Caesarean section and quality of obstetric care
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1 Caesarean section and quality of obstetric care Gjennombruddsprosjekt for keisersnitt September 2014 Michael Robson The National Maternity Hospital Dublin, Ireland
2 Gjennombruddsprosjekt for keisersnitt September 2014 Inclusivity with commitment Establish and agree a methodology Leave a legacy
3 My Aim Methodology Caesarean Section and quality of obstetric care Intrapartum Caesarean Section a different approach in classification
4 How do we assess quality of obstetric care? Safety and outcome
5 What influences quality? Structure (resources) Building Equipment Staff
6 What influences quality? Processes (guidelines)
7 What influences quality? Organisation Philosophy Leadership Truly multidisciplinary approach Good communication Key decision making Fail safe mechanisms Professionals knowledge of information Ability to respond and change Ability to perform
8 What influences quality? Simplicity
9 How do we assess quality of obstetric care? Quality is measured by safety and outcome and Structure, processes, guidelines, organisation and simplicity respond to and directly affect quality
10 How do we assess quality of obstetric care? Outcome
11 Challenges in assessing quality of obstetric care Which outcomes? Physical Satisfaction
12 Challenges in assessing quality of obstetric care Events and outcomes (including interventions and complications) Feedback, adverse events, complaints and medico-legal cases
13 Labour events and outcomes (including interventions and complications) Events Any intrapartum event thought by the mother, midwife, obstetrician or neonatologist to influence any of the labour outcome measures Outcomes Any outcome thought by the mother, midwife, obstetrician or neonatologist to affect the health and satisfaction of either mother or baby Robson MS. Labour Ward Audit. In: Management of Labour and Delivery. Ed. R.Creasy, 1997 Blackwell Science pp
14 Challenges in assessing quality of obstetric care Definitions of events and outcomes Need to be objective as much as possible and consistently implemented
15 No perinatal event or outcome should be considered in isolation from other events, outcomes and organisational issues Risk-Benefit Calculus Perinatal morbidity and mortality Maternal morbidity and mortality Feedback, adverse incidents, complaints and medicolegal cases Staff and infrastructure resources Maternal satisfaction and staff satisfaction Financial
16 Feedback, complaints, adverse events, and medico-legal cases Difficult but important
17 Challenges in assessing quality of obstetric care We need to account for significant epidemiological variables
18 Challenges in assessing caesarean section (or any other event) and quality of obstetric care Classification and denominators
19 Epidemiology of Perinatal Outcome We need to classify all perinatal outcome so that objective comparisons can be made of fetal and maternal outcomes over time in one unit and between different units both nationally and internationally
20 But to do that We need a consistent and objective structure within which we can examine fetal and maternal outcomes
21 Classifying Perinatal Outcome the 10 Groups The Ten Groups Have Been Created From the Previous Obstetric Record, Course, Category and Gestation Robson MS. Classification of Caesarean Sections. Fetal and Maternal Review 2001; 12: Cambridge University Press
22 Classifying Perinatal Outcome the 10 Groups Previous obstetric record Nulliparous Multiparous without a scar Multiparous with a scar
23 Classifying Perinatal Outcome the 10 Groups Category of pregnancy Single cephalic Single breech Multiple pregnancy Transverse or oblique lie
24 Classifying Perinatal Outcome the 10 Groups Course Spontaneous labour Induced labour Caesarean section before labour Emergency Elective
25 Classifying Perinatal Outcome the 10 Groups Gestation The number of completed weeks at delivery
26 National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups Nullip single ceph >=37 wks spon lab 2 Nullip single ceph >=37wks ind. or CS before lab 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 5 Previous caesarean section single ceph >= 37 wks 6 All nulliparous breeches 7 All multiparous breeches (incl previous caesarean sections) 8 All multiple pregnancies (incl previous caesarean sections) 9 All abnormal lies (incl previous caesarean sections) 10 All single ceph <= 36 wks (incl previous caesarean sections)
27 National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups Total number of caesarean sections over the overall total number of women 1 Nullip single ceph >=37 wks spon lab / % 1176/ Nullip single ceph >=37wks ind. or CS before lab 2896/ Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/ Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 Number of caesarean sections over the total number of women in each group 5 Previous caesarean section single ceph >= 37 wks 3364/ All nulliparous breeches 1177/ All multiparous breeches (incl previous caesarean sections) 685/815 8 All multiple pregnancies (incl previous caesarean sections) 654/ All abnormal lies (incl previous caesarean sections) 220/ All single ceph <= 36 wks (incl previous caesarean sections) 882/2546
