Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study.

OBJECTIVE: To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes. DESIGN: A facility-based, multicentre, prospective cohort study. SETTING: Thirteen maternity hospitals located in Nigeria and Uganda. POPULATION: A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour. METHODS: Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic. OUTCOMES: Severe adverse birth outcomes. RESULTS: The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty-nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves. CONCLUSIONS: Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the 'one-centimetre per hour' rule should be re-evaluated. FUNDING: Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879). TWEETABLE ABSTRACT: The alert line in check: results from a WHO study.

Linear and non-linear analysis of uterine contraction signals obtained with tocodynamometry in prediction of operative vaginal delivery.

OBJECTIVE: The aim of this study was to explore whether linear and non-linear analysis of uterine contraction (UC) signals obtained with external tocodynamometry can predict operative vaginal delivery (OVD). MATERIALS AND METHODS: The last 2 h before delivery (H1 and H2) of 55 UC recordings acquired with external tocodynamometry in the labour ward of a tertiary care hospital were analysed. Signal processing involved the quantification of UCs/segment (UCN), and the linear and non-linear indices: Sample Entropy (SampEn) measuring signal irregularity; interval index (II) measuring signal variability, both of which may be associated with uterine muscle fatigue, and high frequency (HF), associated with maternal breathing movements. Thirty-two women had normal deliveries and 23 OVDs. Statistical inference was performed using 95% confidence intervals (95% CIs) for the median, and areas under the receiver operating curves (auROCs), with univariate and bivariate analyses. RESULTS: A significant association was found between maternal body mass index (BMI) and UC signal quality in H1, with moderate/poor signal quality being more frequent with higher maternal BMI. There was an overall increase in contraction frequency (UCN), signal regularity (SampEn), signal variability (II), and maternal breathing (HF) from H1 to H2. The OVD group exhibited significantly higher values of signal irregularity and variability (SampEn and II) in H1, and higher contraction frequency (UCN) and maternal breathing (HF) in H2. Modest auROCs were obtained with these indices in the discrimination between normal and OVDs. CONCLUSIONS: The results of this exploratory study suggest that analysis of UC signals obtained with tocodynamometry, using linear and non-linear indices associated with muscle fatigue and maternal breathing, identifies significant changes occurring during labour, and differences between normal and OVDs, but their discriminative capacity between the two types of delivery is modest. Further refinement of this analysis is needed before it may be clinically useful.

[Requirements and current state of birth documentation in Germany]. / Moderne Anforderungen und derzeitiger Standard in der Geburtsdokumentation in Deutschland.

INTRODUCTION: The partogram is a central record in everyday practice for midwifes and obstetricians. For legal enquiries it is one of the most important documents, however, so far there is no standardised partogram in use in Germany. This study explores the current requirements and develops a standardised partogram. MATERIAL AND METHODS: In Germany 95 hospitals with a focus on tertiary referral centres were randomly selected to be questioned. Obstetricians and midwifes were asked to answer a questionnaire, which was based on a current literature search and expert interviews. RESULTS: 49 obstetricians (51.6%) and 24 midwives (25.3%) returned the questionnaires. 80% of those regularly cooperate with the other specialty with a partogram. 75% are using a standardised partogram, 8% an empty page and 6% computerised obstetric records. Most responders are using parameters which are defined in the current guidelines of the German Society of Obstetrics and Gynaecology. Variations were especially pronounced in the scoring system of the cardiotocogram and on legal issues. Room for improvement of the current documentation was documented in half of the cases. DISCUSSION: There is a need for optimising the current birth documentation. With the results of the questionnaire a standardised model for a partogram was developed.

Rapid assessment of partograph utilisation in selected maternity units in Kenya.

