We were discussing the cases for presentation the next day. The partographs obviously needed to be redrawn to justify the decision for LSCS.
Patient had been 4cm dilated for over 16 hours. Contraction monitoring was patchy, plotted for 3 hours out of the 16 and plotted as inadequate. FHR checked 7 times during that period. Oxytocin started at 15dpm, no information on what happened afterwards.
Contractions
Our inability to monitor contractions is not just a staffing problem, it’s become an organizational culture.
It’s true that in 60-70% of the time, we do not have enough midwives to offer one on one care. It however appears that in the 30-40% of situations where there are more midwives than patients, contractions are still not checked. What are the consequences of not checking contractions though?
Oxytocin titration
Well, it barely happens. First of all, the midwives are too busy to count those drops every 30 minutes. The dorsiflows are barely there. Nobody thinks the labor wards are worth investing in perfusors. What are the consequences of not titrating though?
For the mother and baby, no contraction monitoring and titration of oxytocin means surgery that may not be needed, unrecognized hyperstimulation which is quite common, fetal distress and death and uterine rupture.
What are the consequences to the midwives though? Nothing. They don’t have to answer any questions to anyone.
What are the consequences for the doctors? They have to perform surgeries that they would otherwise not perform for fear of litigation, they just can’t ask that the labor should now be properly monitored after 12 hours have gone by. In centers where doctors have to present to seniors at morning meetings, they have to ‘redraw’ these partographs. And they get chastised for poor contraction monitoring. In other places where nobody asks, nobody really bothers.
The system ends up dealing with excessive morbidity and cost of surgery.
I think on this issue, one of the biggest needs in most big centers today is accountability amongst midwifery staff. There should be partograph rounds where midwives project their partographs from the night before and discuss it.
I suspect they will be empowered, they will be able to accurately point out the difficulties they face with meeting the expectations of the system, it will reduce the LSCS rate for failure to progress and fetal distress and it will make the Ghanaian labor ward safer.
