Birth asphyxia following delayed recognition and response to abnormal labour progress and fetal distress in a 31-year-old multiparous Malawian woman

Abstract

Reducing neonatal mortality is one of the targets of Sustainable Development Goal 3 on good health and well-being. The highest rates of neonatal death occur in sub-Saharan Africa. Birth asphyxia is one of the major preventable causes. Early detection and timely management of abnormal labour progress and fetal compromise are critical to reduce the global burden of birth asphyxia. Labour progress, maternal and fetal well-being are assessed using the WHO partograph and intermittent fetal heart rate monitoring. However, in low-resource settings adherence to labour guidelines and timely response to arising labour complications is generally poor. Reasons for this are multifactorial and include lack of resources and skilled health care staff. This case study in a Malawian hospital illustrates how delayed recognition of abnormal labour and prolonged decision-to-delivery interval contributed to birth asphyxia, as an example of many delivery rooms in low-income country settings.

Case presentation

A 31-year-old woman was admitted to the labour ward in a rural Malawian hospital at 9:40 in August 2017. Earlier at 4:00, she presented to a health centre 19 kilometres away in active stage of labour with 8 cm cervical dilatation. She was diagnosed with poor progress of labour and there was a decreased fetal heart rate (FHR). She was therefore referred by ambulance. She was estimated at 38 weeks gestation based on fundal height. Her obstetric history revealed three previous pregnancies resulting in three healthy vaginally born children who were still alive. Her last pregnancy had been complicated by postpartum haemorrhage. No complications occurred during her current pregnancy. She had visited antenatal care once and had no medical conditions. She was divorced and had not received any formal education. On examination, her membranes had already ruptured and liquor was clear. Regular contractions with a frequency of three per minute were present, and the cervix remained at 8 cm dilatation. The woman’s vital signs were normal. The FHR was 104 bpm, but 126 bpm during the next confirmation auscultation 45 min later. As part of routine care in this hospital, a urinary catheter was inserted to facilitate emptying of the bladder during progress of labour. Saline was administered intravenously. According to the local guidelines, oxytocin augmentation was contraindicated as fetal distress was suspected. During the following 2 hours, the FHR was auscultated on two occasions by different healthcare workers. At 11:30, the woman was fully dilated, but the descent of the fetal head was only 2/5 and the FHR was abnormally decreased to 84 bpm. At 11:45, the clinical officer assessed the woman and made the decision for emergency caesarean section because of fetal distress and suspected cephalopelvic disproportion. At 14:00, a hypotonic baby boy of 3600 g was born covered in meconium stained liquor. The Apgar scores at 1 and 5 min were 5 and 7, respectively. Oropharyngeal suctioning was performed. The baby was admitted to the neonatal care unit for further oropharyngeal suctioning and oxygen supply. The next day, he developed seizures and received a loading dose of 73 mg intravenous phenobarbital. Oxygen was supplied for 2 days. No subsequent seizures occurred. The baby was discharged after 4 days and was taken home by his mother, who had recovered quickly. Five months after discharge, the baby had no major developmental problems. We were unable to follow-up with a detailed assessment.

Global health problem list

• Low-income countries such as Malawi are still far from meeting Sustainable Development Goal 3’s target to end preventable deaths of newborns and reduce neonatal mortality to at least as low as 12 per 1000 live births, because of persisting suboptimal intrapartum care.

• Birth asphyxia is a major preventable cause of neonatal morbidity and mortality in low-income countries and forms a large global burden.

• Adequate intrapartum routine care and timely emergency obstetric and newborn care can prevent birth asphyxia, but in many settings adherence to labour guidelines and timely response to arising labour complications is poor.

Global health problem analysis

The global burden of birth asphyxia

In accordance with Sustainable Development Goal 3’s second target (SDG 3.2) and Every Newborn Action Plan, all countries should end preventable deaths of newborns and reduce neonatal mortality to at least as low as 12 per 1000 live births by 2030.^{1 2} Currently, an estimated 2.6 million newborns die every year worldwide (19 per 1000 live births), with large global inequities: from 3 per 1000 live births in Northern America and Europe to the highest rates in Central and Southern Asia (27 per 1000 live births) and sub-Saharan Africa (28 per 1000 live births).³ To realise SDG 3, understanding and addressing the numbers and causes of neonatal death and stillbirths is essential.⁴ Globally, birth asphyxia is one of the leading causes of neonatal mortality, next to prematurity and severe infections.^{5 6}

Birth asphyxia is a medical condition resulting from oxygen deprivation during the perinatal period, often leading to brain injury in the newborn infant. This is reflected by the development of insults during the first hours after birth, and in the most severe cases permanent developmental disorders such as cerebral palsy, mental retardation, epilepsy or death.⁷ The pathophysiology of birth asphyxia is complex. Generally, it occurs due to reduced oxygen delivery to the infant’s brain, as a result of impeded placental blood flow.⁸ Primary management consists of resuscitation with bag and mask ventilation. After resuscitation, treatment consists of maintaining stable vital signs.⁹ In some cases and settings, therapeutic hypothermia can be indicated.

