Did the introduction of an electronic booking form for elective caesarean section improve compliance with guidelines for gestational age at delivery?

Abstract

Background

The Preterm Birth Collaborative in Australia aims to reduce unnecessary preterm and early-term deliveries, addressing preterm birth as a leading cause of infant mortality and long-term disability. Mater Mother’s Hospital (MMH), a tertiary obstetric centre, participates in the national ‘Every Week Counts’ initiative to minimize unnecessary early-term caesarean sections (CSs). Elective CS before 39 weeks raises the risk of neonatal intensive care unit admissions and developmental delays. MMH introduced an electronic CS booking form to improve compliance with clinical guidelines for gestational age at birth and to reduce unwarranted clinical variation.

Methods

A single-centre retrospective audit analysed CS data prior to and post implementing the electronic booking form. Data from 3 months pre- and 3 months post- were extracted from hospital records, assessing demographics, clinical indication, and compliance with national or hospital guidelines. The booking form, created with OnBase software, provided a recommended delivery window based on risk factors, requiring justification for deviations. Compliance with guidelines and rates of unplanned labour before scheduled CS were assessed.

Results

Six months of CS were reviewed, among 1059 screened patients, 557 elective CS cases were assessed, with 283 pre-implementation and 274 post-implementation. Overall compliance with clinical guidelines improved from 90.5% to 94.5% (P = .06). A significant improvement was observed in patients with maternal or foetal risk factors, increasing compliance from 86.8% to 93.3% (P = .04). Compliance among low-risk patients remained high (95.2% pre-implementation vs. 96.8% post-implementation, P = .52). The proportion of CS cases presenting with spontaneous rupture of membranes (SROM) or labour before the scheduled procedure remained unchanged (23.6% vs. 24.8%, P = .75).

Conclusion

The introduction of an electronic CS booking form in conjunction to clinical prioritization improved compliance with clinical guidelines for recommended gestational age at time of delivery, particularly for patients with maternal or neonatal risk factors. While the booking form did not significantly impact overall compliance or the rate of patients presenting with SROM or in labour requiring emergency CS, it highlights the valuable role of digital innovation in reducing unwarranted clinical variation. Future research should explore broader implementation across various healthcare settings.

Introduction

The Preterm Birth Collaborative in Australia aims to reduce the rate of unnecessary preterm and early term deliveries nation-wide. Preterm birth being the leading cause of death in young children and one of the major causes of lifelong disability [1]. Early term birth also has significant implications for the newborn which extend into childhood [2]. With a worldwide rise in the rate of caesarean section (CS) over vaginal delivery, ensuring avoidance of early planned CS without medical indication has become a national priority [3].

Mater Mother’s Hospital (MMH) is a large tertiary hospital serving the South Brisbane community, providing comprehensive obstetric services, and acting as a referral centre for complex obstetric care in Queensland, Australia. As an active member of the national Preterm Birth Collaborative, MMH is dedicated to the ‘Every Week Counts’ initiative, a national program aimed at reducing unnecessary early term births, particularly those occurring without valid medical or obstetric indications. This initiative underscores the risks associated with elective early-term deliveries, including those performed via CS. Research has shown that early term birth—defined as delivery between 37 and 38 weeks of gestation—can increase the likelihood of neonatal complications such as respiratory issues, feeding difficulties, and longer hospital stays [4]. Furthermore, elective CSs before 39 weeks are associated with a higher risk of neonatal intensive care unit admissions, as well as potential long-term developmental and cognitive delays [5, 6]. Audits conducted as part of MMH’s contribution to the Preterm Birth Collaborative revealed instances of low-risk pregnancies being delivered before 39 weeks, highlighting the need for ongoing support in clinical decision-making to ensure that elective early-term deliveries are only considered when medically necessary.

In order to improve scheduling and compliance with guidelines, MMH developed a new electronic booking form for all public elective CS bookings. The form provided clinical prompts regarding timing of birth based on risk factors and required clinicians to justify any ‘override’ of recommended clinical guidelines.

