International Journal of Reproduction, Contraception, Obstetrics and Gynecology
Poornima HN et al. Int J Reprod Contracept Obstet Gynecol. 2023 Aug;12(8):2399-2402
www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789
DOI: https://dx.doi.org/10.18203/2320-1770.ijrcog20232279 Original Research Article
New World Health Organization labour care guide in reducing
intrapartum caesarean section rates at tertiary care hospital-Hassan institute of medical sciences, Hassan Poornima H. N., Nayanashree V.*, Premalatha H. L., Nirmala Doreswamy
Department of Obstetrics and Gynaecology, Hassan Institute of Medical Sciences, Hassan, Karnataka, India
Background: The Aim of this study was to assess whether labour monitoring using new WHO LCG will result in reducing intra partum caesarean sections. Methods: A analytical study was conducted from the month of September 2022 to January 2023 among 1735 pregnant women admitted at Hassan institute of Medical Sciences, in active phase of labour (5cm cervical dilatation and above) after obtaining informed consent. Results: In the present study, the New WHO Labour Care guide was plotted for 1735 pregnant women among which 1668 (96%) of the total patients had vaginal delivery, while 67 (4%) of the patients underwent Cesarean Section. Among the patients who underwent Cesarean Section it was found that1082 (94%) of the total Cesarean Sections were in latent phase of labour before plotting of the new WHO Labour care guide whereas only about 67 (6%) of Cesarean Section were conducted in active phase of labour. Among the patients who underwent LSCS in the active phase of labour majority were due to fetal distress 29(43%), 21(31%) due to Cephalopelvic disproportion, 13(20%) due to Non progression of labour and about 4(6%) due to Deep Transverse Arrest Conclusions: Majority of the caesarean sections were conducted in the latent phase of labour. The New WHO Labour Care guide has reduced the occurrence of intrapartum caesarean sections in the active phase of labour. However the overall rate of caesarean section must be controlled by reducing the number of Cesarean Sections conducted in latent phase of labour, that is before plotting the New WHO labour care guide.
Keywords: Labour care guide, Active phase of labour, Caesarean section rate
INTRODUCTION way higher than world health organization's ideal 10-
15%.3 Rise in caesarean section rates worldwide is a Caesarean section rates have been steadily increasing over worrisome trend due to the various complications the past few years all around the world, 12.1% in 2005 to associated with caesarean surgery such as increased blood 21.1% in 2015.1 In India too, the rates of caesarean loss, infections, increased maternal morbidity and deliveries have increased alarmingly, from 8% of mortality. Subsequent pregnancies following caesarean deliveries in 2005 to 17% of deliveries in 2016. 2 The section become high risk pregnancies and pose various National family health survey (NFHS) revealed that the challenges in the form of uterine rupture, adherent national C-section delivery rate stands at 21.5 per cent, placenta, intra-abdominal adhesions, scare dehiscence,
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Poornima HN et al. Int J Reprod Contracept Obstet Gynecol. 2023 Aug;12(8):2399-2402
scar rupture, scar pregnancy, isthmocele. As per WHO, no Statistical analysis
region in the world is justified in having a caesarean section rate of greater than 15%.4 Reducing the incidence Data will be collected and it will be exported to Microsoft of primary caesarean section is the need of the hour to Excel sheet version 16.2. For statistics analysis statistical bring down caesarean section rates over all. software will be used. Results were tabulated using Graphs, pie charts and bar diagrams. Frequencies and The new WHO labour care guide (LCG) was introduced proportions will be calculated in percentages. by WHO in 2015, a labour monitoring tool that can be used in all settings and makes provision for safe and respectful RESULTS labour experience.5 Previously Partograph was most commonly used for labour monitoring tool. The LCG In the present study, the New WHO labour care guide was differs from the Partograph in various aspects. While the plotted for 1735 pregnant women for duration of 5 months partograph recorded the labour from 4 cm cervical and the progress of labour was monitored. dilatation, the LCG considers onset of active labour to be from 5 cm cervical dilatation. Also, the LCG has a column for monitoring of second stage of labour, but the Partograph plotting ends on reaching full cervical dilatation. Shared decision making, provision of labour 4% companion are other important aspects covered in the LCG. Apart from all of these, the major difference between the partograph and the LCG is the time allowed for reaching full cervical dilatation after start of active labour. 96% While the Partograph follows a strict 1cm/hour expected rate of dilatation, LCG provides different alert values at different stages of cervical dilatation until full cervical dilatation is reached. The duration of labour in the active NORMAL DELIVERY CESAREAN SECTION phase of labour according to the old Partograph is 10hours. Whereas the new modified labour care guide partograph has a total duration of 18.5hours, by increasing the duration of 2nd stage of labour by 3hours to promote Figure 1: Outcome of labour following plotting of normal vaginal delivery in a normally progressing labour. WHO new labour care guide.
