1624 RCOG NSCS Audit

141 Pages·2001·0.54 MB·English

by  Hard Disk

The National Sentinel
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Caesarean Section Audit
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Caesarean Section Audit
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Report
ISBN 1-900364-66-2
9 781900 364669
RCOG Clinical Effectiveness Support Unit October 2001
The National Sentinel
Caesarean Section Audit
Report
RCOG Clinical Effectiveness Support Unit
October 2001
First published October 2001
© Royal College of Obstetricians and Gynaecologists 2001
ISBN 1-900364-66-2
The use of registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant laws
and regulation and therefore free for general use.
Product liability: the RCOG can give no guarantee for information about drug dosage
and application thereof contained in this publication. In every individual case the
respective user must check its accuracy by consulting other pharmaceutical literature.
Published by the RCOG Press at the
Royal College of Obstetricians and Gynaecologists
27 Sussex Place
Regent’s Park
London
NW1 4RG
Registered Charity No. 213280
Typesetting and printing: FiSH Books, London.
This document should be referenced as:
J Thomas, S Paranjothy Royal College of Obstetricians and Gynaecologists
Clinical Effectiveness Support Unit. National Sentinel Caesarean Section
Audit Report. RCOG Press; 2001.
All correspondence with regard to the content of this Audit should be addressed to:
Clinical Effectiveness Support Unit
Tel: [phone]
Email: [email protected]
Copies of this publication can be obtained from:
RCOG Bookshop
Tel: [phone]
Fax: [phone]
Email: [email protected]
Website: www.rcog.org.uk
Contents
List of Tables iv
List of Figures vi
List of Appendices vi
Abbreviations vii
Glossary of terms used in the survey viii
Contributors and acknowledgements x
Foreword xvii
Introduction xix
1. Background 1
2. Audit methodology 5
3. Data coverage and response rates 14
4. Methods of delivery 17
5. Caesarean section rate: the influence of population and clinical characteristics 24
6. Decision making before caesarean section 45
7. Classification of urgency of caesarean section 49
8. Decision-to-delivery intervals for emergency caesarean section 54
9. Reducing maternal morbidity from caesarean section 57
10. Organisational factors 60
11. Anaesthetic care 83
12. Maternal views of childbirth 95
13. Obstetricians’views of childbirth 104
Conclusion 111
References 113
Appendices 119
iii
Tables
Table 2.1 Levels of evidence
Table 4.1 International caesarean section rates
Table 4.2 Trends in method of delivery
Table 4.3 Method of delivery
Table 4.4a Overall, primary and repeat caesarean section rate by region
Table 4.4b Elective and emergency caesarean section rate
Table 4.5a Caesarean section rate (CSR) for clinical groups: phase one
Table 4.5b Caesarean section rate (CSR) for clinical groups: phase two
Table 4.6 Primary indication for caesarean section as reported by clinicians
Table 5.1a Distribution of demographic characteristics: numbers by region (phase
one data, all women)
Table 5.1b Distribution of demographic characteristics: phase two data
Table 5.2a Caesarean section rate (CSR) by demographic characteristics: phase one
Table 5.2b Caesarean section rate (CSR) by demographic characteristics: phase two
Table 5.3 Crude and adjusted odds ratios for age and ethnicity
Table 5.4a Caesarean section rate (CSR) by gestational age and birth weight: phase
one
Table 5.4b Caesarean section rate (CSR) according to birthweight and gestational age:
phase two
Table 5.5a Distribution of onset of labour: numbers by region
Table 5.6b Onset of labour and caesarean section rate (CSR)
Table 5.7 Term singleton cephalic pregnancies: caesarean section rate (CSR)
Table 5.7a Distribution of birthweight by gestational age: numbers by region (phase
one)
Table 5.7b Distribution of birthweight by gestational age (phase two)
Table 5.8a Distribution of breech babies according to gestational age: numbers by
region
Table 5.8b Caesarean section rate (CSR) for breech babies according to gestational
age
Table 5.9a Distribution of twin pregnancies according to gestational age: numbers by
region
Table 5.9b Caesarean section rate (CSR) for twin pregnancies according to gestational
age
Table 6.1 Decision making before caesarean section (CS)
Table 7.1 Classification of urgency of caesarean section: binary versus four grades of
urgency
Table 7.2 Classification of caesarean section by grades of urgency, by region
Table 7.3 Primary indications for caesarean section (as reported by clinicians) by
grade of urgency
Table 8.1 Decision to delivery interval for acute obstetric emergencies
Table 9.1 Reducing morbidity from caesarean section (CS)