The aim of this project was to evaluate the impact of the new electronic smart booking form. We hypothesize that implementation of the new booking procedure for elective CS at MMH could significantly reduce unwarranted clinical variation relating to guidelines for gestational age at birth by CS. The main outcomes assessed included compliance with guidelines for gestational age at delivery for all elective CS, with stratification into low- and high-risk CS. Our secondary objective was to assess the rate of booked CSs presenting in labour, or prelabour rupture of membranes, necessitating an emergency procedure for delivery prior to booked procedure date.

Methods

Study design

This is a single-centre retrospective audit comprising data from CS performed between the dates of 11 July 2023 to 28 June 2024, utilizing 3 months of data pre implementation and 3 months of data post implementation of the CS booking form. Multiple gestations were counted once only when assessing compliance.

Data were extracted from the hospital patient database and reviewed case by case in order to identify demographics, patient risk factors, mode of delivery, gestational age at time of delivery, and any significant preceding events. These data were then compared to hospital, state and national guidelines for recommendations regarding timing of delivery.

Booking form

A booking form was constructed through the OnBase software program [7]. The form was designed to ensure accuracy of Expected Due Date (EDD) of the pregnancy and to identify any specific risk factors which would impact recommended timing of delivery. The e-booking form would then provide a date range window for proposed CS timing. As an example, a low-risk elective repeat CS would be booked into a 7-day window from 39 + 0 to 39 + 6 weeks gestation. Similar windows were booked at earlier gestations when guidelines recommended early term birth (for example previous classical CS window was from 37 + 0 to 37 + 6 weeks gestation). If there was a request to alter the timing of this CS beyond the prompted date driven by clinical guidelines, an override function was necessary which prompted documentation of the justification for override and review by senior clinician. Furthermore, a senior obstetrician performed clinical triage prior to confirmation of the CS date within the 7-day suggested window provided by the form. This secondary review confirmed presence of risk factors requiring early term delivery, and prioritized CS booked within the same time frame.

Data collection and statistical analysis

Medical chart review of all eligible patients was complete. Relevant clinical data was extracted. The appropriate gestational age for delivery was determined by correlation of patient information with hospital and national guidelines (Table 1). EDD calculation was based on hospital guidelines. The EDD was calculated by last menstrual period (LMP) or alternatively, the earliest first trimester ultrasound (USS) with a crown-rump length (CRL) ≥10 mm if cycles were irregular, contraception was used or if there was a discordance of more than 3 days from the date calculated by LMP. Two clinical staff were required to agree upon EDD at antenatal booking.

Table 1.

Recommended gestational age at elective caesarean by risk factor

Risk factor	Gestational age
Low-risk	39 + 0–39 + 6
Previous classical	37 + 0–37 + 6
GDM controlled	39 + 0–39 + 6
Pre-existing diabetes/GDM poor control	38 + 0–38 + 6
Gestational hypertension	38 + 0–38 + 6
Pre-eclampsia	37 + 0–37 + 6
Vasa-previa	34 + 0–35 + 6
Placenta accreta spectrum	35 + 0–35 + 6
Multiple pregnancy
DCDA	37 + 0–37 + 6
MCDA	36 + 0–36 + 6
MCMA	36 + 0–36 + 6
Foetal growth restriction	From 37 + 0

To determine compliance with guidelines for gestational age at delivery, a number of additional characteristics impacting recommended gestational age at delivery in addition to the indication for CS were reviewed in each case. These include foetal anomaly, poorly controlled gestational diabetes, pre-existing diabetes, hypertensive disorders, multiple pregnancy and foetal growth restriction, abnormal placentation, and other conditions requiring early delivery. Cases were determined to be non-compliant with guidelines if Elective CS was performed prior to the gestational age recommended by hospital guidelines.

All statistical analyses were performed using Microsoft Excel for Mac version 16.66.1.

An ethics application was submitted and approved by the Mater Human Research Ethics Committee. The research was deemed to be compliant with the NHMRC guidance—Ethical Considerations in Quality Assurance and Evaluation Activities 2014.

