Csr audit hashem 2016 last modification

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Information about Csr audit hashem 2016 last modification

Published on November 7, 2016

Author: HashemYassin

Source: slideshare.net

1. Caesarean Section Audit Report ~ 2016 Supervision: Haifa A Al-Chalabi FRCOG Done by: Hashem M Yaseen MBBS

2. Introduction & Background 1. Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons. 2. at population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates. 3. Caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Caesarean sections should ideally only be undertaken when medically necessary. 4. Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate. 5. The effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear ~WHO Statement on Caesarean Section Rates 2015

3. • In 2004 comparison of CS rates in Jordan between two periods, 1990-1992 and 1999-2001 showed 2.9% increase in the CS rate in the second period (8% to 10.9%) ~ Hindawi IM1, Saudi Med J. 2004 • According to WHO in 2010, the CSR in Jordan was 18.5 % ~World Health Report (2010) Background Paper, No 30 • The rate of cesarean sections was higher (27.7%) in The National Maternal Morbidity Study (2007-2008) that conducted by The Higher Population Council in collaboration with the Jordanian Health Sector. Introduction & Background

4. Introduction & Background • This audit presents the findings of the data of caesarean section rate (CSR) in the Department of Obstetric and Gynecology in King Abdullah university hospital (KAUH OG). • The audit provides information about the range and determinants of CSR with comparative data about demographic and clinical factors that may be influential. • The data collected in this audit represent set of data collected between October to December in the year 2015 • This audit can be used as the basis for the development of continued local audit.

5. Audit methodology • Detailed information was collected for every caesarean delivery that took place during the three-month study period using clinical data form • There were 18 questions on each clinical data form covering demographic characteristics, details of the index pregnancy, previous obstetric history • Information was collected for all births and all CS using closed questions. All questions were pre-coded. Data were entered manually into SPSS. • Data pertaining to infants who were less than 24 weeks of gestation were excluded from the analysis. Data items collected on all births • Mother’s age • Parity • Number of previous caesarean sections • Gestation age • Labour ( not in labour, spontaneous, induced) • Number of babies • Presentation at delivery • Mode of delivery • Outcome of pregnancy (live/stillbirth) • Birthweight of baby(ies)

6. Distribution ofDistribution of womenwomen characteristicscharacteristics Total maternities (n) Maternities (n) by the mode of deliveries (n) % (n) % Age (years) < 35 120 27.8 301 77.4 ≥ 35 311 72.2 88 22.6 Parity P0 96 22.3 83 21.3 MP no CS 71 16.5 274 70.4 MP with CS 264 61.2 32 8.3 Previous C-section 0 171 39.7 357 91.8 1 134 31.1 32 8.2 ≥ 2 126 29.2 0 0 Gestations (weeks) < 28 4 ~1 5 1.3 28-32 13 3.1 6 1.5 33 - 36 58 13.5 22 5.7 37 - 40 339 78.5 317 81.5 ≥ 41 17 3.9 39 10 Birth weight (grams) < 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3 Onset of labour Spontaneous 91 21.1 301 77.4 IOL* 44 10.2 88 22.6 Not in Labour 296 68.7 0 0 Presentation# Cephalic 369 85.6 386 99.2 Breech 30 7 1 0.3 Number of Fetuses 1 400 92.7 387 99.5 2 23 5.3 2 ^ 0.5 ≥ 3 8 2 0 0 389431 Distribution of demographic characteristics (** including normal vaginal deliveries, assisted vaginal deliveries, and vaginal delivaries after C-section "VBAC" ) CS Vaginal ** 820 # for the singletone fetus ^ were less than 32 wks (* by vaginal prostaglandin, IV oxytocin, or amniotomy)

7. Methods of delivery The Audit results • The total number of deliveries during the three-month study period is 820 cases • The vaginal delivery rate was 46.7 % (including VBAC) • CSR (Primary and repeated) was 52.6 %. CS Count 159 56.60% Count 141 50.20% Count 131 50.80% Count 431 52.60% Total Monthly distribution of CSR Date of delivery October November December

8. Methods of delivery The Audit results • The monthly distribution of CSR in each month of study period, which is comparable in each month, around 51 per cent. 56.6% 50.8% 50.2%

