title: 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.
  
  
  METHODS
  A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff.
  
  
  METHODS
  Two Tanzanian rural mission hospitals.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of International Health, Immunology, and Microbiology, University of Copenhagen, Copenhagen, Denmark. nanna_maal@hotmail.com
authors.forename: N
authors.initials: N
authors.lastname: Maaløe
authors.forename: B L
authors.initials: BL
authors.lastname: Sorensen
authors.forename: R
authors.initials: R
authors.lastname: Onesmo
authors.forename: N J
authors.initials: NJ
authors.lastname: Secher
authors.forename: I C
authors.initials: IC
authors.lastname: Bygbjerg
mesh_terms: D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D004630:Emergencies; D004638:Emergency Treatment / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006780:Hospitals, Rural / Q000706:statistics & numerical data; D006801:Humans; D008485:Medical Audit; D008880:Midwifery; D007744:Obstetric Labor Complications / Q000601:surgery*; D011247:Pregnancy; D011785:Quality Assurance, Health Care; D013636:Tanzania; D000078329:Workforce; D055815:Young Adult