Clinical audit to enhance safe practice of skilled birth attendants for the fetus with nuchal cord: evidence from a refugee and migrant cohort

BMC Pregnancy and Childbirth

Rose McGready¹  François H Nosten¹  Mary Ellen Gilder²  Aye Min²  Nay Win Tun²  Ma Ner²  Paw Si Say²  Nan San Wai²  Colley Paw Dabu²  Megan Parr³ 

[1] Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom;Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, PO Box 46, Mae Sot, Tak 63110, Thailand;Women’s and Children’s Services, Launceston General Hospital, Launceston, Tasmania, Australia

关键词: Skilled birth attendant;    Registered midwife;    Quality improvement;    Nuchal cord;    Interprofessional learning;    Audit cycle;   

Others  :  1127582
DOI  :  10.1186/1471-2393-14-76

 received in 2013-03-31, accepted in 2014-02-13,  发布年份 2014

【 摘 要 】

Background

Current evidence for optimal management of fetal nuchal cord detected after the head has birthed supports techniques that avoid ligation of the umbilical cord circulation. Routine audit found frequent unsafe management of nuchal cord by skilled birth attendants (SBAs) in migrant and refugee birth centres on the Thai-Burmese border.

Method

The audit cycle was used to enhance safe practice by SBA for the fetus with nuchal cord. In the three birth centres the action phase of the audit cycle was initially carried out by the doctor responsible for the site. Six months later a registered midwife, present six days per week for three months in one birth facility, encouraged SBAs to facilitate birth with an intact umbilical circulation for nuchal cord. Rates of cord ligation before birth were recorded over a 24 month period (1-July-2011 to 30-June-2013) and in-depth interviews and a knowledge survey of the SBAs took place three months after the registered midwife departure.

Results

The proportion of births with nuchal cord ligation declined significantly over the four six monthly quarters from 15.9% (178/1123) before the action phase of the audit cycle; to 11.1% (107/966) during the action phase of the audit cycle with the doctors; to 2.4% (28/1182) with the registered midwife; to 0.9% (9/999) from three to nine months after the departure of the registered midwife, (p < 0.001, linear trend). Significant improvements in safe practice were observed at all three SMRU birth facilities. Knowledge of fetal nuchal cord amongst SBAs was sub-optimal and associated with fear and worry despite improved practice. The support of a registered midwife increased confidence of SBAs.

Conclusion

The audit cycle and registered midwife interprofessional learning for SBAs led to a significant improvement in safe practice for the fetus with nuchal cord. The authors would encourage this type of learning in organizations with birth facilities on the Thai-Burmese border and in other similar resource limited settings with SBAs.