Table 10.1 Number of inpatient beds (antenatal, intrapartum, postnatal) and
admission rooms by region
Table 10.2 Size of maternity units: percentage (%) of units within a region according
to number of deliveries
Table 10.3 Provision of neonatal services (national and regional)
Table 10.4 Median percentage of days (or nights) for each unit with at least 1.15
midwives per woman in labour by region
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Table 10.5 Number and percentage of units where the standard of at least 1.15
midwives per woman in labour was met at least 60% of the time (day or
night) by region
Table 10.6 Median (IQR) percentage of days (or nights) for each unit when there was
at least one midwife per woman in labour by region
Table 10.7 Mean ratio (SD) of total number of midwives to total number of women
on labour ward, by region
Table 10.8 Midwifery models for staffing
Table 10.9 Median number of consultant obstetricians and gynaecologists employed
per unit per 1000 deliveries
Table 10.10 Median (IQR) percentage of days (or nights) for each unit when a
consultant obstetrician ward round occurred, according to region
Table 10.11 Median (IQR) percentage of days (or nights) for each unit when there was
a consultant obstetrician present, according to region
Table 10.12 Dedicated obstetric consultant cover per week for units with greater than
1000 delivery rate, by region
Table 10.13 Consultant presence at potentially complicated caesarean deliveries
Table 10.14 Labour ward staffing and facilities
Table 10.15 Labour ward facilities: obstetric theatres
Table 10.16 Availability of fetal heart monitors
Table 10.17 Audit standards: staffing and facilities survey by region
Table 11.1 Regional analgesia service-provision
Table 11.2 Anaesthesia: units meeting audit standards for regional anaesthesia and
acid prophylaxis
Table 11.3 Anaesthesia: unit policies for acid prophylaxis
Table 11.4 Estimated blood loss at caesarean section
Table 11.5 Anaesthesia: units meeting audit standard for transfusion services
Table 11.6 Anaesthesia: units meeting audit standard for monitoring equipment
during anaesthesia
Table 11.7 Availability of high-dependency or intensive care units and facilities
available within maternity high-dependency units
Table 11.8 Mothers who needed high-dependency or intensive care after caesarean
section, by location of facility
Table11.9 Distribution of units with operational anaesthetic guidelines in labour
ward, by region
Table 11.10 Units meeting anaesthetic services and staffing standards
Table 12.1 Characteristics of women responding to the maternal survey
Table 12.2 Maternal preferences for childbirth
Table12.3 Maternal survey: views on childbirth in general
Table 13.1 Clinical management
Table 13. 2 Clinician advice for women in labour who have had a previous caesarean
section
Table 13.3 Clinical management: response to maternal request for a caesarean
section in the absence of any medical indications
v
Figures
Figure 1 International caesarean section rate
Figure 2 Caesarean section rate by maternal age
Figure 3 Information about birth
Figure 4 Maternal preferences for this birth
Figure 5 Maternal views on childbirth
Figure 6 Maternal birth preferences by preferences about mode of delivery
Figure 7 Clinicians’views on childbirth
Figure 8 Clinicians’views about risks and benefits of elective caesarean section
Appendices
A Phase one hospitals by each region
B Phase two hospitals
C Data collection tools
i Denominator data collection form
ii Denominator data collection form key
iii Clinical data form
iv Clinical data form key
v Organisational survey: staffing and facilities for labour ward
vi Organisational survey: obstetric anaesthetic services
vii Data verification checklist
viii Labour ward diary
D Phase two data collection tools
i Maternal survey
ii Survey of clinicians’views
vi
Abbreviations used in the
survey
CS Caesarean section
CSR Caesarean section rate(s)
CTG Cardiotocograph(y)
ECG Electrocardiogram
EFM Electronic fetal monitoring
ECV External cephalic version
FBS Fetal blood sampling
FHR Fetal heart rate
HDU High-dependency unit
HELLP Haemolysis, elevated liver enzymes and low platelet count
HES Hospital episode statistics
ITU Intensive care unit
LREC Local research and ethics committee
MREC Multicentre research and ethics committee
NCEPOD National Confidential Enquiry into Perioperative Deaths
NICU Neonatal intensive care unit
NSCSA National Sentinel Caesarean Section Audit
ODP Operating department practitioner
OR Odds ratio
SCBU Special care baby unit
SROM Spontaneous rupture of membranes
RCT Randomised controlled trial
VBAC Vaginal birth after caesarean section
WHO World Health Organization
vii
Glossary of terms
Auditable standard An agreed standard against which practice can be
assessed.
