Table 2.

Professionals’ perceived barriers and facilitators for adherence to CS guidelines

Most important influencing factors per domain:
Domain I Guideline itself	Domain II Professionals	Domain II Professionals	Domain IV Social	Domain V Organizational
Design • The guidelines are designed for an average patient, instead of an individual	Clinical characteristics • Non-adherence to the guidelines due to patient characteristics	Information by others • Negative experience of friends/family (eg with external cephalic version)	Hampering collaboration • Between obstetricians and anesthesiologists regarding epidural analgesia • Between midwives and obstetricians/residents	No agreements regarding • Responsibility for counseling: the midwife or obstetrician • Variation in standard policy between hospitals (regarding e.g. fetal scalp blood sampling, breech deliveries) • Indications for CS
Availability • Guidelines are not easy available • Local protocols are not up to date	Counseling • No or too late agreement regarding the possibility of a preterm birth	Patients’ view • Patients do not accept any risks for the fetus. • Refusal of external cephalic version.	Variation in policy • Between different obstetricians
	Documentation • Unclear documentation on mode of birth counselling • Unclear documentation on previous births		Strict hierarchy • Preventing adequate feedback	Staffing • Appropriate staff not present at the discussion regarding obstetrical decisions • Inadequate staffing and allocation of tasks • Midwives are not invited for audits
	Knowledge and skills Insufficient experience or expertise regarding: • Breech deliveries • Foley catheter induction in case of previous CS • Estimation of fetal weight • Fetal scalp blood sampling • External cephalic version			Availability of staff • Obstetricians • Anesthesiologists • Inadequate to provide 1-on- 1 support to women in labour
	Attitude • Policy depends on time (day/night) • Fetal scalp blood sampling is time consuming			Availability of diagnostics • Partogram • Fetal scalp blood sampling
	Disagreement with guidelines • Behaviour therapy in case of fear for pain is not always strictly necessary • Epidural analgesia is not strictly necessary in case of failure to progress in labor • Don’t use a partogram in case of rapid labour progression ▪ CS should be mentioned in case of severe shoulder dystocia in previous pregnancies, even if there is no residual damage ▪ Assessment by an obstetrician in case of failure to progress before performing a CS depends on a residents’ experience