The National Sentinel Caesarean Section Audit Report The National Sentinel Caesarean Section Audit The National Sentinel Caesarean Section Audit 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: +44 (0)20 7772 6342 Email: [email protected] Copies of this publication can be obtained from: RCOG Bookshop Tel: +44 (0)20 7772 6275 Fax: +44 (0)20 7724 5991 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 iv The National Sentinel Caesarean Section Audit 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 A factor that may offer an alternative explanation for the observed association between an exposure and the outcome in which we are interested.