Evolution of the Quality of the Partogram in 96 Health Care Facilities of 3 Provincial Health Divisions in the Democratic Republic of the Congo

The partogram is an accurate labor monitoring tool for reducing maternal and perinatal mortality due to prolonged labor and dystocia. The aim of this study is to assess how the quality of the partogram has evolved in health care institutions (HCI in short) that have benefited from the primary health care support project (ASSP in short) after formative supervision. This is a descriptive study by periodic clinical audit between 2020 and 2022, carried out in 96 HCI in 3 provincial health divisions (DPS in short) of DR Congo. Each photographed partogram page was sent to the project’s central level for review by a team of experts (3 obstetric gynecologists and 3 midwives). The compliance rate for completing partograms in the 96 health facilities of the 3 DPS was 86.8%. The rate of traceability of labor continuity was 88.2%, and that of traceability of acts, incidents and treatments during labor was 87.1%. Finally, the compliance rate for filling out partograms in the immediate post-partum period was 81%. A clear improvement was noted between the January 2020 and March 2022 assessments.

Attitudes, Practices and Factors Affecting the Use of the Partogram by Professionals Attending to Women in Labour and Delivery in the Bafut Health District

Introduction: Given that the provision of care to the childbirth process is not purely in the hands of educated and trained midwives, the competency in application of midwifery tools may be inadequate and consequently affect the quality of care. The Partogram is the single most important tool which has been scientifically proven to reduce maternal and foetal morbidity and mortality. Though important, many healthcare providers do not use it regularly in the monitoring of labour. Objectives: Our objectives were to determine the attitudes, practices, proportion of parturients monitored using a Partogram and the factors limiting the use of the Partogram by professionals attending to women in labour and delivery (PAWLD) in the Bafut Health District. Methods: This was a cross-sectional study carried out amongst 65 Professionals attending to women in labour and delivery in the Bafut Health District that lasted 6 months. All the data were collected by our self. First through a face to face interview with a questionnaire, secondly with an observational guide used to assess Partograms filled and lastly using delivery registers to obtain the proportion of parturients monitored with a Partogram. The data analysis was done using the statistic software Epi Info version 7 and Microsoft Excel. Results: This study revealed that 47 (72.3%) of participants had good attitudes, 34 (52%) had good practices, 375 (79.3%) parturients were monitored using a Partogram, and the lack of in-service training, low number of staff and poor knowledge on Partogram use were identified as the main limiting factors to the use of the Partogram. Being a health assistant was statistically significantly associated with having a poor practice with a p-value of 0.047 and odds ratio 5.33 [1.03 - 26.45] we obtained just 1 (1.54%) filled according to the WHO standards. Conclusions and Recommendations: In the Bafut Health District, 7 out of 10 PAWLDs have a positive attitude towards the use of the Partogram, while a poor practice is predominant as a result 4 out of 5 deliveries were monitored using a Partogram with only 1.54% of the Partograms filled according to WHO standards. The lack of in-service training, lack of PAWLD and poor knowledge on Partogram usage are the major drawbacks to the use of the Partogram. We therefore recommend that continues medical education (CME) be organised on the use of the Partogram.

Use of the partogram in labor:Analysis of its application in different care models

Objective: To compare and identify possible differences in the use of the partogram in different models of delivery and birth care. Design/Setting: This was a cross-sectional study performed in two Brazilian hospitals with different models of care: Natural Birth Center (NBC) and Traditional Obstetric Center (TOC). Data were collected from the medical records of 112 mothers with low obstetric risk who underwent an intrapartum cesarean section. Socioeconomic and demographic variables, obstetric history, partogram labor evolution, complications, and indication of cesarean section were included. A significance level of 5% and a confidence interval of 95% were considered. Data were analyzed in accordance with the Brazilian Ministry of Health and World Health Organization recommendations. Findings: In the NBC, the use of the partogram follows the Ministry of Health recommendations for filling-in variables with greater frequency and significance (p p = 0.00, OR = 42.2) and continuous records (p = 0.00, OR = 53.3). However, obstetric interventions, such as use of oxytocin, amniotomy and cesarean delivery were concentrated in area 1 of the partogram in both institutions. Conclusions: In this study, the NBC used the instrument most adequately;however there was no difference from the other model (TOC) and regarding the moment of interventions, many of them were early. This finding implies that, regardless of the care model, the partogram has been used bureaucratically and not as a guiding instrument of assistance envisioning safely and timely practices. In other words, aside from a “humanized” physical structure, it is necessary that obstetric practices should be focused on best evidence, thus reducing maternal and perinatal risks.

