".".'"'", 1~ Longman (;rllUl~ UK I,td 1992
Midwifery
Obstructed labour: its contribution to maternal mortality Barbara E Kwast
E v e r y y e a r 85,000 w o m e n die f r o m o b s t r u c t e d l a b o u r a n d m a n y m a n y m o r e lose their b a b y a n d h a v e d e b i l i t a t i n g physical d a m a g e as a result. I n this p a p e r the e x t e n t o f t h e p r o b l e m is d e s c r i b e d . M e t h o d s by w h i c h o b s t r u c t e d l a b o u r c a n b e p r e v e n t e d a r e given. E a r l y d e t e c t i o n a n d p r o m p t r e f e r r a l f o r a p p r o p r i a t e t r e a t m e n t a r e vital if d a m a g e is to be m i n i m i s e d . T h i s r e q u i r e s p a r t i c u l a r a t t e n t i o n in m i d w i f e r y e d u c a t i o n w h i c h m u s t i n c l u d e c o m m u n i t y e x p e r i e n c e w h i c h fosters d i a l o g u e a n d s t r e n g t h e n s p r e v e n t i o n . T h i s p a p e r is b a s e d o n o n e originally g i v e n at t h e I C M / W H O / U N I C E F p r e - c o n g r e s s w o r k s h o p in K o b e , J a p a n , O c t o b e r 1990.
INTRODUCTION Every year half a million women die in pregnancy and childbirth (see Kwast 1991a). T h e major obstetric causes are haemorrhage, sepsis, pregnancy induced hypertension (eclampsia), obstructed labour and illicit induced abortion. T h e contribution haemorrhage, sepsis and pregnancy induced hypertension make to mortality have already been reviewed (Kwast 1991b, 1991c, 1991d, 1992). In this p a p e r the extent of the problem of obstructed labour in relation to maternal mortality is reviewed. Factors contributing to maternal mortality are identified.
THE MAGNITUDE Obstructed labour is a most dangerous complication in obstetrics and claims an average of 17% Barbara E Kwast MComm H, PhD, SCM, MTD, Women's Health Advisor, Mothercare, John Snow Inc., 1616 N Fort Myer Drive, Arlington, Virginia 22209, USA. Correspondence and requests for offprints to BEK
of all maternal deaths (Kwast, 1989). This means that 85,000 lives are lost due to this cause annually and, if nothing is done, one million lives will be lost due to obstructed labour between now and the turn of the century. Data on mortality from obstructed labour are not complete, probably because many of these deaths may be classified under sepsis, postpartum haemorrhage and obstetric shock. Deaths from ruptured uterus must in the majority have resulted from neglected obstructed labour. In Karawa, Zaire, twenty maternal deaths were described over a 2-year period from 19811983 (Smith et al, 1986). Sixteen of these women (18%) had been in labour for more than 18 h and 9 (48%) for more than 40h: Prolonged labour resulted in 14 cases of uterine rupture, which increased the risk of death more than a 100-fold. O f 48,974 deliveries f r o m 1982 to 1986 in the Ilorin University Teaching Hospital in Nigeria, 1992 were by caesarean section (Ojo et al, 1988). Obstructed labour was the single most important indication fi)r caesarean section. Obstructed labour was the most likely factor to lead to maternal sepsis, which was responsible for 82% of the maternal deaths (Ojo et al, 1988).
