Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study

Abstract

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.

The prevalence of uterine fundal pressure during the second stage of labour for women giving birth in health facilities: a systematic review and meta-analysis

“…In light of current recommendations internationally, the ongoing use of fundal pressure in health facilities needs to be addressed. In some countries, continued use of fundal pressure may be affected by a lack of resources, where providers use fundal pressure to try and prevent the need for more invasive interventions and associated out of pocket costs [ 5 , 7 , 43 ]. For example, Mishra et al describe the use of fundal pressure and other bedside interventions to expedite birth in Nepal, as there are insufficient resources to ensure emergency caesarean sections are consistently available in primary and secondary level facilities [ 43 ].…”

“…Quality intrapartum care is essential to optimise maternal, fetal and neonatal peripartum outcomes and experiences of care [ 4 ]. Ideally, maternity care practices should reflect the latest evidence and clinical guidelines, however there are recognised gaps between recommended care and actual practice in many settings [ 5 , 6 ].…”

“…Application of external force through fundal pressure has previously been thought to assist vaginal birth, reducing the need for alternative and more invasive interventions to manage prolonged second stage—such as vacuum extraction, forceps delivery or Cesarean section [ 9 ]. Additionally, use of fundal pressure in some resource poor settings may be attributed to a lack of access to alternative interventions [ 5 ] 43 . While fundal pressure is used during caesarean section to assist expulsive effort (to deliver the fetus when the uterus is not contracted), its use in vaginal birth is more controversial [ 7 ].…”

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia – a cross-sectional study

“…Studies in Cambodia revealed that there was a gap between practices and evidence-based guidelines, although substantial technical support in obstetric and midwifery training courses had been provided for two decades [16][17][18][19][20]. One possible reason behind this gap is a lack of evidence-based knowledge in maternity care [16,20]. However, there has been no systematic assessment of knowledge on intrapartum care practices among skilled birth attendants in Cambodia.…”

Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India – A SWOT analysis

“…Exploring the scientific evidence and understanding the underlying basis is important to improve the labor room practices. [ 17 ] Present study was intended to carry out a situational analysis on LR documentation in secondary facilities using SWOT framework and develop strategies to address the existing gaps. The findings of this study will help the primary care physicians and the facility nodal persons to strengthen their labor room facility for better maternal health care.…”