Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

Abstract

ObjectiveIn low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting.MethodsA baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit.ResultsTwo hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01).ConclusionA criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

Use of a criteria‐based audit to optimize uptake of cesarean delivery in a low‐resource setting

“…after implementation of audit‐feedback recommendations) was conducted from July 1 to December 30, 2015. Two main sources of information were used in the present study: previously published CBA data from MNH and the MNH obstetric database (2013–2016).…”

“…Using Epi Info version 7 (CDC, Antanta, Georgia, USA), the minimum required sample size for CBA was calculated based on the number deliveries at MNH in 2012 (n=110 433), with a cesarean delivery rate of 49% . The minimum required sample size for baseline CBA of obstructed labor was 256, assuming that 767 had undergone cesarean delivery.…”

“…As the aim was to detect a 10% improvement in standard of care, post‐CBA substandard care was estimated to be 40%. Therefore, the minimum sample size required for re‐audit was 250 . Similarly, the proportion of substandard care was unknown; and was therefore estimated at 50% with an absolute precision of 5%.…”

“…Patients with obstructed labor and fetal distress were conveniently sampled by selecting eligible participants until the required sample size was reached. The sample size of studied patients with obstructed labor and fetal distress were predetermined from the previously published studies . Participants with both obstructed labor and fetal distress were included in the obstructed labor group.…”

“…Inadequate emergency obstetric and neonatal care (EmONC) during delivery and within the first 48 hours after delivery is an appreciable contributor to substandard care in both rural and urban health facilities in Tanzania . Other factors include non‐evidence‐based obstetric practice, limited skills and use of vacuum extraction, poor organization and teamwork among staff during care, and substandard management before cesarean delivery …”