Falling caesarean section rate and improving intra-partum outcomes: a prospective cohort study

Abstract

Objective: To evaluate caesarean section (CS) rates and moderate to severe hypoxaemic ischaemic encephalopathy (HIE) rates with other core intra-partum outcomes following reconfiguration of maternity services in Cardiff, South Wales, UK.

Design: Cohort study of births from 2006 to 2015.

Settings: A University tertiary referral centre for foetal and maternal medicine with 6000 births/year, University Hospital of Wales, United Kingdom.

Method: Data relating to births from 1 January 2006 to 31 December 2015 were extracted from the computerized maternity database on a yearly basis. Case notes of all mothers and babies for the same duration were hand searched for documentation of HIE. HIE data was also collected prospectively by neonatologist (SC) and obstetrician (PA).

Main outcome measures: Incidence of caesarean section births, babies with moderate to severe HIE, instrumental vaginal births, obstetric anal sphincter injuries (OASIS) associated with instrumental delivery, and major post-partum haemorrhage (MPPH) of 2500 mL or more.

Results: During this 10-year period, a downward trend in emergency CS rate was seen from 15.6% in 2006 to 10.5% in 2015, reducing total CS rate from 25.5% in 2006 to 21.2% in 2015. A downward trend in the incidence of moderate and severe HIE was seen over the same period. There was an increase in operative vaginal births (OVB) from 12.8% to 15%. The rate of spontaneous vaginal births (SVB) remained stable. The incidence of OASIS remained constant and MPPH rate has fallen.

Conclusions: Following amalgamation of two medium sized obstetric units and the opening of a Midwifery Led Unit (MLU), core intrapartum outcomes have improved. Contributing factors are the introduction of regular multidisciplinary training with enhanced team working, compulsory education for obstetricians and midwives on cardiotocograph (CTG) interpretation, increased consultant presence on delivery suite, robust risk management systems and broad multidisciplinary agreement on clinical guidelines promoting vaginal birth.

Keywords:

• Caesarean section
• instrumental vaginal delivery
• hypoxaemic ischaemic encephalopathy
• obstetric anal sphincter injuries
• major postpartum haemorrhage

Acknowledgements

We thank all maternity staff at the University Hospital of Wales. A special acknowledgement goes to the midwifery coordinators on the labour ward, for their dedicated work. The support and team working of ancillary staff such as Maternity Care Assistances, Portering staff, Haematology, and other laboratory staff has been invaluable to help achieve safety levels that we have achieved. We also thank experts in foetal monitoring at St. George’s Hospital, London for educating our staff over the last decade.

Ethical statement

Data were routinely collected as a part of our local service evaluation and quality improvement programme and was therefore exempted from the need for ethical approval.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.