Obstructed labour is defined from observing the process of labour from the first stage of cervical dilatation through the second stage of expulsion The diagnostic technology implicit in the partogramis particularly appropriate (WHO 1994). There is no doubt that the partogram has meant dramatic if not revolutionary improvement in the perception of the birthing process in countries where no such notion was present before. Some recent reports have elaborated on modifications of the conventional WHO partogram with alleged advantages. In one study the action line was subject to a randomised trial, indicating that the CS rate was lower when labour was managed using a partogram with a four hour action line (Lavender et al. 1998). In other studies innovative reconstructive steps have been taken to facilitate partogram use (Wacker et al. 1998, Tay & Yong 1996). It has been alleged that its use is complicated, since it demands the skill of mathematical abstraction (Dujardin et al.1992, Walraven 1994). Even if it is useful in peripheral units its use in higher-level health care centres has been advocated (Lennox 1981). Obstructed labour - sensu strictiori- implies an obstacle to deliver via the vaginal route. Since both the mechanical components in this process, the foetal head and the mother’s pelvis, are both to some extent malleable, obstructed labour can be overcome by a variety of means. In the following we are going to make a distinction between management of obstructed labour by abdominal delivery and by vaginal delivery. Abdominal Delivery While general agreement seems to prevail in most settings that a minimum CS rate might be of the order of 5% many studies now reveal that the CS rate may be well below 1% in many settings. Calculations on “unmet obstetrical needs” can use the verified CS rate as against the calculated need of CSs in a defined population. The difference in such settings from the reality in more affluent settings is striking considering CS rates in the order of 50-70% in some urban settings. The reasons for this “pandemic” in current CS practices have been ascribed to fear of legal consequences of alleged mismanagement and to proper commercialisation of obstetric practice (Vimerkati et al. 2000). International comparisons have shown that there has been no improvement in perinatal mortality that parallels the steep increase in CS rate (Figure 1). An increasing number of unnecessary CSs will also lead to an increasing number of unnecessarily ruptured uteri in subsequent pregnancies. 8
Figure 1. The upper diagram reflects the tendency in the USA towards high frequency of caesarean sections, while the lower diagram shows the situation in Dublin, Ireland where a very low frequency of caesarean sections has been maintained. The perinatal mortality has undergone a more or less identical development in Ireland an in the USA.