Fernandez Hospital Caesarean Section Rates

Fernandez Hospital Accepts the Initiative to Display its Caesarean Section Rates

In a recent petition to the Ministry for Child Development, Ms. Subarna Ghosh has collected nearly a lakh of supporters who want to make it mandatory for all doctors and hospitals to declare the percentage of Caesarean delivery rates to patients.

Ms. Ghosh felt that the C section that she personally underwent was “misleading and manipulated and her choice was overridden”. According to Ms. Ghosh, to discourage the trend of indiscriminate conducting of C sections, women need to be made aware of C section rates of different hospitals and maternity homes so they can choose their hospital carefully.

Caesarean Section Rates (CSR) have increased exponentially worldwide. India, with its varied levels of maternity services, is also facing an epidemic of CSRs. We, at Fernandez Hospital have tried to maintain an appropriate CSR ratio.

We are a tertiary referral perinatal centre accredited for training postgraduates and post doctoral fellows. While this increases our patient volumes it also brings in a variety of challenges, some of which are:

1. Advanced maternal age with medical complications
2. Increasing incidence of morbid obesity with co-morbidities
3. Assisted reproductive techniques with couples not open to vaginal births
4. Maternal request for ‘Muhurtham’ C Section

Our data represents an institutional cohort with a bigger proportion of high risk mothers. People come from varied distances, some from neighbouring states.

We initiated an audit on CSR in 2002 using Robson Classification. This is an ongoing audit where data is displayed in the hospital.

The most common reasons for CSR and our efforts to minimize the rates are :

• Presumed fetal compromise: It is the most common indication for an emergency C section. We have the option of doing a fetal blood sampling, fetal scalp electrode for better monitoring and decisions. Training and certification in fetal monitoring techniques for all doctors working in the Labour Ward is mandatory.
• Failure to progress: This is explained better as a caesarean done when the cervix fails to dilate despite good labour pains. New guidelines from the American College of OBGYN1 have suggested a more conservative approach with reference to definition, (cervix dilated to 6 cm) and intervention that follows. These protocols have been adopted by us.
• VBAC and ECV Option: We offer the option of VBAC (vaginal birth after caesarean section), and ECV (external cephalic version — turning the baby to head-down position) for breech presentation.
• Multifetal pregnancy: Vaginal delivery is becoming rare in twin pregnancies in India. We have the facilities to monitor both babies throughout labour, using FSE (fetal scalp electrode applied on first baby’s scalp), as this is the main concern during labour.
• Induction of labour: Reducing inductions would lead to a reduction of overall caesarean section rates. We have a protocol and definite indications for induction of labour, with a constant watch on the rates, averaging 25% currently.

ROBSON CLASSIFICATION

In 2001, Michael Robson proposed a system that classifies women into 10 groups, based on their obstetric characteristics (parity, previous CS, gestational age, onset of labour, fetal presentation and the number of fetuses). Since the system can be applied prospectively and its categories are totally inclusive and mutually exclusive, every woman that is admitted for delivery can be immediately classified based on these few basic characteristics which are usually routinely collected worldwide in obstetric wards. In 2015, WHO2 suggested Robson classification to be used worldwide as an audit tool.

ROBSON GROUPING

The litmus test for any hospital would be group 1. This group encompassesthe woman with a singleton baby with head down position, uncomplicated pregnancy and who sets into labour spontaneously. A CSR in this group is vital as it impacts the woman’s future obstetric career. We at Fernandez Hospital focus on the first four groups of Robson as these women have never had a caesarean before. The distribution of our deliveries into the specific 10 groups is shown below.

• Blue represents Group 1–5 : term, cephalic population
• Grey represents Group 6 and 7 : breech
• Green represents Group 8 : multifetal pregnancy
• Brown represents Group 9 : abnormal lie, where vaginal delivery is not possible
• Orange represents Group 10 : preterm cephalic births

Fernandez Hospital Data

December 2016 : Total Deliveries — 738

We have tried to maintain a strict control on the induction of labour. Our data clearly shows that it increases the risk of a C section in this group of women.

Our professional midwives (introduced in August 2011) offering intrapartum support to low risk women have helped reduce unnecessary interventions. The incidence of epidural analgesia has decreased from an initial 66% in 2011 to 41% in 2016. The hospital is committed to promoting natural birth. With overwhelming volumes we are making every effort to humanize birth, offer midwifery support and work towards reducing the primary Caesarean in every birthing woman.

Fernandez Hospital Caesarean Section Rates

January 2017

Total Deliveries: 712

Reflections on C Section Rate — January 2017

With reference to Group 1 (Nulliparous with single, cephalic pregnancy > 37 weeks — spontaneous labour) our rate has shown a steep rise to almost 30% — too high for our own benchmark of wanting to keep it below 20%. On analyzing we found that 10 of the 44 were maternal requests and 7 were non-progress of labour. 25 were performed for presumed fetal compromise. In this group of women wherever it is possible we assess fetal scalp lactate levels to help make the right decision. Despite our efforts this group is unacceptably high. We plan to review this group in more detail. In Group 5 (multiparous with previous cesarean, cephalic presentation, > 37 weeks) 21 opted for a trial of labour, of which 9 (42.9%) had a successful VBAC.

Robson Classification

In 2001, Michael Robson proposed a system that classifies women into 10 groups, based on their obstetric characteristics (parity, previous CS, gestational age, onset of labour, fetal presentation and the number of fetuses). Since the system can be applied prospectively and its categories are totally inclusive and mutually exclusive, every woman that is admitted for delivery can be immediately classified based on these few basic characteristics which are usually routinely collected worldwide in obstetric wards. In 2015, WHO2 suggested Robson classification to be used worldwide as an audit tool.