Background: Caesarean section (CS) rates in Ampang Hospital (AH) were on the rise in January-April 2016. 1/3 of CS was done for fetal distress (FD). Therefore, reducing CS for FD will effectively reduce CS rate.

Standard and Target: The World Health Organisation (WHO) stated that CS rates above 10-15% confer no additional health benefits. However, increasing CS rates is a global concern. Our target CS rate was set at 26.5% as per UK CS rates.

Methodology: A retrospective audit was conducted in January-December 2016. The first round of audit was done in January-April 2016. Based on the findings, changes were implemented in May 2016. A re-audit was conducted in June-December 2016.

Results of First Round: The CS rates in January-April 2016 rose from 22.3% to 27.4% to exceed the target of 26.5%.

Implement Change: In effort to reduce CS rates, senior registrar involvement was made compulsory for diagnosis of FD, alongside conducting cardiotocography (CTG) workshops and enforcing CTG machine maintenance.

Re-Audit: However, despite implementing changes, the CS rates in June-December 2016 continued to rise, from 24.7% to 29.4%. The average CS rates prior to and after implementation of changes increased from 24.7% to 27.3% (p=0.18503).

Of 750 CS for FD in 2016, 590 (78.7%) had CTG abnormalities, 297 (39.6%) had meconium stained liquor, but only 168 (22.4%) had antenatal risk factors. For the neonatal outcomes, only 5 (0.7%) had cord arterial pH <7 and only 10 (1.3%) had 5-minute Apgar score <7.

Discussion: Further strategies that may be employed for re-audit include not doing CTG for low-risk pregnancies and considering fetal blood sampling for pathological CTG. This continuous audit will be valuable for future development of a national guideline.