The number of deaths due to birth asphyxia is much higher in low-income and middle-income countries compared with high-income countries (25% vs 7%).¹⁰ Birth asphyxia forms a large global burden of disease with 50.2 million disability-adjusted life years.¹¹ In low-income and middle-income countries, an estimated 50% of birth asphyxia survivors are affected with neurodevelopmental impairment, resulting in less school learning potential and economic productivity.^{12 13} Malawi has made slow progress on reducing neonatal death¹³ during the Millennium Development Goals period, but the country is still far from meeting SDG 3.2. Strengthening access and quality of health remain major challenges. Currently, the neonatal mortality rate is 23/1000 live births¹⁴ and the stillbirth rate is 24/1000.¹⁵ Asphyxia accounts for 22% of neonatal death,¹⁶ although the incidence might be higher due to misclassification and under-reporting of early neonatal death.⁷ Malawi’s SDG 3 index score is 42.8, signifying the country’s position between the worst (0) and the best or target (100) outcome. This score is currently not meeting the growth rate needed to achieve SDG 3 by 2030.¹⁷ To meet SDG 3.2 and reduce the global burden of birth asphyxia, prevention, early detection and timely response in labour are critical.

Prevention of birth asphyxia: adequate routine intrapartum fetal monitoring coupled with timely emergency obstetric care

Prolonged labour, maternal haemorrhage, obstructed labour and umbilical cord accidents are important determinants of birth asphyxia.^{18 19} For timely intervention in case of abnormal labour and fetal distress during labour, early detection is key. There is insufficient evidence for the effectiveness of various techniques of monitoring fetal well-being. Yet, in all labour guidelines, the condition of the fetus can be assessed through fetal heart rate monitoring (FHRM) with or without the aid of a confirmatory test. FHRM can be performed through either intermittent auscultation (IA) by Pinard or hand-held Doppler or continuous cardiotocography. In low-income countries, IA is often the only available and safest FHRM method for the mother because advanced methods are associated with higher false positive rates of fetal distress and unnecessary caesarean sections.^20–22 There is no evidence regarding the optimal frequency of IA, but a frequency of at least every 15–30 min during the active first stage and at least every 5 min in second stage for at least 1 min duration are often recommended.^{23 24} A normal FHR is generally regarded as 120–160 bpm.²⁵ While these frequencies are echoed in the Malawi national guidelines,²⁶ regular assessment of the FHR can be challenging. For example, in a referral hospital in the capital Blantyre, the FHR was monitored every 2 hours or not at all.¹⁶ Similar patterns have been described for other low-resources settings, such as a referral hospital in Tanzania, where half of stillbirths were intra-hospital, the median time interval from last FHRM to delivery was 210 min in 2015²⁷ and in a hospital in Mozambique, where FHR was monitored on partographs in just 50% of labours, regardless if women had risk factors for asphyxia.²⁸ A study in Nepal also showed inadequate FHR monitoring during labour that was associated with increased risk of intrapartum stillbirths.²⁹ Poor adherence to guidelines may cause late detection of fetal compromise and could therefore lead to poor neonatal outcome.

If fetal distress is detected, the following interventions should be considered according to local hospital guidelines: supplying oxygen therapy, placing the woman in left lateral position and administering fluid bolus. If the FHR does not improve, operative delivery should be performed within 30 min.^{26 30} Although evidence of correlation of decision-to-delivery-interval (DDI) and perinatal outcome is currently lacking,³¹ in case of fetal distress any delay may worsen intrapartum hypoxia and is therefore unjustified.³² A DDI below 30–75 min has been widely recommended,^33–35 although this seems not always feasible in low-resource settings.^{27 36 37} In two studies performed at tertiary hospitals in Nigeria, mean DDI in case of fetal distress was 2.9 (±2.5) h³⁸ and 68.7 (±39.7) min, respectively.³²

