Quality of vital sign monitoring during obstetric hospitalizations at a regional referral and teaching hospital in Uganda: an opportunity for improvement
Godfrey Rwambuka Mugyenyi1, Joseph Ngonzi1, Blair Johnson Wylie2,3, Jessica Elizabeth Haberer3,4,5, Adeline Adwoa Boatin3,4,6,&
1Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda, 2Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, États-Unis, 3Harvard Medical School, Boston, USA, 4Center for Global Health, Massachusetts General Hospital, Boston, MA, USA, 5Department of Medicine, Harvard Medical School, Boston, MA, USA, 6Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Adeline Adwoa Boatin, Department of Obstetrics and Gynecology, Massachusetts
General Hospital, Harvard Medical School, Boston, MA, USA
vital sign monitoring is a key component of safe facility-based obstetric care. We aimed to assess quality of care around vital sign monitoring during obstetric hospitalizations in a tertiary-care facility in a resource-limited setting.
retrospective review of obstetric records at a tertiary care facility.
We assessed documentation of vital signs including fetal and maternal heart
rate, and maternal blood pressure, temperature, oxygen saturation and urine
output. The primary outcome was the quality of vital sign monitoring (high-
versus low-quality based on frequency of monitoring). We compared quality of
monitoring with timing of admission, presence of complication, and delivery
mode using chi-squared tests.
among 360 records of obstetric admissions (94% of a planned random sample), 96% documented a delivery. Of these, 8% of pregnant women and 11% of postpartum women had high-quality vital sign monitoring documented on initial evaluation at admission. For women delivering during the hospitalization, 0.8% of women delivering had high-quality monitoring in the first four hours postpartum, with higher rates of high-quality monitoring in women delivering vaginally compared to those delivered by cesarean (1.4% versus 0%, p<0.001). There were no differences in rates of quality monitoring by time of admission, or obstetric complication.
very few obstetric hospitalizations had high-quality vital sign monitoring. Attention towards improving vital sign monitoring is a critical need.
Promoting facility-based childbirth in areas of high maternal mortality is a key strategy to prevent maternal deaths, which continue to be concentrated in sub-Saharan Africa and South-East Asia . However, despite increases in the proportion of women delivering at facilities, reductions in mortality have not been as rapid as expected. Gaps in quality of care at facilities are thought to account for up to 50% of preventable deaths [2-4].
Vital sign (VS) monitoring is a critical component of high quality facility-based obstetric care and often is the first step to identify maternal complication and intervene when needed [5,6]. VS abnormalities are often seen in common obstetric complications, including the most common causes of maternal mortality: hemorrhage, hypertensive disease, and sepsis . For example, hemorrhagic shock can be detected through elevated heart rate (HR), lowered blood pressure (BP), and low urine output (UOP). Similarly, abnormalities in BP and UOP may indicate worsening hypertensive disease. In such clinical scenarios, prompt treatment can avert more dangerous sequelae and ultimately death. Early warning systems, which are increasingly being adopted to improve timeliness in the recognition and management of obstetric complications, rely on VS assessment to score and triage patients [8,9].
Along with competing priorities on busy clinical wards, a shortfall
in health care providers may mean that for women undergoing childbirth in
facilities or hospitalized for other obstetric indications, VS monitoring
may be inadequate. Studies assessing partograph use at facilities in sub-Saharan
Africa have demonstrated low completion rates with incomplete fetal and
maternal monitoring [10-13]. However, data is lacking
on the completeness of vital sign monitoring throughout an obstetric hospitalization,
i.e. at other time points than the intrapartum period, and in particular
in the immediate postpartum period, when up to 45% of maternal deaths occur
. As obstetric complications can occur in both
the antepartum, and in the immediate postpartum period (which the partograph
does not capture), we aimed to understand the quality of monitoring for
the duration of an obstetric admission. In this study, we performed a retrospective
review to determine the frequency and quality of vital sign monitoring during
obstetric hospitalizations to a tertiary care hospital in Uganda. Our secondary
objective was to assess if the hospitalization day (weekend versus weekday),
presence of complications or mode of delivery (for parturients) was associated
with differences in the proportion of women receiving high quality monitoring.
