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

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 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)

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

28. National Maternity Hospital, Dublin Caesarean Sections - the the 10 Groups 2005-2011 2005-2011 12040/61166 19.7% Size of group % 1 Nullip single ceph >=37 wks spon lab 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 Size of each group is the total number of women in each group divided by the overall total number of women

29. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2005-2011 12040/61166 19.7% Size of group % C/S rate in gp % 1 Nullip single ceph >=37 wks spon lab 1176/16421 26.87.2 2 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.034.9 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.01.2 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.012.4 5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.458.7 6 All nulliparous breeches 1177/1273 2.092.5 7 All multiparous breeches (incl previous caesarean sections) 685/815 1.384.0 8 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.860.7 9 All abnormal lies (incl previous caesarean sections) 220/220 0.4100 10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.234.6 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

30. National Maternity Hospital, Dublin 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 % 1 Nullip single ceph >=37 wks spon lab 1176/16421 26.87.21.9 2 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.034.94.7 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.01.20.4 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.012.41.3 5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.458.75.5 6 All nulliparous breeches 1177/1273 2.092.51.9 7 All multiparous breeches (incl previous caesarean sections) 685/815 1.384.01.1 8 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.860.71.1 9 All abnormal lies (incl previous caesarean sections) 220/220 0.41000.4 10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.234.61.4 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 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

31. National Maternity Hospital, Dublin 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 % 1 Nullip single ceph >=37 wks spon lab 1176/16421 26.87.21.9 2 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.034.94.7 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.01.20.4 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.012.41.3 5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.458.75.5 6 All nulliparous breeches 1177/1273 2.092.51.9 7 All multiparous breeches (incl previous caesarean sections) 685/815 1.384.01.1 8 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.860.71.1 9 All abnormal lies (incl previous caesarean sections) 220 0.41000.4 10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.234.61.4 Groups 1,2 and 5 contribute to two thirds of all caesarean section rates and are the source of biggest variation between units

32. 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 % 1 Nullip single ceph >=37 wks spon lab 1176/16421 26.87.21.9 2 Nullip single ceph >=37wks ind. or CS before lab 2896/8619 14.034.94.7 3 Multip (excl prev caesarean sections) single ceph >=37 wks spon lab 220/18321 30.01.20.4 4 Multip (excl prev caesarean sections) single ceph >=37wks ind. or CS before lab 766/6139 10.012.41.3 5 Previous caesarean section single ceph >= 37 wks 3364/5735 9.458.75.5 6 All nulliparous breeches 1177/1273 2.092.51.9 7 All multiparous breeches (incl previous caesarean sections) 685/815 1.384.01.1 8 All multiple pregnancies (incl previous caesarean sections) 654/1077 1.860.71.1 9 All abnormal lies (incl previous caesarean sections) 220 0.41000.4 10 All single ceph <= 36 wks (incl previous caesarean sections) 882/2546 4.234.61.4 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 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

35. 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

36. 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

37. 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

38. 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

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

40. 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.

41. 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)

42. 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

43. Monitoring contractions No more than 5 contractions in 10 minutes (most common) NulliparousNo 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

44. Continual audit is obligatory

45. Incidence of Oxytocin 2011

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

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

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

50. 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

51. Classification of indications for Caesarean Sections - in labour Fetal reason (No oxytocin) DystociaIUA (Inefficient uterine action <1cm/hr) Inability to treat (Fetal intolerance) Inability to treat (Mechanical/OC) Poor response(Full treatment) No oxytocin EUA (Efficient uterine action >1cm/hr)

52. Classification of indications for Caesarean Sections - in labour Fetal reason (No oxytocin) DystociaIUA (Inefficient uterine action <1cm/hr) Inability to treat (Fetal intolerance) Inability to treat (Mechanical/OC) Poor response(Full treatment) No oxytocin EUA (Efficient uterine action >1cm/hr) CPD (Cephalopelvic Disproportion) POP (Malposition)

53. 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

54. 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

55. 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

56. Detailed audit of labour events and outcome Group 1

58. Detailed audit of labour events and outcome Group 3

60. 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

61. 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

62. 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

63. 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

64. 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

65. VBAC Antenatal classes Essential Patient leaflet

66. VBAC What influence does the previous CS have? Previous dilatation Indication

67. VBAC What influence does the EFW have? Generally very little

68. VBAC Epidural Not a problem

69. VBAC What are the risks? Rupture Unpredictable

70. VBAC Would it be easier just to deliver everyone by CS When Drawbacks

71. 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

72. VBAC How do we audit VBAC Denominator

73. Group 5 2011 - uterine rupture No uterine ruptures No neonatal deaths No encephalopathy

74. Group 5 2011 - distribution of onset of delivery

75. Group 5 2011 - distribution of CS

76. Group 5 2011 - CS rate and indications in spontaneous labour CS rate in induced labour 41.2% (49/119)

77. Group 5 2011 - other outcomes of spontaneous labour

78. Group 5 2011 - distribution of CS

79. Group 5 2011 - repeat CS in women with one previous CS only and no medical indication

80. Induction of Labour General problems Aim Different definitions Incorrect use of the definition Correct definition but assessed in isolation Poor collection of data

81. NMH Groups 1 and 2 2011

82. Group 2 2011 Group 2(b)

83. NMH Groups 3 and 4 2011

84. Group 4 2011

85. Care on the Labour Ward Safety first simplicity second Mrobson@nmh.ie