Steps of a safe Caesarean Section: A Delphi Study of South African Experts as a basis for surgical training

Abstract

Abstract Background Caesarean section is the most common surgery globally. In low- and middle-income countries, including South Africa, caesarean section-associated maternal and perinatal complications are of concern, some of which are attributed to lack of clinical skill and training. There is no standard technique for performing or teaching caesarean sections in South Africa. This study aimed to determine the essential and comprehensive steps of a safe caesarean section, according to South African experts.Methods A modified three-round Delphi survey method was used. The steps were divided into pre-operative, intra-operative and post-operative steps. Email invitations were sent to a panel of South African obstetric experts. These were defined as obstetric medical specialists currently or previously actively involved in caesarean section training in the South African public sector identified by the research team or suggested by institutional heads. Aimed sample size was 15, and a consensus was reached according to the confidence intervals (CIs). For the first two rounds, a 7-point Likert scale was used; exclusion was defined as a CI < 4, and inclusion of a CI > 6; CIs 4.1–5.9 were re-evaluated in the next round. In round three, only steps that did not reach consensus were presented to the panel as essential or sub-steps (or excluded). The final list was reviewed by stakeholders, who are clinicians frequently performing caesarean sections.Results Invitations were sent to 44 experts: 28 (64%) completed round one, 20 (45%) round two and 19 (43%) round three. Twenty-five (92%) experts had > 11 years of professional experience, and 22 (82%) had performed more than 1000 caesarean sections each. There were 30 steps deemed essential after three rounds: 11 essential/12 sub-steps preoperatively, 14 essential/15 sub-steps intraoperatively and 5 essential/9 sub-steps postoperatively. Stakeholders agreed with most and had some additional suggestions.Conclusion This panel and stakeholders suggested 34 essential and 40 sub- or considered steps for a safe caesarean section. A defined task list can standardise the procedure and training. This may be an important step toward increasing the safety and quality of caesarean sections, especially in low- and middle-income settings where junior doctors perform most caesarean sections, often without supervision.