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