Amena Fardous
Cwm Taf Morgannwg University Health Board, UKPresentation Title:
Audit on the prerequisites of assisted vaginal delivery
Abstract
Aim: The aim of this audit was to assess compliance with the documentation of prerequisites for assisted vaginal birth (AVB), as outlined in the RCOG Green-Top Guideline No. 26 and the Cwm Taf Morgannwg University Health Board guideline. Specifically, the audit evaluated whether abdominal palpation and station were documented prior to attempted instrumental deliveries.
Methods: A retrospective audit was undertaken using an agreed questionnaire based on the above guidelines. Data were collected from case notes of instrumental vaginal deliveries (forceps and vacuum) performed at Prince Charles Hospital between July 2024 and December 2024. Sixty-four case notes were retrieved by the Clinical Audit & Effectiveness Department. Twenty-two were excluded due to unavailable documents and three due to incomplete records, leaving 39 cases for inclusion. The data were analyzed in line with the audit proforma, focusing on key documentation indicators and adherence to standards.
Results and Discussion: Abdominal palpation and fetal station were documented in 100% of reviewed cases. However, only 2 cases (5%) specifically recorded the degree of fetal head descent as ≤1/5 palpable, compared to the ideal standard of 100%. Where station was documented, all attempted instrumental deliveries were performed at station at the ischial spines or below (100%). Documentation practices varied considerably—some clinicians used the formal operation note, others the clinical notes or the dedicated instrumental delivery proforma. Documentation gaps were also attributed to the merger of hospital sites and incomplete case records. Importantly, failed instrumental deliveries that resulted in caesarean section were not included, limiting the comprehensiveness of this dataset.
Conclusion: While documentation of abdominal palpation and station was consistently present, detail and standardization were inadequate. The completion of the instrumental delivery proforma should be mandatory, and inclusion of failed assisted deliveries is essential. A prospective re-audit following education and reinforcement of documentation standards is recommended to ensure ongoing adherence to national and local guidelines, improve data accuracy, and enhance maternal and neonatal outcomes.
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