Consent and monitoring
Over 15 months from 31 July 2017 until 24 October 2018, 474 women (157 from CH Rennie and 317 from CB Dunbar Hospitals) admitted in the first or second stages of labour and without obstetric complications were approached. 461 gave their informed consent to participate in the FHR monitoring (97%) and 13 refused.
At CH Rennie Hospital, data were collected from 21 March 2018 until 24 October 2018. 157 mothers were approached for consent. Three refused [case number 6 (too much pain); case number 54 (no reason); and case number 75 (no reason). In those who refused, only monitoring as part of the partograph, was undertaken.
Three (case numbers 4, 10 and 153) had consented but after monitoring for 8, 12 and 36 contractions respectively, stopped monitoring because of the pain and tiredness.
At CB Dunbar Hospital data were collected from 31 July 2017 until 23 October 2018. 317 mothers were approached for consent. 307 gave their informed consent and 10 refused. In 4 of these cases, where the mother said her pain was too much to allow her to do it, the obstetric clinician or midwife continued to undertake the monitoring with the sonicaid. In one of these latter 4 cases (CBD 251) a student midwife undertook all of the monitoring and identified a change in FHR (see Table 5). In the other 6 cases, no FHR monitoring was undertaken except as directed as part of the partograph was undertaken.
Out of the 307 mothers who consented, there were 7 cases where the mothers initially refused but then changed their minds and undertook monitoring for the rest of their labour. In one of these latter cases the mother shared the monitoring with her midwife.
In an additional 7 cases, the mother consented but subsequently stopped monitoring (1 through tiredness, 1 because of pain and 5 with no reasons given).
In an additional 19 cases where the mother consented but then stopped monitoring, a midwife or obstetric clinician took over (17 cases) until delivery or shared the monitoring with the mother (2 cases). Of these 19 cases, 14 gave pain as the reason, 4 gave tiredness or weakness and one gave no reason.
426 of 461 (92%) participating mothers were able to complete the monitoring themselves (152 from CH Rennie Hospital and 274 from CB Dunbar Hospital).
Maternal age
Maternal age was available for 445 participants. 52 (12%) were aged under 18 years; 23 mothers aged 17; 20 aged 16; 5 aged 15; 3 aged 14; and one aged 13 years.
Maternal experiences; the feeling of empowerment experienced by the mothers and the importance of the lack of any pain control that is not available during labour in the public hospitals in Liberia.
400 participants provided written or verbal (transcribed) comments on their experiences of the monitoring.
386 mothers found listening to their unborn baby a positive experience expressing one or more of the following words or phrases: alright, not bad, good, fine, helpful, loved or liked it, happy, comfortable, gives me joy, or other positive comments such as “Thank you”. A selection of these comments is shown in Table 2, including some from mothers who identified changes in FHR.
14 reported only negative comments: 5 reported weakness or tiredness (including feeling nauseated in one case), 7 reported pain (which in 3 interfered with the monitoring), 1 said it was not easy and 1 said it was bad.
Table 2 Selected maternal comments from participants at CB Dunbar and CH Rennie Hospitals
Case Number
|
Comment
|
1 CHR
|
The monitoring was fine, it gave me courage to go through my pain knowing my baby was fine
|
16 CHR
|
The monitoring was good, it made me get closer to my baby…… due to the exercise she will always come to CH Rennie for maternity care during pregnancy
|
35 CHR
|
I felt that I am important when you told me to be a part of my baby monitoring process. It helps me a lot
|
37 CHR
|
The monitoring was good. It help even us that cannot read or write listen to our own baby
|
40 CHR
|
I thank god for the programme I am happy to hear my baby heart-beat. Please continue it
|
43 CHR
|
I am comfortable doing this as it helped me form part of my baby monitoring
|
61 CHR
|
Listening to my baby heart sound was very helpful to me. I felt that my right was respected as I took in my baby monitoring. Thanks for this program. I am happy.
|
62 CHR
|
I am happy to hear my baby heart. I knew that I was carrying a live baby in my womb.
