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?
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 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
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
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
Classifying Perinatal Outcome
– the 10 Groups
Previous obstetric record
Nulliparous
Multiparous without a scar
Multiparous with a scar
Classifying Perinatal Outcome
– the 10 Groups
Category of pregnancy
Single cephalic
Single breech
Multiple pregnancy
Transverse or oblique lie
Classifying Perinatal Outcome
– the 10 Groups
Course
Spontaneous labour
Induced labour
Caesarean section before labour
Emergency
Elective
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
Total number of caesarean sections over
the overall total number of women
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
National
Hospital,
Dublin
Size of eachMaternity
group is the total number
of
women in each group divided by the overall
total number of women
Caesarean Sections - the the 10 Groups 2005-2011
2005-2011
12040/61166
19.7%
Size of
group
%
1176/16421
26.8
2 Nullip single ceph >=37wks ind. or CS before lab
2896/8619
14.0
3 Multip (excl prev caesarean sections) single ceph
>=37 wks spon lab
220/18321
30.0
4 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
2.0
7 All multiparous breeches (incl previous caesarean
sections)
685/815
1.3
8 All multiple pregnancies (incl previous caesarean
sections)
654/1077
1.8
9 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
1 Nullip single ceph >=37 wks spon lab
CS rate in each group is worked out for
National Maternity Hospital,
Dublin
each group by dividing the number of
caesarean sections by the total number of
women in each group
Caesarean Sections - the 10 Groups
2005-2011
12040/61166
19.7%
Size of
group
%
C/S
rate in
gp %
1176/16421
26.8
7.2
2 Nullip single ceph >=37wks ind. or CS before lab
2896/8619
14.0
34.9
3 Multip (excl prev caesarean sections) single ceph
>=37 wks spon lab
220/18321
30.0
1.2
4 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
92.5
7 All multiparous breeches (incl previous caesarean
sections)
685/815
1.3
84.0
8 All multiple pregnancies (incl previous caesarean
sections)
654/1077
1.8
60.7
9 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
1 Nullip single ceph >=37 wks spon lab
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
National Maternity Hospital, Dublin
Caesarean Sections
- depend
the 10
This will
on theGroups
size of the group as well as the
CS rate in each group
2005-2011
12040/61166
19.7%
Size of
group
%
C/S
rate in
gp %
Contr of
each gp
19.7 %
1176/16421
26.8
7.2
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
2896/8619
14.0
34.9
4.7
3 Multip (excl prev caesarean sections) single ceph
>=37 wks spon lab
220/18321
30.0
1.2
0.4
4 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
1.9
7 All multiparous breeches (incl previous caesarean
sections)
685/815
1.3
84.0
1.1
8 All multiple pregnancies (incl previous caesarean
sections)
654/1077
1.8
60.7
1.1
9 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
1 Nullip single ceph >=37 wks spon lab
Groups 1,2 and
5 contribute to two thirds of
National Maternity Hospital,
Dublin
all caesarean section rates and are the
source of biggest variation between units
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 %
1176/16421
26.8
7.2
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
2896/8619
14.0
34.9
4.7
3 Multip (excl prev caesarean sections) single ceph
>=37 wks spon lab
220/18321
30.0
1.2
0.4
4 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
1.9
7 All multiparous breeches (incl previous caesarean
sections)
685/815
1.3
84.0
1.1
8 All multiple pregnancies (incl previous caesarean
sections)
654/1077
1.8
60.7
1.1
9 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
1 Nullip single ceph >=37 wks spon lab
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
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 %
1176/16421
26.8
7.2
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
2896/8619
14.0
34.9
4.7
3 Multip (excl prev caesarean sections) single ceph
>=37 wks spon lab
220/18321
30.0
1.2
0.4
4 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
1.9
7 All multiparous breeches (incl previous caesarean
sections)
685/815
1.3
84.0
1.1
8 All multiple pregnancies (incl previous caesarean
sections)
654/1077
1.8
60.7
1.1
9 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
1 Nullip single ceph >=37 wks spon lab
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 quality
Differences in significant epidemiological factors
Differences 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 effects
Shortens 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
Caesarean Section
Efficient Uterine Action
Progress >1cm/hr
Inefficient Uterine Action
Progress <1cm/hr
Classification of indications for Caesarean
Sections - in labour
Fetal reason
(No oxytocin)
Dystocia
IUA
(Inefficient uterine action <1cm/hr)
Inability to treat
Inability to treat
Poor response
No oxytocin
EUA
(Fetal intolerance)
(Mechanical/OC)
(Full treatment)
(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
Inability to treat
Poor response
No oxytocin
EUA
(Fetal intolerance)
(Mechanical/OC)
(Full treatment)
(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
Hypothesis
The incidence and distribution of your caesarean sections together
with fetal and maternal outcome will depend on your timing, rate of increase
and 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
Hypothesis
The incidence and distribution of your caesarean sections together
with fetal and maternal outcome will depend on your timing, rate of increase
and maximum dose of oxytocin. This will in turn will beinfluenced by when you
rupture your membranes
Detailed audit of labour events
and outcome Group 1
Detailed audit of labour events
and outcome Group 1
Detailed audit of labour events
and outcome Group 3
Detailed audit of labour events
and 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 unfavourable
give 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
When
Drawbacks
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
Aim
Different definitions
Incorrect use of the definition
Correct definition but assessed in isolation
Poor collection of data
NMH Groups 1 and 2
2011
Group 2
2011
Group 2(b)
NMH Groups 3 and 4
2011
Group 4
2011
Care on the Labour Ward
Safety first simplicity second
Mrobson@nmh.ie