Table 1

Plan–Do–Study–Act (PDSA) cycles

PlanDoStudyAct
PDSA-1 (2 January 2019–8 January 2019)The SR on duty to categories all PW into 1 of the 10 Robson groups and to write the group no on case sheet.
The SN on duty to note the group no for each delivery in the birth register.
The consultant to check the completeness and correctness of group no on case sheet at the time of clinical rounds and again at the time of discharge of the patient.		For 1 week as planned
A print out of Robson’s ten groups classification was kept for ready reference.		At the end of the week the QI team reviewed this improvement process and observed that all PW delivered in that week were not correctly categorised into the ten groups. Some were misclassified and some were missed. On discussion the team felt that it might be because of the reason that the process and the concept was very new to the LR team.The team decided to guide and supervise the LR team on this new process and to rectify any incorrect or missing data on the case sheet as a routine as the LR team keeps on changing.
The team adapted and continued this process.
PDSA-2
(4 February 2019–10 February 2019)		To incorporate the Robson form into the doctor’s duty report book to collect daily data for no of CS done in each group by the same team who performed the CS between 9:00 and 9:00 hours.
The consultant obstetrician to supervise the data collection daily the following morning for its correctness and completeness and to get filled the missing data, if any.		For a week as planned. The consultant obstetrician in the team, oriented the postgraduate duty doctors about the form and the way to fill it.Duty doctors found this additional step in their workflow convenient and not time-consuming but they had to refer to the Robson classification frequently. Some of the doctors missed the data entry in the Robson form which they completed next morning in the presence of the consultant. For the consultant obstetrician it was not taking much time to verify the data daily in the morning rather it provided an opportunity to discuss the process again and again. It helped in orienting the newly joined resident doctors and other doctors in the department to understand this new improvement process.The team adopted and continued the same process for a month. At the end of the month, they had the record of all CS done daily in a month with proper categorisation into one of the ten groups according to Robson classification.
Both the new processes were continued in a similar way. Gradually duty doctors were able to document the process more efficiently, had very few missing data and required minimal corrections.
PDSA-3 (6 April 2019–12 April 2019)To fill the revised Robson form to mark the indication for CS in each groupFor a week as planned.The revised Robson form worked well and duty doctors found it easy to mention no of CS against the indication for CS. In case of any doubt, they discussed it in the following morning and completed the form. The consultant obstetrician supervised the whole process of data collection.The team adopted the revised Robson form and continued the new processes for another 3 months.
PDSA-4 (July 2019)To analyse the indication of emergency CS done in last 24 hours.
To record the no of unnecessary CS in a month.		For a month as planned.This intervention seemed effective and the team got to know the factors contributing to unnecessary CS delivery.The team developed strategies to address these factors.
PDSA-5 (1 August 2019–7 August 2019)To post one additional SR to support the LR team for conducting CS delivery and other emergency surgical procedures between 14:00 and 21:00 hours and to assist them as and when required.For a week as planned.This change idea worked very well. The SR on duty in LR had not to leave the LR for operative procedures and was present full time to monitor the labouring patient in LR. They felt supported in decision-making for mode of delivery in difficult situation. The other routine services were managed despite posting one SR for LR duty.The team adopted this change idea and started posting an SR on 14:00–21:00 hours duty routinely.

  • LR, labour room; PW, pregnant women; SN, staff nurse; SR, senior resident.