|
70 CHR
|
Thank you for this. It help me but I was in pain and so it make me angry first but I overcome it later (aged 16)
|
95 CHR
|
Getting involved in the process is something amazing to me. I felt part of my care and thank God that I have a live baby.
|
156 CHR
|
I feel important in the coming of my baby. This modern method is very important it help a lot thank you
|
158 CHR
|
I like it so much doctor that real good thing the government put in place here. I will tell all my sisters that pregnant to come to the hospital
|
4 CBD
|
According to mum it is a good step to do because it helps you to notice danger sooner.
|
51 CBD
|
I found the monitoring helpful it helps me go through my pain.
|
52 CBD
|
I felt good listening to my baby it helped me to learn a new thing
|
123 CBD
|
According to mum, this is the first time seeing patient to be working for herself. She said it is a good thing to do but when in labour is bad because of the pain.
|
133 CBD
|
Patient said she’s very happy because she seen baby breathing well and she herself okay. According to patient any time she pregnant she will come and give birth to CB Dunbar hospital.
|
138 CBD
|
According to mum, she love the procedure but is not easy to go through.
|
139 CBD
|
According to mum, she love the idea because other pregnant women goes to the hospital and comes back with no baby in their hands it looks sorry full.
|
151 CBD
|
Mother said she found the monitoring helpful in that she has a live baby. She was cooperative and was asking other mothers to join the process.
|
162 CBD
|
Patient admitted that it was good thing for herself to listen to her baby heart-beat. It made her believe that her baby can breathe inside her mother’s womb.
|
169 CBD
|
Mother was happy to hear her baby heart beat because she stay in labour for long and worry about her unborn baby
|
180 CBD
|
According to patient she was surprised to know that baby heart can beat in the mother stomach and it help her to know about her baby wellbeing.
|
200 CBD
|
I like to have the same chance to listen to my unborn baby the next time I am in labour
|
203 CBD
|
I enjoy listening to my baby but my next labour there should be pain medicine for labour
|
239 CBD
|
It help me to put more effort for my baby. To know that my baby is still living in my stomach.
|
242 CBD
|
It is hard to be in pain and monitor your baby. You must be doing it for us. Thank God my baby is living but it is too hard. The machine can cause more pain on the stomach.
|
255 CBD
|
It help me because it did not allow me to go to surgery. It help me because my baby was born alive and by normal vaginal delivery. It help me so much even though is more difficult to do but I try doing to have got good result. (vaginal breech delivery).
|
274 CBD
|
It is very good and helpful to me. At least all “big bellies” should know how to do the monitoring before the stomach can hurt.
|
275 CBD
|
I like the monitoring it make my baby live. No problem with the monitoring. It only hard to hold the machine when your stomach hurting.
|
Legend to Table 2. Additional maternal comments following changes in fetal heart rate are reported in Tables 3 and 5 below. Abbreviations are defined in the list given earlier in the manuscript.
Out of the 386 providing positive comments, 86 also reported how much they were affected by pain or severe pain. This pain interfered with their ability to undertake the monitoring in 52 of the 86 (60%).
Within the 386 with positive comments, 44 women also reported discomfort, 5 reported tiredness and weakness and 4 reported difficulties applying the sonicaid.
Three mothers said that they would hope that monitoring would be available during their future pregnancies. 6 would return to the hospitals to deliver as a result of the project. An additional 6 mothers said they would hope that monitoring will continue to be available so that other mothers can benefit and 5 said they would encourage other mothers to participate. 9 participants said monitoring helped to cope with labour pain.
Technical and administrative problems identified
The initial design of the tick sheet documenting each contraction monitored did not always allow enough space to record every contraction and obtaining extension sheets was sometimes a logistic problem. To minimise the workload of the scarce midwifery workforce, forms were also re-designed to record clinical data that were appropriate but not excessive given time restraints.
Due to a communication problem, 69 mothers at CB Dunbar Hospital (between 19 Feb 2018 and 8 May 2018) incorrectly monitored their FHR every 30 minutes (similar to the partograph). However, unlike the partograph, monitoring was always undertaken for the 1 minute immediately following the nearest contraction to each 30-minute window.
