Background Caesarean sections without medical indication cause substantial maternal and perinatal ill-health, particularly in low-income countries where surgery is often less safe. In presence of adequate labour monitoring and by appropriate use of evidence-based interventions for prolonged first stage of labour, unnecessary caesarean sections can be avoided. We aim to describe the incidence of prolonged first stage of labour and the use of amniotomy and augmentation with oxytocin in a low-resource setting in Malawi. Methods Retrospective analysis of medical records and partographs of all women who gave birth in 2015 and 2016 in a rural mission hospital in Malawi. Primary outcomes were incidence of prolonged first stage of labour based on partograph tracings, caesarean section indications and utilization of amniotomy and oxytocin augmentation. Results Out of 3246 women who gave birth in the study period, 178 (5.2%) crossed the action line in the first stage of labour, of whom 21 (11.8%) received oxytocin to augment labour. In total, 645 women gave birth by caesarean section, of whom 241 (37.4%) with an indication ‘prolonged first stage of labour’. Only 113 (46.9%) of them crossed the action line and in 71/241 (29.5%) membranes were still intact at the start of caesarean section. Excluding the 60 women with prior caesarean sections, 14/181 (7.7%) received oxytocin prior to caesarean section for augmentation of labour. Conclusion The diagnosis prolonged first stage of labour was often made without being evident from labour tracings and two basic obstetric interventions to prevent caesarean section, amniotomy and labour augmentation with oxytocin, were underused.

Objective Prolonged second stage of labour potentially leads to maternal and perinatal complications. Options for clinical management are augmentation with oxytocin, instrumental vaginal birth or second-stage caesarean section. We aimed to describe incidence, management and outcome of prolonged second stage of labour in a low-resource setting in Malawi. Methods Retrospective analysis of medical records and partographs of all women who gave birth in 2015-2016 in a rural mission hospital in Malawi, comparing labour tracings with management protocols. Primary outcomes were incidence of prolonged second stage, instrumental vaginal birth and caesarean section. Furthermore, management and outcomes were assessed. Women arriving in hospital in the second stage of labour were compared to women arriving in an earlier stage of labour. Results Of all 3,426 women giving birth in the study period, 307 (9.0%) were diagnosed with prolonged second stage, based on their partographs. Of these women, 22 (7.2%) had labour augmented with oxytocin, 31 (10.1%) gave birth by vacuum extraction and 64 (20.9%) by caesarean section. Spontaneous vaginal birth occurred in 212 (69.0%). In total, 566/3,426 (16.5%) women were admitted whilst already in the second stage of labour of whom 538/566 (95.1%) had spontaneous vaginal births and 38/566 (6.7%) ended up having prolonged second stage registered in their partographs. Conclusion Prolonged second stage of labour is relatively common in this hospital, although diagnosis may be hampered by a very sizeable proportion of women arriving whilst already in the second stage, although a large majority of these women gave birth spontaneously. Caesarean section occurred twice as often as vacuum extraction, suggesting a role for additional training and decision-making during childbirth to support the use of vacuum extraction.