4
MIDWIFERY
These numbers do not even reflect the countless number of women who did not die, but lost their child in the process and are left with the most debilitating condition which is vesico-vaginal fistula (VVF). Obstetric fistula is the most disabling of all pregnancy complications and is common in certain well-defined geographical regions in Africa and parts of" the Indian subcontinent, e.g. Nepal, Bangladesh and Pakistan (WHO, 1989a). There are reports of obstetric fistula from several Eastern Mediterranean countries such as Iran and Turkey as well as from Ecuador in South America (WHO, 1989a). Some hospitals situated in areas where VVF is common report hundreds of women waiting for fistula repair (Tahzib, 1988). The Fistula Hospital in Addis Ababa handles about 700 cases a year and has done so for over 20 years (Kelly, 1983). A survey conducted in Northern Nigeria of 1443 patients operated on for vesico-vaginal fistulae revealed that prolonged labour was responsible for 84% of the fistulae (Tahzib, 1983). Only 6% of these women had been delivered in the referral hospital; 64% had been delivered at home and 30% delivered in the health centre. Thirty-three per cent of these women were under 16 years of age, and 52% were primiparous. The younger women usually had more severe lesions and a greater amount of fibrosis in the vagina (Tahzib, 1983). Obstructed labour is due to mechanical factors, not to disturbances of uterine physiology. An important distinction because mechanical factors can be anticipated whereas primary disorders of uterine action usually cannot. These mechanical factors are in the main due to abnormal feto-pelvic relationships. They often cause prolongation of labour, bu t labour is only truly obstructed when further progress is impossible without assistance (Lawson, 1967).
FACTORS A F F E C T I N G PREVALENCE Medical causes The commonest cause of obstruction is cephalopelvic disproportion (CDP) due to pelvic con-
traction. This usually results from stunted growth of women by malnutrition and untreated infection in childhood and adolescence. Another reason for contracted pelvis may be too early a start in childbearing, soon after the menarche and before the growth of the pelvis is complete. In certain areas where osteomalacia is endemic it may produce secondary pelvic deformities in women who have had successful previous deliveries. The Zaria study showed that the youngest and shortest primiparae both had the highest prevalence of contracted pelvis, were at greatest risk of developing CPD and of requiring delivery by caesarean section or embryotomy if the fetus was dead (Harrison et al, 1985). With increasing maternal age and height, the rates of these three pregnancy complications fell. The tallest women, irrespective of their age and Prenatal care status, rarely had contracted pelvis or CPD. However, there was also one point of real interest in that early teenage girls who were under 1.60m in height had less risk of CPD if they received antental care with nutritional supplements and malaria prophylaxis, and hence produced bigger babies (Harrison et al, 1985). Another important cause of obstructed labour may be malpresentations which occur more frequently in parous women. Occasionally, soft tissue abnormalities or an abnormal fetus may cause obstructed labour.
Cultural causes There are cultural reasons for early marriage, non-utilisation of the formal health care system and keeping women at home for days in labour. In some settings, if labour is prolonged, this may be a sign of unfaithfulness during pregnancy and only spontaneous childbirth will prove the contrary. In other settings, traditional healers have to be consulted for the reason for delay. Traditional practices, such as premature expulsire efforts, have unfavourable effects on both mother and fetus. Several studies in East Africa tell of the use of traditional medicines, which have oxytocic
MIDWIFERY
properties, for women in prolonged labour with resulting rupture of" uterus (Keller, 1987; Lawson, 1967). Remedies may also be applied rectally or externally and in some circumstances abdominal massage or internal manipulations may be applied. A small community survey o f fathers, mothers and grandmothers of different families conducted during a district team problem solving workshop in Malawi in 1987 revealed that there was no concept of risk factors related to obstructed labour (WHO, 1988). During that same workshop, women leaving the antenatal clinic were re-interviewed and asked whether the woman's choice of place for delivery was discussed with her and 64% responded negatively, even if they had had risk factors for obstructed labour identified.