Birth/delivery data
In 461 participants, there were 33 caesarean sections (7.2%) including 14 with FHR changes. There were 20 vacuum deliveries (4.3%) including 9 with FHR changes, (the latter included a mother with a stillborn baby identified during the training in the use of the sonicaid, confirmed by ultrasound scan).
Clinical information and outcomes for participants where changes in FHR were identified.
Table 3 Clinical information and outcomes of FHR changes identified by monitoring. Abbreviations: see list
Hospital and number
|
Maternal age (years) and parity
|
Change in FHR identified
|
Action taken
|
Apgar scores at 1 and 5 minutes
|
Resuscitation given
|
Maternal comment
|
CHR 46
|
29, G5P2
|
By mother. FHR 115 plus meconium Confirmed by MW
|
Lateral tilt and intravenous cannula with NS bolus Vacuum delivery
|
9 and 10
|
None
|
According to patient she lost her fetus during past pregnancy. Here she was happy when she noticed her fetal heart beat was dropping and the quick response that was processed
|
CHR 50
|
34, G3P2
|
By MW and mother. No FHR plus meconium
|
Ultrasound confirmed IUFD. Vacuum delivery was undertaken
|
NA
|
NA
|
NA
|
CHR 99
|
17, G2P0
|
By mother at 46th contraction FHR 109 with meconium
|
Cervix fully dilated and urged to push
|
4 and 7
|
Yes. Bag and mask ventilation, adrenaline and chest compressions for 10 minutes. Admitted to the NNU for post resus care and close monitoring
Discharged aged 7 days.
|
Listening to my baby heart was good. It help me to know that something was happening to her. No problem with it. Thank you.
|
CHR 102
|
19, G2P0
|
By mother FHR 119 at 49th contraction. There was + meconium present
|
Vacuum delivery
|
7 and 10
|
No
|
I like the thing I was doing but it was hard to do because of the pain.
|
CHR 133
|
23, G2P1
|
By mother FHR 119, 117, 116. No meconium. patient was not progressing at this stage. 2 cm cervical dilatation with mild contractions.
|
MW/OC took over the monitoring due to the bradycardia. Doctor contacted. Patient was laterally tilted, given oxygen, D50%, hydrated and rushed to the OR for CS.
|
7 and 10
|
No
|
Thank you for this program. If not so my baby was going to die. The only thing that the pain.
|
CHR 135
|
24, G2P1
No previous CS
|
By mother FHR 163-165 with meconium. Signs of Bandl’s ring and obstructed labour with haematuria identified.
|
Not receiving oxytocin. Emergency CS
|
9 and 10
|
No
|
Thank you for saving my life and my baby. It really helpful to listen to my baby heart to know what was happening to me.
|
CHR 136
|
26, G3P2
|
By mother FHR 119,110,118. No meconium.
OC and doctor contacted and confirmed bradycardia
|
Given facial oxygen, lateral tilt, N/S and D50%. Patient was 6cm dilated at this stage. Emergency CS
|
8 and 10
|
No
|
I feel good when I was listening to my baby heart. It help me to know what happen to my baby.
|
CHR 157
|
19, G1P0
|
By mother at 46th contraction FHR 117, then 114, then 116, then 113. No meconium. Fully dilated but descent only minus 2
|
Lateral tilt, D50%, oxygen, NS and FHR still below 120 and when head reached 0 station re: ischial spines after 10 minutes and then vacuum delivery
|
9 and 10
|
No
|
Thank you for what you bringing because when it was not because of it I was not coming to know say my baby heart was not beating good. That just the pain was giving me hard time thank all.
|
CBD 16
|
17, G1P0
|
FHR found to be 95-100 by mother, FHR was repeated by midwife and confirmed low, 95-98, and Doctor on call was also informed.
