WHAT IS A LOW CESAREAN SECTION RATE? ANSWERS FROM A NEW CLASSIFICATION SYSTEM FOR INTRAPARTUM

CESAREAN SECTION

Session: How to maintain low caesarean section rate

Declaration of Good Standing and Conflict of Interest DisclosureMy presentation complies with FIGO’s policy for declaration of good standing and conflict of interest disclosure;

I do not have a financial interest in any product or service related to my presentation;

My participation at this Congress is not supported in any way by a company or organization

Jörg Kessler, Bergen, Norway

Learning objectives

- Be familiar with basic information on Norwegian perinatal statistics

- Understand the philosophy of a new classification system for cesarean delivery during labor

- Acknowledge the potential value of this system in obstetric quality monitoring

Perinatal mortality, Norway (>22 weeks or >500 g)

02468

10

1999 2003 2007 2011 2015

per 1

000

Cerebral palsy, Norway (all types)

Hollung, S. J. et al (2018). EJPN, 22(5), 814–821.

10

12

14

16

18

1999 2004 2009 2014

%

Cesarean delivery, total, Norway

10

12

13

15

17

18

1999 2004 2009 2014

%

Cesarean delivery, total, Norway, Regions

2

4

6

8

10

12

1999 2004 2009 2014

%

Cesarean delivery, Group 1, Norway, Regions

Para 0, >37 weeks, cephalic, spontaneous

Nor-why-cesarean study

Why do we perform cesarean section during labor ?

A systematic approach !

Medical Birth Registry Norway

Classification of intrapartum CS

Fetal (no oxytocin) Dystocia

Efficient uterine action (EUA)Inefficient uterine action (IUA)

EUA - Persistent malposition

EUA - Cephalopelvic disproportion

IUA - Oxytocin -Poor response

IUA -Oxytocin - Inability to treat - Over contracting

IUA -Oxytocin - Inability to treat - Fetal intolerance

IUA -No oxytocin given

Murphy, M. et al. (2015). AJOG, 213(5), 673.e1–673.e8.

Classification of intrapartum CS

- Indication for delivery- Progress of labor- Management (oxytocin)

- Independent of local guidelines- Mutually exclusive

What it tells: Universal use:

Murphy, M. et al. (2015). AJOG, 213(5), 673.e1–673.e8.

Classification of intraprtum CS –Interobserver study

- Seminar ahead of project start

- N=49 participants (11 midwifes, 6 trainees, 32 consultants)

- Training: lecture, group session (2,5 h)

- Test: N=10 cases for classification

- Degree of agreement - Cohen`s Kappa

Methods - interobserver study

PartographOxytocin

Fetal monitoring trace

Results - promising degree of agreement

Level of κ Strength of agreement N (%)

<0.20 Poor 0

0.21-0.40 Fair 0

0.41-0.60 Moderate 9 (18%)

0.61-0.80 Good 20 (41%)

0.81-1.00 Very good 20 (41%)

Nor-why-cesarean study

Data collection: 6 months 15.02.2017- 15.08.2017

Inclusion criteria: - Singleton pregnancy- Gestational age >36+6 weeks- Start of labor: spontaneous or induced

Exclusion criteria: - Multiple pregnancy- Gestational age <37+0 weeks- Pre-labor cesarean delivery

Study population

Non-participating units

n=4689 17.8%Participating units

n=21668 82.2%

Spontaneous start of labor or inductionn=20435 94.3%

Cesarean delivery before laborn=1234 5.7%

Valid project form

n=19061 93.3%No valid project form

n=1374 6.7%

Deliveries, singleton, >36+6 weeks, total n=26357

10-groups classification – all units, NorwayGroup Description n Size of the

group n CS % CS within group Contribution to overall CS

Total 21641 100 % 3003 13,9 % 13,9 %

1 Nullip, ceph, spont 6323 29,2 % 514 8,1 % 2,4 %

2a Nullip, ceph, ind 2182 10,1 % 508 23,3 % 2,3 %

2b Nullip, ceph, CS 135 0,6 % 135 100 % 0,6 %

3 Multip, ceph, spont 8058 37,2 % 116 1,4 % 0,5 %

4a Multip, ceph, ind 1969 9,1 % 93 4,7 % 0,4 %

4b Multip, ceph, CS 178 0,8 % 178 100 % 0,8 %

5a Multip, prev CS, ceph, spont 997 4,6 % 204 20,5 % 0,9 %

5b Multip, prev CS, ceph, ind 468 2,2 % 159 34,0 % 0,7 %

5c Multip, prev CS, ceph, CS 545 2,5 % 545 100 % 2,5 %

6 Nullip, breech 428 1,9 % 328 76,6 % 1,5 %

7 Multip, breech 314 1,4 % 179 57,0 % 0,8 %

10-groups classification - all units, CS full dilatationGroup Description n CS full dilatation

Total 18844 295 (1.5%)

