csr audit hashem 2016 last modification

Caesarean Section Audit Report ~ 2016

Supervision: Haifa A Al-Chalabi FRCOGDone by: Hashem M Yaseen MBBS

Introduction & Background 1. Caesarean sections are effective in saving maternal and infant lives, but only when they are required for

medically indicated reasons.

2. at population level, caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates.

3. Caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications. Caesarean sections should ideally only be undertaken when medically necessary.

4. Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate.

5. The effects of caesarean section rates on other outcomes, such as maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being are still unclear

~WHO Statement on Caesarean Section Rates 2015

• In 2004 comparison of CS rates in Jordan between two periods, 1990-1992 and 1999-2001 showed 2.9% increase in the CS rate in the second period (8% to 10.9%)

~ Hindawi IM1, Saudi Med J. 2004

• According to WHO in 2010, the CSR in Jordan was 18.5 %

~World Health Report (2010) Background Paper, No 30

• The rate of cesarean sections was higher (27.7%) in The National Maternal Morbidity Study (2007-2008) that conducted by The Higher Population Council in collaboration with the Jordanian Health Sector.

Introduction & Background

Introduction & Background • This audit presents the findings of the data of caesarean section rate

(CSR) in the Department of Obstetric and Gynecology in King Abdullah university hospital (KAUH \ OG).

• The audit provides information about the range and determinants of CSR with comparative data about demographic and clinical factors that may be influential.

• The data collected in this audit represent set of data collected between October to December in the year 2015

• This audit can be used as the basis for the development of continued local audit.

Audit methodology• Detailed information was collected for every caesarean delivery that took place

during the three-month study period using clinical data form• There were 18 questions on each clinical data form covering demographic

characteristics, details of the index pregnancy, previous obstetric history• Information was collected for all births and all CS using closed questions. All

questions were pre-coded. Data were entered manually into SPSS. • Data pertaining to infants who were less than 24 weeks of gestation were excluded

from the analysis.

Data items collected on all births

• Mother’s age• Parity• Number of previous caesarean sections• Gestation age• Labour ( not in labour, spontaneous, induced) • Number of babies • Presentation at delivery• Mode of delivery• Outcome of pregnancy (live/stillbirth)• Birthweight of baby(ies)

Distribution of Distribution of women women

characteristicscharacteristics

Total maternities (n)

Maternities (n) by the mode of deliveries

(n) % (n) %Age (years)

< 35 120 27.8 301 77.4≥ 35 311 72.2 88 22.6

ParityP0 96 22.3 83 21.3

MP no CS 71 16.5 274 70.4MP with CS 264 61.2 32 8.3

Previous C-section0 171 39.7 357 91.81 134 31.1 32 8.2

≥ 2 126 29.2 0 0Gestations (weeks)

< 28 4 ~1 5 1.328-32 13 3.1 6 1.5

33 - 36 58 13.5 22 5.737 - 40 339 78.5 317 81.5

≥ 41 17 3.9 39 10Birth weight (grams)

< 1500 16 3.7 8 2.11500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3

Onset of labourSpontaneous 91 21.1 301 77.4

IOL* 44 10.2 88 22.6Not in Labour 296 68.7 0 0

Presentation#Cephalic 369 85.6 386 99.2Breech 30 7 1 0.3

Number of Fetuses1 400 92.7 387 99.52 23 5.3 2 ^ 0.5

≥ 3 8 2 0 0

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Distribution of demographic characteristics

(** including normal vaginal deliveries, assisted vaginal deliveries, and vaginal delivaries after C-section "VBAC" )

CS Vaginal **820

# for the singletone fetus

^ were less than 32 wks

(* by vaginal prostaglandin, IV oxytocin, or amniotomy)

Methods of deliveryThe Audit results

• The total number of deliveries during the three-month study period is 820 cases• The vaginal delivery rate was 46.7 % (including VBAC)• CSR (Primary and repeated) was 52.6 %.

CSCount 159

56.60%Count 141

50.20%Count 131

50.80%Count 431

52.60%Total

Monthly distribution of CSR

Date of delivery October

November

December

Methods of deliveryThe Audit results

• The monthly distribution of CSR in each month of study period, which is comparable in each month, around 51 per cent.