Setting: this is a retrospective review of maternal records from 2013
at Mbarara Regional Referral Hospital (MRRH), a publicly-funded teaching
hospital in Southwestern Uganda. VS monitoring is performed by medical
doctors and midwives. VS are recorded in admission and progress notes
and partographs. In 2013, the hospital employed 14 obstetricians
and 22 midwives and performed ~10,000 deliveries with a maternal
mortality rate of
100,000 livebirths, caesarean rate of 39% and perinatal mortality
rate of 56 per 1,000 births.
Chart selection: we obtained the medical records numbers of all women
admitted to MRRH maternity ward from a surgical services quality
assessment registry created to track surgical outcomes at MRRH. All
maternity ward hospitalizations
were captured using this registry between 2013 and 2014 and coded
by admission diagnosis [15,16].
The registry included details on surgical procedures and hospital
outcomes but did not
include clinical documentation such as vital signs. We therefore
used the registry only to identify obstetric hospitalizations. From
this registry we
selected all obstetric hospitalizations during 2013. Obstetric hospitalizations
included women admitted for antepartum (i.e., prelabor), intrapartum
and postpartum indication. Using a random sample generator (Excel
Version 16.29.1), we selected
a random sample (3.5%, n=384) of records.
Sample size estimation: we powered our study to provide a reasonable
estimate of our primary outcome: the proportion of women with high quality
vital sign monitoring at chosen time periods. As prior estimates of this
proportion of women with documented high-quality vital sign assessment for
our chosen time periods was unknown, we based our sample size calculation
assuming an estimated proportion i.e., P of 0.5. which is the recommended
proportion when a population proportion is unknown. This approach provides
the largest sample size for a given precision and confidence level .
Using this proportion, a sample of 384 was thus considered as as sufficient
to estimate the proportion level with a precision level of 0.05 (i.e. proportion
estimate ± 5%) and 95% confidence level .
Data variables: from retrieved medical charts we extracted data on
date and timing of admission, labor status (early labor: < 4cm cervical dilation;
active labor: 4-10cm cervical dilation; second stage of labor; or
postpartum) and VS documented including fetal HR if pregnant on admission
HR, BP, respiratory rate (RR), temperature (Temp,) UOP and oxygen
saturation. UOP was assessed only in the postpartum period. We noted
if VS were documented
at admission, in the first four hours postpartum, and on each subsequent
postpartum day until discharge. Documented complications were also
hypertensive disorders of pregnancy (HDPs), antepartum hemorrhage,
chorioamnionitis, uterine rupture, postpartum haemorrhage (PPH),
sepsis, wound infection or
dehiscence, re-operation after a caesarean or laparotomy following
a vaginal delivery, peripartum hysterectomy, intensive care unit
(ICU) admission, and
maternal or perinatal (stillbirth or neonatal) death. To assess whether
staffing volumes differed by timing of shift and day of week, we
also reviewed the
number of midwives available per shift including night/day and weekday/weekend
from staffing logbooks kept by the head midwife.
Outcomes: our primary outcome was quality of VS monitoring, dichotomized
as high- and low-quality based on frequency of monitoring. For pregnant
women at admission, we defined high-quality monitoring as the assessment of
of fetal HR, maternal HR, BP and Temp (Table
1). All other women with fewer assessments were categorized as having
low-quality monitoring. For women who were postpartum at admission,
we defined high-quality monitoring as the assessment of maternal HR, BP and
categorized all other women having fewer assessments as having low-quality
monitoring. We also applied this definition in the immediate four
hours postpartum and on subsequent postpartum days for women delivering at
the hospitals. These
definitions are based on professional guidelines from obstetric societies,
including guidance from the Uganda Ministry of Health [6,18-20].
