Primary cesarean delivery rate: Potential impact of a checklist

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Primary cesarean delivery rate: Potential impact of a

checklist

M. Toumi, E. Lesieur, J.-B. Haumonte, C. D’ercole, F. Bretelle

To cite this version:

M. Toumi, E. Lesieur, J.-B. Haumonte, C. D’ercole, F. Bretelle. Primary cesarean delivery rate:

Potential impact of a checklist. Journal of Gynecology Obstetrics and Human Reproduction, Elsevier,

2018, 47 (9), pp.419-424. �10.1016/j.jogoh.2018.08.006�. �hal-02006618�

Original

Article

Primary

cesarean

delivery

rate:

Potential

impact

of

a

checklist

M.

Toumi

,

E.

Lesieur

,

J.-B.

Haumonte

,

J.

Blanc

,

C.

D’ercole

,

F.

Bretelle

*

a_{UniversityHospitalcentersNordandConceptioninMarseille,France}

b_{DepartmentofGynaecologyandObstetrics,Gynepole,AP-HM,AssistancePublique-HoˆpitauxdeMarseille,AMU,Aix-MarseilleUniversite´,France} c_{HoˆpitalStJoseph,Marseille,France}

d

Re´seauMe´diterrane´e(PACACorseMonaco),France

e

Unite´ deRecherchesurlesMaladiesInfectieusesTropicalesetEmergentes,UM63,CNRS7278,IRD198,INSERM1095,Marseille,France

Introduction

Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing worryingly[1].AnAmericanstudypublishedshowedthat50%of theincreaseinthenumberofcesareansectionswasduetothefirst cesareanrate[2].ForZhangetal.,iterativecesareansafterauterine scarcontributedto45.1%ofscheduledcesareansandto30.9%ofall cesareansperformedintheUnitedStatesbetween2002and2008 [3].InFrance,cesareandeliveryrosefrom10.9%in1981to20.2%in 2016[4].The2016FrenchNationalPerinatalSurveyshowedthat anincreaseinoverallcesareandeliverieswasmainlyduetofirst cesareanrate(71.5%)[5].Althoughincertainobstetricsituations,

cesarean delivery is undoubtedly theonly acceptable obstetric outcomeintermsofmaterno-fetalsafety,otherindicationsseem toraisequestionsintermsofthebenefit-riskbalance.Indeed,a cesarean section remains a surgical intervention that includes short,mediumandlong-termrisks[6].

Efforts are made worldwide to curb the cesarean section rates. In France, in 2012, Guidelines on scheduled cesarean section indications and in 2017 about normal delivery were published [7,8]. In March 2014, the American Congress of Obstetricians and Gynecologists (ACOG) issued recommenda-tions to reduce the number of first cesareans, based on the challengingpracticesandonrememberinggoodpractices[9].In Canada,in2015,ateamevaluatesaninterventionalstrategyto reducecesareansectionsrate.Thiscombinedtherecallofgood practices,theimplementationofauditsandbiofeedbackforthe obstetricalteam. Asignificantreduction inthe overall rate of cesarean was thus demonstrated, in hospitals where the ‘‘interventional’’ training strategy was implemented [10]. A Frenchuni-centricstudycarriedoutattheUniversityHospitalof Grenoble in 2015 based on the same type of approach gave similarresults[11].

ARTICLE INFO

Articlehistory: Received26April2018

Receivedinrevisedform9July2018 Accepted20August2018 Availableonline24August2018

Keywords: Cesareansection Firstcesareandelivery Arrestoflabor Breechpresentation Suspectedfetalmacrosomia

ABSTRACT

Background. – Cesarean section is the most common surgical procedure performed in developed countries.Itsincidenceisincreasingtoaworrisomeextent.The2003FrenchNationalPerinatalSurvey showedthattheinflationintheoverallcesareanratewasmainlyduetoanincreaseinthefirstcesarean deliveryrate.

Objective. –Toevaluateanewtool:achecklistthatintenttodecreasethefirstcesareandeliveryrate. Studydesign.–Retrospective,observational,multi-centerstudy.Anewtool,a‘‘Firstcesareandelivery’’ checklistwasbuiltaccordingAmericanandFrenchguidelines.Womenwithfull-termofpregnancy, nulliparousormultiparouswithafirstcaesareandeliveryincludingarrestoflabor,breechpresentation or suspected fetal macrosomia were included. The checklistwas applied. Potentially preventable cesareanswereanalyzed.

