Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion‐based audit at two Tanzanian rural hospitals

Abstract

Objective To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour.Design A quality assurance analysis of a retrospective criterionbased audit supplemented by in-depth interviews with hospital staff.Setting Two Tanzanian rural mission hospitals.Population Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed.Methods Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings.Main outcome measures Prevalence of suboptimal management and themes emerging from an analysis of the transcripts.Results Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. ConclusionThe lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.

Maternal near-miss and death and their association with caesarean section complications: a cross-sectional study at a university hospital and a regional hospital in Tanzania

“…MNM and deaths attributed to CS complications are especially worrying in the light of rapidly rising CS rates in many low-income countries [12, 15, 17, 27]. Reports that CSs are performed on non-medical indications [27, 28] and among low-risk groups [15] raise concerns about unnecessary morbidity and mortality after CS. Our estimate of the risk of death due to CS complications (between 1.0 and 4.7 per 1,000 operations) compared to a study from the US (0.0087 per 1,000 operations) [20] illustrates the danger CS might constitute in low-resource settings [13].…”

Utility of the Robson Ten Group Classification System to determine appropriateness of caesarean section at a rural regional hospital in KwaZulu-Natal, South Africa

“…A study from Tanzania revealed that many CSs were done on the basis of reliance on the CTG alone to diagnose fetal distress, without ready availability of invasive techniques such as fetal scalp pH and lactate levels to limit false-positive diagnoses. [13] There is also a risk that the habit of easy resort to CS, especially in low-resource settings, may act as a barrier to other more effective improvements in obstetric care. [13] Our results confirm that use of the RTGCS is feasible for auditing CS rates in a rural regional health facility and results in findings different to those in an urban setting, potentially leading to target setting relevant to the local population.…”

“…[13] There is also a risk that the habit of easy resort to CS, especially in low-resource settings, may act as a barrier to other more effective improvements in obstetric care. [13] Our results confirm that use of the RTGCS is feasible for auditing CS rates in a rural regional health facility and results in findings different to those in an urban setting, potentially leading to target setting relevant to the local population. This work should encourage local rural health authorities to adopt the RTGCS in an endeavour to reduce high CS rates and improve child and maternal outcomes.…”

Safety concerns for caesarean section

“…But facility-based rates have increased at a worrying pace over the past decade, very often on dubious or even plainly wrong indications. 2 Nowadays, in many hospitals caesarean section will be performed for 'obstructed labour' even with intact membranes. Inefficient uterine action in primigravid women is seldom treated with oxytocin augmentation, and instrumental vaginal delivery in the second stage of labour has become almost non-existent.…”

“…We also advocate for cost-effective models that would make caesarean section readily available and safe. 2 The reluctance of women to have repeat caesarean section is down to several factors, ranging from previous experiences, poor outcomes attributed to the primary surgery, ignorance, unfounded fear, lack of confidence in the healthcare system, and high cost of the operation. Efforts should therefore be made to inform women on the implication of a previous scar and resources availed to boost their confidence in the health systems, rather than assuming 'that is how they are'.…”