A clinical audit of emergency caesarean deliveries at Kenyatta National Hospital
Background: The rate of emergency caesarean deliveries is increasing worldwide beyond the recommended rate of 15% of all deliveries in spite of well-documented evidence of increased maternal morbidity and mortality associated with caesarean delivery (CD). In addition, high CD rates lead to high cost of healthcare, increased workload and challenges in ensuring improved quality of care. These issues continue to weigh heavily on the health sector especially in developing countries. The recommended decision to delivery time interval for performing emergency caesarean deliveries is sixty minutes locally and thirty minutes internationally a target that has remained elusive. Before any medical strategies can be designed to improve the total quality of emergency CD care the current clinical practice needs to be audited and the optimal institutional rate of caesarean deliveries identified factoring in it's population characteristics. Objective: To audit the indications, responsiveness and immediate outcomes of emergency caesarean deliveries at Kenyatta National Hospital (KNH). Study design: Descriptive retrospective study. Setting: Kenyatta National Hospital, Nairobi, Kenya. Main measure of outcome: Indications of emergency CD, decision to delivery interval (DDI), association between indications and DDI, association between indications and perinatal outcome and association between DDI and perinatal outcome. Participants: All women delivered by emergency CD at KNH during the period from l ' April 2011 to 30th June 2011 inclusive. Results: During the study period, there were 2754 deliveries, 930 were emergency CD giving an emergency caesarean delivery rate of 33.8%. Quality of records was poor with a file retrieval rate of 95.2% yielding 885 files, 45 (4.8%) files could not be traced. Of the retrieved files, 56.7% had complete data and were analyzed. The leading indications of emergency CD were, NRFS (27.3%), Failed VBAC (16.1 %), dystocia (13.9%), malpresentation/malposition (9.4%), >=2PS in labour (9.2%) and pre-eclampsia/eclampsia (6.4%) in that order. The overall responsiveness was poor with decision to delivery time interval of less than thirty minutes being achieved in only 5.4% of the participants. 76.9% of the participants were delivered more than 90minutes after the decision. Even in extremely urgent indications the response was poor with only 60% and 75% of participants with cord prolapsed and uterine rupture respectively being delivered in less than sixty minutes.523 babies were delivered of whom 25.8% were preterm, 1.9% were asphyxiated and 6.3% were stillbirths. Fresh Still Births (FSB) comprised 56.3% of the stillbirths. DDI did not demonstrate a statistically significant impact on immediate perinatal outcome (p- value>0.001). APH, Pre-eclampsia/eclampsia and uterine rupture had a statistically significant impact on the neonatal outcome (p- val ue>O. 001). Conclusion: Record keeping was far from optimal and responsiveness in emergency CD was poor. NRFS, Failed VBAC and dystocia were the leading indications of emergency CD. DDI had no significant impact on the neonatal outcome. Perinatal mortality rate was 6.3%. Recommendations: There is need to ensure the compliance to the local decision to delivery interval (DDI) standard of 60 minutes with an eventual aim of getting within the 30 minutes international recommended response time. A record keeping protocol ought to be established to guide and improve on the record keeping. There is also need for regular clinical audits to ensure continued improvement in the quality of care in emergency CD.