Table 4. SWOT analysis of methods of intrapartum foetal monitoring.
| Strengths | Weaknesses | Opportunities | Threats | |
|---|---|---|---|---|
| IA | Detection of non-viable foetuses[36,59] | False results due to poor equipment [36] | Allows planning for safer delivery if intrauterine foetal death (on admission)[59]-Coupling of IA and partograph for monitoring[26,27,45] -Doppler may be preferred by care providers and pregnant women[26,27] | Limited human resources[36] |
| Lower cost and sustainable[27] | Cannot detect subtle abnormalities or changes in FHR e.g. baseline variability[31,41,53] | Can be used as an intrapartum stillbirth indicator for monitoring quality improvement of care for interventions (on admission)[59] Can lead to prompt emergency obstetric and neonatal care obstetrical[36] |
Not always used on admission/intrapartum[36,59] | |
| Can detect ir/regular rhythms, accelerations and decelerations[26,27,31,41] | Difficult to use, time-consuming and labour intensive[27,36] | Training may improve performance[59] | False results due poorly trained staff[36,46,59] | |
| Allows mobility of the women[31] | Uncomfortable for the mother and staff (Pinard)[26,36] | Promotes ‘‘hands-on” support to the labouring woman[31] | Lack of foetal monitoring protocol[46] | |
| Requires no additional resources/electricity (Pinard/wind-up Doppler)[27,36] Hand-held Doppler: Gives a steady number of beats per minute[26,27] |
Maternal heart rate may occasionally be counted[26] | Non-adherence to frequency, duration of monitoring and documentation[31] Underutilisation of partograph[27,40] |
||
| Device easy to use with minimal training[26,36,59] | Delays in action taking (long diagnosis to delivery time) [26,27,31] | |||
| Audible to both mother and caregiver (even in noisy labour wards) [27] | Unavailability of operative delivery[26] | |||
| Unavailability of FBS and cord blood analysis to confirm foetal compromise[26,27] | ||||
| May require repair and additional resources (Doppler)[26,27] | ||||
| Responsible of large proportion of CS are due to suspected foetal distress[31,41] | ||||
| CTG | Non-invasive(external) [26,28,30,34,37–39,43,44,47,48,50,53,56–58,60] -Continuous traces of FHR [26,28,30,34,37–39,43,44,47,48,50,53,56–58,60] |
Associated with high false positivity for foetal distress[26,28,30,34,37–39,43,44,47,48,50,53,56–58,60] -Admission CTG might not predict foetal distress several hours after admission. [32,48] |
Can be used intermittently during labour [26] | Potential increase in unnecessary interventions (e.g. caesarean section)[30,34,38,39,47,50] |
| Able to detect subtle changes in FHR e.g. baseline variability [26,28,30,34,37–39,43,44,47,48,50,53,56–58,60] | Low inter-observer agreement[47] | Admission test: Screening test for foetal distress on admission[32,34,44,48] | Costly and requires maintenance [26] | |
| Several pathological features are predictive of foetal acidosis [26,28,30,34,37–39,43,44,47,48,50,53,56–58,60] |
Susceptible to technical and mechanical failure resulting in poor quality of traces and interpretation[26] | Admission test: Prevent unnecessary delay in intervention[32] | Non-adherence of staff to protocol[26] | |
| Admission test: Triaging: allows selection of patients for closer monitoring during limited resources[32,34,44,48] | Limited or unavailability of CTG machine[31,34,41] | |||
| Delays in action taking (long diagnosis to delivery time) [26] | ||||
| No facility to perform FBS[41,50] | ||||
| Unstable electricity supply[31] | ||||
| Medicolegal climate[47] | ||||
| Contraction may impair maternal perception of foetal movement[61] | ||||
| Foetal stimulation tests | Non-/less- invasive[56] | Poor maternal perception of subtle foetal movement[60,61] | Safer to use in over-distended and scarred uterus [60] | |
| Fast, simple and cheaper[45,60,61] | Can be used to increase diagnostic accuracy of FHR monitoring: IA [45] or EFM[32,34,48,56,60]and MSAF[45] as an alternative to FBS[45,61] | |||
| No additional device necessary (scalp stimulation)[45] | Screening tool in early labour[60,61] | |||
| No rupture of membranes required[45] | ||||
| rBPP | Simple and fast[51] | Not adequate as a screening test[51] | May be used as an additional back up test[51] | |
| Relatively inexpensive[51] | ||||
| UADV | Feasible and no discomfort in labour[33] | Not useful in detecting foetal acidosis during labour[49] | ||
| Non-invasive and simple[33,49] | ||||
| MSAF | A warning sign that closer attention is warranted[58] | Highly unreliable when used alone[43,45] | More reliable when combined with FHR monitoring (IA [31,41,46] and CTG[39,43,58]) | Association with an increase in caesarean[39,58] |
| Require ruptured membranes[39] | ||||
|
FBS and FPO |
FPO is less invasive than FBS[42] | Recordings take 30 minutes (time-consuming)[42] | May decrease unnecessary interventions (e.g. CS) [42] | |
| FPO may be an alternative to foetal blood sampling[42] | ||||
| Partograph | Provides recording of the foetal and maternal parameters[25,29] | Too detailed[40] | Encourages supportive care to women [24] | Incorrect and/ incompletion of partographs: e.g. due to lack of time, motivation, human resources[24,29,40,54] |
| Single page[55] | Requires intensive and repeated training[40] | Helps interpret findings[40] | Loss of partographs[54] | |
| Visual presentation with clear overview of progress of labour[55] | Applicable mostly in first stage of labour[25,54,55] | Training and supervision improves use[29,54] | The need for photocopying[40] | |
| Accompanied by management protocol[25] | Helps communication and hand-over of patients between staff [25,40] | Lack of updated versions[40] | ||
| Permits evaluation of quality of care[40] | Removal of latent phase causes incomplete follow-up and difficulty in diagnosing prolonged latent phase[29] | |||
| Timely referral[29] | Unavailability of guidelines in labour wards[40] | |||
| Early diagnosis of complications and early decision making[40] | Non-adherence to protocol[29] | |||
| Labour wards can opt for adapted local management protocols[25] | Lack of training and supervision[40] | |||
| Universal application[25,40] | Lack of appropriate intervention[26,27] | |||
| High rates of referral[25,29] |
CTG = cardiotography, CS = caesarean, IA = Intermittent Auscultation, FBS = Foetal blood sampling, FHR = Foetal heart rate, FPO = Foetal pulse oximetry, MSAF = Meconium-staining amniotic fluid, rBPP = Rapid biophysical profile, SWOT = Strengths, Weaknesses, Opportunities, Threats, UADV = Umbilical artery Doppler velocity.