产时超声监测胎心及胎方位结合新产程图产程管理对产妇分娩方式及妊娠结局影响

目的:探究产时超声监测结合新产程图产程管理对初产妇分娩方式和妊娠结局的影响。方法:选取2022年10月-2023年10月本院分娩且行阴道试产的单胎、足月妊娠初产妇,依据产时监测方式不同分为常规组(电子监护仪联合新产程图产程管理)和超声组(彩色多普勒超声监测结合新产程图产程管理),经倾向性匹配评分法排除基线资料混杂因素后,两组各获得134例产妇,对比两组分娩方式、阴道分娩产妇各产程时间、产后盆底肌功能(活力值、功值、峰值)、不良分娩结局。结果:超声组剖宫产率(22.4%)低于常规组(34.3%),超声组阴道分娩产妇第一产程(10.5±0.8h)、第二产程(79.5±11.5min)均短于常规组阴道分娩产妇(10.8±1.0h、93.4±13.2min),两组阴道分娩产妇盆底肌活力值、功值、峰值均低于同组剖宫产产妇(P<0.05);超声组不良分娩结局发生率与常规组无差异(P>0.05)。结论:超声监测胎心及胎方位结合新产程图产程管理用于初产妇,可缩短产程时间,降低剖宫产率,改善母婴结局。

8025例阴道分娩人群新旧产程管理下分娩及妊娠结局比较

目的:探讨新旧产程管理对妊娠结局的影响。方法:选择本院阴道分娩的低危初产妇分为新产程组(2014年10月-2015年3月,新产程管理,n=4146)和旧产程组(2013年10月-2014年3月,旧产程管理,n=3879)。评价两组第一、二、总产程时限、分娩方式、产时发热、分娩镇痛、产后出血率、会阴侧切、阴道助产、新生儿体重、新生儿窒息及新生儿入住新生儿重症监护室情况。结果:新产程组第一、第二产程及总产程时间均长于旧产程组,分娩镇痛率(38.5%)、新生儿体重(3391.5±377.7g)及产后出血率(10.9%)高于旧产程(26.4%、3372.6±372.1g和6.3%),会阴侧切率(25.1%)低于旧产程组(36.8%)(均P<0.05);产时发热(6.5%)、阴道助产率(8.9%)、新生儿窒息(0.9%)以及新生儿入住重症监护室的发生率(8.4%)与旧产程组(6.2%、8.7%、1.2%及7.3%)无差异(P>0.05)。结论:新产程管理下新生儿结局与旧产程未见差异,但尚不能完全证实对产后出血安全性。

腰麻-硬膜外联合镇痛产程进展分析

目的 了解腰麻 -硬膜外联合麻醉和产妇自控硬膜外镇痛 (CSEA +PCEA)是否对产程进展存在影响。方法 回顾性分析 2 0 0 2年 3月～ 8月 5 0 7例阴道分娩健康初产妇病历资料 ,观察组 (CSEA +PCEA)共2 5 9例 ,对照组 (未采用CSEA +PCEA) 2 4 8例 ,通过产程图比较两组产程进展。结果 观察组第一产程活跃期及第二产程时间分别为 (2 71 93± 12 7 4 4 )min和 (5 7 39± 35 5 2 )min ,较对照组活跃期 (188 0 8± 110 2 9)min及第二产程时间 (44 84± 31 92 )min延长 (P <0 0 0 1) ;观察组产程图宫口曲线较Friedman产程图倾斜角度较小 ,即活跃期进展较慢 ,平均每小时宫口开大 1 5cm。结论 腰麻及硬膜外联合镇痛后活跃期进展减慢 ;镇痛后的产程处理不应单纯按照传统Friedman产程图。CSEA +PCEA不适宜作为理想的分娩镇痛方式。