|
Patient was placed in a left literal tilt position Patient was reviewed and decision to CS was taken for fetal distress plus prolonged labour
|
6 and 9
|
None
|
Not requested at this stage in programme
|
CBD 17
|
22, G3P1
|
Mother reported a change in FHR but when checked by MW found FHR to be normal at 142. Meconium was present
|
Doctor informed but no action was considered necessary
|
6 and 10
|
None
|
Not requested at this early stage in programme
|
CBD 25
|
14, G1P0
|
On 11th contraction mother reported slow heart rate. MW was contacted but she found FHR was 153. There was no meconium the OC was contacted.
|
Mother’s membranes were ruptured and vacuum delivery undertaken
|
7 and 10
|
None
|
Not requested at this early stage in programme
|
CBD 33
|
17, G1P0
|
Mother noted change and contacted MW on 15th contraction. MW noted FHR 118 and informed OC. Meconium was present repeat fetal heart rate was 105.
|
Mother put in lateral tilt position and informed Dr who reviewed patient and found fetal heart rates 110, 105, and 108. Emergency CS was performed
|
8 and 10
|
None
|
Not requested at this early stage in programme
|
CBD 38
|
22, G2P1
|
On 11th contraction mother noticed bradycardia. Midwife confirmed FHR 118 put patient in left lateral position and called OC. Grade 3 meconium was present. OC.found FHR 110.
|
Left lateral tilt. Cervix was fully dilated and vacuum delivery undertaken.
|
6 and 9
|
Bag and mask ventilation. Admitted NNU for 5 days and treated for sepsis.
|
Not requested at this early stage in programme
|
CBD 43
|
22, G1P0
|
Yes - by MW following refusal by mother FHR 95-100 on two successive occasions
|
Lateral tilt and subsequent CS
|
5 and 7
|
Bag and mask ventilation and admitted to NNU. No HIE and went home.
|
Following initial consent, patient later refused to monitor her FHR. Says she was tired of monitoring.
|
CBD 125
|
28, G3P2
|
Mother on 14th contraction noticed change in FHR. And weakness. She called for help and FHR was102. No meconium was present.
|
OC contacted, lateral tilt and intravenous (IV) cannula with 500ml of Ringer Lactate given. Normal vaginal delivery followed.
|
6 and 10
|
This baby was resuscitated for 5 minutes with bag and mask ventilation and then transferred to the NNU where he was immediately placed on nasal CPAP and an IV line was opened to serve antibiotics because amniotic fluid was also purulent and foul smelling. IV fluid (Dextrose 10%) was set up. Baby was managed for 7 days in the NNU and was discharged home with good outcome.
|
According to mum monitoring is hard at certain times. She knew her babies heart rate was low and we took quick action and now the baby is in her hands so she thank the organisation.
|
CBD 128
|
16, G1P0
|
On the 14th contraction the mother called the MW because the FHR was low. The MW confirmed FHR 98, called for help and undertook lateral tilt. Meconium was present.
|
The OC was contacted. She opened IV line and gave R/L 1000 mL, informed the doctor on call. The doctor came and assessed the patient and said we should prepare patient for CS. CS was done for prolonged labour and abnormal FHR.
|
5 and 10
|
Neonate was resuscitated for 7 minutes by bag and mask ventilation before transferring to the NNU. She was placed on nasal CPAP for 24 hrs and was also managed for risk of sepsis. Neonate improved after 8 days and was discharged.
|
According to mum it is okay because this help the doctor nurses to take quick action
|
CBD 131
|
15, G1P0
|
On the 7th contraction, mother detected fetal bradycardia. MW called and checked and confirmed FHR 105. Meconium was present. Grade 3 OC was called.
|
Lateral tilt was undertaken and fast vaginal delivery arranged as 9cm cervix dilated. Birth weight 1.9Kg small for dates.
|
7 and 10
|
Baby was resuscitated for 2 minutes by bag and mask ventilation and then transferred to NNU. She was placed on nasal CPAP for 24hrs and patient condition improved. Baby was also managed for risk of neonatal sepsis because mother’s amniotic fluid was purulent, foul-smelling during delivery. The baby was discharged home after 10 days with a weight of 2.3kg
|
Patient initially refused procedure but later on she was encouraged to do it herself and everything went well
|
CBD 147
|
28, G5P4
|
On 6th contraction, mother detected bradycardia. MW confirmed FHR 108. Meconium was present.
