Abstract
BackgroundProlonged second stage of labour is a major cause of perinatal and maternal morbidity and mortality in low-income countries. Vacuum extraction is a proven effective intervention, hardly used in Africa. Many authors and organisations recommend (re)introduction of vacuum extraction, but successful implementation has not been reported. In 2012, a program to increase the use of vacuum extraction was implemented in Mulago Hospital, Uganda. The program consisted of development of a vacuum extraction guideline, supply of equipment and training of staff. The objective of this study was to investigate the impact of the program.MethodsAudit of a quality improvement intervention with before and after measurement of outcome parameters. Setting: Mulago Hospital, the national referral hospital for Uganda with approximately 33 000 deliveries per year. It is the university teaching hospital for Makerere University and most of the countries doctors and midwives are trained here. Data was collected from hospital registers and medical files for a period of two years. Main outcome measures were vacuum extraction rate, intrapartum stillbirth, neonatal death, uterine rupture, maternal death and decision to delivery interval.ResultsMode of delivery and outcome of 12 143 deliveries before and 34 894 deliveries after implementation of the program were analysed. The vacuum extraction rate increased from 0.6 – 2.4 % of deliveries (p < 0.01) and was still rising after 18 months. There was a decline in intrapartum stillbirths from 34 to 26 per 1000 births (-23.6 %, p < 0.01) and women with uterine rupture from 1.1 – 0.8 per 100 births (-25.5 %, p < 0.01). Decision to delivery interval for vacuum extraction was four hours shorter than for caesarean section.ConclusionsA program to increase the use of vacuum extraction was successful in a high-volume university hospital in sub-Saharan Africa. The use of vacuum extraction increased. An association with improved maternal and perinatal outcome is strongly suggested. We recommend broad implementation of vacuum extraction, whereby university hospitals like Mulago Hospital can play an important role.To support implementation, we recommend further research into outcome of vacuum extraction and into vacuum extraction devices for low-income countries. Such studies are now in progress at Mulago Hospital.
Highlights
Prolonged second stage of labour is a major cause of perinatal and maternal morbidity and mortality in low-income countries
In the first six months after implementation vacuum extraction was used in 1.9 %, in the six months 2.1 % and the last six months 2.4 % of deliveries
In the 18 months after implementation 805 vacuum extractions were performed with 63 failures (8.5 %)
Summary
Prolonged second stage of labour is a major cause of perinatal and maternal morbidity and mortality in low-income countries. Vacuum extraction is one of the evidence-based interventions that can prevent complications by shortening the second stage of labour [8,9,10,11]. It prevents women from having a caesarean section with its increased risk of maternal and perinatal morbidity and mortality in the index and subsequent pregnancies compared to (assisted) vaginal delivery [12,13,14,15]. The objective of this study was to investigate the impact of the program
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