Results. –Among571firstcesareansection,178wereeligibletochecklistapplication.147chartswere analyzedinthestudy.11.9%offirstcesareandeliveriesperformedwerepotentiallyavoidableafter applyingthechecklist.Thisrepresented6.6%ofallcesareans.

Conclusion. –Thechecklistbasedontherecallofgoodpracticescouldbeaninterestingtooltodecrease thefirstcesareanrate.

C 2018ElsevierMassonSAS.Allrightsreserved.

* Correspondingauthorat:DepartmentofGynaecologyandObstetricsandUMR CNRS-IRD6236–Faculte´ deMe´decinedeMarseille,Universite´ delaMe´diterrane´e; HoˆpitalNord,DepartmentofGynaecologyandObstetrics,ChemindesBourrely, 13915MarseilleCedex20,France.

E-mailaddresses:toumi.myriam@gmail.com(M.Toumi),

emmanuelle.lesieur@gmail.com(E.Lesieur),jb.haumonte@gmail.com

(J.-B.Haumonte),julieblanc@live.fr(J.Blanc),Claude.D’ERCOLE@ap-hm.fr

(C.D’ercole),florence.bretelle@ap-hm.fr(F.Bretelle).

Available

online

at

ScienceDirect

www.sciencedirect.com

https://doi.org/10.1016/j.jogoh.2018.08.006

Ourobjectivewastoevaluatethepotentialimpactofachecklist withtheaimtodecreasefirstcesareandelivery.

Materialsandmethods

Thisisaretrospectivemulti-centerstudy.Ourobjectivewasto analyzetheimpactofthe‘‘Firstcesareandelivery’’checklistonthe firstcesareanrate.TheprojectwasapprovedbytheResearchEthics CommitteeonObstetricsandGynecology(CEROG)in2016,underthe noticenumberCEROGOBS2016-08-30.

Patients

Women who underwent a first cesarean delivery between November1st 2014 and September 1st 2015in the University HospitalcentersNordand ConceptioninMarseille,Francewere selected.Womenwithfull-termofpregnancy(gestationalage37 weeksofgestation),nulliparousormultiparouswithanexclusive historyofvaginaldeliveryandwithanindicationforacesarean sectionaccordingtothechecklistwereeligible.Womenmatching thechecklisteligibilitycriteriaandwhosemedicalrecords were searchablewereincludedinthestudyforanalysis,theygavetheir reasonedandinformedconsenttobepartofthestudy.The non-inclusioncriteriawere:prematurity(gestationalage<37weeksof gestation), multiplegestation, united and multi-scarred uterus, history of uterine surgery with uterine cavity intrusion (e.g. polymyomectomy), immediate emergencies or suspected materno-fetal risks (retro placental hematoma, pre-eclampsia, cordprolapse,metrorrhagia,placentaprevia)andnon-reassuring fetalheart-rate(FHR)tracingaccordingtoCNGOF2007guidelines. Studydesign

Thechecklistwas basedonthe Frenchrecommendationsand American expert opinion and (Fig. 1). Data were collected retrospectivelyfromthematernitybirthregistersbyone investi-gator.Thechecklistwasnextappliedtocesareansthatmeetthe eligibility and inclusion criteria. We then evaluated the first cesareans that were potentially preventable after applying the checklist.Suspectedmacrosomiawasdefinedbyafetalestimated ultrasoundweightgreaterthan908percentileaccordingtoHadlock. Outcomes

Theprimaryoutcomewastherateofpotentiallypreventable firstcesareansafterapplyingthechecklist.Therateofpotentially preventablecesarean section wasassimilateto therateof non conformity to check list with at least one missing criteria. A cesareanwasconsideredaspotentialpreventableoravoidableifat leastonemorecriteriaofthechecklistwasnotpresent(Fig.1).

The secondary outcomes were: indications for first cesarean delivery, overall cesarean rate in general, overall cesarean rate potentiallypreventableafterapplyingthechecklist,analysisofthe differentmissingcheck-listcriteriaaccordingtothefirstcesarean indications.

Statisticalanalysis

Quantitativedatawereexpressedasanaveragewithstandard deviation. Qualitative data were reported as numbers and percentages.StatisticalanalysiswasperformedwiththeIBMSPSS Statisticsversion20software.

Results

Amongthestudyperiod571patientsthatunderwentcesarean section,178womenwithafirstcesareandeliverywereeligiblefor

theapplicationofthechecklist. Thirty-onemedicalchartscould notbeanalyzed.