9. •Table 3 shows the CSR, primary and repeat CSR. The primary CSR shown is the rate of CS for women who have not had a previous CS, regardless of parity and cause. This was 39.6 % of CSR. • The repeat CSR was 60.4 %, including 31.6 % with previous one CS, and 28.8 % with two or more previous CS. Higher rates of repeat CS are associated with higher overall CSR. •Rate of vaginal birth after CS (VBAC) is around 4%. This is including 31 of cases (19% of cases who have previous one CS). •Of all CS, 57.3% were classified as elective, 42.7% were emergency procedures. Primary Once Two and more 171 135 125 431 39.60% 31.60% 28.80% 100.00% Table 3: Primary and Repeat CSR Previous C-section Total

10. Primary indications to perform CSPrimary indications to perform CS  the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS) * (including uncontrolled DM, active herpes, Heart disease, Sever Cholestasis, Takayaso complicated with elevated BP) ß (including 3rd & 4th degree perineal tears, previous pelvic floor surgery due to genital prolapse) π (large cervical fibroid, hx of uterine perforation) # Failure to progress Frequency Percent Failed induction 9 34.6 In labour 17 65.4 $ Previous caesaran section Frequency Percent Once 37 24 Two and more 119 76 ** Maternal request Frequency Percent Primary 28 35.4 Once 51 64.6 Frequency Valid Percent Previous caesaran section $ 156 35.9 Maternal request ** 79 18.2 Presumed fetal compromise IUGR Bad CTG 72 16.6 Multiple pregnancy 29 6.7 Failure to progress (induction in labour)# 26 6 Breech presentation 24 5.5 Pre-eclampsia Eclampsia HELLP 9 2.1 Previous infertility 9 2.1 Malpresentation Unstable lie 8 1.8 Maternal medical disease* 6 1.4 Placenta previa, not actively Bleeding 4 0.9 Antepartum Hemorrhage 4 0.9 Previous physically traumatic vaginal deliveryß 4 0.9 Cord prolapse 2 0.5 other (maternal) π 2 0.5 Total 434 100 Table 5: Primary indication to perform CS

11. Primary indications to perform CSPrimary indications to perform CS  the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS) •The most frequently cited indication for CS is repeat CS (previous caesarean section). The percentage of CS reported to be performed for this indication is around 36 %. Frequency Valid Percent Previous caesaran section $ 156 35.9 Maternal request ** 79 18.2 Presumed fetal compromise IUGR Bad CTG 72 16.6 Multiple pregnancy 29 6.7 Failure to progress (induction in labour)# 26 6 Breech presentation 24 5.5 Pre-eclampsia Eclampsia HELLP 9 2.1 Previous infertility 9 2.1 Malpresentation Unstable lie 8 1.8 Maternal medical disease* 6 1.4 Placenta previa, not actively Bleeding 4 0.9 Antepartum Hemorrhage 4 0.9 Previous physically traumatic vaginal deliveryß 4 0.9 Cord prolapse 2 0.5 other (maternal) π 2 0.5 Total 434 100 Table 5: Primary indication to perform CS

12. Primary indications to perform CSPrimary indications to perform CS  the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS) •Maternal request is the second most commonly cited reason for performing a CS, it is reported by clinicians to be performed for maternal request contributed 18.2 % overall CSR. But 51 cases of maternal request (64.6%) have one previous CS, and they asked for CS directly without trial of labour, which means that 35.4 % of cases were primarily performed for maternal request ( 28 of cases) which equal 6.44% of overall CSR. Frequency Valid Percent Previous caesaran section $ 156 35.9 Maternal request ** 79 18.2 Presumed fetal compromise IUGR Bad CTG 72 16.6 Multiple pregnancy 29 6.7 Failure to progress (induction in labour)# 26 6 Breech presentation 24 5.5 Pre-eclampsia Eclampsia HELLP 9 2.1 Previous infertility 9 2.1 Malpresentation Unstable lie 8 1.8 Maternal medical disease* 6 1.4 Placenta previa, not actively Bleeding 4 0.9 Antepartum Hemorrhage 4 0.9 Previous physically traumatic vaginal deliveryß 4 0.9 Cord prolapse 2 0.5 other (maternal) π 2 0.5 Total 434 100 Table 5: Primary indication to perform CS

