Kane Daniel, Shanahan Ita, Geary Michael, Malone Fergal D, Kent Etaoin, Burke Naomi
Royal College of Surgeons in Ireland, Rotunda Hospital Dublin, Ireland.
Royal College of Surgeons in Ireland, Rotunda Hospital Dublin, Ireland.
Eur J Obstet Gynecol Reprod Biol. 2021 Mar;258:358-361. doi: 10.1016/j.ejogrb.2021.01.036. Epub 2021 Jan 23.
The rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates.
This was a population-based study in a tertiary referral centre from 2008-2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p < .05.
There were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90-1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01-1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07-1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) CONCLUSION: This study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.
全球剖宫产率正在上升。未生育、足月、单胎、头先露、自然临产的女性（罗布森1组/RG1）被认为剖宫产风险较低。据推测，由于医生疲劳，夜间或周末进行的剖宫产更多。2013年，我们机构实施了《欧洲工作时间指令》（EWTD）以限制医生工作时间，其目的是减少疲劳，但可能会破坏医疗服务的连续性。本研究旨在确定夜间和周末值班以及EWTD的实施对我们RG1剖宫产率的影响。
这是一项在2008年至2017年期间于一家三级转诊中心进行的基于人群的研究。我们研究的纳入标准仅限于RG1。数据来自一个已建立的临床数据库，包括分娩方式和时间。分类变量的描述性统计以数量和百分比表示。相对频率使用卡方检验进行检验。所有统计分析均使用SPSS 26版进行。统计学显著性定义为p<0.05。
在10年的研究期间共有86473例分娩。RG1组有18761名女性。总体而言，RG1组的剖宫产率为12.9%（n = 2415）。RG1组中，工作日分娩者（12.9%，n = 1726/13430）和周末分娩者（12.9%，n = 689/5331，OR 0.99，95%CI = 0.90 - 1.09，p = 0.89）的剖宫产率在统计学上无差异。白天的剖宫产率为12.1%（n = 777/6411），夜间为13.3%（n = 1638/12350，OR 1.10，95%CI = 1.01 - 1.21，p = 0.03）。比较EWTD实施前后的时间段，剖宫产率有显著增加（12.1%，n = 1319/10873对13.9%，n = 1096/7888，OR 1.17，95%CI = 1.07 - 1.27，p < 0.001）。关于EWTD实施前后RG1组的其他分娩方式，手术阴道分娩（OVD）率有统计学显著下降（40.1%，n = 4360对37.7%，n = 2973，OR 0.90，95%CI = 0.85 - 0.95，p = .001）
本研究表明产科实习医生的工作模式、RG1组的剖宫产率和OVD率之间存在关联；这种关联在夜间和EWTD实施后最为明显。产科实习医生的工作模式不太可能是剖宫产率上升和OVD率下降的唯一相关因素。应考虑满足产科实习医生在减少产房接触时间的情况下实现其能力的需求。需要进一步研究以确定模拟培训的替代安排是否可以提高OVD率并降低剖宫产率。
