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Table 2 Professionals’ perceived barriers and facilitators for adherence to CS guidelines

From: Identification of barriers and facilitators for optimal cesarean section care: perspective of professionals

Most important influencing factors per domain:
Domain I
Guideline itself
Domain II
Professionals
Domain II
Professionals
Domain IV
Social
Domain V
Organizational
Design
• The guidelines are designed for an average patient, instead of an individual
Clinical characteristics
• Non-adherence to the guidelines due to patient characteristics
Information by others
• Negative experience of friends/family (eg with external cephalic version)
Hampering collaboration
• Between obstetricians and anesthesiologists regarding epidural analgesia
• Between midwives and obstetricians/residents
No agreements regarding
• Responsibility for counseling: the midwife or obstetrician
• Variation in standard policy between hospitals (regarding e.g. fetal scalp blood sampling, breech deliveries)
• Indications for CS
Availability
• Guidelines are not easy available
• Local protocols are not up to date
Counseling
• No or too late agreement regarding the possibility of a preterm birth
Patients’ view
• Patients do not accept any risks for the fetus.
• Refusal of external cephalic version.
Variation in policy
• Between different obstetricians
Documentation
• Unclear documentation on mode of birth counselling
• Unclear documentation on previous births
Strict hierarchy
• Preventing adequate feedback
Staffing
• Appropriate staff not present at the discussion regarding obstetrical decisions
• Inadequate staffing and allocation of tasks
• Midwives are not invited for audits
Knowledge and skills Insufficient experience or expertise regarding:
• Breech deliveries
• Foley catheter induction in case of previous CS
• Estimation of fetal weight
• Fetal scalp blood sampling
• External cephalic version
Availability of staff
• Obstetricians
• Anesthesiologists
• Inadequate to provide 1-on- 1 support to women in labour
Attitude
• Policy depends on time (day/night)
• Fetal scalp blood sampling is time consuming
Availability of diagnostics
• Partogram
• Fetal scalp blood sampling
Disagreement with guidelines
• Behaviour therapy in case of fear for pain is not always strictly necessary
• Epidural analgesia is not strictly necessary in case of failure to progress in labor
• Don’t use a partogram in case of rapid labour progression
▪ CS should be mentioned in case of severe shoulder dystocia in previous pregnancies, even if there is no residual damage
▪ Assessment by an obstetrician in case of failure to progress before performing a CS depends on a residents’ experience