ccdhb 2012 womens annual clinical report.pdf

Women's HealtH service

capital & coast District HealtH BoarD riDDiforD street, Wellington

private Bag 7902, Wellington soutH, neW ZealanD

pHone (04) 385 5999

The Women’s healTh serviceAnnuAl CliniCAl RepoRt

2012

Capital & Coast District Health Board

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Project team

this report was prepared by:

Keith Fisher, Data Analyst, Decision Support UnitCarolyn Coles, Quality Facilitator, Surgery, Women and Children’s DirectorateDr Rose Elder, Clinical Leader, ObstetricsDr Jackie Hawley, Clinical Leader, GynaecologyDr Robyn Maude, Associate Director of MidwiferyMargaret Thomson, Charge Nurse Manager, Ward 4 North Gynaecology

reProduction of material

The Women’s Health Service (WHS), Capital and Coast District Health Board (C&C DHB), permits the reproduction of material from this publication without prior notification, provided that the WHS C&C DHB is acknowledged as the source and any information used must not be distorted or changed.

disclaimer

The purpose of this publication is to promote, discuss and audit outcomes. The opinions expressed in this publication do not necessarily reflect the official views of the WHS and C&C DHB.

acknowledgements

This WHS Annual Clinical Report contains major changes to the layout and content compared to previous annual reports. In designing this report the project team acknowledges use of the layout design of the National Women’s Annual Clinical Report 2011.

We would like to acknowledge contributions from the following: Dr Peter Abels, Obstetrician and GynaecologistDr Anju Basu, Obstetrician and GynaecologistPauline Bennett-Tamati, Business Services OfficerDenise Braid, Charge Nurse Manager, Women’s ClinicsDr Howard Clentworth, Gynaecological OncologistChristina Cuncarr, Charge Midwife Manager, Ward 4 North MaternityGill Dawidowski, Charge Nurse Manager, Te Mahoe UnitRosemary Escott, Nurse Manager, Neonatal Intensive Care UnitHazel Irvine, PMMRC/AMOSS Midwife CoordinatorShelley James, Charge Midwife Manager, Delivery SuiteFiona Jones, Clinical Midwife SpecialistDr Fali Langdana, Obstetrician and GynaecologistDr Elaine Langton, Clinical Leader, Obstetric AnaesthesiaDr Dean Maharaj, Obstetrician and GynaecologistStuart McGregor, Charge Sonographer, Women’s Ultrasound ServiceDr Alan McKenzie, Specialist AnaesthetistDiana Murray, Charge Midwife Manager, Primary Maternity CareJustine Plunkett, Operations Manager, Women’s Health ServiceJenny Quinn, Charge Midwife Manager, Kenepuru Maternity UnitNoreen Roche, Lead Maternity CarerDr Jeremy Tuohy, Clinical Leader, Maternal Fetal MedicinePenny Wyatt, Lactation Consultant

report Design anD print proDuction: tBD Design ltD, Wellington

pHotograpHs: communications, capital & coast District HealtH BoarD

JennY Quinn, cHarge miDWife manager, Kenepuru maternitY unit

alison curran, acting cHarge miDWife manager, paraparaumu maternitY unit

issn 1177-7168

The Women’s Health Service Annual Clinical Report 2012

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It is my pleasure to present the 2012 Women’s Health Service Annual Clinical Report. This is our 10th report.

In 2012 the focus was on the implementation of the Ministry of Health (MOH) Maternity Quality and Safety Programme. This is a national framework for DHB quality and safety improvement and reporting and provided us with guidance for the revised format for this year’s annual clinical report.

Our primary purpose for producing these reports is to identify and acknowledge our achievements. It is also an opportunity to identify where improvements can be made to the care provided to women and their babies. This then allow us to improve the quality and safety of our service.

Thank you to all that have contributed to this report but special thanks must go to Carolyn Coles and Keith Fisher who have spent many hours in the production of this report.

Justine PlunkettOPERATIONS MANAGERWomen’s Health Service


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1 Introduction 15

1.1 Purpose of this report 15

1.2 Report structure 15

1.3 Clinical indicators 17

1.4 Women and babies included in this report 17

1.5 Data sources 18

1.6 Data quality 18

1.7 Data analysis 19

2 Service provision 21

2.1 Maternity Services 21

2.2 Lead Maternity Carer Services 25

2.3 Specialist Maternal Mental Health Service 25

2.4 Gynaecology Services 26

2.5 Ultrasound Scanning Service 27

2.6 Quality, Health and Safety 28

2.7 University of Otago 29

2.8 Victoria University of Wellington 29

2.9 Otago Polytechnic 30

3 Quality, health & safety 31

3.1 Maternity Quality Safety Programme (MQSP) Governance and Objectives 31

3.2 Reportable events 35

3.3 Adverse Serious (SAC2) and Sentinel (SAC1) events 35

3.4 Adverse maternity outcomes 36

3.5 Compliments, complaints and HDC cases 36

3.6 Health and safety 37

3.7 Audits 37

3.8 Controlled documents 38

4 Learning development and research 39

4.1 Quality forum 39

4.2 RANZCOG integrated training programme 39

4.3 Midwife educators 40

4.4 Graduate midwifery programme 41

contents


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5 Summary statistics for 2012 43

5.1 Place of birth 43

5.2 Maternity demographics and outcomes 45

5.3 Neonatal outcomes 47

5.4 ACHS maternal and perinatal clinical indicators 49

5.5 Gynaecology outcomes 51

5.6 ACHS gynaecology clinical indicators 52

6 Antenatal and postnatal clinics 53

6.1 Obstetric diabetic clinics 55

6.2 Anaesthesia clinics 56

6.3 Pregnancy and parenting education 56

7 Maternity service demography 57

7.1 Domicile 57

7.2 Age 58

7.3 Ethnicity 61

7.4 Parity 64

7.5 Smoking 65

7.6 Body mass index 67

7.7 Lead maternity carer (LMC) at booking 68

7.8 Hospital Primary Care 70

8 Antenatal complications 71

8.1 Preterm birth 71

8.2 Multiple pregnancy 74

8.3 Diabetes in pregnancy 76

8.4 Maternal Fetal Medicine service & Ultrasound scan service 78

8.5 Maternal cardiac 81

9 Labour and birth 83

9.1 Mode of birth 84

9.2 Labour and birth by parity group 87

9.3 Various rates 93

9.4 Induction of labour 95

9.5 Breech presentation and external cephalic version (ECV) 97

9.6 Outcome of selected primipara (ACHS) 99

9.7 Obstetric anaesthesia 100

9.8 Primary maternity units 104

9.8.1 Kenepuru Maternity Unit 104

9.8.2 Paraparaumu Maternity Unit 105

10 Labour and birth outcomes 107

10.1 Perineal trauma 107

10.2 Postpartum haemorrhage 108

10.3 Surgical site infection (ACHS) 109

10.4 Neonatal outcomes 110

10.4.1 Gender 110

10.4.2 Plurality 110

10.4.3 Birth weight 111


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10.4.4 Gestational age 114

10.4.5 Apgar score 115

11 Postnatal care 117

11.1 Postnatal consumer satisfaction survey 117

11.2 Infant feeding 118

11.3 Newborn hearing screening 121

11.4 NICU admissions and outcomes 122

12 Perinatal mortality 123

12.1 Perinatal mortality rates 123

12.2 Perinatal mortality by maternal age and ethnicity 125

12.3 Causes of perinatal deaths 127

13 Maternal mortality and morbidity 131

13.1 Maternal mortality 131

13.2 Severe maternal morbidity 132

13.3 Admissions to the Intensive Care Unit 132

14 Gynaecology Clinics 133

14.1 Gynaecology outpatient service 133

14.2 Colposcopy service 135

14.3 Te Mahoe unit 137

15 Gynaecology Services 141

15.1 Gynaecology inpatient service 141

15.2 Endometriosis service 145

15.3 Urogynaecology service 146

15.4 Gynaecology oncology service 147

15.5 Adverse gynaecological outcomes 149

15.6 ACHS gynaecology clinical indicators 150

16 Appendices 153

16.1 Extra data tables 153

16.2 Abbreviations 165

16.3 References 166

16.4 ACHS clinical indicator definitions 167


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tables

Table 1: Clinical audits approved in 2012 37

Table 2: Place of birth for the Capital & Coast DHB region for 2012 43

Table 3: Key demographic statistics for women giving birth in 2012 45

Table 4: Mode of labour by parity group for 2012 46

Table 5: Mode of birth by parity group for 2012 46

Table 6: Various mode of birth rates and postpartum outcomes for 2012 46

Table 7: Neonatal outcomes for babies in 2012 47

Table 8: Perinatal mortality for babies in 2012 48

Table 9: ACHS obstetric clinical indicators for 2012 50

Table 10: ACHS infection control clinical indicator for 2012 51

Table 11: ACHS gynaecology clinical indicators for 2012 52

Table 12: Obstetric outpatient clinic attendances and DNA rates for years 2009 to 2012 54

Table 13: Ethnicity distribution of women seen at obstetric diabetic outpatient clinics in 2012 55

Table 14: Domicile by District Health Board (DHB) area and by gestation at birth for 2012 57

Table 15: Age group distribution by birth facility for 2012 58

Table 16: Maternal age group distribution for years 2005 to 2012 59

Table 17: Ethnicity distribution by birth facility for 2012 61

Table 18: Maternal ethnicity groups for years 2005 to 2012 62

Table 19: Age group distribution within each ethnicity group for 2012 62

Table 20: Parity for years 2005 to 2012 64

Table 21: Grouping by Caesarean Section (CS) history for years 2005 to 2012 64

Table 22: Rates of smoking at booking time by ethnicity and age groups for 2012 65

Table 23: Rates of smoking at booking time by ethnicity group for years 2005 to 2012 66

Table 24: Body mass index (BMI) categories at booking by age group for 2012 67

Table 25: Body mass index (BMI) categories at booking by ethnicity group for 2012 67

Table 26: LMC bookings by trimester at time of first visit, for years 2008 to 2012 68

Table 27: LMC at time of booking by facility of birth for 2012 69

Table 28: LMC at time of booking for years 2008 to 2012 69

Table 29: Ethnicity group distribution by booking LMC for 2012 69

Table 30: Parity group distribution by booking LMC for 2012 70

Table 31: Parity by ethnicity for women booked with Hospital Midwifery Primary Care for 2012 70

Table 32: Preterm rates by maternal age group for 2012 72


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Table 33: Preterm rates by maternal ethnicity group for 2012 72

Table 34: Perinatal outcome of preterm births by gestation for 2012 73

Table 35: Multiple pregnancy numbers and rates for years 2003 to 2012 74

Table 36: Ethnicity of women with GDM and Type 2 diabetes giving birth in 2012 76

Table 37: Ethnicity distribution within diabetes type for women attending clinic in 2012 76

Table 38: Mode of birth by diabetes type for births in 2012 within C&C DHB 77

Table 39: Referrals to Maternal Fetal Medicine for years 2010 to 2012 78

Table 40: Ultrasound scanning service volumes for years 2008 to 2012 79

Table 41: Amniocentesis and CVS indications for years 2008 to 2012 80

Table 42: Outcomes after amniocentesis and CVS for 2011 and 2012 (Jan-Sep) 81

Table 43: Mode of birth for years 2003 to 2012 84

Table 44: Mode of birth by age group for 2012 86

Table 45: Mode of birth by ethnicity group for 2012 86

Table 46: Peer group comparison for ACHS obstetric clinical indicator 2.1 93

Table 47: Various rates for years 2005 to 2012 94

Table 48: Primary indication for induction of labour by parity and CS history group for 2012 95

Table 49: Mode of birth after induction of labour for main primary indication groups for 2012 96

Table 50: Peer group comparison for ACHS obstetric clinical indicators 1.1 to 1.4 99

Table 51: Summary of neuraxial blocks for years 2011 and 2012 100

Table 52: Indications for anaesthesia support in 2012 100

Table 53: Mode of delivery after neuraxial block in labour in 2012 101

Table 54: Anaesthesia for caesarean section in 2012 101

Table 55: Urgency of caesarean section for years 2011 and 2012 102


Table 57: Age and ethnicity distribution for the women who gave birth at KMU in 2012 104

Table 58: Age and ethnicity distribution for the women who gave birth at PMU in 2012 105

Table 59: Peer group comparison for ACHS obstetric clinical indicators 3.1 to 3.6 107

Table 60: Peer group comparison for ACHS obstetric clinical indicators 7.1 and 7.2 108

Table 61: Primary postpartum blood loss for years 2005 to 2012 108

Table 62: ACHS infection control clinical indicator 1.16 109

Table 63: Gender for years 2005 to 2012 110

Table 64: Plurality for years 2005 to 2012 110


Table 66: Birth weights of all babies by maternal age group for 2012 111

Table 67: Birth weights of all babies by maternal ethnicity group for 2012 112

Table 68: Birth weights for liveborn babies for years 2005 to 2012 113

Table 69: Gestational age for liveborn babies for years 2005 to 2012 114

Table 70: Gestational age groups for liveborn babies for years 2005 to 2012 115


Table 72: Apgar score at 5 minutes for liveborn babies by maternal age group for 2012 116

Table 73: Apgar score at 5 minutes for liveborn babies by maternal ethnicity group for 2012 116

Table 74: Apgar scores at 5 minutes for liveborn babies for years 2005 to 2012 116


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Table 75: Infant feeding at time of initial discharge, by birth facility for 2012 118

Table 76: Infant feeding at time of initial discharge, by mode of birth for 2012 119

Table 77: Infant feeding at time of initial discharge, by maternal age for 2012 119

Table 78: Infant feeding at time of initial discharge, by maternal ethnicity for 2012 120

Table 79: UNHSEIP volumes for years 2010 to 2012 121

Table 80: NICU admissions and outcomes for liveborn babies, by gestation group for 2012 122


Table 82: Perinatal mortality numbers and rates for years 2005 to 2012 124

Table 83: Perinatal mortality rate by maternal age groups for years 2005 to 2012 125

Table 84: Adjusted perinatal mortality rate by maternal age groups for years 2005 to 2012 125

Table 85: Perinatal mortality rate by maternal ethnicity groups for years 2005 to 2012 126

Table 86: Adjusted perinatal mortality rate by maternal ethnicity groups for years 2005 to 2012 126

Table 87: Summary of factors related to the 23 stillbirths in 2012 127

Table 88: Stillbirths by perinatal death classification for the years 2006 to 2012 128

Table 89: Summary of factors related to the 7 early neonatal deaths < 7 days in 2012 129

Table 90: Early neonatal deaths by perinatal death classification for the years 2006 to 2012 130

Table 91: Incidence of AMOSS reportable severe maternal morbidities for 2011 and 2012 132

Table 92: Gynaecology outpatient clinic attendances and DNA rates for years 2009 to 2012 134

Table 93: Gynaecology waiting time numbers per month for 2012 135

Table 94: Colposcopy outpatient clinic attendances and DNA rates for years 2009 to 2012 136

Table 95: Colposcopy waiting time numbers per month for 2012 136

Table 96: DHB distribution of women attending Te Mahoe unit in years 2007 to 2012 137

Table 97: Numbers and rates for Te Mahoe for years 2007 to 2012 139

Table 98: Elective gynaecology surgery volumes for years 2009 to 2012 142

Table 99: Acute gynaecology surgery volumes for years 2009 to 2012 142

Table 100: Elective gynaecology surgery volumes and breakdown of surgical procedures for 2012 143

Table 101: Acute gynaecology surgery volumes for 2012 144

Table 102: Postnatal readmissions for 2012 144

Table 103: Non-surgical acute admissions for 2012 145

Table 104: Total endometriosis procedures for 2012 146

Table 105: Urogynaecology surgery procedures for years 2008 to 2012 147

Table 106: Gynaecology oncology referral numbers by DHB for years 2009 to 2012 147

Table 107: Histological confirmed gynaecology oncology cases for newly referred women in 2012 148

Table 108: Gynaecology oncology surgery procedures for 2012 148

Table 109: Adverse gynaecologic outcomes for 2012 149

Table 110: Group comparison for ACHS gynaecology clinical indicators for years 2010 to 2012 151

Table 111: Place of birth for the C&C DHB region for the years 2003 to 2012 154

Table 112: Place of birth by C&C DHB birthing facility for the years 2003 to 2012 155

Table 113: Ethnicity group distribution within each age group for 2012 155

Table 114: Parity by age group for 2012 156

Table 115: Parity by ethnicity group for 2012 156

Table 116: Maternal ethnicities within the six ethnicity groups for years 2005 to 2012 157


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Table 117: Mode of birth group percentages for years 1997 to 2012 158

Table 118: Mode of birth group by age group for all women in 2012 158

Table 119: Mode of birth group by age group for primiparous women in 2012 158

Table 120: Mode of birth group by age group for multiparous women without previous CS in 2012 159

Table 121: Mode of birth group by age group for multiparous women with previous CS in 2012 159

Table 122: ACHS obstetric clinical indicators (Jan-Jun, Jul-Dec 2012) and table notes 160

Table 123: ACHS infection control clinical Indicators (Jan-Jun, Jul-Dec 2012) and table notes 162

Table 124: ACHS gynaecology clinical indicators (Jan-Jun, Jul-Dec 2012) and table notes 163


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Figure 1: C&C DHB quality framework diagram 28

Figure 2: WHS Governance Structure 32

Figure 3: Number of reportable events by month for 2012, with a linear trend line 35

Figure 4: Age group percentage distribution for years 2005 to 2012 59

Figure 5: Ethnicity group distribution within each maternal age group for 2012 60

Figure 6: Age group distribution within each maternal ethnicity group for 2012 63

Figure 7: Labour and birth branch diagram for all women with multiple pregnancies for 2012 75

Figure 8: Mode of birth group rates for years 1997 to 2012, for all C&C DHB facilities combined 85

Figure 9: Labour and birth branch diagram for all women for 2012 87

Figure 10: Labour and birth branch diagram for primiparous women for 2012 88

Figure 11: Labour and birth branch diagram for multiparous women without previous CS for 2012 89

Figure 12: Labour and birth branch diagram for multiparous women with previous CS for 2012 90

Figure 13: Mode of birth group by age group for all women for 2012 91

Figure 14: Mode of birth group by age group for primiparous women for 2012 91

Figure 15: Mode of birth group by age group for multiparous women without previous

CS for 2012 92

Figure 16: Mode of birth group by age group for multiparous women with previous CS for 2012 92

Figure 17: Labour and birth branch diagram for singleton breech presentations for 2012 97

Figure 18: Perinatal mortality rates (perinatal and adjusted) for years 2005 to 2012 124

figures


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1.1 PurPose of this rePort

The purpose of this WHS Annual Clinical Report is:

• To document the services provided within the Maternity and Gynaecology Services at C&C DHB during the calendar year.

