title: Characterisation of the learning curve of caesarean section.
abstract: BACKGROUND
  Caesarean section is one of the common operations in medicine. As almost all interventions, the quality of the operation depends on the training and skills of the surgeon. This study aims at characterising the learning curve of caesarean section.
  
  
  METHODS
  All patients with a singleton pregnancy who underwent a caesarean section between 2000 and 2009 in our university hospital were identified. We analysed datasets from beginners (no experience at all) and experienced surgeons (>300 caesarean sections, consultant) comparing the parameter incision-suture time (I-S time), incision-delivery time (I-D time), maternal blood loss, umbilical artery pH (ua-pH), APGAR score after 1, 5 and 10 min, mean time in hospital and postoperative complications. In addition, the first 100 caesarean sections of each beginner surgeon were divided in groups of 10 (1-10, 11-20, etc.) and analysed using the above-mentioned parameters. The learning curves were calculated.
  
  
  RESULTS
  2,515 of 3,844 operations were carried out by 23 experienced surgeons versus 1,329 operations by 22 beginners. The I-S time and I-D time was significantly higher in the beginners group than in the experienced surgeon's group (45.9 vs. 41.3 min, p < 0.001). Furthermore, for the first ten caesarean sections, the mean I-S time (47.9 min, 95% CI 45.7-50.0 min vs. 31-40th caesarean section with 43.1 min, 95% CI 40.9-45.3 min, p < 0.0001) and I-D time (9.5 min, 95% CI 8.6-10.5 min vs. 71-80th caesarean section with 4.8 min, 95% CI 4.2-5.4 min, p < 0.0001) was significantly higher than of the subsequent datasets of ten operations, showing a typical learning curve.
  
  
  CONCLUSIONS
  The learning curve for the total operation time and incision-delivery time reaches a flatter part after 10-15 caesarean sections. However, the learning process is highly individualised and difficult to predict, so that supervision and evaluation of the trainee by an experienced surgeon is important.
authors.affiliation: Hannover Medical School, University Women's Hospital, Hannover, Germany. soergel.philipp@mh-hannover.de
authors.forename: P
authors.initials: P
authors.lastname: Soergel
authors.forename: T
authors.initials: T
authors.lastname: Jensen
authors.forename: L
authors.initials: L
authors.lastname: Makowski
authors.forename: C
authors.initials: C
authors.lastname: von Kaisenberg
authors.forename: P
authors.initials: P
authors.lastname: Hillemanns
mesh_terms: D001034:Apgar Score; D016063:Blood Loss, Surgical; D002585:Cesarean Section / Q000009:adverse effects / Q000193:education*; D002983:Clinical Competence; D005260:Female; D005312:Fetal Blood / Q000737:chemistry; D006801:Humans; D006863:Hydrogen-Ion Concentration; D007396:Internship and Residency; D059032:Learning Curve; D007902:Length of Stay; D011183:Postoperative Complications / Q000209:etiology; D011247:Pregnancy; D013997:Time Factors