Audit in Caeserean section At Rural Tertiary health care center

1. A Clinical Audit And
Confidential Enquiry Of
Caeserean Section Indications
At Tertiary Health Care Centre
Dr. Ketki Thool , Senior Resident , MGIMS
Sewagram Wardha , Maharashatra.
Guide: Prof Shuchi Jain,Prof Poonam V Shivkumar

2. INTRODUCTION

3. INTRODUCTION
Caesarean section
(CS ) is a surgical
intervention which
is carried out to
ensure safety of
mother and child
when vaginal
delivery is not
possible

4.  The incidence of caesarean section is
steadily rising. In the last few decades, the
caesarean rates have increased dramatically
in the developed world as well as developing
countries .
 The rapid increase of CS rate throughout
the world has become a serious public health
issue .

5.  As early as 1960, Munro
Kerr wrote
“ I fear that today more than
ever before , there is a
danger of abdominal delivery
being regarded as the
legitimate methods of
dealing with each and every
obstetrical abnormality.”

6. OBJECTIVES

7. • To determine Caeserean section rate in
tertiary health care center .
• To find out commonest indication of
caeserean section in four categories.
• To identify various aspects of decision
taking by confidential enquiry .
OBJECTIVES

8. MATERIALAND
METHODS

9. MATERIAL AND METHODS
Place Of Study: MGIMS, SEVAGRAM
Study Period:
18 months (January 2015 - June 2016)
Study Population :Phase I-2548 Pregnant women who
underwent caeserean section.
PhaseII- 515 women who underwent CS (for confidential
enquiry)
Study Design: Prospective study

10. INCLUSION CRITERIA
All pregnant women who underwent
caeserean section during study period.
All eligible women giving informed
written consent.

11.  Data was retrived from the files and
filled in data collection sheet.
 Files were traced during working hours in the
labour ward and post natal ward within 24 hours of
the CS.
According to indication mentioned
on files CS was distributed into 4
categories according to NICE
guidelines.

12. Classification of Caeserean
section on basis of urgencyCategory I Urgent threat to the life or the
health of a woman or fetus.
Category
II
Maternal or fetal compromise
but not immediately life
threatening.
Category
III
Needing earlier than planned delivery
but without currently evident maternal or
fetal compromise
Category
IV
At a time acceptable to both the woman
and the caesarean section team,
understanding that this can be affected
by a number of factors.

13.  Simultaneously a confidential enquiry was done.
 A predesigned form was filled from health
professional in labour room and anesthetist present
during CS.
 It was done for every 5th CS
and was divided into respective
categories and results were
analyzed.

14. STATISTICAL METHODS:
• descriptive and inferential statistics
using chi square test
SOFTWARE:
• SPSS 17.0
• EPI-INFO 6.0 VERSION
• Graphpad Prism 6.0

15. RESULTS

16. Results
0
1000
2000
3000
4000
5000
6000
7000
8000
Total deliveries Vaginal deliveries Cesarean deliveries
6908
4360
2548
NumberofSubjects
CSR-
36.88
%

17. Type of
Caesarean
section(CS)
Number %
Category I 576 22.62
Category II 984 38.61
Category III 723 28.37
Category IV 265 10.40
Total 2548 100.0
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
22.62%
38.61%
28.37%
10.40%
%ofsubjects
Category of Cesarean Section

18. RESULTS
Indications in Category I
and
Paritywise
distribution

19. Indications in Category I Nulliparous % Multiparous %
Total %
Fetal Bradycardia 342 59.38 70 12.15 412 71.53
Placenta Previa with active
bleeding and in collapsed state
21 3.65 18 3.13 39 6.77
Placental Abruptio with maternal
and foetal compromise
44 7.64 24 4.17 68 11.81
Cord Prolapse 13 2.26 6 1.04 19 3.30
Obstructed Labour 14 2.43 8 1.39 22 3.82
Previous lscs with eminent scar
rupture
0 0.00 11 1.91 11 1.91
Retained 2nd twin 3 0.52 2 0.35 5 0.87
Total 437 75.87 139 24.13 576 100.00
‫-2א‬value 11.25,p=0.50,NS,p>0.05

