What is the audit for Lower Segment Caesarean Section (LSCS)?

From the Guidelines

A Lower Segment Cesarean Section (LSCS) audit is crucial for evaluating and improving maternal care quality in healthcare facilities, and I strongly recommend implementing a comprehensive LSCS audit system as outlined in the Enhanced Recovery After Surgery Society guidelines 1. The audit should include key metrics such as primary cesarean rates, repeat cesarean rates, maternal morbidity (including infection rates, hemorrhage, and thromboembolism), and neonatal outcomes. To implement this effectively, establish a multidisciplinary team including obstetricians, midwives, anesthesiologists, and quality improvement specialists who meet regularly to review cases. Some key points to consider when implementing an LSCS audit include:

• Use standardized documentation forms to capture relevant data points
• Implement a classification system like the Robson Ten Group Classification to categorize cesarean deliveries
• Regular feedback sessions with clinical staff to identify opportunities for improvement and potentially reduce unnecessary cesarean deliveries. As noted in the Enhanced Recovery After Surgery Society guideline, a “focused” pathway process for scheduled and unscheduled ERAS CD has been created for this ERAS CD guideline from “decision to operate (30 - 60 minutes before skin incision) to hospital discharge” 1. This systematic approach allows for meaningful comparison of rates over time and between institutions, ultimately promoting evidence-based practice, identifying training needs, and improving maternal and neonatal outcomes through continuous quality improvement. The most recent and highest quality study, although not directly comparing different audit systems, emphasizes the importance of audit and feedback in improving surgical quality and safety for obstetric surgical deliveries 1.

From the Research

LSCS Audit Findings

• The use of antibiotic prophylaxis in LSCS surgeries has been studied extensively, with findings indicating a significant reduction in postpartum infectious morbidity 2, 3.
• A study conducted in Oman found that there was a great diversity in antibiotic regimes used in different hospitals, with only one hospital having written guidelines 2.
• The study also found that cephalosporin was used in the majority of cases, but there was little consistency in the generation prescribed, with second-generation cefuroxime being the most popular 2.
• Another study found that carbetocin was probably the most effective agent in reducing blood loss and the need for additional uterotonics during cesarean delivery 4.
• A study conducted in India found that the incidence of surgical site infections (SSIs) after LSCS was 10.3 per 100 surgeries, with superficial SSI being the most common 5.
• The study also found that inappropriate pre-surgical antibiotic prophylaxis, anemia, previous LSCS, intra-operative blood transfusion, and comorbid illnesses were significantly associated with SSIs 5.

Recommendations for LSCS Audit

• Based on the findings, it is recommended that hospitals develop and implement written guidelines for antibiotic prophylaxis in LSCS surgeries 2, 3.
• The use of carbetocin as a uterotonic agent should be considered, as it has been shown to be effective in reducing blood loss and the need for additional uterotonics 4.
• Hospitals should also implement measures to reduce the risk of SSIs, such as appropriate pre-surgical antibiotic prophylaxis, and address comorbid illnesses and other risk factors 5, 6.
• The timing of intravenous prophylactic antibiotics should be administered preoperatively to reduce maternal infectious morbidities 6.