Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Problem Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units. Approach In 2014­2018, we carried out the PartoMa study at Zanzibar's tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care. Local setting Around 11 500 women gave birth annually in the hospital. Of the 35­40 birth attendants employed, each cared simultaneously for 3­6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1­5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used. Relevant changes Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1­5 halved to 28 per 1000 live births. Lessons learnt After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively

The effect of Female Genital Mutilation on perineal injuries among women in labour in Dodoma Region, Tanzania

Introduction: Female Genital Mutilation (FGM) is widespread in Tanzania and poses a risk when women give birth.Objective: To determine the association between FGM and perineal injury among women in labour in DodomaMethods: A matched case-control study of 364 randomly selected consenting women in labour was conducted in Dodoma Region between January 2017 and June 2018. Controls (no perineal injury) were matched to the cases (with perineal injury) based on maternal age at a ratio 2:1 making a sample of 243 controls and 121 cases. FGM and perineal injury was directly observed during labour using WHO guidelines. Data were analysed by using SPSS version 20 for Window (SPSS Inc., Chicago, IL, USA). Frequency tables were generated and bivariate analyses were conducted. The association between FGM and perineal injury was determined using chi-squared statistics.Results: Of the 364 women were investigated 40.4% (n=147) were circumcised and 59.6% (n=217) were not. There was a significant association between FGM and perineal injury (p=0.001).Conclusion: The FGM rate was high. FGM (total and Type II) was significantly associated with perineal injury

Midwives' knowledge and use of partographs at Juba Teaching Hospital, South Sudan

Background:Evidence shows that good knowledge of partographs and proper application of this knowledge results in a remarkable reduction in prolonged and obstructed labour and reduces maternal mortality. Obstructed labour can be prevented by a simple and cost-effective health intervention tool, the partograph. A partograph is a graphical record of the progress of labour and salient conditions of the mother and foetus plotted against time in hours. This provides an opportunity for early identification of deviation from normal progress. Early detection of prolonged labour greatly contributes to prevention of obstructed labour and related complications.Objective:To assess midwives' knowledge and use of partographs in the maternity ward of Juba Teaching Hospital, South Sudan.Methods:A cross-sectional descriptive study was conducted to assess utilisation of partographs among healthcare providers in Juba Teaching Hospital. All providers working at the time of the study were included. An interviewer administered questionnaire prepared in English was used to assess socio-demographic and other related variables of respondents as well as knowledge and practice. Ethical procedures were followed at every step. Results:Only 20% of the 30 respondents were registered midwives, 67% knew the components -of a partograph, and 93% could differentiate between normal and abnormal labour with the use of a partograph. The factors affecting the use of partographs included; shortage of partographs in the ward, lack of protocols on partograph use, understanding semantics of the English language, absence of refresher training, late reporting of mothers to the ward, and a shortage of staff. Conclusions: Despite good knowledge of the partograph, about half of the providers do not use them. We recommend training and recruitment of more qualified midwives, a continuous supply of partographs to improve use of partographs continuous supportive supervision, mentoring of staff and motivation schemes

Labor, delivery and postpartum complications in nulliparous women with female genital mutilation admitted to Karamara hospital

Objectives:To assess labor, delivery and postpartum complications in nulliparous women with FGM/C and evaluate the attitude of mothers towards elimination of FGM.Methods:A prospective hospital based study using structured questionnaire was conducted between January to March 2015 at Karamara hospital, Jijiga, Ethiopia. All nulliparous women admitted for labor and delivery were included. Data were collected regarding circumcision status, events of labor, delivery; postpartum and neonatal outcomes as well as attitude of mothers towards elimination of FGM/C. Results:Two hundred sixty four (92.0%) of the women had FGM/C with most (93.0%) undergoing Type III FGM. The mean age of the women was 22 yr. Failure to progress in 1st stage and prolonged 2nd stage of labor occurred in 165 (57.0%) and189 (65.6%) of the cases respectively. Caesarean section was performed in 17.0% and instrumental delivery in 23.0%. 64.5% required episiotomies, 83.3% had an anterior episiotomy, 29 % had perineal tears, 25.7%% experienced post-partum hemorrhage and 24% postpartum infection. Among the newborns, there were 6.4% perinatal deaths; 18.8 % low birth weight and 1.5% birth injuries. Almost all complications were more frequently seen in circumcised compared to non-circumcised women. Conclusions: The prevalence of FGM is high and it substantially increases the risk of many maternal complications. Health professionals should be aware of these complications and support/care of women with FGM should be integrated at all levels of reproductive health care provision. Capacity building of responsible health professional should be initiated in the area with intensification of FGM eradication activities