Health service factors Estimates of coverage of maternity care in 1988 show that only 52% of births are attended by a trained birth attendant in developing countries compared to 99% in developed countries (WHO, 1989b). This figure is 38% for Africa, 49% for Asia and 86% for Latin America. These estimates include deliveries by trained traditional birth attendants where they exist. There are now a number of confidential enquiries or medical audits available which highlight avoidable factors in maternal deaths. In almost all of these reports avoidable factors were present in 80% to 90% of cases (Mtimavalye et al, 1980; Chi et al, 1981; Walker et al, 1986; Keller 1987; Kwast et al, 1989). While one study clearly states that the ability of health care providers to use obstetric interventions is limited when women arrive in poor condition, other avoidable tactors included lack of attention to risk tactors (33%) (Price, 1984). Difficulty in obtaining blood transfusion is mentioned, due to supply, equipment and personnel shortages (Mtimavalye et al, 1980; Chi et al, 1981; Frost, 1984; Justesen, 1985; Walker et al, 1986; Keller et al, 1987; Ojo et al, 1988; Kwast et al, 1989). Non-use of the partograph in labour (18%) of those delivering in hospital is stated as a contributory factor in maternal mortality due to
5
obstructed labour (Price, 1984). Detailed analysis of deaths following dystocia or prolonged labour (20% of total maternal deaths) revealed that maternal deaths were twice as high in hospitals with a low rate o f partograph use as in those with a 50% use rate. Staff factors, errors of judgement, lack o f expertise and omission of essential tasks contributed to 10% of the mortality. Sixty-four per cent of the maternal deaths outside the hospital were due to failure to act on risk factors at the village (38%), health centre (15%), or dispensary (11%). Delay in referral and transportation problems accounted for another 15% of maternal deaths outside the hospital.
PROBLEMS RELATED TO MIDWIFERY EDUCATION If maternal mortality due to obstructed labour is to be reduced midwives have to be educated in its early detection so that appropriate referral can be made. This education should include the following: 1. An understanding of the need to know the provision for maternity care in their area. 2. An understanding of the need to know the patterns of childbearing in their community, e.g. is childbearing among very young women common? 3. The importance of surveying the health status of their community, e.g. how many short women are under nourished? Is malaria endemic and what is the incidence of anaemia? 4. The importance of knowing about the belief systems relative to labour and childbirth in their community and do they know the practices of the TBAs? Are TBAs, or fi)r that matter trained health workers or midwives, acceptable to attend women in labour? (Where childbirth is associated with pollution, practices may differ considerably from what we think they are (Levitt et al, 1987). 5. The need to anticipate conditions which predispose to obstructed labour both
6
MIDWIFERY
d u r i n g p r e g n a n c y a n d in the course of labour. Midwives m u s t be able to p e r f o r m pelvic assessment confidently a n d m u s t be able to use a p a r t o g r a p h . Midwives m u s t be able to participate in e m e r g e n c y resuscitation o f a w o m a n in obstructed labour, e.g. c o m m e n c e intravenous therapy, empty the bladder, c o m m e n c e i n t r a m u s c u l a r or i n t r a v e n o u s therapy, e m p t y the stomach t h r o u g h a gastric tube before a g e n e r a l anaesthetic is i n d u c e d . It is vital that the necessary regulatory m e c h a n i s m s are in place so that midwives can a d m i n i s t e r these life-saving therapies. Midwives m u s t be able to give the necessary health e d u c a t i o n to the w o m a n a n d h e r family in the event of an o b s t r u c t e d l a b o u r or a r u p t u r e d uterus. T h e w o m a n must be told why she h a d an o p e r a t i o n in a n a t t e m p t to help her p r e v e n t disaster n e x t time. Midwives must be able to give effective contraceptive advice so that the w o m a n can be helped to space her n e x t p r e g n a n c y .
