Clinical Practice Guideline for Planned Cesarean Section: Intraoperative Interventions

Abstract

Problem & Purpose: Thirty percent of all births in the United States are performed by cesarean delivery (CD) making it the most common surgical procedure performed. Common complications include Spinal Induced Hypotension (SIH) and Post Spinal Shivering (PSS), which can have a detrimental impact on the mother and the fetus. Another factor that contributes to infant morbidity and mortality is not practicing delayed cord clamping (DCC). Lack of guidelines to manage intraoperative complications and DCC results in a variation in practice among anesthesia providers, leading to an increase in maternal and fetal morbidity and mortality. The purpose of this quality improvement project was to develop a clinical practice guideline (CPG) incorporating evidence based best practice interventions to standardize and optimize care of women undergoing planned CD to reduce the incidence of SIH and PSS. It also included the standardization of delayed cord clamping (DCC) times to decrease morbidity and mortality among healthy infants. Methods: An extensive literature review focused on management of SIH, PSS and DCC was conducted. A CPG was drafted and presented to a team consisting of Director of Obstetrics Anesthesia and Director of Fetal and Maternal medicine who analyzed the CPG utilizing the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Modifications were made based on results and the CPG was presented to the anesthesia providers within organization who evaluated the usability of the CPG utilizing the Peer Feedback Questionnaire (PFQ). Results: Two AGREE II tools were distributed and completed representing a 100% response rate. Each of the domains on AGREE II tool received a score greater than 70% indicating good quality. The overall guideline assessment score was 91.7%. A total of 39 PFQs were distributed to anesthesia providers, 17 were completed representing a 43% response rate. Analysis of the PFQ revealed a total percentage of agreement of 87.4% with a standard deviation of 6.6. The percentage of agreement was also calculated for the five subscales. Quality and acceptance of CPG received the highest scores of 97.9% and 87.5% respectfully while the lowest score of 39% was obtained in applicability. Conclusion: Favorable results on AGREE II tool and PFQ demonstrated the CPG was of good quality and well accepted by anesthesia providers. Implementation of the CPG has the potential to improve the standardization and optimization of women undergoing planned CD as well as standardizing DCC times to improve infant morbidity and mortality.