56.6%

50.8%50.2%

•Table 3 shows the CSR, primary and repeat CSR. The primary CSR shown is the rate of CS for women who have not had a previous CS, regardless of parity and cause. This was 39.6 % of CSR.

• The repeat CSR was 60.4 %, including 31.6 % with previous one CS, and 28.8 % with two or more previous CS. Higher rates of repeat CS are associated with higher overall CSR.

•Rate of vaginal birth after CS (VBAC) is around 4%. This is including 31 of cases (19% of cases who have previous one CS).

•Of all CS, 57.3% were classified as elective, 42.7% were emergency procedures.

Primary Once Two and more171 135 125 431

39.60% 31.60% 28.80% 100.00%

Table 3: Primary and Repeat CSRPrevious C-section

Total

Primary indications to perform CSPrimary indications to perform CS

the primary indication that given by obstetricians for performing all CS. There may be more than one indication contributing to the decision to perform CS (e.g. a woman may have both a breech presentation and previous one CS)

* (including uncontrolled DM, active herpes, Heart disease, Sever Cholestasis, Takayaso complicated with elevated BP)

ß (including 3rd & 4th degree perineal tears, previous pelvic floor surgery due to genital prolapse)

π (large cervical fibroid, hx of uterine perforation)

# Failure to progress Frequency PercentFailed induction 9 34.6In labour 17 65.4

$ Previous caesaran section Frequency PercentOnce 37 24Two and more 119 76

** Maternal request Frequency PercentPrimary 28 35.4Once 51 64.6

FrequencyValid

PercentPrevious caesaran section $ 156 35.9Maternal request ** 79 18.2

Presumed fetal compromise \ IUGR \ Bad CTG

72 16.6

Multiple pregnancy 29 6.7

Failure to progress (induction \ in labour)#

26 6Breech presentation 24 5.5

Pre-eclampsia \ Eclampsia \ HELLP

9 2.1

Previous infertility 9 2.1

Malpresentation \ Unstable lie 8 1.8Maternal medical disease* 6 1.4

Placenta previa, not actively Bleeding

4 0.9

Antepartum Hemorrhage 4 0.9

Previous physically traumatic vaginal deliveryß

4 0.9

Cord prolapse 2 0.5

other (maternal) π 2 0.5Total 434 100

Table 5: Primary indication to perform CS



•The most frequently cited indication for CS is repeat CS (previous caesarean section). The percentage of CS reported to be performed for this indication is around 36 %.

FrequencyValid



72 16.6





9 2.1




4 0.9



4 0.9

Cord prolapse 2 0.5





•Maternal request is the second most commonly cited reason for performing a CS, it is reported by clinicians to be performed for maternal request contributed 18.2 % overall CSR. But 51 cases of maternal request (64.6%) have one previous CS, and they asked for CS directly without trial of labour, which means that 35.4 % of cases were primarily performed for maternal request ( 28 of cases) which equal 6.44% of overall CSR.

FrequencyValid



72 16.6





9 2.1




4 0.9



4 0.9

Cord prolapse 2 0.5





•Presumed fetal compromise, including suspected intrauterine growth restriction or an abnormal CTG was the third most commonly cited indication, contributing 16.6% overall.

FrequencyValid



72 16.6





9 2.1




4 0.9



4 0.9

Cord prolapse 2 0.5





•CS performed for malpresentation (including Breech presentation, unstable lie, and other malpresentations) was the fourth most commonly reported indication. Overall, 7.3% (range between 5.5 % for Breech and 1.8% for other) of CS were performed for this indication.

