Influence of three organisational measures on the cesarean section rate in a tertiary care University Hospital

Abstract

To evaluate the influence of three organizational measures on the cesarean section rate over two consecutive years, in the Department of Obstetrics and Gynaecology of a tertiary care University Hospital. Clinical records of births occurring in the years 2001 and 2002 were retrospectively evaluated, in order to identify the annual rate of emergency and elective cesarean sections. Other data recorded were the type of deliveries in each on-call team, newborn 1-min and 5-min Apgar scores, neonatal intensive care unit admissions, principal motive for emergency cesareans, time of day and week-day of emergency cesareans. In the first week of 2002, the results of the first year's evaluation were presented to all staff at the Department. At that time, an information pamphlet was distributed to all health care professionals, reminding them of the risks associated with cesarean section. From then on, all emergency cesareans were discussed on the following work-day, in a clinical meeting involving all obstetrical staff. Statistical analysis was carried out using the chi-squared test, with the level of significance being established at 0.05. In 2001 there were 3009 births, overall cesarean section rate was 36.5%, and emergency cesarean rate was 30.5%. Cesarean section rates varied between 23.3% and 43.4%, amongst the eight on-call teams. In 2002 there were 2959 births, overall cesarean section rate was 27.6%, and emergency cesarean rate was 20.4%. Cesarean section rates in on-call teams varied between 14.3% and 31.5%. Over the two years, a reduction of 8.9 percentage points (p<0.001) in overall cesarean section rate, and of 10.1 points (p<0.001) in emergency cesareans were observed. During the same period elective cesareans increased 1.2 percentage points (p=0.052) and instrumental deliveries increased 3.2 points (p=0.002). There were less cesarean sections due to arrested labour (154 cases) and non-reassuring fetal state (46 cases), although these motives remained preponderant. The number of newborns with low 1-min Apgar decreased significantly, while those with low 5-min Apgar and intensive care unit admission remained constant. The introduction of three relatively simple organizational measures enabled a significant reduction in the cesarean section rate over a one-year period, without changing the incidence of the main neonatal outcome indicators.