|
OC contacted. Lateral tilt performed. IV cannula inserted and given NS 500ml. Normal vaginal delivery occurred.
|
5 and 8
Male
|
Bag and mask ventilation given. No HIE occurred but he needed 5 days of antibiotics for umbilical infection.
|
Patient worry when the heart rate was reducing but at last she was happy because her baby came through
|
CBD 153
|
32, G5P3
|
On 2nd contraction monitored, Mother identified rapid heart rate. MW confirmed FHR 190 and called for help,
|
Doctor called and attended. Lateral tilt and IV cannula and N/S 500ml set up.
Vacuum delivery was undertaken.
|
6 and 8
|
Neonatal clinician was called and baby resuscitated with bag and mask ventilation and recovered within 1 minute. Responded well and taken to NNU for suspicion of sepsis. No HIE.
|
Mother said she was happy with the monitoring because she could have had a dead baby if she didn’t monitor. She’s also asking other mothers to accept and be part of the process
|
CBD 158
|
17, G2P1
|
On 6th contraction, Mother reported fall in HR. MW confirmed FHR 109 Meconium present.
|
Lateral tilt applied and IV cannula inserted with R/L 500mls plus Dextrose 50% 30ml. OC contacted and quickly delivered the baby vaginally.
|
6 and 7
|
Mildly depressed but no resuscitation needed. Neonatal clinician continued monitoring and care.
|
Patient was very happy because she call for help and action was taken quickly by the OB clinician and her baby was saved.
|
CBD 160
|
26, G3P0
|
On 27th contraction, Mother detected slowing of FHR. MW confirmed FHR 109. Grade 2 meconium was present. Dr on call contacted.
|
Lateral tilt and IV cannula inserted. R/L 500mls given IV. Doctor arrived and undertook CS.
|
7 and 10
|
Resuscitated for 2 minutes with bag and mask ventilation.
|
According to mother she was very happy, and she told everybody thanks because of the monitoring her baby was saved
|
CBD 169
|
16, G1P0
|
On 7th contraction mother noted fast heart rate. MW confirmed FHR 167. Patient came in fully dilated but evidence of obstructed labour due to persistent occipito-posterior malposition.
|
Lateral tilt and IV cannula inserted. NS 500mls given IV. Doctor arrived and undertook CS.
|
9 and 10
|
None needed
|
Mother was happy to hear her baby heart beat because she stay in labour for long and worry about her unborn baby
|
CBD 172
|
42, G9P8
|
On the 7th contraction mother noted a slow heart rate. MW confirmed FHR 102. Meconium was present and a cord prolapse identified.
|
The OC was notified and implemented knee chest position and inserted NS 300mls into the bladder to reduce cord compression. IV cannula was inserted and NS 500mls given. A CS was then undertaken.
|
6 and 10
Depressed breathing.
|
Resuscitated for 1-3 mins with bag and mask ventilation. Taken to NNU as 30 weeks’ gestation No HIE. Home after 14 days
|
According to mother monitoring is good but she cannot continue it herself due to pain. At last she said it help her with a live neonate
|
CBD 177
|
17, G2P1 previous CS
|
On 12th contraction, MW reported a FHR 124. Meconium present. FHR then dropped to 119.
|
OC was called and after lateral tilt established IV line and gave 500ml NS. A CS was then undertaken.
|
7 and 8
|
No resuscitation needed but foul-smelling amniotic fluid at CS led to NNU admission and IV antibiotics.
|
Mother agreed to the process, she started it but discontinue due to pain and was helped by midwife and OB clinician. Mother said it’s a good thing, it help her have a live baby
|
CBD 188
|
32, G1P0
|
On the 8th contraction mother noted a slow heart rate. MW confirmed FHR 110. Meconium was present. OC informed and FHR was 112. Cervix fully dilated.
