Delphi consensus statement on intrapartum fetal monitoring in low‐resource settings

Abstract Objective To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low‐resource settings. Methods Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low‐resource settings scored the importance of intrapartum fetal monitoring methods. Results 71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low‐risk pregnancies during the first stage of labor and after every contraction for high‐risk pregnancies in the second stage, (4) contraction monitoring hourly for low‐risk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high‐risk women in the first stage or low‐risk women in the second stage of labor. Conclusion There is a gap between international recommendations and what is physically possible in many labor wards in low‐resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low‐resource settings.

Evidence is lacking to develop an ideal intrapartum fetal monitoring system to improve perinatal outcomes. Practice is guided by expert consensus and obstetric culture, which often originate in highincome countries. 8 For low-risk pregnancies, assessment of fetal heart rate (FHR) by intermittent auscultation (IA) for 30-60 seconds is commonly recommended every 15 or 30 minutes in the active phase of the first stage of labor, and after every contraction or at 5-minute intervals in the second stage. The strength and frequency of contractions are generally determined every 30 minutes over a 10-minute period.

A substantial mismatch exists between international guidelines
and what is locally achievable. In high-volume low-resource settings, the ratio of skilled birth attendants (SBAs) to deliveries often exceeds one to three. 9,10 The challenges in labor monitoring are well known, yet current recommendations do not take into consideration the limited T A B L E 1 Fetal and contraction monitoring recommendations in renowned international and national guidelines. Feasible implementation strategies are needed to support overwhelmed SBAs and help them to manage the high number of deliveries. Evidence indicates that clinical recommendations that are realistic, simple, and easy to understand have a greater chance of translation into practice. 12 WHO encourages regional, national, and subnational adaptation of their guidelines. 13 It is therefore paramount to explore how international guidelines can be adapted to more closely reflect the reality at the targeted maternity units that need the most guidance.
With use of a Delphi procedure, we aimed to determine a package of achievable strategies of intrapartum fetal monitoring for busy low-resource maternity wards with a focus on admission tests, FHR monitoring, adjunctive tests, and contraction monitoring in relation to low-and high-risk pregnancies in the first and second stage of labor. Emtree terms related to "intrapartum," "fetal surveillance," "outcomes,"

| MATERIALSANDMETHODS
and "low-and middle-income countries." In addition, international, national, and local guidelines were searched for recommendations on the frequency and duration of FHR and contraction monitoring (Table 1). 9 The definitions used to guide participants are given in Box 1, and the outcomes are listed in Supplementary Tables S1 and S2.
A three-round electronic Delphi survey is a well-established consensus method allowing anonymous consultation with controlled  Consensus was defined a priori as at least 70% of stakeholders scoring an item as "agree/strongly agree" and less than 15% scoring it as "disagree/strongly disagree." Exclusion of items required at least 70% of stakeholders scoring the item as "disagree/strongly disagree" and less than 15% scoring it as "agree/strongly agree." Items that did not meet these criteria were classified as "no consensus." For multiplechoice questions, a level of 70% agreement was used. If consensus was reached, participants were informed and the outcome was left out from subsequent rounds. Outcomes that nearly reached consensus were discussed by the steering committee for a final decision.
Attrition analysis was performed by comparing the medians of outcomes among those who participated in subsequent rounds to the medians of those who did not.  Table S1).

