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Safety, simplicity and quality a commitment to childbirth Antrim October 2013

Maternity QI Collaborative. Safety, simplicity and quality a commitment to childbirth Antrim October 2013. Michael Robson The National Maternity Hospital Dublin, Ireland Mrobson@nmh.ie. Safety. How do you assess the safety of a labour ward?.

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Safety, simplicity and quality a commitment to childbirth Antrim October 2013

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  1. Maternity QI Collaborative • Safety, simplicity and quality • a commitment to childbirth • Antrim October 2013 Michael Robson The National Maternity Hospital Dublin, Ireland Mrobson@nmh.ie

  2. Safety How do you assess the safety of a labour ward?

  3. How do you assess the safety of a delivery ward? Structure (resources) Building Equipment Staff

  4. How do you assess the safety of a delivery ward? Processes (guidelines)

  5. 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

  6. How do you assess the safety of a delivery ward? Organisation Philosophy Leadership Multidisciplinary approach Key decision making Fail safe mechanisms

  7. 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

  8. 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.

  9. 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

  10. 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

  11. 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

  12. How do you assess the safety of a delivery ward? Key decision making Need to be clearly highlighted Clear delegation and responsibility Consistency

  13. How do you assess the safety of a delivery ward? Failsafe mechanisms No isolation of care Continual communication Ability to access most senior staff

  14. 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

  15. How do you assess the safety of a delivery ward? Outcome Quality is related to outcome and outcomes guide processes

  16. Safety and Quality in Labour and Delivery Should currently be measured in terms of available validated information

  17. 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

  18. But to do that We need a consistent and objective structure within which we can examine fetal and maternal outcomes

  19. Classification systems Principles for classification system It must be simple, easy to implement, informative and useful The groups must be Objectively 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

  20. Classification must be able to incorporate other variables related to caesarean section rates and other outcomes Significant epidemiological factors Age, BMI, Fetal weight, Previous medical history Casemix Maternal and fetal events, outcomes and complications together with indications Organisational systems Economics

  21. Classifying Perinatal Outcome – the 10 Groups The Ten Groups Have Been Created From the Previous Obstetric Record, Course, Category and Gestation Robson MS. Classification of Caesarean Sections. Fetal and Maternal Review 2001; 12:23-39. Cambridge University Press

  22. Classifying Perinatal Outcome – the 10 Groups Previous obstetric record Nulliparous Multiparous without a scar Multiparous with a scar

  23. Classifying Perinatal Outcome – the 10 Groups Category of pregnancy Single cephalic Single breech Multiple pregnancy Transverse or oblique lie

  24. Classifying Perinatal Outcome– the 10 Groups Course Spontaneous labour Induced labour Caesarean section before labour Emergency Elective

  25. Classifying Perinatal Outcome – the 10 Groups Gestation The number of completed weeks at delivery

  26. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2005-2011

  27. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2005-2011 Total number of caesarean sections over the overall total number of women Number of caesarean sections over the total number of women in each group

  28. 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 the 10 Groups 2005-2011

  29. 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

  30. 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

  31. 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 Caesarean Sections - the 10 Groups

  32. National Maternity Hospital, Dublin 2008 Caesarean Sections - the 10 Groups 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

  33. 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

  34. The 10 Group Classification- and the advantage of standardisation Any differences in sizes of groups or outcome are either due to Poor data quality Differences in significant epidemiological factors Differences in practice

  35. 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

  36. 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 effects Shortens the labour Decreases need for oxytocin

  37. Use of oxytocin - essentials Safe Discussed and consensus achieved Strict implementation Audited Reviewed

  38. 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.

  39. Concentration, maximum dose and rate of increase Concentration 10iu in 1L (Probably most common) 30mls equivalent to 5mu Rate of increase30 mls/15mins (5mu/15 mins) Maximum dose 180mls/hr (30mu/min)

  40. 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

  41. 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

  42. Continual audit is obligatory

  43. Incidence of Oxytocin 2011

  44. Incidence of Oxytocin 2011

  45. Classification of indications for Caesarean Section in labour (dystocia) Fetal reason Dystocia

  46. Classification of indications for Caesarean Sections - in labour Fetal reason (No oxytocin) Dystocia

  47. Classification of indications for Caesarean Sections - in labour Fetal reason (No oxytocin) DystociaIUA (Inefficient uterine action <1cm/hr) EUA (Efficient uterine action >1cm/hr)

  48. Classification of indications for Caesarean - Efficient and Inefficient uterine action Caesarean section Efficient Uterine Action Progress >1cm/hr Caesarean Section Inefficient Uterine Action Progress <1cm/hr

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