1. The National Maternity
Mölndals Sjukhus
March 2017
Perinatal audit
– what is the purpose?
Michael Robson
The National Maternity
Hospital
Dublin, Ireland 1

2. Key issues in the Maternity Services
Safety, consistency and quality

3. Key issues in the Maternity Services
How do we assess quality in
the Maternity Services?

4. Assessing Quality
Structure (resources)
Building
Equipment
Staff

5. Assessing Quality
Processes (guidelines)

6. Assessing Quality Organisation Philosophy Leadership
Truly multidisciplinary approach
Good communication
Key decision making
Fail safe mechanisms

7. Assessing Quality Outcome
Events and outcomes (including complications)
Complaints, adverse events, medico-legal cases (incidents)
Professionals knowledge of information
Ability to respond and change as a result of information
Ability to perform and continuously reassess information

8. Assessing Quality
Women, healthcare professionals and governments are interested in safety and quality
Safety and quality are ultimately related to outcome and
outcome guides processes

9. Perinatal Audit - what is the purpose?
The first measure of quality in any organisation is knowing
what your results are

10. Perinatal Audit - what is the purpose?
Safety and quality of care provided by a labour and delivery unit
should be assessed in terms of available validated perinatal audit
and
only then ultimately in appropriate outcomes when all the necessary information is available

11. Perinatal Audit - what is the purpose?
The second measure of quality is enabling the ability to understand the results, compare them with other delivery units and use them to improve quality of care

12. Evidence based medicine
Competing Philosophies
Process driven (Randomised trials)
Outcome driven (Perinatal audit)

14. Randomised trials depend on relative outcomes over a
limited period of time while perinatal audit concentrates on
absolute outcomes over an indefinite period of time

15. As randomised trials continue to ascend in the evolution of evidence based medicine, we must recognise and respect their limitations when examining complex phenomena in heterogeneous populations
Andrew Kotaska
BMJ 2004

16. Perinatal Audit - why is it so difficult?
Not recognised as an entity, specialist area or even at all useful (poor relation of randomised controlled trials)
Collection of routine quality data is resource dependent, requiring total organisational commitment
No accepted classification, principles or training programmes

17. Perinatal Audit - what is the purpose?
In theory at least, it should be simpler to standardise
measurement of outcomes rather than processes

18. Perinatal Audit - what is the purpose?
If standardising measurement of outcome is established and
accepted, a greater degree of comparison, learning and communication can and will take place
It might then be reasonably expected that processes would
gradually merge over time

19. Perinatal Audit - what is the purpose?
Embrace different ways of care
and
rather than concentrating on standardising processes
standardise the way we carry out perinatat audit so greater
learning and comparison can take place between delivery units

20. Perinatal Audit – collection of routine quality data is resource dependent, requiring total organisational commitment
Few delivery units, regions, countries have committed to routine
quality data collection

21. Perinatal audit starts at the individual unit level with
Perinatal Audit – collection of routine quality data is resource dependent, requiring total organisational commitment
Perinatal audit starts at the individual unit level with
The Clinical Report

26. Perinatal Audit The current challenges Routine data collection
Classification of data

27. The Maternal and Newborn Clinical Managment System (MN-CMS) - routine data collection
A means of clinical communication
Concept of a virtual record and clinical care
Storage of information
Access to and the use of additional resources to improve care
Information available for analysis

28. Perinatal Audit - classification of data
Unless we classify data in a systematic and consistent way the more confused we will become

29. Perinatal audit – no accepted classification, principles or training
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

30. But to do that
We need a consistent, objective and overarching structure (classification) within which we can examine fetal and maternal outcomes

31. Labour and delivery events and outcomes (including “interventions” and complications)
Any intrapartum event, on its own insignificant to the mother, midwife, obstetrician or neonatologist but may influence one of the labour outcomes
Outcomes
Any outcome thought by the mother, midwife, obstetrician
or neonatologist to affect the health and satisfaction of
either mother or baby
Robson MS. Labour Ward Audit. In: Management of Labour and Delivery. Ed. R.Creasy, 1997 Blackwell Science pp

32. Is a Caesarean Section an event or an outcome?

33. Principles of Perinatal Audit
Overall rates of any events or
outcomes are on their own meaningless

34. Principles of Perinatal Audit
No perinatal event or outcome (including CS) should be considered in isolation from other events, outcomes and organisational issues
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

35. No perinatal event or outcome should be considered in isolation from other events and outcomes
Risk-Benefit Calculus
Perinatal morbidity and mortality
Maternal morbidity and mortality
Labour and delivery events and outcomes
Complaints, adverse incidents and medico-legal cases
Maternal satisfaction and staff satisfaction
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

36. Perinatal Mortality Rate NMH (88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies)
Groups SB
IPD
NND
(per 1000)
1 & 2
83/35406
0/35406
19/35406
(2.3)
(0)
(0.5)
3 & 4
46/35317
0/35317
17/35317
(1.3) 5
13/8682
0/8682
6/8682
(1.5)
(0.7) 8
27/3294
0/3294
53/3294
(8.3)
(16.1)
6,7,9 & 10
192/6953
2/6953
126/6953
(27.6)
(0.3)
(18.1)

37. HIE NMH (88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies)
Group
HIE
(per 1000)
1 & 2
50/35406
(1.4)
3 & 4
25/35317
(0.7) 5
5/8682
(0.6) 8
2/3294
6,7,9 & 10
0/6953
(0)

38. Principles of Perinatal Audit
Classification must be able to incorporate other variables
related to perinatal events and outcome
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section.