28 National Size of each group Maternity is the total number Hospital, of Dublin women in each group divided by the overall total number of women Caesarean Sections - the 10 Groups Nullip single ceph >=37 wks spon lab / % Size of group % 1176/ Nullip single ceph >=37wks ind. or CS before lab 2896/ Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/ Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/ Previous caesarean section single ceph >= 37 wks 3364/ All nulliparous breeches 1177/ All multiparous breeches (incl previous caesarean sections) 685/ All multiple pregnancies (incl previous caesarean sections) 654/ All abnormal lies (incl previous caesarean sections) 220/ All single ceph <= 36 wks (incl previous caesarean sections) 882/
29 National Maternity Hospital, Dublin CS rate in each group is worked out for each group by dividing the number of caesarean sections by the total number of women in each group Caesarean Sections - the 10 Groups Nullip single ceph >=37 wks spon lab / % Size of group % C/S rate in gp % 1176/ Nullip single ceph >=37wks ind. or CS before lab 2896/ Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/ Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/ Previous caesarean section single ceph >= 37 wks 3364/ All nulliparous breeches 1177/ All multiparous breeches (incl previous caesarean sections) 685/ All multiple pregnancies (incl previous caesarean sections) 654/ All abnormal lies (incl previous caesarean sections) 220/ All single ceph <= 36 wks (incl previous caesarean sections) 882/
30 National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups Nullip single ceph >=37 wks spon lab Absolute contribution of each group to the overall CS rate is worked out by dividing the number of CS in each group by the overall population of women This will depend on the size of the group as well as the CS rate in each group / % Size of group % C/S rate in gp % Contr of each gp 19.7 % 1176/ Nullip single ceph >=37wks ind. or CS before lab 2896/ Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/ Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/ Previous caesarean section single ceph >= 37 wks 3364/ All nulliparous breeches 1177/ All multiparous breeches (incl previous caesarean sections) 685/ All multiple pregnancies (incl previous caesarean sections) 654/ All abnormal lies (incl previous caesarean sections) 220/ All single ceph <= 36 wks (incl previous caesarean sections) 882/
31
32 Detailed audit of labour events and outcome Group 1 NMH 28/2108
33 Detailed audit of labour events and outcome Group 3 NMH 21/2705
34 Group 5 NMH other outcomes of spontaneous labour
35 Groups 1 and 2 NMH 2012
36 Group 2 NMH 2012
37 The 10 Group Classification - and the advantage of standardisation Any differences in sizes of groups or outcome within the groups are either due to Poor data quality Differences in significant epidemiological factors Differences in practice
38 Quality of overall maternity care Will not improve until we audit events and outcomes in a standardised way and understand their relationships [email protected]
39 Intrapartum Caesarean Section a different approach in classification Gjennombruddsprosjekt for keisersnitt September 2014 Michael Robson The National Maternity Hospital Dublin, Ireland [email protected]
40 Indications Inductions Caesarean sections
41 Definitions Application Multiple Growth No indication Retrospective Indications
42 Indications Solution Relating classification to objectively defined clinically relevant groups of cases with organisational and management implications which make it possible to change and improve care
43 Classifying Caesarean Sections the 10 Groups Previous obstetric record Nulliparous Multiparous without a scar Multiparous with a scar
44 Classifying Caesarean Sections the 10 Groups Category of pregnancy Single cephalic Single breech Multiple pregnancy Transverse or oblique lie
45 Classifying Caesarean Sections the 10 Groups Gestation The number of completed weeks at delivery
46 Classifying Caesarean Sections the 10 Groups Course Spontaneous labour Induced labour Caesarean section before labour Emergency Elective
47 Classifying Caesarean Sections Caesarean section before labour Elective Planned 24 hours, normal working hours, neither induced or in spontaneous labour, 39 weeks Emergency All other caesarean sections
48 Classification of indications for Caesarean Sections - prelabour Fetal Maternal No medical reason
49 Caesarean section on request
50 Women will always choose the type of delivery that seems safest for them and their babies If women choose a type of delivery that we disagree with then either they may be right and we may be wrong, the care that is being provided is not what we think it is or appropriate information is not available
51 Caesarean section on request Definition At the time of the request in the opinion of the obstetrician there is a greater relative risk of a significant adverse outcome to mother or baby by carrying out a caesarean section than awaiting spontaneous labour and delivery or inducing labour (within any of the 10 groups)
52 Intrapartum Caesarean Section a different approach in classification Dystocia the biggest issue in labour and deivery