• To demonstrate trends in the population groups, service provision, interventions and outcomes over time.

• To report on the implementation of the Maternity Quality Safety Programme and list the planned actions and expected outputs.

1.2 rePort structure

This publication continues the series of annual clinical reports produced by the WHS with the first report in the series published in 2004.

The chapters in this report contain discussion and analysis of data displayed in tables and figures. Additional data tables relevant to a particular section are listed in the Appendices section at the end of the report. The report has the following chapters.

Chapter 1: introduction

This chapter lists the purpose and structure of the report, and describes the data sources and methodology.

Chapter 2: Service provision

This chapter describes the services provided within the Maternity and Gynaecology Services at C&C DHB.

Chapter 3: Quality, health and safety

The Maternity Quality Safety Programme is described. Reportable event numbers are reported as are the recommendations of two serious event reviews. Common themes are identified in women’s feedback and the outcomes of those clinical audits completed in 2012 highlighted.

Chapter 4: learning development and research

Learning development and education programmes within the WHS and allied educational organisations are described.

1. introduction


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Chapter 5: Summary statistics for 2012

Summary numbers for the 2012 calendar year are presented. These include birth numbers, maternal demographics and outcomes, neonatal outcomes, and gynaecology outcomes. Clinical indicators for Obstetrics and Gynaecology as defined by the Australian Council on Healthcare Standards (ACHS) are listed.

Chapter 6: Antenatal and postnatal clinics

Obstetric antenatal and postnatal outpatient clinics are discussed. Attendance numbers at these clinics are tabulated. The obstetric diabetic clinic, the anaesthesia pre-assessment clinic and pregnancy parenting and education classes are discussed in detail.

Chapter 7: Maternity Service demography

This chapter contains the demographic characteristics of the women who gave birth in 2012. Information is presented on domicile, age, ethnicity, parity, smoking status at the time of booking, body mass index and lead maternity carer (LMC) at booking. No analysis of socioeconomic status by deprivation score is possible from the current database.

Chapter 8: Antenatal complications

Antenatal complications such as preterm birth, multiple pregnancy, diabetes in pregnancy and cardiac problems in pregnancy are discussed. The Maternal Fetal Medicine service and the Ultrasound scan service are described.

Chapter 9: labour and birth

This chapter presents labour and mode of birth numbers and analyses these by maternal age, ethnicity and parity group. Induction of labour and breech presentation are discussed. A report on obstetric anaesthesia is provided by the Department of Anaesthetics and Pain Management. Reports are presented from the primary birthing facilities at Kenepuru and Paraparaumu Maternity Units. Outcomes for select primipara (ACHS) are tabulated.

Chapter 10: labour and birth outcomes

Outcomes for perineal trauma and postpartum haemorrhage are discussed. Neonatal outcomes by gender, plurality, birth weight, gestational age and Apgar score are presented.

Chapter 11: postnatal care

Information is presented on a postnatal consumer satisfaction survey, infant feeding, newborn hearing screening, and admissions to the Neonatal Intensive Care Unit (NICU).

Chapter 12: perinatal mortality

This chapter provides information and analyses those fetal and neonatal deaths that occurred in C&C DHB during 2012. Analysis is done by maternal age and ethnicity.

Chapter 13: Maternal mortality and morbidity

Information on maternal deaths over the last 10 years is discussed. Data reported to the Australasian Maternity Outcomes Surveillance System (AMOSS) on severe maternal morbidities is tabulated. Reasons for admission to ICU are listed.

Chapter 14: Gynaecology clinics

Gynaecology and colposcopy outpatient clinics are discussed. Attendance numbers at these clinics are tabulated. Reports are presented for the colposcopy services and Te Mahoe unit.

Chapter 15: Gynaecology services

Reports are presented for the gynaecology inpatient, endometriosis, urogynaecology and gynaecologic oncology services. Adverse gynaecological outcomes are discussed. The ACHS gynaecology clinical indicators are tabulated and discussed.

Chapter 16: Appendices

Extra data tables not presented in the main text of the report are tabulated here. Abbreviations, references and the ACHS clinical indicator definitions are listed.


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1.3 clinical indicators

The Australian Council on Healthcare Standards (ACHS) is an authorised accreditation agency with the Australian Commission on Safety and Quality in Health Care. The ACHS Clinical Indicator Program is a data collection and reporting service that assists organisations to measure and manage an aspect of clinical care. ACHS provide customised reporting enabling single health care organisations to compare their own performance to other similar organisations. The WHS has been using this system since 2003 to benchmark their performance.

Data was submitted to ACHS for both six month periods in 2012 for obstetrics, infection surveillance and gynaecology.

This is the third time we have tabulated peer group comparisons.

The clinical indicator results for the WHS for 2012 are presented in chapter 5 “Summary Statistics for 2012”,

and the detailed peer group comparison tables for 2012 are listed in the Appendices (Table 122, Table 123 and Table 124). The peer group comparisons contain our rate, the 99% confidence interval, the expected number of events and the number of excess events. These comparisons can be used to determine areas for improvement or reassurance regarding the existing level of performance.

The obstetric peer group comparison is for all organisations that have a NICU and / or more than 3000 births per year. Comparisons of C&C DHB rates against the overall ACHS peer group rates for the years 2010 to 2012 are presented in those chapters of the report to which they pertain.

The gynaecology peer group comparison is with all organisations submitting data in this category.

Detailed definitions of the ACHS clinical indicators are listed in the Appendices.

1.4 women and babies included in this rePort

The maternity section of this report includes maternal and infant data pertaining to women giving birth to babies at and beyond twenty weeks gestation at any of the three birthing facilities in the C&C DHB area during the 2012 calendar year. Also included are those women who were booked to give birth at a facility but had an unplanned home birth or gave birth en route to the birthing facility. Note that data for these women

and babies have not been included in previous annual reports. Data for years prior to 2012 for these “births before arrival” are now included in this report in all time series tables and figures.

The gynaecology section includes information on women who received care from the various gynaecology inpatient and outpatient services.


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1.5 data sources

The information in this report has been sourced from the following database systems.

• Maternity – from PIMS (Perinatal Information Management System)

• Maternal Anaesthesia – Department of Anaesthesia database

• Maternal Diabetes – PIMS and outpatient data from C&C DHB Patient Management Systems

• Maternal Fetal Medicine and Perinatal Ultrasound Scan Service – Viewpoint database

• Gynaecology – Outpatient data from C&C DHB Patient Management Systems, surgery data

extracted by the Decision Support Unit from the Patient Management System and Theatres ORSOS database, the Gynaecology Oncology database, and data from the Te Mahoe Unit database

• Quality, Health & Safety – Decision Support Unit and C&C DHB Patient Management Systems

The PIMS database is due for replacement within the next year. A new Maternity Clinical Information System (MCIS) will be implemented in all District Health Boards over the next few years. This is a National Health IT Board (Ministry of Health) project, and C&C DHB will be one of the first District Health Boards to change to the new national system.

1.6 data quality

Daily and monthly checks, queries and corrections are done on key data fields in the PIMS maternity database.

No formal audits have been undertaken to ascertain the quality or accuracy of the data entered into PIMS and other data systems, or provided in the individual reports which have been included here. We expect that there are limitations in the quality of some of the data in this report.


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1.7 data analysis

The data have been extracted and analysed using Microsoft Access and Excel. Data tables are formatted with either column or row percentages as indicated. Numbers are entered in columns denoted by the abbreviation “No.” and percentages in the columns denoted by “%”. The table captions indicate the years for which the data are tabulated.

In 2005 PIMS was implemented at the Paraparaumu Maternity Unit thus completing 100% collection of all births occurring within C&C DHB birthing facilities.The following assumptions have been made for the maternity data:

• The maternal age was calculated as at the time of the birth.

• All babies born from 20 completed weeks gestation and/or over 400 grams birth weight are included.

• For multiple pregnancies, only one mode of birth has been assigned to the mother, with the mode prioritized as caesarean, forceps, Ventouse, vaginal breech, then normal vaginal birth.

• Maternal obstetric and caesarean section (CS) history was determined from the ‘Parity’ and ‘CS history’ data fields in PIMS.

• Vaginal breech births have been included in the assisted vaginal birth group.


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2.1 maternity services

C&C DHB provides primary, secondary, tertiary and regional maternity services.

national services

The Maternal Fetal Medicine (MFM) unit at Wellington is part of the New Zealand MFM Network and provides nationwide care for high risk obstetric and fetal medicine, in concert with Christchurch and Auckland.

Maternal

The WHS is a tertiary level facility that accepts referrals from around New Zealand if capacity is exceeded in other tertiary units.

• The care and management of women with major cardiac disease including those who may require bypass surgery during pregnancy is referred to Auckland.

• Women with liver disease requiring transplant would also be cared for in Auckland.

Fetal / neonatal

The WHS accepts maternal transfers and NICU provides intensive care to babies from other New Zealand DHBs, particularly if their units are at capacity.

• The WHS does not undertake laser ablation for twin to twin transfusion.

regional services

Maternal

The WHS is responsible for tertiary maternal transfers from the central region of New Zealand, which includes Whanganui, Hawkes Bay, Mid-Central, Wairarapa, Hutt Valley, and Nelson-Marlborough DHBs.

The multidisciplinary diabetes antenatal clinic provides tertiary pre-conception counseling and pregnancy care to women with complex needs residing in the Hutt Valley and Wairarapa DHBs.

A multidisciplinary team provides care for women with complex cardiac conditions from the lower North Island including Hutt Valley, Wairarapa, Mid-Central, Whanganui and Hawkes Bay DHBs.

Fetal

MFM is a tertiary service whose catchment area includes the lower North Island and the upper South Island. An MFM outreach clinic is held in Taranaki DHB once a month.

The MFM service is also a training centre for sub-specialists in MFM.

MFM specialise in:

• Management and supervision of high risk screening from screening programmes

2. service Provision


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• Provision of antenatal diagnosis by amniocentesis, cordocentesis and chorionic villous sampling

• Management of major fetal anomalies

• Transfusions for red blood cell incompatibility

• Multifetal reduction

• Management of fetal cardiac anomalies that are unlikely to require immediate cardiac surgery

• Management of other cardiac disease

• Management of fetal genetic conditions in pregnancy

• Management of fetal surgical conditions in pregnancy

• Telemedicine consultation for the central region.

newborn

The Neonatal Intensive Care Unit (NICU) is located on Level 4 of the Wellington Regional Hospital adjacent to the Delivery Suite and Ward 4 North. NICU provides heath care services to premature and sick newborns. NICU works closely with the WHS.

NICU is contracted to provide:

• Level 3 neonatal intensive care including surgery, to the central region of New Zealand including the Hutt Valley, Wairarapa, Mid-Central, Hawkes Bay, Whanganui and Nelson-Marlborough DHBs. Current capacity is 20 level 3 cots.

• Level 2 neonatal care for the C&C DHB area covering Wellington, Porirua and the Kapiti Coast. Current capacity is 20 level 2 cots.

• NICU provides a regional service for babies requiring surgery and laser treatment for retinopathy of prematurity.

The newborn service also includes the following support services:

• Neonatal Emergency Transport Service

• Neonatal Homecare Service

• Specialist Lactation Service

• Paediatric Outpatient Service

• Child Development Unit (as part of the Child Health Service).

district services

The maternity service is comprised of:

• Delivery Suite

• Ward 4 North - one antenatal and two postnatal pods

• Acute Assessment Unit

• Kenepuru Maternity Unit

• Paraparaumu Maternity Unit

• Specialist antenatal outpatient clinics held at Wellington, Kenepuru and Paraparaumu and include:

> High risk antenatal

> Secondary antenatal consultation

> Diabetic antenatal

> VBAC / OASIS

> MFM consultation clinic

> MFM clinic

> Obstetric anaesthesia pre-assessment clinic.

Wellington Regional Hospital - Delivery Suite

Delivery Suite is a modern, purpose-built, state-of-the-art birthing suite catering for the needs of women and their families. There are 12 self-contained, fully equipped labour and birthing rooms where care can be provided to low and high risk women alike.

An operating theatre and post anesthetic care unit are located within the Delivery Suite and it is conveniently located on the same floor as the NICU and Ward 4 North.

Each birthing room has its own pool or bath providing women with the opportunity to birth in water. Pain relief options include entonox, pethidine, epidural and remifentanyl patient controlled analgesia.

One to one labour and birth care is provided by core midwives to women whose LMC is the Primary Care team, the High Risk team, MFM or the Diabetic service.

Core midwives provide labour and birth care to women who have booked under the care of a private obstetrician (Shared Care) and to women whose care has been transferred to secondary or tertiary services following the identification of a problem. Care can also be provided by core midwives to midwife LMCs who require relief.


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Wellington Regional Hospital - Ward 4 north Antenatal and postnatal

The antenatal and postnatal ward is divided into three pods.

Pod B is an antenatal pod with 15 beds. Two flexi beds are shared with inpatient gynaecology. The Pohutakawa room is purpose built and available for women who have experienced a peripartum loss.

Pods C and D each contain 12 postnatal beds. Postnatal care is provided to primary, secondary and tertiary women and their babies. Daily breastfeeding classes are held on the ward.

A lactation consultant is available Monday to Friday for additional support and advice for those women with complex breastfeeding issues.

All women and babies who have been reviewed and are clincially stable have the option of transferring to one of two outlying maternity units at Kenepuru or Paraparaumu.

Acute Assessment unit

The Acute Assessment unit is based on Level 3, Wellington Regional Hospital. Acute Assessment is open Monday to Friday from 8am to 6pm and provides acute care to those women who are more than 20 completed weeks pregnant or recently postpartum. Pregnant women may require pre-eclamptic screening, assessment of abdominal pain, vaginal bleeding, possible deep vein thrombosis and postpartum infections including mastitis, wound reviews and endometritis. After hours these assessments are carried out in Delivery Suite.

Kenepuru Maternity unit

Kenepuru Maternity Unit is a primary birthing facility located in the Kenepuru Community Hospital at Porirua. This unit is situated 20 to 30 minutes drive north of Wellington.

Kenepuru Maternity Unit provides services to women living in the Porirua Basin who birth at the unit or who birth at Wellington Regional Hospital and transfer postnatally.

The Unit:

• Is an eight bed facility with two birthing rooms and six postnatal rooms.

