Intrapartum fetal heart rate monitoring using a handheld Doppler versus Pinard stethoscope: a randomized controlled study in Dar es Salaam

Abstract

BackgroundFetal stethoscopes are mainly used for intermittent monitoring of fetal heart rate (FHR) during labor in low-income countries, where perinatal mortality is still high. Handheld Dopplers are rarely available and are dependent on batteries or electricity. The objective was to compare the Pinard stethoscope versus a new wind-up handheld Doppler in the detection of abnormal FHR.Materials and methodsWe conducted a randomized controlled study at Muhimbili National Hospital, Tanzania, from April 2013 to September 2015. Women with gestational age ≥37 weeks, cephalic presentation, normal FHR on admission, and cervical dilatation <7 cm were included. Primary outcome was abnormal FHR detection (<120 or >160 beats/min). Secondary endpoints were time to delivery, mode of delivery, and perinatal outcomes. χ2, Fisher’s exact test, Mann–Whitney test, and logistic regression were conducted. Unadjusted and adjusted odds ratios were calculated with respective 95% confidence interval.ResultsIn total, 2,844 eligible women were assigned to FHR monitoring with Pinard (n=1,423) or Doppler (n=1,421). Abnormal FHRs were more often detected in the Doppler (6.0%) versus the Pinard (3.9%) arm (adjusted odds ratio =1.59, 95% confidence interval: 1.13–2.26, p=0.008). Median (interquartile range) time from abnormal FHR detection to delivery was comparable between Doppler and Pinard, ie, 80 (60,161) and 89 (52,165) minutes, respectively, as was the incidence of cesarean delivery (12.0% versus 12.2%). The incidence of adverse perinatal outcomes (fresh stillbirths, 24-hour neonatal admissions, and deaths) was similar overall; however, among newborns with abnormal FHR delivered vaginally, adverse outcomes were less incident in Doppler (7 of 43 births, 16.3%) than in the Pinard arm (10 of 23 births, 43.5%), p=0.021.ConclusionIntermittent FHR monitoring using Doppler was associated with an increased detection of abnormal FHR compared to Pinard in a low-risk population. Time intervals from abnormal FHR detection to delivery were longer than recommended in both arms. Perinatal outcomes were better among vaginally delivered newborns with detected abnormal FHR in the Doppler arm.

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

“…17,49 In LIC, FHR monitoring is conducted mostly by intermittent assessment with either hand-held Doppler or Pinard stethoscope. 7,50 However, FHR monitoring is rarely conducted according to current international guidelines (Table 1). 45,[51][52][53][54][55][56][57] The reasons for this inadequacy include ineffective FHR monitoring equipment, a shortage of human resources, and a lack of locally adapted guidelines.…”

“…Secondly, previous studies, including Study I in this thesis, have documented an increased effectiveness of FHR abnormalities detection using Doppler technology. 7,50 The Moyo device uses Doppler technology with increased sensors, and it was therefore believed that its implementation would be beneficial in terms of quality of FHR monitoring and, consequently, perinatal outcomes.…”

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

“…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…”