Using a criterion based audit to assess impact of Lucas classification of urgency of caesarean section on pregnancy outcomes at Kawempe National Referral Hospital

Abstract

Background: Global caesarean section (C-section) rates have increased from around 7% in 1990 to 21% in 2023. In Uganda, the C-section rate stands at 6% and 11% among first-order births indicating a high incidence of primary C-sections. Tertiary facilities in Africa with a high C-section load have a long decision-delivery interval (DDI) which leads to poor pregnancy outcomes. C-section triaging reduces the DDI of C-sections and improves pregnancy outcomes but is rarely done in most busy African maternity units. The purpose of this study was therefore to evaluate the impact of Lucas classification of urgency of C-section on pregnancy outcomes at Kawempe National Referral Hospital (KNRH). Methods: This was a criterion-based audit which assessed the current practice of grading of urgency of C-sections at KNRH. Adverse pregnancy outcomes of all deliveries and the DDI of emergency C-sections was retrospectively collected for 1 month before and 1 month after the introduction of Lucas classification of urgency of C-sections. Data was entered and managed from the Open Data Kit tool, then exported to STATA for analysis. Proportional Z-test and paired T-Test analysis was conducted to assess the difference in the occurrence of the identified adverse pregnancy outcomes and the DDI respectively, before and after introduction of the Lucas Classification. The significance level was measured at 5%. Results: Prior to the intervention no C-section triaging was done using the Lucas classification while after the intervention, 7.1% of emergency C-sections were triaged. Several pregnancy outcomes significantly reduced after the intervention and these were; maternal death from 0.6% to 0.4% (P=0.046), 3rd and 4th degree tears from 1.5% to 0.8% (P=0.036), excess blood loss and transfusion from 3.4% to 1.6% (P=0.029), low Apgar score from 15.5% to 13.5% (P=0.038), fresh still birth from 2.3% to 1.9% (P=0.026). NICU admission (term babies) from 11.5% to 16.4% (P=0.017). The mean DDI reduced from 9.8 hours before the intervention to 3.4 hours after intervention, indicating a percentage reduction of 65.3% (P<0.0001). Conclusion: The use of the Lucas classification of urgency of C-sections lead to improved pregnancy outcomes and a reduction in the DDI of emergency C-sections at KNRH. Recommendations: Adoption of the Lucas classification by KNRH and other busy maternity hospitals can lead to improved pregnancy outcomes. Creation of a network of champions to encourage continued use of the classification. Further research and guidelines to classify category 1 emergency C-sections based on indications and level of urgency.