• Is open and staffed by core midwives 24 hours a day throughout the year. This is a sole charge position.

• Antenatal, labour and birth care is provided by the women’s LMC.

• Postnatal care is provided by experienced core midwives in partnership with the women’s LMC.

• Core midwives provide support and assistance for labouring women, newborn babies and LMCs as and when required.

• A secondary antenatal consultation clinic is run once a week allowing women to be seen in their own community.

paraparaumu Maternity unit

Paraparaumu Maternity Unit is a primary birthing facility situated in a wing of the Kapiti Health Centre in Paraparaumu. The unit is situated approximately 45 to 60 minutes drive north of Wellington.

Paraparaumu Maternity Unit provides services to women living on the Kapiti Coast who birth at the unit or who birth at Wellington Regional Hospital and transfer postnatally.

The Unit:

• Has one birthing room with a birthing pool and two postnatal rooms.

• Is open and staffed by core midwives 24 hours a day throughout the year. This is a sole charge position.

• Antenatal, labour and birth care is provided by the women’s LMC.

• Postnatal care is provided by experienced core midwives in partnership with the women’s LMC.

• Core midwives provide support and assistance for labouring women, newborn babies and LMCs as and when required.

• A secondary antenatal consultation clinic is held once a fortnight allowing women to be seen in their own community.

• Antenatal and birth preparation classes are also provided for those women choosing Paraparaumu Maternity Unit.

Midwifery teams

The limited availability of midwife LMCs has meant that C&C DHB have been providing primary maternity care to some women. The Primary Care team is a group of midwives who provides antenatal and postnatal care to these women. Antenatal clinics are held at Wellington and Kenepuru Hospitals (Monday to Friday). Labour


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and birth care is undertaken by core midwives in Delivery Suite.

The Shared Care team provides midwifery antenatal and postnatal care with a private obstetrician. Antenatal clinics are held at the obstetrician’s rooms. Labour and birth care for these women is undertaken by core midwives in Delivery Suite.

The High Risk team midwives provide midwifery antenatal and postnatal care to women attending the Diabetic, MFM, and High Risk clinics, on occasion they also care for women attending secondary consultation clinics at C&C DHB. Labour and birth care is undertaken by core midwives in Delivery Suite. The High Risk midwives also provide postnatal care to women from the Kapiti Coast and outside the Wellington region who have recently given birth and the baby requires admission to NICU.

newborn Hearing Screening Service

The Newborn Hearing Screening service offer hearing screening to all babies born at C&C DHB. Babies are screened in the postnatal pods at Wellington Regional Hospital, and at Kenepuru and Paraparaumu Maternity Units. Outpatient clinics are also available at each of these facilities.

community services

Antenatal education

Free pregnancy and parenting education classes are provided at Wellington and Kenepuru Hospitals to women who are not currently accessing antenatal education. These classes were set up to address inequities of access to antenatal education programmes for Mäori, Pacific People, women from ethnic minorities and those on a low income. The objective is to improve health outcomes for these women and their families and to increase the number of first-time pregnant women accessing C&C DHB funded antenatal education.

Breastfeeding education and support

Free breastfeeding classes are provided by the Clinical Midwife Specialist Lactation, at Wellington and Kenepuru Hospitals on a monthly basis. The classes are run over two days.

Chinese breastfeeding classes are run in conjunction with Hutt Valley DHB at Petone every two months and are run over two days.

The Community Breastfeeding Team is comprised of the community lactation coordinator, Pacific lactation consultant and two Pacific breastfeeding support workers who provide lactation consultancy support in the homes of women and at the Breastfeeding Centre.

A particular focus of the Community Breastfeeding Team is Mäori and Pacific women and those with complex needs. The Breastfeeding Centre is situated in the Whanau Centre in Cannon’s Creek, Porirua, and is a drop in centre open on Thursdays and Fridays from 10am to 2pm.


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2.2 lead maternity carer services

midwife lmcs

Lead Maternity Carers in the Wellington region are almost exclusively midwife LMCs. There are a small number of obstetricians and no general practitioners providing LMC care.

Midwife LMCs are self employed and tend to work in supportive group practices. Midwife LMCs provide care for pregnant women residing throughout the Wellington region from as far north as Otaki to Island Bay in the south. Midwife LMCs have an access agreement with C&C DHB that allows them to provide care to women in the hospitals’ facilities.

Women choose a midwife LMC and enter into a partnership with continuity of care planned accordingly. The midwife LMC is responsible for the planning and provision of maternity services at no cost to the woman.

Antenatal care is provided in the community either in clinic rooms or at the woman’s home. The woman is supported to birth wherever is appropriate for her (hospital or home) and postnatal care is provided for up to six weeks in the woman’s home.

If the woman’s care moves out of the midwife’s scope of practice then care is negotiated with the obstetric team to ensure appropriate management and continuity meet the woman’s needs. These three way discussions usually take place in antenatal consultation clinics held in Paraparaumu, Kenepuru or Wellington Regional Hospital.

LMC midwives are paid via Section 88 of The Public Health and Disability Act. Payments are made at the completion of each module of care.

Each year a number of midwife LMCs mentor newly graduated midwives into LMC practice through the Midwifery First Year of Practice Programme whereby ensuring growth and capacity in the community setting.

obstetrician lmcs

There are two obstetric LMCs in the Wellington area. They provide antenatal care in community clinics and employ midwives to provide antenatal and postnatal midwifery care. Labour care is provided by core midwives. LMC obstetricians are also funded via Section 88 but there is an additional charge to the woman for this private service.

2.3 sPecialist maternal mental health service

The specialist maternal mental health service (SMMHS) is the only C&C DHB service delivering maternal mental health services. The team consists of 5.3 full time equivalent staff who provide clinical services to women residing in the Wellington, Porirua, Kapiti Coast and Hutt Valley areas.

The SMMHS also provide case consulting and training to all central region DHBs including the Hutt Valley, Wairarapa, Hawkes Bay, Whanganui, Mid-Central and Tairawhiti.

The criteria for referral to the SMMHS are the existence of a moderate to severe mood or psychotic

disorder which is associated with pregnancy. Referrals are accepted antenatally and up to nine months postpartum. The average wait-time for women to be seen by the SMMHS is two weeks.

In 2012 there were 267 referrals made to SMMHS. One hundred and thirty three referrals (49.8%) were made by general practitioners, and midwives referred 43 women (16.1%). Ninety-one referrals (34.1%) were made by DHB clinicians including obstetricians, social workers and other community mental health services. A similar number of women were referred in 2011.


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2.4 gynaecology services

C&C DHBs gynaecology service provides care to women referred by general practitioners or other specialties, who have gynaecological symptoms, dysfunctions and / or diseases of the female reproductive system or genital tract.

regional services

C&C DHBs gynaecology service provides:

• Gynaecological oncology services and support to the Mid-Central, Hawkes Bay, Wairarapa and Nelson-Marlborough DHBs. The Christchurch gynaecology oncology service provides collegial support and backup to the gynaecology oncology team in Wellington.

• An extended regional service for all vulval skin disorders.

• Urogynaecology support to Mid-Central and Nelson-Marlborough DHBs.

Wellington Regional Hospital - te Mahoe unit

Te Mahoe provides comprehensive pregnancy counselling as well as first and second trimester termination of pregnancy services for women between 5 and 19+1 weeks gestation.

The Te Mahoe social work / counselling team provides as appropriate the following services:

• Pre-decision counselling

• Pre-abortion couple/family counselling

• Post abortion counselling

• Pregnancy or pregnancy loss counselling for woman, couples and family

• MFM counselling services are available upon request

• Support services referral

• Further counselling if required

Te Mahoe is contracted to provide termination of pregnancy services to the following DHBs:

• Mid-Central – first and second trimester service

• Whanganui – first and second trimester service

• Hutt Valley – first and second trimester service

• Tairawhiti – second trimester service

• Hawkes Bay – second trimester service

• Nelson-Marlborough – second trimester service

• Wairarapa – second trimester service.

district services

The gynaecology service is comprised of:

• Ward 4 North – one gynaecology pod

• Acute Assessment Unit

• Day stay surgery

• Specialist gynaecology outpatient clinics held at Wellington, Kenepuru and Paraparaumu and include:

> General gynaecology

> Gynaecology oncology

> Gynaecology skin

> Urogynaecology

> Colposcopy

> Infertility (non-tertiary)

> Endometriosis.

Wellington Regional Hospital - Ward 4 north inpatient Gynaecology

Ward 4 North Pod A provides the inpatient gynaecology acute and elective services for C&C DHB. The service has provision for 14 beds with twelve beds in Pod A and two in Pod B. There are also two flexi-beds in Pod B for use as and when required.

Pod A downsizes to ten beds on weekends and public holidays. The gynaecology pod also provides an acute after hours assessment service for women requiring urgent attention.

Admissions to Pod A include acute non-surgical gynaecology (including women with chronic pain), elective gynaecology surgery, urogynaecology surgery, tertiary gynaecology oncology services, and acute early pregnancy care for women who are less than 20 weeks pregnant, readmissions greater than 10 days postpartum and after hours Te Mahoe inpatient admissions.


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Surgical Admissions units

The Surgical Admissions Unit (Wellington Regional Hospital), the Kenepuru Surgical Medical Unit and the Surgical Medical Ward (Kenepuru Hospital) provide additional beds for elective gynaecology surgery.

All women are admitted as day of surgery admissions to the surgical admissions units, day cases will be discharged home from the second stage recovery area.

Women having surgical procedures requiring a longer length of stay are transferred postoperatively to the inpatient wards.

operating theatre Availability

There are 10 half day operating lists each week at Wellington Regional Hospital for elective gynaecological surgery, two of these lists are designated for gynaecological malignancy. There are also two lists each week at Kenepuru for less complex women where a large proportion of surgeries are laparoscopic (key-hole) minimally invasive day case procedures.

Acute Assessment unit

The Acute Assessment unit is based on Level 3, Wellington Regional Hospital. Acute Assessment is open Monday to Friday from 8am to 6pm and provides acute care to those women who are not

pregnant and those who are pregnant but less than 20 completed weeks gestation. Women are seen in Acute Assessment with undiagnosed abdominal pain, for review of a Bartholins abscess, acute dysfunctional uterine bleeding, postoperative complications, suspected or confirmed ectopic pregnancy, hyperemesis gravidarum and miscarriage management.

A small number of women require inpatient admission but many are managed by regular outpatient review or booked for day case surgery. Women requiring urgent after hours assessment are seen in Ward 4 North, Pod A.

The Acute Assessment unit is staffed by two nurse-midwives, a house officer and a registrar. From October 2012 a change to the Resident Medical Officers (RMO) roster resulted in a registrar being allocated to the Acute Assessment unit from Monday to Friday. This registrar is responsible for the acute theatre list for women requiring evacuation of retained products of conception (ERPOC). They also help with the triaging of referrals being sent to the service by answering calls from GPs, LMCs and other services within the hospital about early pregnancy or gynaecology issues.

2.5 ultrasound scanning service

The perinatal ultrasound service plays a critical role in the evaluation and monitoring of women with gynaecological and obstetric problems.

The gynaecological team is supported through the provision of detailed pelvic scanning for patients attending clinics and those admitted acutely.

The service provides imaging support to high risk antenatal and diabetic clinics for regular monitoring of these at-risk pregnancies.


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2.6 quality, health and safety

Improving healthcare outcomes and patient safety is a priority for C&C DHB. As part of the DHB Clinical Governance infrastructure the Women’s Health Clinical Governance Group ensures that systems are in place to enable managers and clinicians to share responsibility and accountability for patient safety, to minimise risks to consumers and to continuously monitor and improve the quality of clinical care.

This is supported by a Quality Facilitator (0.7FTE), whose role is to coordinate the Maternity Quality Safety Programme and assist in the effective application of the C&C DHB Quality Framework across the WHS.

Figure 1: c&c DhB qualiTy FrameWork Diagram


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2.7 university of otago

Collaborations in research between the Department of Obstetrics and Gynaecology, University of Otago (Wellington) and C&C DHB are ongoing, with university staff supporting and mentoring Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) Integrated Training Programme (ITP) trainees. University staff are also involved with registrar teaching and training.

Medical students are trained via the University of Otago, Wellington School of Medicine. In their 5th

and 6th years they have clinical placements and training within the WHS.

Collaborations already exist between members of the University of Otago and the Women’s Health Research Unit (WHRU, Department of Primary Care), the New Zealand College of Midwives, Victoria University of Wellington (VUW), and the WHS clinical audit and research committee.

2.8 victoria university of wellington

The Graduate School of Nursing, Midwifery and Health (GSNMH) is located at Wellington Regional Hospital and is part of Victoria University's Faculty of Humanities and Social Sciences. The school specialises in postgraduate qualifications for nurses, midwives and health professionals. Qualifications range from postgraduate certificates and diplomas to Master's degrees and PhDs.

The GSNMH vision is to shape the health and future of Aotearoa/New Zealand by:

• leading to improvements in health outcomes

• building leaders in research, policy and practice

• providing expertise in nursing, midwifery and health.

The GSNMH programmes have been developed through extensive consultation with clinicians,

managers, current and potential students, and are internationally benchmarked. The framework for the qualifications has a straightforward yet flexible structure of progression. Through a “building blocks” approach our programmes will enable clinicans to gain qualifications that reflect their knowledge, skills and clinical experience.

Over the last few years many C&C DHB nurses and midwives have commenced and completed study programmes at VUW. The WHS has a close relationship with the GSNMH and has provided clinical placement for midwives engaged in the Health Workforce New Zealand (HWNZ) funded postgraduate certificate in Midwifery (Complex Care) since 2009. In 2012 C&C DHB had approximately 20 midwives engaged in study and the Associate Director of Midwifery, who is seconded to the GSNMH, completed a PhD in Midwifery.


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2.9 otago Polytechnic

The Bachelor of Midwifery at Otago Polytechnic leads to registration as a midwife in New Zealand. Meeting the Midwifery Council of New Zealand’s new standards for midwifery education, it also aligns with the midwifery education requirements of the European Union and the United Kingdom.

Otago Polytechnic uses a blend of face to face and distance-learning allowing students to study where they live. There are a number of satellite sites available throughout the country, including Wellington, that are staffed with midwifery lecturers who provide individual

support, run tutorials and coordinate local midwifery practice. Otago Polytechnic midwifery students from the Wellington satellite have had their clinical placements within C&C DHB maternity services for three years now and several graduates have joined our staff through the one year graduate midwife orientation programme. C&C DHB welcomes the opportunity to be involved in supporting locally grown midwives and look forward to seeing them flourish as practitioners of the future.


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3.1 maternity quality safety Programme (mqsP) governance and objectives

background

In 2009, the New Zealand Government agreed to the development of the Maternity Quality Initiative, including work to improve the collection and reporting of maternity data. Representatives from midwifery, obstetrics, anaesthesia, paediatrics, general practice and maternity consumers worked together with the Ministry of Health to develop the National Maternity Quality and Safety Programme (MQSP).

In 2012, the MQSP was rolled out across all DHBs supported by the development of the New Zealand Maternity Standards, New Zealand Maternity Clinical Indicators, the Revised Referral Guidelines and Maternity Service Specifications.

The MQSP involves ongoing, systematic review by local multidisciplinary teams that work together to identify potential improvements to maternity services and work to implement those improvements. The programme is driven by local midwifery and medical leaders working together, with consumers, midwife LMCs and other community groups to monitor and improve maternity care at C&C DHB.

The intent of the programme is to bring together professional and consumer stakeholders to collaboratively monitor and improve maternity care for women, their babies and their families.

objectives

In April 2012 the WHS outlined their planned approach to ensuring that a comprehensive MQSP was established to ensure the ongoing quality improvement and systematic review of maternity services.

The WHS objectives were to:

• Ensure representation and involvement of midwife LMCs and primary care providers in MQSP improvement activities.

• Improve mechanisms for the discussion and dissemination of data, guidance or guidelines, innovative practice, new research and local initiatives to midwife LMCs and other community-based maternity practitioners.

• Ensure consumer representation and involvement in MQSP improvement activities.

• Improve on and support seamless, collaborative maternity care with integrated hospital and community-based clinicians and services.

• Improve communication and maternity care teamwork across the region.

3. quality, health & safety


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governance structure

The WHS has a governance structure that has been in existence and working effectively for a number of years. The structure consists of monthly multidisciplinary meetings that focus on quality and risk review, clinical audit and research and overall clinical governance.

