Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review

Abstract

BackgroundThe majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation.Methods and findingsThe review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings.Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation.There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10–15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28–34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.ConclusionsFrom the available evidence, the partograph is associated with improved perinatal outcomes and is recommended for use with intermittent auscultation for intrapartum monitoring in low resource settings. CTG is associated with higher caesarean section rates without proven benefits for perinatal outcomes, and should not be recommended in low-resource settings. High-quality evidence considering implementation barriers and enablers is needed to determine the optimal foetal monitoring strategy in low-resource settings.

Quality of intrapartum care: direct observations in a low-resource tertiary hospital

“…Although this approach underreports the problem, the findings highlight the challenge of adhering to guidelines in these settings. In other resource-limited settings of Sub-Saharan Africa, randomised control trials on innovative FHRM devices failed to show improvement in perinatal outcomes due Values are given as mean (standard deviation) *Significant level at 0.05: there were less senior doctors in the evening and night, and less intern doctors at night compared to morning shifts to non-adherence to FHRM international guidelines and obstetric response [21][22][23][24]. In this hospital, international guidelines were adapted to locally-acceptable minimum standards [9].…”

Assessment of foetal heart rate monitoring devices in referral hospitals in Tanzania: Towards improved quality of intrapartum care

“…median (IQR) of 60 (30,100) to 45 (21,85) minutes (p 0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p 0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p 0.001).…”

“…26,39 The use of a partograph during labour is fundamental to improving the quality of intrapartum care and subsequent perinatal outcomes in LIC. 41 If FHR and partograph use is implemented properly, this may result in a significant reduction of perinatal deaths and the associated long-term morbidities. 9 Unfortunately, in sub-Saharan Africa there is a substantial gap in quality, whereby less than half of births have appropriate partograph documentation.…”

“…Using a CTG increased the odds of caesarean section by approximately 30% with no benefits on perinatal outcomes observed. 41 The review recommended the use of intermittent FHR monitoring combined with partograph a feasible technique to improve new-born outcome. Implementation studies on these methods were also recommended.…”

<p>Midwives’ and Women’s Perception on Moyo Fetal Heart Rate Monitor for Intrapartum Fetal Heart Rate Monitoring; A Cross-Sectional Study</p>

“…7 In the resource-limited settings with high neonatal mortality rates, FHR monitoring is mainly performed intermittently using Pinard Fetoscope. 8 However, recently, Doppler has been tested for intermittent FHR monitoring in several parts of low-resource setting showing evidence of effectiveness in detecting abnormal FHR. [9][10][11] The wind-up hand-held Doppler use among women seems to be more preferred by laboring women as compared to fetoscope.…”