1077380 clinical practice guideline cephalopelvic disproportion
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Clinical Practice guidelineClinical Practice guideline
““Cephalopelvic disproportion”Cephalopelvic disproportion”
QAQAภาควิ�ชาสู�ติ�ศาสูติร์�และนร์�เวิชวิ�ทยาภาควิ�ชาสู�ติ�ศาสูติร์�และนร์�เวิชวิ�ทยา
29 29 ติ�ลาคม ติ�ลาคม 25472547
Trend of Cesarean Section around the world
0
5
10
15
20
25
30
1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
%
Australia Finland
Iceland Italy
Japan Netherlands
Portugal Sweden
United Kingdom United States
C/S rate in USA 1989-1996
=Total C/S = Primary C/S = VBAC
Race and/or Hispanic origin
Age of mother
Primary cesarean rate by age, race, and Hispanic origin of
mother:United Stated, 1989, 1996, and
2002
Non - Hispanic
black
Non - Hispanic
white
Hispanic
Under 30 years
30 – 39 years
40 years andover
1989
1996
2002
Cesarean section rate Thailand, 1990-96.
Tangcharoensathien et al 1997
38.5542 44.49 46.47
49.18 49.91 51.45
15.19 15.98 16.96 18.44 19.98 21.13 22.44
0
10
20
30
40
50
60
1990 1991 1992 1993 1994 1995 1996
%
District hosp MOPH provincial hosp Other Pub hosp
Private Hospital National average
Impacts
Mistrust
Incorrect attitude
Inequity
Inefficiency
Wasted resource
Lawsuit
To reach the appropriate rate for LT/CSTo reach the appropriate rate for LT/CS
• Professional community takes leading role for ch
ecking and balancing to optimum, by peer review,
and guidelines
• Purchasing community - introduce appropriate
measures
• Empower women on vaginal delivery through inte
nsive and better quality ANC
T
Situation in Songklanagarind Hospital
3.8
46.3 47 46.9 48.3 49.9 50.554.3 53.8 52
54.7
12.59.4
11.99.5
11.29.1 6.7 6.9 6.3
15.714.611.6 12.3 11.8 10.7 9.6
7.8 8.1 6.1
0.4 0.5 0.3 0.6 0.6 0.7 0.3 0.5 0.3 0.4
26.2 27.329.3 29.2
26.529 29
31.133.2 35
0
10
20
30
40
50
60
90 91 92 93 94 95 96 97 98 99
NL
C/S
V/EF/E
BREECH
Modes of delivery in Songklanagarind Hospital
10.7 11.3 11.5 11.5 11.4 12.3 11.5 10.6 12.2 12.7
15.6 16 17.8 17.7 15.1 16.7 17.5 20.5 21 22.3
0
5
10
15
20
25
30
35
40
PRIMARY
PREVIOUS
Indications for Cesarean Section In
Songklanagarind Hospital
90 91 92 93 94 95 96 97 98 99 Year
%
0
5
10
15
20
25
30
Indication for Primary Cesarean Section
90 91 92 93 94 95 96 97 98 99 Year
CPD.
Fetal Distress
Failed Induction
Other
%
22.4
33.3
22.9
26.1
45.7
34.5
25.2
13.814.1
14.7
14.2
20.7
15.7
18.7
15.2
14.2
11.8
20.718.8
14.211.5
14.2
17.8
25.9
36.4
23.6
19
44.3
29.8
23.4
9.8
22.1
0
10
20
30
40
50
Cesarean Section Practice of Staffs
Private
Service
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 number
%
1. Cervix ≥ 3 cm.
2. Good uterine contraction ≥ 2 hrs.
3. Protraction or arrest disorder
4. If 1, 2, 3 are not met, needed two obstetricians
evaluation.
First Guideline of CPD diagnosis(modified from ACOG recommendation)
CPG was approved by Department committee
and implemented in 2000
• Physician compliance with the CPG was
89.2%
C.Suwanrath-Kengpol et al. Int. J. for Quality in Health Care 2004;16;327-332
• Pregnant outcomes were not different
between the two periods
• Cesarean section rate due to CPD was
decreased from 10.7% in 1999 to
8.6% in 2002
Table 4 Factors associated with physician non-compliance using a multivariate logistic regression mode
Factors Odds ratio 95% CI P-value……………………………………………………………………………………….…….. Private care 16.0 3.7 - 69.6 <0.001
Birthweight 3500 g 2.6 1.3 - 5.1 0.01
Short stature (<150 cm) 3.4 1.2 - 9.5 0.02
Nulliparity 5.0 0.6 - 38.9 0.13
Age 35 years 1.0 0.4 - 2.9 0.98
95%CI, 95% confidence interval.