The MQSP is governed by a Maternity Quality and Safety Programme Governance group, who report to the WHS Clinical Governance group. This multidisciplinary governance group includes the WHS

operations manager, clinical leader obstetrics, associate director of midwifery, quality facilitator surgery women and children’s directorate, two midwife LMC liaison representatives (including a Mäori and Pacifica focus), two maternity consumer representatives, and a Mäori representative (see attached Governance Structure). Representation from other health professionals will be invited as required (for example, a neonatologist).

The MQSP Governance group meets monthly to oversee and guide the implementation of the programme.

Figure 2: Whs governance sTrucTure


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mqsP strategic Plan deliverables 2012

In 2012 a gap analysis was undertaken of the current quality improvement systems within C&C DHB and the WHS. An implementation plan was subsequently developed that provided the MQSP with specific actions, deliverables, timelines and measures to address the identified gaps. This was summarised in the WHS strategic plan that was submitted to the Ministry of Health and approved in September 2012.

mqsP deliverables achieved in 2012

Setting up the overarching multidisciplinary MQSP Governance group within WHS:

• Ensuring Mäori and Pacific representation is included on the MQSP Governance group

• Ensuring that consumer representation is in place as per the Governance groups agreed Terms of Reference

• Ensuring that Midwife LMC representation is in place as per Governance groups agreed Terms of Reference

• Facilitating linkages between all community and hospital-based practitioners, consumers and advocacy groups

• Budget approved by Governance group and endorsed by C&C DHB general manager and chief executive Planning and Funding

• The first MQSP Governance group meeting was convened on 24 July 2012.

Service delivery was strengthened by the following quality and safety initiatives.

• Additional resources are in place to support the current monitoring systems for more timely SAC 1 and SAC 2 event reviews. Midwife LMCs and maternity consumers will be co-opted where and when appropriate.

• Senior medical officers who are on call for delivery suite and the acute services are no longer assigned concurrent clinical responsibilities and their allocated time has increased from four to eight hours.

• Other changes made to the medical roster include increasing the number of antenatal clinics and the availability of senior medical staff during post surgical rounds.

• Implementation of shared or interdisciplinary training and education opportunities (including the management of obstetric emergencies).

• In addition to the diabetic antenatal clinic held in Wellington a second diabetic antenatal clinic commenced at Kenepuru Hospital. The addition of this clinic has seen the “did not attend” rates reduce significantly.

• Work has been undertaken with the DHB psychologist to evaluate the wellbeing of relationships between midwives and obstetric staff within the DHB. A six monthly interface meeting between senior midwives and senior medical staff has been formalised to improve communication and an escalation plan has been put in place to provide a system for contacting additional senior medical staff if required urgently. The psychologist has also worked with clinicians of the WHS to optimise interactions at the perinatal education meeting to encourage functional communication.

• Following reportable event and adverse outcome trend monitoring a safe sleep campaign for babies was initiated. Micro-teaching sessions were undertaken with midwifery staff and an on-line audio-visual education tool called “through the tubes” installed. Safe sleeping banners, posters and cot cards were sourced and standardised throughout the WHS. A retrospective clinical audit looking for evidence of safe sleeping discussions with parents has commenced and a prospective re-audit will commence in March 2013 to assess the effectiveness of this campaign.

• The Maternity Support Services Specification was rewritten with the assistance of the MQSP Governance group.

• Information pertaining to ACHS (2011) and Ministry of Health (2009) clinical indicators were sent to all C&C DHB maternity staff including links to the Health Quality and Safety Commission website.

• An anonymous postnatal inpatient survey was undertaken during September. An explanation of how the survey was conducted, the response rate and copies of the survey results were sent to the MQSP Governance group.

• A fully automated point of care lactate meter was sourced for delivery suite. The meter is easy to use and the results are more reliable. Results are able to be directly uploaded into the Medical Applications Portal.


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• A fully automated point of care urinalysis machine was sourced for women’s clinics. The use of the machine removes subjectivity, enhances consistency and reduces false positive results. Results are able to be directly uploaded into the Medical Applications Portal.

mqsP deliverables to be undertaken 2013

There are several major pieces of work to be undertaken by the service in 2013.

• To ensure the collection of comprehensive and consistent maternity data, the Ministry of Health will be implementing a new national Maternity Clinical Information System. The successful vendor Clevermed and the National Clinical Reference group are currently making the system suitable for New Zealand maternity services. C&C DHB has been selected as an early adopter site for the Clevermed system and anticipates a “go live” date of November 2013.

• A multidisciplinary implementation group will determine what is required from a DHB perspective to enable the Clevermed system to “go live”.

• Implementation and training for the Clevermed system will be required for all hospital based medical and midwifery staff and LMCs using the system throughout C&C DHB’s maternity services.

• Implementation and training of core midwives in the use of the lactate meter.

• Following receipt of the WHS ACHS clinical indicator report (2012) and New Zealand maternity clinical indicator report (2011) a multidisciplinary working group will be convened to improve the current induction of labour (IOL) policy and process. This will include:

- The communication and assessment process required to book an IOL.

- Communication required with the on call registrar regarding the woman’s cervical status prior to prostaglandin insertion.

- Handover from LMC to core midwifery staff.

- Handover of clinical responsibility to the on call registrar and consultant when an IOL is being performed overnight in Pod B.

- Clarification of the policy for CTG monitoring in early labour.

- Regular fetal surveillance and CTG monitoring meetings will be reinstated.

- The outcomes of women who received cervical priming in Pod B during 2012 will be audited.

- Consideration will be given to the use of a Foley catheter for cervical ripening.

• The second clinical indicator that the service intends to review pertains to blood transfusion during the birth admission.

- A review of the WHS postpartum haemorrhage rates will be undertaken.

- A clinical audit will also be undertaken looking at whether iron deficiency anaemia prior to an elective or emergency caesarean section affects women’s blood transfusion requirements and recovery outcomes postoperatively.

• The credentialing for all resident medical officers will be formalised earlier in their placement.

• Evaluate the changes made in October 2012 to the medical roster.

• The content and layout of the 2012 WHS annual clinical report will be revised to expand upon previously identified areas for improvement.

• Implement mechanisms for discussion and dissemination of data, guidance or guidelines, innovative practice, new research and local initiatives to midwife LMCs and other community-based maternity practitioners.

• Local data communication out to community including consultation with Iwi. This deliverable was carried over from 2012.

• An anonymous antenatal, intrapartum and postnatal inpatient satisfaction survey will be undertaken.


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3.2 rePortable events

At C&C DHB all healthcare incidents are entered into an electronic reportable events system (RL6). Lower level events are generally resolved at the Charge Midwife / Nurse Manager level. All events are reviewed at the Quality and Patient Safety meeting the following month. There were 213 reportable events entered during 2012.

Figure 3: numBer oF reporTaBle evenTs By monTh For 2012, WiTh a linear TrenD line

30

25

20

15

10

5

0Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12

3.3 adverse serious (sac2) and sentinel (sac1) events

Two reportable events were reviewed and considered serious (SAC2) events. The first occurred in June and the second in August. Both events were thoroughly investigated using appropriate review methodologies and the following recommendations were made:

• Re-educate all staff regarding C&C DHB’s “Obstetrics Surgery / Procedures Trial” policy.

• Review obstetric registrar orientation and credentialing to ensure that levels of competence, supervision and teaching required are widely known to on-call obstetricians.

• Review the indications for initiating the obstetric senior medical officer escalation plan.

• Review the C&C DHB “Induction of Labour” policy and process.

• Send a memo to all WHS clinicians in acute areas reminding them of the importance of attending handover.

• Ensure that all medical staff who see women who are being assessed for VBAC antenatally, clearly document the management plan which has been agreed with the couple and the LMC.

• Clearly document any specific issues or concerns identified during the antenatal period as this will assist staff when the LMC is not present.


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• Undertake a documentation audit of the current VBAC consenting practices. Once common themes are identified registrar teaching sessions will be initiated.

All recommendations are assigned to named clinicians. Progress is monitored monthly via the patient quality and safety meeting until all actions have been completed.

3.4 adverse maternity outcomes

For a number of years the maternity service has collected information on adverse maternity outcomes. The adverse maternity outcome data collection form requires completion by clinicians prior to transferring women and babies to the postnatal pods.

A specific list of variables allows the service to monitor trends. However if the clinician completing the adverse maternity outcome form is concerned about

some other aspect of care and requests a review then this information can be entered on the form. The adverse outcome rates are reported at the quarterly multidisciplinary quality forums and occur alongside reportable event reporting. In some “near miss” cases a learning opportunity is recognised and direct feedback is given to the appropriate person by either the clinical leader of obstetrics or the associate director of midwifery.

3.5 comPliments, comPlaints and hdc cases

The WHS regularly receives feedback about women’s experiences via the C&C DHB Patient Liaison Office and the Health and Disability Commissioner’s (HDC) Office. Feedback provides the WHS with an opportunity to learn about and improve the services we provide.

In 2012 the WHS received 150 written compliments. The two most consistently identified themes pertained to respect, dignity and support, and the standard of clinical care received. During this same period the service also received 49 complaints. The three most

common concerns raised by women related to the standard of clinical care they received, respect, dignity and support, communication and information. There were 2 HDC cases reported during this time.

All feedback received by the WHS is taken seriously and we seek to resolve all complaints in a fair and effective way. Concerns raised by women about aspects of the care they received may be discussed with clinicians on a case by case basis, or more generally via micro teaching sessions, perinatal education meetings, midwifery and quality forums.


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3.6 health and safety

All hazard registers and environmental inspections were completed as per health and safety schedules for all departments within the WHS. Monthly health and safety topics were displayed throughout the service and staff were encouraged to be cognisant of each month’s topic.

The WHS took an active role in the influenza vaccination campaign with a champion from gynaecology inpatients training as a vaccinator. Overall, the number of staff from within the WHS who were vaccinated showed some improvement.

Staff from within the WHS also took part in Earthquake Shake out day and on-line ChemWatch training to ensure that all chemical inventories are entered onto an electronic database.

significant health and safety issues

There were no significant health and safety issues identified during 2012.

3.7 audits

In 2012, 8 audits were approved by the clinical audit and research committee. Clinicians who submit a proposal to the committee do so on the understanding that they will be required to submit a copy of their final report to the committee upon completion and present their audit findings at a quality forum.

Three of the eight clinical audits approved in 2012 were completed that same year. Progress on the five remaining audits is monitored monthly and it is anticipated that all will be completed in 2013.

TaBle 1: clinical auDiTs approveD in 2012

Audit title Author

1.How many babies born between 35 and 37 weeks gestation are admitted directly to the postnatal ward and cared for as per policy Management of babies 35-37 weeks gestation or 2.0-2.5 kg on the postnatal ward?

Gail Austin (ACMM)Therese Hungerford-Morgan (Midwife)Angela Saunders (Registered Nurse)

2. Neonatal Weight Loss. Jennifer Petrovich Midwife

3. Induction of labour for suspected fetal macrosomia: are we adherent to current evidence based best practice standards?

Sam LepineObstetric Senior House Officer

4. Is the daily baby check for babies on the postnatal pods being completed once every 24 hours during their postnatal stay?

Pip PenheyMidwife

5. Is the current fetal femur length normative scale applicable to the New Zealand population?

Laura NeussUltrasonographer

6.Are safe sleep and sudden unexpected death in infancy (SUDI) education conversations with parents being undertaken and documented in hospital records?

Carol McCord Midwife

7. How many patients failed to complete a successful trial of void in 2011 and what factors contributed to this?

Kerri GunnRegistered Nurse

8. Review of anatomy scans detection rate of major cardiac abnormalities Jeremy TuohyObstetrician


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Clinical Audit one: how many babies born between 35 and 37 weeks gestation are admitted directly to the postnatal ward and cared for as per policy?

Midwives working in the postnatal pods are caring for considerably more late preterm low birth weight babies than they did in 2010. Overall compliance with the policy is very good.

The audit team recommended:

• Annual re-auditing to ensure maximum compliance with policy

• Developing a comprehensive observation chart for preterm low birth weight babies being cared for on the postnatal pods.

• Plotting baby weights on customised GROW charts to determine whether babies are growth restricted or constitutionally small.

Clinical Audit two: neonatal weight loss.

This audit identified that 15.9% of the babies audited were not weighed within the correct timeframe. Of those babies who were eligible for weighing prior to discharge 8.4% were not weighed. Weighing babies is a non-invasive assessment that can alert clinicians to potential problems that can be dealt with in a timely manner. Weighing can also identify lactation difficulties that with early correction, support and guidance could result in successful and ongoing lactation for most women.

The auditor recommended:

• Reminding staff about the correct timeframe when babies should be weighed

• Annual re-auditing to ensure maximum compliance with policy.

Clinical Audit three: induction of labour for suspected fetal macrosomia: are we adherent to current evidence based best practice standards?

There is no evidence that a systematic policy of labour induction for suspected fetal macrosomia in non-diabetic women can reduce maternal or neonatal morbidity.

The auditor recommended:

• Routine induction of labour (IOL) for suspected macrosomia is not recommended

• Vigilance on the part of both referrers and accepting clinicians in non-validated indications for induction

• Increased use of GROW charts

All reports and recommendations made are tabled at the clinical audit and research committee’s monthly meeting. All accepted recommendations are monitored monthly for progress.

3.8 controlled documents

In 2012 the Ministry of Health’s Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) were published. As a result of this publication a new protocol entitled “Emergency transfer from Kenepuru or Paraparaumu primary maternity facilities to Wellington Regional Hospital” was developed.

Document owners were notified of the new referral guidelines and the MQSP Governance group will ensure that all existing documents are aligned as and when they come up for renewal.

At the end of 2012 the WHS had:

• 190 policies, procedures, protocols and guidelines in use (including the obstetric quick references)

• 92 patient information brochures / sheets.

The obstetric and gynaecology HealthPoint web pages (www.healthpoint.co.nz) allow women to obtain up to date information on services the WHS provides 24 hours a day, 7 days a week. This information is reviewed regularly and can be downloaded onto a Smartphone or iPad.


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4.1 quality forum

The quality forum enables nursing, midwifery and medical staff to present the outcomes of interesting obstetric and gynaecology case reviews, adverse

outcomes, trend monitoring and the results of recently completed clinical audit activities. Attendance is voluntary and scheduled at three monthly intervals.

4.2 ranZcog integrated training Programme

RANZCOG offers postgraduate training in obstetrics and gynaecology. Membership / fellowship training involves six years of postgraduate hospital-based training and assessment. The first four years are called the ITP and the last two years are the Electives.

The four-year ITP includes the following:

• Rotation through a minimum of three different hospitals, with at least 12 months in a tertiary hospital and 6 months in a rural hospital

• Logged clinical work in obstetrics and gynaecology resulting in attainment of prescribed competency levels in specified procedures

• Utilising the resources of Trainee Connect via the online.ranzcog e-learning platform

• Experience in gynaecological oncology

• Assessment through various methods (both formative and summative).

In New Zealand the three regions for training are Northern, Central and Southern.

C&C DHB is part of the central rotation for ITP. Other hospitals in this rotation are in the Hutt Valley, Mid-Central and Hawkes Bay DHBs. C&C DHB is the tertiary centre that trainees rotate through. Each year Wellington also takes one or two first year ITP candidates.

C&C DHB has eight registrars at any given time at various levels of training. Senior registrars in their fifth and sixth year of training (electives) do sub-speciality training in the areas of infertility, MFM, gynaecologic oncology, laparoscopic surgery and urogynaecology.

4. learning develoPment and research


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At C&C DHB there are two training supervisors and a coordinator for central regional training. A teaching session is held once a week and the registrars partake in training and learning requirements stipulated by RANZCOG.

4.3 midwife educators

The midwifery education team consists of a clinical midwife specialist and two clinical midwife educators. A core midwife also supported the education team.

The midwifery educators facilitated and participated in 61 study days in 2012. The midwife educators coordinated the Graduate Midwifery Programme for eight midwives, the Return to Practice Programme for one midwife and provided orientation programmes for 27 midwives and nurses who were new to the service. Orientation days for new LMC midwives were also provided.

PromPt course

Three PROMPT (Practical Obstetric Multi-Professional Training) days were run by the clinical midwife specialist, the clinical leader obstetrics and the clinical leader obstetric anaesthesia. The course is designed to improve teamwork and communication during an obstetric emergency. Emergencies are simulated with the use of actors. The “emergencies” take place in the unit, using real equipment, ensuring that the simulation occurs in “real time”. The midwives and doctors practise in their normal clinical roles. Five courses were run in 2012. For the first time, two courses were delivered at the primary maternity units. Paramedics and call takers from Wellington Free Ambulance also participated at the days run in the primary maternity facilities.

