 74 times/h, decreasing to 29 times at term. The number, the mean, and the longest durations of periods with no fetal movement, meaning no fetal movements were found for more than 5 min, were 1.56 times/h, 7.95 and 14.25 min, respectively, at 28 weeks, and increasing to 2.54 times, and 9.63 and 19.67 min, respectively, at term.ConclusionsThis study provides normal reference values for gross fetal movement count using the fetal movement acceleration measurement recorder.


Assuntos
Acelerometria , Monitorização Fetal/métodos , Monitorização Fetal/normas , Movimento Fetal , Adulto , Feminino , Feto , Idade Gestacional , Humanos , Recém-Nascido , Masculino , Gravidez , Segundo Trimestre da Gravidez , Terceiro Trimestre da Gravidez , Cuidado Pré-Natal , Valores de Referência , Nascimento a Termo , Fatores de Tempo , Adulto Jovem
17.
Int J Gynaecol Obstet ; 139 Suppl 1: 17-26, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29218726

RESUMO

OBJECTIVE: To explore current practices, challenges, and opportunities in relation to monitoring labor progression, from the perspectives of healthcare professionals in low-resource settings. METHODS: Thematic analysis of qualitative data (in-depth interviews [IDIs] and focus group discussions [FDGs]) obtained from a purposive sample of healthcare providers and managers in selected health facilities in Nigeria and Uganda. RESULTS: A total of 70 IDIs and 16 FGDs with doctors, midwives, and administrators are included in this analysis. Labor monitoring encompasses a broad scope of care jointly provided by doctors and midwives. A range of contextual limitations was identified as barriers to monitoring labor progression, including staff shortages, lack of team cooperation, delays in responding to abnormal labor observations, suboptimal provider-patient dynamics, and limitations in partograph use. Perceived opportunities to improve current practices included streamlining clinical team cooperation, facilitating provider-client communication, encouraging women's uptake of offered care, bridging the gaps in the continuum of monitoring tasks between cadres, and improving skills in assessment of labor progress, and accuracy in its documentation. CONCLUSION: Healthcare providers face many challenges to effective monitoring of labor progress in low-resource settings. This analysis presents potential opportunities to improve labor monitoring practices and tools in these contexts.


Assuntos
Atitude do Pessoal de Saúde , Monitorização Fetal/psicologia , Pessoal de Saúde/psicologia , Trabalho de Parto/psicologia , Adulto , Feminino , Monitorização Fetal/normas , Grupos Focais , Instalações de Saúde , Humanos , Tocologia/normas , Nigéria , Percepção , Gravidez , Pesquisa Qualitativa , Uganda
18.
Tidsskr Nor Laegeforen ; 137(17)2017 09 19.
Artigo em Inglês, No | MEDLINE | ID: mdl-28925199

RESUMO

BACKGROUND: The Directorate of Health's national guide Et trygt fødetilbud ­ kvalitetskrav til fødselsomsorgen [A safe maternity service ­ requirements regarding the quality of maternity care] was published in December 2010 and was intended to provide a basis for an improved and more predictable maternity service. This article presents data from the maternity institutions on compliance with the quality requirements, including information on selection, fetal monitoring, organisation, staffing and competencies. MATERIAL AND METHOD: The information was acquired with the aid of an electronic questionnaire in the period January­May 2015. The form was sent by e-mail to the medical officer in charge at all maternity units in Norway as at 1 January 2015 (n=47). RESULTS: There was a 100 % response to the questionnaire. The criteria for selecting where pregnant women should give birth were stated to be in conformity with the quality requirements. Some maternity institutions failed to describe the areas of responsibilities of doctors and midwives (38.5 % and 15.4 %, respectively). Few institutions recorded whether the midwife was present with the patient during the active phase. Half of the maternity departments (level 2 birth units) reported unfilled doctors' posts, and a third of the university hospitals/central hospitals (level 1 birth units) reported a severe shortage of locum midwives. Half of the level 2 birth units believed that the quality requirements had resulted in improved training, but reported only a limited degree of interdisciplinary or mandatory instruction. INTERPRETATION: The study reveals that there are several areas in which the health enterprises have procedures that conform to national quality requirements, but where it is still unclear whether they are observed in practice. Areas for improvement relate to routines describing areas of responsibility, availability of personnel resources and staff training.


