Impact Of Physicians Decision Making On Cesarean Section In Nulliparous Women In Spontaneous Labor

摘要

Background: The current study tries to explain a wide variation in the Cesarean Section rate of an obstetric team attending nulliparous women at term in spontaneous labor.Methods: Physicians were divided in two Groups: Group A formed by doctors in the first quartile of Cesarean section rate and Group B formed by doctors in the fourth quartile. Differences in maternal and fetal factors, clinical practice and perinatal outcomes were studied.Results: No differences were observed in maternal and gestational characteristics. No significant differences were found in length of the first stage of delivery (5,02 hours vs. 5,31 hours; p>0,05) nor in the second stage (1,82 hours vs. 1,99 hours; p>0,05). There were significant differences in obstetric practice: Group A presented a significant lower trend in diagnosis of dystocia (23,26% vs. 46,84%, p<0,05), fetal loss of wellbeing (0,72% vs 9,30%; p<0,05) and use of forceps(11,72% vs 27,14%; p<0,05). No differences were found in use of epidural analgesia (89,86% vs 78,29%, p>0,05) and episiotomy (60,94% vs. 50%; p>0,05). Perinatal outcomes were similar in both Groups.Conclusions: Cesarean section in nulliparous women were significantly influenced by individual physician’s decisions due to possible over diagnosis of dystocia and fetal compromise. These results should inspire specific actions to homogenize results between different professionals. INTRODUCTION Cesarean section rates worldwide have been increasing in the past few years. In Europe it increased by 13,8% in the last 14 years1. Causes of this increase are not simple or easy to understand and vary in function of different factors such as parity, category of pregnancy, and course of pregnancy and delivery. Therefore, it’s necessary to classify different groups of women to understand the causes of cesarean section rates.The Ten Group Classification System (TGCS) is a new approach to classify the obstetric population according to total inclusive and mutually exclusive categories2. This system allows to better understand obstetric events creating solid and robust groups that are comparable between different delivery units.Nulliparous women at term with single gestation and cephalic presentation in spontaneous onset of labor (Group 1 of the TGCS) are often the largerst contributor to overall obstetric population. Therefore, its contribution to the overall cesarean section rate uses to be quite important3.The cesarean section rate shows wide variation among different geographic areas4. Inside an Obstetric unit we can also observe differences between professionals involved in the obstetric process. This variation is usually justified because of some maternal characteristics (age, weight, ethnicity), obstetric pathologies (hypertension, diabetes) or fetal compromise (growth restriction, loss of fetal wellbeing…). In summary, we can categorize the causes of cesarean section rates in two big groups: 1) increasing proportions of patients with conditions necessitating cesarean delivery; or 2) changes in physician practice patterns, leading to cesarean deliveries that would not have been performed previously.The aim of this study is to better understand differences in the cesarean section rate among professionals in our team, taking into account maternal and obstetric factors but also focusing on obstetric practice and perinatal outcomes. METHODS We conducted a retrospective analysis of women belonging to TGCS Group 1 admitted for spontaneous onset labor to our Delivery Unit during 2015. Our institution, the Hospital Universitari General De Catalunya (HUGC), is a tertiary hospital in the region of Barcelona (Spain), serving 2400 deliveries per year. The medical team is formed by local staff and external doctors who attend their own patients.Data were extracted from our local database which contains records of all patients admitted in the labor ward. These records include information about the medical team, characteristics of patients, monitori