•Multiple pregnancies was the fifth commonly reported indication for CS, contributing 6.7%

•Failure to progress is the sixth commonly cited reason for performing a CS, either induction of labour or spontaneously onset of labour

FrequencyValid



72 16.6





9 2.1




4 0.9



4 0.9

Cord prolapse 2 0.5



Influence of population and clinical Influence of population and clinical characteristics on caesarean section rate characteristics on caesarean section rate

Maternal ageMaternal ageBackgroundLess than one-third of ever-married women (31 percent) are under age 30. This represents a decline from 34 percent in 2002 and 32 percent in 2007 and 2009. This decline in the proportion of young women in the ever-married population is mainly the consequence of increasing age at marriage. In contrast, the proportion of ever-married women age 30-49 has increased from 66 percent in 2002 to 68 percent in 2007 and 2009 and to 69 percent in 2012. ~ The 2012 Jordan Population and Family Health Survey (JPFHS)

On average, a woman in Jordan will give birth to less than one child (0.8) by age 25 and, similarly, about two children (1.9) between the ages of 25 and 34 years. In the age group 15-19 years, fertility rates are quite low (26 births per 1,000 women). Rates then increase dramatically to reach a maximum of 209 births per 1,000 women in the age group 25-29 years. Above age 29, rates decline slowly but regularly. ~ (2012 JPFHS)




< 35 120 27.8 301 77.4>= 35 311 72.2 88 22.6

ParityP0 96 22.3 83 21.3

MP no CS 71 16.5 274 70.4MP with CS 264 61.2 32 8.3

Previous C-sectionPrimary 171 39.7 357 91.8

Once 134 31.1 32 8.2Two and more 126 29.2 0 0

Gestations (weeks)less 28 4 ~1 5 1.328-32 13 3.1 6 1.5

33 - 36 58 13.5 22 5.737 - 40 339 78.5 317 81.5

41and more 17 3.9 39 10



CS Vaginal **820

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Maternal ageMaternal age

The Audit results•The average age of mothers giving birth in our hospital during the study period was 29 years.

•The average age at birth of the first baby was 24 years.


Overall, 2% of mothers were under 20 years old. The proportion of mothers over 35 years old was 25% overall; about 7% of mothers were over 40 years old

. The rates were lowest for mothers under 20 years old (33.3%); they were 57.8% for mothers aged between 35 years and 39 years and 57.6% for those aged more than 40 years.

33.3%

57.8%

57.6%


The rate of emergency CS was higher in the mothers under 20 years old (5 of 6 cases were emergency), 83.3%, while the rates of emergency and elective CS were 50% for both in mothers aged between 25-29 years old, While 33% of CS were emergency in mothers aged above 35 years old .

83.3%




< 35 120 27.8 301 77.4>= 35 311 72.2 88 22.6

ParityP0 96 22.3 83 21.3

MP no CS 71 16.5 274 70.4MP with CS 264 61.2 32 8.3


Once 134 31.1 32 8.2Two and more 126 29.2 0 0


33 - 36 58 13.5 22 5.737 - 40 339 78.5 317 81.5

41and more 17 3.9 39 10



CS Vaginal **820

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Parity and previous caesarean sectionParity and previous caesarean sectionThe Audit results•As Table shows, the CSR was 22% for primigravid women, 16 % for multiparous women who had not had a previous CS and 61 % for multiparous women who had had at least one previous CS.

•The most common primary indications reported for women having a primary CS were presumed fetal compromise (16.6%), multiple pregnancy (6.7%), failure to progress (6%) and Breech presentation (5.5%).


Parity and previous caesarean sectionParity and previous caesarean section

The Audit results•This group includes both nulliparous and multiparous women but the majority (61%) having a primary CS were multiparous women who had had at least one previous CS. The most common indications for women having a repeat CS were previous CS (36%), maternal request as reported by clinicians (6.44% of overall CSR), failure to progress (2%), presumed fetal compromise (7%) and malpresentation (4%).