BACKGROUND: Prolonged labour causes maternal and perinatal morbidity and mortality. Its sequela include obstructed labour, uterine rupture, maternal exhaustion, postpartum haemorrhage, puerperal sepsis, obstetric fistula, stillbirths, birth asphyxia and neonatal sepsis. These complications can be reduced by using the partograph to assess the progress of labour. The Ministry of Health, Kenya has adopted this tool for labour management in the country and the standardised partograph is recommended for use in all delivery units. OBJECTIVE: To determine the utilisation of the partograph in the management of labour in selected health facilities in Kenya. DESIGN: A descriptive cross sectional study. SETTING: Nine health facilities -ranging from a tertiary hospital to health centre, including public private and faith based facilities in four provinces in Kenya. RESULTS: All facilities apart from Pumwani Maternity Hospital and one health centre were using the partograph. The correct use was low, the knowledge on the use of the tool was average and there was minimal formal training being provided. Staff shortage was listed as the most common cause of not using the tool. Contractions were recorded 30-80%, foetal heart rate 53-90% and cervical dilatation 70-97%. Documentation of state of the liquor, moulding and descent as well as maternal parameters such as pulse, and blood pressure and urinalysis were minimally recorded. Supplies for monitoring labour such as fetoscopes and blood pressure machines were in short supply and sometimes not functional. Overall, the poor usage was contributed to staff shortages, lack of knowledge especially on interpretation of findings, negative attitudes, conflict between providers as to their roles in filling the partograph, and senior staff themselves not acting as role models with regards to the use, advocacy and implementation of the partograph. CONCLUSION: The partograph was available in most units. However, accurate recording of parameters to monitor the foetus, the mother and progress of labour as recommended was mostly not done. Shortage of staff, lack of knowledge, lack of team work, lack of supplies and negative attitude among healthcare providers were some of the obstacles noted to hamper partograph use.

Older age and higher parity are associated with nonuse of the partograph at Mbarara Regional Referral Hospital, Uganda.

OBJECTIVE: To determine the frequency of partograph use, the proportion of mothers with partographs completed to standard, the completeness of recorded parameters, and factors associated with nonuse at Mbarara Regional Referral Hospital (MRRH), Uganda. METHODS: A retrospective review of medical records from mothers admitted to MRRH's postnatal ward between October 2016 and March 2017. Partograph use and whether it had been completed to standard were analyzed. RESULTS: Of 527 study participants, 409 (77.6%) records contained a partograph, of which only 17 (4.2%) had been completed to standard. Parameters most commonly completed to standard were monitoring of cervical dilatation (n=41, 10%), fetal heart rate (n=21, 5.1%), and uterine contractions (n=18, 4.4%). Age older than 30 years (prevalence ratio 1.73; 95% CI, 1.14-2.64) and parity greater than or equal to five (prevalence ratio 1.88; 95% CI, 1.19-2.98) were associated with nonuse of the partograph. Birth outcome was recorded in 98.8% (n=404) of partographs. CONCLUSION: Appropriate use of the partograph to monitor mothers in labor was extremely low; most common use was to record birth outcomes. Older mothers and those with higher parity were less likely to have their labor monitored using a partograph and should be targeted for partograph interventions.

Assessment of partograph utilization and associated factors among obstetric care givers at public health institutions in central zone, Tigray, Ethiopia.

OBJECTIVES: Partograph is one of the best effective obstetric tools used to monitoring labor and prevent prolonged or obstructed labor which accounts for about 22% of maternal deaths in Ethiopia. This study was aimed to assess partograph utilization and associated factors among obstetric care givers. Facility based cross sectional study was used in the randomly selected health facilities. Total 220 obstetric care givers were selected using simple random sampling technique. Data were entered and analyzed using SPSS version 22.0. Bivariate and multivariate logistic regression analysis was used to identify the associations of each explanatory variable with the outcome variable. Finally, odds ratio with its 95% confidence interval and p-value of 0.05 was used to identify significant variables. RESULT: Out of 198 obstetric care providers, 73.3% used partograph to monitor progress of labor. Those who were diploma holders (AOR = 3.8, CI = 2.2-6.2), receiving basic emergency obstetrics and new born care training (AOR = 5.6, CI 1.1-28.5), age between 20 and 29 years-old (AOR = 0.1, CI = 0.01-0.50), and male health care providers (AOR = 0.37, CI = 0.44-0.95) were factors significantly associated with partograph utilization. Partograph utilization in this study was below the WHO recommendation. Especial emphasizes and interventions should be given to increase partograph utilization.

Rejection of the maternal electrocardiogram in the electrohysterogram signal.

The electrohysterogram (EHG) signal is mainly corrupted by the mother's electrocardiogram (ECG), which remains present despite analog filtering during acquisition. Wavelets are a powerful denoising tool and have already proved their efficiency on the EHG. In this paper, we propose a new method that employs the redundant wavelet packet transform. We first study wavelet packet coefficient histograms and propose an algorithm to automatically detect the histogram mode number. Using a new criterion, we compute a best basis adapted to the denoising. After EHG wavelet packet coefficient thresholding in the selected basis, the inverse transform is applied. The ECG seems to be very efficiently removed.

Home uterine activity monitoring in the prevention of very low birth weight.

