on the basis of data collection for clinical audit indicators and robson analysis of month 1-6 of...

Find an Opportunity for Improvement PLAN THE PROJECT

DO THE WORK THAT IS NEEDED

CHECK THE RESULTS

AFLAJ GENERAL HOSPITALDECREASE PRIMARY CESAREAN SECTION RATE

Performance Improvement Project

On the basis of data collection for clinical audit indicators and Robson analysis of month 1-6 of 1435 by clinical audit team in general directorate, our hospital has increase primary cesarean section especially in prime gravida. For that there was a recommendation to start performance improvement project to decrease the primary cesarean delivery.

ACT TO MAINTAIN THE CHANGES

LEADER: Dr. Ismail Fathi (Head of OB-GYNE) FACILITATOR: Dr. Muhammad Younus (Deputy Quality Director)MEMBERS: Dr. Mohammad Khalaf (OB-GYNE Specialist) Dr. Samir Hemeda (OB-GYNE Resident) Sis. Angelina Acuna (Charge Midwife of L&D Dept) Sis. Anna Kristie Ledesma (Quality Coordinator)

Activity Responsibility Target Date Resource Outcome1. Do not admit the patient to DR unless at least 3cm dilatation or other medical problem

All the physician working in OBG department

From month 7 of 1435

Admission policy Early admission is one of the cause of cesarean delivery

2. Apply the new standard for partogram All the physician working in OBG department


New guide line Active phase of labor start at 6cm

3. Induction of labor for postdates patients:a, should start at 41 w + 3 days(unless any other medical reason)b, should be preceded by ripening of cervixc, should not be declared fail unless oxytocin has tried (except contraindication)



New guide line -Decrease the cesarean birth-Decrease the maternal and fetal morbidity- increase the vaginal delivery

4. CTG interpretation should be done according to the departmental policy and procedure , not by subjective evaluation



Departmental policy and procedure

Decision for CS will be in solid indication

5.Cases suspected for macrosomia should be evaluated by multidisciplinary approached with radiologist and clinical correlation

All the physician working in OBG department plus the Radiologist


Departmental policy and procedure or protocol

-CS can be decrease-Decrease fetal and maternal morbidity

6. Trials of vaginal delivery should be given for the case of breech or twins, after proper counseling and consent from the patient and guardian with preparation for CS if indicated.

All the physician working in OBG and Anesthetist




7. Instrumental (ventouse) delivery will be conducted with consent for possible CS and informed OR for possible emergency CS.

All the physician working in OBG, OR staff and Anesthetist




CURRENT ACTIONS

Encouraging the patient for vaginal deliveryEducating the patient and family to attend the antenatal

clinic Using clinical guideline by all the gynecologist for 80%

causes of CS according to the pareto principle Using the informative broacher to educate the patients

Future Plan:

Decrease the cesarean delivery up to the regional as well as the international benchmark.

Organize a Team

Clarify Current Process

Patients attend DR with sure diagnosis

of labour

Assessment of pelvic capacity

Contracted pelvis (CPD) Adequate pelvis

CTG and Partogram

Normal

Allow vaginal delivery

Suspicious

Follow up

PathologicCTG

C-Section

CTG request

Result of CTG/

Partogram

NSVD

Consent for CS

Understand the Current Problem

Increased Rate of

Primary C Section

MENMETHODS

MATERIALS EQUIPMENTENVIRONMENT

Misinterpretation of the significance

of meconium

Patient; Uncontrolled DM,HTNLack cervical ripening, foetal distress, late presentation, no follow-up in antenatal care clinic Lack of pain tolerance

Wrong calculations

of dates

No file, no follow-up

investigation report CTG: Lack of

objective CTG

Early admission to DR

Lack of Consultant support

Physicians; -Inappropriate induction, - Presumed failure to progress and foetal distress, need consultant opinion -Afraid of litigation, Misinterpretation

of Partogram

Select Desired Outcome

The cesarean delivery will be decreased Patient safety will be increasedHospital cost will be decreasedPatient & relative satisfaction will be increased

INDICATION MONTH 6 MONTH 7 MONTH 8 MONTH 9 MONTH 10 MONTH 11 TOTAL Obstructed Labor and CPD 2 1 3 3 1 10

Oligohydramnios 2 2 1 5 Breech and Twin Pregnancy 2 3 1 2 2 2 12

Failure to progress 3 2 3 2 2 12 Fetal Distress 4 1 5

PROM, Old Primi 1 1 PIH 1 1

Poor Variability with Type I deceleration 1 1 Total 11 8 3 11 7 7 47

Primary Cesarean Section from Month 6-11, 1435

Primary Cesarean Section in Primi gravida from Month 6-11, 1435INDICATION MONTH 6 MONTH 7 MONTH 8 MONTH 9 MONTH 10 MONTH 11 TOTAL

Obstructed Labor 2 1 0 3 2 1 9 Oligohydramnios 1 0 0 2 0 1 4

Fetal Distress 2 1 3 PROM, Old Primi 1 1

Failure to progress 1 1 1 2 5 Breech 1 1 1 3

Total 6 4 1 6 5 3 25

0

2

4

6

8

10

12

10

5

12 12

5

1 1 1

Histogram of Primary Cesarean Section from Month 6-11, 1435

Breech

and Twin Pregnancy

Failu

re to

progre

ss

Obstr

ucted La

bor and CPD

Oligohydra

mnios

Feta

l Dist

ress

PROM, O

ld Primi

PIH

Poor Varia

bility w

ith Type I d

ecelera

tion-113579

111315

0

20

40

60

80

100

12 12 105 5

1 1 1

INDICATION OF PRIMARY CS Cumulative %

Pareto Chart of Primary Cesarean Section from Month 6-11, 1435

Histogram of Primary Cesarean Section in Primigravida from Month

6-11, 1435

0123456789

9

43

1

5

3

Pareto Chart of Primary Cesarean in Primigravida Section from Month 6-

11, 1435

Obstr

ucted La

bor

Failure

to pro

gress

Oligohydramnios

Fetal Dist

ress

Breech

PROM, O

ld Primi

0

2

4

6

8

10

0102030405060708090100

9

5 4 3 31

Indication of Primary CS Cumulative %

on the basis of data collection for clinical audit indicators and robson analysis of month 1-6 of...

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