Onehundredandforty-sevenwomenwerethereforeincluded intheretrospectiveanalysis(Fig.2).Amongthem,68(46.2%)were potentiallypreventableafterapplyingthechecklist.Amongthem 47 Cesarean with arrest of labor, 14 women with breech presentationandfor7patientswithsuspectedfetalmacrosomia. Characteristics of the study population are shown in Table 1. Indications for first cesarean delivery are given in Table 2. The overall rate of caesarean section was23.2% (1035/4467 deliveries).Thefirstcesareanratewas12.8%(571/4467).55.2%of thecesareansperformedwerefirstcesareans(571/1035).

Concerning our primary outcome, 11.9% of first cesarean deliveriesperformedwerepotentiallypreventableafterapplying the checklist (68/571). This represented 6.6% of all cesarean sections(68/1035).

The description of non-conformity to check-list criteria accordingtothecesareanindicationscanbefoundbelow(n=68): Arrestoflabor(number=47patients)

- Duringfirst stage oflabor andlatencyphase (cervicaldilatation <6cm).Sixteenpatientshadatleastanon-conformityto check-list criterion. When the decision to perform a cesarean was made,themeancervicaldilatationwas4.2cm(1.04)andthe meandurationofarrestoflaborwas3.76h(1.69).

- Duringfirststageoflaborandactivephase(cervicaldilatation 6cm).Elevenpatientshadatleastonenon-conformityto check-listcriterionwithanarrestoflaboroflessthan4h.Themean timeoflaborarrestwhenthedecisiontoperformacesareanhas beenmadewas2.75h(0.88).

- In the second stage of labor: full cervical dilatation, with non-engagementofthefetalhead,20patientshadanarrestoflaborof less than 3h. Theaverage delay of dilatation when cesarean sectionwasperformedwas2.6h(0.67).6additionalpatients had at least one non-conformity criteria to check-list with no manualrotationofthefetalocciputofatransverseorposterior positionoramisdiagnosisofoposteriorposition.

Breechpresentation(n=14patients)

- Forfourteenpatientshadatleastonenon-conformitycriteriato check-listandthencesareansectioncouldpossiblypreventable. Externalmanoeuverversionwasnotproposedto7patientsand refusedby7.

Suspectedfetalmacrosomia(n=7patients)

- Sevenpatientshadatleastonecheck-listcriteriamissingand thenavoidable.Intheabsenceofassociateddiabetes,4patients hadafirstcesareaneventhoughthefetalweightestimatewas lessthan5000g.Inthecaseofdiabetes,3hadafirstcesarean eventhoughthefetalweightestimatewaslessthan4250g.

Discussion

Ourresultsshowthat 11.9%offirstcesareandeliverieswere potentially preventableafterapplyingthechecklist (i.e.withat least onenon conformity criteria). This represented 6.6% of all cesareansections.Thisprojectionexerciseis certainly question-able and rough but it suggests the potential interest of this checklistinclinicalpractice.Basedonliteraturedata,andforeach situationthepotentialrateofvaginaldelivery,38patientsoutof

M.Toumietal./JGynecolObstetHumReprod47(2018)419–424 420

the68 withatleastonenonconformitychecklist criteriacould potentially have a vaginal delivery, i.e. more than half of the patients(55.9%).

The main indication for a first cesarean delivery was non-reassuringfetal-hearttracing,butthisindicationwasnotincluded

inthechecklist.Thiswasfollowedbyarrestoflabor.Thisgroupis themaincontributortofirstcesareansectionmainlypotentially avoidable accordingtoourresults.For activephase in thefirst stageof labor, a prospective studyof 542womenshowedthat extendingtheminimumperiodofoxytocintreatmentfrom2toat least4hforactivephasearrestinthefirststageoflaborallowed 92%ofwomentogivebirthvaginallywithoutadverselyaffecting theneonataloutcome[12].

Atthecurrenttime,variousrecommendationsareavailablefor thelengthofthesecondstageoflabor[8,9].Theoptimalduration dependsmoreontheobstetricalteamhabitsthanaparameterthat hasbeenthesubjectofaprecisemethodology.InFrance,itwas previouslygenerallyadmittedthatthistimeshouldnotexceed2h. Althoughrecentstudieshavesuggestedalongertoleranceinthe absence of non-reassuring fetal heart-rate tracing, this 2h dilatationruleisstillwidelyapplied.Americanrecommendations areinfavorofaminimumdelayof3hinthenulliparouswomen and 2h in multiparous women [9]. Rouse et al. showed in a retrospectiveseriesof4126patientsthatthevaginaldeliveryrate was55%beyond3hofarrestoflabor[13].

