Learning From Experience: Development of a Cognitive Task List to Perform a Caesarean Section in the Second Stage of...

Caesarean section at full cervical dilatation is a challenging procedure with a higher risk of fetal and maternal morbidity. We wished to elicit the essential clinical components of a CS at full dilatation performed skilfully and safely.

We conducted a prospective study with both qualitative (individual interviews) and quantitative (questionnaire) components. In the qualitative components, senior clinicians were interviewed using open-ended questions regarding techniques used for performance of CS at full cervical dilatation. Interviews were recorded and thematic analysis was performed until saturation was achieved. In the second (quantitative) component of the study, clinicians completed a questionnaire regarding tips and techniques to perform a CS at full cervical dilatation.

For the qualitative component, 15 clinicians agreed to participate. There was a 90% (n = 27) response rate to the questionnaire. Common themes from both components of the study included the advice to routinely re-examine the patient (with abdominal and vaginal examinations) in the operating room after induction of anaesthesia to determine pelvic architecture, fetal size, and the station of the presenting part, and especially to assess for progress since the initial decision to perform a CS in the labour room. When the decision is made to proceed with CS, the following modifications to a standard CS technique were suggested: first, to make a more superior transverse uterine incision than usual, and second, to secure each uterine angle separately before uterine closure is commenced in order to identify and manage angle extension and thereby minimize blood loss. Other modifications, such as vaginal disimpaction of the fetal head before beginning the operation, were more controversial. Participants developed their own techniques by combining teaching from senior obstetricians, watching others operate, and learning from their own clinical experience.

There is an increasing role for good quality clinical training programs on how best to perform complex deliveries such as CS at full cervical dilatation. After identifying the essential components of CS at full cervical dilatation reported by multiple skilled clinicians, these can then be translated into a useful educational tool.