39. Classification must be able to incorporate other variables related to perinatal events and outcome
Significant epidemiological factors
Age, BMI, Fetal weight, Casemix
Data collection must be aligned
Organisational systems
Staff and infrastructure resources
Economics of childbirth

40. Principles of an ideal classification system
Simple, easy to implement, informative and useful
Robust, self validating and universal
Prospectively determined, clinically relevant, identifiable, totally accountable and replicable
The groups must be objectively not subjectively defined, mutually exclusive and totally inclusive
Remove variables, but interpret accordingly

41. Classifying Perinatal Events and Outcome – the 10 Groups, Obstetrical Concepts and their Parameters
Previous Obstetric Record
Nulliparous
Multiparous without a scar, Multiparous with a scar
Category of pregnancy
Single cephalic
Single breech
Multiple pregnancy
Single transverse or oblique lie
Course
Spontaneous labour
Induced labour
Prelabour caesarean section
Gestation
The number of completed weeks at delivery

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

43. Philosophy of the 10 Group Classification
Based on the premise that all information
(epidemiological, maternal and fetal events, outcomes,
cost and organisational)
will be more clinically relevant by stratifying them
using the 10 groups

45. Perinatal Audit - what is the purpose?
To record and understand what we do in order to
improve maternity care

46. Quality of maternity care
Will not improve until we all continuously audit events and outcomes in a standardised way and understand their relationships
But it is important to acknowledge immediately that a caesarean section rate cannot be considered in isolation and we need to consider other outcome criteria.
The perinatal morbidity and mortality, the maternal morbidity and mortality, maternal and indeed paternal satisfaction, complaints, medicolegal cases, resources and even staff satisfaction. All these criteria can be affected in different directions by changes in the caesarean section. 46

47. Classifying Perinatal Outcome – the 10 Group classification system (TGCS)
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

48. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015
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)

49. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015
Total number of caesarean sections over the overall total number of women
2015
2379/9180
25.9%
1 Nullip single ceph >=37 wks spon lab
178/2043
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
5 Previous caesarean section single ceph >= 37 wks
816/1118
6 All nulliparous breeches
193/200
7 All multiparous breeches (incl previous caesarean sections)
120/129
8 All multiple pregnancies (incl previous caesarean sections)
119/190
9 All abnormal lies (incl previous caesarean sections)
35/35
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
Number of caesarean sections over the total number of women in each group

50. 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 2015
2015
2379/9180
25.9%
Size of
group %
1 Nullip single ceph >=37 wks spon lab
178/2043
22.2
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
16.2
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
27.5
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
11.3
5 Previous caesarean section single ceph >= 37 wks
816/1118
12.2
6 All nulliparous breeches
193/200
2.2
7 All multiparous breeches (incl previous caesarean sections)
120/129
1.4
8 All multiple pregnancies (incl previous caesarean sections)
119/190
2.1
9 All abnormal lies (incl previous caesarean sections)
35/35
0.4
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
4.5

51. 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 2013
2015
2379/9180
25.9%
Size of
group %
C/S
rate in gp %
1 Nullip single ceph >=37 wks spon lab
178/2043
22.2
8.7
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
16.2
39.3
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
27.5
1.6
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
11.3
13.6
5 Previous caesarean section single ceph >= 37 wks
816/1118
12.2
73.0
6 All nulliparous breeches
193/200
2.2
96.5
7 All multiparous breeches (incl previous caesarean sections)
120/129
1.4
93.0
8 All multiple pregnancies (incl previous caesarean sections)
119/190
2.1
62.6
9 All abnormal lies (incl previous caesarean sections)
35/35
0.4
100
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
4.5
36.7

52. 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 2013
2015
2379/9180
25.9%
Size of
group %
C/S
rate in gp %
Contr of each gp
25.9 %
1 Nullip single ceph >=37 wks spon lab
178/2043
22.2
8.7
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
16.2
39.3
6.4
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
27.5
1.6
0.5
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
11.3
13.6
5 Previous caesarean section single ceph >= 37 wks
816/1118
12.2
73.0
8.9
6 All nulliparous breeches
193/200
2.2
96.5
7 All multiparous breeches (incl previous caesarean sections)
120/129
1.4
93.0
1.3
8 All multiple pregnancies (incl previous caesarean sections)
119/190
2.1
62.6
9 All abnormal lies (incl previous caesarean sections)
35/35
0.4
100
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
4.5
36.7

53. Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the source of biggest variation between units 17.2%
National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2013
2015
2379/9180
25.9%
Size of
group %
C/S
rate in gp %
Contr of each gp
25.9 %
1 Nullip single ceph >=37 wks spon lab
178/2043
22.2
8.7
1.9
2 Nullip single ceph >=37wks ind. or CS before lab
585/1490
16.2
39.3
6.4
3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab
41/2525
27.5
1.6
0.5
4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab
142/1041
11.3
13.6
5 Previous caesarean section single ceph >= 37 wks
816/1118
12.2
73.0
8.9
6 All nulliparous breeches
193/200
2.2
96.5
7 All multiparous breeches (incl previous caesarean sections)
120/129
1.4
93.0
1.3
8 All multiple pregnancies (incl previous caesarean sections)
119/190
2.1
62.6
9 All abnormal lies (incl previous caesarean sections)
35/35
0.4
100
10 All single ceph <= 36 wks (incl previous caesarean sections)
150/409
4.5
36.7