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ได้พิมพ์โดยNang-klao Tomson ได้เปลี่ยน 10 ปีที่แล้ว
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Clinical Practice guideline “Cephalopelvic disproportion”
QA ภาควิชาสูติศาสตร์และนรีเวชวิทยา 29 ตุลาคม 2547 Clinical Practice guideline “Cephalopelvic disproportion”
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Trend of Cesarean Section around the world
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C/S rate in USA =Total C/S = Primary C/S = VBAC
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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
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Impacts Mistrust Incorrect attitude Inequity Inefficiency
Wasted resource Lawsuit
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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
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Situation in Songklanagarind Hospital
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Modes of delivery in Songklanagarind Hospital
90 91 92 93 94 95 96 97 98 99 NL C/S V/E F/E BREECH
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Indications for Cesarean Section Songklanagarind Hospital
Year % PRIMARY PREVIOUS
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Indication for Primary Cesarean Section
% CPD. Fetal Distress Failed Induction Other Year
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Cesarean Section Practice of Staffs
Private % Service number
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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
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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;
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Table 4 Factors associated with physician non-compliance using a multivariate logistic regression mode Factors Odds ratio % CI P-value ……………………………………………………………………………………….…….. Private care < Birthweight 3500 g Short stature (<150 cm) Nulliparity Age 35 years %CI, 95% confidence interval.
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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
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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;
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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
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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
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เกณฑ์การวินิจฉัย CPD (ชุด 2) สูติแพทย์ 2 ท่าน ที่ลงนามต่อท้ายนี้ วินิจฉัยว่าผู้ป่วยมี CPD จำเป็น้องผ่าตัดโดย เกณฑ์การวินิจฉัยยังไม่ครบ สาเหตุ (ระบุ)………………………………………………… ลงชื่อ สูติแพทย์คนที่ 1……………………รหัส………………. ลงชื่อสูติแพทย์คนที่ 2……………………รหัส……………….
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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
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Compliance Rate of Revised CPG
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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
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Non-compliance factors (multivariate logistic regression model)
Odds Ratio 95% CI P-value Private care 3.3 0.018 EFW ≥ 3,500 g. 2.37 – 17.06 < 0.001 Bishop score < 7 6.4 1.27 – 8.53 0.014
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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
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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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Thank You Thank You Thank you
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