Shahela Nasir
Manchester University NHS Foundation Trust (MFT), United KingdomPresentation Title:
Audit of CS rate in NTSV: A Quality Improvement Project
Abstract
Introduction: Caesarean delivery is a life-saving procedure when medically indicated,
but associated with negative impact on maternal and neonatal outcomes.
Each C-delivery increases complication rates for women. Many pregnant
women undergo procedures such as C-sections, repeat C-sections, and
labour inductions that may not be medically indicated. NTSV includes low
risk, first time mom nulliparous, singleton (no twins) with gestational age at
or beyond 37wk with vertex presentation (no breech or transverse lie) who
underwent cs following either spontaneous or induced labour. By
decreasing the C-section rate in this low risk population by improved
quality care can lead to healthy outcomes and cost effectiveness. Alliance
for Innovation on Maternal Health states (AIM, 2022) states, “No one disputes
that caesarean birth can be a lifesaving procedure, with obvious
benefits to mother and baby when vaginal birth is no longer safe.The
Leapfrog Group, 2015 stated that the high NTSV C-section rate and its
extreme variation among hospitals serve as prime examples of a healthcare
system plagued by inconsistent quality and the overuse of avoidable
procedures. In addition, the Joint Commission (TJC, 2015) called the
rise in caesarean “ an epidemic” and recognized “there is no data that
higher rates improve any outcomes, yet the C-section rates continue to rise.”
Over the years, global CS rates have significantly increased from around 7%
in 1990 to 21% today surpassing the ideal acceptable CS rate which is
around 10%–15% according to the WHO (2021).These trends are projected to
continue increasing over the current decade where both unmet needs and
overuse are expected to coexist with the projected global rate of 29% by 2030
(Betran et al.,2021). Due to the uterine scar, the first CS carries intrinsic
risk of repeat CS (RCS) in future pregnancies, justifying the Cragin’s
dictum back in 1916 “once a caesarean always a caesarean”(Barber et
al.,2011). The NTSV(nulliparous term singleton vertex) caesarean
delivery rate has been recognized as a meaningful benchmark. Although it
is considered as a low risk population, with rising trends it
contributed to overall increased caesarean section rate globally. Caesarean
birth has short-term complications, including blood loss, infection, and venous
thrombosis (Bauserman et al., 2015) and long-term effects in subsequent
pregnancies and births, including abnormal placentation and increased
risk of haemorrhage and hysterectomy (Marshall et al.,2011). We
have to critically explore the contributing factors to reduce the rising CS
rates, evaluate current practices, and implement quality improvement
projects, and develop strategies that could form part of a workplace
improvement plan.
Aim & Objective: The audit was conducted to identify and analyse indications for
Caesarean Section in the NTSV at Prince Sultan Hospital, KSA.To reveal
possible areas where clinical practice can be changed to safely reduce
CS rates. It reflects the impact on the patient and demonstrates that by
reducing unnecessary CS in the NTSV population, which is the ultimate
aim. Ensuring safety for both mother & baby and improving patient
expectations.
Design: The 14 months audit is a prospective review which is conducted in the
labour ward of the department of obstetrics & gynaecology at Prince
Sultan Hospital from november 2021 to december 2022.
Method:
Inclusion criteria: All nulliparous women with gestational age at or >37wk with cephalic
presentation who underwent CS following either spontaneous or induced
labour.
Exclusion criteria: All nulliparous patients with abnormal lie and non-vertex presentations,
preterm & multiple pregnancy.
Results: The total number of gravidas who delivered during the study period were
1952, out of which 289(14.80%) were NTSV, among them spontaneous labour were
70.9%, induced were 13.4%, and instrumental deliveries were 12.11%. The CS
among NTSV were found to be 26.9%, and vaginal deliveries were 73%. The main
indications for emergency caesarean sections in NTSV were foetal distress,
non-progress of labour, failed induction i.e. 57%, 28% and 7.6%, respectively.
The overall CS rate was 639(32.7%), and the contribution of NTSV to the overall
CS rate was 3.99%. The average cs rate is 27.60% over 14 months which is
comparable to the national target goal of 26.7% in NTSV. Interpretation of
umbilical artery cord ph were normal (>7.25) in 62.2%, abnormal (<7.20)
in 22.2%,and borderline (7.21-7.24) in 15.6% among CS for foetal distress.
Biography
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