Vaginal VBAC CS VaccumCount 79 0 100 3 182% within Parity

43.40% 0.00% 54.90% 1.60% 100.00%

Count 260 0 69 2 331% within Parity

78.50% 0.00% 20.80% 0.60% 100.00%


0% 10.10% 89.30% 0.30% 100.00%


42.90% 3.80% 52.60% 0.70% 100.00%Total

Table 10: Parity * Mode of delivery CrosstabulationMode of delivery

TotalParity P0

MP no CS

MP with CS




< 35 120 27.8 301 77.4>= 35 311 72.2 88 22.6

ParityP0 96 22.3 83 21.3

MP no CS 71 16.5 274 70.4MP with CS 264 61.2 32 8.3


Once 134 31.1 32 8.2Two and more 126 29.2 0 0


33 - 36 58 13.5 22 5.737 - 40 339 78.5 317 81.5

41and more 17 3.9 39 10



CS Vaginal **820

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Gestation and birthweightGestation and birthweightBackground•ICD-11 classification defines low birthweight as less than 2500 g, very low birthweight as less than 1500 g and extremely low birthweight as less than 1000 g. Gestational age is defined as the duration of gestation measured from the first day of the last normal menstrual period expressed as completed days or completed weeks. Preterm birth is defined as less than 37 completed weeks, term as 37 completed weeks to less than 42 completed weeks, post term as 42 completed weeks or more.

•The incidence of low birthweight was 10% in Jordan 1997

~ Low Birthweight: Country, regional and global estimates. UNICEF, New York, 2004.

Birth weight (grams)less 1500 16 3.7 8 2.1

1500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3


Gestation and birthweightGestation and birthweight

The Audit results•Overall, 80% of mothers had their babies at term and 7% delivered post term. Ten percent of mothers delivered at 33–36 weeks and about 3.5 % delivered at less than 33 weeks of gestation.



The Audit results•Overall, 12.2 % of babies were low birthweight (less than 2500 g), 2.9% were very low birthweight (less than 1500 g), and 2.9% of babies weighed more than 4000 g at birth.

•The average birthweight at term was 3107 g; 2.8 % of babies weighed more than 4000 g.

Birth weight (grams) Frequency Percentless 1500 24 2.9

1500-2499 76 9.32500-4000 696 84.9more 4000 24 2.9

Total 820 100



The Audit results•For those babies born at term, 5.1 % were low birthweight, 0.4 % were less than 1500 g.

Influence of population and clinical Influence of population and clinical characteristics on caesarean section ratecharacteristics on caesarean section rate


1500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3


IOL* 44 10.2 88 22.6Not in Labour 296 68.7 0 0

PresentationCephalic 369 85.6 386 99.2Breech 30 7 1 0.3Other # 32 7.4 2 0.5

Number of FetusesSingletone 400 92.7 387 99.5

Twin 23 5.3 2 ^ 0.5More 8 2 0 0

OutcomeNursery 366 84.9 351 90.2

NICU 62 14.4 32 8.2Death $ 3 0.7 6 1.6

# twins


$ IUFD (2 cases were term pregnancies, the others were less than 32 wks


Induction of labourInduction of labourBackground•Induction of labour is defined as an intervention designed to artificially initiate uterine contractions leading to progressive dilatation and effacement of the cervix and birth of the baby. This includes women with intact membranes and women with spontaneous rupture of the membranes but who are not in labour.

~RCOG Clinical Effectiveness Support Unit. Induction of Labour. Evidence-based Clinical Guideline No. 9. London: RCOG Press; 2001.



1500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3


IOL* 44 10.2 88 22.6Not in Labour 296 68.7 0 0



Twin 23 5.3 2 ^ 0.5More 8 2 0 0


NICU 62 14.4 32 8.2Death $ 3 0.7 6 1.6

# twins




Induction of labourInduction of labourBackground•Induced labour was associated with fetal distress; electronic fetal monitoring predicts fetal distress and operative deliveries; operative deliveries had an effect on lower Apgar scores at 1 minute; Apgar scores at 1 minute have a direct effect on fetal distress, lower Apgar scores at 5 minutes and need for resuscitations. Oxytocin for induction predicted perineal trauma, perianal trauma has a direct effect on postpartum haemorrhage . Postpartum haemorrhage had a direct effect on lower haemoglobin level six weeks following birth, birth weight had a direct effect on Apgar score at 5 minutes.

~Hatamleh R, Sinclair M, Kernohan G, Bunting B (2013). The Cumulative Effect of Induction of Labour on Maternal and Infant Morbidity in Northern Jordan. Int. Res. J. Basic Clin.

