Real-time analgesic efficacy and factors determining drug requirements of combined spinal-epidural analgesia for labor: a prospective cohort study.

PURPOSE: Combined spinal-epidural analgesia (CSEA) is effective but not sufficient for labor pain. This study was conducted to assess the real-time analgesic efficacy, side effects of anesthetic drug dosage, and maternal satisfaction in labor to provide reference for the optimization of labor analgesia. METHODS: This was a prospective, cohort, single-center study that included 3020 women who received CSEA for labor analgesia. The visual analogue scale (VAS) for labor pain, real-time anesthetic drug dosage, side effects, adverse labor outcomes, factors influencing average drug dosage, and maternal satisfaction with CSEA were assessed. RESULTS: Overall, the VAS labor pain score was lowest at the first hour after the anesthesia was given. After 4 h for primiparas and 3 h for multiparas, the VAS score was greater than 3 but the anesthetic drug dosage did not reach the maximum allowed dosage at the same time. The average anesthetic drug dosage was positively correlated with fever, urinary retention, uterine atony, prolonged active phase, prolonged second stage, assisted vaginal delivery, and postpartum hemorrhage. The average anesthetic drug dosage was the highest in women ≤ 20 years old, those with a body mass index (BMI) ≥ 24.9 kg/m2, and those with a primary or secondary education level. CONCLUSION: Appropriate age guidance and emphasis on education of labor analgesia, weight management during pregnancy, and real-time anesthetic dosage adjustment during labor based on VAS pain score may have positive effects on the satisfaction of labor analgesia. CLINICAL TRIAL NUMBER AND REGISTRY: Clinicaltrials.gov (ChiCTR2100051809).

Evaluation of an external fetal electrocardiogram monitoring system: a randomized controlled trial.

OBJECTIVE: The objective of the study was to compare interpretability of 2 intrapartum abdominal fetal heart rate-monitoring strategies. We hypothesized that an external fetal electrocardiography monitoring system, a newer technology using wireless abdominal pads, would generate more interpretable fetal heart rate data compared with standard external Doppler fetal heart rate monitoring (standard external monitoring). STUDY DESIGN: We conducted a randomized controlled trial at 4 Utah hospitals. Patients were enrolled at labor admission and randomized in blocks based on body mass index to fetal electrocardiography or standard external monitoring. Two reviewers, blinded to study allocation, reviewed each fetal heart rate tracing. The primary outcome was the percentage of interpretable minutes of fetal heart rate tracing. An interpretable minute was defined as >25% fetal heart rate data present and no more than 25% continuous missing fetal heart rate data or artifact present. Secondary outcomes included the percentage of interpretable minutes of fetal heart rate tracing obtained while on study device only, the number of device adjustments required intrapartum, clinical outcomes, and patient/provider device satisfaction. We determined that 100 patients per arm (200 total) would be needed to detect a 5% difference in interpretability with 95% power. RESULTS: A total of 218 women were randomized, 108 to fetal electrocardiography and 110 to standard external monitoring. Device setup failure occurred more often in the fetal electrocardiography group (7.5% [8 of 107] vs 0% [0 of 109] for standard external monitoring). There were no differences in the percentage of interpretable tracing between the 2 groups. However, fetal electrocardiography produced more interpretable fetal heart rate tracing in subjects with a body mass index ≥30 kg/m2. When considering the percentage of interpretable minutes of fetal heart rate tracing while on study device only, fetal electrocardiography outperformed standard external monitoring for all subjects, regardless of maternal body mass index. Maternal demographics and clinical outcomes were similar between arms. In the fetal electrocardiography group, more device changes occurred compared with standard external monitoring (51% vs 39%), but there were fewer nursing device adjustments (2.9 vs 6.2 mean adjustments intrapartum, P < .01). There were no differences in physician device satisfaction scores between groups, but fetal electrocardiography generated higher patient satisfaction scores. CONCLUSION: Fetal electrocardiography performed similarly to standard external monitoring when considering percentage of interpretable tracing generated in labor. Furthermore, patients reported overall greater satisfaction with fetal electrocardiography in labor. Fetal electrocardiography may be particularly useful in patients with a body mass index ≥30 kg/m2.

Automatic ultrasound technique to measure angle of progression during labor.

