Management of prolonged first stage of labour in a low-resource setting: lessons learnt from rural Malawi

Wouter Bakker,Jos Van Roosmalen,Thomas Van Den Akker,Elisabeth Van Dorp,Alfred Nkotola,Misheck Kazembe

doi:10.1186/s12884-021-03856-9

Wouter Bakker, Jos Van Roosmalen + Show 4 more

Open Access

https://doi.org/10.1186/s12884-021-03856-9

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Abstract

BackgroundCaesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi.MethodsRetrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation.ResultsOut of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolonged first stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour.ConclusionThe diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused.

Highlights

Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, in low-income countries where surgery is often less safe
A considerable number of women arrived in the second stage (566, 16.5%), of whom 39 (6.9%) were referred from other health facilities
Fiftytwo women only had a documented prolonged second stage of labour and were left out of further analysis, along with 135 (5.5%) women for whom it was unclear whether the action line was crossed

Summary

Introduction

Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, in low-income countries where surgery is often less safe. There has been a substantial increase in births by caesarean section, as described in the latest Lancet series on optimizing caesarean section use [1,2,3] While this increase is most alarming in regions such as LatinAmerica and the Middle-East, there was an increase in sub-Saharan Africa [1, 4]. This increase at population level is seen by some as a welcome development, since it may indicate improved access to caesarean section in rural areas where women were previously unable to access comprehensive emergency obstetric care [5, 6]. The authors suggest that overuse of caesarean sections may result from lack of clinical experience and skills among maternity caregivers and fear of litigation [3]

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