OBJECTIVES: Despite controversy regarding the efficacy of home uterine activity monitoring (HUAM), it is currently licensed for detection of preterm labor in women with previous preterm deliveries. In practice, however, it is being more widely utilized in an effort to prevent preterm delivery. This study seeks to determine which group of mothers delivering very low birth weight (VLBW) infants would have qualified for HUAM given three different sets of criteria and in which women it could have been used to help prolong gestation. METHODS: The authors reviewed the medical records of mothers of VLBW infants born in five U.S. locations (N = 1440), retrospectively applying three sets of eligibility criteria for HUAM use: (a) the current FDA licensing criterion for use of HUAM, a previous preterm birth; (b) indication for HUAM commonly cited in published reports; (c) a broad set of criteria based on the presence of any reproductive or medical conditions that might predispose to premature delivery. The authors then analyzed the conditions precipitating delivery for each group to determine whether delivery might have been prevented with HUAM and tocolytic therapy. RESULTS: Only 4.4% of the total group of women delivering VLBW infants would have been eligible for HUAM under the FDA criterion and might potentially have benefited from this technology. If extremely broad criteria had been applied to identify those eligible for monitoring, under which almost 80% of all women who delivered VLBW infants would have been monitored, only 20.3% of the total group would have been found eligible and would potentially have benefited. If such broad criteria were applied to all pregnant women, a sizable proportion of pregnancies would be monitored at great expense with small potential clinical benefit. CONCLUSIONS: Because VLBW births are usually precipitated by conditions that are unlikely to benefit from HUAM, this technology will have little impact on reducing VLBW and neonatal mortality rates. More comprehensive preventive strategies should be sought.

[PGF2 and the induction of the trial of labor. The prognostic value of uterine contractions]. / PGE2 e induzione del travaglio di parto. Valore prognostico delle contrazioni uterine.

BACKGROUND: Uterine contractions during the first hour following intracervical application of dinoprostone would show the myometrial sensitivity to prostaglandins E2 (PGE2) and could be a good practical marker of the real prospects of success of an attempt to induce labor according to the above mentioned modalities. The verification of such an hypothesis is the principal aim of this work. METHODS: The study was carried out on a group of 90 cardiotocograms recorded soon after a sample of pregnant women at term underwent labor induction by intracervical application of a gel containing 0.5 mg of PGE2 (dinoprostone). Special attention was paid to some characteristics of the cardiotocograms obtained during the first hour following administration of the gel: regularity of uterine contractions, total number of contractions, number of contractions having an intensity equal or superior to 50 mmHg, mean number of contractions during a period of 10 minutes, mean number of "effective" contractions during a period of 10 minutes, presence or absence of "excessive uterine activity" (tachysystole and/or hypersystole). RESULTS: Some cardiotocographic patterns were associated with a higher percentage of successful inductions, but the observed differences, not statistically significant, do not seem to be clinically interesting. CONCLUSIONS: However, it's not possible to exclude that a longer period of uterine contractions monitoring, perhaps lasting 2 hours instead of only 60 minutes, could lead to more useful information for the management choices.

Surveyed use of fetal and uterine monitoring during maternal surgery.

The goal of this study was to determine the frequency and methods of intraoperative fetal and uterine monitoring during maternal surgery in the United States. Maternal surgery was defined as nonobstetric surgery during pregnancy that required general or regional anesthesia. We mailed a 21-item questionnaire to the perioperative nurse managers of US hospitals at which more than 2,000 babies are delivered annually (n = 579). Nearly 60% of responding hospitals routinely used some form of fetal monitoring during maternal surgery; more than 40% of responding hospitals did not use intraoperative fetal and uterine monitoring routinely during maternal surgery.

Electrohysterographic conduction velocity estimation.

Monitoring and analysis of the fetal-heart and the uterine-muscle activity, referred to as electrohysterogram (EHG), is essential to permit timely treatment during pregnancy. While remarkable progress is reported for monitoring of the fetal cardiac activity, the EHG measurement and interpretation remains challenging, and limited knowledge is available on the underlying physiological processes. In particular, little attention has been paid to the analysis of the EHG propagation, whose characteristics might indicate the presence of coordinated uterine contractions leading to intrauterine pressure increase. Therefore, this study focuses for the first time on the noninvasive estimation of the conduction velocity of EHG action potentials by means of multichannel EHG recording and surface high-density electrodes. A maximum likelihood algorithm, initially proposed for skeletal-muscle electromyog-raphy, is modified for the required EHG analysis. The use of clustering and weighting is introduced to deal with poor signal similarity between different channels. The presented methods were evaluated by specific simulations, proving the combination of weighting and clustering to be the most accurate method. A preliminary EHG measurement during labor confirmed the feasibility of the method. An extensive clinical validation will however be necessary to optimize the method and assess the relevance of the EHG conduction velocity for pregnancy monitoring.