References
Chi I, Agoestina T, H a r b i n J 1981 Maternal mortality in twelve teaching hospitals in Indonesia; an epidemiological analysis. International ,Journal of Gynaecology & Obstetrics 19:259 Frost O 1984 Maternal and perinatal deaths in an Addis 7. Ababa hospital. Ethiopian Medical Journal 22: 143146 Harrison K A, Rossiter C E, Chong H 1985 Relations between maternal height, fetal birthweight and cephalopelvic disproportion suggest that young Nigerian primigravidae grow during pregnancy. In: Harrison K A ted) Childbearing, Health and Social Priorities. British Journal of Obstetrics & Gynaecology, 92 Suppl 5 : 4 0 - 4 8 Justesen A 1985 An analysis of maternal mortality in Muhimbili Medical Centre, D a r e s Salaam, July 1983 to J u n e 1984. ,Journal of Obstetrics & Gynaecology of East and Central Africa 4 : 5 - 8 Keller M E 1987 Maternal mortality at Kamuzu Central Hospital for 1985. Medical Quarterly, Journal of the 8. Medical Association of Malawi 4(i): 13 16 KellyJ 1983 Vesico-vaginal fistulae In Studd J ted) Progress in obstetrics and gynaecology. Churchill Livingstone, London Kwast B E 1989 Maternal mortality: levels, causes, and promising interventions. Journal of Biosociology, Suppl 10:51-67 Kwast B E 1991a Maternal mortality: the magnitude and the causes. Midwifery 7 (1): 4 7 9. Kwast B E 1991 b Postpartum haemorrhage: its contribution to maternal m()rtality. Midwifery 7 (2): 64-70 Kwast B E 1991c Puerperal sepsis: its contribution to maternal mortality. Midwifery 7 (3): 102-105 Kwast B E 1991d The hypertensive disorders of pregnancy: their contribution to maternal mortality. Midwifery 7 (4): 155-161 Kwast B E 1992 Abortion: its contribution to maternal mortality. Midwifery 8 (1): 8-11 CONCLUSION Kwast B E, Bekele M, Yoseph S e t al 1989 Confidential enquires into Maternal deaths in Addis Ababa, T h e total n u m b e r o f w o m e n who die f¥om Ethiopia 1981-1983. ,Journal of Obstetrics & Gynaecology of Eastern & Central Africa 8: 75-82. obstructed l a b o u r is n o t k n o w n as f r e q u e n t l y death is a t t r i b u t e d to o t h e r causes. H o w e v e r it is Lawson J B 1967 Obstructed labour. In: Lawson J B & Stewart D B (eds) Obstetrics and Gynaecology in the k n o w n that every year 85,000 w o m e n die from Tropics. Edward Arnold, London obstructed labour_ Its cause is a mechanical Levitt M J, Shrestha K R, McGinn E et al 1987 Influence of the formal training on knowledge, failure, there is a lack o f fit b e t w e e n the fetus a n d attitude and practices of TBAs in Nepal. Paper m a t e r n a l pelvis. O b s t r u c t e d l a b o u r is most presented at National Counol for International Health (NCIH) 1987. Annual International Health c o m m o n in the y o u n g teenager, a n d the w o m a n Conference, Washington DC, J u n e 15th Unpublished of short stature d u e to u n d e r - n o u r i s h m e n t . As paper, NCIH, 1701 K Street NW, Washington DC with o t h e r causes of m a t e r n a l mortality poor 20006, USA. Ojo V A, Adetoro O O, Okwerekwu, D E O 1988 socio-economic status are c o n t r i b u t o r y factors. Characteristics of maternal deaths t~)llowing I f m a t e r n a l mortality f r o m o b s t r u c t e d l a b o u r is caesarean section in a developing country. to be r e d u c e d midwives m u s t be e d u c a t e d to International,Journal of Gynaecology & Obstetrics 27: 171-176 detect the c o n d i t i o n p r o m p t l y a n d seek the a p p r o p r i a t e aid. Midwives m u s t also be taught Price T G 1984 Preliminary Report on maternal deaths in the South Highlands of Tanzania in 1983. Journal a n d be c o n f i d e n t to provide the necessary resusof Obstetrics and Gynaecology of East and Central Africa 3 (103): 163-110 citative therapies.
6.
MII)WI FERY Rendle-Short C W 1961 Causes of maternal deaths among Africans in Kampala. Journal of Obstetrics and Gynaecology of the British Commonwealth 68: 44 Smith J B, Burton N F, Nelson G e t al 1986 Hospital deaths in a high risk obstetric population: Karawa, Zaire. International Journal o f Gynaecology & Obstetrics 24 (3): 225-234 Tahzib F 1983 Epidemiological determinants of vesicovaginal fistulas. British .Journal of Obstetrics and Gynaecology 90:387-391 Tahzib F 1988 What of those injured mothers who do not die? Obstetric fistulae - a cause for concern.