1 Nullip, ceph, spont 5913 110 (1.9%)

2a Nullip, ceph, ind 2052 80 (3.9%)

3 Multip, ceph, spont 7501 18 (0.2%)

4a Multip, ceph, ind 1859 8 (0.4%)

5a Multip, prev CS, ceph, spont 910 25 (2.7%)

5b Multip, prev CS, ceph, ind 434 11 (2.5%)

6 Nullip, breech 203 39 (19.2%)

7 Multip, breech 181 3 (1.7%)

Failed vaginal operative delivery -

cesarean deliveryParticipatingunits

Intrapartum CS classification, total, all unitsGroup 1, 2a, 3, 4a, 5a,b, 6, 7

n Proportion

Total 19062 100 %

Vaginal delivery 17515 91,8 %

Cesarean delivery:

Fetal (no oxytocin) 412 2,0 %

Dystocia, EUA, MP 82 0,4 %

Dystocia, EUA, CPD 50 0,2 %

Dystocia, IUA, Poor response 421 2,1 %

Dystocia, IUA, ITT, Overcontracting 40 0,2 %

Dystocia, IUA, ITT, Fetal intolerance 365 1,8 %

Dystocia, IUA, No oxytocin given 177 0,9 %

Intrapartum CS classification vs. 10 groups, all unitsGroup 1- Nullip, ceph, spont 2a - Nullip, ceph, ind

n Proportion n Proportion

Total 5907 100 % 2048 100 %

Vaginal delivery 5455 92,3 % 1603 78,3 %

Cesarean delivery:

Fetal (no oxytocin) 110 1,9 % 106 5,2 %

Dystocia, EUA, MP 28 0,5 % 18 0,9 %

Dystocia, EUA, CPD 13 0,2 % 10 0,5 %

Dystocia, IUA, Poor response 153 2,6 % 142 6,9 %

Dystocia, IUA, ITT, Overcontracting 19 0,3 % 10 0,5 %

Dystocia, IUA, ITT, Fetal intolerance 100 1,7 % 140 6,8 %

Dystocia, IUA, No oxytocin given 28 0,5 % 18 0,9 %

Intrapartum CS classification vs. 10 groups, all unitsGroup 5a - Multip, prev CS, ceph, spont 5b - Multip, prev CS, ceph, ind

n Proportion n Proportion

Total 909 100 % 433 100 %

Vaginal delivery 747 82,1 % 294 67,9 %

Cesarean delivery:

Fetal (no oxytocin) 46 5,0 % 31 7,2 %

Dystocia, EUA, MP 7 0,8 % 1 0,2 %

Dystocia, EUA, CPD 7 0,8 % 3 0,7 %

Dystocia, IUA, Poor response 36 3,9 % 35 8,1 %

Dystocia, IUA, ITT, Overcontracting 3 0,3 % 5 1,2 %

Dystocia, IUA, ITT, Fetal intolerance 30 3,3 % 35 8,1 %

Dystocia, IUA, No oxytocin given 33 3,6 % 29 6,7 %

Intrapartum CS classification vs. BMI, all unitsGroup 1 BMI<27 BMI>27

n Proportion n Proportion

Total 4266 100 % 777 100 %

Vaginal delivery 3987 93,5 % 671 86,4 %

Cesarean delivery:

Fetal (no oxytocin) 64 1,5 % 23 3,2 %

Dystocia, EUA, MP 15 0,4 % 18 0,9 %

Dystocia, EUA, CPD 8 0,2 % 10 0,5 %

Dystocia, IUA, Poor response 96 2,3 % 142 4,9 %

Dystocia, IUA, ITT, Overcontracting 12 0,3 % 4 0,5 %

Dystocia, IUA, ITT, Fetal intolerance 63 1,5 % 26 3,3 %

Dystocia, IUA, No oxytocin given 21 0,5 % 18 0,9 %

Intrapartum CS classification vs. gest. age, all unitsGroup 1 <41 weeks >41weeks

n Proportion n Proportion

Total 4305 100 % 1601 100 %

Vaginal delivery 4034 93,7 % 1421 86,4 %

Cesarean delivery:

Fetal (no oxytocin) 69 1,6 % 41 2,6 %

Dystocia, EUA, MP 22 0,5 % 6 0,4 %

Dystocia, EUA, CPD 8 0,2 % 5 0,3 %

Dystocia, IUA, Poor response 82 1,9 % 71 4,4 %

Dystocia, IUA, ITT, Overcontracting 13 0,3 % 6 0,4 %

Dystocia, IUA, ITT, Fetal intolerance 59 1,4 % 41 2,6 %

Dystocia, IUA, No oxytocin given 18 0,4 % 10 0,6 %

Key Messages

-Continuous monitoring of maternal and neonatal outcome at each obstetric unit is essential to improve obstetric care

-A new classification system for cesarean delivery during labor has been tested successfully in Norway

-Specific patterns for classification were found assessing the Robson-10-groups, post-term pregnancies and maternal obesity