Results

A total of 1059 participants were initially screened for the study, 502 were excluded due to undergoing emergency CSs without a planned elective procedure (Fig. 1). For statistical analysis and data interpretation, multiple gestation births were combined into a single entry. A total of 557 CS cases were included in the analysis, 135 of which were initially scheduled as elective CS but required expedited delivery due to spontaneous rupture of membranes (SROM) or labour onset—the gestational age at the elective booked procedure was considered for these patients. Of the included participants, 283 belonged to the pre-e-booking form cohort, while 274 were part of the post-e-booking form cohort (Table 2).

Figure 1.

Workflow of the study and participants

Table 2.

Characteristics of pre and post smart form implementation groups

	Pre, N = 283	Post, N = 274	P value
Maternal age (mean)	33.15	33.83	.12a
Gestational age at birth	39.0	39.0	.09b
Median (IQR)	(38.0–39.2)	(38.2–39.3)
Parity median (IQR)	1 (1–2)	1 (1–2)	.89b
Indication for CS, n (%)			.06c
Elective repeat CS	165 (47.69)	181 (52.31)
Malpresentation	30 (58.82)	21 (41.18)
Maternal request	35 (50)	35 (50)
Multiple pregnancy	10 (62.50)	6 (37.50)
Previous obstetric complication	12 (63.16)	7 (36.84)
Other	31 (56.36)	24 (43.63)
Risk factors present, n (%)			.03c
Nil maternal/foetal risks	124 (43.8)	96 (35.0)
One or more maternal/foetal risks	159 (56.2)	178 (65.0)

^aStudent t-test.

^bMann–Whitney U-test.

^cChi-square—calculated for elective repeat and all other indications.

N is total number of participants.

Overall compliance with guidelines for gestational age at delivery for all elective CS is outlined in Table 3. Compliance was high in both groups, with 90.5% compliant prior to the smart booking form, and 94.5% compliant post smart booking form, however this was not statistically significant.

Table 3.

Compliance with gestational age guidelines for delivery

	Pre E form compliant with guidelines (%)	Post E form compliant with guidelines (%)	P-value (chi-squared)
All elective CS	256/283 (90.5)	259/274 (94.5)	.06
Elective CS without additional risks	118/124 (95.2)	93/96 (96.8)	.52
Elective CS with additional risks	138/159(86.8)	166/178 (93.3)	.04
Elective CS performed as emergency CS due to SROM/labour.	67/283 (23.6)	68/274 (24.8)	.75

There was no difference in the high compliance rates for women without additional risk factors with 95.2% vs. 96.8% respectively, P = .52. However, compliance for CS with documented maternal or neonatal risk factors illustrated a significant improvement with recommendations for gestational age at time of delivery, with 86.8% compliance prior to the smart booking form, and 93.3% post smart booking form (P = .04).

The rate of booked CSs presenting with SROM or in labour prior to elective booking was not significantly different following smart booking form introduction.

Discussion

Statement of principal findings

In an attempt to improve compliance with clinical guidelines for recommended gestational age at time of CS, the implementation of an electronic smart booking form did not have a significant impact on compliance for all booked elective CS (P = .06) or overall gestational age at birth. However, with respect to patients with any documented neonatal or maternal risk factors there was a significant effect on compliance (P = .04). Finally, out of 557 booked elective CS, 24% presented with SROM or labour prior to their booked procedure date, with the electronic smart booking form having no significant impact on this (P = .75). Overall, our findings illustrate that a smart booking form can improve compliance with recommended gestational age at time of delivery in some clinical circumstances.

Patients with risk factors present account for over 60% of elective deliveries across the study period with improved compliance noted regardless of the additional underlying risk factors such as hypertensive disorders, gestational diabetes, foetal anomaly and more. Of interest, the proportion of patients with documented risk factors increased following the introduction of the smart booking form. It may be that the need for documented justification of users of the over-ride function improved documentation of the presence of risk factors.

