A clinical audit of postoperative care after emergency caesarean section for obstructed labour at a national referral hospital in Uganda
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Background
Postoperative complications after emergency caesarean section (C/S) due to obstructed labour (O/L) are a significant contributing factor to maternal morbidity in low-resource settings. At Kawempe National Referral Hospital (KNRH) in Kampala, Uganda, hospital records from late 2024 showed an overall adverse outcome rate of approximately 10% among all women delivered by caesarean section, with postpartum haemorrhage (PPH) and surgical site infection (SSI) among the recorded outcomes. Women who deliver by C/S for O/L are particularly a high-risk group, yet adherence to postoperative care standards in this group had not been systematically evaluated. This audit therefore aimed at assessing whether a clinical audit could improve the quality of postoperative care among women undergoing C/S for O/L.
Methods
A criterion-based audit cycle was conducted at a national referral hospital in Kampala, Uganda over six months. At baseline, 150 case files of mothers who delivered by caesarean section due to O/L were reviewed retrospectively, and care practices were evaluated against six care standards derived from World Health Organization (WHO) and Médecins Sans Frontieres (MSF) guidelines. These included: monitoring of vital signs (blood pressure, pulse rate, respiratory rate, temperature, oxygen saturation), administration of analgesia, surgical site care, administration of prophylactic and empirical antibiotics, monitoring for postpartum haemorrhage (monitoring uterine tone and vaginal bleeding), and bladder care. Findings were shared with stakeholders, and gaps were identified. Interventions such as continuous medical education (CME) sessions, protocol dissemination, and workflow adjustments, co-developed with stakeholders, were rigorously implemented for 2 months and 2 weeks. An endline audit was done by reviewing 149 case files. Data analysis involved a comparative description of the baseline and endline audits to determine statistical significance using a chi-square test. To assess the overall level of adherence to postoperative care standards, a composite indicator overall mean care score was computed for both baseline and endline phases. This metric was derived by aggregating compliance across all evaluated components of the standards.
Results
Statistically significant improvements were noted in three standards: Antibiotic administration-prophylactic antibiotics administration (38.0% to 60.4%; p<0.001) and empiric antibiotics administration on Day 1(metronidazole-13.7% to 96.2%, p<0.001), urine output monitoring on Day 1(17.3% to 28.9%; p=0.012), and analgesia administration (paracetamol and rectal diclofenac-50% to above 80%, p<0.002). However, critical gaps persisted, with no observed improvement in vital sign monitoring and surgical site care, and a paradoxical decline in uterine tone monitoring (90.0 to 88.7%; p=0.667). The overall mean care score improved from 46.7% at baseline to 61.1% at endline (absolute increase of +14.4% points).
Conclusion
The results of this study show that a clinical audit is a feasible quality improvement tool that can enhance postoperative care for mothers who deliver by C/S due to O/L in low-resource settings. However, there is a need to evaluate the other standards that did not have an improvement.