One of the advantages of these days, is that systems that do not work when trialled are examined and rectified if at all feasible.

technical skills days for midwives

The Midwifery Council determines the content of these days and requires all midwives to attend two technical skill days over a three year period. The midwife educators develop these days in collaboration with

other midwife educators within the lower North Island region. Sixteen days were provided in 2012. These days are available to both core and LMC midwives.

core days for midwives and nurses

Fourteen core days were provided in 2012. These days consist of emergency management training, manual handling, adult CPR and newborn resuscitation. Attendance at this day is a compulsory annual requirement. 180 nurses and midwives attended these days in 2012.

cPr and newborn resuscitation

These days were designed to enable LMC midwives to achieve their annual CPR and newborn resuscitation requirements in accordance with the Midwifery Council recertification programme. Four courses were provided and forty three LMC midwives attended.

ePidural days for midwives

Three epidural study days were facilitated by the midwife educators and a specialist anaesthetist. Thirty seven core and LMC midwives attended.

newborn life suPPort course

Nine newborn life support courses were offered in 2012. These were coordinated by the NICU clinical nurse educator. The course is taught jointly by NICU staff and midwives from the WHS. Core and LMC midwives, nurses and doctors from NICU, and staff from other areas of the DHB who may require newborn resuscitation skills also attended the course.


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Perineal suturing workshoPs

Three perineal suturing workshops for midwives were run this year. These are open to both hospital and community based midwives. There were thirty six participants.

diabetes management for midwives

Two courses were facilitated by the clinical nurse specialist diabetes and a clinical midwife educator. This day was designed to give midwives a refresher on the pathophysiology of diabetes, and the current management of pregnant women with diabetes.

PrecePtor day for midwives

One day is provided each year to ensure that midwives understand the requirements of student midwives, graduate midwives, midwives returning to practice, and midwives commencing work within the WHS.

midwifery forums

Two midwifery forums were run in 2012. Guest speakers were invited. Ethical issues and difficulties encountered in midwifery practice were presented and discussed. Both core and LMC midwives attended these days.

the quality and leadershiP Programme for midwives

The quality and leadership programme is the midwifery career pathway. There are three domains, competent, confident and leadership. All midwives are considered to be in the competent domain, until they have applied to progress to the confident or leadership domain. In 2012 seven midwives progressed to the confident level and six midwives progressed to the leadership level.

4.4 graduate midwifery Programme

The graduate midwifery orientation programme runs for twelve months and is aimed at the midwife developing and consolidating their midwifery knowledge and practice within a supportive environment working across the scope of practice in primary, secondary and tertiary maternity services.

There is an initial two week orientation programme to start, and planned study days throughout the year and the graduate midwife rotates through our primary services, Kenepuru, Delivery Suite, and the antenatal/postnatal areas.

The programme is facilitated by a dedicated clinical midwife educator who is a clinical and non-clinical resource. In addition, each area has experienced

midwives who are assigned to support the graduate midwives during their orientation time for each rotation and continue to support them further in their day to day practice as they gain confidence.

Throughout the programme the graduate midwives participate in facilitated informal group discussions providing them with an opportunity to share experiences, ideas, good times and difficulties with their peers in a safe environment.

At the completion of the programme the graduate midwife participates in a formal appraisal.


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Key statistics for maternity, gynaecology, and the ACHS clinical indicators are documented here to give a “snapshot” of what happened in 2012. Brief analysis is

provided and more in-depth analysis is in the following chapters of this report.

5.1 Place of birth

There were 3920 babies born to 3850 women in 2012. 28 (0.7%) of these births were to women who had booked to give birth at a birthing facility but had an unplanned home birth or a birth in-transit before admission to a facility. 20 of the 28 “births before arrival” were subsequently admitted to Wellington Regional Hospital. There were five “births before arrival” admitted to Kenepuru Maternity Unit and three admitted to Paraparaumu Maternity Unit.

Planned home birth numbers are not collected in the DHBs maternity database. The New Zealand Ministry of Health collates these numbers based on LMC claims for service. The number of homebirths for 2012 is not currently available but is likely to be similar to the number in 2011 when there were 127 planned home births in C&C DHB. This number was 3.1% of the total births in 2011.

TaBle 2: place oF BirTh For The capiTal & coasT DhB region For 2012

Mothers Babies

Place of Birth No. % Place of Birth No. %

Wellington Delivery Suite 3450 89.6 Wellington Delivery Suite 3520 89.8

Kenepuru Maternity Unit 240 6.2 Kenepuru Maternity Unit 240 6.1

Paraparaumu Maternity Unit 132 3.4 Paraparaumu Maternity Unit 132 3.4

Births before arrival 28 0.7 Births before arrival 28 0.7

Total 3850 100 Total 3920 100

5. summary statistics for 2012


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See Table 111 for the place of birth numbers for the last 10 years 2003 to 2012. Table 112 has the number of births by birthing facility for 2003 to 2012, with the “births before arrival” included in the birthing facility to which they were admitted.

The number of births which occurred in 2012 were the lowest since 2005. There were an average of 3905 mothers and 3992 babies over the last ten years.


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5.2 maternity demograPhics and outcomes

TaBle 3: key Demographic sTaTisTics For Women giving BirTh in 2012

Variable Category Number Of Total %

Ethnicity * NZ European 1912 49.7

Other European 461 12.0

Mäori 481 12.5

Pacific Peoples 359 9.3

Asian 535 13.9

Other 102 3850 2.6

Age < 20 years 172 4.5

20 – 24 498 12.9

25 – 29 826 21.5

30 – 34 1205 31.3

35 – 39 904 23.5

≥ 40 245 3850 6.4

Average age for all women 31.3

Average age for first time mothers 29.6

Lead MaternityCarer (at booking)

Midwife LMC 2835 73.6

Hospital Midwifery Primary Care 320 8.3

Obstetrician & Midwife LMC 144 3.7

Obstetrician & Hospital Midwifery Shared Care 229 5.9

Hospital Secondary / Tertiary 322 3850 8.4

Parity ** Primiparous 1741 45.2

Multiparous with no previous Caesarean Section (CS) 1541 40.0

Multiparous with 1 previous CS 465 12.1

Multiparous with more than 1 previous CS 103 3850 2.7

Smoking ratesby ethnicity (at booking)

NZ European 119 1912 6.2

Other European 11 461 2.4

Mäori 197 481 41.0

Pacific Peoples 67 359 18.7

Asian 7 535 1.3

Other 1 102 1.0

Total 402 3850 10.4

* The ethnicity groups used in this report contain the following ethnicities. The method by which ethnicity is determined is explained in section 7.3.

NZ European: New Zealand European/Pakeha.Other European: Other European, European not further defined.Mäori: New Zealand Mäori.Pacific Peoples: Cook Island Mäori, Fijian, Niuean, Samoan, Tokelauan, Tongan, Pacific Island not further defined, Other Pacific Island.Asian: Chinese, Indian, Southeast Asian, Asian not further defined, Other Asian.Other: African, Latin American/Hispanic, Middle Eastern, Other, Not stated.

** Parity:Primiparous: A woman who has not previously given birth from 20 completed weeks gestation. (Also called nulliparous or Para ‘0’)Multiparous: A woman who has previously given birth from 20 completed weeks gestation.


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TaBle 4: moDe oF laBour By pariTy group For 2012

Mothers PrimiparousMultiparous, no

previous CSMultiparous, with

previous CSTotal

Labour No. % No. % No. % No. %

Spontaneous 954 54.8 1030 66.8 171 30.1 2155 56.0

Induced 631 36.2 412 26.7 50 8.8 1093 28.4

Pre-labour CS 156 9.0 99 6.4 347 61.1 602 15.6

Total 1741 100 1541 100 568 100 3850 100

TaBle 5: moDe oF BirTh By pariTy group For 2012


previous CSMultiparous, with

previous CSTotal

Mode No. % No. % No. % No. %

Vaginal

Normal 810 46.5 1317 85.5 97 17.1 2224 57.8

Forceps 179 10.3 25 1.6 11 1.9 215 5.6

Ventouse 153 8.8 15 1.0 24 4.2 192 5.0

Manual rotation 0 0.0 1 0.1 0 0.0 1 0.0

Breech 10 0.6 12 0.8 5 0.9 27 0.7

1152 66.2 1370 88.9 137 24.1 2659 69.1

Caesarean

Emergency 502 28.8 116 7.5 140 24.6 758 19.7

Elective 87 5.0 55 3.6 291 51.2 433 11.2

589 33.8 171 11.1 431 75.9 1191 30.9

Total 1741 100 1541 100 568 100 3850 100

TaBle 6: various moDe oF BirTh raTes anD posTparTum ouTcomes For 2012

Variable Number Of Total %

“Normal birth” (at term and spontaneous labour and normal birth) 1532 3850 39.8

Elective CS with indication of a previous CS 241 433 55.7

Emergency CS performed in established labour 522 758 68.9

Primary CS (first CS for women without a previous CS) 760 3282 23.2

Episiotomy 522 3850 13.6

Postpartum haemorrhage of 1000mls or more after a vaginal birth 86 2659 3.2

Postpartum haemorrhage of 1000mls or more after a CS birth 117 1191 9.8


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5.3 neonatal outcomes

TaBle 7: neonaTal ouTcomes For BaBies in 2012

Variable Category Number Of Total %

Gender Female 1889 48.2

Male 2031 3920 51.8

Plurality Single 3782 96.5

Twins 132 3.4

Triplets 6 3920 0.2

Gestation 20+0 – 23+6 weeks 31 0.8

24+0 – 27+6 weeks 57 1.5

28+0 – 31+6 weeks 84 2.1

32+0 – 36+6 weeks 294 7.5

All preterm 466 11.9

37+0 – 41+6 weeks 3407 86.9

≥ 42+0 weeks 47 3920 1.2

Birth weights for liveborn <500g 2 0.1

500g-999g 53 1.4

1000g-1499g 46 1.2

1500g-1999g 84 2.2

2000g-2499g 158 4.1

2500g-2999g 476 12.3

3000g-3499g 1192 30.7

3500g-3999g 1266 32.7

4000g-4499g 517 13.3

4500g-4999g 76 2.0

≥ 5000g 7 3877 0.2

Average weight 3375g

Maximum weight 5415g

Apgar < 7 at 5 minutes for liveborn * Preterm 31 427 7.3

Term 41 3450 1.2

Total 72 3877 1.9

Admissions to the Neonatal ICU(Some discharged from Ward 4 North)

Preterm 355 427 83.1

Term 389 3450 11.3

Total 744 3877 19.2

Breastfeeding at discharge(excludes discharges from NICU)

Exclusive 2728 79.6

Full 116 3.4

Partial 483 14.1

Artificial 102 3429 3.0

* Apgar: Numerical score used to evaluate the infant’s condition at one and five minutes after birth. Five variables are scored: heart rate, breathing, muscle tone, reactivity to stimulation and colour. Values of 0, 1 or 2 are assigned to each variable, with 10 being the maximum Apgar score.


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TaBle 8: perinaTal morTaliTy For BaBies in 2012

Babies Number Rate

Total babies 3920

Liveborn babies 3877

Fetal deaths (stillbirths and TOPs, 20 completed weeks gestation or more) 43 10.97 / 1000 total babies

Stillbirths 23 5.87 / 1000 total babies

Early neonatal deaths (died < 7 days) 7 1.81 / 1000 liveborn babies

Late neonatal deaths (died between 7 and < 28 days) 3 0.77 / 1000 liveborn babies

All neonatal deaths (died < 28 days) 10 2.58 / 1000 liveborn babies

PMMRC Rates *

Perinatal mortality (fetal and early neonatal deaths) 50 12.76 / 1000 total babies

Adjusted perinatal mortality (stillbirth and early neonatal deaths) 30 7.65 / 1000 total babies

Perinatal related mortality (fetal and all neonatal deaths) 53 13.52 / 1000 total babies

* PMMRC = Perinatal & Maternal Mortality Review Committee


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5.4 achs maternal and Perinatal clinical indicators

Overall the maternity service’s clinical indicators compared favourably with other organisations submitting data within Australasia. Our rates for “selected primipara who have a spontaneous vaginal birth” “selected primipara undergoing caesarean section” and “selected primipara undergoing episiotomy and sustaining a perineal tear while giving birth vaginally” do however require further attention. These results demonstrate that C&C DHB is statistically significantly different to all other organisations submitting data for these particular indicators and where our results are undesirably lower or higher than the expected rates.

The 2012 peer group comparison data has also identified eight clinical indicators where the aggregate rate is outside our 99% confidence interval. C&C DHB is statistically significantly different to all other organisations submitting data for the following indicators:

• Selected primipara who have a spontaneous vaginal birth

• Selected primipara undergoing caesarean section

• Selected primipara sustaining a perineal tear and no episiotomy

• Selected primipara undergoing episiotomy and sustaining a perineal tear while giving birth vaginally

• Women having a general anaesthetic for a caesarean section

• Babies with birth weight less than 2750g at 40 weeks gestation or beyond

• Term babies born with an Apgar score of less than 7 at five minutes post delivery

• Inborn term babies transferred / admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality.

To view the complete table with peer comparisons for 2012 refer to Table 122.


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TaBle 9: achs oBsTeTric clinical inDicaTors For 2012

Indicator Number and Description 2012 Numerator Denominator Rate (%)

1.1Selected primipara who have a spontaneous vaginal birth (H)

Jan-Jun 217 516 42.05

Jul-Dec 213 544 39.15

1.2 Selected primipara who undergo induction of labour (L)Jan-Jun 161 516 31.20

Jul-Dec 155 544 28.49

1.3 Selected primipara who undergo an instrumental vaginal birth (L)

Jan-Jun 104 516 20.16

Jul-Dec 126 544 23.16

1.4 Selected primipara undergoing caesarean section (L)Jan-Jun 128 516 24.81

Jul-Dec 153 544 28.13

2.1 Vaginal delivery following a previous primary caesarean section (N)

Jan-Jun 35 176 19.89

Jul-Dec 49 177 27.68

3.1 Selected primipara with intact perineum or unsutured perineal tear (H)

Jan-Jun 67 388 17.27

Jul-Dec 63 391 16.11

3.2 Selected primipara undergoing episiotomy AND no perineal tear while giving birth vaginally (L)

Jan-Jun 108 388 27.84

Jul-Dec 120 391 30.69

3.3Selected primipara sustaining a perineal tear AND no episiotomy (L)

Jan-Jun 161 388 41.49

Jul-Dec 166 391 42.46

3.4Selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally (L)

Jan-Jun 52 388 13.40

Jul-Dec 42 391 10.74

3.5 Selected primipara requiring surgical repair of the perineum for third degree tear (L)

Jan-Jun 22 388 5.67

Jul-Dec 28 391 7.16

3.6 Selected primipara requiring surgical repair of the perineum for fourth degree tear (L)

Jan-Jun 0 388 0.00

Jul-Dec 3 391 0.77

4.1Women having a general anaesthetic for a caesarean section (L)

Jan-Jun 40 590 6.78

Jul-Dec 31 598 5.18

7.1 Women who give birth vaginally who receive a blood transfusion during the same admission (L)

Jan-Jun 25 1295 1.93

Jul-Dec 28 1336 2.10

7.2 Women who undergo caesarean section who receive a blood transfusion during the same admission (L)

Jan-Jun 22 590 3.73

Jul-Dec 18 598 3.01

8.1Deliveries with birth weight less than 2750g at 40 weeks gestation or beyond (L)

Jan-Jun 10 793 1.26

Jul-Dec 6 789 0.76

9.1Term babies born with an Apgar score of less than 7 at five minutes post delivery (L)

Jan-Jun 28 1685 1.66

Jul-Dec 15 1742 0.86

10.1Inborn term babies transferred / admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality (L)

Jan-Jun 137 1644 8.33

Jul-Dec 188 1700 11.06

(L) – A low rate is desirable (H) – A high rate is desirable (N) – Desirable rate is unspecifiedRates in italic / greyed highlight results that require attention.Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.


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TaBle 10: achs inFecTion conTrol clinical inDicaTor For 2012


1.16 Deep incisional/organ/space surgical site infection (SSI) in lower segment caesarean section procedures (L)

Jan-Jun 4 586 0.68

Jul-Dec 6 598 1.00

5.5 gynaecology outcomes

There has been an overall increase in the number of women attending gynaecology clinics within the WHS in 2012. Attendances at general gynaecology clinics increased 11.1% from 2011 and total gynaecology clinic attendances increased 9.2% from 2011. There was also an 8.2% increase in attendance to all colposcopy clinics from 2011 to 2012.