20. 0%
20%
40%
60%
80%
71.53%
6.77% 11.81%
3.30% 3.82%
1.91% 0.87%
%ofsubjects
Indications

21. 59.38%
3.65%
7.64%
2.26%
2.43%
0%
0.52%
12.15%
3.13%
4.17%
1.04%
1.39%
1.91%
0.35%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Fetal
Bradycardia
Placenta
Previa with
active
bleeding and
in collapsed
state
Placental
Abruptio
with
maternal and
foetal
compromise
Cord
Prolapse
Obstructed
Labour
Previous
lscs with
eminent scar
rupture
Retained
2nd twin
%ofsubjects
Indications
Nulliparous
Multiparous

22. RESULTS
Indications in
Category II and
Paritywise
distribution

23. Indications Nulliparous % Multiparous % Total %
Non reassuring fetal status 303 30.79 79 8.03 382 38.82
Breech presentation in active phase
of labour
117 11.89 28 2.85 145 14.74
Previous LSCS with doubtfull scar
integrity in active phase of labour
0 0.00 141 14.33 141 14.33
Abnormal presentation in active
phase of labour
55 5.59 31 3.15 86 8.74
Deteriorating maternal condition 43 4.37 37 3.76 80 8.13
Deep transverse arrest 44 4.47 17 1.73 61 6.20
Failure to progress in active phase of
labour
54 5.49 11 1.12 65 6.61
Prolonged labour 18 1.83 6 0.61 24 2.44
Total 634 64.43 350 35.57 984 100.00

24. 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
30.79%
11.89%
0%
5.59%
4.37%
4.47%
5.49%
1.83%
8.03%
2.85%
14.33%
3.15%
3.76%
1.73%
1.12%
0.61%
%ofsubjects
Nulliparous Multiparous

25. RESULTS
Indications in
Category III and
Paritywise
distribution

26. Indications Nulliparous % Multiparous % Total %
Failure of induction 152 21.02 25 3.46 177 24.48
Previous LSCS with inadequate
pelvis in latent phase
0 0.00 314 43.43 314 43.43
Previous LSCS with fetoplacental
insufficiency in latent phase of
labour
0 0.00 113 15.63 113 15.63
Breech in latent phase of labour 26 3.60 40 5.53 66 9.13
Previous two LSCS in latent phase of
labour
0 0.00 20 2.77 20 2.77
CPD in latent phase of labour 23 3.18 5 0.69 28 3.87
Mother to fetus transmission 0 0.00 5 0.69 5 0.69
Total 204 28.22 519 71.78 723 100.00
‫-2א‬value 72.18,p=0.0001,Significant

27. -10%
0%
10%
20%
30%
40%
50%
60%
21.02%
0%
0%
3.60%
0%
3.18%
0%
3.46%
43.43%
15.63%
5.53%
2.77%
0.69%
0.69%
%ofsubjects
Indications
Nulliparous Multiparous

28. RESULTS
Indications in
Category IV and
Paritywise
distribution

29. Indications Nulliparous % Multiparous % Total %
Previous CS with inadequate
pelvis
0 0.00 109 2.64 109 41.13
Breech presentation with
inadequate pelvis
53 20 12 20.75 65 24.52
Placenta previum major degree 3 8.68 10 16.98 13 4.90
Maternal request 5 0.00 38 16.23 43 16.37
Contracted pelvis 8 1.13 0 6.04 8 3.01
Abnormal Presentation 3 1.89 7 7.92 10 3.77
Previous two LSCS 0 3.02 11 5.28 11 4.1
Mother to foetus transmission 3 1.13 0 2.64 3 1.1
Previous uterine incision 1 0.37 2 0.75 3 1.1
Total 76 28.67 189 71.32 265 100.00
‫-2א‬value 44.60,p=0.0001,Significant

30. -10%
0%
10%
20%
30%
40%
50%
60%
Failure of
induction
Previous
LSCS with
inadequate
pelvis
Previous LSCS
with
fetoplacental
insufficiency
Breech in
latent phase of
labour
Previous two
LSCS in latent
phase of labour
CPD in latent
phase of labour
Mother to fetus
transmission
21.02%
0%
0%
3.60%
0%
3.18%
0%
3.46%
43.43%
15.63%
5.53%
2.77%
0.69%
0.69%
%ofsubjects
Indications
Nulliparous Multiparous