53 The problem No working definition or classification to aid diagnosis, treatment and continuous audit to assess whether caesarean section for dystocia can be reduced
54 Dystocia Confusing terminology Failure to progress Failure to advance Arrest Dystocia (should be used as a description of the whole labour)
55 Classification of indications for Caesarean Sections - in labour Requirements Objective classification of indications for CS in labour Needs to be related to the use of oxytocin Classification can be used irrespective of oxytocin regimen or criteria for diagnosis of dystocia Outcomes will reflect the oxytocin regimen, criteria for diagnosis of dystocia and the incidence of dystocia
56 Classification of CS in labour Variables Diagnosis of labour Assessment of progress Oxytocin regimen
57 Classification of CS in labour Fetal (no oxytocin) Variables Diagnosis of labour Assessment of progress Oxytocin regimen
58 Classification of CS in labour Fetal (no oxytocin) Dystocia Variables Diagnosis of labour Assessment of progress Oxytocin regimen
59 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Variables Diagnosis of labour Assessment of progress Oxytocin regimen
60 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Variables Diagnosis of labour Assessment of progress Oxytocin regimen
61 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Variables Diagnosis of labour Assessment of progress Oxytocin regimen
62 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Variables Diagnosis of labour Assessment of progress Oxytocin regimen
63 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance Variables Diagnosis of labour Assessment of progress Oxytocin regimen
64 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given Variables Diagnosis of labour Assessment of progress Oxytocin regimen
65 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition Variables Diagnosis of labour Assessment of progress Oxytocin regimen
66 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Variables Diagnosis of labour Assessment of progress Oxytocin regimen
67 Oxytocin No CS No (spont/induct) Yes 1 st /2 nd Stage. Maximum dose mu/min Yes Fetal (no oxytocin) Dystocia (oxytocin) (inability to treat fetal) Dystocia (oxytocin) (poor response) Dystocia (oxytocin) inability to treat overcontracting) Dystocia (no oxytocin) Acid/Base No/Yes
68 Applying the classification Nulliparous vs multiparous +/- scar Spontaneous vs induction Single cephalic vs obstetrical abnormalities Premature labour
69 Classification of Caesarean Sections in labour Group 1 NMH 2012 Hypothesis The incidence and distribution of your caesarean sections together with fetal and maternal outcome will depend on your timing, rate of increase and maximum dose of oxytocin. This will in turn be influenced by when you rupture your membranes
70 Classification of Caesarean Sections in labour Group 3 NMH 2012 Hypothesis The incidence and distribution of your caesarean sections together with fetal and maternal outcome will depend on your timing, rate of increase and maximum dose of oxytocin. This will in turn will beinfluenced by when you rupture your membranes
71 Group 5 NMH CS rate and indications in spontaneous labour CS rate in induced labour 44% (44/100)
72
73 The issues surrounding CS rates need to be redefined and substantiated. This will mean a completely new philosophy and an acceptance that large prospective databases are going to be more helpful than randomised controlled trials both in providing more insight about labour and delivery and more importantly also ensuring that we are providing safe and quality care
74 An internationally accepted perinatal classification is much needed to scientifically study the effects of rising CS rates It is the responsibility of all professionals to make this happen In the future it will be this failure rather than the increase in the CS rate itself that will be most critically questioned
75 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Variables Diagnosis of labour Assessment of progress Oxytocin regimen
76 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Intact membranes Variables Diagnosis of labour Assessment of progress Oxytocin regimen
77 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Intact membranes Delay in oxytocin Variables Diagnosis of labour Assessment of progress Oxytocin regimen
78 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Intact membranes Delay in oxytocin Inadequate dose oxytocin Variables Diagnosis of labour Assessment of progress Oxytocin regimen
79 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Intact membranes Delay in oxytocin Inadequate dose oxytocin Appropriate dose but hesitant use Variables Diagnosis of labour Assessment of progress Oxytocin regimen
80 Classification of CS in labour Fetal (no oxytocin) Dystocia Inefficient uterine action () Efficient uterine action (EUA) Poor response Inability to treat overcontracting Inability to treat fetal intolerance No oxytocin given EUA Persistent malposition EUA CPD (obstructed labour multips) Error in diagnosis, induction Intact membranes Delay in oxytocin Inadequate dose oxytocin Appropriate dose but hesitant use Variables Diagnosis of labour Assessment of progress Oxytocin regimen
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