Abstract
ObjectiveThere is no consensus on the essential parameters to monitor during childbirth, when to start, and the rate of monitoring them. User disagreement contributes to inconsistent use of the twelve-item modified World Health Organization partograph that is started when the cervix is at least 4 cm dilated. The inconsistent use is associated with poor outcomes at birth. Our objective was to identify the perspectives of childbirth experts on what and when to routinely monitor during childbirth in low resource settings as we develop a more acceptable childbirth clinical decision support tool.MethodWe carried out a Delphi study with two survey rounds in early 2018. The online questionnaire covered the partograph items like foetal heart, cervical dilation, and blood pressure, and their monitoring rates. We invited panellists with experience of childbirth care in sub-Saharan Africa. Consensus was pre-set at 70% panellists rating a parameter and we gathered some qualitative reasons for choices.ResultsWe analysed responses of 76 experts from 13 countries. There was consensus on six important parameters including foetal heart rate, amniotic fluid clearness, cervical dilation, strength of uterine contractions, maternal pulse, and blood pressure. Two in three experts expressed support for changing the monitoring intervals for some parameters in the partograph. 63% experts would raise the partograph starting point while 58% would remove some items from it. Consensus was reached on monitoring the cervical dilation at 4-hourly intervals and there was agreement on monitoring the foetal heart rate one-hourly. However, other parameters only showed majority intervals and without reaching agreement scores. The suggested intervals were two-hourly for strength of uterine contractions, and four-hourly for amniotic fluid thickness, maternal pulse and blood pressure. The commonest reason for their opinions was the more demanding working conditions.ConclusionThere was agreement on six partograph items being essential for routine monitoring at birth, but the frequency of monitoring could be changed. To increase acceptability, revisions to birth monitoring guidelines have to be made in consideration of opinions and working conditions of several childbirth experts in low resource settings.
Highlights
About 303,000 women and a higher number of babies died in 2015 from pregnancy-related causes [1] like obstructed labour
Consensus was reached on monitoring the cervical dilation at 4-hourly intervals and there was agreement on monitoring the foetal heart rate one-hourly
It was a Delphi study that focused on foetal heart monitoring (FHM) in low income countries, but less than 10% of participants were from low income countries
Summary
About 303,000 women and a higher number of babies died in 2015 from pregnancy-related causes [1] like obstructed labour. Obstructed labour directly contributes 6–8% maternal deaths but it plays a role in other causes of death and morbidity for mother and baby [2, 3]. At least 80% of the poor pregnancy outcomes are preventable through interventions like adequate monitoring of the labour and delivery process [2, 5, 6]. The monitoring is hampered by lack of user-friendly tools for labour management, limited access to evidence-based clinical guidelines for the providers and users of maternal health services, maternity provider factors, weak referral networks and limited health financing [9, 10]. The parameters are often based on weak evidence that there are no studies to support the starting point and optimal frequency of examinations for the foetal heart and cervical dilation which are the most measured parameters [14,15,16,17]
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