7
Sokoto, In Obstetric fistulae, a review of available infbrmation. Document WHO/MCH/MSM/91.5, WHO, Geneva World Health Organization 1988 District Team Problem Solving, report o f a workshop, Liwonde, Malawi, 21-30 October, 1987. Document FHE 87.8, WHO, Geneva World Health Organization 1989a The prevention and treatment of obstetric fistulae. Document WHO/FHE/ 89.5, WHO, Geneva World Health Organization 1989b Coverage of maternity care. Document WHO/FHE/89.2, WHO, Geneva
Midwifery
Obstructed labour: its contribution to maternal mortality Barbara E Kwast
E v e r y y e a r 85,000 w o m e n die f r o m o b s t r u c t e d l a b o u r a n d m a n y m a n y m o r e lose their b a b y a n d h a v e d e b i l i t a t i n g physical d a m a g e as a result. I n this p a p e r the e x t e n t o f t h e p r o b l e m is d e s c r i b e d . M e t h o d s by w h i c h o b s t r u c t e d l a b o u r c a n b e p r e v e n t e d a r e given. E a r l y d e t e c t i o n a n d p r o m p t r e f e r r a l f o r a p p r o p r i a t e t r e a t m e n t a r e vital if d a m a g e is to be m i n i m i s e d . T h i s r e q u i r e s p a r t i c u l a r a t t e n t i o n in m i d w i f e r y e d u c a t i o n w h i c h m u s t i n c l u d e c o m m u n i t y e x p e r i e n c e w h i c h fosters d i a l o g u e a n d s t r e n g t h e n s p r e v e n t i o n . T h i s p a p e r is b a s e d o n o n e originally g i v e n at t h e I C M / W H O / U N I C E F p r e - c o n g r e s s w o r k s h o p in K o b e , J a p a n , O c t o b e r 1990.
INTRODUCTION Every year half a million women die in pregnancy and childbirth (see Kwast 1991a). T h e major obstetric causes are haemorrhage, sepsis, pregnancy induced hypertension (eclampsia), obstructed labour and illicit induced abortion. T h e contribution haemorrhage, sepsis and pregnancy induced hypertension make to mortality have already been reviewed (Kwast 1991b, 1991c, 1991d, 1992). In this p a p e r the extent of the problem of obstructed labour in relation to maternal mortality is reviewed. Factors contributing to maternal mortality are identified.
THE MAGNITUDE Obstructed labour is a most dangerous complication in obstetrics and claims an average of 17% Barbara E Kwast MComm H, PhD, SCM, MTD, Women's Health Advisor, Mothercare, John Snow Inc., 1616 N Fort Myer Drive, Arlington, Virginia 22209, USA. Correspondence and requests for offprints to BEK
of all maternal deaths (Kwast, 1989). This means that 85,000 lives are lost due to this cause annually and, if nothing is done, one million lives will be lost due to obstructed labour between now and the turn of the century. Data on mortality from obstructed labour are not complete, probably because many of these deaths may be classified under sepsis, postpartum haemorrhage and obstetric shock. Deaths from ruptured uterus must in the majority have resulted from neglected obstructed labour. In Karawa, Zaire, twenty maternal deaths were described over a 2-year period from 19811983 (Smith et al, 1986). Sixteen of these women (18%) had been in labour for more than 18 h and 9 (48%) for more than 40h: Prolonged labour resulted in 14 cases of uterine rupture, which increased the risk of death more than a 100-fold. O f 48,974 deliveries f r o m 1982 to 1986 in the Ilorin University Teaching Hospital in Nigeria, 1992 were by caesarean section (Ojo et al, 1988). Obstructed labour was the single most important indication fi)r caesarean section. Obstructed labour was the most likely factor to lead to maternal sepsis, which was responsible for 82% of the maternal deaths (Ojo et al, 1988).