OBJECTIVE: To evaluate the accuracy and reliability of an automatic ultrasound technique for assessment of the angle of progression (AoP) during labor. METHODS: Thirty-nine pregnant women in the second stage of labor, with fetus in cephalic presentation, underwent conventional labor management with additional translabial sonographic examination. AoP was measured in a total of 95 acquisition sessions, both automatically by an innovative algorithm and manually by an experienced sonographer, who was blinded to the algorithm outcome. The results obtained from the manual measurement were used as the reference against which the performance of the algorithm was assessed. In order to overcome the common difficulties encountered when visualizing by sonography the pubic symphysis, the AoP was measured by considering as the symphysis landmark its centroid rather than its distal point, thereby assuring high measurement reliability and reproducibility, while maintaining objectivity and accuracy in the evaluation of progression of labor. RESULTS: There was a strong and statistically significant correlation between AoP values measured by the algorithm and the reference values (r = 0.99, P < 0.001). The high accuracy provided by the automatic method was also highlighted by the corresponding high values of the coefficient of determination (r2 = 0.98) and the low residual errors (root mean square error = 2°27' (2.1%)). The global agreement between the two methods, assessed through Bland-Altman analysis, resulted in a negligible mean difference of 1°1' (limits of agreement, 4°29'). CONCLUSIONS: The proposed automatic algorithm is a reliable technique for measurement of the AoP. Its (relative) operator-independence has the potential to reduce human errors and speed up ultrasound acquisition time, which should facilitate management of women during labor. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Intention to Use Mobile-Based Partograph and Its Predictors Among Obstetric Health Care Providers Working at Public Referral Hospitals in the Oromia Region of Ethiopia in 2022: Cross-Sectional Questionnaire Study.

BACKGROUND: A partograph is a pictorial representation of the relationship between cervical dilatation and the time used to diagnose prolonged and obstructed labor. However, the utilization of paper-based partograph is low and it is prone to documentation errors, which can be avoided with the use of electronic partographs. There is only limited information on the proportion of intention to use mobile-based partographs and its predictors. OBJECTIVE: The objective of this study was to determine the proportion of obstetric health care providers at public referral hospitals in Oromia, Ethiopia, in 2022 who had the intention to use mobile-based partographs and to determine the predictors of their intention to use mobile-based partographs. METHODS: We performed an institution-based cross-sectional study from June 1 to July 1, 2022. Census was conducted on 649 participants. A self-administered structured English questionnaire was used, and a 5% pretest was performed. Data were entered into EpiData version 4.6 and exported to SPSS version 25 for descriptive analysis and AMOS (analysis of moment structure; version 23) for structural and measurement model assessment. Descriptive and structural equation modeling analyses were performed. The hypotheses developed based on a modified Technology Acceptance Model were tested using path coefficients and P values <.05. RESULTS: About 65.7% (414/630; 95% CI 61.9%-69.4%) of the participants intended to use mobile-based electronic partographs, with a 97% (630/649) response rate. Perceived usefulness had a positive influence on intention to use (ß=.184; P=.02) and attitude (ß=.521; P=.002). Perceived ease of use had a positive influence on attitude (ß=.382; P=.003), perceived usefulness (ß=.503; P=.002), and intention to use (ß=.369; P=.001). Job relevance had a positive influence on perceived usefulness (ß=.408; P=.001) and intention to use (ß=.185; P=.008). Attitude positively influenced intention to use (ß=.309; P=.002). Subjective norms did not have a significant influence on perceived usefulness (ß=.020; P=.61) and intention to use (ß=-.066; P=.07). CONCLUSIONS: Two-thirds of the obstetric health care providers in our study intended to use mobile-based partographs. Perceived usefulness, perceived ease of use, job relevance, and attitude positively and significantly influenced their intention to use mobile-based electronic partographs. The development of a user-friendly mobile-based partograph that meets job and user expectations can enhance the intention to use.

Impact of WHO Labor Care Guide on reducing cesarean sections at a tertiary center: an open-label randomized controlled trial.