|
Lateral tilt and placed in delivery room for vacuum delivery. However, within 5 minutes delivered spontaneously. A very short umbilical cord was present.
|
5 and 7
Depressed breathing
|
Resuscitated for 5 mins with bag and mask ventilation and taken to NNU and given antibiotics. Later became stable and discharged.
|
The monitoring was good, it is a good idea and I hope it will continue because it will save a lot of babies as it did mine. Sometimes the midwives are busy so this will help them, and help us the mothers too. Mother was hospital medical director ‘s sister in-law
|
CBD 235
|
31, G5P4
|
On the 30th contraction mother noted a slow heart rate. MW confirmed FHR 118.
|
MW performed lateral tilt and informed the OC and set up IV infusion of R/L 500ml. Dr ordered repeat and FHR 106. Cervix only 4cm dilated. Descent 3 / 5. Discussion for CS was done but no CS materials available so patient was referred to another hospital.
|
8 and 9
|
None needed after CS at referral hospital
|
I like listening to my baby heart but I don’t know if my baby will live again now that I am going to a different hospital.
Outcome at second hospital after CS was good for mother and baby.
|
CBD 251
|
19,
G1P0
|
On the 20th contraction OC and student MW noted a slow FHR 105. No meconium seen.
|
Lateral tilt was undertaken. The cervix was already 10 cm dilated and there were poor maternal efforts. An IV cannula was inserted and she was given 30 ml dextrose 50%. Baby was delivered by vacuum.
|
5 and 6
|
Yes by neonatal clinician bag and mask ventilation for 5-10 mins. Admitted to NNU for neonatal depression. Neonate recovered quickly on nasal CPAP. Improved and went home well.
|
Mother had refused monitoring but this was done by student MW.
|
CBD 272
|
19
G1P0
|
On 30th contraction mother noted slowing of FHR. There was no meconium at this time. MW and OC identified FHR of 115, 118,122.
|
Lateral tilt and Doctor notified. An IV cannula inserted and given N saline 500ml plus Dextrose 50% 30ml. The cervix was
10cm dilated. OC did vacuum with Dr present but failed 3 times. Dr and OC proceeded to immediate CS. Intraoperative meconium was present
|
5 and 7
|
Bag and mask ventilation for mild respiratory depression. Recovered rapidly and went home.
|
The monitoring is good but I was not able to do it all by myself because of the pain and my foot pain. Yes my baby is living so it help. No problem with it but the pain can be too much.
|
CBD 273
|
22
G4P0
|
On 51st contraction mother noted slowing of fetal heart rates. MW recorded FHR 109, 178,120,110,181,102,130
Meconium was present
|
Lateral tilt was performed, and OC notified. IV fluids were started and 30 ml of 50% dextrose given IV. The doctor was also called and due to FHR changes, high station O, and bad obstetric history (G4P0) proceeded with the OC to CS.
|
8 and 10
|
None
|
The monitor help me to inform the midwife that my baby was not breathing good. So I see it to be good for all the big belly with stomach hurting pain.
|
Abbreviations are defined in the list given earlier in the manuscript.
Table 3 describes the clinical information and outcomes relating to identified FHR changes. Changes in FHR were reported in 28 of 461 participants (6.1%,) which in two cases were not confirmed by the attending midwife giving 26 confirmed cases (5.6%). In 23 of the 26 confirmed cases, the FHR decreased and in 3 the FHR increased. Two changes related to unrecognized obstetric complications, with one mother found to have Bandl’s ring with obstructed labour and the other cord prolapse.
One of the 26 changes in FHR was identified by a midwife who had taken-over monitoring from a mother who became too tired to continue. In a second case, the mother had refused to undertake monitoring herself but had consented to the monitoring being undertaken by a student midwife.
In 18 of the 26 (69%) with confirmed FHR changes, there was accompanying meconium-stained liquor.
13 of the 26 (50%) the neonates with prior FHR changes had low Apgar scores and needed resuscitation. There were no deaths following resuscitation. One baby had convulsions managed with phenobarbital, recovered and was feeding normally at discharge home aged 7 days. None of the other 26 neonates developed birth asphyxia (also known as Hypoxic Ischaemic encephalopathy-HIE) .