4
MIDWIFERY
These numbers do not even reflect the countless number of women who did not die, but lost their child in the process and are left with the most debilitating condition which is vesico-vaginal fistula (VVF). Obstetric fistula is the most disabling of all pregnancy complications and is common in certain well-defined geographical regions in Africa and parts of" the Indian subcontinent, e.g. Nepal, Bangladesh and Pakistan (WHO, 1989a). There are reports of obstetric fistula from several Eastern Mediterranean countries such as Iran and Turkey as well as from Ecuador in South America (WHO, 1989a). Some hospitals situated in areas where VVF is common report hundreds of women waiting for fistula repair (Tahzib, 1988). The Fistula Hospital in Addis Ababa handles about 700 cases a year and has done so for over 20 years (Kelly, 1983). A survey conducted in Northern Nigeria of 1443 patients operated on for vesico-vaginal fistulae revealed that prolonged labour was responsible for 84% of the fistulae (Tahzib, 1983). Only 6% of these women had been delivered in the referral hospital; 64% had been delivered at home and 30% delivered in the health centre. Thirty-three per cent of these women were under 16 years of age, and 52% were primiparous. The younger women usually had more severe lesions and a greater amount of fibrosis in the vagina (Tahzib, 1983). Obstructed labour is due to mechanical factors, not to disturbances of uterine physiology. An important distinction because mechanical factors can be anticipated whereas primary disorders of uterine action usually cannot. These mechanical factors are in the main due to abnormal feto-pelvic relationships. They often cause prolongation of labour, bu t labour is only truly obstructed when further progress is impossible without assistance (Lawson, 1967).
FACTORS A F F E C T I N G PREVALENCE Medical causes The commonest cause of obstruction is cephalopelvic disproportion (CDP) due to pelvic con-
traction. This usually results from stunted growth of women by malnutrition and untreated infection in childhood and adolescence. Another reason for contracted pelvis may be too early a start in childbearing, soon after the menarche and before the growth of the pelvis is complete. In certain areas where osteomalacia is endemic it may produce secondary pelvic deformities in women who have had successful previous deliveries. The Zaria study showed that the youngest and shortest primiparae both had the highest prevalence of contracted pelvis, were at greatest risk of developing CPD and of requiring delivery by caesarean section or embryotomy if the fetus was dead (Harrison et al, 1985). With increasing maternal age and height, the rates of these three pregnancy complications fell. The tallest women, irrespective of their age and Prenatal care status, rarely had contracted pelvis or CPD. However, there was also one point of real interest in that early teenage girls who were under 1.60m in height had less risk of CPD if they received antental care with nutritional supplements and malaria prophylaxis, and hence produced bigger babies (Harrison et al, 1985). Another important cause of obstructed labour may be malpresentations which occur more frequently in parous women. Occasionally, soft tissue abnormalities or an abnormal fetus may cause obstructed labour.
Cultural causes There are cultural reasons for early marriage, non-utilisation of the formal health care system and keeping women at home for days in labour. In some settings, if labour is prolonged, this may be a sign of unfaithfulness during pregnancy and only spontaneous childbirth will prove the contrary. In other settings, traditional healers have to be consulted for the reason for delay. Traditional practices, such as premature expulsire efforts, have unfavourable effects on both mother and fetus. Several studies in East Africa tell of the use of traditional medicines, which have oxytocic
MIDWIFERY
properties, for women in prolonged labour with resulting rupture of" uterus (Keller, 1987; Lawson, 1967). Remedies may also be applied rectally or externally and in some circumstances abdominal massage or internal manipulations may be applied. A small community survey o f fathers, mothers and grandmothers of different families conducted during a district team problem solving workshop in Malawi in 1987 revealed that there was no concept of risk factors related to obstructed labour (WHO, 1988). During that same workshop, women leaving the antenatal clinic were re-interviewed and asked whether the woman's choice of place for delivery was discussed with her and 64% responded negatively, even if they had had risk factors for obstructed labour identified.