Although we did not include UOP in our definitions of high-quality
monitoring, we also assessed the extent to which it was documented. We restricted
analysis of VS documentation beyond PPD 0 to records where an admission
date and discharge date were recorded, as this confirmed inpatient status
women. We also assessed if clinical documentation (progress note)
was present in the postpartum period. Given differences in length of stay
by mode of delivery,
we examined VS documentation on PPD 1 only for women delivering vaginally
and on PPD 1 to 3 for those delivered by caesarean. A sensitivity
analysis was performed with the exclusion of Temp as metric for high-quality
at all three time points. Our secondary objective was to assess if
quality of vital sign monitored varied by 1) day of week, 2) mode of delivery
3) whether or not the woman had a complication. For the exposure
of day of week, we dichotomized this into weekday vs weekend. Mode of delivery
into vaginal delivery vs cesarean delivery and only assessed for
women delivering during the hospitalization in the postpartum period (i.e.,
women with admitted
for antepartum indications and postpartum indications were excluded
from this analysis). Complication status was dichotomized into women with
one or more
complications and women without any complications. We measured the
mean number of nursing staff by day of shift (i.e., weekday versus weekend)
if this differed by day of the week, however we did not directly
compare quality of vital sign monitoring to mean number of staff.
Statistical analysis: we calculated the proportion of women with high-
and low-quality VS monitoring on admission, in the immediate four hours postpartum
and on each postpartum day. Using the chi-squared test, we compared these
proportions between women undergoing caesarean versus vaginal delivery, in
women with and without complications (one or more), and day of the week (i.e.,
weekend versus weekend). Mean nursing staff present were summarized by day
of shift (i.e. weekend versus weekend). Data was analyzed using Stata version
13 (Statacorp, College Station, TX, USA).
A total of 11,060 admissions to the MRRH maternity ward were recorded in 2013 (Figure 1). Of the 384 medical records numbers selected randomly, 360 (93.8%) charts were retrieved; the remaining charts could not be located. Of the 360 charts, 97.5% (n=351) were of women admitted during the antenatal or intrapartum period and 2.5% (n=9) were admitted postpartum. Of the 351 women pregnant at the time of admission, on initial evaluation, 11.6% (n=41) had no evidence of labor, 26.2% (n=92) were in early labor, 41.6% (n=146) in active labor and 20.5% (n=72) in the second stage of labor. A total of 337 (96.1%) records reported an intrapartum period with a delivery occurring. Of these, 119 (35.3%) women had a caesarean delivery, 5 (1.5%) had a vacuum delivery. The remainder were spontaneous vaginal deliveries.
Vital sign assessment
The proportion of charts with documented VS on admission are presented in Table 2. Eight percent (n=29/351) of pregnant women and 11% of postpartum women (n=1/9) had high-quality monitoring on admission. The most common individually checked VS was fetal HR, documented in 83% (n=291/351) of charts. Maternal HR, BP and Temp were documented in 48% (n=170/351), 50% (n=177/351), and 11% (n=39/315) of charts, respectively. Among postpartum admissions, the most frequently documented VS was maternal HR in 67% (n=6/9) of admissions, followed by BP, which was documented in 44% (n=4/9).
For women delivering in the hospital, very few charts had documentation of VS in the first four hours postpartum (Table 3). Less than 1% (n=3) of the 337 women delivering had documentation of high-quality monitoring in the first four hours. More women who delivered vaginally had high-quality monitoring in the first four hours after delivery compared to those delivered by caesarean at 1.4 % vs 0% (p<0.001), but this was still a rare event. In a sensitivity analysis with Temp excluded, the proportion with high-quality VS monitoring increased to 5% (n=16) of women. The most frequent VS measured in the first four hours post-delivery was BP, documented in 7% of women, followed by HR, documented in 4% of women. Temp and RR were documented in 0.9% (n=3) of women. No woman had UOP documented at any time point in the postpartum period.