METHODS 6% Study type, place and duration
Current study was an analytical study conducted at
department of obstetrics and gynaecology, Hassan institute of medical sciences from September 2022 to January 2023.
Inclusion criteria 94%
All women admitted in Labour ward in active phase of
labour (cervical dilatation >5cm), after obtaining consent. Cesarean section in active phase of labour Cesarean Section in latent phase of labour Exclusion criteria
Previous LSCS cases and Non cephalic presentation were Figure 2: Distribution of Cesarean Section in active excluded. and latent phase of labour.
Procedure Out of 1735 patients for which the New WHO labour care guide was plotted, 1668 (96%) patients had vaginal All pregnant women in active phase of labour (>5cm delivery, while 67(4%) of the patients underwent Cesarean cervical dilatation) were considered as study subjects. Section (Figure 1). On comparing the rates of Cesarean Labour progress was monitored and plotted on the New Section, it was found that 1082 (94%) of the total Cesarean WHO labour care guide. Outcomes of labour, incidence of Section were done before the plotting of New WHO intra partum caesarean section rates and the reasons for Labour Care guide i.e. before the onset of active phase of caesarean section after the onset of active phase were labour and only about 67 (6%) of Cesarean Section were studied and analysed. done following the plotting of New WHO labour care guide i.e after the onset of active phase of labour (Figure
International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume 12 · Issue 8 Page 2400 Poornima HN et al. Int J Reprod Contracept Obstet Gynecol. 2023 Aug;12(8):2399-2402
2). Among the patients who underwent Cesarean Section monitored by the new WHO Labour Care guide.9 The in the active phase of labour, 29 (43%) were due to fetal incidence of caesarean section in active phase of labour distress, 21 (31%) due to Cephalopelvic disproportion, 13 due to arrest of labour was about 20% in our study (20%) due to Non progression of labour and about 4 (6%) compared to 1.7% in a study by Anna et al.10 This could be due to deep transverse arrest (Figure 3). due to a smaller size in our study compared to the study by Anna et al, Vogel et al in his study concluded that women who were admitted for antepartum caesarean section do FETAL DISTRESS not experience labour, and therefore do not require a LCG NON PROGRESION OF LABOUR as part of their care and hence anticipation of effectiveness CPD of labour care guide in reducing antepartum caesarean DTA 6% rates was not possible.11 This was similar to our study where we observed that a maximum (94%) of caesarean sections occurred in latent phase of labour before plotting 31% 43% of the new WHO Labour care guide, necessitating to reduce the number of caesarean sections conducted before the onset of active phase of labour, and thereby decreasing the caesarean section rates. However, there are hardly any 20% studies determining the rates of intrapartum caesarean section after monitoring using the new WHO Labour Care Guide for comparison with our present study which Figure 3: Indications for cesarean section following necessitates further need for studies. As said by Ghulaxe LCG. et al Labour Care guide has evolved to motivate best practices with proof-based, compassionate care during Table 1: Indications for cesarean section following delivery, which add advancement of excellent, considerate LCG. care for all women, new mothers, and their families.12,13 Indication N % Limitations Fetal distress 29 43 Non progresion of labour 13 20 Limitations of current study were that this study was CPD 21 31 conducted to study the effectiveness of the new WHO DTA 4 6 Labour Care guide in reducing the intrapartum caesarean rates. However, we did not compare the results with that DISCUSSION of the conventional simplified WHO partogram. This comparison would have helped us in weighing the benefits Over 140 million women give birth each year worldwide and disadvantages of the new WHO Labour care guide and and the proportion of births attended by skilled health simplified partogram. personnel is steadily increasing.6 To facilitate effective implementation of the WHO recommendations on CONCLUSION intrapartum care, the new WHO Labour care guide was designed. The LCG was designed for health personnel to monitor the well-being of women and babies during labour In the present-day obstetric practice, caesarean sections are through regular assessments to identify any deviation from on a higher trend. It is necessary for proper monitoring of normality. The new WHO Labour Care Guide seems to be normal labour using the New WHO Labour care guide to a more robust tool that covers the first stage active phase know the progress of labour. In our study it was found that and second stage of labor in a multifaceted way. The LCG the number of caesarean sections in the latent phase of is intended as a resource to ensure quality evidence-based labour were more compared to the caesarean section care, with a special emphasis on ensuring safety, avoiding conducted in active phase of labour. It is the need of the unnecessary interventions, and providing supportive care.5 hour to analyse the indication for caesarean section in Special attention is given to monitor and avoid prolonged latent phase of labour so that caesarean section rate can be labor, unnecessary oxytocin augmentation and caesarean brought down. deliveries. The LCG mainly focuses on clinical parameters rather than parameters obtained from USG.7 As published Funding: No funding sources by Vogel et al this LCG might possibly revolutionize labor Conflict of interest: None declared monitoring in a woman-centered manner with shared Ethical approval: The study was approved by the decision making.8 Institutional Ethics Committee
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