Six of the 26 with confirmed FHR changes (23%) were born by vacuum, 14 by Caesarean Section (CS) (54%), and 6 (23%) by vaginal delivery. In one case (CBD 272), CS followed a failed vacuum delivery.
Clinical information and outcomes in 3 newborn infants needing resuscitation at birth where mothers had refused to participate in FHR monitoring.
Table 4 Clinical information and outcomes in newborn infants needing resuscitation at birth where mothers had refused consent to participate in the FHR monitoring. For abbreviations see list.
Hospital and number
|
Maternal age (years) and parity
|
Change in FHR identified on partograph
|
Delivery
|
Apgar scores at 1 and 5 minutes;
Wt. of baby
|
Resuscitation given
|
Maternal comment
|
Other possibly relevant information?
|
CBD 71
|
32, G3P2
|
None
|
Normal vaginal delivery
|
2 and 3
3.4Kg
|
Resuscitated with bag and mask ventilation, chest compressions and oxygen
Admitted NNU but later died aged 2 days from HIE
|
Mother refused monitoring and staff did not take over
|
|
CBD 184
|
25, G2P1
|
None
|
Normal vaginal delivery
|
4 and 6
Depressed
2.8Kg
|
Resuscitation was done with bag and mask ventilation and was taken to the neonatal ward. Treated with antibiotics. Outcome was good and discharged.
|
None
|
Patient refused to continue her fetal heart rate monitoring even though she did monitor the first contraction
|
CBD 192
|
18, G1P0
|
None
|
Normal vaginal delivery
|
2 and 6
Very depressed
|
Resuscitated by bag and mask ventilation by neonatal clinician
Died aged 3 days from HIE
|
None
|
Patient refused to continue her fetal heart rate monitoring even though she did monitor the first contraction
|
Abbreviations are defined in the list given earlier in the manuscript.
Clinical information and outcomes in newborn infants needing resuscitation at birth where mothers had refused to participate in FHR monitoring.
In one, the baby was born with Apgar scores of 2 at 1 minute and 3 at 5 minutes and, despite resuscitation, died of HIE in the neonatal unit aged 2 days.
In 2 other cases, there were low Apgar scores at 1 and 5 minutes (4 and 6; and 2 and 6) and the babies needed resuscitation. Both were admitted to the neonatal unit. One responded well to resuscitation with no evidence of HIE and was discharged home well. The other died aged 3 days from birth asphyxia/HIE.
Clinical information and outcomes in 8 neonates needing resuscitation where no FHR changes had been identified
Table 5 Clinical information and outcomes in newborn infants needing resuscitation at birth where monitoring had not identified any FHR changes
Hospital and number
|
Maternal age (years) and parity
|
Change in FHR identified
|
Delivery
|
Apgar scores at 1 and 5 minutes;
Wt. of baby
|
Resuscitation given
|
Maternal comment
|
CBD 164
|
25, G2P1
|
None. Monitored only every 30 minutes immediately following 14 contractions
|
Preterm labour and normal vaginal delivery
|
5 and 7 depressed at birth
1.8 Kg
|
Neonatal clinician called, resuscitated with bag and mask for 12 minutes and taken to neonatal ward
No HIE
|
Mother said the monitoring help her with her baby, she got a live baby. She was willing and cooperative and ask other mothers to accept the monitoring
|
CBD 176
|
18, G1P0
|
None.