BACKGROUND: The World Health Organization Labor Care Guide was introduced in December 2020 to implement World Health Organization (WHO) guidelines on intrapartum care for a positive childbirth experience. OBJECTIVE: This study aimed to determine the effect of the WHO Labor Care Guide on labor outcomes, especially in reducing primary cesarean deliveries, and its acceptability by healthcare providers. STUDY DESIGN: This open-label randomized control trial was conducted from September 2021 to December 2021 on 280 low-risk antenatal women admitted for delivery at a busy tertiary care institute in North India. After informed consent, women were allocated into the study and control groups. Labor monitoring was performed using the WHO Labor Care Guide in the study group and the World Health Organization-modified partograph in the control group. Women who had a cesarean delivery in the latent phase of labor were excluded from the study. The primary outcome was mode of delivery, whereas the secondary outcomes were duration of active labor, maternal complications (postpartum hemorrhage and puerperal sepsis), duration of hospital stay, Apgar score at 5 minutes, and neonatal intensive care unit admission. The labor outcomes in both groups were compared. In the study group, the acceptability, difficulty, and satisfaction levels of the users were assessed using a 5-point Likert scale. The "learning curve" for the use of the Labor Care Guide (LCG) was determined. SPSS software (version 21.0; IBM Corporation, Chicago, IL) was used for statistical analysis. RESULTS: After excluding women who underwent cesarean delivery in the latent phase, 136 women in the study group and 135 women in the control group were observed for labor outcomes. The cesarean delivery rate was 1.5% in the study group vs 17.8% in the control group (P=.0001). The duration of the active phase of labor was significantly shorter in the study group than in the control group (P<.001). The 2 groups were similar in terms of maternal complications, duration of hospital stay, and Apgar score. The learning curve took average levels of 6.50 and 2.25 Labor Care Guide plots to shift from "very difficult" to "neutral" and "neutral" to "easy," respectively. After an initial learning curve, acceptability and satisfaction levels were found to be high in the WHO Labor Care Guide users. CONCLUSION: The WHO Labor Care Guide is a simple labor monitoring tool for the reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications.

Autonomic response to fetal acidosis using an experimental sheep model.

BACKGROUND: The autonomic nervous system has a major role in fetal adaptation to hypoxia. Its activity might be assessed using heart rate variability and heart rate deceleration analyses. OBJECTIVE: To evaluate the ability of different heart rate variability and morphological deceleration analyses to predict fetal acidosis during labor in an experimental fetal sheep model. STUDY DESIGN: Repeated 1-minute total umbilical cord occlusions were performed at mild (1minute every 5 min), moderate (1 min every 3 min), and severe (1 min every 2 min) umbilical cord occlusion periodicities until arterial pH reached 7.10. Hemodynamic,blood gas analysis, morphological analysis of decelerations (magnitude, slope, and area ofdecelerations), and heart rate variability parameters were recorded throughout the experiment.Heart rate variability analysis included temporal analysis (root mean square of successivedifferences between adjacent RR intervals, standard deviation of normal to normal RR intervals, short term variability), spectral analysis (low frequencies, high frequencies,normalized high frequencies), and a new index developed by our team, the Fetal Stress Index.We defined and compared three pH groups: >7.20, 7.10-7.20, and <7.10. RESULTS: Eleven experiments were performed. Repetitive umbilical cord occlusions resulted in progressive fetal acidosis. Fetal Stress Index was correlated with pH and lactate (p < 0.05) and increased with acidosis. There were no significant correlations between pH, lactate, and other indices (spectral analysis, temporal analysis, or morphological analysis of decelerations). CONCLUSION: This protocol allowed us to identify the progressive onset of fetal acidosis in an experimental model close to labor. Fetal Stress Index is a heart rate variability method that varies with acidosis and indicates an increase in parasympathetic nervous system activity in response to fetal acidosis.

The effect of Expanding Maternal and Neonatal Survival interventions on improving the coverage of labor monitoring and complication prevention practices in hospitals in Indonesia: A difference-in-difference analysis.

OBJECTIVE: To assess whether the Expanding Maternal and Neonatal Survival (EMAS) program was associated with improved care provided during hospital-based childbirth. METHODS: A quasi-experimental study with two rounds of data collection examined whether EMAS interventions improved facility-based labor and childbirth care. Direct clinical observations were conducted for 1208 deliveries across 13 hospitals in 12 districts. Primary outcome measures included implementation of standard practices to reduce the risk of complications during labor and childbirth for both women and newborns. RESULTS: Adjusted difference-in-difference analysis compared the mean difference in quality scores between EMAS intervention hospitals and comparison sites and consistently found significantly better performance in EMAS sites: 14 points higher for labor monitoring (ß-coefficient 14.1; 95% confidence interval [CI], 7.1-21.0); 38 points higher for newborn resuscitation readiness (ß-coefficient 38.1; 95% CI, 31.1-45.2); and 33 points higher for infection prevention practices (ß-coefficient 32.6; 95% CI, 28.5-36.8). CONCLUSION: EMAS approaches emphasizing facility readiness and adherence to performance standards significantly improved labor monitoring and complication prevention practices during childbirth.

