For pregnant women laboring at home, especially if
they are nulliparous, it can be challenging to determine the right time to go
to the hospital. Are often admitted women who present to the hospital in early
labor while still in the latent phase? Postponing admission until the onset of
the active phase of labor is a suggested approach to reduce obstetric
interventions in women in spontaneous labor at term, with the fetus in cephalic
presentation. This decision should be individualized based on maternal and fetal
risks. However, the WHO recommends delaying admission to the delivery room
until the first stage or active phase is present only in research settings [4].
Abnormal fetal heart rate (FHR) in the intrapartum period may indicate a
hypoxic state in a fetus as a result of placental blood flow interruption, and
because abnormal FHR is a potential predictor of newborn asphyxia, monitoring
of it is essential for quality intrapartum care. Conversely, poor intrapartum
FHR monitoring contributes to intrapartum fetal deaths. Improvements in
intrapartum monitoring have had proven results. The WHO recommends intermittent
monitoring of FHR during labor in underdeveloped countries but does not endorse
a particular tool. In health facilities in countries with social inequality,
the Pinard stethoscope is widely used to assess FHR in the intrapartum period
instead of cardiotocography (the standard of care in high-resource countries)
or portable Doppler devices [5, 6]. Many high-risk pregnancy conditions go
undetected until delivery in low-income women. In Uganda, they developed a
training protocol in rural point-of-care ultrasound to detect fetal distress or
death, malpresentation, multiple gestation, placenta previa, oligohydramnios,
and preterm labor. This mixed methods study assessed the 2-week training
curriculum and trainees' ability to perform standard scanning and
interpretation of ultrasound images. Surveys to assess the confidence of health
personnel are applied before training, immediately after, and at a 3-month follow-up.
After the lecture and practical demonstrations, each student performed 25
supervised scans and was required to pass an observed structured clinical
examination. Of 25 participants, 22 passed the OSCE on the first attempt (mean
score 89%). Image quality improved over time; the final error rate at week 8
was less than 5%, with an overall kappa of 0.8–1 for all measures between the
two reviewers.
Table
1: Variables
considered in the study.
|
Variable
|
Mean
|
SD
|
IC 95%
|
Cases
|
%
|
|
Age
|
27
|
7
|
(25,63 - 28,37)
|
100
|
100
|
|
Gestation weeks
|
32
|
11.2
|
(10,05 - 53,95)
|
|
|
|
Preeclampsia
|
|
|
|
65
|
65
|
|
Eclampsia
|
|
|
|
3
|
3
|
|
Hellp
Syndrome
|
|
|
|
3
|
3
|
|
Hemorrhage
|
|
|
|
31
|
31
|
|
Sepsis
|
|
|
|
2
|
2
|
|
Hypovolemic
Shock
|
|
|
|
26
|
26
|
|
Intensive
care unit
|
|
|
|
94
|
94
|
|
Deliveries
|
|
|
|
11
|
11
|
|
Caesarean
section
|
|
|
|
67
|
67
|
|
Transabdominal
Hysterectomy
|
|
|
|
10
|
10
|
|
Instrumental
curettage
|
|
|
|
4
|
4
|
This study demonstrates that healthcare personnel with
no prior ultrasound experience can detect high-risk conditions during labor
with a high rate of quality and accuracy [7, 8]. In the last decade, acute
obstetric care (AOA) has become centralized in many high-income countries. In
their qualitative study, van den Berg LMM et al. (8) explored how stakeholders
perceived and experienced the organization of maternity care in the
Netherlands, where AOA was centralized. They intentionally selected a heterogeneous
group of fifteen maternity care stakeholders, including female patients, for
semi-structured interviews. Three main themes were identified: 1) Lack of
participation. 2) The process of making adaptations in the organization of
maternity care. 3) Maintain the quality of care. Stakeholders in this study
were motivated to maintain a high quality of maternity care and therefore made
accommodations at various organizational levels. However, they felt they needed
more participation during the planning of AOA centralization and stressed the
importance of a collaborative process when making adaptations after AOA
centralization. Finally, regions with AOA centralization plans should invest
time and money in change management, encourage early involvement of all maternity
care stakeholders, and recognize AOA centralization as an emotional,
professional life event associated with a feeling of insecurity [9]. Maternal
mortality has been the primary way of determining the outcome of maternal and
obstetric care. Nevertheless, maternal morbidities occur more frequently than
maternal deaths; therefore, maternal near miss has been suggested as a helpful
indicator for evaluating and improving maternal health services [10]. Conducted
a study to explore women's experiences close to maternal death and survived and
their perception of the quality of care received. This study used a qualitative
phenomenological approach with an in-depth interview method in two
tertiary-level hospitals. All women admitted to delivery rooms, OB/GYN wards,
and intensive care units in 2014 were examined for any vital organ dysfunction
or failure based on the WHO Criteria for a near miss-maternal accident. Thirty
women who had experienced maternal near misses between the ages of 22 and 45
were included in the analysis. Almost all (93%) had secondary and upper
secondary education, and 63% were employed. Women's perceptions of the quality
of their care were influenced by competence and promptness in care delivery,
interpersonal communication, information sharing, and quality of resources.