Stud. 1(7):87-102



1500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3


IOL* 44 10.2 88 22.6Not in Labour 296 68.7 0 0



Twin 23 5.3 2 ^ 0.5More 8 2 0 0


NICU 62 14.4 32 8.2Death $ 3 0.7 6 1.6

# twins




Induction of labourInduction of labourThe Audit results•The overall rate of induction of labour was 16.2 %. Forty-seven percent of inductions were in women who were primigravid, 53% in women who were multiparous with no previous CS.

•Overall, 84% of inductions were carried out before 41 weeks and 16% after 41 weeks of gestation, 3% of inductions were carried before 32 weeks of gestations, and the remaining 4% carried between 33-36 wks.


The Audit results•The overall CSR among women who had induction of labour was about 34%. Among primigravid women, the CSR was 43%, and among multiparous women with no previous CS it was 16%.

•The most influential factor in deciding to perform these CS was presumed fetal compromise (48% cases), failure to progress (35% cases), maternal refusal to continue IOL (11% cases), and cord prolapsed (4% = 2 cases).

Induction of labourInduction of labour


Multiple pregnanciesMultiple pregnancies

Background •The National Maternal Morbidity Study (2007-2008) that conducted by The Higher Population Council in collaboration with the Jordanian Health Sector found that multiple pregnancies accounts 5.1 % as one of the main reasons for cesarean section between Jordanian women.

•Same study found Also that multiple pregnancies considered as a morbidity, on which contributed 1.6 % in current pregnancy (2007-2008) and History of 1.3 % morbidity during last pregnancy (before the current) regarding Jordanian women.



1500-2499 58 13.4 18 4.62500-4000 342 79.5 354 91more 4000 15 3.4 9 2.3


IOL* 44 10.2 88 22.6Not in Labour 296 68.7 0 0



Twin 23 5.3 2 ^ 0.5More 8 2 0 0


NICU 62 14.4 32 8.2Death $ 3 0.7 6 1.6

# twins




Multiple pregnanciesMultiple pregnanciesBackground

•The incidence of twins varies considerably between communities and families and has recently increased because of the number of older mothers and the use of fertility treatments and assisted conception.

•Infants from a twin pregnancy are at a higher risk of death around the time of birth than are infants from a singleton pregnancy.

•Some of this is due to a higher risk of preterm birth.

•The second-born twin has an increased risk of a poor perinatal outcome compared with the first-born twin

~Hofmeyr G, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD006553. DOI:

10.1002/14651858.CD006553.pub3


Multiple pregnanciesMultiple pregnancies

The Audit results•The multiple birth rate was approximately 40 per 1000 pregnancies. The twinning rate was 30 per 1000 pregnancies. Higher order births occurred at a rate of 10 per 1000.•Preterm birth was more common with multiple pregnancy. Sixty four percent of twin pregnancies delivered before 37 weeks gestation (compared with 10.5 % of singletons).

less 28 28-32 33 - 36 37 - 40 41and moreCount 7 12 66 646 56 787% within Number of Fetuses

0.90% 1.50% 8.40% 82.10% 7.10% 100.00%

% of Total 0.90% 1.50% 8.00% 78.80% 6.80% 96.00%Count 2 3 11 9 0 25% within Number of Fetuses

8.00% 12.00% 44.00% 36.00% 0.00% 100.00%

% of Total 0.20% 0.40% 1.30% 1.10% 0.00% 3.00%Count 0 4 3 1 0 8% within NumBer of Fetuses

0.00% 50.00% 37.50% 12.50% 0.00% 100.00%

% of Total 0.00% 0.50% 0.40% 0.10% 0.00% 1.00%Count 9 19 80 656 56 820% within NumBer of Fetuses

1.10% 2.30% 9.80% 80.00% 6.80% 100.00%

% of Total 1.10% 2.30% 9.80% 80.00% 6.80% 100.00%

Total

Table 26: Number of Fetuses * Gestations (weeks) CrosstabulationGestations (weeks)

TotalNumber of Fetuses Singleton

Twin

More

Decision making beforeDecision making beforeCaesarean sectionCaesarean section

CSR upon Maternal requestCSR upon Maternal requestBackground• Cesarean delivery on maternal request is defined as a primary prelabor cesarean delivery on

maternal request in the absence of any maternal or fetal indications.

