Godfrey Mugyenyi R, Wilson Tumuhimbise, Esther Atukunda C, Leevan Tibaijuka, Joseph Ngonzi, Musa Kayondo, Micheal Kanyesigye, Angella Musimenta, Fajardo Yarine T, Josaphat Byamugisha K
Mbarara University of Science and Technology.
Makerere University College of Health Sciences.
medRxiv. 2024 Sep 5:2024.09.04.24313073. doi: 10.1101/2024.09.04.24313073.
Obstructed labour, a sequel of prolonged labour, remains a significant contributor to maternal and perinatal deaths in low- and middle-income countries.
We evaluated the modified World Health Organization (WHO) Labour Care Guide (LCG) in detecting prolonged and or obstructed labour, and other delivery outcomes compared with a traditional partograph at publicly-funded maternity centers of rural Mbarara district and City, Southwestern Uganda.
Since November 2023, we deployed the LCG for use in monitoring labour by trained healthcare providers across all maternity centers in Mbarara district/City. We systematically randomized a total of six health center IIIs (HCIIIs) out of 11, and all health center IVs (HCIVs), reviewed all their patient labour monitoring records for their first quarter of 2024 (LCG-intervention) and 2023 (partograph-before LCG introduction). Our primary outcome was the proportion of women diagnosed with prolonged and or obstructed labour. Our secondary outcomes included; tool completion, mode of delivery, labour augmentation, stillbirths, maternal deaths, Apgar score, uterine rupture, postpartum haemorrhage (PPH). Data was collected in RedCap and analyzed using STATA version 17. Statistical significance was considered at p<0.05.
A total of 2,011 women were registered; 991 (49.3%) monitored using the LCG, and 1,020 (50.7%) using a partograph, 87% (1,741/2011) delivered from HCIVs and 270/2011 (13%) from HCIIIs. Mean maternal age (25.9; SD=5.6) and mean gestation age (39.4; SD=1.8) were similar between the two groups. A total of 120 (12.4%) cases of prolonged/obstructed labour were diagnosed (100 for LCG versus 20 for partograph), with the LCG having six times higher odds to detect/diagnose prolonged/obstructed labour compared to the partograph (aOR=5.94; CI 95% 3.63-9.73, P<0.001). Detection of obstructed labour alone increased to 12-fold with the LCG compared to the partograph (aOR=11.74; CI 95% 3.55-38.74, P<0.001). We also observed increased Caesarean section rates (aOR=6.12; CI 4.32-8.67, P<0.001), augmentation of labour (aOR=3.11; CI 95% 1.81-5.35, P<0.001), and better Apgar Score at 5 minutes (aOR=2.29; CI 95% 1.11-5.77, P=0.025). The tool completion rate was better for LCG compared to (58.5% versus 46.3%), aOR=2.11; CI 95% 1.08-5.44, P<0.001. We observed no differences in stillbirths, maternal deaths, post-partum haemorrhage (PPH) and uterine rupture.
Our data shows that LCG diagnosed more cases of prolonged and or obstructed labour compared to the partograph among women delivering at rural publicly funded facilities in Mbarara city/district. We also observed increased C-sections, labour augmentation, and 5-minute Apgar scores. There were no differences in stillbirths, maternal deaths, PPH and uterine rupture. More controlled and powered studies should evaluate the two tools for other delivery outcomes, in different sub-populations.Trial registration number NCT05979194 clinical trials.gov.
梗阻性分娩是产程延长的后果，在低收入和中等收入国家仍然是孕产妇和围产期死亡的重要原因。
在乌干达西南部姆巴拉拉市和区的公共资助产科中心，我们评估了改良的世界卫生组织（WHO）产程护理指南（LCG）在检测产程延长和/或梗阻性分娩以及其他分娩结局方面与传统产程图的比较。
自2023年11月以来，我们在姆巴拉拉市/区的所有产科中心部署了LCG，供经过培训的医疗保健人员用于监测产程。我们从11个卫生中心III（HCIII）中系统随机抽取了6个，以及所有卫生中心IV（HCIV），审查了它们在2024年第一季度（LCG干预组）和2023年（引入LCG之前的产程图组）的所有患者产程监测记录。我们的主要结局是被诊断为产程延长和/或梗阻性分娩的妇女比例。我们的次要结局包括；工具完成情况、分娩方式、产程加强、死产、孕产妇死亡、阿氏评分、子宫破裂、产后出血（PPH）。数据在RedCap中收集，并使用STATA 17版进行分析。统计学显著性以p<0.05为标准。
共登记了2011名妇女；991名（49.3%）使用LCG进行监测，1020名（50.7%）使用产程图进行监测，87%（1741/2011）在HCIV分娩，270/2011（13%）在HCIII分娩。两组之间的平均产妇年龄（25.9；标准差=5.6）和平均孕周（39.4；标准差=1.8）相似。共诊断出120例（12.4%）产程延长/梗阻性分娩病例（LCG组100例，产程图组20例），与产程图相比，LCG检测/诊断产程延长/梗阻性分娩的几率高6倍（调整后比值比[aOR]=5.94；95%置信区间[CI] 3.63 - 9.73，P<0.001）。与产程图相比，仅梗阻性分娩的检测率增加到12倍（aOR=11.74；CI 95% 3.55 - 38.74，P<0.001）。我们还观察到剖宫产率增加（aOR=6.12；CI 4.32 - 8.67，P<0.001）、产程加强（aOR=3.11；CI 95% 1.81 - 5.35，P<0.001）以及5分钟时更好的阿氏评分（aOR=2.29；CI 95% 1.11 - 5.77，P=0.025）。LCG的工具完成率优于产程图（58.5%对46.3%），aOR=2.11；CI 95% 1.08 - 5.44，P<0.001。我们在死产、孕产妇死亡、产后出血（PPH）和子宫破裂方面未观察到差异。
我们的数据表明，在姆巴拉拉市/区农村公共资助设施分娩的妇女中，与产程图相比，LCG诊断出更多产程延长和/或梗阻性分娩病例。我们还观察到剖宫产率、产程加强和5分钟阿氏评分增加。在死产、孕产妇死亡、PPH和子宫破裂方面没有差异。更多对照且有足够样本量的研究应在不同亚人群中评估这两种工具对其他分娩结局的影响。试验注册号NCT05979194 clinicaltrials.gov。
