Caesarean Section Audit

1. Mölndals Sjukhus March 2017 Caesarean Section Audit Michael Robson The National Maternity Hospital Dublin, Ireland Mrobson@nmh.ie

3. Classification System of Indications Pre labour Spontaneous and induced labour

4. Caesarean Section Audit Total Caesarean Section rate NMH (2015) 25.9% Pre labour 15.9 % After spontaneous or induced labour 10.0% (3.8% and 6.2%)

5. Caesarean Section Audit Classification of indications

6. Classification of Indications forCaesarean Sections- problems Definitions Application Multiple Growth No indication Retrospective

7. Current Classification Systemsof Indications Repeat Caesarean Section Breech Dystocia Fetal Distress Others

8. Classification of Caesarean Sections - prelabour Fetal Maternal No medical reason

9. Classification of Caesarean Sections after Spontaneous and Induced labour

10. Dystocia An enigma

11. Probably the most common problem in labour and the biggest contributor directly or indirectly to the rising caesarean section rate

12. Dystocia What can we agree on?

13. General management of labour Assumption is made that all the simple measures are encouraged Antenatal classes specific to your labour management Previous visits to labour ward Friendly staff and comfortable environment Clear, consistent and honest advice from staff Mobilisation and position One to one care Appropriate individualised relief of stress/pain

14. Dystocia Aetiology Powers Inefficient uterine action, dysfunctional labour, incoordinate uterine action Passenger Weight, malposition, malpresentation (face, brow) Pelvis Cephalopelvic disproportion, Obstructed Labour

15. Dystocia What can’t we agree on?

16. Dystocia Terminology Difficult, abnormal, prolonged labour Failure to progress Failure to advance Labour arrest Obstructed labour

17. Dystocia Dystocia Some use dystocia to describe the whole labour and some use it for a brief period of time in the labour No consistent definition as an indication for caesarean section

18. Active Management of Labour- abnormal or difficult labour(Dystocia) Described as when delivery is by caesarean section, or vaginally by the efforts of the doctor, when duration exceeds 12 hours, or when some harmful effect befalls either mother or child BMJ 1973; 3:135-137

19. General management of labour Contentious Issues Diagnosis of labour Timing of Artificial Rupture of the Membranes Incidence, timing and regimen of Oxytocin used

20. General management of labour Less contentious issues in which we still differ and may affect the incidence of dystocia Fetal monitoring Incidence and type of epidural

21. Dystocia Things that we probably do not disagree on but we could be more consistent in our management and analysis

22. Understanding how dystocia is interpreted in the context of particular labours Nulliparous vs multiparous +/- scar Spontaneous vs induction Single cephalic vs obstetrical abnormalities Premature labour

23. Classification of indications ofCaesarean Sections- after spontaneous or induced labour Requirements Objective classification of CS in labour (spontaneous/induced) Oxytocin needs to be part of it Audit of other events and outcomes will reflect the type of management and quality of care Classification can be used irrespective of type of management (diagnosis of labour, fetal monitoring, criteria for assessing and treatment of poor progress, ARM and oxytocin regimen and epidurals)

24. Classification of Caesarean Sections– after spontaneous or induced labour Three questions that may help us? Is the indication for caesarean section fetal (no oxytocin) or ‘dystocia’ Has cervical dilatation been more or less than 1 cm/hr Was oxytocin used?

25. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8

28. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8

34. Fundamentals of studying dystocia

35. Fundamentals of studying dystocia

36. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8

38. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8

40. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8

47. Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural Variables Diagnosis of labour Fetal monitoring Assessment of progress ARM and Oxytocin regimen Epidural One to one care Murphy M, Butler M, Coughlan B, et al. Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol 2015;213:673.e1-8