Comparison between the Outcome of Trial of Labour and Elective Repeat Caesarean Section in Kiambu District Hospital: a Retrospective Cohort Study

Objective: To determine the pregnancy outcomes in patients with one previous Caesarean section scar who underwent trial of labour as compared to those who had elective repeat Caesarean section at Kiambu District Hospital. Design: A retrospective cohort study. Setting: Post natal wards of Kiambu District Hospital. Subjects: Medical records of all mothers with one previous Caesarean section scar who had delivered in Kiambu District Hospital were obtained and the information used to fill questionnaires. Maternal morbidity was assessed primarily based on post-natal hospital stay. Other maternal morbidity measures assessed included occurrence of uterine rupture; maternal death; need for hysterectomy; maternal blood loss; presence of visceral injury (bladder or gut) and post delivery infectious morbidity. In addition; the failure rate of trial of labour was determined. Foetal outcome was assessed based on APGAR score at five minutes; need for admission to the new born unit and the occurrence of early neonatal death. Results: A total of 142 participants were recruited of which 71 had undergone TOL and 71 had undergone ERCS. Clinical pelvimetry was the most common criteria used for selection of patients for TOL since 100% of all patients in the TOL group were assessed this way as compared to 80.3% in the ERCS group. The success rate of TOL was 50.7% in this study. Successful TOL was associated with less hospital stay since 91.6% stayed for two days or less as compared to ERCS where 84.5% stayed for 3-4days (P0.001). Similarly; blood loss was less for those who had successful TOL where 97.2% lost less than 500mls as compared to ERCS where 85.9% lost 500mls or more. Maternal outcomes were worse in the 49.7% who failed TOL since only 57.1% of them had a post-natal hospital stay of three to four days as compared to 84.5% in the ERCS group( p

Comparison of 25 and 50 Microgram of Misoprostol for Induction of Labour in Nulliparous Women with Postdate Pregnancy in Port Harcourt

Background: Induction of labor for postdate pregnancy using misoprostol is one of the most common interventions in pregnancy. However; the optimal dose of misoprostol is yet to be determined with previous reports utilizing different dosages. Objective: The main objective of this study was to compare the effectiveness and safety of 25 ?g versus 50 ?g of intravaginal misoprostol for induction of labor in nulliparous women with postdate pregnancy. Methodology: This was a prospective study in which 88 nulliparous women with postdate pregnancy were randomly selected to receive either 25 ?g or 50 ?g of misoprostol for induction of labor. Student's t-test and Chi-square test were used to compare proportions. Results: There was no significant difference between the two groups with regard to the induction-vaginal delivery interval between the two doses. The proportion of women delivering vaginally with a single dose of misoprostol (11/40 vs. 23/43; P = 0.01) and vomiting were significantly greater in the 50 ?g group. However; there was no significant difference between both groups in terms of the need for augmentation of labor; caesarean section; tachysystole and hyperstimulation syndrome. Conclusion: Intravaginal administration of 25 ?g of misoprostol appears to be as effective; but safer than 50 ?g for induction of labor in nulliparous women with postdate pregnancy

Predictors of vaginal delivery in nulliparous mothers

Background: Nulliparity is an obstetric high-risk group whose labor, compared with multiparae, are more likely to develop labor abnormalities that requires intervention. The aim of this report is todetermine factors that influence vaginal delivery in nulliparae. Materials and Methods: A prospective cross-sectional study was done on 286 eligible booked nulliparae in labor, to determine factors associated with vaginal delivery. Information about each patient's social demographic factors, and physical characteristics such as height and weight, events in labor and mode of delivery were recorded in the data sheet. Bivariate analysis was done using Chi square, while multivariate analysis was done using logistic regression. Level of significance was put at P < 0.05. Results: Of a total of 944 primigravidae delivered in the unit during the study period, 286 (30.3%) were eligible for the study. Vaginal delivery was achieved in 214 (74.8%) of the eligible parturient, while 72 (25.2%) had emergency caesarean delivery. Indications for the caesarean delivery were: failure to progress (46; 63.9%), fetal distress (20; 27.8%), maternal distress (5; 8.0%), and rapidly developing pre-eclampsia in labor (1, 0.3%). The birth weight of the baby ranged between 2.0 and 4.5 kg with mean weight of 3.1 ± 0.4 kg. Birth weight (odd ratio [OR] = 0.40, 95% confidence interval [CI] = 0.21-0.78), fetal head engagement in early labor (OR = 10.30, 95% CI = 1.35-78.69), and maternal body mass index (BMI) (odd ratio [OR] = 2.08, 95% confidence interval [CI] = 1.03-4.20) were found to be predictors of vaginal delivery. Conclusion: Normal range of maternal BMI, fetal head engagement and normal range of fetal birth weight were found to be the factors associated with vaginal delivery in nulliparae. Variations in these three factors may be the underlying reason for failure to progress, which is the most common indication for caesarean section among this population of parturient