The Partograph in Childbirth: An Absolute Essentiality or a Mere Exercise?

WHO has recommended use of the partograph, a low-tech paper form that has been hailed as an effective tool for the early detection of maternal and fetal complications during childbirth. Yet despite decades of training and investment, implementation rates and capacity to correctly use the partograph remain low in resource-limited settings. Nevertheless, competent use of the partograph, especially using newer technologies, can save maternal and fetal lives by ensuring that labor is closely monitored and that life-threatening complications such as obstructed labor are identified and treated. To address the challenges for using partograph among health workers, health-care systems must establish an environment that supports its correct use. Health-care staff should be updated by providing training and asking them about the difficulties faced at their health center. Then only the real potential of this wonderful tool will be maximally utilized.

"I Was Relieved to Know That My Baby Was Safe": Women's Attitudes and Perceptions on Using a New Electronic Fetal Heart Rate Monitor during Labor in Tanzania.

To increase labor monitoring and prevent neonatal morbidity and mortality, a new wireless, strap-on electronic fetal heart rate monitor called Moyo was introduced in Tanzania in 2016. As part of the ongoing evaluation of the introduction of the monitor, the aim of this study was to explore the attitudes and perceptions of women who had worn the monitor continuously during their most recent delivery and perceptions about how it affected care. This knowledge is important to identify barriers towards adaptation in order to introduce new technology more effectively. We carried out 20 semi-structured individual interviews post-labor at two hospitals in Tanzania. A thematic content analysis was used to analyze the data. Our results indicated that the use of the monitor positively affected the women's birth experience. It provided much-needed reassurance about the wellbeing of the child. The women considered that wearing Moyo improved care due to an increase in communication and attention from birth attendants. However, the women did not fully understand the purpose and function of the device and overestimated its capabilities. This highlights the need to improve how and when information is conveyed to women in labor.

Acquiring Knowledge about the Use of a Newly Developed Electronic Fetal Heart Rate Monitor: A Qualitative Study Among Birth Attendants in Tanzania.

In an effort to reduce newborn mortality, a newly developed strap-on electronic fetal heart rate monitor was introduced at several health facilities in Tanzania in 2015. Training sessions were organized to teach staff how to use the device in clinical settings. This study explores skilled birth attendants' perceptions and experiences acquiring and transferring knowledge about the use of the monitor, also called Moyo. Knowledge about this learning process is crucial to further improve training programs and ensure correct, long-term use. Five Focus group discussions (FGDs) were carried out with doctors and nurse-midwives, who were using the monitor in the labor ward at two health facilities in Tanzania. The FGDs were analyzed using qualitative content analysis. The study revealed that the participants experienced the training about the device as useful but inadequate. Due to high turnover, a frequently mentioned challenge was that many of the birth attendants who were responsible for training others, were no longer working in the labor ward. Many participants expressed a need for refresher trainings, more practical exercises and more theory on labor management. The study highlights the need for frequent trainings sessions over time with focus on increasing overall knowledge in labor management to ensure correct use of the monitor over time.

Simultaneous Recording and Analysis of Uterine and Abdominal Muscle Electromyographic Activity in Nulliparous Women During Labor.

OBJECTIVE: To record and characterize electromyography (EMG) from the uterus and abdominal muscles during the nonlabor to first and second stages of labor and to define relationships to contractions. METHODS: Nulliparous patients without any treatments were used (n = 12 nonlabor stage, 48 during first stage and 33 during second stage). Electromyography of both uterine and abdominal muscles was simultaneously recorded from electrodes placed on patients' abdominal surface using filters to separate uterine and abdominal EMG. Contractions of muscles were also recorded using tocodynamometry. Electromyography was characterized by analysis of various parameters. RESULTS: During the first stage of labor, when abdominal EMG is absent, uterine EMG bursts temporally correspond to contractions. In the second stage, uterine EMG bursts usually occur at same frequency as groups of abdominal bursts and precede abdominal bursts, whereas abdominal EMG bursts correspond to contractions and are accompanied by feelings of "urge to push." Uterine EMG increases progressively from nonlabor to second stage of labor. CONCLUSIONS: (1) Uterine EMG activity can be separated from abdominal EMG events by filtering. (2) Uterine EMG gradually evolves from the antepartum stage to the first and second stages of labor. (3) Uterine and abdominal EMG reflect electrical activity of the muscles during labor and are valuable to assess uterine and abdominal muscle events that control labor. (4) During the first stage of labor uterine, EMG is responsible for contractions, and during the second stage, both uterine and abdominal muscle participate in labor.

