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

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 %
After spontaneous or induced labour %
(3.8% and 6.2%)

5. Caesarean Section Audit
Classification of indications

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

7. Current Classification Systems of 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:

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 of Caesarean 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. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

28. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

34. Fundamentals of studying dystocia

35. Fundamentals of studying dystocia

36. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

38. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

40. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

47. Classification of CS after spontaneous or induced labour
Fetal
(no oxytocin)
Dystocia
Inefficient uterine action (IUA)
IUA
Poor response
Error in diagnosis, induction
Intact membranes
Delay in oxytocin
Inadequate dose oxytocin
Appropriate dose but hesitant use
Inability to treat overcontracting
Inability to treat fetal intolerance
No oxytocin given
Efficient uterine action (EUA)
EUA Persistent malposition
EUA CPD
(obstructed labour multips)
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
One to one care
Variables
Diagnosis of labour
Fetal monitoring
Assessment of progress
ARM and Oxytocin regimen
Epidural
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 Obstet Gynecol 2015;213:673.e1-8

52. Classification of Caesarean Sections in labour Group 1 NMH 2015
Hypothesis
The incidence and distribution of your caesarean sections together
with fetal and maternal events and 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

53. (NMH 2015)

54. (NMH 2015)

55. (NMH 2015)

56. (NMH 2015)

57. (NMH 2015)

58. (NMH 2015)

59. (NMH 2015)

60. Audit of dystocia Diagnois of labour and assessment of progress
ARM and Oxytocin rates together with their timing
Fetal monitoring
CS rates (classified by TGCS and then indications)
Induction rate
PPH (>1000mls and blood transfusion rate classified by TGCS)
Length of labour
Incidence of one to one care
Patient satisfaction
Neonatal outcomes

61. May help us better understand labour
Classification of Caesarean Section after spontaneous or induced labour
May help us better understand labour
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section. 61

62. Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the source of biggest variation between units 17.2%
National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2013
2015
2379/9180
25.9%
Size of
group %
C/S
rate in gp %
Contr of each gp
25.9 %
1 Nullip single ceph >=37 wks spon lab
178/2043
22.2
8.7
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
16.2
39.3
6.4
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
27.5
1.6
0.5
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
11.3
13.6
5 Previous caesarean section single ceph >= 37 wks
816/1118
12.2
73.0
8.9
6 All nulliparous breeches
193/200
2.2
96.5
7 All multiparous breeches (incl previous caesarean sections)
120/129
1.4
93.0
1.3
8 All multiple pregnancies (incl previous caesarean sections)
119/190
2.1
62.6
9 All abnormal lies (incl previous caesarean sections)
35/35
0.4
100
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
4.5
36.7

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

64. Overall Caesarean Section rates - are not helpful
Current classifications of caesarean sections
Primary and repeat
Sub groups of women
Indications

65. Purpose of classification of Caesarean Section

66. Principles of an ideal classification system
Simple, easy to implement, informative and useful
Robust, self validating and universal
Prospectively determined, clinically relevant, identifiable, totally accountable and replicable
The groups must be objectively defined, mutually exclusive and totally inclusive
Subjective criteria used further down in the classification
Remove variables, but interpret accordingly

67. No perinatal event or outcome should be considered in isolation from other events and outcomes
Risk-Benefit Calculus
Perinatal morbidity and mortality
Maternal morbidity and mortality
Labour and delivery events and outcomes
Complaints, adverse incidents and medico-legal cases
Maternal satisfaction and staff satisfaction
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

68. Classification must be able to incorporate other variables related to perinatal events and outcome
Significant epidemiological factors
Age, BMI, Fetal weight, Casemix
Data collection must be aligned
Organisational systems
Staff and infrastructure resources
Economics of childbirth

69. Is a Caesarean Section an event or an outcome?