The Baby has not Come: Obstructed Labour

Antenatal care can pick out some women who are at risk of obstructed labour and a plan should be made for them to deliver in hospital. Careful monitoring in labour with appropriate use of abdominal and vaginal examinations can identify those who are not progressing. The partograph can give this valuable information in visual form. If the contractions are not regular and strong the safe use of oxytocin will increase the number of normal deliveries and therefore avoid some Caesarean sections

Clinical Significance of Low Serum Magnesium in Pregnant Women Attending the University of Benin Teaching Hospital

Objective: Magnesium level is known to decline during pregnancy. A suggested role for magnesium deficiency in conditions like pre-eclampsia and pre-term birth has prompted studies with conflicting evidence. The primary objective of this study was to determine the prevalence of hypomagnesemia in pregnancy; while the secondary objectives attempted to define maternal and fetal outcome due to hypomagnesemia.Subjects and Methods: A pilot study was performed to determine the mean serum magnesium level for the population of female patients attending the University of Benin Teaching Hospital. The result of the pregnant population in the pilot study was used as a reference for hypomagnesemia in this study. Thereafter; a prospective cohort study of antenatal women recruited in the second trimester and followed-up till delivery and 1 week post-partum was done. Serum magnesium estimates were done with samples collected at recruitment and delivery. The magnesium levels determined at recruitment were used to divide the subjects into two groups of hypomagnesemic and normomagnesemic patients. Their sociodemographic and clinical characteristics were used to generate a database for analysis.Results: The prevalence of magnesium deficiency was 16.25. Hypomagnesemia was significantly correlated with the occurrence of pre-eclampsia (P = 0.011); leg cramps (P = 0.000) and pre-term birth (P = 0.030). A logistic regression analysis showed that hypomagnesemia had an Odds ratio of 22 for pre-eclampsia. There was no maternal mortality or early neonatal death.Conclusion: Pre-eclampsia and pre-term birth are associated with hypomagnesemia in pregnancy; hence; magnesium supplementation or magnesium-rich diet consisting of green leafy vegetables; soy milk and legumes may improve outcome

Knowledge of outcome of pregnancy and labour among rural pregnant teenagers, in Limpopo province, South Africa

Teenage pregnancy has been associated with poor health and poverty for the teen mother and the child; and has serious consequences for society. The purpose of this study was to explore the knowledge of outcomes of pregnancies and labour among rural pregnant teenagers in Limpopo; South Africa. This cross-sectional study involved 966 randomly selected pregnant teenagers and teen mothers still within 6 weeks of their postnatal period in two hospitals. A structured questionnaire was used to collect data on demography; prenatal care; complications of pregnancy and delivery; mode of delivery and outcome of pregnancy. The findings of the study revealed that 40.0teens mothers reported low birth weight and premature babies; and by caesarean 27.2. The risk of cephalopelvic disproportion was the commonest indication for caesarean section amongst all primigravidae. The perinatal mortality rate among the teenagers (58.2/1 000) was slightly high. The findings of this study revealed that majority of teen mothers did not book for antenatal care during the first trimester; which is an ideal period for a pregnant mother as advised by Regulation R2488 of 1990. This is worrisome as late antenatal clinic attendance provides little or no time for appropriate screening and management of risk factors. Support should be provided for teenagers who; by accident or choice; have become pregnant; so that they can have the optimal care and outcome

The Expectations of Fathers Concerning Care Provided by Midwives to the Mothers during Labour

