Using the medical audit cycle to reduce cesarean section rates Michael S. Robson, MD, Ian W. Seudamore, MD, and Sheila M. Walsh, RGN, RM Pembt~ry, United Kingdom OBJECTIVE: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates. STUDY DESIGN: A retrospective medical audit of all deliveries from 1984 to 1988 was performed. The groups of women contributing most to the overall cesarean section rate were identified. Strategies for labor management directed at the primary indication for cesarean section (dystocia) were developed and introduced. The effect was monitored prospectively from 1989 through 1992. Data were analyzed with the X2 test RESULTS: A total of 21,125 deliveries were studied. After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.000t). This was primarily responsible for the overall decrease in the cesarean section rate. CONCLUSION: Effective medical audit of labor management can reduce cesarean section rates. (AM J OBSTET GYNECOL1996;174:199-205.)

Key words: Audit, medical audit, cesarean section, dystocia, labor

T h e r e are wide geographic differences in cesarean section rates, but almost all c o n t i n u e to rise) M t h o u g h the precise relationship between increasing cesarean rates and m a t e r n a l and perinatal morbidity and mortality- is controversial,2. 3 health economics d e m a n d a better understanding of those relationships and ways in which unrewarding surgical intervention at great financial C O S t 4 can be avoided. Obstetric and midwifery training and practices influence cesarean section rates, 1' 5, 6 but less is known about what controls or changes training and practice. 7-~° Medical audit is " t h e systematic and critical analysis of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting o u t c o m e and quality of life for the patient. ''1~ T h e medical audit cycle takes the c o n c e p t of medical audit a stage further, aiming to instigate change and improve care. I2 Appropriate clinical standards are established, c u r r e n t practice is c o m p a r e d , modification of m a n a g e m e n t takes place, and medical audit is c o n t i n u e d with emphasis on c o m p l e t i n g this " f e e d b a c k loop. ''~3 T h e aim of such medical audit is to improve the effectiveness and efficiency of health care. By use of the principles of the medical audit cycle, 12

l~rom the Departments of Obstetrics and Midwifery, Pembury Hospital. Receivedfor publication December 22, 1994; revised April 20, 1995; accepted May 4, 1995. Reprint requests: M. S. Robson, MD, Department of Obstetrics and Gynaecology, WycombeGeneralHospital, High Wycombe,Buckinghamshbe, United Kingdom HPll 2Tl: Copyright © 1996 by Mosby-Year Book, inc. 0002-9378/96 $5. O0+ 0 6/1/66062

cesarean section rates over the 5-year period 1984 to 1988 were d e t e r m i n e d , appropriate standards for practice and outcomes were set, practice was c o m p a r e d with standards, a specific area of m a n a g e m e n t was modified, and finally medical audit was c o n t i n u e d to assess the effect of modification of m a n a g e m e n t . T h e purpose was to see whether introduction and c o m p l e t i o n of the medical audit cycle could influence the cesarean section rate. Material and m e t h o d s

In J u n e 1989 midwives and physicians, working together, began to assess labor ward practice by use of the medical audit cycle (Fig. 1) adapted for the labor ward. T h e aim was a safe delivery of m o t h e r and baby, with minimal intervention and m a x i m u m maternal satisfaction. A retrospective medical audit of the cesarean section rates from 1984 to 1988 was p e r f o r m e d . Data were collected in the category, parity, course, and gestational age of every w o m a n who was delivered during this period, providing a historic control consisting of the entire local obstetric population for a 5-year p e r i o d (Table I). Initially data collection was manual until a c o m p u t e r software program, Midwifery Audit, was written. Cesarean section n u m b e r s and rates in clinically relevant groups of w o m e n were t h e n established by analysis with these prospective criteria as indicated in Tables II and III. T h e object was to identify the groups of w o m e n contributing most to the cesarean section rate. Results

Table IV demonstrates that nulliparous and multiparous w o m e n contributed approximately equally to the 199

200

Robson,Scudamore, and Walsh

Labor outcome

D e t e r m i n e existing standards

\ / Labor events

January 1996 AmJ Obstet Gynecol

/ Assessment of management

Audit

¢,

Modification o f management Fig. 1. Labor ward audit cycle.

n u m b e r of cesarean sections in the years 1984 to 1988. Table V shows that approximately three fourths (1105/ 1518) of all cesarean sections were p e r f o r m e d in singleton, cephalic, term pregnancies. Two subgroups of w o m e n contributed approximately two thirds (724/1105) of these cesarean sections. They were spontaneously laboring nulliparous w o m e n with a singleton, cephalic t e r m pregnancy (group A, n = 300) and nmltiparous w o m e n with a scarred uterus and singleton, cephalic t e r m pregnancy (group B, n = 424) (Table V). These two groups of w o m e n therefore a p p e a r e d to be of most significance to the overall cesarean section rate. G r o u p B contributed m o r e than group A to the overall cesarean section rate but as a group have a h i g h e r risk of complications in labor, especially those with m o r e than one cesarean section. Modification of m a n a g e m e n t in group B would therefore n o t have b e e n easy. A better way to reduce the contribution of group B to the overall cesarean section rate was to prevent the first cesarean section and h e n c e reduce the size of the group itself. Changes in m a n a g e m e n t were therefore directed toward group A. In our medical audit the primary indication for cesarean section in group A was dystocia. This is a finding supported by o t h e r published studies. TM 15 O'Driscoll et a1.16 described a philosophy for the m a n a g e m e n t of labor that is associated with a low cesarean section rate. In particular, they describe the m a n a g e m e n t of labor in spontaneously laboring nulliparous w o m e n with a singleton, cephalic, t e r m pregnancy. This has b e e n successfully used elsewhere to reduce the cesarean section rate. 1v-19 Because dystocia was found to be the primary indication for cesarean section in group A at Pembury, a decision was m a d e to i m p l e m e n t selected c o m p o n e n t s of this philosophy. A set of m a n a g e m e n t guidelines for spontaneous labor in nulliparous w o m e n (group A) were developed and i n t r o d u c e d (Table VI). No o t h e r formal changes in the m a n a g e m e n t of labor of any group of w o m e n were made. The criteria for the diagnosis of labor were intentionally kept flexible. This was i n t e n d e d to place emphasis on the identification of w o m e n in dysfunctional labor before conventional criteria would permit. It was ac-

Table I. Data collection

Category of pregnancy Singleton: Cephalic, breech, or abnormal lie Multiple pregnancies Parity of woman Nulliparous Multiparous: Without uterine scar Multiparous: With uterine scar Course of labor and delivery Spontaneous or induced labor Cesarean section before labor Gestational age of pregnancy

Table II. Analysis by category and gestation

M1 singleton, cephalic, term M1 breeches and abnormal lies M1 premature births (