Background
Methods
Design
Setting
Study population
Development interview guide and data collection
1) Quality indicators on planned CS |
a) General counseling, CS is not mentioned (vaginal birth is the normal conduct)
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1. Twin pregnancy and first child cephalic position |
2. Fetal macrosomia (<4.5 kg in maternal diabetes, <5 kg no maternal diabetes) |
3. Preterm labour, cephalic position |
4. Small for gestational age without fetal distress |
5. Previous shoulder dystocia without impaired perinatal outcome |
b) Counseling directed at vaginal birth (vaginal birth and CS are options, vaginal birth is preferred)
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6. Position of the placenta at 1-2 cm of the internal os |
Request for CS without medical grounds: |
7. Explore reason for request |
8. Discuss (dis)advantages to CS birth |
9. In case of extreme fear: offer psychological counselling |
10. Preterm breech birth (frank, complete breech) |
c) Counseling mentioning both vaginal birth and CS as equal options
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11. Breech presentation at term |
Previous CS (inform on risks and chance of successful vaginal birth after cesarean) |
12. Inform on low risk of uterine rupture |
13. Inform on high chance of successful vaginal birth after cesarean |
14. Inform on increased risk and lower success rate in case of need for labour induction |
d) Prevention of planned CS
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15. Offer external cephalic version in case of non-cephalic position |
16. Use of internal audit on CS |
2) Quality indicators on emergency CS |
17. In case of suspected fetal distress use ST analysis or micro blood analysis |
In case of non-progressive labour first stage: |
18. Rupture of membranes, |
19. Urinary catheterization, |
20. Use of pain medication, preferably epidural analgesia, |
21. Adequate contractions or augmentation of labour |
In case of non-progressive labour second stage in nulliparous women: |
22. Active pushing recommended, |
23. Adequate contractions recommended, |
24. Consider vacuum extraction if the head is <1/5th palpable per |
Abdomen |
25. Continuous support during labour for women with or without prior training |
26. Use of partogram |
27. Involvement of consultant obstetrician in decision making for CS |
Data analysis
Results
Most important influencing factors per domain: | ||||
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Domain I Guideline itself | Domain II Professionals | Domain II Professionals | Domain IV Social | Domain V Organizational |
Design • The guidelines are designed for an average patient, instead of an individual | Clinical characteristics • Non-adherence to the guidelines due to patient characteristics | Information by others • Negative experience of friends/family (eg with external cephalic version) | Hampering collaboration • Between obstetricians and anesthesiologists regarding epidural analgesia • Between midwives and obstetricians/residents | No agreements regarding • Responsibility for counseling: the midwife or obstetrician • Variation in standard policy between hospitals (regarding e.g. fetal scalp blood sampling, breech deliveries) • Indications for CS |
Availability • Guidelines are not easy available • Local protocols are not up to date | Counseling • No or too late agreement regarding the possibility of a preterm birth | Patients’ view • Patients do not accept any risks for the fetus. • Refusal of external cephalic version. | Variation in policy • Between different obstetricians | |
Documentation • Unclear documentation on mode of birth counselling • Unclear documentation on previous births | Strict hierarchy • Preventing adequate feedback | Staffing • Appropriate staff not present at the discussion regarding obstetrical decisions • Inadequate staffing and allocation of tasks • Midwives are not invited for audits | ||
Knowledge and skills Insufficient experience or expertise regarding: • Breech deliveries • Foley catheter induction in case of previous CS • Estimation of fetal weight • Fetal scalp blood sampling • External cephalic version | Availability of staff • Obstetricians • Anesthesiologists • Inadequate to provide 1-on- 1 support to women in labour | |||
Attitude • Policy depends on time (day/night) • Fetal scalp blood sampling is time consuming | Availability of diagnostics • Partogram • Fetal scalp blood sampling | |||
Disagreement with guidelines • Behaviour therapy in case of fear for pain is not always strictly necessary • Epidural analgesia is not strictly necessary in case of failure to progress in labor • Don’t use a partogram in case of rapid labour progression ▪ CS should be mentioned in case of severe shoulder dystocia in previous pregnancies, even if there is no residual damage ▪ Assessment by an obstetrician in case of failure to progress before performing a CS depends on a residents’ experience |
Domain I: The CS guideline recommendations
This barrier mainly applies to guidelines aiming at vaginal birth in specific situations, such as fetal macrosomia, labour dystocia, breech presentation and previous shoulder dystocia. Furthermore, obstetricians mentioned that guidelines were not easily available on the professional website, whereas residents noted that local protocols were not always recently updated.‘If the woman is nulliparous, pregnant with a child that is expected to be large for gestational age and with a fetal head not engaged at term, it depends on her characteristics whether or not I will discuss a CS’.
Domain II: The professional domain‘It depends on the client whether or not I would discuss a CS or induction of labour. If the shoulder dystocia was severe, I would not risk to experience that again.’
Lack of experience regarding clinical skills in daily practice was also mentioned among all types of professionals to affect guideline adherence, mainly concerning vaginal breech deliveries, fetal scalp blood sampling and external cephalic version. A midwife adds:You have planned a CS for a woman with a history of fetal macrosomia (4500 grams) and shoulder dystocia. If labour starts prematurely, you might advise her to undergo a vaginal birth, since the expected fetal weight is probably less than 4000 grams’.
One of the obstetricians describes:‘The mode of delivery in case of a breech presentation depends on the expertise of the obstetrician in attendance’.
Another barrier mentioned by the residents regarding the use of fetal scalp blood sampling is the large variation in policy between obstetricians as well as between hospitals. Some obstetricians favour a vacuum extraction when full dilatation of the cervix is reached, whereas others would perform fetal scalp blood sampling in order to, possibly, avoid an operational vaginal birth.‘I believe that we perform a fetal scalp blood sampling about 5 times a year’…. ‘I think this is probably due to insufficient expertise among some of the obstetricians’.
Domain III: The patient context
Domain IV: The social context‘Counselling in pregnancy is fundamentally different, since it concerns the mother but also her child. Women seem more concerned for their current child than for a possible future pregnancy. Sometimes weighing the risks of a vaginal birth after previous CS and taking consequences for future pregnancies into account, is difficult even for healthcare providers’.
Clear agreements on availability of epidural analgesia are mentioned to be a facilitator in this situation.‘In our hospital, the residents are not allowed to independently consult the anaesthesiologist at night. We first have to call the obstetrician, and he or she has to consult the anaesthesiologist. It is a barrier for providing epidural anaesthesia at night.’
Domain V: The organizational context
In women with a previous CS, obstetricians and residents stated that, although a consultation in secondary care is preferred before 20 weeks of pregnancy, the current habit of referral to secondary care at 36 weeks of pregnancy seems too late for an adequate shared decision making process on mode of birth. Women are often already fully focussed on a particular mode of birth, which makes counselling by an obstetrician more difficult. Protocols for cooperation between first and secondary care, considering mode of birth counselling, as well as timing of referral, would facilitate optimal care.‘Obstetricians are sometimes even angry that we already performed the mode of birth counselling and that the pregnant woman chose her mode of birth..’
Domain VI: The financial/ legislation domain‘At first, we had to send the collected blood samples to the laboratory. After they bought a new device, approximately 3 out of 4 samples could not be analysed. You do not wish to experience that.’
‘In our hospital improved support during labour could reduce CS rates. However, we know upfront that an increase in staffing is not an option.’