safety, simplicity and quality - a commitment to childbirth antrim october 2013 michael robson the...
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Safety, simplicity and quality
- a commitment to childbirth
Antrim October 2013
Michael RobsonThe National Maternity
HospitalDublin, Ireland
Maternity QI Collaborative
Safety
How do you assess the safety of a labour ward?
How do you assess the safety of a delivery ward?
Structure (resources)
Building
Equipment
Staff
How do you assess the safety of a delivery ward?
Processes (guidelines)
How do you assess the safety of a delivery ward?
Outcome
Events and outcomes
Adverse events
Professionals knowledge of information
Ability to respond and change
How do you assess the safety of a delivery ward?
Organisation
Philosophy
Leadership
Multidisciplinary approach
Key decision making
Fail safe mechanisms
How do you assess the safety of a delivery ward?
Philosophy
Each labour ward must decide what they are trying to achieve
Everyone must be aware of it
Normality needs to be defined
National Maternity Hospital
Philosophy
Curtailment of duration of exposure to stress, with avoidance of the physical and emotional trauma, which is likely to follow prolonged labour
The prevention of prolonged labour BMJ 1969; 2:477-480.
National Maternity Hospital- normal labour
Described as when a baby is born vaginally, by the efforts of the mother, within a reasonable timespan, provided no harm befalls either party as a result of their experience. Twelve hours is regarded a reasonable time span.
Active Management of Labour BMJ 1973; 3:135-137
How do you assess the safety of a delivery ward?
Leadership
Clear lines of responsibility
Delegation
Ability to encourage communication
Ability to encourage response and change
Ability to encourage a disciplined approach
How do you assess the safety of a delivery ward?
Multidisciplinary approach
Clear lines of responsibility and hierarchial discipline must be combined with good
working relationships within and between the different disciplines
Nothing must be allowed to divide professionals
How do you assess the safety of a delivery ward?
Key decision making
Need to be clearly highlighted
Clear delegation and responsibility
Consistency
How do you assess the safety of a delivery ward?
Failsafe mechanisms
No isolation of care
Continual communication
Ability to access most senior staff
How do you assess the safety of a delivery ward?
Key processes and decisions in labour and delivery
Pre-labour Caesarean section
Induction of labour
Diagnosis of labour
Maternal and fetal welbeing
Rupture of membranes
Use of oxytocin and philosophy on dystocia
Management of second stage
Operative delivery
Management of third stage
How do you assess the safety of a delivery ward?
Outcome
Quality is related to outcome and outcomes
guide processes
Safety and Quality in Labour and Delivery
Should currently be measured in terms of
available validated information
Epidemiology of Perinatal Outcome
We need to classify all perinatal outcome
so
that objective comparisons can be made of fetal and maternal outcomes over time in one unit and between different units both
nationally and internationally
But to do that
We need a consistent and objective structure within which we can examine fetal and maternal outcomes
Classification systems
Principles for classification system
It must be simple, easy to implement, informative and useful
The groups must beObjectively not subjectively defined, mutually exclusive and totally inclusive
Must be prospectively determined, clinically relevant,identifiable, totally accountable and replicable
It must be universal, robust and self validating
Must be able to incorporate other variables and outcomes
Classification must be able to incorporate other variables related to caesarean section rates
and other outcomes
Significant epidemiological factorsAge, BMI, Fetal weight,
Previous medical historyCasemix
Maternal and fetal events, outcomes and complications together with indications
Organisational systemsEconomics
Classifying Perinatal Outcome – the 10 Groups
The Ten Groups Have Been Created From the Previous ObstetricRecord, Course, Category and Gestation
Robson MS. Classification of Caesarean Sections. Fetal and Maternal Review 2001; 12:23-39.
