Clinical Practice guideline “Cephalopelvic disproportion” QA ภาควิชาสูติศาสตร์และนรีเวชวิทยา 29 ตุลาคม 2547 Clinical Practice guideline “Cephalopelvic disproportion”

Trend of Cesarean Section around the world

C/S rate in USA 1989-1996 =Total C/S = Primary C/S = VBAC

Race and/or Hispanic origin Age of mother Primary cesarean rate by age, race, and Hispanic origin of mother: United Stated, 1989, 1996, and 2002 Non - Hispanic black Non - Hispanic white Hispanic Under 30 years 30 – 39 years 40 years and over 1989 1996 2002

Impacts Mistrust Incorrect attitude Inequity Inefficiency Wasted resource Lawsuit

To reach the appropriate rate for LT/CS Professional community takes leading role for checking and balancing to optimum, by peer review, and guidelines Purchasing community - introduce appropriate measures Empower women on vaginal delivery through intensive and better quality ANC

Situation in Songklanagarind Hospital

Modes of delivery in Songklanagarind Hospital 90 91 92 93 94 95 96 97 98 99 NL C/S V/E F/E BREECH

Indications for Cesarean Section Songklanagarind Hospital 90 91 92 93 94 95 96 97 98 99 Year % PRIMARY PREVIOUS

Indication for Primary Cesarean Section % CPD. Fetal Distress Failed Induction Other 90 91 92 93 94 95 96 97 98 99 Year

Cesarean Section Practice of Staffs Private % Service 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 number

First Guideline of CPD diagnosis (modified from ACOG recommendation) 1. Cervix ≥ 3 cm. 2. Good uterine contraction ≥ 2 hrs. 3. Protraction or arrest disorder 4. If 1, 2, 3 are not met, needed two obstetricians evaluation. CPG was approved by Department committee and implemented in 2000

Cesarean section rate due to CPD was Physician compliance with the CPG was 89.2% Cesarean section rate due to CPD was decreased from 10.7% in 1999 to 8.6% in 2002 Pregnant outcomes were not different between the two periods C.Suwanrath-Kengpol et al. Int. J. for Quality in Health Care 2004;16;327-332

Table 4 Factors associated with physician non-compliance using a multivariate logistic regression mode Factors Odds ratio 95% CI P-value ……………………………………………………………………………………….…….. Private care 16.0 3.7 - 69.6 <0.001 Birthweight  3500 g 2.6 1.3 - 5.1 0.01 Short stature (<150 cm) 3.4 1.2 - 9.5 0.02 Nulliparity 5.0 0.6 - 38.9 0.13 Age 35 years 1.0 0.4 - 2.9 0.98 95%CI, 95% confidence interval.

Summary Cesarean Section rate was decreased, but higher than WHO recommendation Department committee approved revised CPG in December 2002 Revised CPG was implemented in January 2003

Trend of CS rate due to CPD CPG 1 CPG 2 --- Predicted CS rate Observed CS rate WHO recommendation C.Suwanrath-Kengpol et al. Int. J. for Quality in Health Care 2004;16;327-332

CRITERIA FOR DIAGNOSIS OF CPD 2000 2003 Old CPG Revised CPG Cervix ≥ 3 cm Cervix ≥ 4 cm and 80% of effacement Good contraction ≥ 2 hrs. Same Protraction or arrest disorder If 1, 2, 3 not met, needed 2 obstetricians evaluation

เกณฑ์การวินิจฉัย CPD (ชุด 1) ขอรับรองว่าผู้ป่วยรายนี้มีปัจจัยต่าง ๆ ดังต่อไปนี้ 1. Cervix dilate> 4 cm. Efface > 80% มี ไม่มี 2. Good uterine contraction > 2 Hr. มี ไม่มี 3. Arrest / Protraction of labor มี ไม่มี 4. Prolonged second stage มี ไม่มี ลงชื่อ …………………………MD. รหัส……………………. กรณีไม่ครบ 1,2 ,3 หรือ 1,2,4 โปรดใช้เกณฑ์ชุด 2

เกณฑ์การวินิจฉัย CPD (ชุด 2) สูติแพทย์ 2 ท่าน ที่ลงนามต่อท้ายนี้ วินิจฉัยว่าผู้ป่วยมี CPD จำเป็น้องผ่าตัดโดย เกณฑ์การวินิจฉัยยังไม่ครบ สาเหตุ (ระบุ)………………………………………………… ลงชื่อ สูติแพทย์คนที่ 1……………………รหัส………………. ลงชื่อสูติแพทย์คนที่ 2……………………รหัส……………….

Cesarean Section Rate for CPD 2003 8 . 4 5 2 6 12 10 9 14 CS rate (%) Total Non-private Private Type of service Before CPG After CPG

Compliance Rate of Revised CPG

Pregnancy outcomes of cesarean section due to CPD before CPG N = 226 after CPG N = 229 P-value PP complication (%) 2.7 1.7 0.54 APGAR at 1 min < 4 (%) 4 - 6 (%) 0.4 4.9 1.3 3.9 0.55 APGAR at 5 min < 7 (%) 0.9 0.16 Thick meconium stained in AF (%) 9.3 10.9 0.57 Admission to NICU (%) 0.37

Non-compliance factors (multivariate logistic regression model) Odds Ratio 95% CI P-value Private care 3.3 1.23-8.91 0.018 EFW ≥ 3,500 g. 2.37 – 17.06 < 0.001 Bishop score < 7 6.4 1.27 – 8.53 0.014

Outcomes of Revised CPG Compliance with the revised CPG = 83% (target compliance = 85%) After revised CPG, no adverse effect of pregnancy outcomes Cesarean section rate did not decrease within 1 year period

Summary Using the revised CPG: decreased the difference of cesarean section rate between private and non-private groups (7% vs. 4%) CPG Evaluation as research (2 publications) Using CPG as a study model for medical personnel

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