Various reasons for delay in DDI have been previously described and are multifactorial. They include lack of labour staff, delay in transfer to theatre, unavailability of operating theatre, anaesthesiologist or the surgeon.^38–40 The low use of assisted vaginal delivery options in low-income countries might also contribute to a longer DDI and poor perinatal outcome.^{41 42}

Perinatal audits may help to identify delaying or sub-optimal care obstacles and implement appropriate solutions at a local setting.^{43 44} Simulation training in case of emergency caesarean section and training in assisted vaginal delivery may help to shorten DDI.⁴⁵ In the presented case, irregular assessment of the fetal condition, the timing of diagnosing abnormal labour progress and the DDI of 135 min probably contributed to the poor neonatal outcome. Both mother and child did not develop serious complications, although the long-term outcome of the baby remains undetermined.

Challenges faced in providing timely and quality obstetric care in low-income settings

The hospital where this case was presented is a secondary level facility with approximately 200 beds. There are six beds available at the labour ward. On a regular day, there are four clinicians/medical officers, four nurses and two patient attendants assigned to the maternity ward; one clinician, two nurses and two patient attendants stay at the labour ward, the other staff members are assigned to either antenatal or postnatal care. The patient attendants do not deliver medical care but help for example with measuring the mothers’ vital signs and cleaning the delivery room. On average, there are nine deliveries a day, leading to more than 3000 deliveries a year. This results in a nurse: labouring woman ratio of 1: 3–4. During a regular clinical morning meeting, all nurses (n=10) explained that the labour ward was often so crowded that on daily basis women were sent outside to await progression of labour with their relative within hospital grounds. Monitoring the FHR every 30 min was practically impossible due to lack of staff. Also, alternations of staff taking care of the women might lead to delays and inconsistent FHR monitoring. The reasons for the delayed DDI were not discussed.

Previously described causes of non-adherence to labour guidelines and suboptimal care consist of lack of resources, shortage of staff, inadequate training as well as structural and organisational deficiencies in healthcare facilities and professionals. In addition, low motivation and job dissatisfaction may result from high workloads, low salaries, poor living conditions and inadequate support from supervisors and leaders.^{16 46 47} These are examples of commonly described ‘supply-side’ barriers in the ‘three delays model’.⁴⁸ Malawi experiences severe shortage of healthcare staff and essential medical products, technologies and logistics. Contributing factors include inadequate funding, high burden of disease and weak supply chain management. Only 53% of hospitals and 5% of health facilities can provide a full package of comprehensive and basic emergency obstetric and neonatal care services. There are persistent gaps in human resource capacity across all districts and healthcare levels within Malawi’s public sector, with a 45% vacancy rate.⁴⁹ With a density of three doctors, nurses and midwives per 10 000 population, Malawi is far from meeting the minimum threshold of 23 established by the WHO to ensure essential maternal and child health services.⁵⁰ In addition, Malawi’s health sector faces uneven distribution of healthcare staff, with only a few doctors working in local district hospitals. Retaining healthcare staff is impeded by inadequate management support,⁵¹ concerns about increased workload and staff shortages. Critical shortages of skilled staff inhibit timely and quality obstetric care, which has a significant impact on maternal and neonatal outcomes.⁵² Clearly, there is urgent need for training, employing and retaining of more healthcare workers, as well as improving healthcare facilities to accommodate the increasing number of facility-based deliveries and to improve neonatal outcomes. Motivation and adherence to intrapartum guidelines can also be improved when labour staff members are involved in developing intrapartum guidelines and when these guidelines are better adapted to the local setting.⁵³

Patient’s perspective.

I understood that my baby had asphyxia. I was worried about the outcome and felt detached. Generally, my experience at the health centre and hospital was good, although I would be happy if the team at the health centre dedicates more time to patient monitoring. I would recommend quick decision-making in cases like this.

Learning points.

• Early detection and timely management of abnormal labour progress and fetal distress are essential to reduce the global burden of birth asphyxia and neonatal mortality rates in low-income countries.

• Fetal heart rate monitoring could be useful in preventing birth asphyxia if appropriate and timely response to fetal distress is available.

• Reasons for delay and suboptimal perinatal care in low-income settings are multifactorial and include shortage of resources and skilled healthcare staff leading to increased workload and job dissatisfaction.

• Evaluations of quality of labour and perinatal care should be performed to identify delaying and sub-optimal care factors and implement appropriate solutions to problems identified at local settings.

• Availability of more healthcare workers with an adequate skills set, resource allocation and improving education of intrapartum and emergency obstetric care are key.