Midwives have been criticised for neglecting the expectations and needs of fathers. They either ignore the fathers or pressure them into becoming more involved than they would choose; if allowed to provide support to the mothers during labour. Whilst midwives are providing woman-centred care; it is important that they remember to involve the fathers in decision-making and to acknowledge their role; expectations and needs; because the birth of a child is one of the most important events in a person's lifetime. This study focused on fathers' expectations of the care provided to mothers by the midwives during labour. A qualitative; explorative; descriptive and contextual study design was utilised. In-depth qualitative interviews were conducted with fathers about the care provided to their partners or wives by midwives. Data were then analysed with an open descriptive method of coding that is appropriate for qualitative research. The results of the interviews were subsequently positioned within a holistic health-promotive nursing theory that encompassed body; mind and spirit. The results revealed that fathers saw the provision of comfort and support as the two main aspects for mothers in labour that they expected from midwives. The findings were that midwives should improve their communication skills with the mothers; as well as with the fathers if they are available. Fathers expected midwives to encourage them to accompany the mother during labour and to facilitate bonding between father; mother and baby. The results of this study should assist midwives to provide holistic quality care to mothers and fathers during labour

The Effect of Maternal HIV Status on Perinatal Outcome at Mowbray Maternity Hospital and Referring Midwife Obstetric Units; Cape Town

Objectives. To study the effect of maternal HIV status on perinatal outcome at Mowbray Maternity Hospital (a secondary-level hospital in Cape Town) and its satellite community midwife obstetric units. Design. A retrospective descriptive and comparative study.Setting. Public sector maternity facilities serving historically disadvantaged populations. Subjects. All deliveries at Mowbray Maternity Hospital and its referral midwife obstetric units from January to December 2008. Outcome measures. Stillbirth; early neonatal death; perinatal mortality and neonatal encephalopathy rates in HIV-positive and HIVnegative subjects. Results. There was a total of 18 870 deliveries at the units studied; 3 259 (17.2) of them to HIV-positive mothers. The stillbirth rate in the HIV-positive population was 17.1/1 000 births; compared with 8.3/1 000 in the HIV-negative population (odds ratio (OR); 2.07; 95 confidence interval (CI) 1.5 - 2.8). The early neonatal death rate in the HIV-positive population was 4.6/1 000 live births; compared with 3.1/1 000 in the HIV-negative population (OR 1.46; 95 CI 0.8 - 2.6). The perinatal mortality rate in the HIV-positive population was 21.7/1 000 births; compared with 11.7 in the HIV-negative population (OR 1.91; 95 CI 1.4 - 2.5). A comparison of the pattern of primary obstetric causes of perinatal mortality showed that infection; intra-uterine growth restriction (IUGR) and antepartum haemorrhage (APH) were significantly more common as causes for perinatal death in the HIV-positive population. The risk of neonatal encephalopathy in the HIV-exposed population was 4.9/1 000 live births compared with 2.07 in the HIV-negative group (OR 2.36; 95 CI 1.28 - 4.35). The 1 643 women (8.7 of total deliveries) who were not tested for HIV were at particularly high risk of adverse perinatal outcome. This group included women who had either declined testing or not attended for antenatal care. Conclusion. The perinatal mortality rate in the group of HIV-exposed mothers was significantly higher than that in the HIV-negative group due to a higher stillbirth rate. Infection; IUGR and APH were significantly more common obstetric causes for mortality in the HIV-infected population. The risk of neonatal encephalopathy was also significantly higher in the HIV-positive population

Prediction of Successful Induction of Labour with Dinoprostone in a Homogeneous Group of Patients

Objectives. The aim of the present study was to compare the efficiency of transvaginal ultrasonography and the Bishop's scoring system in predicting the success of labour induction. Methods. Transvaginal ultrasonography for cervical evaluation and cervical palpation for Bishop scoring were performed in all patients by the same obstetrician. This prospective study was conducted in the Perinatology and Maternity Care Unit of Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital between September 2007 and February 2008. Eighty-four patients induced with prostaglandin E2 (dinoprostone) for medical indications were included in the study. Results. No significant association was found between transvaginal measurement of cervical length and the success of labour induction (p=0.201). We found no statistically significant difference between failure of labour induction and successful labour induction in terms of transvaginal measurement of cervical length (area under the curve (AUC) 0.583; 95 confidence interval (CI) 0.452 - 0.714). A significant association between the Bishop's score and failure of labour induction (p=0.029) was found. A statistically significant relationship was found between failure of labour induction and successful labour induction in terms of the Bishop's score (AUC 0.632; 95 CI 0.513 - 0.751). The best cut-off point for predicting successful labour induction was a Bishop's score of 2 or more. The sensitivity and specificity levels associated with this point were 82.4 and 44.9; respectively (positive predictive value 50.9 and negative predictive value 78.6). Conclusions. Bishop's scoring system was more successful than assessment of cervical length by ultrasound in predicting failed induction in a homogeneous group of patients in whom labour was induced with prostaglandin E2