Costs, self-attitude, and personal beliefs influenced the predisposition to
seek medical care. The self-assessment of the maternal event, their perception
of the quality of care, their predisposition to seek medical care, and the
social support received were the four major themes that emerged from the
experiences and perceptions of women with a near-miss. Women with near misses
viewed their experiences as frightening and experienced other negative
emotions, such as a sense of impending doom. Factors influencing women's
perceptions of quality of care should concern those seeking to improve hospital
services. Adding a maternal near-miss review program provides insight into
factors related to caregiving or willingness to seek care; if addressed, it can
improve future medical care and patient outcomes. Interventions aimed at
reducing maternal mortality are increasingly complex. Understanding how complex
interventions are delivered, to whom, and how they work is critical to ensuring
their rapid scale-up. Other authors applied an intervention to classify vital
signs in routine maternal care in eight countries with low and middle-income
populations to reduce a composite result of morbidity and mortality. This
intervention was a stepwise implementation effectiveness trial. In this study,
they presented the results of evaluating mixed methods processes. The objective
was to describe the implementation and the local context and to integrate the
results to determine if differences in the effect of the intervention could be
explained. The duration and content of the implementation, acceptance of the
intervention, and its impact on clinical management were recorded. These were
integrated with interviews and focus groups at three months and six to nine
months after implementation. Measures were ranked and averaged across
implementation domains to determine the effect on effectiveness to create a
composite strength score and then correlated with the primary outcome. Overall,
61% (n = 2747) of health workers received training in the intervention (16 to
89%) with a mean of 11 days. The acceptance and acceptability of the
intervention was good. All clusters demonstrated improved availability of vital
signs equipment. There was an increase in the proportion of women who had their
blood pressure measured in pregnancy after the intervention (79% vs. 98%; OR
1.30 (1.29–1.31)) and no significant change in referral rates (3.7% vs 4.4% OR
0.89; (0.39–2.05)). The availability of resources and referral systems were
acceptable and effective and influenced health. This process evaluation has
satisfactorily described the quantity and quality of implementation. Variations
in implementation and setting did not explain differences in the effectiveness
of the intervention on maternal mortality and morbidity [11-13]. In the UK,
midwives are involved in discussions with the multidisciplinary team about
whether they can provide obstetric high-dependency care in the delivery room or
whether care should be escalated to the intensive care team [14]. conducted a
study to explore the question: What factors influence midwives to provide
obstetric care in the delivery room or request care outside the obstetric unit
in hospitals far from tertiary referral centers? In district general hospitals,
focus groups were organized with midwives in three obstetric units in England,
with annual birth rates ranging from 1,500 to 5,000 per year. Used three
scenarios in the form of handover video vignettes as triggers for the focus
groups. 1) Physiologically unstable severe preeclampsia; 2) significant
postpartum Hemorrhage requiring invasive monitoring; 3) recent admission of a
woman with chest pain who receives facial oxygen and requires continuous
electrocardiographic monitoring. Organized two focus groups in each obstetric
unit with experienced midwives. Data were analyzed using a qualitative
approach. Factors influencing midwives' decisions to escalate care included
care setting, diagnosis, and fetal or neonatal factors—the overall care plan, including
the need for EKG and invasive monitoring. Midwives from the smaller obstetric
unit could not access the OHDC facilities. Midwives in the larger obstetric
units provided OHDC but identified varying degrees of skill and sometimes used
'workarounds' to facilitate care delivery. Midwifery staffing levels, skill
mix, and workload were also necessary. Some differences of opinion were evident
between midwives working in the same obstetric units regarding whether OHDC
could be provided and the support they would request to help them provide. The
findings indicate that there may be inequitable provision of OHDC at the local
level. Robust systems are required to promote safe and equitable OHDC care,
including midwifery skills development and precise escalation guidelines to
minimize alternative solutions. Midwives' training should include strategies to
prevent skills loss. Optimizing maternal health in low-resource settings
requires a concerted approach to simultaneously increase access to skilled
delivery care and improve the quality of emergency and preventive maternal
health care provided. Established evidence-based interventions, but poor
quality limits health benefits despite increased access. Assessing quality and
implementing quality improvement approaches at various health system levels is
imperative to address health priorities. Maternal care quality improvement
evaluations suggest improving standardized monitoring strategies and
identifying optimal implementation strategies to translate findings into practice
within different low-resource settings to increase adoption and sustainability
[15].