31. CONFIDENTIAL ENQUIRY
RESULTS

32. CONFIDENTIAL ENQUIRY
RESULTS
Indications CAT I % CATII % CAT
III
% CAT
IV
Total %
Genuine 79 73.83% 157 79.70% 116 76.82% 55 91.66% 407 79.02
%
Uncertain 28 26.17% 40 20.30% 35 23.17% 5 8.34% 108 20.98
107 100 197 100 151 100 60 100 515 100
Confidential enquiry revealed
79.022% indications of LSCS as
genuine.
Compairing indication for which patient was shifted
for Caesarean section and which was found uncertain
by health personnel .

33. 0%
20%
40%
60%
80%
100%
120%
Genuine Uncertain
73.83%
26.17%
79.70%
20.30%
76.82%
23.17%
91.66%
8.34%
%ofpatients
Indications
CAT I CAT II CAT III CAT IV

34. CONFIDENTIAL
ENQUIRY RESULTS
Indications CAT I % CATII % CAT III % CAT
IV
% Total %
Yes 10 10.20 32 16.58 20 13.43 1 1.6 63 12.2
3
No 97 90.65 165 83.75 131 86.75 59 98.3
3
452 87.7
6
107 100 197 100 151 100 60 100 515 100
Decision Taken on
investigations and not
assessing clinically
12.23% cases
decision was taken
on basis on
investigation.

35. 0%
20%
40%
60%
80%
100%
120%
Yes No
10.20%
90.65%
16.58%
83.75%
13.43%
86.75%
1.67%
98.33%
%ofsubjects
Decision taken on investigations
CAT I CAT II CAT III CAT IV

36. DISCUSSION

37. Audit revealed that CSR 36.8%
Other studies
CSR Study done
by
Teaching hospital in Delhi1998-
99
25.4% Kambo I Bedi
Etal( 5)
Maternity hospital in mumbai
2003
16% Mehta A ,
Verstralen
Etal (6)
Teaching hospital in Mexico
2001
21% Khawaja N
and etal (7)
Teaching hospital in Nigeria
1997
30% Ugwu EOV
,Obioha etal
(11)
Teaching hospital in France
2001
15% David S and
etal(8)

38. Category I main indication was foetal
bradycardia .
Category II common indication was
non reasssuring foetal status followed by
Breech.
Category III common indication was
Previous LSCS in Labour with
inadequate pelvis
Category IV common indication was previous
LSCS followed by breech

39.  Foetal bradycardia was common indication for
emergency caeserean section, similar finding was
seen in study done by Naeem M etal(13) . However
Kathyrn etal in subafrican area found obstructed
labour to be a common indication (14).
 Common indication for elective caeserean section
was previous LSCS with inaequate pelvis. Similar
finding was noted by Jackson and etal in 1998 (165)

40.  In a study done at King Edward Memorial Hospital
by Quinlivan Julie and etal reported that common
indication for elective CS was maternal choice
because of refusal for trial of labour following
LSCS(1999).(17)
 Study showed that previous Lscs is an important
factor and contributor in increasing CSR as out of
total LSCS 41.32% women had at least 1 previous
Lscs . Similar findings were noted by Gegory etal in
his study (1994)(18).

41. CONCLUSION

42. CONCLUSIONS
Audit revealed that CSR was high(36.8%) according to WHO
standard.
According to NICE guidelines, 60 % CS were done in
emergency or urgency and rest were sheduled / Elective.
53% CS were done in nulliparous women and main indicatin
was foetal distress while 47% CS were in multiparous
women who had atleast one previous LSCS.
Confidential enquiry revealed that 79.02% CS had genuine
indication while 20.98 % indication were questionable.

43. Confidential enquiry
implication
Possible areas of
improvement
Reviewing of indications like Foetal bradycardia ,
non reasuring Foetal status, previous LSCS in labour etc
• Invovement of senior staff and faculty in decision
making and conduct of CS .
Training of junior faculty in conducting VBAC ,
instrumental delivery and vaginal breech delivery .

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