A concerted effort was made to reduce the waiting times for gynaecology first specialist assessments (FSA).

This was achieved by July 2012 with no women waiting more than 4 months for a FSA.

There has been an increase in both elective and acute surgery volumes from 2011 to 2012 mainly because of increased use of theatre time for Wellington day surgeries.

There has been a 27.8% decline in the number of terminations of pregnancy between 2007 and 2012. There has been a steady decline in the number of terminations performed each year with an 11% reduction in numbers from 2011 to 2012.


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5.6 achs gynaecology clinical indicators

Overall the gynaecology service’s clinical indicators compared favourably with other organisations submitting data within Australasia. See the complete table with peer comparisons in the Appendices (Table 124).

TaBle 11: achs gynaecology clinical inDicaTors For 2012


1.1Patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecological surgery for benign disease (L)

Jan-Jun 10 390 2.56

Jul-Dec 8 429 1.86

1.2Patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecological surgery for malignant disease (L)

Jan-Jun 5 57 8.77

Jul-Dec 5 61 8.20

2.1Patients suffering injury to a major viscus with repair, during an gynaecological operative procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 7 412 1.70

Jul-Dec 2 455 0.44

3.1

Patients suffering an injury to a major viscus with repair, during a laparoscopic gynaecological operative procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 245 0.00

Jul-Dec 2 271 0.74

3.2

Patients receiving an injury to a ureter at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 15 0.00

Jul-Dec 0 12 0.00

3.3

Patients receiving a bladder injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 15 0.00

Jul-Dec 0 12 0.00

4.1 Laparoscopic management of an ectopic pregnancy (H)Jan-Jun 15 16 93.75

Jul-Dec 12 14 85.71

5.1Patients receiving injury to a major viscus with repair, during a pelvic floor repair procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 51 0.00

Jul-Dec 0 70 0.00

5.2Patients receiving a ureter injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 51 0.00

Jul-Dec 0 70 0.00

5.3Patients receiving a bladder injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0 51 0.00

Jul-Dec 0 70 0.00

(L) – A low rate is desirable(H) – A high rate is desirable (N) – Desirable rate is unspecified


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The following table lists the attendance volumes and “did not attend” rates for all medical and midwifery outpatient clinics for the last four years 2009 to 2012.

6. antenatal and Postnatal clinics


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TaBle 12: oBsTeTric ouTpaTienT clinic aTTenDances anD Dna raTes For years 2009 To 2012

Attendance volumes Did not attend rates

Obstetric Clinic 2009 2010 2011 2012 2009 2010 2011 2012

No. No. No. No. % % % %

Medical

Antenatal 1889 2154 2306 2484 9.3 10.3 9.0 7.3

Diabetic 1038 1714 1845 1555 12.5 11.0 12.3 6.8

High risk 1075 939 1109 1297 8.7 7.3 12.7 11.3

MFM counselling 985 1156 1013 907 5.3 3.3 2.4 1.8

Acute assessment 1904 3059 2738 2564 0.2 0.3

Preassessment 394 466 540 581 12.2 12.0 11.1 11.4

Pre-20 weeks 533 857 877 185 11.4 8.3 8.1 7.0

VBAC antenatal 65 3.1

VBAC pre-20 weeks 5

Virtual – MFM 3 52

Virtual - Obstetric 1

Total - Medical 7818 10345 10432 9695 7.2 6.2 7.1 5.5

Midwifery

MFM antenatal 8 6 4 15

MFM postnatal 3

High risk antenatal 227 175 108 128

High risk antenatal community 430 413 373 473

High risk postnatal 190 139 138 122

High risk postnatal community 1050 1163 1383 1353 0.3 0.2 0.1

Primary antenatal 2820 2520 2368 2232 8.7 13.4 9.6 10.4

Primary antenatal education class 6 341 224 24.6 33.5

Primary antenatal community 13 8 43 37

Primary postnatal 663 175 166 613 0.2

Primary postnatal community 2064 2910 2491 1959 0.1 0.0

Primary pre-20 week 430 564 481 389 9.8 9.6 8.9 4.9

Shared care antenatal 22 34 6 8

Shared care antenatal community 1004 835 847 802 0.2 0.2

Shared care postnatal 259 181 149 203

Shared care postnatal community 2062 1678 1618 1717

Total - Midwifery 11245 10807 10516 10275 2.6 3.7 3.4 3.3

Grand Total - Obstetric 19063 21152 20948 19970 4.5 4.9 5.2 4.4


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6.1 obstetric diabetic clinics

The analysis in this section is based on data for women who attended obstetric diabetic outpatient clinics during 2012. This data was sourced from the patient management systems of C&C DHB and a database kept in clinic.

The clinics were attended by 272 women. 241 women had diabetes and 31 women had other endocrine disorders. 253 (93%) of the 272 women were C&C DHB domiciled, 8 (3%) from the Hutt Valley DHB and the rest were from other DHBs.

TaBle 13: eThniciTy DisTriBuTion oF Women seen aT oBsTeTric DiaBeTic ouTpaTienT clinics in 2012

NZ European

Other European

MäoriPacific

PeoplesAsian Other Total

No. % No. % No. % No. % No. % No. % No. %

Diabetes

GDM 72 64.9 16 88.9 13 56.5 23 59.0 59 80.8 7 87.5 190 69.9

Type 1 18 16.2 1 5.6 1 4.3 2 5.1 1 1.4 0 0.0 23 8.5

Type 2 5 4.5 0 0.0 7 30.4 10 25.6 6 8.2 0 0.0 28 10.3

Other

Thyroid 14 12.6 1 5.6 1 4.3 2 5.1 6 8.2 1 12.5 25 9.2

Other 2 1.8 0 0.0 1 4.3 2 5.1 1 1.4 0 0.0 6 2.2

Total 111 100 18 100 23 100 39 100 73 100 8 100 272 100

There is an increase in the incidence of diabetes in the community and this will be occurring in women of reproductive age. Diabetes nurses and midwife educators have been doing training sessions and diabetes has been discussed in forums such as the perinatal education meeting. There seems to be an increased awareness with regard to screening and the risks of untreated diabetes in pregnancy. However communication from the PMMRC indicated that rates of screening could still be improved.

The weekly diabetes antenatal clinic provides antenatal care for women with pre-existing diabetes or gestational diabetes, and for women with other

endocrine disorders. In early 2012 a second diabetes clinic was initiated at Kenepuru. Our clinic population was divided evenly between the two areas. Having to come into Wellington Regional Hospital was inconvenient and costly for women living in the Porirua and Kapiti Coast areas so a clinic closer to them was seen as appropriate. Establishing scanning facilities adjacent to the clinic at Kenepuru has also improved access and care for these women and their babies.

Table 12 shows that attendance volumes have decreased and DNA rates have dropped dramatically from 12.3% in 2011 to 6.8% in 2012.


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6.2 anaesthesia clinics

Two anaesthesia clinics are held per week, one on Wednesdays for women requiring elective caesarean section and one on Thursdays for women with more complex medical conditions. An average of 50 women per month attend these, but late referrals often make it difficult for women to be seen in a timely manner. There is a possibility of an additional monthly clinic at Kenepuru to reduce the travel for women from the Kapiti Coast. As much of the anaesthesia assessment consists of examining women for adequate airway and appropriate spinal mobility, phone assessments are not usually possible.

581 women were seen in clinics in 2012 and an additional 66 women (11%) did not attend their appointments. If a woman is referred to the anaesthesia clinic it is important that she is informed that she has been referred, knows the reason for the referral and some effort is made to ensure she attends. With the review of midwifery roles in the outpatient department it is hoped that this will improve the attendance rate.

6.3 Pregnancy and Parenting education

wellington hosPital antenatal education class

This class is used by women who are being cared for by the primary care team, the high risk team or have a midwife LMC, but have not been able to source free antenatal education elsewhere. 45 women and their families attended.

wellington hosPital antenatal assessment and education class

These education classes are structured to run alongside antenatal assessments so enabling the majority of women attending to have their antenatal assessment prior to the education class commencing. 66 women and their families attended.

kenePuru hosPital antenatal assessment and education class

This clinic was run using the same format as the Wellington clinic. Feedback from women attending the antenatal assessment and education class was that the classes were helpful, but attendance was low. The frequency of these classes and attendance numbers were reviewed. In July the class was changed to a one day education only class once a month. 54 women and their families attended.

The number of women attending education classes run by the C&C DHB has increased from 152 in 2011 to 171 in 2012. There were women from 14 different ethnic groups attending classes in 2012.

There has been a definite increase in the number of first-time pregnant women accessing C&C DHB funded antenatal education classes. There has also been an increase in the number of families attending classes in order to support women through their learning experience.


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This chapter describes the demographic characteristics of the women giving birth at C&C DHB birthing facilities in 2012.

7.1 domicile

93% of all births were to women from the local catchment area. 275 women were from other DHBs with most being from the Hutt Valley and Mid-Central DHBs.

TaBle 14: Domicile By DisTricT healTh BoarD (DhB) area anD By gesTaTion aT BirTh For 2012

Mothers < 28 weeks 28+0 – 31+6 32+0 – 36+6 Term 37+0 – 40+6

Post term ≥41+0 Total

DHB * No. % No. % No. % No. % No. % No. %

Capital and Coast 35 44.3 29 40.3 211 80.5 2655 96.0 645 96.3 3575 92.9

Hutt Valley 6 7.6 14 19.4 16 6.1 67 2.4 15 2.2 118 3.1

Hawkes Bay 12 15.2 4 5.6 4 1.5 7 0.3 0 0.0 27 0.7

Wairarapa 3 3.8 4 5.6 7 2.7 5 0.2 1 0.1 20 0.5

Whanganui 5 6.3 5 6.9 3 1.1 3 0.1 0 0.0 16 0.4

Mid Central 9 11.4 2 2.8 7 2.7 22 0.8 9 1.3 49 1.3

Nelson Marlborough 5 6.3 8 11.1 3 1.1 5 0.2 0 0.0 21 0.5

Other North Island 4 5.1 6 8.3 10 3.8 3 0.1 0 0.0 23 0.6

Other South Island 0 0.0 0 0.0 1 0.4 0 0.0 0 0.0 1 0.0

Total 79 100 72 100 262 100 2767 100 670 100 3850 100

* Domicile determined from patient address.

7. maternity service demograPhy


58 |

7.2 age

The median age of New Zealand women giving birth in 2012 is 30 years (Statistics New Zealand, 2013) whereas C&C DHBs median age was 31.9 years.

The proportion of women (40 years of age and over) giving birth at C&C DHB is 6.4% compared with 4.1% of the New Zealand birthing population. The proportion of women (35 years of age and over) giving birth at C&C DHB is almost 29.8% compared with 21.5% of the New Zealand birthing population. In 2012 the MoH published the “Report on Maternity”

from 2010 national data and reported that the percentage of normal vaginal births decreased with advanced maternal age. A rate of 74.0% was reported for women less than 20 years of age compared with 51.9% for women aged 40 years and over. The opposite trend was seen in women who had a caesarean section rate of 14.2% if less than 20 years of age compared with 38.5% for women aged 40 years and over. There are implications for older women in C&C DHB that are reflected in our intervention rates and outcomes.

TaBle 15: age group DisTriBuTion By BirTh FaciliTy For 2012

Mothers Wellington Kenepuru Paraparaumu C&C DHB 2010 (NZ) †

Age No. % No. % No. % No. % No. %

< 20 132 3.8 28 11.4 12 8.9 172 4.5 4582 7.1

20 – 24 401 11.6 69 28.2 28 20.7 498 12.9 12121 18.8

25 – 29 718 20.7 72 29.4 36 26.7 826 21.5 16113 25.0

30 – 34 1128 32.5 43 17.6 34 25.2 1205 31.3 17782 27.6

35 – 39 857 24.7 26 10.6 21 15.6 904 23.5 11190 17.4

≥ 40 234 6.7 7 2.9 4 3.0 245 6.4 2669 4.1

Not stated 0 0.0 0 0.0 0 0.0 0 0.0 28 0.0

Total 3470 100 245 100 135 100 3850 100 64485 100

Average age 31.7 27.5 29.0 31.3

Median age 32.3 27.2 28.7 31.9 30.0 *

† (Report on Maternity 2010, NZ Ministry of Health, 2012).* NZ median age for 2012 (www.stats.govt.nz)

The average age for all women and for first time mothers has remained fairly constant over the last eight years since 2005 (see next table).


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TaBle 16: maTernal age group DisTriBuTion For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Age No. % No. % No. % No. % No. % No. % No. % No. %

< 20 202 5.4 183 4.6 219 5.4 212 5.3 216 5.4 187 4.8 172 4.4 172 4.5

20 – 24 427 11.4 484 12.2 508 12.6 531 13.3 492 12.3 512 13.2 487 12.4 498 12.9

25 – 29 768 20.5 730 18.4 783 19.3 811 20.3 832 20.8 762 19.6 823 21.0 826 21.5

30 – 34 1288 34.3 1435 36.2 1342 33.2 1238 31.0 1292 32.3 1263 32.5 1285 32.8 1205 31.3

35 – 39 893 23.8 928 23.4 959 23.7 997 24.9 967 24.2 959 24.6 937 23.9 904 23.5

≥ 40 176 4.7 207 5.2 236 5.8 210 5.3 196 4.9 208 5.3 213 5.4 245 6.4

Total 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100

Average age

All mothers 31.2 31.4 31.2 31.1 31.2 31.3 31.3 31.3

First time mothers 29.4 29.8 29.5 29.2 29.4 29.6 29.8 29.6

Figure 4: age group percenTage DisTriBuTion For years 2005 To 2012

2005 2006 2007 2008 2009 2010 2011 2012

40.0 %

35.0 %

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

<20 20-24 25-29 30-34 35-39 >=40

The following figure plots the ethnicity distribution for each age group for 2012. Refer to Table 113 in the Appendices for the underlying data. Mäori and Pacific women are over-represented in the under 25 year age groups.


60 |

Figure 5: eThniciTy group DisTriBuTion WiThin each maTernal age group For 2012

70.0 %

60.0 %

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

< 20 yrs 20 - 24 yrs 25 - 29 yrs 30 - 34 yrs 35 - 39 yrs ≥ 40 yrs Total

NZ European Other European Mäori Pacific Peoples Asian Other


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7.3 ethnicity

Reporting of ethnicity is complex and different systems are used in various reports. The New Zealand Ministry of Health uses a prioritised ethnicity classification system. The prioritised ethnicity classification system works by an individual choosing multiple ethnicities based on their preferences or self-concept. The classification system then determines the ethnicity group value for multiple ethnicities using a hierarchical system of 21 ethnicity descriptions. This is based on the following priority: Mäori, Pacific peoples, Asian, other groups except NZ European, NZ European. Thus, any person who selects Mäori as one of their three ethnicities will be recorded as Mäori. (Hospital based Maternity events 2006, NZ Ministry of Health,

2010). Therefore any comparison between C&C DHB and New Zealand percentage distribution values needs to be treated with caution.

The method of ethnicity reporting used in this report is the sole classification method. Three ethnicity descriptions can be collected in the PIMS database but 90% of women giving birth at C&C DHB facilities in 2012 indicated one ethnicity only. For the remaining 10% with multiple ethnicities, the first selected ethnicity value has been used.

Women of different ethnic groups vary in their utilisation of available maternity services. This influences their pregnancy risk factors and outcomes.

TaBle 17: eThniciTy DisTriBuTion By BirTh FaciliTy For 2012

Mothers Wellington Kenepuru Paraparaumu C&C DHB 2010 (NZ) †

Ethnicity No. % No. % No. % No. % No. %

NZ European 1749 50.4 73 29.8 90 66.7 1912 49.7 26184 40.6

Other European 432 12.4 12 4.9 17 12.6 461 12.0 6138 9.5

Mäori 384 11.1 77 31.4 20 14.8 481 12.5 16348 25.4

Pacific Peoples 293 8.4 65 26.5 1 0.7 359 9.3 7536 11.7

Asian 512 14.8 17 6.9 6 4.4 535 13.9 6966 10.8

Other 100 2.9 1 0.4 1 0.7 102 2.6 1313 2.0

Total 3470 100 245 100 135 100 3850 100 64485 100

† (Report on Maternity 2010, NZ Ministry of Health, 2012).


