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

OBJECTIVE: To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour.
DESIGN: A quality assurance analysis of a retrospective criterion-based 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.
CONCLUSION: The 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.