National Women’s Annual
Clinical Report 2010
Prof J Quinlivan
Acknowledgements
• Kirsty Walsh: Acting General
Manager, Clinical Services
Women’s health
• Carolyn Whiteman: Service
Manager Newborn Service
Paediatric Intensive Care,
Paediatrics and Congenital Cardiac
Service
• Malcolm Battin: Clinical Director
Newborn Service
• Jenny McDougall: Clinical Director
Obstetrics
• Mahesh Harilall: Clinical Director
Gynaecology
• Pam Hewlett: Acting Clinical
Leader Midwifery
• Lesley McCowan: Head of
Department of Obstetrics and
Gynaecology
Marjet Pot: Project Co-ordinator
Lynn Sadler: Epidemiologist
Andrea Hickman: Data
management/Analyst
Overview
• 7709 mothers delivered 7866 babies.
• No major changes in pattern of delivery
modality since 2002.
Some excellent results
• General
– Breast feeding
– Quit campaign
• Low complication rates in
– General Gynaecology
– Gynaecology Oncology
• Obstetrics
– HIE (below benchmark)
– VBAC (above benchmark)
Breast feeding
• Baby friendly hospital initiative
• 81.6% of mothers achieved ‘exclusive
breastfeeding’ on discharge from NW.
• WHA Benchmark 77%
Smoking and better help for
smokers to quit
• New program “Better Help for Smokers to
Quit.”
• Emphasis on documentation
of the ABC of smoking cessation.
• Referrals to ADHB
Smokefree Pregnancy
Service.
Summary statistics maternity
Indicator
WHA
NW 2010 NW
N=7709 Public
2010
N=2329
Preterm birth
11.7-11.9 10.1
17.1
HIE (Gd 2/3)
0.10
0.06
0.08
CS
28-29.6
32.3
33.3
Summary statistics 2
Indicator
WHA
NW 2010 NW
N=7709 Public
2010
N=2329
10.1
10.8
VBAC
7.9-9.1
Maternal age
23.4-23.8 31.1
25.1
Episiotomy
17.8-18.6 24.0
14.9
3rd/4th degree
tears
2.8-3.5
2.1
2.3
Summary statistics 3
Indicator
WHA
NW 2010 NW
N=7709 Public
2010
N=2329
PPH 1000-1500
Vaginal births
PPH >1500
Vaginal births
PPH 500-1500
CS
1.9-2.4
3.1
4
1.4-1.7
2.7
4
49.4
67
74.6
Transfusion
All births
1.6-2.1
2.5
3.8
Closing the audit gap
1.
2.
3.
4.
5.
Maternal age
Perineal care
Post partum haemorrhage
Induction of labour for post dates
Urogynaecology mesh
Maternal age at NW
• Older population of women giving birth
• Big rise in women aged 35-39years
• Corresponding fall in women aged 21-25
years
21-25 years
35-40 years
1991/1992
22-23%
9-10%
2009/2010
12-13%
23-24%
Differing health concerns
• Older pregnant women are more likely
to have:
– tertiary education,
– higher family income.
• The main obstetric worries centre on:
–
–
–
–
Miscarriage,
Structural and genetic abnormalities,
Physical demands of caring for a new baby,
Post partum recovery.
» Loke AY, Poon CF. J Clin Nurs 2011; 20: 1141-50
Maternal Age and Medical Risk
• Older women report less satisfaction with
pregnancy risk counselling.
• Counselling for risk is complex
• Genetic disease and miscarriage may be
identified early
• Dissatisfaction arises from unexpected
complications arising from the diagnosis of an
underlying disease such as diabetes and
hypertension.
– O’Reilly-Green C, Cohen WR. Obst Gynecol Clinics North Am
1993; 20:313-31.
Worries about
stillbirth
• Systematic review of 31 retrospective cohort
and 6 case control studies found that greater
maternal age was associated with increased
risk of still birth.
• Relative risks vary from 1.20 to 4.53.
» Huang L et al. CMAJ 2008; 178: 165-172.
Adverse neonatal outcome
• Retrospective study comparing outcomes of
women aged <35, 35-40, and >40.
• 45,033 nulliparous women, singleton pregnancy.
• Significant linear association documented
between advanced maternal age and:
– IUGR, LBW, congenital malformations, perinatal
mortality.
– Most of the risk driven by gestational age at delivery,
presence of IUGR and malformations.
» Salem YS et al. Arch Gynecol Obstet 2011; 282: 755-9
Perinatal death from
intrapartum anoxia at term
• Retrospective cohort study of 1,043,002
women with singleton term cephalic infants.
• Compared with women aged 25-34 years,
older women had a increased risk of delivery
related perinatal death at term
– OR 2.20 95%CI 1.42-3.40
• Excess risk explained by intrapartum anoxia
– Primip OR 5.34 95%CI 2.34-12.20
– Multip 2.14 95%CI 0.99-4.60
» Pasupathy D et al J Epid Com Med 2011; 65: 241-5.
The older pregnant woman
Different
concerns to
younger
women
Less satisfied
with
counselling
More
stillbirths
More adverse
pregnancy
outcomes
Given the progressive change in
demographics, how do you
ensure you deliver a service that
meets the needs of the older
demographic?
35-40 years
1991/1992
9-10%
2009/2010
23-24%
2030
?? 40% ??
Perineal Care at NW
Why is it a case of chalk & cheese?
Perineal care at NW
Indicator
WHA
NW 2010 NW
N=7709 Public
2010
N=2329
Episiotomy
18
24.0
14.9
3rd/4th degree
tears
2.8-3.5
2.3
2.1
Episiotomy rates by LMC at birth
BM: Episiotomy = 18%
Indicator
Total Episiotomy 3rd/4th
degree
tear
Independent
midwife
2737 24.6%
2.6%
Private
Obstetrician
NW Community
862
37.7%
2.0%
1060 15.2%
2.5%
Perineal care
• >85% of women having a vaginal
birth experience perineal trauma.
• 1/3 of women require suturing
following vaginal delivery.
• Perineal trauma may cause long
term problems
– 10% long term pain
– 25% dyspareunia or urinary
problems
– 10% fecal incontinence
» Best Practice Perineal Care Key points
Outcomes from the new NW
Perineal Tear Clinic
• Commenced October 2010
• ACC funded
• Aim to review all 3rd/4th degree tears and
complicated perineal injuries at 6/52 and
4/12.
• Clinic saw 72 women from October to end of
2010
• Where indicated, women were referred to a
psychologist or rectal surgeon.
Best practice advice
• Restricting use of episiotomy
reduces the risk of posterior perineal trauma
• Episiotomies should only be used when there
are clear maternal or fetal indications. This
policy increases the likelihood of an intact
perineum and does not increase the risk of
3rd degree tears
– Best Practice Perineal Care Key points
Best practice advice
• Midline incisions may be more likely to result
in severe tears.
• Vaccum delivery reduces the rate of severe
perineal trauma compared to forceps delivery
but increases the risk of cephalhaematoma
and retinal haemorrhage in the newborn.
• Continuous support during labour reduces the
rate of assisted birth and therefore of
perineal trauma.
– Best Practice Perineal Care Key points
Best Practice and Episiotomy
Must be able to identify the INDICATION.
Episiotomy Indication (circle if yes)
No
Delay 2nd stage
Yes
Fetal distress CTG
Fetal distress pH/Lactate
Assisted vaginal delivery
Patient tearing posteriorly
Other _______________