On the basis of data collection for clinical audit indicators and Robson analysis of month 1-6 of 1435 by clinical audit team in general directorate, our hospital has increase primary cesarean section especially in prime gravida. For that there was a recommendation to start performance improvement project to decrease the primary cesarean delivery. LEADER: Dr. Ismail Fathi (Head of OB-GYNE) FACILITATOR: Dr. Muhammad Younus (Deputy Quality Director) MEMBERS: Dr. Mohammad Khalaf (OB-GYNE Specialist) Dr. Samir Hemeda (OB-GYNE Resident) Sis. Angelina Acuna (Charge Midwife of L&D Dept) Sis. Anna Kristie Ledesma (Quality Coordinator) ActivityResponsibilityTarget DateResourceOutcome 1. Do not admit the patient to DR unless at least 3cm dilatation or other medical problem All the physician working in OBG department From month 7 of 1435 Admission policy Early admission is one of the cause of cesarean delivery 2. Apply the new standard for partogram All the physician working in OBG department From month 7 of 1435 New guide line Active phase of labor start at 6cm 3. Induction of labor for postdates patients: a, should start at 41 w + 3 days(unless any other medical reason) b, should be preceded by ripening of cervix c, should not be declared fail unless oxytocin has tried (except contraindication) All the physician working in OBG department From month 7 of 1435 New guide line -Decrease the cesarean birth -Decrease the maternal and fetal morbidity - increase the vaginal delivery 4. CTG interpretation should be done according to the departmental policy and procedure, not by subjective evaluation All the physician working in OBG department From month 7 of 1435 Departmental policy and procedure Decision for CS will be in solid indication 5.Cases suspected for macrosomia should be evaluated by multidisciplinary approached with radiologist and clinical correlation All the physician working in OBG department plus the Radiologist From month 7 of 1435 Departmental policy and procedure or protocol -CS can be decrease -Decrease fetal and maternal morbidity 6. Trials of vaginal delivery should be given for the case of breech or twins, after proper counseling and consent from the patient and guardian with preparation for CS if indicated. All the physician working in OBG and Anesthetist From month 7 of 1435 Departmental policy and procedure or protocol -CS can be decrease -Decrease fetal and maternal morbidity 7. Instrumental (ventouse) delivery will be conducted with consent for possible CS and informed OR for possible emergency CS. All the physician working in OBG, OR staff and Anesthetist From month 7 of 1435 Departmental policy and procedure or protocol -CS can be decrease -Decrease fetal and maternal morbidity  Encouraging the patient for vaginal delivery  Educating the patient and family to attend the antenatal clinic  Using clinical guideline by all the gynecologist for 80% causes of CS according to the pareto principle  Using the informative broacher to educate the patients  Encouraging the patient for vaginal delivery  Educating the patient and family to attend the antenatal clinic  Using clinical guideline by all the gynecologist for 80% causes of CS according to the pareto principle  Using the informative broacher to educate the patients Future Plan: Patients attend DR with sure diagnosis of labour Assessment of pelvic capacity Contracted pelvis (CPD) Adequate pelvis CTG and Partogram Normal Allow vaginal delivery Suspicious Follow up Pathologic CTG C-Section CTG request Result of CTG/ Partogram NSVD Consent for CS Increased Rate of Primary C Section MEN METHODS MATERIALS EQUIPMENTENVIRONMENT Misinterpretation of the significance of meconium Patient; Uncontrolled DM,HTN Lack cervical ripening, foetal distress, late presentation, no follow-up in antenatal care clinic Lack of pain tolerance Wrong calculations of dates No file, no follow-up investigation report CTG: Lack of objective CTG Early admission to DR Lack of Consultant support Physicians; -Inappropriate induction, - Presumed failure to progress and foetal distress, need consultant opinion -Afraid of litigation, Misinterpretation of Partogram  T he cesarean delivery will be decreased  Patient safety will be increased  Hospital cost will be decreased  Patient & relative satisfaction will be increased INDICATIONMONTH 6MONTH 7MONTH 8MONTH 9MONTH 10MONTH 11TOTAL Obstructed Labor and CPD Oligohydramnios Breech and Twin Pregnancy Failure to progress Fetal Distress41 5 PROM, Old Primi1 1 PIH 1 1 Poor Variability with Type I deceleration 11 Total Primary Cesarean Section from Month 6-11, 1435 Primary Cesarean Section in Primi gravida from Month 6-11, 1435 INDICATIONMONTH 6MONTH 7MONTH 8MONTH 9MONTH 10MONTH 11TOTAL Obstructed Labor Oligohydramnios Fetal Distress 21 3 PROM, Old Primi 1 1 Failure to progress Breech Total Histogram of Primary Cesarean Section from Month 6-11, 1435 Pareto Chart of Primary Cesarean Section from Month 6-11, 1435 Histogram of Primary Cesarean Section in Primigravida from Month 6-11, 1435 Pareto Chart of Primary Cesarean in Primigravida Section from Month 6-11, 1435