Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study

Abstract

BackgroundIntrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo).MethodologyA pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate.ResultsMoyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. 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). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population.ConclusionImplementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.

Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low‐ and middle‐income countries

“…15 In an observational study in Tanzania, cesarean rates were 5.4% for women with continuous Doppler monitoring, as compared with 2.6% for those with intermittent Pinard monitoring (P<0.001). 19 Other studies in Uganda 16 and Tanzania 17,18 showed no difference in cesarean rates between Doppler and Pinard groups.…”

“…Six studies addressed the effectiveness of Doppler versus Pinard stethoscope for the detection of abnormal FHR during intermittent or continuous FHR monitoring in the intrapartum period (Table 1). [15][16][17][18][19][20] Freeplay (wind-up) Doppler, 17 Moyo strap-on Doppler using the continuous or intermittent monitoring function, 18,19 and the Huntleigh pocket Doppler. 15…”

“…In the other four studies, no difference in adverse perinatal outcomes was seen between Doppler and Pinard fetoscope for FHR monitoring (Table 1). [15][16][17]19…”

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

“…Also, the study aimed to measure and identify challenges, rather than detect differences in outcomes for varying quality of care. Hence, it was still unable to determine the effect foetal monitoring has, if any, on birth outcomes [16]. The results should then lead to adequately-powered studies including clinical auditing in other LMICs to estimate the quality of the intrapartum (foetal) monitoring and linking it to birth outcomes.…”

“…The gold standard for clinical quality assessment is direct observation that captures the real-life experiences and behaviour of birth attendants; yet, they are rarely used [10,11]. Similarly, few studies have assessed the adequacy of intrapartum foetal monitoring in low-resource settings [12][13][14][15][16]. This study used continuous direct observation to assess the quality of intrapartum care, with a specific focus on foetal monitoring and the structural requirements to delivering intrapartum quality care.…”