1. Our first intervention will be the establishment in daily practice of three guidelines and two consent forms that were published by the Hellenic Society of Obstetrics and Gynecology (HSOG). The guidelines and the consent forms can be found at the relevant link. Realizing  the crucial need for applying evidence-based medicine in obstetrics, HSOG has published these guidelines and consent forms, based on international guidelines. All of them were freely available for comments on the HSOG website (www.hsog.gr) for at least one month. Following this, further feedback was given by the HSOG’s Scientific Committee, subsequent to which the guidelines were approved by the Society’s Board for final publication. The same procedure was followed for the two consent forms. The allocated trial coordinator or local opinion leader discusses and disseminates the guidelines among the professional staff at the respective units, providing the opportunity to identify specific barriers. This is a prerequisite in order to adapt the planned activities for overcoming the barriers and develop an implementation timetable.
  2. At least one session by the trial coordinators and the staff will take place early in each participating unit, so as the local obstetricians are informed on the objectives and interventions of the study. Prior to this, correspondence by post will provide the necessary
    details, including the trial questionnaires, etc. A local visit will take place just prior to the intervention period.
  3. All staff involved in deliveries and collaborate with participating obstetricians will participate in a 1-day interactive workshop just prior to the study initiation focusing on the use of the purpose built electronic platform and presentation of study’s questionnaires.
  4. All staff involved in deliveries and collaborates with participating obstetricians will participate in a 4-day interactive workshop just prior to the intervention period of the study:
    • Day 1: Presentation and interactive discussion of HSOG’s guidelines, CS indications  and clinical scenarios.
    • Day 2: Cardiotocography (CTG) course based on the physiological interpretation. The course will run in each unit a week before the intervention period and all   participating professionals of the unit will be trained on a structured approach to  CTG interpretation, more accurate evaluation of fetal distress and how they can  avoid unnecessary interventions .
    • Day 3: Obstetric emergencies course (with topics like breech delivery, VBAC, delivery of twins, induction and augmentation of labor). The course involves training on how to do the recommended practices. All birth attendants will receive training sessions conducted by the opinion leaders/instructors on mannequins.
    • Day 4: Course on organization of labor ward and launch of C/S meetings with review of patient notes.

The workshops will be given in 4 consecutive days and will be conducted by experienced trainers. Training groups will be constrained to a maximum of 11 participants per time in order to reassure adequate training. The purpose is to make clear the study’s objectives:

    • Focus on the need of an evidence based clinical practice
    • Review HSOG’s guidelines about labor induction, caesarean section and vaginal birth after caesarean section, along with HSOG’s consent forms
    • Find the barriers for the use of those guidelines in the participating obstetric
    • Overcome barriers and implement the guidelines
  1. Throughout the intervention period, compliance with guidelines will be enhanced by regular follow-up meetings with the opinion leaders and members of the steering committee by physical presence, tele conferences or phone calls. Feedback will also be adjusted independently based on locally preferred routes of better tailoring the intervention into the unit’s daily practice. Additional visits may follow if deemed necessary, based on platform statistics.
  2. Use of an online application embedded in the electronic questionnaire with Robson 10- group classification criteria and feedback on the unit’s CS rates monthly, so as to know which category is higher and can be reduced further.
  3. Live real-time statistics provided by the online platform, in a regular basis, so that the participating units will be able to see their and other units’ performance anonymously. This type of feedback is expected to improve adherence to the interventions.
  4. Local CS meetings will be held three times a month, in each unit, where all CS cases will be discussed. The members of steering committee or local opinion leaders may actively participate in these meetings by physical presence, tele-conferences or phone calls. This is a way to further enhance compliance.
  5. Local CTG interpretation meetings will be held weekly, in each unit, where all “abnormal” CTG cases that led to CS will be discussed. This is an additional way to further enhance compliance.
  6. Reminders of good obstetric practice will be placed in labor wards, staff rooms, patient notes, vaginal birth packages and above theatre hand washers. There will be short messages for enhancement of vaginal birth reminding birth attendants of hints to reduce CS rates. The text of the reminders will be prepared by the study’s executive committee according to the designed recommendation and will take into account the characteristics and barriers of obstetrical practice in Greece.