Health service factors Estimates of coverage of maternity care in 1988 show that only 52% of births are attended by a trained birth attendant in developing countries compared to 99% in developed countries (WHO, 1989b). This figure is 38% for Africa, 49% for Asia and 86% for Latin America. These estimates include deliveries by trained traditional birth attendants where they exist. There are now a number of confidential enquiries or medical audits available which highlight avoidable factors in maternal deaths. In almost all of these reports avoidable factors were present in 80% to 90% of cases (Mtimavalye et al, 1980; Chi et al, 1981; Walker et al, 1986; Keller 1987; Kwast et al, 1989). While one study clearly states that the ability of health care providers to use obstetric interventions is limited when women arrive in poor condition, other avoidable tactors included lack of attention to risk tactors (33%) (Price, 1984). Difficulty in obtaining blood transfusion is mentioned, due to supply, equipment and personnel shortages (Mtimavalye et al, 1980; Chi et al, 1981; Frost, 1984; Justesen, 1985; Walker et al, 1986; Keller et al, 1987; Ojo et al, 1988; Kwast et al, 1989). Non-use of the partograph in labour (18%) of those delivering in hospital is stated as a contributory factor in maternal mortality due to
5
obstructed labour (Price, 1984). Detailed analysis of deaths following dystocia or prolonged labour (20% of total maternal deaths) revealed that maternal deaths were twice as high in hospitals with a low rate o f partograph use as in those with a 50% use rate. Staff factors, errors of judgement, lack o f expertise and omission of essential tasks contributed to 10% of the mortality. Sixty-four per cent of the maternal deaths outside the hospital were due to failure to act on risk factors at the village (38%), health centre (15%), or dispensary (11%). Delay in referral and transportation problems accounted for another 15% of maternal deaths outside the hospital.
PROBLEMS RELATED TO MIDWIFERY EDUCATION If maternal mortality due to obstructed labour is to be reduced midwives have to be educated in its early detection so that appropriate referral can be made. This education should include the following: 1. An understanding of the need to know the provision for maternity care in their area. 2. An understanding of the need to know the patterns of childbearing in their community, e.g. is childbearing among very young women common? 3. The importance of surveying the health status of their community, e.g. how many short women are under nourished? Is malaria endemic and what is the incidence of anaemia? 4. The importance of knowing about the belief systems relative to labour and childbirth in their community and do they know the practices of the TBAs? Are TBAs, or fi)r that matter trained health workers or midwives, acceptable to attend women in labour? (Where childbirth is associated with pollution, practices may differ considerably from what we think they are (Levitt et al, 1987). 5. The need to anticipate conditions which predispose to obstructed labour both
6
MIDWIFERY
d u r i n g p r e g n a n c y a n d in the course of labour. Midwives m u s t be able to p e r f o r m pelvic assessment confidently a n d m u s t be able to use a p a r t o g r a p h . Midwives m u s t be able to participate in e m e r g e n c y resuscitation o f a w o m a n in obstructed labour, e.g. c o m m e n c e intravenous therapy, empty the bladder, c o m m e n c e i n t r a m u s c u l a r or i n t r a v e n o u s therapy, e m p t y the stomach t h r o u g h a gastric tube before a g e n e r a l anaesthetic is i n d u c e d . It is vital that the necessary regulatory m e c h a n i s m s are in place so that midwives can a d m i n i s t e r these life-saving therapies. Midwives m u s t be able to give the necessary health e d u c a t i o n to the w o m a n a n d h e r family in the event of an o b s t r u c t e d l a b o u r or a r u p t u r e d uterus. T h e w o m a n must be told why she h a d an o p e r a t i o n in a n a t t e m p t to help her p r e v e n t disaster n e x t time. Midwives must be able to give effective contraceptive advice so that the w o m a n can be helped to space her n e x t p r e g n a n c y .
References
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Sokoto, In Obstetric fistulae, a review of available infbrmation. Document WHO/MCH/MSM/91.5, WHO, Geneva World Health Organization 1988 District Team Problem Solving, report o f a workshop, Liwonde, Malawi, 21-30 October, 1987. Document FHE 87.8, WHO, Geneva World Health Organization 1989a The prevention and treatment of obstetric fistulae. Document WHO/FHE/ 89.5, WHO, Geneva World Health Organization 1989b Coverage of maternity care. Document WHO/FHE/89.2, WHO, Geneva