Cesarean Section rate was decreased, but higher than WHO recommendation
Department committee approved revised CPG in December 2002
Revised CPG was implemented in January 2003
Summary
Trend of CS rate due to CPD
--- Predicted CS rate Observed CS rate WHO recommendation
CPG 2
C.Suwanrath-Kengpol et al. Int. J. for
Quality in Health Care 2004;16;327-332
CPG 1
CRITERIA FOR DIAGNOSIS OF CPD
Old CPG Revised CPG
Cervix ≥ 3 cmCervix ≥ 4 cm and
80% of effacement
Good contraction ≥ 2 hrs. Same
Protraction or
arrest disorderSame
If 1, 2, 3 not met, needed
2 obstetricians evaluationSame
2000 2003
เกณฑ์�การ์วิ�น�จฉั�ย CPD (ช�ด 1) ขอร์�บร์องวิ#าผู้�%ป่'วิยร์ายน�(ม�ป่)จจ�ยติ#าง ๆ ด�งติ#อไป่น�(
1 Cervix dilate> 4 cm. Efface > 80% ม� ไม#ม�
2 . Good uterine contraction > 2 Hr. ม� ไม#ม�
3 . Arrest / Protraction of labor ม� ไม#ม�
4 . Prolonged second stage ม� ไม#ม� ลงช,-อ ………………………… .ร์หั�สู……………………. กร์ณ�ไม#คร์บ 1 ,2 ,3 หัร์,อ 1,2,4 โป่ร์ดใช%เกณฑ์�ช�ด 2
เกณฑ์�การ์วิ�น�จฉั�ย CPD (ช�ด 2)สู�ติ�แพทย� 2 ท#าน ท�-ลงนามติ#อท%ายน�( วิ�น�จฉั�ยวิ#าผู้�%ป่'วิยม� CPDจ2าเป่3น%องผู้#าติ�ดโดย เกณฑ์�การ์วิ�น�จฉั�ยย�งไม#คร์บสูาเหัติ� (ร์ะบ�)…………………………………………………ลงช,-อ สู�ติ�แพทย�คนท�- 1 ……………………ร์หั�สู……………….ลงช,-อสู�ติ�แพทย�คนท�- 2……………………ร์หั�สู……………….
Cesarean Section Rate for CPD 2003
8.4 8.5
5.26.4
12 .2
10 .9
0
2
4
6
8
10
12
14
CS rate (%)
Total Non-private PrivateType of service
Before CPG
After CPG
8376.6
92.4
0
20
40
60
80
100
Compliance rate (%)
Total Private Non-private
TotalPrivateNon-private
Compliance Rate of Revised CPG
before CPG
N = 226
after CPG
N = 229
P-value
PP complication (%) 2.7 1.7 0.54
APGAR at 1 min
< 4 (%)
4 - 6 (%)
0.4
4.9
1.3
3.9
0.55
APGAR at 5 min < 7 (%) 0 0.9 0.16
Thick meconium stained in AF (%)
9.3 10.9 0.57
Admission to NICU (%) 0.4 1.7 0.37
Pregnancy outcomes of cesarean section due to CPD
Non-compliance factors (multivariate logistic regression model)
Factors Odds Ratio
95% CI P-value
Private care 3.3 1.23-8.91 0.018
EFW ≥ 3,500 g. 3.3 2.37 – 17.06 < 0.001
Bishop score < 7 6.4 1.27 – 8.53 0.014
• Compliance with the revised CPG = 83%
(target compliance = 85%)
• After revised CPG, no adverse effect of
pregnancy outcomes
• Cesarean section rate did not decrease
within 1 year period
Outcomes of Revised CPG
• Using the revised CPG: decreased the difference
of cesarean section rate between private and non-
private groups (7% vs. 4%)
• CPG Evaluation as research (2 publications)
• Using CPG as a study model for medical personnel
Summary