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Changes in maternal ethnicity over time show an increase in the Asian group (9.1% in 2005 to 13.9% in 2012) and the Other European group (8.8% in 2005 to 12.0% in 2012). The New Zealand European group has declined from 55.1% in 2005 to 49.7% in 2012.

TaBle 18: maTernal eThniciTy groups For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Ethnicity No. % No. % No. % No. % No. % No. % No. % No. %

NZ European 2069 55.1 2169 54.7 2089 51.6 2059 51.5 2058 51.5 1946 50.0 1954 49.9 1912 49.7

Other European 331 8.8 401 10.1 440 10.9 440 11.0 462 11.6 456 11.7 497 12.7 461 12.0

Mäori 519 13.8 543 13.7 553 13.7 562 14.1 531 13.3 525 13.5 488 12.5 481 12.5

Pacific Peoples 370 9.9 393 9.9 394 9.7 389 9.7 407 10.2 387 9.9 385 9.8 359 9.3

Asian 343 9.1 373 9.4 400 9.9 405 10.1 412 10.3 440 11.3 486 12.4 535 13.9

Other 122 3.2 88 2.2 171 4.2 144 3.6 125 3.1 137 3.5 107 2.7 102 2.6

Total 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100

The distribution of each ethnicity within each of these six ethnicity groups for years 2005 to 2012 is tabulated in Table 116 in the Appendices.

The average age varies between ethnicity groups but Mäori and Pacific women are younger on average. Both NZ European and Other European groups were older on average. The figure below shows the age distribution in each ethnicity group.

TaBle 19: age group DisTriBuTion WiThin each eThniciTy group For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Age No. % No. % No. % No. % No. % No. % No. %

< 20 52 2.7 3 0.7 76 15.8 35 9.7 2 0.4 4 3.9 172 4.5

20 – 24 196 10.3 17 3.7 140 29.1 85 23.7 47 8.8 13 12.7 498 12.9

25 – 29 352 18.4 55 11.9 116 24.1 107 29.8 169 31.6 27 26.5 826 21.5

30 – 34 640 33.5 186 40.3 70 14.6 75 20.9 206 38.5 28 27.5 1205 31.3

35 – 39 540 28.2 159 34.5 62 12.9 39 10.9 81 15.1 23 22.5 904 23.5

≥ 40 132 6.9 41 8.9 17 3.5 18 5.0 30 5.6 7 6.9 245 6.4

Total 1912 100 461 100 481 100 359 100 535 100 102 100 3850 100

Average 32.3 34.0 27.1 28.2 31.4 31.0 31.3


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Figure 6: age group DisTriBuTion WiThin each maTernal eThniciTy group For 2012

< 20 yrs 20 - 24 yrs 25 - 29 yrs 30 - 34 yrs 35 - 39 yrs ≥ 40 yrs

50.0 %

45.0 %

40.0%

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

NZ EuropeanOther

European Mäori Pacific Peoples Asian Other Total


64 |

7.4 Parity

The parity rates for all women have remained consistent for the last 8 years. Tables for 2012 of parity by age group and parity by ethnicity group are listed in the Appendices (Table 114 and Table 115).

TaBle 20: pariTy For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Parity No. % No. % No. % No. % No. % No. % No. % No. %

0 1680 44.8 1813 45.7 1844 45.6 1854 46.4 1828 45.8 1717 44.1 1787 45.6 1741 45.2

1 1249 33.3 1321 33.3 1372 33.9 1273 31.8 1299 32.5 1285 33.0 1327 33.9 1294 33.6

2 513 13.7 503 12.7 524 12.9 528 13.2 533 13.3 574 14.8 491 12.5 528 13.7

3 182 4.8 183 4.6 167 4.1 200 5.0 189 4.7 183 4.7 178 4.5 163 4.2

4 73 1.9 88 2.2 82 2.0 66 1.7 73 1.8 83 2.1 64 1.6 79 2.1

> 4 57 1.5 59 1.5 58 1.4 78 2.0 73 1.8 49 1.3 70 1.8 45 1.2

Total 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100

This next table shows the distribution of previous CS history for women who gave birth in each year from 2005 to 2012. About 45% of women are primiparous

and about 15% are multiparous with one or more previous CS. This table does not indicate the birth outcome for these groups of women.

TaBle 21: grouping By caesarean secTion (cs) hisTory For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Parity grouping

No. % No. % No. % No. % No. % No. % No. % No. %

Primipara 1680 44.8 1813 45.7 1844 45.6 1854 46.4 1828 45.8 1717 44.1 1787 45.6 1741 45.2

Multipara, with :

0 previous CS 1588 42.3 1616 40.7 1641 40.5 1562 39.1 1635 40.9 1589 40.8 1578 40.3 1541 40.0

1 previous CS 391 10.4 456 11.5 477 11.8 471 11.8 431 10.8 464 11.9 460 11.7 465 12.1

> 1 previous CS

95 2.5 82 2.1 85 2.1 112 2.8 101 2.5 121 3.1 92 2.3 103 2.7

Total 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100


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7.5 smoking

The Ministry of Health have defined a 90% target for women who identify as smokers at the time of their pregnancy confirmation. These women should be offered advice and support to quit smoking when booking with their LMC or visiting their general practitioner.

There is strong evidence that advice however brief is effective in prompting quit smoking attempts and long-term quit smoking success.

Before registration documentation is accepted by the WHS for data entry to the PIMS database a “smoking dependence and cessation referral record” for the pregnant woman must be completed by their LMC.

This form collects information on the woman’s smoking status at the time of booking. Women who indicate that they would like help to stop smoking are provided with information about the cessation support options currently available. The support options include nicotine replacement therapy, consultation with the C&C DHB smoking cessation coordinator or referral to one of four cessation support programmes. The programmes are Quitline, Aukati Kai Paipa, Pacific Smoking Cessation or Quit Smoking Service.

Data on smoking is recorded in the PIMS database and in the C&C DHB patient management system.

Fewer than 0.5% of women had missing data. There are four data options in PIMS to identify the number of cigarettes smoked per day. These have been combined in the following analysis to denote if a woman was a smoker. The category “given up” has been assigned to the non-smoking group.

The following table gives the smoking rates within each age group for each of the ethnicity groups. Numbers in each “age - ethnicity group” cell are the number of women smoking, the total number of women, and their rate. For example, in the “< 20 years, NZ European” group, 14 of 52 women smoked which is a rate of 26.9%.

The smoking rate for all women in 2012 was 10.4%, but Mäori women had a rate of 41% and Pacific women a rate of 18.7%. In 2011 National Women’s reported an overall rate of 6.6% at booking and rates of 34.5% for Mäori women and 13.5% for Pacific women (Auckland District Health Board 2012).

Young women under 25 years had high smoking rates with a combined rate of 30.3%. National Women’s reported a rate of 19.8% in 2011 for all women 25 years and younger.

TaBle 22: raTes oF smoking aT Booking Time By eThniciTy anD age groups For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

EthnicityNumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NZ European

14 26.9 48 24.5 24 6.8 18 2.8 11 2.0 4 3.0 119 6.2

52 196 352 640 540 132 1912

Other European

0 0.0 0 0.0 4 7.3 3 1.6 4 2.5 0 0.0 11 2.4

3 17 55 186 159 41 461

Mäori41 53.9 67 47.9 45 38.8 21 30.0 15 24.2 8 47.1 197 41.0

76 140 116 70 62 17 481

Pacific Peoples

8 22.9 23 27.1 20 18.7 12 16.0 3 7.7 1 5.6 67 18.7

35 85 107 75 39 18 359

Asian1 50.0 1 2.1 3 1.8 2 1.0 0 0.0 0 0.0 7 1.3

2 47 169 206 81 30 535

Other0 0.0 0 0.0 1 3.7 0 0.0 0 0.0 0 0.0 1 1.0

4 13 27 28 23 7 102

Total64 37.2 139 27.9 97 11.7 56 4.6 33 3.7 13 5.3 402 10.4

172 498 826 1205 904 245 3850


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Detailed booking data has been collected since 2005 for births at all three C&C DHB birthing facilities. The next table shows the overall smoking rates for each ethnicity group from 2005 to 2012.

The smoking rates for all women have gradually declined from 14.6% in 2005 to 10.4% in 2012.

The rate for Mäori women has reduced from 46% in 2005 to 41% in 2012.

The issue of smoking rates will become a priority to be addressed. The development of further strategies and interventions and the implementation of these will be required.

TaBle 23: raTes oF smoking aT Booking Time By eThniciTy group For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

EthnicityNumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NumDen

Rate%

NZ European

185 8.9 196 9.0 201 9.6 169 8.2 158 7.7 154 7.9 141 7.2 119 6.2

2069 2169 2089 2059 2058 1946 1954 1912

Other European

12 3.6 21 5.2 19 4.3 14 3.2 10 2.2 10 2.2 20 4.0 11 2.4

331 401 440 440 462 456 497 461

Mäori238 45.9 242 44.6 243 43.9 248 44.1 236 44.4 236 45.0 193 39.5 197 41.0

519 543 553 562 531 525 488 481

Pacific Peoples

101 27.3 81 20.6 103 26.1 89 22.9 92 22.6 83 21.4 87 22.8 67 18.7

370 393 394 389 407 387 385 359

Asian7 2.0 8 2.1 8 2.0 11 2.7 9 2.2 4 0.9 5 1.0 7 1.3

343 373 400 405 412 440 486 535

Other6 4.9 2 2.3 7 4.1 5 3.5 5 4.0 5 3.6 2 1.9 1 1.0

122 88 171 144 125 137 107 102

Total549 14.6 550 13.9 581 14.4 536 13.4 510 12.8 492 12.6 448 11.4 402 10.4

3754 3967 4047 3999 3995 3891 3917 3850


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7.6 body mass index

Maternal weight gain in pregnancy has implications on intervention rates and outcomes. There is an increased risk of pre-eclampsia, gestational diabetes, fetal macrosomia, and caesarean section (PMMRC, 2012).

Information and recommendations on healthy weight gain in pregnancy are available.

TaBle 24: BoDy mass inDex (Bmi) caTegories aT Booking By age group For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

BMI * No. % No. % No. % No. % No. % No. % No. %

< 19 7 4.6 18 3.9 39 4.9 41 3.5 17 1.9 4 1.7 126 3.4

19 – 25 76 50.3 201 43.4 384 48.6 669 56.8 476 53.8 115 48.9 1921 51.9

26 – 30 47 31.1 127 27.4 199 25.2 298 25.3 245 27.7 76 32.3 992 26.8

31 – 35 14 9.3 64 13.8 89 11.3 106 9.0 86 9.7 24 10.2 383 10.3

36 – 40 4 2.6 34 7.3 47 5.9 42 3.6 28 3.2 9 3.8 164 4.4

41 – 45 2 1.3 14 3.0 17 2.2 10 0.8 24 2.7 4 1.7 71 1.9

> 45 1 0.7 5 1.1 15 1.9 12 1.0 9 1.0 3 1.3 45 1.2

Total 151 100 463 100 790 100 1178 100 885 100 235 100 3702 100

* BMI = Weight (kg) / Height2 (m2). BMI calculated from booking weights and heights. Missing data is excluded from the table (3.9% of the total women for 2012)

TaBle 25: BoDy mass inDex (Bmi) caTegories aT Booking By eThniciTy group For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

BMI * No. % No. % No. % No. % No. % No. % No. %

< 19 49 2.6 17 3.8 6 1.4 1 0.3 49 9.4 4 4.0 126 3.4

19 – 25 1045 56.1 272 60.7 151 34.7 51 15.2 347 66.9 55 54.5 1921 51.9

26 – 30 492 26.4 113 25.2 147 33.8 106 31.6 100 19.3 34 33.7 992 26.8

31 – 35 170 9.1 31 6.9 70 16.1 87 26.0 19 3.7 6 5.9 383 10.3

36 – 40 61 3.3 9 2.0 35 8.0 57 17.0 2 0.4 0 0.0 164 4.4

41 – 45 28 1.5 5 1.1 15 3.4 21 6.3 1 0.2 1 1.0 71 1.9

> 45 19 1.0 1 0.2 11 2.5 12 3.6 1 0.2 1 1.0 45 1.2

Total 1864 100 448 100 435 100 335 100 519 100 101 100 3702 100

* BMI = Weight (kg) / Height2 (m2). BMI calculated from booking weights and heights. Missing data is excluded from the table (3.9% of the total women for 2012)


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7.7 lead maternity carer (lmc) at booking

The PMMRC recommendations regarding early booking have been made to enable early antenatal screening, to detect underlying maternal medical conditions and risk factors and to provide advice and support with respect to lifestyle choices.

Improved rates of booking in the first trimester of pregnancy have been noted over the last five years within the C&C DHB region.

C&C DHB had a long standing contract with a service provider to assist women looking for a midwife LMC. However the number of women who accessed this service and successfully found an LMC had decreased over recent years. C&C DHB recently reviewed the service specification and as a result decided to contract for a revised service.

The new service components will include:

• Developing close working relationships with primary health organisations and their general practitioner members, C&C DHB, the College of Midwives and the Ministry of Health to ensure that midwife LMC information is accurate and up to date within the Capital and Coast district

• Creating an electronic website that provides information on maternity services within the district with links to relevant websites

• Producing information pamphlets which will provide key messages and the step by step process for finding a midwife.

The WHS will tender for two sections of the proposal “enabling and supporting women in their decision to find a midwife LMC” and “early antenatal education”.

TaBle 26: lmc Bookings By TrimesTer aT Time oF FirsT visiT, For years 2008 To 2012

Mothers 2008 2009 2010 2011 2012

Trimester at booking No. % No. % No. % No. % No. %

First (0 – 13+6 weeks) 2122 53.1 2267 56.7 2256 58.0 2339 59.7 2444 63.5

Second (14+0 – 26+6 weeks) 1282 32.1 1184 29.6 1126 28.9 1124 28.7 931 24.2

Third (27+0 – 40 weeks) 274 6.9 232 5.8 222 5.7 186 4.7 195 5.1

Gestation at first visit not stated 321 8.0 312 7.8 287 7.4 268 6.8 280 7.3

Total 3999 100 3995 100 3891 100 3917 100 3850 100


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TaBle 27: leaD maTerniTy carer (lmc) aT Time oF Booking By FaciliTy oF BirTh For 2012

Mothers Wellington Kenepuru Paraparaumu C&C DHB

LMC at booking No. % No. % No. % No. %

Midwife LMC 2455 70.7 245 100.0 135 100.0 2835 73.6

Hospital Midwifery Primary Care 320 9.2 320 8.3

Obstetrician & Midwife LMC 144 4.1 144 3.7

Obstetrician & Hospital Midwifery Shared Care 229 6.6 229 5.9

Hospital Secondary / Tertiary 322 9.3 322 8.4

Total 3470 100 245 100 135 100 3850 100

The number of women booking with a midwife LMC has remained fairly constant at about 70% over the last five years. There has however been a decline in the

number of women cared for by a private obstetrician and midwife LMC combination. This was due to a number of obstetricians giving up private practice.

TaBle 28: leaD maTerniTy carer (lmc) aT Time oF Booking For years 2008 To 2012

Mothers 2008 2009 2010 2011 2012

LMC at Booking No. % No. % No. % No. % No. %

Midwife LMC 2812 70.3 2813 70.4 2683 68.9 2660 67.9 2835 73.6

Hospital MW Primary Care 264 6.6 371 9.3 396 10.2 361 9.2 320 8.3

Obst. & Midwife LMC 404 10.1 300 7.5 300 7.7 261 6.7 144 3.7

Obst. & Hosp. MW Shared 219 5.5 165 4.1 159 4.1 253 6.5 229 5.9

Hospital Secondary/Tertiary 300 7.5 346 8.7 353 9.1 382 9.8 322 8.4

Total 3999 100 3995 100 3891 100 3917 100 3850 100

TaBle 29: eThniciTy group DisTriBuTion By Booking lmc For 2012

Mothers Midwife LMCHospital

Midwifery Primary Care

Obstetrician & Midwife

LMC

Obstetrician & Hospital Midwifery

Shared Care

Hospital Secondary /

TertiaryTotal

Ethnicity No. % No. % No. % No. % No. % No. %

NZ European 1397 49.3 108 33.8 101 70.1 159 69.4 147 45.7 1912 49.7

Other European 334 11.8 40 12.5 19 13.2 36 15.7 32 9.9 461 12.0

Mäori 371 13.1 29 9.1 1 0.7 5 2.2 75 23.3 481 12.5

Pacific Peoples 280 9.9 46 14.4 1 0.7 0 0.0 32 9.9 359 9.3

Asian 384 13.5 83 25.9 17 11.8 23 10.0 28 8.7 535 13.9

Other 69 2.4 14 4.4 5 3.5 6 2.6 8 2.5 102 2.6

Total 2835 100 320 100 144 100 229 100 322 100 3850 100


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TaBle 30: pariTy group DisTriBuTion By Booking lmc For 2012

MothersMidwife

LMC

Hospital Midwifery Primary

Care

Obstetrician & Midwife

LMC

Obstetrician & Hospital Midwifery

Shared Care

Hospital Secondary /

TertiaryTotal

Parity No. % No. % No. % No. % No. % No. %

Primiparous 1284 45.3 160 50.0 66 45.8 105 45.9 126 39.1 1741 45.2

Multip. & no CS 1173 41.4 109 34.1 53 36.8 87 38.0 119 37.0 1541 40.0

Multip. prev. CS 378 13.3 51 15.9 25 17.4 37 16.2 77 23.9 568 14.8

Total 2835 100 320 100 144 100 229 100 322 100 3850 100

7.8 hosPital Primary care

The primary care team are a group of midwives who provide antenatal and postnatal care to women who have been unable to locate an LMC. Antenatal clinics are held at Wellington Regional Hospital and Kenepuru

Hospital Monday to Friday. Labour and birth care is undertaken by core midwives in delivery suite.

