Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study

Abstract

Introduction Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic. Method and materials We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic. Results The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic. Conclusion Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.

Observational study comparing heart rate in crying and non-crying but breathing infants at birth

“…Exclusion of circa 15% of babies born with caesarean section limits the generalisability of the findings. 12 This study was underpowered to explore differences in outcome beyond admission to neonatal intensive care unit. Lastly, the potential relationship between non-crying and hypoxia as the explanatory mechanism for bradycardia and tachycardia could not be defined due to lack of concomitant oxygen saturation measurement.…”

“…Outcome data of the study were measured with NeoBeat HR monitor that has been shown to record efficient and reliable HR data 13. Trained external data collectors directly observed all births and classified crying status immediately after stabilisation 11 12 21. To further increase reliability of the crying classification, we cross-tabulated data from breathing observations made real time during the initial stabilisation and found high rates of agreement.…”

“… 12 Providers were trained in Rapid Feedback for quality Improvement in Neonatal rEsuscitation (REFINE), an HR-guided neonatal resuscitation protocol, including HBB second edition supplemented by a half-day orientation on the use of continuous HR monitoring. 12 …”

“…Research nurses not part of the clinical care team recorded delivery room observations including periods of breathing and time of cord clamping using a purpose-designed application (Liveborn, Laerdal Medical, Stavanger, Norway). 12 Oxygen saturation data were not recorded. Crying status after birth, and maternal and neonatal demographics were recorded on a supplemental application (SUSTAIN).…”

“…Deliveries were attended by a nurse-midwife or a skilled birth attendant with on-call support from a general medical doctor, paediatrician and obstetrician when needed. 12 Providers were trained in Rapid Feedback for quality Improvement in Neonatal rEsuscitation (REFINE), an HR-guided neonatal resuscitation protocol, including HBB second edition supplemented by a half-day orientation on the use of continuous HR monitoring. 12 Participants All live-born vaginally delivered singleton neonates at or beyond 33 weeks of gestation or with birth weight of >2500 g were eligible for this study.…”