| DISCUSSION
The international Delphi procedure with input from experts from 39 countries resulted in consensus on five aspects of intrapartum fetal monitoring for busy low-resource maternity units: (1)  The study involved a substantial group of participants (n=107) representing 39 countries. Importantly, the majority (>80%) of experts had experience of labor care in low-resource settings. The subsequent attrition of particularly midwives and pediatricians is, however, a limitation. These two stakeholder groups were not represented in the steering committee, and the effect of this cannot be ruled out.
Although effort was taken to include a proportionate representation of experts from LMIC, the response rates of these experts were lower than those in high-income countries, possibly owing to access to the online survey. An inherent limitation is linked to the expert-based approach, which was chosen because of the lack of scientific evidence.
However, the results may provide a foundation for future studies to generate evidence. Variation in the experts' definitions of pregnancy risk status, low-resource setting, and suboptimal/abnormal FHR, as well as their preferred methods in their clinical practice, might also have influenced responses.
In the present study, fetal assessment on admission and monitor- no consumables, such as batteries or gel. Users, however, might struggle to hear FHR in busy and noisy wards. The effect of handheld Doppler on operative delivery rates is not well established, and the instrument may not be readily available in low-resource settings owing to the associated consumables and associated costs. 19 Innovations are being developed to overcome such problems. 20 Cardiotocography was considered useful only for high-risk pregnancies during the second stage. This contrasts with the international guidelines summarized in Table 1, which all advice continuous CTG monitoring for high-risk women during the whole period of labor (apart from the WHO, which does not express an opinion on this matter). In the present survey, however, concerns were raised about the validity and feasibility of CTG, even for high-risk women in the second stage, owing to a lack of evidence of improvement in perinatal outcomes and increased rates of cesarean in high-income countries, high costs and maintenance, regular training of staff, and difficulties in the interpretation of CTG traces. 8,21 Nonetheless, this consensus reveals the underlying urgent need for optimal FHR surveillance and timely management (e.g., instrumental deliveries) in the second stage, which may prevent stillbirth or severe birth asphyxia. 22 Meeting this need calls for novel FHR monitoring innovations as an alternative to CTG, such as the Moyo monitor (Laerdal Global Health, Stavanger, Norway) for intermittent prolonged monitoring of FHR. 23 In the absence of evidence on optimal and minimal safe frequencies and duration of IA and monitoring of contractions, there was little deviation from established guidelines, except for the recommended hourly monitoring of contractions. A key methodologic finding of the study may be how clearly difficult it is for experts to deviate from international guidelines or common practice (culture and tradition) in order to reach reality. Yet, the actuality of the gap in human resources in many labor wards in LMICs implies that such guidelines are physically unachievable. 6,9,24 If one SBA simultaneously attends three laboring women with FHR according to the Until human resource needs are met and rigorous evidence is available, respectful guidance for overworked health providers requires an achievable frequency of assessments for routine intrapartum care. 9 Therefore, it should be explored how future Delphi studies can better include the "reality-based evidence," including task prioritization, in the decision-making for best possible management in resource-constrained settings.
Invasive adjunctive tests were discouraged because of concerns of improper procedures and interpretation, higher risk of infection, and sustainability. For an abnormal FHR, a change in maternal position and use of affordable tocolytic drugs (if available) to stop or reduce contractions were considered important, particularly in the case of a long decision-to-delivery interval. Non-invasive alternative adjunctive tests, including maternal perception of fetal movements, and fetal acoustic and scalp stimulation tests, received little support from the experts. Strikingly, obstetricians opposed the use of maternal perception of fetal movement during labor. Likely reasons are its apparent absence in actual clinical practice and limited evidence. 25 During the consultation meeting, however, it was suggested that the presence of fetal movement helps to confirm fetal wellbeing and might aid in guiding clinical management, a point that was agreed among midwives.
In conclusion, consensus was reached that intrapartum fetal monitoring in low-resource settings might benefit from a standard admission test and the use of IA by handheld Doppler in both stages of labor. With regard to the study's consensus on FHR assessment frequencies, reality proves them to be unachievable in many highvolume maternity units in low-income countries. This emphasizes the unacceptable reality and calls for more and well-trained staff.
Implementation research on how to strengthen admission assessment and intrapartum surveillance, and related effects on perinatal survival is paramount. Consideration should be given to clinical experience, patient preference, and locally derived data for developing achievable context-specific guidelines toward reducing intrapartum morbidity and mortality in low-resource settings.   TableS4. Attrition analysis. Table 1.