Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2025
Summary
The evaluation of an electronic smart form for booking and scheduling elective Caesarean Section (CS) in a busy obstetric hospital.
Dates: 2022- 2024
Implementation sites: Mater Mothers' Hospital
Partnerships: N/A.
Aim
This project aimed to reduce unwarranted early term birth through the provision of cognitive prompts to clinicians completing the booking form and improved clinical prioritisation in scheduling elective CS.
Outcomes
- The Smart form was successfully implemented, reducing clinician and administrative staff burden.
- The Smart form enabled tailored information to be provided to women and families via email.
- The Smart form increased compliance with guidelines for gestational age at delivery for women with risk factors from 86.8% prior to and 93.3% following introduction of the form (p=0.04).
Background
Elective CS should be performed at or after 39+0 in women without significant clinical risk. Even when risks are present, tailoring gestational age (GA) at delivery to maximise fetal maturity without excessive risk is important for clinical outcomes. Guidelines exist for recommended GA at birth for both low risk and at-risk pregnancies, however, there remains unwarranted variation to these guidelines in clinical practice. Delivery prior to recommended GA leads to both short - and long-term adverse outcomes in babies - and hence reducing early term birth is a national priority. Reasons for unwarranted variation can include lack of clinician awareness of guidelines, and logistical issues preventing booking CSs at the ideal GA.
At the Mater Mothers' Hospital, elective CS bookings were historically made by phone, often by a midwife or junior doctor, usually at 36 weeks. Not only did this result in clinician time being utilised on the phone, on hold or waiting for call backs, CS’s were booked on a first come first served basis, and semi-urgent CS’s, sometimes with risks, were not given the priority required. Administration staff were subsequently required to contact women when “re-shuffling” to accommodate urgent priority cases, leading to inefficiency and often unhappy families. A better system was need that supported clinician decision making about timing of birth and provided senior and multidisciplinary oversight in the prioritisation and scheduling of cases.
Methods
An interprofessional team of obstetricians, midwives, administration staff, theatre nurses, information technology experts and a member of the quality improvement team was convened as a project group. Utilising existing software for induction of labour bookings (OnBase) a CS booking form was created. The Smart form provided cognitive prompts for clinicians, and a recommended gestational age for the commencement of a seven-day booking window for the CS, informed by the stated indication for CS. Clinicians were able to over-ride this suggested window with clinical justification and were prompted for senior review if relevant. The form also had free text space to indicate if the woman needed to be advised of the booking via telephone interpreter, or if there were other important booking considerations.
Following submission of the form, women were sent SMS and email communication with booking information and links to consumer reviewed information on caesarean birth, recovery and baby care. A senior obstetrician then categorised upcoming cases into high, medium and low priority based on the information provided on the form and in the woman’s health record. Finally, administration and clinical staff scheduled the CSs for the following week taking into consideration clinical prioritisation and other scheduling requirements. Once scheduled a further SMS and email was sent to the woman, advising of fasting, arrival and booking times, with further links to relevant information sites. Women’s finalised date and time were mostly provided seven days prior to the scheduled date, but never later than four days prior. A retrospective review was undertaken of all booked elective CS 6 months prior to and 6 months following the introduction of the smart form.
A total of 557 cases were included in the analysis, 283 prior to the smart form and 274 following the smart form. GA at booking was reviewed in the context of indication for CS and other risk factors present including fetal anomaly, poorly controlled gestational diabetes, pre-existing diabetes, hypertensive disorders, multiple pregnancy and fetal growth restriction, abnormal placentation and other conditions requiring early delivery. Maternal characteristics and indications for CS were similar in both groups. The smart form group had a higher proportion of CS with risk factors identified (65.0% vs 56.2%, p=0.03) suggesting that the smart form may have led to improved documentation of risk factors. Compliance with guidelines for GA at birth for women without additional risk factors was high in both groups (95.2% pre smart form and 96.8% post smart form, p=0.52). Compliance improved for women with risk factors from 86.8% pre smart form to 93.3% post smart form (p=0.04). Although not formally measured, administrative staff report less time spent rescheduling cases and on phone calls with staff and patients.
Discussion
This project required a dedicated interprofessional team with adequate IT support to deliver improved outcomes for patients and hospital staff. The ability to duplicate an existing system for IOL bookings was critical for success, however significant variation and complexity in how CS’s are scheduled required major changes in both the form and the process. The ability to locally modify a smart form to the bespoke needs of CS scheduling was a major strength of this project. This included cognitive prompts for planning for maternal, fetal and psychosocial risks, and automated recommendations for GA booking in line with established guidelines. The smart form not only allowed for communication by SMS and email with the woman, but emails could be sent notifying relevant teams of booking time and date for improved communication across the service.
A major challenge during the project was the significant time required to model and test all the variations in booking scenarios, including CS indications, model of care and individual patient needs. The ongoing rounds of testing and form improvement dragged on over many months without a dedicated human resource. Evaluation was limited to a 12-month period, and we may have seen a greater impact on compliance in low-risk women with a larger sample size.
We also did not formally evaluate the consumer experience of this change, which would be a recommendation for others undertaking a project such as this. The project has provided the opportunity for our team to revise our induction of labour booking system to align with many of the positive aspects of the CS booking form developed during the CS booking form project. This includes automated patient emails with links to relevant consumer reviewed information, contact numbers and clinical review processes for patients who may change their mind regarding induction of labour after the booking has been submitted. Consumer evaluation of this improvement has commenced. Despite the project taking more than two years to launch, the benefits in patient care, communication and resource utilisation have been realised.
References
N/A
Key contact
Dr Sarah Janssens
Director Obstetrics and Gynaecology
Mater Mothers' Hospital
Email: sarah.janssens3@mater.org.au