【 授权许可】

   
2014 Parr et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Pearson R, Kusakabe K: Thailand’s hidden workforce: Burmese migrant women factory workers. London, UK: Zed Books; 2012.
• [2]Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, Bustreo F, Cavagnero E, Cometto G, Daelmans B, de Francisco A, Fogstad H, Gupta N, Laski L, Lawn J, Maliqi B, Mason E, Pitt C, Requejo J, Starrs A, Victora CG, Wardlaw T: Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 2010, 375(9730):2032-2044.
• [3]Austin J, Guy S, Lee-Jones L, McGinn T, Schlecht J: Reproductive health: a right for refugees and internally displaced persons. Reprod Health Matters 2008, 16(31):10-21.
• [4]McGready R, Brockman A, Cho T, Cho D, van Vugt M, Luxemburger C, Chongsuphajaisiddhi T, White NJ, Nosten F: Randomized comparison of mefloquine-artesunate versus quinine in the treatment of multidrug-resistant falciparum malaria in pregnancy. Trans R Soc Trop Med Hyg 2000, 94:689-693.
• [5]Hoogenboom G: Quality of maternal health care at Shoklo Malaria Research Unit in Maela Refugee camp in 2008. Amsterdam: Royal Tropical Institute, Vrije Universiteit Amsterdam; 2009. http://www.search4dev.nl/search?fileid=186298;docsPerPage=1 webcite
• [6]Whelan A, Blogg J: ‘Halfway people’: refugee views of reproductive health services. Global public health 2007, 2(4):373-394.
• [7]Carrara VI, Hogan C, De Pree C, Nosten F, McGready R: Improved pregnancy outcome in refugees and migrants despite low literacy on the Thai-Burmese border: results of three cross-sectional surveys. BMC Pregnancy Childbirth 2010, 11:45.
• [8]Graham W, Wagaarachchi P, Penney G, McCaw-Binns A, Antwi KY, Hall MH: Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries. Bull World Health Organ 2000, 78(5):614-620.
• [9]Wagaarachchi PT, Graham WJ, Penney GC, McCaw-Binns A, Yeboah Antwi K, Hall MH: Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynaecol Obstet 2001, 74(2):119-130. discussion 131
• [10]Henry E, Andres RL, Christensen RD: Neonatal outcomes following a tight nuchal cord. J Perinatol 2012, 33:231-234.
• [11]Rhoades DA, Latza U, Mueller BA: Risk factors and outcomes associated with nuchal cord. A population-based study. J Reprod Med 1999, 44(1):39-45.
• [12]Schaffer L, Burkhardt T, Zimmermann R, Kurmanavicius J: Nuchal cords in term and postterm deliveries–do we need to know? Obstet Gynecol 2005, 106(1):23-28.
• [13]Sinnathuramy TA: The nuchal cord incidence and significance. J Obstet Gynaec Brit Cwlth 1966, 73:226-231.
• [14]Cohain JS: Nuchal cords are necklaces, not nooses. Midwifery Today Int Midwife 2010, 93:46-48. 67–48
• [15]Dunn PM: Tight nuchal cord and neonatal hypovolaemic shock. Arch Dis Child 1988, 63(5):570-571.
• [16]Mercer JS, Erickson-Owens D: Management of nuchal cord. J Midwifery Women’s Health 2007, 52(5):524-525. author reply 525–526
• [17]Vanhaesebrouck P, Vanneste K, de Praeter C, Van Trappen Y, Thiery M: Tight nuchal cord and neonatal hypovolaemic shock. Arch Dis Child 1987, 62(12):1276-1277.
• [18]Shepherd AJ, Richardson CJ, Brown JP: Nuchal cord as a cause of neonatal anemia. Am J Dis Child 1985, 139(1):71-73.
• [19]Baxley EG, Gobbo RW: Shoulder dystocia. Am Fam Physician 2004, 69(7):1707-1714.
• [20]Iffy L, Varadi V, Papp E: Untoward neonatal sequelae deriving from cutting of the umbilical cord before delivery. Med Law 2001, 30:628-634.
• [21]Nelson KB, Grether JK: Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight. Am J Obstet Gynecol 1998, 179(2):507-513.
• [22]Jackson H, Melvin C, Downe S: Midwives and the fetal nuchal cord: a survey of practices and perceptions. J Midwifery Women’s Health 2007, 52(1):49-55.
• [23]Anderson EE: Management of the nuchal cord in relation to vaginal delivery. J Nurse Midwifery 1991, 36(6):377-378.
• [24]Schorn MN, Blanco JD: Management of the nuchal cord. J Nurse Midwifery 1991, 36(2):131-132.
• [25]Mercer JS, Nelson CC, Skovgaard RL: Umbilical cord clamping: beliefs and practices of American nurse-midwives. J Midwifery Women’s Health 2000, 45(1):58-66.
• [26]Jefford E, Fahy K, Sundin D: The nuchal cord at birth: what do midwives think and do? Midwifery Today 2009, 89(44–46):69.
• [27]Jefford E, Fahy K, Sundin D: Routine vaginal examination to check for nuchal cord. Br J Midwifery 2009, 17(4):246-249.
• [28]Reed R: Nuchal cords: think before you check. Pract Midwife 2007, 10(5):18-20.
• [29]Harvey SA, Blandon YC, McCaw-Binns A, Sandino I, Urbina L, Rodriguez C, Gomez I, Ayabaca P, Djibrina S: Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward. Bull World Health Organ 2007, 85(10):783-790.
• [30]Nyamtema AS, de Jong AB, Urassa DP, van Roosmalen J: Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania. BMC Pregnancy Childbirth 2011, 11:94. BioMed Central Full Text
• [31]Siddiqi K, Newell J, Robinson M: Getting evidence into practice: what works in developing countries? Int J Qual Health Care 2005, 17(5):447-454.
• [32]Nosten F, ter Kuile F, Maelankirri L, Decludt B, White NJ: Malaria during pregnancy in an area of unstable endemicity. Trans R Soc Trop Med Hyg 1991, 85(4):424-429.
• [33]McGready R, Simpson JA, Cho T, Dubowitz L, Changbumrung S, Bohm V, Munger RG, Sauberlich HE, White NJ, Nosten F: Postpartum thiamine deficiency in a Karen displaced population. Am J Clin Nutr 2001, 74(6):808-813.
• [34]Adegoke A, Utz B, Msuya SE, van den Broek N: SkilledBirth Attendants: who is who? A descriptive study of definitions and roles from nine Sub Saharan African countries. PloS one 2012, 7(7):e40220.
• [35]Creswell JW, Klassen AC, Plano Clark VL, Smith KC for the Office of Behavioral and Social Sciences Research: Best practices for mixed methods research in the health sciences. National Institutes of Health; 2011. Date retrieved. http://obssr.od.nih.gov/mixed_methods_research webcite
• [36]Krippendorf K: Content analysis: An introduction to its methodology. Beverly Hills, CA: Sage Publications; 19080
• [37]Billings DM, Halstead JA: Teaching in Nursing: A Guide for Faculty. 3rd edition. St. Louis, Missouri: Saunders; 2009.
• [38]Frambach JM, Driessen EW, Chan LC, van der Vleuten CP: Rethinking the globalisation of problem-based learning: how culture challenges self-directed learning. Med Educ 2012, 46(8):738-747.
• [39]Hoffman SJ, Harnish D: The merit of mandatory interprofessional education for pre-health professional students. Med Teach 2007, 29:e235-e242.
• [40]Allen JA, Currey J, Considine J: Annual resuscitation competency assessments: a review of the evidence. Aust Crit Care 2013, 26(1):12-17.
• [41]Olenick M, Allen LR, Jr Smego RA: Interprofessional education: a concept analysis. Adv Med Educ Pract 2010, 1:75-84.