Cambridge University Press
Classifying Perinatal Outcome – the 10 Groups
Previous obstetric record
NulliparousMultiparous without a scarMultiparous with a scar
Classifying Perinatal Outcome – the 10 Groups
Category of pregnancy
Single cephalicSingle breechMultiple pregnancyTransverse or oblique lie
Classifying Perinatal Outcome– the 10 Groups
Course
Spontaneous labourInduced labourCaesarean section before labour
EmergencyElective
Classifying Perinatal Outcome – the 10 Groups
Gestation
The number of completed weeks at delivery
National Maternity Hospital, Dublin
Caesarean Sections - the 10 Groups 2005-2011
1 Nullip single ceph >=37 wks spon lab
2 Nullip single ceph >=37wks ind. or CS before lab
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
5 Previous caesarean section single ceph >= 37 wks
6 All nulliparous breeches
7 All multiparous breeches (incl previous caesarean sections)
8 All multiple pregnancies (incl previous caesarean sections)
9 All abnormal lies (incl previous caesarean sections)
10 All single ceph <= 36 wks (incl previous caesarean sections)
National Maternity Hospital, Dublin
Caesarean Sections - the 10 Groups 2005-2011
2005-2011
12040/61166
19.7%
1 Nullip single ceph >=37 wks spon lab 1176/16421
2 Nullip single ceph >=37wks ind. or CS before lab 2896/8619
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139
5 Previous caesarean section single ceph >= 37 wks 3364/5735
6 All nulliparous breeches 1177/1273
7 All multiparous breeches (incl previous caesarean sections) 685/815
8 All multiple pregnancies (incl previous caesarean sections) 654/1077
9 All abnormal lies (incl previous caesarean sections) 220/220
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546
Number of caesarean sections over the total number of women in
each group
Number of caesarean sections over the total number of women in
each group
Total number of caesarean sections over the overall total number of women
Total number of caesarean sections over the overall total number of women
National Maternity Hospital, Dublin
Caesarean Sections - the the 10 Groups 2005-2011
2005-2011
12040/61166
19.7%
Size of
group %
1 Nullip single ceph >=37 wks spon lab 1176/16421 26.82 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.03 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.04 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.0
5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.4
6 All nulliparous breeches 1177/1273 2.07 All multiparous breeches (incl previous caesarean sections) 685/815 1.38 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.89 All abnormal lies (incl previous caesarean sections) 220/220 0.4
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.2
Size of each group is the total number of women in each group divided by the overall
total number of women
Size of each group is the total number of women in each group divided by the overall
total number of women
National Maternity Hospital, Dublin
Caesarean Sections - the 10 Groups
2005-2011
12040/61166
19.7%
Size of
group %
C/S
rate in gp %
1 Nullip single ceph >=37 wks spon lab 1176/16421 26.8 7.22 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.0 34.93 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.0 1.24 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.0 12.4
5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.4 58.7
6 All nulliparous breeches 1177/1273 2.0 92.57 All multiparous breeches (incl previous caesarean sections) 685/815 1.3 84.08 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.8 60.79 All abnormal lies (incl previous caesarean sections) 220/220 0.4 100
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.2 34.6
CS rate in each group is worked out for each group by dividing the number of
caesarean sections by the total number of women in each group
CS rate in each group is worked out for each group by dividing the number of
caesarean sections by the total number of women in each group
National Maternity Hospital, Dublin
Caesarean Sections - the 10 Groups
2005-2011
12040/61166
19.7%
Size of
group %
C/S
rate in gp %
Contr of each gp
19.7 %1 Nullip single ceph >=37 wks spon lab 1176/16421 26.8 7.2 1.92 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.0 34.9 4.73 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.0 1.2 0.44 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.0 12.4 1.3
5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.4 58.7 5.5
6 All nulliparous breeches 1177/1273 2.0 92.5 1.97 All multiparous breeches (incl previous caesarean sections) 685/815 1.3 84.0 1.18 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.8 60.7 1.19 All abnormal lies (incl previous caesarean sections) 220/220 0.4 100 0.4
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.2 34.6 1.4