Data on VS monitoring beyond PPD 0 were available for 86% (n=296) of records. Just over 12% (n=15) of women who delivered vaginally had any clinical documentation on PPD 1; <1% (n=1) of these women had high-quality VS monitoring documented. HR was documented in 4% (n=5), BP 6% (n=7), and Temp 0.8% (n=1). Women delivered by caesarean had clinical documentation in 78% of records on PPD 1, 2, and 3. High-quality monitoring was performed in 3.6% (n=4), 2.8% (n=3) and 3.4% (n=3) of women on PPDs 1, 2, and 3, respectively. Excluding Temp, the proportion with high-quality monitoring rose to 29%, 17.8%, and 10.1% on PPDs 1, 2, and 3, respectively. No UOP was documented in any of the available clinical records.
Staffing and vital sign documentation
Table 4 summarizes mean number of midwives during different shifts (day, evening, and night). Significantly more midwives were available on weekday compared to weekend day shifts (6.4 versus 4.3, p<0.001) and day shifts compared to evening and night shifts (5.8 versus 2.9 and 3.0, respectively). However, we found no significant difference in the proportion of records with high-quality monitoring for admissions on a weekday versus weekend (7% versus 9%, p=0.5) nor during the first fours after delivery for deliveries on a weekday versus weekend 9% versus 4%, p=0.1).
PPH was the most common complication, occurring in 5% (n=8) of women. HDPs occurred
in 6 (1.7%) of women. There was one (0.28%) maternal death, 11 (3.0%) stillbirths
and one (0.3 %) neonatal death. One or more complication was recorded in 42
(11.0%) women (Table
5). High-quality monitoring was performed more frequently in women
without a complication compared to women with a complication at admission (4.8%
versus 8.5%, p=0.4) and in the first fours after delivery (1% vs 0%, p=0.6),
however these differences were not statistically significant.
In this review, we examined VS documentation for obstetric care in a busy tertiary care facility in Uganda. We found VS documentation rarely met international normative quality standards with <9% of women having high-quality monitoring on admission and <1% of women undergoing delivery having high-quality monitoring in the immediate postpartum period. Notably, among women undergoing caesarean, there was no documentation of any VS in the first four hours after delivery. Mean nurse staffing availability, day of week and presence of an obstetric complication did not significantly influence rates of VS documentation.
Our study findings mirror those seen in other low-resourced obstetric
settings. In a trial conducted in India where checklists were tested as
an intervention to improve quality of care during facility-based childbirth,
maternal BP and Temp were checked in <38% of women in the intervention arm
and less than 3% of women in the control arm .
However, our findings are somewhat different from a study in the same facility
(MRRH) assessing frequency of VS monitoring among non-obstetric patients
with severe sepsis in a medical ward. In that study, audits demonstrated
that 96% of patients had at least one BP measurement in the first 24 hours
of admission, with a steep decline in monitoring over the course of their
inpatient stay . This higher level of monitoring
observed on admission compared to our findings may be due to differences
in staff: patient volumes in different wards. For example, although nursing
staffing on the medicine and obstetrics wards is about the same at MRRH,
the obstetrics unit often has five-fold higher patient census with a higher
We found no documentation of VS monitoring in the first four hours
after delivery among the 119 women undergoing caesarean in this study. This
is noteworthy. In two recent studies, the risk of mortality after caesarean
was demonstrated to be 50 times higher in 22 sub-Saharan countries and other
low- and middle-income countries compared to high-income countries [23,24].
Although the root causes of higher mortality are not yet understood, these
findings point to the importance of perioperative monitoring for women undergoing
caesarean and our study demonstrates a dire lack of such monitoring. In
high-resource settings, routine, high frequency VS monitoring around childbirth
is considered standard of care. Nursing guidelines in the United States
recommend the assessment of maternal HR and BP every 15 minutes for two
hours in the immediate postpartum period and more frequently if complications
are encountered . To achieve this goal, 1:1 nursing
to patient ratio is recommended during that time, which is similar to the
level of care found in intensive care units. Our findings in this resource-limited
setting indicate that women receive far less monitoring, even when complications
are present. Given the staffing availability, this situation is unsurprising.