Monitored only every 30 minutes immediately following 13 contractions
|
Normal vaginal delivery
|
5 and 10 depressed at birth
3.9Kg
|
Neonatal clinician was called, did 10-15 mins bag and mask ventilation. Oxygen saturation 54%. Admitted NNU. No HIE and went home aged 7 days
|
According to mother the monitoring is good, it help her deliver her baby live. She was interested in doing it
|
CBD 179
|
18, G2P1
|
None. Monitored only every 30 minutes immediately following 11 contractions
|
Normal vaginal delivery
|
7 and 10
2.8 Kg
|
Bag and mask ventilation used
for 5 minutes and then recovered. No HIE
|
Appreciated the listening to her baby until birth. She recommended that all labouring mothers should be able to listen to their fetus during labour
|
CBD 224
|
29, G2P1
|
No abnormality detected following 12 contractions
|
Vacuum delivery unable to push
|
5 and 8
3.9Kg
|
Resuscitated by bag and mask for 10 minutes. Admitted NNU and given 7 days antibiotics. No HIE.
|
It help because with all the pain I refused to listen to them. I still got my baby by talking to me good. I found it very good because it help me in getting my baby. No problem.
|
CBD 238
|
23, G2P1
|
No abnormality detected following 15 contractions
|
Normal vaginal delivery
|
2 and 0
1.3 Kg
34 weeks’ gestation
|
Resuscitated by bag and mask ventilation plus chest compressions for 25 minutes. But then died.
|
I like the monitoring. I enjoy listening to my baby even though he didn’t survive
|
CBD 240
|
15, G1P0
|
No abnormality detected following 58 contractions
|
Normal vaginal delivery episiotomy for baby stuck at perineum
|
5 and 7
2.5Kg
|
Resuscitated by bag and mask ventilation by neonatal clinician for 8 minutes then improved and discharged. No HIE.
|
I see the monitoring good for me and my baby because it my make me to know that my baby is still living. 9th grade student
|
CBD 243
|
23, Gravida
G2P1
|
No abnormality detected following 23 contractions
|
Vacuum for reduced maternal effort
|
6 and 8
3.1 Kg
|
Bag and mask resuscitation for 7 minutes. Baby was admitted to the NNU for observation.
No HIE but had malaria and was treated for 10 days and then discharged well.
|
I like the monitoring. It make me born a living baby but it is hard to do. It is hard to be in pain and holding the machine.
Patient is not literate.
|
CBD 286
|
23, Gravida
G1P0
|
No abnormality detected following 12 contractions
|
Vacuum for exhaustion: couldn’t push
|
7 and 8
3.3 Kg
|
Bag and mask resuscitation one-two breaths only before baby breathed. Not admitted to NNU.
|
I find it good. It help me because my baby is alive. No problem with it.
|
Abbreviations are defined in the list given earlier in the manuscript.
Clinical information and outcomes in newborn infants needing resuscitation at birth where monitoring had not identified any FHR changes.
In addition to the neonates requiring resuscitation where FHR changes had been detected, 8 other neonates without detected changes in the FHR required resuscitation (Table 5). One (case CBD 238) was preterm/low-birth weight and died at birth. None of the remaining 7 developed birth asphyxia/HIE.
In one neonate (Case number 224) it was unclear who had undertaken the monitoring and for how long. A vacuum delivery was undertaken for failure to push, Apgar scores were 5 and 8 and the baby required 10 minutes of bag and mask ventilation. He was discharged home aged 7 days well. No evidence of birth asphyxia/HIE was evident on clinical assessment.
Three cases were born following vacuum delivery and 5 cases by vaginal delivery, including in one mother who needed an episiotomy to expedite delivery (case CBD 240).
Three of the neonates had been monitored in utero every 30 minutes only in a temporary deviation to the protocol because of a communication problem with one of the trainee obstetric clinicians but none developed birth asphyxia/HIE.
Costs associated with collecting data
The costs of the project were low. The fetal doppler monitors (Sonicaids: 12 in total) were USD 40 each. Rechargeable AA batteries were used. Additional costs included paper and printing for the consent, data collection and monitoring forms including the internet costs of scanning and sending them to MCAI for analysis and KY jelly (or locally available clear hair gel) for interfacing the ultrasound probe with the abdomen: commercial ultrasound gel was too expensive.
Missing data
Because of problems with the completion of medical records and the work pressure on the health workers involved, it was sometimes difficult to fill the gaps of any missing information, such as birth weights, retrospectively. Every effort was made by the management committee to minimise missing data, especially regarding maternal and neonatal outcomes.