1. National Women’s Annual Clinical Report 2010 Prof J Quinlivan

2. 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

3. Overview 7709 mothers delivered 7866 babies. No major changes in pattern of delivery modality since 2002.

4. Some excellent results General –Breast feeding –Quit campaign Low complication rates in –General Gynaecology –Gynaecology Oncology Obstetrics –HIE (below benchmark) –VBAC (above benchmark)

5. Breast feeding Baby friendly hospital initiative 81.6% of mothers achieved ‘exclusive breastfeeding’ on discharge from NW. WHA Benchmark 77%

6. 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.

7. Summary statistics maternity IndicatorWHANW 2010 N=7709 NW Public 2010 N=2329 Preterm birth11.7-11.910.117.1 HIE (Gd 2/3)0.100.060.08 CS28-29.632.333.3

8. Summary statistics 2 IndicatorWHANW 2010 N=7709 NW Public 2010 N=2329 VBAC7.9-9.110.110.8 Maternal age23.4-23.831.125.1 Episiotomy17.8-18.624.014.9 3 rd /4 th degree tears 2.8-3.52.32.1

9. Summary statistics 3 IndicatorWHANW 2010 N=7709 NW Public 2010 N=2329 PPH 1000-1500 Vaginal births 1.9-2.43.14 PPH >1500 Vaginal births 1.4-1.72.74 PPH 500-1500 CS 49.46774.6 Transfusion All births 1.6-2.12.53.8

10. Closing the audit gap 1. Maternal age 2. Perineal care 3. Post partum haemorrhage 4. Induction of labour for post dates 5. Urogynaecology mesh

11. 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 years35-40 years 1991/199222-23%9-10% 2009/201012-13%23-24%

12. 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

13. 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.

14. 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.

15. Adverse neonatal outcome Retrospective study comparing outcomes of women aged 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

16. 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.

17. The older pregnant woman Different concerns to younger women Less satisfied with counselling More stillbirths More adverse pregnancy outcomes

18. 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 1991/19929-10% 2009/201023-24% 2030?? 40% ??

19. Perineal Care at NW Why is it a case of chalk & cheese?

20. Perineal care at NW IndicatorWHANW 2010 N=7709 NW Public 2010 N=2329 Episiotomy1824.014.9 3 rd /4 th degree tears 2.8-3.52.32.1

21. Episiotomy rates by LMC at birth IndicatorTotalEpisiotomy3 rd /4 th degree tear Independent midwife 273724.6%2.6% Private Obstetrician 86237.7%2.0% NW Community106015.2%2.5% BM: Episiotomy = 18%

22. 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

23. Outcomes from the new NW Perineal Tear Clinic Commenced October 2010 ACC funded Aim to review all 3 rd/ 4 th 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.

24. 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 3 rd degree tears –Best Practice Perineal Care Key points

25. 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

26. Best Practice and Episiotomy Must be able to identify the INDICATION. EpisiotomyIndication (circle if yes) No Yes Delay 2 nd stage Fetal distress CTG Fetal distress pH/Lactate Assisted vaginal delivery Patient tearing posteriorly Other _______________