Case–control study The study reviews exposures or risk factors, comparing the
exposure in people who have the outcome of interest, for
example the disease or condition (i.e. the cases) with
patients from the same population who do not have the
outcome (i.e. controls).
Cohort study The study involves identification of two groups (cohorts) of
patients, one of which has received the exposure of interest
and one of which has not. These groups are followed
forward to see if they develop the outcome (i.e. the disease
or condition) of interest.
Confounder Afactor that may offer an alternative explanation for the
observed association between an exposure and the
outcome in which we are interested.
Cross-sectional study The observation of a defined population at a single point in
time or time interval. Exposure and outcome are
determined simultaneously.
Denominator data The denominator data forms refer to the data completed for
every birth that occurred within a unit during the audited
period, irrespective of the type of delivery that was
undertaken.
Median If the data is arranged in an increasing order, the middle
value is the median. The range is the difference between
the largest and smallest values. The interquartile range
(IQR) is the difference between the bottom quarter and top
quarter of the data. This is the summary statistic used when
the data is not normally distributed.
Mean This is the summary statistic used when the data follows a
normal distribution. It is the sum of all the values divided
by the number of values. The standard deviation gives a
measure of the spread of individual values about the mean.
Meta-analysis This is an overview of a group of studies that uses
quantitative methods to produce a summary of the results.
Number needed to treat This is the number of patients who need to be treated to
prevent one outcome.
Odds ratio Describes the odds that a case (a person with the
condition) has been exposed to a risk factor relative to the
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The National Sentinel Caesarean Section Audit
odds that a control (a person without the condition) has
been exposed to the risk. The crude odds ratio describes
the association without taking into consideration the
possible effect of any confounders. Adjusted odds ratios
describe the association having adjusted for the effect of
confounders.
Positive predictive value This is the percentage of people who have a positive test
who really have the condition. The predictive value is
dependent upon the prevalence of the disease in the
population being tested, i.e. if the disease is rare, the
predictive value is low, due to the greater influence of false
positive tests.
Randomised controlled trial Agroup of patients is randomised into an experimental
group and a control group. These groups are followed up
for the variables and outcomes of interest. This study is
similar to a cohort study but the exposure is randomly
assigned. Randomisation should ensure that both groups
are equivalent in all aspects except for the exposure of
interest.
Risk ratio Risk is a proportion or percentage. The risk ratio is the ratio
of risk of developing the outcome of interest in an exposed
group compared with the risk of developing the same
outcome in the control group. It is used in randomised
controlled trials and cohort studies.
Risk difference This is the difference in risk of developing the outcome of
interest between the exposed and control groups.
Systematic review This is a literature review using a systematic approach to
minimise bias and random errors, which is documented in
a materials and methods section, may or may not include
meta-analysis.
Sensitivity The ability of the test to detect those who have the disease,
i.e. the proportion (%) of people with the condition who
are detected as having it by the test.
Specificity The ability of the test to identify those without the disease,
i.e. the proportion of people without the condition who are
correctly reassured by a negative test.
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