• Recent study (2015) aimed to determine the popularity of cesarean sections on demand among women in Saudi Arabia They found 80.9% of the study population preferred vaginal delivery. Among the women who preferred vaginal delivery, 62.8% did so because they needed a shorter time to return to normal life, while 70.3% of the women who preferred CS did so because they wanted to avoid labor pains.

• Estimates of the prevalence of cesarean delivery on maternal request range from 1 to 18 percent of all cesarean deliveries worldwide, and <1 to 3 percent of all cesarean deliveries in the United States

~ PubMed: Trends in maternal request cesarean delivery from 1991 to 2004. [Obstet Gynecol. 2007]

• The potential benefits of elective cesarean delivery as compared to vaginal delivery are not fully understood but are thought to include decreased risk of urinary incontinence, pelvic organ prolapse, anal sphincter damage, and fecal incontinence. Elective cesarean delivery also has the benefit of flexible timing for mother and physician.

~ NIH State-of-the-Science Conference: Cesarean Delivery on Maternal Request March 27–29, 2006


CSR upon Maternal requestCSR upon Maternal requestBackground• Given the balance of risks and benefits associated with cesarean delivery on

maternal request, the Committee on Obstetric Practice offers the following recommendations:

• In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended.

The following is recommended in cases in which cesarean delivery on maternal request is planned:

• Cesarean delivery on maternal request should not be performed before a gestational age of 39 weeks.

• Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management.

• Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa,placenta accreta, and gravid hysterectomy increase with each cesarean delivery

~ Cesarean delivery on maternal request. Committee Opinion No. 559. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013:121;904–7.


CSR upon Maternal requestCSR upon Maternal request

The Audit resultsThe table above shows the frequency of maternal request according to the

mother’s age. The majority of request found in the age between 25-29 years, accounts around 39 %. 9% of maternal request noticed in the younger group between 20 – 24 years.

Frequency Percent20-24 7 8.925-29 31 39.230-34 24 30.435-39 10 12.7

more = 40 7 8.9Total 79 100

CSR upon Maternal request: Mother's age (years)



The Audit resultsThe reported rate of maternal request for elective CS was 87.3 %

* An emergency CS due to maternal refusal to continue vaginal delivery (already in labour)

Frequency PercentElective 69 87.3

Emergency* 10 12.7Total 79 100

CSR upon Maternal request : C-section



The Audit resultsCS that reported by clinicians to be performed for maternal request contributed 18.2

% overall CSR. But 51 cases of maternal request (64.6%) have one previous CS, and they asked for CS directly without trial of labour, which means that 35.4 % of cases were primarily performed for maternal request ( 28 of cases) which equal 6.44% of overall CSR

Frequency PercentOnce 51 64.6

Primary 28 35.4Total 79 100

CSR upon Maternal request : Previous C-section



The Audit resultsThe table above compares maternal request in primigravid women, multiparous women

who had not had a previous CS and multiparous women who had had at least one previous CS. The findings were 22.8%, 11.4 %, and 65.8 % respectively

Frequency PercentMP no CS 9 11.4

MP with CS 52 65.8P0 18 22.8

Total 79 100

CSR upon Maternal request : Parity



The Audit resultsFinally, the effect of consultants in the decisions for doing CS upon maternal request, either

as a primary CS, or maternal refusal to has Trial of labour. For more details we suggest a survey for consultant response to maternal request, If a woman wants to have a CS she should be able to have one, or should not be interfered with a natural process of birth unless necessary.

Frequency PercentA 14 17.7B 1 1.3C 10 12.7D 4 5.1E 2 2.5F 7 8.9G 14 17.7H 10 12.7K 9 11.4L 3 3.8M 5 6.3

Total 79 100

CSR upon Maternal request : Specialist (doctor \ Proof)

Caesarean Section Audit Report ~ 2016

Supervision: Haifa A Al-Chalabi FRCOGDone by: Hashem M Yaseen MBBS

csr audit hashem 2016 last modification

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