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. 2019 Feb 8;9(2):e027317. doi: 10.1136/bmjopen-2018-027317

Table 5.

Process of development of quality improvement recommendations

Key findings from the analysis Possible explanations that emerged from hospital staff discussion Agreed recommendations for quality improvement

  1. High intrapartum CS rate in group 1, with potentially inappropriate indications (main current indication was CTG abnormality)

  1. Possible inappropriate interpretation of fetal monitoring

  2. Possible inappropriate use of oxytocin

  3. Possible inappropriate indications to CS

  1. Develop a training plan for strengthening capacities of staff in CTG interpretation*

  2. Hands-on trainings on instrumental delivery

  3. Supportive supervision and monitor overtime staff skills in CTG interpretation and instrumental delivery

  4. Adoption of Robson classification of CS indications (22)

  5. Criterion-based audits of CS indications

  6. Regular risk management meetings with emphasis on diagnosis of fetal distress

  1. High rate of IOL and high rates of CS in women undergoing IOL (high contribution of group 2a to total CS rate and high CS rate in group 4a)

  1. Possible inappropriate indications for IOL

  2. Possible inappropriate use of prostaglandin/oxytocin

  3. Possible Inappropriate CTG interpretation

  4. Possible misdiagnosis of failed IOL

  1. Consultant meeting to update IOL protocols (agreeing on criteria for failed IOL according to recent evidence)*

  2. Criterion-based audits on IOL

  3. Monitor IOL indications, complications and abnormal CTG associated with use of prostaglandins or oxytocin

  1. High prevalence of prelabour CS (group 2b) with more frequent CS indications: abnormal CTG, potentially inappropriate indications (25%), presence of maternal/fetal pathological conditions

  1. Inappropriate indications for prelabour CS

  1. Update protocols on indications for prelabour CS

  2. Criterion-based audits on indications for prelabour CS

  3. Review cases of CS for abnormal CTG during staff training

  1. High CS rate in groups 3 and 4a (multiparous). More frequent indication is abnormal CTG

  2. Very high CS rate in group 5, majority are elective. Past CS is the main indication

  1. Rate of CS in multiparous women suggests suboptimal care in this group of women

  2. Inappropriate interpretation of CTG

  3. Low offer of TOLAC

 Recommendations #1,2,3

  1. Criterion-based audits of offers and unsuccessful cases of TOL

  2. Use of patient education leaflets to inform women of TOL benefits and establishment of a nurse-led TOLAC counselling service*

  3. Monitoring the prevalence of TOLAC

  1. Breech is the fourth most common indication for CS

  1. Refusal by mothers to accept ECV due to preconceived prejudices

  1. Develop an information leaflet on the value of ECV

  1. Low rate of CS for dystocia with half of CS done in second stage

  2. Low CS rate in group 9

  1. Possible problems in data quality

  2. Possible misclassification of a few number of cases

 Recommendation #2,4

  1. Training for data collectors and hospital staff on definitions used for the Robson’s classification according to the WHO manual, stressing also the definition of dystocia

  2. Add few internal validation rules in the database (previous CS, breech, dystocia) and strengthen monitoring on these variables.

  1. High contribution to CS rate from group 10. Majority of the indications for maternal/fetal pathological conditions

  1. Iatrogenic indications of IOL/CS in the late preterm period

 Recommendation #7 (update protocols of IOL and elective CS criteria in late preterm and SGA)
Recommendation #5 (criterion-based audits on cases of IOL and elective CS)

CS, caesarean section; CTG, cardiotocography; ECV, external cephalic version; IOL, induction of labour; SGA, small for gestational age; TOL, trial of labour; TOLAC, trial of labour after caesarean.