Assuntos
Centros de Assistência à Gravidez e ao Parto/normas , Salas de Parto/normas , Parto Obstétrico/normas , Fidelidade a Diretrizes , Maternidades/normas , Unidade Hospitalar de Ginecologia e Obstetrícia/normas , Qualidade da Assistência à Saúde/normas , Centros de Assistência à Gravidez e ao Parto/organização & administração , Competência Clínica , Salas de Parto/organização & administração , Feminino , Monitorização Fetal/normas , Hospitais/normas , Maternidades/organização & administração , Humanos , Tocologia , Noruega , Unidade Hospitalar de Ginecologia e Obstetrícia/organização & administração , Seleção de Pacientes , Admissão e Escalonamento de Pessoal/normas , Médicos , Gravidez , Medição de Risco , Desenvolvimento de Pessoal , Inquéritos e Questionários , Recursos Humanos
19.
J Gynecol Obstet Hum Reprod ; 46(2): 131-135, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28403968

RESUMO

OBJECTIVE: Different classification of fetal heart rate (FHR) pattern have been proposed: FHR classified as either "reassuring" or "non-reassuring", the National Institute of Child Health and Human Development (NICHD) published in 2008 a 3-tier system, the French College of Gynecology and Obstetrics (CNGOF) recommended in 2013 a 5-tier system and recently in 2015, the Federation International of Gynecology and Obstetrics (FIGO) proposed a new classification based on a 3-tier system. Our objective was to assess the inter-observer reliability of these 4 existing classifications. STUDY DESIGN: Four observers reviewed 100 FHR without clinical information. FHR were obtained from term singleton pregnancies. Fetal heart rate patterns were classified by one 2-tier ("reassuring vs. non-reassuring"), two 3-tier (NICHD 2008 and FIGO 2015), and one 5-tier (CNGOF 2013) fetal heart classifications. RESULTS: The global agreement between observers was moderate for each classification: 0.58 (0.40-0.74) for the 2-tier, 0.48 (0.37-0.58) for the NICHD 2008, 0.58 (0.53-0.63) for the CNGOF 2013 and 0.59 (0.49-0.67) for the FIGO 2015 classification. When FHR was classified as reassuring, it was classified as normal in 85.5% for the NICHD 2008 and in 94.5% for the FIGO 2015. For the CNGOF 2013, 65.0% were classified as normal and 32.5% as quasi normal. There was strong concordance between FIGO category I and "reassuring" FHR (kappa=0.95). CONCLUSION: Inter-observer agreement of FHR interpretation is moderate whatever the classification used. To evaluate the superior interest of one classification, it will be interesting to compare their impact on need of second line techniques and on neonatal outcome.


Assuntos
Cardiotocografia , Sofrimento Fetal/classificação , Sofrimento Fetal/diagnóstico , Monitorização Fetal , Frequência Cardíaca Fetal/fisiologia , Cardiotocografia/classificação , Cardiotocografia/normas , Cardiotocografia/estatística & dados numéricos , Feminino , Monitorização Fetal/classificação , Monitorização Fetal/normas , Monitorização Fetal/estatística & dados numéricos , Idade Gestacional , Humanos , Variações Dependentes do Observador , Gravidez , Reprodutibilidade dos Testes , Terminologia como Assunto
20.
BMC Pregnancy Childbirth ; 16(1): 343, 2016 11 08.
Artigo em Inglês | MEDLINE | ID: mdl-27825311

RESUMO

BACKGROUND: In Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting. METHODS: During 2013-2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher's exact test, when appropriate. RESULTS: In the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients. CONCLUSION: The criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.


Assuntos
Sofrimento Fetal/diagnóstico , Sofrimento Fetal/terapia , Obstetrícia/normas , Melhoria de Qualidade , Adulto , Retroalimentação , Feminino , Monitorização Fetal/normas , Frequência Cardíaca , Hospitais , Humanos , Análise de Séries Temporais Interrompida , Auditoria Médica , Guias de Prática Clínica como Assunto , Gravidez , Tanzânia , Adulto Jovem
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