Place du cathéter de Foley dans la prévention des récurrences des synéchies utérines après hystéroscopie opératoire au Centre Hospitalier de Recherche et d'Application en Chirurgie Endoscopique et Reproduction Humaine (CHRACERH)

Contexte : Les adhérences intra-utérines peuvent entraîner un dysfonctionnement partiel ou complet de l'endomètre avec une altération de la fertilité et du cycle menstruel. La récurrence des synéchies après l'hystéroscopie est l'un des facteurs les plus importants pouvant altérer le pronostic de fertilité en post-opératoire. Objectif : L'objectif de ce travail était d'évaluer l'efficacité du ballonnet du cathéter de Foley intra-utérin dans la prévention des récurrences des synéchies après une hystéroscopie opératoire au CHRACERH. Patientes et méthode : Nous avons mené une étude transversale comparative avec collecte de données rétrospective, sur deux ans (du 1er janvier 2016 au 31 décembre 2017), chez 35 femmes ayant subi une hystéroscopie opératoire pour des synéchies utérines. Chaque patient a été classé dans deux groupes, le groupe (I) avec ballonnet du cathéter de Foley (15 patientes) et le groupe (II) sans ballonnet de cathéter de Foley (20 patientes). Le ballonnet de la sonde de Foley n°14, était placé dans l'utérus des patientes du groupe I et gonflé avec 10 ml de solution saline normale puis était retiré 5 jours après l'opération. Une hystéroscopie de second look était réalisée deux mois après l'opération pour évaluer la récurrence des synéchies dans tous les groupes. La classification de March et al. a été utilisée à cette fin. L'analyse statistique a été réalisée grâce au logiciel SPSS 20 (SPSS Inc., Chicago, IL). Résultats : L'âge moyen était de 40,1 ± 7,0 ans avec un minimum à 29 ans et un maximum à 58 ans. L'IMC moyen était de 27,3 ± 3,8 kg/m2, avec un maximum de 20,6 kg/m2 et un minimum de 37,5 kg/m2. Vingt pour cent de la population étudiée était obèse. Les principaux symptômes cliniques étaient l'aménorrhée (25,7%), l'oligoménorrhée (22,9%) et la dysménorrhée (17,1%). Quarante pour cent (8,6% dans le groupe I vs 31,4% dans le groupe II) de la population étudiée avaient une synéchie légère, 42,9% (22,9% dans le groupe I contre 20% dans le groupe II) avaient une synéchie modérée et 17,1% (11,4% dans le groupe I vs 5,7% dans le groupe II) avaient une synéchie sévère selon la classification de March. Treize virgule trois pour cent des patients du groupe I ont eu des récurrences de synéchies contre 30% des patients du groupe II. Il n'y avait pas d'association significative entre l'utilisation de la sonde de Foley et la prévention des récurrences de synéchies (p = 0,42). Le taux de complication total était de 5,7%. L'association entre la survenue d'une complication et le groupe de patients n'était pas significative (p = 0,61). Conclusion : Dans cette étude, il n'y avait pas d'association significative entre l'utilisation de la sonde de Foley et la récurrence des synéchies. Cependant, nous avons eu un faible pourcentage de récurrences dans le groupe avec cathéter de Foley par rapport au groupe sans cathéter Foley

Increasing compliance with maternal and child care quality standards in Ecuador.

OBJECTIVE: To determine the effects of hospital quality assurance interventions on compliance with clinical standards, availability of essential drugs, client satisfaction, and utilization. DESIGN: Quasi-experimental, prospective study with four intervention hospitals and four control hospitals. All eight facilities were purposively selected and of comparable complexity. SETTING: Ministry of Health secondary care facilities in Ecuador. INTERVENTIONS: Facility-based quality improvement teams, job clarification, standards communication, refresher training, strengthening hospital pharmacy committees, monthly monitoring of compliance indicators, and formation of users' committees. MEASURES: Compliance with input and process standards, utilization of services, and patient satisfaction were measured monthly in both groups through review of clinical and administrative records, exit interviews, and patient satisfaction surveys. RESULTS: After 12 months, the quality assurance interventions produced rapid increases in compliance with clinical standards in the intervention hospitals as compared with the control group. These improvements appeared as early as 2 months after the onset of the interventions. No differences were found between intervention and control groups in terms of trends in utilization patterns or client satisfaction. CONCLUSION: Quality assurance interventions made a difference in technical quality of care. Patient satisfaction and utilization do not appear to be directly associated with short-term improvements in compliance with clinical standards. Quality improvement interventions may require longer periods and a specific aim at clients' needs to demonstrate effects on utilization and satisfaction outcome variables.