Pattern and Outcome of Eclampsia Managed at a General Hospital in North-West Nigeria

Hypertensive disorders of pregnancy constitute major threats to maternal health during pregnancy; labour and the post-partum period. Eclampsia is a leading cause of maternal morbidity and mortality especially in low income and middle-income countries.Method: A retrospective review of the clinical records of women managed for eclampsia during a two-year period from December 2004 to November 2006 at the General hospital Aliero was undertaken.Results: Fifty-eight patients were managed for eclampsia during the 2-year period of study. Eclampsia occurred before and during labour in 47 patients while 11 patients had post-partum eclampsia.Conclusion: The reorientation of caregivers and the community in order to enhance awareness of eclampsia is recommended. The promotion of early presentation; routine antenatal care; and prompt referral to secondary center's as well as the provision of the resources for adequate management of eclampsia is advocated

Midwives' Experiences of Managing Women in Labour in the Limpopo Province of South Africa

Introduction:The objective of this study was to explore and describe the experiences of midwives managing women during labour at a tertiary care hospital in the Limpopo Province. An exploratory; descriptive; contextual and inductive design was applied to this qualitative research study. Purposive sampling was used to select midwives who were working in the childbirth unit and had managed women during labour. A sample of 12 midwives participated in this study. Data were collected by means of unstructured individual interviews and analysed through an open coding method by the researchers and the independent co-coder. Findings: Categories identified were lack of mutual participation and responsibility sharing; dependency and lack of decision-making; lack of information-sharing; empowering autonomy and informed choices opportunities; lack of open communication and listening; non-accommodative midwifery actions; and lack of human and material infrastructure. To ensure the validity of the results; criteria to measure trustworthiness were utilized. Conclusions: This study has implications for woman-centered care by midwives managing women in labour and provides appropriate guidelines that should be integrated into the Batho-Pele Principles

Les ruptures uterines au cours du travail; observees au CHUA/GOB Antananarivo Madagascar

La rupture uterine; urgence obstetricale majeure; a fait l'objet d'une etude retrospective au niveau du Centre Hospitalier Universitaire d'Antananarivo; Gynecologie-Obstetrique de Befelatanana (CHUA/GOB) en 2006.Trente-six ont ete enregistres sur 7152 accouchements; soit une rupture pour 199 accouchements. Le profil moyen est celui d'une femme agee de 25 ans a 36 ans (n=20 ; 55;5); multipare (n=22 ; 61;1) et habitant en zone rurale (n=25 ; 69;4). La plupart des gestantes n'ont pas beneficie d'une consultation prenatale reguliere (n=26 ; 72;2). La suture uterine a ete realisee dans 60;9des cas (n=23). Le pronostic etait marque par une mortalite prenatale tres elevee

Assessment of Partogram use during Labour in Rujumbura Health Sub District; Rukungiri District; Uganda

Background: A partogram is a universal tool for monitoring labour. It is used for labour management in Rujumbura HSD; Rukungiri District. However; the District Health Officer reported only 30use of a partogram. The study intended to find out why the low use; and suggest strategies in scaling up. Objectives: To establish extent of use of a partogram; health facility and health workers' factors that affected its use during labour plus the relationship between foetal Apgar score and its use. Materials and Methods: A cross-sectional study involving observations; record reviews and interviewing of staff in 8 health facilities (4 Public and 4 Private Not For Profit) in Rujumbura HSD in Rukungiri district was conducted from May 23rd to 27th June 2008. It employed both qualitative and quantitative methods of data collection. Results: The partogram was used in 69.9of deliveries. The partographs that fulfilled the standard monitoring of foetal heart rate were only 2. There were few trained health workers and lack of guidelines on partogram use. A good Apgar score was associated with standard foetal monitoring and was statistically significant (P 0.001). Conclusions and recommendations: There was poor use of partograms during labour mainly affected by health input factors. We recommended training of health workers on partogram use; provision of guidelines and adequate resources