Healthcare providers' perspectives on labor monitoring in Nigeria and Uganda: A qualitative study on challenges and opportunities.

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.

Uterine and Abdominal Muscle Electromyographic Activities in Control and PCEA-Treated Nulliparous Women During the Second Stage of Labor.

OBJECTIVE: Patient-controlled epidural analgesia (PCEA), used to relieve pain during delivery, delays labor but the mechanism is unknown. The aim was to investigate the effects of PCEA on uterine and abdominal muscles electromyographic (EMG) activity during the second stage of labor. METHODS: This study included 45 nulliparous pregnant women without PCEA, 42 women with standard PCEA treatment given during the first stage of labor and stopped near the end of the first stage, and 22 women with standard PCEA treatment with continued use throughout the first and second stages of labor. The EMG signals were recorded from the abdominal surface using PowerLab hardware and LabChart software (ADInstruments, New South Wales, Australia) and filtered to separate uterine and abdominal EMG. Various EMG burst parameters were obtained. RESULTS: There are no differences ( P > .05) in the age, body mass index, fetal weight, and Apgar scores between the patients from the various groups. PCEA (both stopped and continued) inhibits ( P < .05) duration, number of bursts, and root mean square of uterine EMG. PCEA also produces statistically significant ( P < .001) reductions in abdominal EMG. The decrease in EMG activity is accompanied by a significant ( P < .001) prolongation of the second stage duration (PCEA continued = 95.08 ± 8.60 minutes, PCEA stopped = 79.39 ± 6.25 minutes, no PCEA = 61.00 ± 7.23 minutes). CONCLUSION: PCEA suppresses uterine and abdominal muscle EMG during the second stage of labor but inhibition depends upon the treatment schedule. PCEA prolongs the duration of labor by inhibition of uterine and abdominal muscle and neural activity.

The use of the partograph in labor monitoring: a cross-sectional study among obstetric caregivers in General Hospital, Calabar, Cross River State, Nigeria.

BACKGROUND: Prolonged and obstructed labor is a significant cause of maternal morbidity and mortality in Nigeria, one of the six countries contributing significantly to the global maternal mortality crisis. The use of the partograph would engender a remarkable reduction in the number of these deaths since abnormal markers in the progress of labor would be identified early on. OBJECTIVE: This study aimed to evaluate the non-physician obstetric caregivers' (OCGs) knowledge of partograph use, assess the extent of its use, determine the factors that impede its usage, and unravel the relationship between years of experience and partograph use among the respondents (OCGs) in General Hospital, Calabar, Nigeria. METHODOLOGY: Using a self-administered semi-structured questionnaire, a cross-sectional descriptive study was conducted among 130 purposely selected and consenting OCGs working in the General Hospital, Calabar, Nigeria. RESULTS: The majority of the respondents (70.8%) had good general knowledge of the partograph but lacked detailed and in-depth knowledge of the component parts of the partograph. Knowledge of partograph (χ(2) =12.05, P=0.0001) and partograph availability (χ(2) =56.5, P=0.0001) had a significant relationship with its utilization. Previous training (χ(2) =9.43, P=0.002) was significantly related to knowledge of partograph. Factors affecting utilization were: little or no knowledge of the partograph (85.4%), nonavailability (70%), shortage of staff (61.5%), and the fact that it is time-consuming to use (30%). CONCLUSION: Lack of detailed knowledge of the partograph, nonavailability of the partograph, poor staff numbers, and inadequate training are factors that work against the effective utilization of the partograph in the study facility. Usage of this tool for labor monitoring can be enhanced by periodic training, making partographs available in labor wards, provision of reasonable staff numbers, and mandatory institutional policy.