新旧产程图在巨大儿阴道分娩中的临床研究

目的探讨新产程图管理应用下的巨大儿阴道分娩模式的建立。方法 2013年组为使用旧产程图的巨大儿经阴道分娩孕妇;2014年组为使用新产程图的巨大儿经阴道分娩孕妇。观察剖宫产指征的变化等。结果使用新产程图后的剖宫产率低于使用旧产程图,差异有统计学意义(P<0.05)。结论新产程图在应用过程中,可明显降低剖宫产率,更适应现代人群的变化特点。

新产程标准及Friedman产程图在妊娠期糖尿病初产妇产程中的应用

目的:研究对妊娠期糖尿病(gestational diabetes mellitus,GDM)初产妇采用新产程标准及Friedman产程图进行产程管理的效果。方法:从GDM初产妇中抽选260例纳入本次试验,试验对象入院时间均在2017年3月-2018年3月,根据病历单、双号将这260例患者分为旧产程组130例和新产程组130例,分别采用旧产程标准及Friedman产程图进行产程管理和新产程标准及Friedman产程图进行产程管理,统计两组产妇产程时间、医疗干预情况、分娩方式以及母婴并发症发生情况,并进行组间比较。结果:组间产妇第二产程时长、第三产程时长以及活跃期时长比较,差异均无统计学意义(P>0.05);新产程组潜伏期时长、总产程时长均分别长于旧产程组(t=2.668、2.162,P=0.008、0.032);组间医疗总干预率比较,新产程组48.46%低于旧产程组的65.38%(χ^2=5.838,P=0.016);组间阴道自然分娩率比较,新产程组68.46%高于旧产程组的55.38%(χ^2=4.804,P=0.043);组间剖宫产率比较,新产程组的8.46%低于旧产程组的19.23%(χ^2=4.862,P=0.027);组间母婴并发症总发生率比较,新产程组21.54%低于旧产程组的34.62%(χ^2=4.236,P=0.040)。结论:采用新产程标准及Friedman产程图对GDM初产妇进行产程管理,虽然会稍微延长产程时间,但是却可显著减少医疗干预,降低剖宫产率以及母婴并发症发生率。

巨大胎儿阴道分娩109例产程图分析

目的 :通过对巨大胎儿阴道分娩产程图分析 ,以了解胎儿体重与产程图的关系。方法 :以初产妇巨大胎儿阴道分娩 10 9例为观察组 (分阴道自娩组和阴道手术组 ) ,与初产妇正常体重儿 10 0例 (对照组 )产程图中潜伏期、活跃期、第二产程以及各期胎头下降时速进行比较。结果 :巨大胎儿产程各期与正常体重儿相比差异均有显著性 (P <0 .0 5～P <0 .0 1) ;三组分娩结束时在产程图中所处的位置相比差异有显著性 (P <0 .0 0 5 )。结论 :临产后产程图可作为识别巨大胎儿的最佳手段 ,一旦明确诊断 ,应放宽剖宫产指征。

Using Alert and Action Expected Times of Delivery in Prevention of Prolonged Labor