Absolute contribution of each group to the overall CS rate is worked out by dividing the number of CS in each
group by the overall population of women
This will depend on the size of the group as well as the CS rate in each group
Absolute contribution of each group to the overall CS rate is worked out by dividing the number of CS in each
group by the overall population of women
This will depend on the size of the group as well as the CS rate in each group
National Maternity Hospital, Dublin
Caesarean Sections - the 10 Groups
2005-2011
12040/61166
19.7%
Size of
group %
C/S
rate in gp %
Contr of each gp
19.7 %1 Nullip single ceph >=37 wks spon lab 1176/16421 26.8 7.2 1.92 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.0 34.9 4.73 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.0 1.2 0.44 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.0 12.4 1.3
5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.4 58.7 5.5
6 All nulliparous breeches 1177/1273 2.0 92.5 1.97 All multiparous breeches (incl previous caesarean sections) 685/815 1.3 84.0 1.18 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.8 60.7 1.19 All abnormal lies (incl previous caesarean sections) 220 0.4 100 0.4
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.2 34.6 1.4
Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the
source of biggest variation between units
Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the
source of biggest variation between units
National Maternity Hospital, Dublin 2008
Caesarean Sections - the 10 Groups
2005-2011
12040/61166
19.7%
Size of
group %
C/S
rate in gp %
Contr of each gp
19.7 %1 Nullip single ceph >=37 wks spon lab 1176/16421 26.8 7.2 1.92 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.0 34.9 4.73 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.0 1.2 0.44 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.0 12.4 1.3
5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.4 58.7 5.5
6 All nulliparous breeches 1177/1273 2.0 92.5 1.97 All multiparous breeches (incl previous caesarean sections) 685/815 1.3 84.0 1.18 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.8 60.7 1.19 All abnormal lies (incl previous caesarean sections) 220 0.4 100 0.4
10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.2 34.6 1.4
Groups 6, 7, 8, 9, 10. Small groups, high CS rates but small overall
contributions to the total CS rate and very similar between different units
Groups 6, 7, 8, 9, 10. Small groups, high CS rates but small overall
contributions to the total CS rate and very similar between different units
Philosophy of the 10 Group Classification
Based on the premise that all information
(epidemiological, maternal and fetal events and outcomes, cost and organisational)
will be more clinically relevant by stratifying them using the 10 groups
The 10 Group Classification- and the advantage of standardisation
Any differences in sizes of groups or outcome are either due to
Poor data qualityDifferences in significant epidemiological factorsDifferences in practice
Simplicity- of process and audit
Timing of artificial rupture of the membranes
Use of oxytocin
Audit of caesarean section in labour (dystocia)
Vaginal birth after caesarean section
Induction of labour
Amniotomy is performed at the diagnosis of labour
To assess the fetal condition at the start of labour
Determine which fetuses need continuous electronic monitoring
Other beneficial effectsShortens the labour
Decreases need for oxytocin
Use of oxytocin - essentials
Safe
Discussed and consensus achieved
Strict implementation
Audited
Reviewed
Terminology
Acceleration (augmentation) of labour
Induction of labour
Uterine tachysystole Over contracting
Uterine hypertonus A prolonged contraction
Uterine hyperstimulation When either condition leads to
a non reassuring fetal heart rate
pattern.
Concentration, maximum dose and rate of increase
Concentration 10iu in 1L (Probably most common)
30mls equivalent to 5mu
Rate of increase 30 mls/15mins (5mu/15 mins)
Maximum dose 180mls/hr (30mu/min)
Concentration, maximum dose and rate of increase
Is not the main issue
The issue is the effect on the fetus, the uterus,
how often you use it and other events and outcomes
Monitoring contractions
No more than 5 contractions in 10 minutes (most common)
Nulliparous No more than 7 contractions in 15 minutes (NMH)
Multiparous No more than 5 contractions in 15 minutes (NMH)
Longer period of time to assess contractions
Less maximum contractions over 30 minutes
Continual audit is obligatory
Incidence of Oxytocin 2011
Incidence of Oxytocin 2011
Classification of indications for Caesarean Section in labour (dystocia)
Fetal reason
Dystocia
Classification of indications for Caesarean Sections - in labour
Fetal reason(No oxytocin)
Dystocia
Classification of indications for Caesarean Sections - in labour
