Disclosing suboptimal indications for emergency caesarean sections due to fetal distress and prolonged labor: a multicenter cross-sectional study at 12 public hospitals in Nepal

Helena Litorp,Mats Målqvist,Rejina Gurung,Ashish Kc

doi:10.1186/s12978-020-01039-x

Abstract

BackgroundGlobal caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings. We sought to assess management and outcomes of deliveries with emergency CSs due to fetal distress and prolonged labor at 12 public hospitals in Nepal and determine factors associated with suboptimal CS indications.MethodsWe conducted a cross-sectional study on all deliveries between the 14th of April 2017 and the 17th of October 2018 at 12 public hospitals in Nepal and included all emergency CSs due to fetal distress and prolonged labor. Analysis was conducted using Pearson chi-square test and bivariate and multivariate logistic regression.ResultsThe total cohort included 104,322 deliveries of which 18,964 (18%) were CSs (13,095 [13%] emergency CSs and 5230 [5.0%] elective CSs). We identified 1806 emergency CSs due to fetal distress and 1322 emergency CSs due to prolonged labor. Among CSs due to fetal distress, only 36% had fetal heart rate monitoring performed according to protocol, and among CSs due to prolonged labor, the partograph was completely filled in only 8.6%. Gestational age < 37 weeks and birth weight < 2500 g were associated with more suboptimal CS indications due to fetal distress (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.1–1.8 and aOR 1.7, 95% CI 1.3–2.2 respectively) than those with gestational age > 37 weeks and birth weight > 2500 g. We found no association between suboptimal CS indications and maternal ethnicity or education level.ConclusionsAs fetal heart rate monitoring and partograph are fundamental to diagnose fetal distress and prolonged labor, the inappropriate monitoring proceeding CS decisions disclosed in our study indicate that CSs were performed on suboptimal indications. We call for improved quality of intrapartum monitoring, enhanced documentation in medical records, and structured auditing of CS indications in order to curb the potentially harmful CS trend.

Highlights

Global caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings
Induction of labour was more common among women who underwent CS due to prolonged labour compared to women who underwent CS due to fetal distress and women in the total cohort
There were no large differences in terms of maternal age, education level, ethnicity, birth weight, and gestational age between women who underwent CS due to fetal distress or prolonged labour and the total cohort

Summary

Introduction

Global caesarean section (CS) rates have raised concern of a potential overuse of the procedure in both high- and low-resource settings. In order to make accurate and timely emergency CS decisions, health care providers need to assess the fetal heart rate and monitor the progress of labour using a partograph [4]. Both fetal heart rate monitoring (FHRM) and partograph have shown potential to decrease perinatal deaths in low-resource settings [15,16,17]. There is no evidence on what intervals FHRM should be performed in order to obtain optimal perinatal outcomes [18, 19], the World Health Organization (WHO) and the International Federation of Gynaecology and Obstetrics recommend that fetal heart rate should be assessed every 15–30 min during the first stage of active labour and every 5 min during the second stage of labour [19, 20]. Despite evidence supporting FHRM and partograph use in low-resource settings, many health care providers in developing countries fail to adhere to these recommendations [11, 24,25,26,27,28]

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