Background and Objective: Although globally admitted as the most valuable tool to prevent prolongation of labor, the partogram has failed to be commonly used. This is due to its alleged complexity. Based on the simplified model proposed by Debdas, the so called paperless partogram, we aimed at evaluating the ability of only using the alert and action lines to prevent prolongation of labor. Methods: This was a cross-sectional study including labor records of women delivered at King Baudouin Hospital of Kinshasa (secondary level) from 01/01 till 31/12/2013. The study was approved by the Faculty Ethical Committee. Inclusion criteria were: 1) live singleton pregnancy, 2) cephalic fetal presentation, 3) lack of uterine scar, 4) monitoring in labor ward by 4 cm of cervical dilation, and 5) delivery at term. For every record, the expected time of delivery (ETD = 6 hours after 4 cm of cervical dilation) was considered “Alert EDT” to which 4 hours were added to obtain the “Action EDT”. Irrespective of other fetal and maternal features contained in the traditional partogram Alert and Action ETD were checked a posteriori on Debdas’s model to derive the appropriate outcome of labor. Results: The study included 357 participants, of which 219 primiparous and 138 multiparous. Vaginal delivery took place in 91% of cases. Full cervical dilation was achieved after 8 - 9 hours (9.5 ± 1.8 hours for primiparous and 8.4 ± 1.7 hours for multiparous women), namely 2 - 3 hours following Alert ETD). This duration is close to the Action ETD. For 32 cesarean sections (9%) final decision took place within the Alert ETD. Conclusion: Using only Alert and Action ETD was found convenient to derive appropriate measures for the outcome of labor. So, the paperless partogram is a simplified method to manage the active stage of labor that could prevent prolongation of labor in our setting.

新产程标准对母婴结局影响的Meta分析

目的系统评价新产程标准对母婴结局的影响,为新产程标准的应用提供循证参考。方法计算机检索PubMed、EMbase、Cochrane图书馆、中国知网、维普网、万方数据库、中国生物医学文献数据库中关于新产程标准对母婴结局影响的随机对照试验,检索时限为建库至2021年7月,并检索Clinical Trials.gov、中国临床试验注册中心已注册但未发表的文章。由两名研究者独立筛选文献、提取资料和结局指标数据,并采用Cochrane手册5.3推荐的偏倚风险评估工具评价纳入研究质量。采用Stata 15.1软件进行Meta分析、敏感性分析、发表偏倚分析。结果共纳入14篇文献,共10591例患者。Meta分析结果显示:试验组(新产程标准)患者在降低剖宫产率方面均优于对照组(传统产程标准)(OR=0.38,95%CI 0.32~0.45,P<0.001)。两组产钳助产率、产后出血率、新生儿窒息率比较差异无统计学意义(OR=1.06,95%CI 0.86~1.31,P=0.604;OR=1.09,95%CI 0.88~1.35,P=0.422;OR=1.11,95%CI 0.89~1.38,P=0.370)。结论新产程标准在降低剖宫产率方面优于传统产程标准,在降低产钳助产率、产后出血率及新生儿窒息率方面与传统产程标准差别不大,并未增高或降低产钳助产率、产后出血率以及新生儿窒息率。

新产程时限标准与旧产程时限标准临床应用价值对比分析

目的:探究新产程时限标准与旧产程时限标准的临床应用价值。方法:选择2014年3月-2015年3月本院接诊的120例通过阴道试产、单胎活产孕妇,按照随机数字表法分为研究组和对照组,每组60例。对照组采用Friedman产程时限标准对母婴观察,研究组按照新产程时限标准对母婴进行观察。比较两组母婴产程特性及母婴结局,包括产妇产程实现、围产儿结局、新生儿Apgar评分、产妇妊娠结局、妊娠并发症等。结果:研究组与对照组活跃期比较,差异无统计学意义(P>0.05);研究组与对照组第一、二产程时限比较,差异均有统计学意义(P<0.05);研究组与对照组新生儿胎儿宫内窘迫、新生儿窒息、转入NICU、羊水粪染情况比较,差异均无统计学意义(P>0.05);两组产妇分娩后1、5 min Apgar评分比较,差异均无统计学意义(P>0.05);两组产妇产钳助产、产后出血、会阴切口感染比较,差异均无统计学意义(P>0.05);两组妊娠胎膜早破、脐带脱垂、羊水过多比较,差异均无统计学意义(P>0.05)。结论:新产程标准放宽潜伏时限(第二产程)可以减少不必要的产程干预及新生儿与产妇的并发症;产程观察需结合胎先露下降和宫颈扩张情况来监视胎儿安危与产妇精神;采用新产程时限标准可以通过阴道分娩,从而有效降低剖宫产率,值得在临床上大力应用推广。