Interpretation within the context of the wider literature

Prediger et al. [8] conducted a systematic review to assess strategies to enhance low risk CS delivery compliance with a gestational age of 39 weeks. Here several methods were successful, including updating hospital guidelines and introducing hospital policies. However, multiple strategies faced barriers to implementation and did not always account for varied risk factors and broader guidelines for delivery gestation. Our study illustrated that for patients with any documented maternal or neonatal risk factors—compliance with guidelines for gestational age at delivery was improved.

Consideration may be given to the non-significant impact of the electronic booking form on all CS, inclusive of low risk and malpresentation pregnancies. Given the enhanced awareness of guidelines surrounding delivery in these scenarios, which has been a major focus of obstetric care over recent years. This is illustrated in the pre-booking form compliance of 95%. These low-risk situations reduce the overall observed impact on correction of guideline adherence in patients with risk factors where timing of delivery can be more varied, particularly between vaginal and CS birth.

An additional perspective that supports our findings of improved compliance is that superior information technology infrastructure enhances compliance with clinical guidelines [9]. By having a digital mechanics for booking, the stop checks and assessment by way of a pre-programmed guideline reduces unwarranted clinical error that exists in an analogue booking system.

With respect to patients presenting with SROM or in labour prior to planned elective procedure, the rate of presentation across the study period is in keeping with broader literature. Since the introduction of strategies to reduce early term birth, studies have identified rates from 21.1% to 25% in some instances [10, 11]. The maternal and neonatal implications of this have not been assessed in this study.

Implications for policy, practice, and research

Several considerations arise from this study. Adherence to clinical guidelines for low-risk pregnancies, scheduling low-risk elective CS at 39 weeks of gestation, has been extensively studied and reinforced over the years. However, many institutions face challenges in minimizing unwarranted clinical variation in CS scheduling for patients with risk factors given the variance in guidelines, especially regarding the timing of vaginal or CS delivery.

This study demonstrated that the implementation of an e-booking system, integrated with clinical guidelines combined with senior clinical review, can enhance overall compliance with recommendations for timing of birth. By incorporating a mechanism that allows clinicians to override suggested guidelines with a required justification, the system provides an important cognitive prompt and vehicle to document reasons for early term birth.

Given the complexities of managing high-volume scheduling in large healthcare institutions, the adoption of similar e-booking forms should be considered to improve adherence to clinical guidelines and reduce variability in practice.

Strengths and limitations

The large size of this study allowed for review of both low-risk CS and CS with additional risk factors, where gestational age at delivery has the most variation. It also illustrates and supports the idea that enhanced digital infrastructure can improve clinical care and reduce unwarranted clinical variation. The study’s limitations should also be acknowledged. The study was performed on a 6-month window and may have been underpowered to assess smaller changes in compliance with guidelines, or rates of CS performed as an emergency. Hence, it may be beneficial to implement the booking form on a larger scale across a health service including multiple facilities. By doing this, future studies may include a larger sample size, with more in-depth analysis on the maternal and neonatal outcomes secondary to implementation.

Conclusions

Overall, this study illustrates the potential benefits of integrating electronic systems into clinical workflow to reduce unwarranted clinical variation. Policymakers and healthcare institutions should consider adopting similar interventions, especially in settings where managing variability in care is critical to improving patient outcomes.

Author contributions

Julian Vitali (Writing—original draft, Writing—review & editing, Investigation and Project administration, Formal analysis, Data curation), Sarah Janssens (Resources, Formal analysis, Writing—review & editing), Neha Ravi (Formal analysis, Writing—review & editing), Huda Safa (Methodology and Conceptualization)

Ethics and other permissions

An ethics application was submitted and approved by Mater Human Research Ethics Committee. The research was deemed to be compliant with the NHMRC guidance—Ethical Considerations in Quality Assurance and Evaluation Activities 2014.

Conflict of interest: None declared.

Funding

None declared.

Data availability

For information on deidentified data please contact the corresponding author.