Thediagnosisoffetalheadengagementinthematernalpelvisis sometimesdifficult.Thisremainsasubjectivediagnosis,relyingon operatorexperienceandhasahigherrorrate.Dupuisetal.findan errorrateof12%inthediagnosisoffetalheadengagement,equally distributedbetweenfalsepositivesandfalsenegatives[14].The ‘‘engagementultrasound’’seemstobeamandatorytoolduringthe secondstageoflaborbutitsimpactoncesareansectionrateshould

Fig.2.Flowchartofcesareansectionamongthestudyperiodincludingfirstcesareansectioneligibletochecklistapplication.

Table1

Characteristicsofthe147patientsincludedfortheretrospectiveanalysis.Values areexpressedasmean,standarddeviationsandinnumberandpercentage.

Demographicdata Numbers,percentages

Age 29.8(6.9)

Gestity 2.3(1.8)

Parity 0.6(1.2)

Hypertension

Pre-existing<20weeksofgestation 1(0.07%) Gestational20weeksofgestation 4(2.7%) Diabetes Pre-existing 2(1.4%) Gestational 40(27.2%) Laborinduction 23(15.6%) Dinoprostonea 15(10.2%) Oxytocinb 8(5.4%) Cesarean Scheduledcesarean 22(15%) Emergency,outoflabor 18(12.2%) Emergency,duringlabor 107(72.8%)

a

Dinoprostone(Propess,Ferringlaboratory,94250Gentilly,France).

b

Oxytocin (Syntocinon, Sigma-Tau laboratory, 92130 Issy-les-Moulineaux, France).

M.Toumietal./JGynecolObstetHumReprod47(2018)419–424 422

be evaluate. Manual rotation of the fetal occiput could be an additionaltool toreducethefirstcesareanrateforposterioror transversepositionsofthehead.Inthepresenceofthisfetalhead positionsandinthecaseofsuccessfulmanualrotationduringthe secondstageoflabor,therateofcesareanwouldbebetween0and 9%dependingontheauthor[15–17].Thisattitudeimpliesaprecise knowledgeofthepositionofthefetalheadduringlaborwithan error risk between 20 and 26.6%, regardless of the operator’s experience[18].

Forbreechpresentations,theACOGrecommendsacontrolof the presentation at 36 weeks of gestation and encourages the attempttoexternalcephalicversionwithanaveragesuccessrate ofabout50%accordingtotheauthors[19–21].TheACOGdoesnot mentionthepossibilityofvaginaldeliveryinthecaseofexternal cephalic version failure. The CNGOF allows vaginal delivery of breechpresentationsifdefinedconditionsaremet.InFrance,the successrateofvaginal deliveryattemptson afetus ina breech presentation is between 65% (according the Franco-Belgian PREMODA study) and 70% (according to the French AUDIPOG sentinelnetwork)[22,23].

TheACOG andtheHAS,CNGOFguidelinesare inagreement concerningthefirstcesareandeliveryforsuspectedfetal macros-omia [7,24,25]. In the absence of gestational diabetes, they recommendscesareandeliveryifthefetalweightisgreaterthan 5000g. Despite these common Franco-American recommenda-tions,inourstudywefoundthatthisthresholdwasnotfollowedin practice.

Thestrengthsofourstudyresideinthecontributionofanew tool,the checklist‘‘Firstcesarean delivery’’ basedonnational,

internationalguidelinesandexpertopinions.Theweakpointsare firstlyitsretrospectivedesignandtheextrapolationofthevaginal successratefromliteraturetoourseries.Indeed,althoughalmost halfofthepatientseligibleforthechecklisthadatleastonenon conformitycriteria ofthechecklist,we cannotextrapolatethe final deliveryoutcomeandconclude thatall of thesepatients wouldundergovaginaldelivery.Secondlysomeofthechecklist itemshavealowlevelofrecommendationsuchasultrasoundfor fetal position or engagement diagnosis and fetal rotation of posterior positions. Ourobjective wasto evaluateall thenew available toolsandtheirfurtherpotentialimpactsoncesarean sectionrate.

A prospective study should be therefore implemented. The checklist item could be use in the evaluation of professional practiceasahealthindicator.

Conclusion

Applyingachecklistcouldtobeaninterestingtoolinorderto decreasethefirst cesareandeliveryrate.A prospectivestudy is nowrequiredtobetteranalyzetheimpactofthischecklist. Conflictofinterest

Theauthorsreportnoconflictofinterest. References

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Overallindicationsforthefirstcesareandelivery.Valuesareexpressedinnumbers andpercentage.Ingrey,thecesareansectioneligibletoCheckListapplication.

a

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