影响产程图临床应用的相关因素分析

产程图作为描述产程进展的标准化图形,自提出以来,不断发展演变,其目的是更好地帮助医务人员识别产程中出现的问题,并根据临床管理方案采取干预措施,降低母婴不良结局的发生。但产程图是复杂多变的,理论上的最佳实践干预措施与临床实际操作存在差距。通过对产程图临床应用的研究进展进行回顾并综述,探讨产程图自身因素、医务人员专业技能、孕妇、社会环境、组织背景、经济和政治背景等因素对产程图在临床中有效应用的影响。医务人员应准确识别这些影响因素,正确评估产程图在产科中的地位,并依赖新兴技术将产程图进行改善和优化,从而使产程图得到更好的应用并服务于临床工作。

新产程标准下经皮神经电刺激镇痛的应用观察

目的评价新产程标准下经皮神经电刺激镇痛在足月产妇阴道试产中的应用效果。方法选择2017年1~8月于福永人民医院分娩的247例足月初产妇为研究对象,根据分娩镇痛的情况,分为经皮神经电刺激镇痛组(TENS组,n=86),连续硬膜外镇痛组(CEA组,n=48)及无镇痛的为空白对照组(n=113)。观察并记录三组产妇镇痛前即刻,镇痛起效时,镇痛60 min、120 min及180 min后视觉模拟评分量表(VAS)评分、第一、二产程时间、阴道分娩率、非指征转剖宫产率、催产素及器械助产使用情况,新生儿出生1 min及5 min时Apgar评分以及产妇对分娩镇痛效果满意度评价等数据。结果镇痛效果上,TENS组及CEA组镇痛起效后各时间点VAS评分、疼痛程度组成均优于对照组(P均<0.001),CEA组优于TENS组(P<0.05)。TENS组与对照组产程时间对比没有统计学差异,CEA组则第一、二产程时间均长于其他两组(P均<0.05)。TENS组及CEA组阴道分娩率、非指征转剖宫产率均低于对照组,但差异没有统计学差异(P均>0.05)。三组在催产素及器械助产使用情况、新生儿出生1 min及5 min Apgar评分对比没有统计学差异。结论采用经皮神经电刺激分娩镇痛效果较好,可降低非指征转剖宫产率,对母婴无不利影响,镇痛效果虽不及连续硬膜外镇痛,但其无创、易于操作、费用低廉等特点更易为产妇及家属接受,亦更易于在基层医疗机构开展。

产程图的临床应用

产程图在分娩监护中有重要临床价值,该文就其构成、分期、处理指征、异常产程组成及产程图监测分娩结局等内容加以概述。

第一产程干预方法及其必要性探讨

社会的发展和生活方式的改变使分娩的自然过程发生了变化。依据有关产程进展的最新研究,国内外的相关学会和学术团体呼吁和倡导大家关注和采纳以第一产程宫口扩张6 cm作为活跃期起点标志的新产程图来管理产程,在充分试产的情况下产程没有进展才能确定潜伏期或活跃期的停滞或延长。随着产程时限标准的更改,有必要重新审视以往在第一产程中常用的一些干预方法如阴道检查、人工破膜、宫缩异常的监护与处理以及胎儿监护等措施,对实施这些方法的必要性进行探讨,有助于科学管理产程,给予充分试产的机会,降低剖宫产率。