13. Primary indications to perform CSPrimary indications to perform CS  the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS) •Presumed fetal compromise, including suspected intrauterine growth restriction or an abnormal CTG was the third most commonly cited indication, contributing 16.6% overall. Frequency Valid Percent Previous caesaran section $ 156 35.9 Maternal request ** 79 18.2 Presumed fetal compromise IUGR Bad CTG 72 16.6 Multiple pregnancy 29 6.7 Failure to progress (induction in labour)# 26 6 Breech presentation 24 5.5 Pre-eclampsia Eclampsia HELLP 9 2.1 Previous infertility 9 2.1 Malpresentation Unstable lie 8 1.8 Maternal medical disease* 6 1.4 Placenta previa, not actively Bleeding 4 0.9 Antepartum Hemorrhage 4 0.9 Previous physically traumatic vaginal deliveryß 4 0.9 Cord prolapse 2 0.5 other (maternal) π 2 0.5 Total 434 100 Table 5: Primary indication to perform CS

14. Primary indications to perform CSPrimary indications to perform CS  the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS) •CS performed for malpresentation (including Breech presentation, unstable lie, and other malpresentations) was the fourth most commonly reported indication. Overall, 7.3% (range between 5.5 % for Breech and 1.8% for other) of CS were performed for this indication. •Multiple pregnancies was the fifth commonly reported indication for CS, contributing 6.7% •Failure to progress is the sixth commonly cited reason for performing a CS, either induction of labour or spontaneously onset of labour Frequency Valid Percent Previous caesaran section $ 156 35.9 Maternal request ** 79 18.2 Presumed fetal compromise IUGR Bad CTG 72 16.6 Multiple pregnancy 29 6.7 Failure to progress (induction in labour)# 26 6 Breech presentation 24 5.5 Pre-eclampsia Eclampsia HELLP 9 2.1 Previous infertility 9 2.1 Malpresentation Unstable lie 8 1.8 Maternal medical disease* 6 1.4 Placenta previa, not actively Bleeding 4 0.9 Antepartum Hemorrhage 4 0.9 Previous physically traumatic vaginal deliveryß 4 0.9 Cord prolapse 2 0.5 other (maternal) π 2 0.5 Total 434 100 Table 5: Primary indication to perform CS

15. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Maternal ageMaternal age Background Less than one-third of ever-married women (31 percent) are under age 30. This represents a decline from 34 percent in 2002 and 32 percent in 2007 and 2009. This decline in the proportion of young women in the ever-married population is mainly the consequence of increasing age at marriage. In contrast, the proportion of ever- married women age 30-49 has increased from 66 percent in 2002 to 68 percent in 2007 and 2009 and to 69 percent in 2012. ~ The 2012 Jordan Population and Family Health Survey (JPFHS) On average, a woman in Jordan will give birth to less than one child (0.8) by age 25 and, similarly, about two children (1.9) between the ages of 25 and 34 years. In the age group 15-19 years, fertility rates are quite low (26 births per 1,000 women). Rates then increase dramatically to reach a maximum of 209 births per 1,000 women in the age group 25-29 years. Above age 29, rates decline slowly but regularly. ~ (2012 JPFHS)

16. Total maternities (n) Maternities (n) by the mode of deliveries (n) % (n) % Age (years) < 35 120 27.8 301 77.4 >= 35 311 72.2 88 22.6 Parity P0 96 22.3 83 21.3 MP no CS 71 16.5 274 70.4 MP with CS 264 61.2 32 8.3 Previous C-section Primary 171 39.7 357 91.8 Once 134 31.1 32 8.2 Two and more 126 29.2 0 0 Gestations (weeks) less 28 4 ~1 5 1.3 28-32 13 3.1 6 1.5 33 - 36 58 13.5 22 5.7 37 - 40 339 78.5 317 81.5 41and more 17 3.9 39 10 Distribution of demographic characteristics (** including normal vaginal deliveries, assisted vaginal deliveries, and vaginal delivaries after C-section "VBAC" ) CS Vaginal ** 820 389431 Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Maternal ageMaternal age The Audit results •The average age of mothers giving birth in our hospital during the study period was 29 years. •The average age at birth of the first baby was 24 years.

17. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Overall, 2% of mothers were under 20 years old. The proportion of mothers over 35 years old was 25% overall; about 7% of mothers were over 40 years old . The rates were lowest for mothers under 20 years old (33.3%); they were 57.8% for mothers aged between 35 years and 39 years and 57.6% for those aged more than 40 years. 33.3% 57.8% 57.6%

18. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate The rate of emergency CS was higher in the mothers under 20 years old (5 of 6 cases were emergency), 83.3%, while the rates of emergency and elective CS were 50% for both in mothers aged between 25-29 years old, While 33% of CS were emergency in mothers aged above 35 years old . 83.3%

19. Total maternities (n) Maternities (n) by the mode of deliveries (n) % (n) % Age (years) < 35 120 27.8 301 77.4 >= 35 311 72.2 88 22.6 Parity P0 96 22.3 83 21.3 MP no CS 71 16.5 274 70.4 MP with CS 264 61.2 32 8.3 Previous C-section Primary 171 39.7 357 91.8 Once 134 31.1 32 8.2 Two and more 126 29.2 0 0 Gestations (weeks) less 28 4 ~1 5 1.3 28-32 13 3.1 6 1.5 33 - 36 58 13.5 22 5.7 37 - 40 339 78.5 317 81.5 41and more 17 3.9 39 10 Distribution of demographic characteristics (** including normal vaginal deliveries, assisted vaginal deliveries, and vaginal delivaries after C-section "VBAC" ) CS Vaginal ** 820 389431 Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Parity and previous caesarean sectionParity and previous caesarean section The Audit results •As Table shows, the CSR was 22% for primigravid women, 16 % for multiparous women who had not had a previous CS and 61 % for multiparous women who had had at least one previous CS. •The most common primary indications reported for women having a primary CS were presumed fetal compromise (16.6%), multiple pregnancy (6.7%), failure to progress (6%) and Breech presentation (5.5%).

20. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Parity and previous caesarean sectionParity and previous caesarean section The Audit results •This group includes both nulliparous and multiparous women but the majority (61%) having a primary CS were multiparous women who had had at least one previous CS. The most common indications for women having a repeat CS were previous CS (36%), maternal request as reported by clinicians (6.44% of overall CSR), failure to progress (2%), presumed fetal compromise (7%) and malpresentation (4%). Vaginal VBAC CS Vaccum Count 79 0 100 3 182 % within Parity 43.40% 0.00% 54.90% 1.60% 100.00% Count 260 0 69 2 331 % within Parity 78.50% 0.00% 20.80% 0.60% 100.00% Count 0 31 262 1 307 % within Parity 0% 10.10% 89.30% 0.30% 100.00% Count 352 31 431 6 820 % within Parity 42.90% 3.80% 52.60% 0.70% 100.00% Total Table 10: Parity * Mode of delivery Crosstabulation Mode of delivery Total Parity P0 MP no CS MP with CS

21. Total maternities (n) Maternities (n) by the mode of deliveries (n) % (n) % Age (years) < 35 120 27.8 301 77.4 >= 35 311 72.2 88 22.6 Parity P0 96 22.3 83 21.3 MP no CS 71 16.5 274 70.4 MP with CS 264 61.2 32 8.3 Previous C-section Primary 171 39.7 357 91.8 Once 134 31.1 32 8.2 Two and more 126 29.2 0 0 Gestations (weeks) less 28 4 ~1 5 1.3 28-32 13 3.1 6 1.5 33 - 36 58 13.5 22 5.7 37 - 40 339 78.5 317 81.5 41and more 17 3.9 39 10 Distribution of demographic characteristics (** including normal vaginal deliveries, assisted vaginal deliveries, and vaginal delivaries after C-section "VBAC" ) CS Vaginal ** 820 389431 Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Gestation and birthweightGestation and birthweight Background •ICD-11 classification defines low birthweight as less than 2500 g, very low birthweight as less than 1500 g and extremely low birthweight as less than 1000 g. Gestational age is defined as the duration of gestation measured from the first day of the last normal menstrual period expressed as completed days or completed weeks. Preterm birth is defined as less than 37 completed weeks, term as 37 completed weeks to less than 42 completed weeks, post term as 42 completed weeks or more. •The incidence of low birthweight was 10% in Jordan 1997 ~ Low Birthweight: Country, regional and global estimates. UNICEF, New York, 2004. Birth weight (grams) less 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3

22. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Gestation and birthweightGestation and birthweight The Audit results •Overall, 80% of mothers had their babies at term and 7% delivered post term. Ten percent of mothers delivered at 33–36 weeks and about 3.5 % delivered at less than 33 weeks of gestation.

23. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Gestation and birthweightGestation and birthweight The Audit results •Overall, 12.2 % of babies were low birthweight (less than 2500 g), 2.9% were very low birthweight (less than 1500 g), and 2.9% of babies weighed more than 4000 g at birth. •The average birthweight at term was 3107 g; 2.8 % of babies weighed more than 4000 g. Birth weight (grams) Frequency Percent less 1500 24 2.9 1500-2499 76 9.3 2500-4000 696 84.9 more 4000 24 2.9 Total 820 100

24. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Gestation and birthweightGestation and birthweight The Audit results •For those babies born at term, 5.1 % were low birthweight, 0.4 % were less than 1500 g.

25. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Birth weight (grams) less 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3 Onset of labour Spontaneous 91 21.1 301 77.4 IOL* 44 10.2 88 22.6 Not in Labour 296 68.7 0 0 Presentation Cephalic 369 85.6 386 99.2 Breech 30 7 1 0.3 Other # 32 7.4 2 0.5 Number of Fetuses Singletone 400 92.7 387 99.5 Twin 23 5.3 2 ^ 0.5 More 8 2 0 0 Outcome Nursery 366 84.9 351 90.2 NICU 62 14.4 32 8.2 Death $ 3 0.7 6 1.6 # twins ^ were less than 32 wks $ IUFD (2 cases were term pregnancies, the others were less than 32 wks (* by vaginal prostaglandin, IV oxytocin, or amniotomy) Induction of labourInduction of labour Background •Induction of labour is defined as an intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix and birth of the baby. This includes women with intact membranes and women with spontaneous rupture of the membranes but who are not in labour. ~RCOG Clinical Effectiveness Support Unit. Induction of Labour. Evidence- based Clinical Guideline No. 9. London: RCOG Press; 2001.

26. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Birth weight (grams) less 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3 Onset of labour Spontaneous 91 21.1 301 77.4 IOL* 44 10.2 88 22.6 Not in Labour 296 68.7 0 0 Presentation Cephalic 369 85.6 386 99.2 Breech 30 7 1 0.3 Other # 32 7.4 2 0.5 Number of Fetuses Singletone 400 92.7 387 99.5 Twin 23 5.3 2 ^ 0.5 More 8 2 0 0 Outcome Nursery 366 84.9 351 90.2 NICU 62 14.4 32 8.2 Death $ 3 0.7 6 1.6 # twins ^ were less than 32 wks $ IUFD (2 cases were term pregnancies, the others were less than 32 wks (* by vaginal prostaglandin, IV oxytocin, or amniotomy) Induction of labourInduction of labour Background •Induced labour was associated with fetal distress; electronic fetal monitoring predicts fetal distress and operative deliveries; operative deliveries had an effect on lower Apgar scores at 1 minute; Apgar scores at 1 minute have a direct effect on fetal distress, lower Apgar scores at 5 minutes and need for resuscitations. Oxytocin for induction predicted perineal trauma, perianal trauma has a direct effect on postpartum haemorrhage . Postpartum haemorrhage had a direct effect on lower haemoglobin level six weeks following birth, birth weight had a direct effect on Apgar score at 5 minutes. ~Hatamleh R, Sinclair M, Kernohan G, Bunting B (2013). The Cumulative Effect of Induction of Labour on Maternal and Infant Morbidity in Northern Jordan. Int. Res. J. Basic Clin

27. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Birth weight (grams) less 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3 Onset of labour Spontaneous 91 21.1 301 77.4 IOL* 44 10.2 88 22.6 Not in Labour 296 68.7 0 0 Presentation Cephalic 369 85.6 386 99.2 Breech 30 7 1 0.3 Other # 32 7.4 2 0.5 Number of Fetuses Singletone 400 92.7 387 99.5 Twin 23 5.3 2 ^ 0.5 More 8 2 0 0 Outcome Nursery 366 84.9 351 90.2 NICU 62 14.4 32 8.2 Death $ 3 0.7 6 1.6 # twins ^ were less than 32 wks $ IUFD (2 cases were term pregnancies, the others were less than 32 wks (* by vaginal prostaglandin, IV oxytocin, or amniotomy) Induction of labourInduction of labour The Audit results •The overall rate of induction of labour was 16.2 %. Forty-seven percent of inductions were in women who were primigravid, 53% in women who were multiparous with no previous CS. •Overall, 84% of inductions were carried out before 41 weeks and 16% after 41 weeks of gestation, 3% of inductions were carried before 32 weeks of gestations, and the remaining 4% carried between 33- 36 wks.

28. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate The Audit results •The overall CSR among women who had induction of labour was about 34%. Among primigravid women, the CSR was 43%, and among multiparous women with no previous CS it was 16%. •The most influential factor in deciding to perform these CS was presumed fetal compromise (48% cases), failure to progress (35% cases), maternal refusal to continue IOL (11% cases), and cord prolapsed (4% = 2 cases). Induction of labourInduction of labour

29. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Multiple pregnanciesMultiple pregnancies Background •The National Maternal Morbidity Study (2007-2008) that conducted by The Higher Population Council in collaboration with the Jordanian Health Sector found that multiple pregnancies accounts 5.1 % as one of the main reasons for cesarean section between Jordanian women. •Same study found Also that multiple pregnancies considered as a morbidity, on which contributed 1.6 % in current pregnancy (2007-2008) and History of 1.3 % morbidity during last pregnancy (before the current) regarding Jordanian women.

30. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Birth weight (grams) less 1500 16 3.7 8 2.1 1500-2499 58 13.4 18 4.6 2500-4000 342 79.5 354 91 more 4000 15 3.4 9 2.3 Onset of labour Spontaneous 91 21.1 301 77.4 IOL* 44 10.2 88 22.6 Not in Labour 296 68.7 0 0 Presentation Cephalic 369 85.6 386 99.2 Breech 30 7 1 0.3 Other # 32 7.4 2 0.5 Number of Fetuses Singletone 400 92.7 387 99.5 Twin 23 5.3 2 ^ 0.5 More 8 2 0 0 Outcome Nursery 366 84.9 351 90.2 NICU 62 14.4 32 8.2 Death $ 3 0.7 6 1.6 # twins ^ were less than 32 wks $ IUFD (2 cases were term pregnancies, the others were less than 32 wks (* by vaginal prostaglandin, IV oxytocin, or amniotomy) Multiple pregnanciesMultiple pregnancies Background •The incidence of twins varies considerably between communities and families and has recently increased because of the number of older mothers and the use of fertility treatments and assisted conception. •Infants from a twin pregnancy are at a higher risk of death around the time of birth than are infants from a singleton pregnancy. •Some of this is due to a higher risk of preterm birth. •The second-born twin has an increased risk of a poor perinatal outcome compared with the first-born twin ~Hofmeyr G, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD006553. DOI 10.1002/14651858.CD006553.pub

31. Influence of population and clinicalInfluence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate Multiple pregnanciesMultiple pregnancies The Audit results •The multiple birth rate was approximately 40 per 1000 pregnancies. The twinning rate was 30 per 1000 pregnancies. Higher order births occurred at a rate of 10 per 1000. •Preterm birth was more common with multiple pregnancy. Sixty four percent of twin pregnancies delivered before 37 weeks gestation (compared with 10.5 % of singletons). less 28 28-32 33 - 36 37 - 40 41and more Count 7 12 66 646 56 787 % within Number of Fetuses 0.90% 1.50% 8.40% 82.10% 7.10% 100.00% % of Total 0.90% 1.50% 8.00% 78.80% 6.80% 96.00% Count 2 3 11 9 0 25 % within Number of Fetuses 8.00% 12.00% 44.00% 36.00% 0.00% 100.00% % of Total 0.20% 0.40% 1.30% 1.10% 0.00% 3.00% Count 0 4 3 1 0 8 % within NumBer of Fetuses 0.00% 50.00% 37.50% 12.50% 0.00% 100.00% % of Total 0.00% 0.50% 0.40% 0.10% 0.00% 1.00% Count 9 19 80 656 56 820 % within NumBer of Fetuses 1.10% 2.30% 9.80% 80.00% 6.80% 100.00% % of Total 1.10% 2.30% 9.80% 80.00% 6.80% 100.00% Total Table 26: Number of Fetuses * Gestations (weeks) Crosstabulation Gestations (weeks) Total Number of Fetuses Singleton Twin More

32. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request Background • Cesarean delivery on maternal request is defined as a primary prelabor cesarean delivery on maternal request in the absence of any maternal or fetal indications. • Recent study (2015) aimed to determine the popularity of cesarean sections on demand among women in Saudi Arabia They found 80.9% of the study population preferred vaginal delivery. Among the women who preferred vaginal delivery, 62.8% did so because they needed a shorter time to return to normal life, while 70.3% of the women who preferred CS did so because they wanted to avoid labor pains. • Estimates of the prevalence of cesarean delivery on maternal request range from 1 to 18 percent of all cesarean deliveries worldwide, and <1 to 3 percent of all cesarean deliveries in the United States ~ PubMed: Trends in maternal request cesarean delivery from 1991 to 2004. [Obstet Gynecol. 2007] • The potential benefits of elective cesarean delivery as compared to vaginal delivery are not fully understood but are thought to include decreased risk of urinary incontinence, pelvic organ prolapse, anal sphincter damage, and fecal incontinence. Elective cesarean delivery also has the benefit of flexible timing for mother and physician. ~ NIH State-of-the-Science Conference: Cesarean Delivery on Maternal Request March 27–29, 2006

33. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request Background • Given the balance of risks and benefits associated with cesarean delivery on maternal request, the Committee on Obstetric Practice offers the following recommendations: • In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended. The following is recommended in cases in which cesarean delivery on maternal request is planned: • Cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks. • Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. • Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa,placenta accreta, and gravid hysterectomy increase with each cesarean delivery ~ Cesarean delivery on maternal request. Committee Opinion No. 559. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:121;904–7.

34. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request The Audit results The table above shows the frequency of maternal request according to the mother’s age. The majority of request found in the age between 25-29 years, accounts around 39 %. 9% of maternal request noticed in the younger group between 20 – 24 years. Frequency Percent 20-24 7 8.9 25-29 31 39.2 30-34 24 30.4 35-39 10 12.7 more = 40 7 8.9 Total 79 100 CSR upon Maternal request: Mother's age (years)

35. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request The Audit results The reported rate of maternal request for elective CS was 87.3 % * An emergency CS due to maternal refusal to continue vaginal delivery (already in labour) Frequency Percent Elective 69 87.3 Emergency* 10 12.7 Total 79 100 CSR upon Maternal request : C-section

36. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request The Audit results CS that reported by clinicians to be performed for maternal request contributed 18.2 % overall CSR. But 51 cases of maternal request (64.6%) have one previous CS, and they asked for CS directly without trial of labour, which means that 35.4 % of cases were primarily performed for maternal request ( 28 of cases) which equal 6.44% of overall CSR Frequency Percent Once 51 64.6 Primary 28 35.4 Total 79 100 CSR upon Maternal request : Previous C-section

37. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request The Audit results The table above compares maternal request in primigravid women, multiparous women who had not had a previous CS and multiparous women who had had at least one previous CS. The findings were 22.8%, 11.4 %, and 65.8 % respectively Frequency Percent MP no CS 9 11.4 MP with CS 52 65.8 P0 18 22.8 Total 79 100 CSR upon Maternal request : Parity

38. Decision making beforeDecision making before Caesarean sectionCaesarean section CSR upon Maternal requestCSR upon Maternal request The Audit results Finally, the effect of consultants in the decisions for doing CS upon maternal request, either as a primary CS, or maternal refusal to has Trial of labour. For more details we suggest a survey for consultant response to maternal request, If a woman wants to have a CS she should be able to have one, or should not be interfered with a natural process of birth unless necessary. Frequency Percent A 14 17.7 B 1 1.3 C 10 12.7 D 4 5.1 E 2 2.5 F 7 8.9 G 14 17.7 H 10 12.7 K 9 11.4 L 3 3.8 M 5 6.3 Total 79 100 CSR upon Maternal request : Specialist (doctor Proof)

39. Caesarean Section Audit Report ~ 2016 Supervision: Haifa A Al-Chalabi FRCOG Done by: Hashem M Yaseen MBBS

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