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Clinical Practice guideline “Cephalopelvic disproportion”

QA ภาควิชาสูติศาสตร์และนรีเวชวิทยา 29 ตุลาคม 2547. Clinical Practice guideline “Cephalopelvic disproportion”. Trend of Cesarean Section around the world. C/S rate in USA 1989-1996. =Total C/S. = Primary C/S. = VBAC.

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Clinical Practice guideline “Cephalopelvic disproportion”

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  1. QA ภาควิชาสูติศาสตร์และนรีเวชวิทยา29 ตุลาคม 2547 Clinical Practice guideline “Cephalopelvic disproportion”

  2. Trend of Cesarean Section around the world

  3. C/S rate in USA 1989-1996 =Total C/S = Primary C/S = VBAC

  4. Primary cesarean rate by age, race, and Hispanic origin of mother:United Stated, 1989, 1996, and 2002 1996 2002 1989 Race and/or Hispanic origin Age of mother Non - Hispanicblack Non - Hispanicwhite Hispanic Under 30 years 30 – 39 years 40 years andover

  5. Impacts • Mistrust • Incorrect attitude • Inequity • Inefficiency • Wasted resource • Lawsuit

  6. T To reach the appropriate rate for LT/CS • Professional community takes leading role for checking and balancing to optimum, by peer review, and guidelines • Purchasing community - introduce appropriate measures • Empower women on vaginal delivery through intensive and better quality ANC

  7. Situation in Songklanagarind Hospital

  8. NL C/S V/E F/E BREECH 90 91 92 93 94 95 96 97 98 99 Modes of delivery in Songklanagarind Hospital

  9. Indications for Cesarean Section In Songklanagarind Hospital % 90 91 92 93 94 95 96 97 98 99 Year PRIMARY PREVIOUS

  10. Indication for Primary Cesarean Section % CPD. Fetal Distress Failed Induction Other 90 91 92 93 94 95 96 97 98 99 Year

  11. Cesarean Section Practice of Staffs Private % Service 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 number

  12. First Guideline of CPD diagnosis (modified from ACOG recommendation) 1. Cervix ≥ 3 cm. 2. Good uterine contraction ≥ 2 hrs. 3. Protraction or arrest disorder 4.If 1, 2, 3 are not met, needed two obstetriciansevaluation. CPG was approved by Department committee and implemented in 2000

  13. Physician compliance with the CPG was 89.2% • Cesarean section rate due to CPD was • decreased from 10.7% in 1999 to • 8.6% in 2002 • Pregnant outcomes were not different • between the two periods C.Suwanrath-Kengpol et al. Int. J. for Quality in Health Care 2004;16;327-332

  14. Table 4 Factors associated with physician non-compliance using a multivariate logistic regression modeFactors Odds ratio 95% CI P-value……………………………………………………………………………………….……..Private care 16.0 3.7 - 69.6 <0.001Birthweight  3500 g 2.6 1.3 - 5.1 0.01Short stature (<150 cm) 3.4 1.2 - 9.5 0.02Nulliparity 5.0 0.6 - 38.9 0.13Age 35 years 1.0 0.4 - 2.9 0.9895%CI, 95% confidence interval.

  15. Summary Cesarean Section rate was decreased, but higher than WHO recommendation Department committee approved revised CPGin December 2002 Revised CPG was implemented in January 2003

  16. Trend of CS rate due to CPD CPG 1 CPG 2 --- Predicted CS rate Observed CS rate WHO recommendation C.Suwanrath-Kengpol et al. Int. J. for Quality in Health Care 2004;16;327-332

  17. CRITERIA FOR DIAGNOSIS OF CPD 2000 2003

  18. เกณฑ์การวินิจฉัย CPD (ชุด 1) ขอรับรองว่าผู้ป่วยรายนี้มีปัจจัยต่าง ๆ ดังต่อไปนี้1. Cervix dilate> 4 cm. Efface > 80% มี ไม่มี2. Good uterine contraction > 2 Hr. มี ไม่มี3. Arrest / Protraction of labor มี ไม่มี4. Prolonged second stage มี ไม่มี ลงชื่อ …………………………MD. รหัส……………………. กรณีไม่ครบ 1,2 ,3 หรือ 1,2,4 โปรดใช้เกณฑ์ชุด 2

  19. เกณฑ์การวินิจฉัย CPD (ชุด 2)สูติแพทย์ 2 ท่าน ที่ลงนามต่อท้ายนี้ วินิจฉัยว่าผู้ป่วยมี CPDจำเป็น้องผ่าตัดโดย เกณฑ์การวินิจฉัยยังไม่ครบสาเหตุ (ระบุ)…………………………………………………ลงชื่อ สูติแพทย์คนที่ 1……………………รหัส……………….ลงชื่อสูติแพทย์คนที่ 2……………………รหัส……………….

  20. 14 12 . 2 12 10 . 9 10 8 . 5 8 . 4 8 CS rate 6 . 4 Before CPG (%) 5 . 2 6 After CPG 4 2 0 Type of service Total Non-private Private Cesarean Section Rate for CPD 2003

  21. Compliance Rate of Revised CPG

  22. Pregnancy outcomes of cesarean section due to CPD

  23. Non-compliance factors (multivariate logistic regression model)

  24. Outcomes of Revised CPG • Compliance with the revised CPG = 83% (target compliance = 85%) • After revised CPG, no adverse effect of pregnancy outcomes • Cesarean section rate did not decrease within 1 year period

  25. Summary • Using the revised CPG: decreased the difference of cesarean section rate between private and non-private groups (7% vs. 4%) • CPG Evaluation as research (2 publications) • Using CPG as a study model for medical personnel

  26. Thank You Thank You Thank you

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