单胎头位初产妇产程图分析

目的:探讨存在难产因素初产妇产程图的临床意义。方法:对2009年6月至2010年6月在济南军区总医院住院分娩的326例单胎头位初产妇的产程图进行回顾性分析。结果:产程图异常组中难产因素的构成比和剖宫产率均高于产程图正常组;存在难产因素的组别(胎方位异常组、宫缩乏力组、巨大儿组)产程中各阶段时限均较正常产妇组长,宫颈扩张速度均较正常组慢,胎头位置均高于正常组,以上差异均有统计学意义(P<0.05)。结论:在产程中对产程图中各阶段时限、宫颈扩张速度及胎头位置等指标进行监测,来预测和及时发现头位难产因素的存在,及时给予处理,改善母儿预后。

头位难产识别与处理

头位难产虽然比较常见,但临产前很难识别,主要特征是产程进展缓慢或延长,如果处理不及时或延误诊断会导致母、儿损伤,严重者会留下后遗症甚至导致围产儿死亡。头位难产与很多因素相关,如产次、骨盆大小、胎儿体重、产程中的监测、医护人员的工作经验和识别能力等,但是尚无哪项单一因素能可靠地预测难产。

新产程标准管理下的产程进展和干预研究

目的探讨新产程标准管理对产程进展和干预措施的影响。方法回顾性分析2015年1月1日—2017年12月31日在成都市妇女儿童中心医院阴道分娩的初产妇。以旧产程标准管理者200例,设为对照组(A组);同期根据产程时长将以新产程标准管理者设为观察组:B组100例(临产到宫口开大3 cm时间≥16 h)、C1组100例(2 h≤第二产程<3 h)和C2组100例(第二产程≥3 h)。比较4组在产程中干预措施如缩宫素点滴、人工破膜、间苯三酚软化宫颈、导尿和手转胎头以及第一、二产程时限的差异;比较宫口开全时A组和C1、C2组胎先露、产瘤、胎方位以及胎先露下降进展的差异。结果在缩宫素和间苯三酚使用率、导尿和手转抬头率的组间两两比较上,主要是C2和其他各组之间的差异(P<0.008 5)。C1、C2和A组在第一产程时限,B组和A组在第二产程时限的比较上,差异有统计学意义(P<0.05)。宫口开全时胎先露所在位置,除+1处A组与C2组差异无统计学意义外(P≥0.017),A组和C1、C2组差异有统计学意义(P<0.017)。有无产瘤和是否枕前位的比较上,除枕前位上A和C1组差异无统计学意义(P>0.017)外,其余各组间差异均有统计学意义(P<0.017)。宫口开全后胎先露下降幅度在各组间的两两比较上,0~1 h:A组、C1组、C2组之间的差异均有统计学意义(P<0.05)。1~2 h:C1和C2组之间的差异有统计学意义(P<0.05);在组内横向比较上:C1组0~1 h和1~2 h的胎先露下降幅度差异有统计学意义(P<0.05)。C2组0~1 h、1~2 h和2~3 h胎先露下降幅度差异两两比较均无统计学意义(P>0.05)。结论新产程标准管理下不会增加产程干预,但当第二产程≥3 h,干预增加。应及时处理影响产程的异常因素,控制第二产程在3 h以内。

新产程标准处理产程的可行性分析

目的探讨新产程标准处理产程的可行性分析。方法对照组100例以Fredman产程图处理产程,研究组100例以新产程标准处理产程,对比其剖宫产、阴道助产、催产素使用、产后出血、母体产伤、胎儿窘迫、新生儿窒息、产褥病率等有无差异。结果研究组剖宫产率及催产素使用率(12.00%、10.00%),均明显低于对照组(23.00%、27.00%),差异比较有统计学意义(P<0.05);而在催产素使用率、产后出血率、母体产伤率、胎儿窘迫率、新生儿窒息率及产褥病率等方面,两组差异比较无统计学意义(P>0.05)。结论胎新产程标准处理产程通过减少人工干预,可有效降低剖宫产率及催产素使用率,值得临床进一步推广普及。