On the most robustly staffed weekday shift, we found no more than seven
nurses, with responsibilities for covering all antepartum, intrapartum,
and postpartum patients, translating to a nurse-to-patient ratio of approximately
to 1:25 at best. Furthermore, monitoring after caesarean may be hard to
implement in the absence of a postoperative anesthesia care unit combined
with delays in transport to the postpartum ward.
Addressing this gap in care requires innovative solutions, as we
are unlikely to see large increases in nursing staff in the near future.
Current projections are that shortages in health providers are likely to
worsen, rising from a current shortfall of 7.3 million to 18 million by
2030 and with deficits concentrated in low- and middle- income countries
. As such, new methods of monitoring are needed
to achieve the levels of high-quality monitoring considered normative standards.
Consideration of non-traditional staff, use of family members and advances
in wearable technology may be strategies to improve monitoring during and
around childbirth .
Our study has several limitations. Firstly, our assessment of VS monitoring and clinical outcomes is limited to what is documented in the medical record; therefore, it is possible that some VS monitoring occurred without documentation or that the medical records selected were missing components of the chart. We obtained a random selection of charts to prevent any systematic bias in this regard. However, we noted that over 50% of charts (primarily those of women delivering vaginally) had no documentation of any care received on the first postpartum day one. This finding could imply either poor or lost documentation or represent true gaps in clinical care. However, this data is still relevant to quality of care; deficits in the documentation of VS at one point during admission may impact care at a later point, as clinicians may need to understand the trends in VS to make clinical inferences. Secondly, our sample size was based on an estimate frequency of 50% VS assessment. Given the much lower rates found in this review, a large sample size would be needed to detect clinically significant differences in monitoring by mode of delivery, day of assessment and complication. Lastly, we were unable to compare staff to patient ratios which may be more informative of the workload. This information should be assessed in future prospective work assessing VS monitoring.
In conclusion, most obstetric admissions in this busy tertiary care facility had low-quality VS monitoring, if any monitoring at all. As a foundation of inpatient clinical care, particularly at a referral center, this finding provides a clear target and opportunity for improvement in quality of care. Current global strategies to improve maternal health continue to favor facility birth, with attention still focused on encouraging women to access facilities for delivery. Concomitant attention to improving the quality of care delivered at such facilities is therefore also essential with emphasis placed on how standards can be improved despite resource limitations.
What is known about this topic
- Vital sign monitoring is a key component on safe facility-based childbirth;
- In low-resource settings deficits in vital sign monitoring in non-obstetric populations have been described.
What this study adds
- Evidence demonstrating a critical deficit in postpartum care for women undergoing facility-based delivery;
- Identifies a concrete area for improved quality of care during facility-based childbirth.
The authors declare no competing interests.
GM, JN and AAB the study. All authors contributed to study design. GM, JN and AAB contributed to data collection. AAB performed data analyses. All authors contributed to data interpretation. GM and AAB drafted the manuscript and all other authors provided critical insight and review. All authors read and approved the final version of the manuscript submitted for publication.
AAB is supported by career development awards from the Eunice Kennedy Schriever National Institute of Child Health and Human Development (K23 HD097300-01) and Massachusetts General Hospital Executive Committee on Research through the Center for Diversity and Inclusion. JEH is supported by K24MH114732 from the National Institute of Mental Health. BJW was supported by career development award from the National Institute of Environmental Health Sciences (K23 ES021471).
Tables and figure
Table 1: eligibility criteria, time points for vital sign monitoring evaluation and definitions of high -quality vital sign monitoring
Table 2: vital sign monitoring on admission
Table 3: vital sign monitoring in the postpartum period (n/%) over time and by mode of delivery
Table 4: nursing staffing in the obstetrics and gynecology department during study period
Table 5: obstetric complications documented
Figure 1: flow diagram of medical record chart selection, retrieval and admission outcomes
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