Fetal reason(No oxytocin)
Dystocia IUA (Inefficient uterine action <1cm/hr)
EUA (Efficient uterine action >1cm/hr)
Classification of indications for Caesarean - Efficient and Inefficient uterine action
Caesarean section
Efficient Uterine Action Progress >1cm/hr
Caesarean Section
Inefficient Uterine ActionProgress <1cm/hr
Classification of indications for Caesarean Sections - in labour
Fetal reason(No oxytocin)
Dystocia IUA (Inefficient uterine action <1cm/hr)
Inability to treat (Fetal intolerance)Inability to treat (Mechanical/OC)Poor response (Full treatment)No oxytocin
EUA (Efficient uterine action >1cm/hr)
Classification of indications for Caesarean Sections - in labour
Fetal reason(No oxytocin)
Dystocia IUA (Inefficient uterine action <1cm/hr)
Inability to treat (Fetal intolerance)Inability to treat (Mechanical/OC)Poor response (Full treatment)No oxytocin
EUA (Efficient uterine action >1cm/hr)
CPD (Cephalopelvic Disproportion)POP (Malposition)
Classification of indications for Caesarean Sections - in labour
Objective classification of indications for CS in labour
Can be used irrespective of oxytocin regimen or criteria for diagnosis of dystocia
Outcomes will reflect the oxytocin regimen and criteria for diagnosis of dystocia
Classification of Caesarean Sections in labour Group 1 2005 - 2011
HypothesisThe incidence and distribution of your caesarean sections together with fetal and maternal outcome will depend on your timing, rate of increaseand maximum dose of oxytocin. This will in turn be influenced by when you rupture your membranes
Classification of Caesarean Sections in labour Group 3 2005 - 2011
HypothesisThe incidence and distribution of your caesarean sections together with fetal and maternal outcome will depend on your timing, rate of increaseand maximum dose of oxytocin. This will in turn will beinfluenced by when you rupture your membranes
Detailed audit of labour eventsand outcome Group 1
Detailed audit of labour eventsand outcome Group 1
Detailed audit of labour eventsand outcome Group 3
Detailed audit of labour eventsand outcome Group 3
Group 5 Women with at least one previous caesarean section
and a single cephalic pregnancy >= 37 wks
Heterogenous group including women
More than one previous CS
One previous CS and a vaginal delivery
One previous CS only
Group 5 Women with at least one previous caesarean section
and a single cephalic pregnancy >= 37 wks
Scoring systems
May explain why there is variable success
but
not useful in deciding management
Group 5 Women with at least one previous caesarean section
and a single cephalic pregnancy >= 37 wks
Plan of care
Aim for spontaneous labour
If not in labour by 41 weeks and cervix unfavourablegive date for CS
Induction only if cervix favourable, ARM and wait for 24 hours
Prostin or misoprostol are not given
Group 5 Women with at least one previous caesarean section
and a single cephalic pregnancy >= 37 wks
Plan of care
ARM on diagnosis of labour
Oxytocin only given under strict rules and for a short period of time (2 hours)
Continuous electronic monitoring
Fetal heart rate abnormalities treated by caesarean section
Group 5 Women with at least one previous caesarean section
and a single cephalic pregnancy >= 37 wks
Oxytocin
Evidence of poor contractions
Favourable abdominal and vaginal examination by senior medical staff and after discussion with consultant
Oxytocin only given for 2 hours unless delivery imminent
No more than 5 contractions in 15 minutes
VBAC
Antenatal classes
Essential
Patient leaflet
VBAC
What influence does the previous CS have?
Previous dilatation
Indication
VBAC
What influence does the EFW have?
Generally very little
VBAC
Epidural
Not a problem
VBAC
What are the risks?
Rupture
Unpredictable
VBAC
Would it be easier just to deliver everyone by CS
WhenDrawbacks
Caesarean section on request
Definition
At the time of the request in the opinion of the obstetrician there is a greater relative risk of a significant adverse outcome to mother or baby by carrying out a caesarean section than awaiting spontaneous labour and delivery or inducing labour
VBAC
How do we audit VBAC
Denominator
Group 5 2011- uterine rupture
No uterine ruptures
No neonatal deaths
No encephalopathy
Group 5 2011- distribution of onset of delivery
Group 5 2011- distribution of CS
Group 5 2011- CS rate and indications in spontaneous labour
CS rate in induced labour 41.2% (49/119)
Group 5 2011- other outcomes of spontaneous labour
Group 5 2011- distribution of CS
Group 5 2011- repeat CS in women with one previous CS only and no
medical indication
Induction of Labour
General problems
AimDifferent definitionsIncorrect use of the definitionCorrect definition but assessed in isolationPoor collection of data
NMH Groups 1 and 2 2011
Group 2 2011
Group 2(b)
NMH Groups 3 and 4 2011
Group 4 2011