Midwives working within the primary care team are employees of C&C DHB.

TaBle 31: pariTy By eThniciTy For Women BookeD WiTh hospiTal miDWiFery primary care For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Parity No. % No. % No. % No. % No. % No. % No. %

0 52 48.1 20 50.0 11 37.9 23 50.0 46 55.4 8 57.1 160 50.0

1 40 37.0 14 35.0 8 27.6 9 19.6 28 33.7 2 14.3 101 31.6

2 13 12.0 4 10.0 6 20.7 7 15.2 8 9.6 2 14.3 40 12.5

3 1 0.9 2 5.0 1 3.4 4 8.7 1 1.2 0 0.0 9 2.8

4 2 1.9 0 0.0 1 3.4 3 6.5 0 0.0 1 7.1 7 2.2

> 4 0 0.0 0 0.0 2 6.9 0 0.0 0 0.0 1 7.1 3 0.9

Total 108 100 40 100 29 100 46 100 83 100 14 100 320 100


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8.1 Preterm birth

In 2012, 413 women (10.7%) had a preterm birth at C&C DHB. The preterm birth rate for C&C DHB domiciled women was 7.7% (275/3575) and 50.2% (138/275) for women from other DHBs.

The number of births under 37 weeks has remained stable at just under 11% of pregnancies for the last three years. Although this rate is similar to other tertiary units in New Zealand, comparisons to other units and other countries is difficult as the local data includes women transferred in from secondary units around the region and other tertiary units. In addition the data does not differentiate between spontaneous and iatrogenic preterm births. National Women’s reports both iatrogenic and spontaneous preterm births to monitor these rates over time.

The rate of preterm birth in the local population is 7.7%. This is similar to the rate in Australia (8%) and in Europe (6.2%). The highest rates of preterm birth were in Africa and North America 11.9% and 10.6% of all births, respectively (Bulletin of the World Health Organization).

The advent of progesterone therapy for the prevention of preterm labour has the potential to decrease the rate of preterm delivery. Unfortunately the overall impact of this therapy is limited, as it is currently used for women at increased risk of preterm birth and the majority of women who deliver preterm have no recognisable risk factors.

The survival rate for babies born prematurely is excellent. Accurate assessment of gestational age is necessary to ensure reliable data. Small changes in gestational age around the time of viability can result in a significant change in outcome. It is important to note that all of the babies born alive at 24 weeks gestation survived for more than 28 days. Early recognition of preterm labour allows the extremely preterm neonate to be born in optimal condition with a good chance of survival even at 24 weeks.

Preterm birth remains the leading cause of neonatal death, and is second only to congenital anomaly as a cause of perinatal death (PMMRC, 2012). Mäori women remain more likely to deliver preterm than women of other ethnicities. The PMMRC has identified that access to care and poverty are risk factors which are associated with perinatal death.

8. antenatal comPlications


72 |

TaBle 32: preTerm raTes By maTernal age group For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Gestation No. % No. % No. % No. % No. % No. % No. %

< 24 weeks 3 1.7 3 0.6 7 0.8 11 0.9 6 0.7 0 0.0 30 0.8

24+0 – 27+6 2 1.2 8 1.6 10 1.2 13 1.1 9 1.0 7 2.9 49 1.3

28+0 – 31+6 7 4.1 13 2.6 16 1.9 15 1.2 14 1.5 7 2.9 72 1.9

32+0 – 35+6 6 3.5 16 3.2 33 4.0 39 3.2 32 3.5 12 4.9 138 3.6

36+0 – 36+6 4 2.3 20 4.0 29 3.5 28 2.3 34 3.8 9 3.7 124 3.2

All < 32 weeks 12 7.0 24 4.8 33 4.0 39 3.2 29 3.2 14 5.7 151 3.9

All < 37 weeks 22 12.8 60 12.0 95 11.5 106 8.8 95 10.5 35 14.3 413 10.7

TaBle 33: preTerm raTes By maTernal eThniciTy group For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Gestation No. % No. % No. % No. % No. % No. % No. %

< 24 weeks 13 0.7 1 0.2 9 1.9 2 0.6 5 0.9 0 0.0 30 0.8

24+0 – 27+6 26 1.4 6 1.3 12 2.5 2 0.6 3 0.6 0 0.0 49 1.3

28+0 – 31+6 31 1.6 10 2.2 15 3.1 7 1.9 6 1.1 3 2.9 72 1.9

32+0 – 35+6 71 3.7 11 2.4 18 3.7 15 4.2 17 3.2 6 5.9 138 3.6

36+0 – 36+6 58 3.0 6 1.3 16 3.3 12 3.3 28 5.2 4 3.9 124 3.2

All < 32 weeks 70 3.7 17 3.7 36 7.5 11 3.1 14 2.6 3 2.9 151 3.9

All < 37 weeks 199 10.4 34 7.4 70 14.6 38 10.6 59 11.0 13 12.7 413 10.7


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TaBle 34: perinaTal ouTcome oF preTerm BirThs By gesTaTion For 2012

GestationTotal births

Fetal deaths

Live births

% Live births of Total

Neonatal deaths < 28 days

% of live births surviving ≥ 28 days

20 3 3 0 0.0 0 0.0

21 7 7 0 0.0 0 0.0

22 12 11 1 8.3 1 0.0

23 9 5 4 44.4 1 75.0

24 11 3 8 72.7 0 100.0

25 11 2 9 81.8 0 100.0

26 21 4 17 91.0 0 100.0

27 14 1 13 92.9 1 92.3

28 17 0 17 100.0 2 88.2

29 13 0 13 100.0 0 100.0

30 27 1 26 96.3 1 96.2

31 27 0 27 100.0 1 96.3

32 19 1 18 94.7 0 100.0

33 32 0 32 100.0 0 100.0

34 43 1 42 97.7 1 97.6

35 66 0 66 100.0 0 100.0

36 134 0 134 100.0 0 100.0

Total 466 39 427 91.6 8 98.1


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8.2 multiPle Pregnancy

Birth rates for multiple pregnancies have remained stable. At term there were no multiple pregnancies that had a spontaneous labour. Not awaiting labour is supported by a study undertaken by JM Dodd et al, 2012. Further data considering other outcomes for multiple pregnancies may be worthwhile.

There were no births in 2012 where there was a vaginal birth for the first twin followed by a caesarean section for the second twin.

TaBle 35: mulTiple pregnancy numBers anD raTes For years 2003 To 2012

Mothers 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Multiple pregnancies

No. % No. % No. % No. % No. % No. % No. % No. % No. % No. %

Twin 84 2.14 91 2.46 81 2.16 72 1.81 93 2.30 88 2.20 81 2.03 88 2.26 78 1.99 66 1.71

Triplet 4 0.10 3 0.08 1 0.03 1 0.03 2 0.05 2 0.05 4 0.10 3 0.08 3 0.08 2 0.05

Total 88 2.24 94 2.54 82 2.18 73 1.84 95 2.35 90 2.25 85 2.13 91 2.34 81 2.07 68 1.77


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Figure 7: laBour anD BirTh Branch Diagram For all Women WiTh mulTiple pregnancies For 2012

Pre-labour CS 31 / 51 = 60.8%

% of Total No.

CS 31 100.0% 45.6

Pre-term 51 / 68 = 75.0%

Spontaneous Labour 41 / 51 = 27.5%

% of Total No.

NVB 5 9.8% NVB 4 26.8% 5.9AVB 9 17.6% AVB 7 50.0% 10.3CS 37 72.5% CS 3 21.4% 4.4 51 100% 14 100% 20.6

Induced Labour 6 / 51 = 11.8%

% of Total No.

NVB 1 16.7% 1.5All Women with multiple pregnancies No. = 68

AVB 2 33.3% 2.9CS 3 50.0% 4.4

NVB 7 10.3% 6 100% 8.8

AVB 14 20.6%CS 47 69.1% 68 100%

Pre-labour CS 6 / 17 = 35.3%

% of Total No.

CS 6 100% 8.8

Term 17 / 68 = 25.0%


% of Total No.



% of Total No.

NVB 2 18.2% 2.9AVB 5 45.5% 7.4CS 4 36.4% 5.9 11 100% 16.2

100


76 |

8.3 diabetes in Pregnancy

4.8% (185 / 3850) of women who gave birth in 2012 at C&C DHB had a diagnosis of pre-existing or gestational diabetes. 4.1% (158 / 3850) had GDM,

0.3% (12 / 3850) Type 1 diabetes, and 0.4% (15 / 3850) Type 2 diabetes.

TaBle 36: eThniciTy oF Women WiTh gDm anD Type 2 DiaBeTes giving BirTh in 2012

GDM Type 2

Ethnicity Number Of total births % Number Of total births %

NZ European 58 1912 3.0 2 1912 0.1

Other European 15 461 3.3 0 461 0.0

Mäori 10 481 2.1 5 481 1.0

Pacific Peoples 18 359 5.0 5 359 1.4

Asian 51 535 9.5 3 535 0.6

Other 6 102 5.9 0 102 0.0

Total 158 3850 4.1 15 3850 0.4

TaBle 37: eThniciTy DisTriBuTion WiThin DiaBeTes Type For Women aTTenDing clinic in 2012

GDM Type 1 Type 2 Total

Ethnicity No. % No. % No. % No. %

NZ European 72 37.9 18 78.3 5 17.9 95 39.4

Other European 16 8.4 1 4.3 0 0.0 17 7.1

Mäori 13 6.8 1 4.3 7 25.0 21 8.7

Pacific Peoples 23 12.1 2 8.7 10 35.7 35 14.5

Asian 59 31.1 1 4.3 6 21.4 66 27.4

Other 7 3.7 0 0.0 0 0.0 7 2.9

Total 190 100 23 100 28 100 241 100

Given the number of Pacific Peoples with Type 2 diabetes it is surprising to see the relatively low rates of gestational diabetes (GDM) in this ethnic group. As GDM is often seen as a precursor to Type 2 diabetes it could be expected that the rate of GDM in Pacific Peoples would mirror the rate of Type 2 diabetes in that ethnic group. This may be related to them not being screened, having a false negative screen (Sacks et al, 1989) or reflect the need for ethnically appropriate cut offs for the 50g glucose screen (Nahum

and Huffaker, 1993), (Esakof et al, 2005). National Women’s Annual Report (2011) noted a similar trend with Pacific women and has seen this group over-represented in a group in their clinic that were diagnosed using HbA1c with a normal OGTT. They found 90% of this group needed treatment. Certain ethnic groups are at risk of diabetes. Our women with diabetes reflect the higher rates in Pacific and Asian groups.


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TaBle 38: moDe oF BirTh By DiaBeTes Type For BirThs in 2012 WiThin c&c DhB

Mothers Gestational Type 1 Type 2 Total

Mode No. % No. % No. % No. %

Vaginal

Normal 71 44.9 2 16.7 6 40.0 79 42.7

Forceps 9 5.7 0 0.0 0 0.0 9 4.9

Ventouse 5 3.2 0 0.0 0 0.0 5 2.7

Manual rotation 0 0.0 0 0.0 0 0.0 0 0.0

Breech 0 0.0 0 0.0 0 0.0 0 0.0

85 53.8 2 16.7 6 40.0 93 50.3

Caesarean

Emergency 45 28.5 3 25.0 4 26.7 52 28.1

Elective 28 17.7 7 58.3 5 33.3 40 21.6

73 46.2 10 83.3 9 60.0 92 49.7

Total 158 100 12 100 15 100 185 100

Generally for the diabetes population there is a caesarean rate of 40-50%. Women with pre-existing diabetes often are reported with caesarean section rates around 50-67% (Jensen et al, 2004), (Gunton et al, 2000), (Bell et al, 2008).

There is a high caesarean section rate in women with Type 1 diabetes although the numbers of women with Type 1 diabetes is small.


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8.4 maternal fetal medicine service & ultrasound scan service

The number of referrals to the MFM service and the origin of those referrals have remained relatively stable over the last three years. The service also provides outreach clinics at Taranaki District Health Board once a month. These referrals are not included in the C&C DHB data.

Over the last three years women have been identified by referral category at the initial consultation. The categories have been designed to reflect the two main functions of the service, namely screening and fetal anomaly management, but also several specific fetal

conditions which require either protracted follow-up (twins and RBC antibodies) or considerable inter-regional coordination (cardiac conditions).

With the advent of tele-radiology there have been an increasing number of women managed remotely. This can often be very effective, but is mostly limited by the quality of the ultrasound examination at the referring centre. The MFM service has run educational sessions in the Hawkes Bay and Taranaki to improve the quality of referrals and increase the number of women who are managed locally.

TaBle 39: reFerrals To maTernal FeTal meDicine For years 2010 To 2012

2010 2011 2012

Category No. % No. % No. %

Screening 153 29.4 93 17.7 104 21.7

Multiple pregnancy 22 4.2 38 7.2 15 3.1

Red blood cell antibodies 13 2.5 15 2.9 6 1.3

Cardiac 21 4.0 27 5.1 29 6.1

New (Others) 312 59.9 322 61.2 294 61.4

Telemedicine 0 0.0 31 5.9 31 6.5

Total women referred 521 100 526 100 479 100

Follow up visits 737 718 695

Average visits per patient 3.1 2.4 3.0

The perinatal ultrasound unit provides MFM ultrasound services for the central region. It also undertakes obstetric and gynaecology scanning for women referred to the WHS. The service undertakes approximately 5,000 obstetric and MFM scans a year and 1500 gynaecology scans and this number has remained relatively constant.


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TaBle 40: ulTrasounD scanning service volumes For years 2008 To 2012

2008 2009 2010 2011 2012

Scan or procedure No. % No. % No. % No. % No. %

Early pregnancy scan 863 20.5 750 18.8 460 13.3 410 12.1 507 14.0

Growth scan (≥ 20 weeks) 2707 64.3 2578 64.5 2461 71.4 2483 73.3 2555 70.9

Morphology scan 643 15.3 668 16.7 528 15.3 496 14.6 544 15.1

Total Obstetrics 4213 100 3996 100 3449 100 3389 100 3606 100

MFM scan 1081 76.8 1426 83.5 1327 83.8 1354 87.4 1151 86.2

Amniocentesis 186 13.2 172 10.1 133 8.4 102 6.6 105 7.9

Chorionic villus sampling 89 6.3 77 4.5 55 3.5 45 2.9 52 3.9

Fetal blood sampling 4 0.3 2 0.1 6 0.4 1 0.1 1 0.1

Intrauterine blood transfusion 8 0.6 9 0.5 21 1.3 13 0.8 4 0.3

Amnio drainage 7 0.5 9 0.5 19 1.2 13 0.8 7 0.5

Amnio infusion 0 0.0 2 0.1 2 0.1 0 0.0 0 0.0

Platelet transfusion 1 0.1 1 0.1 4 0.3 0 0.0 1 0.1

Shunt 2 0.1 0 0.0 1 0.1 1 0.1 0 0.0

Embryo reduction/fetocide 9 0.6 6 0.4 10 0.6 12 0.8 11 0.8

Other sampling 20 1.4 4 0.2 6 0.4 8 0.5 3 0.2

Total MFM 1407 100 1708 100 1584 100 1549 100 1335 100

Gynaecology 1475 1485 1547 1451 1456

The screening programme for Down syndrome and other conditions was introduced in 2010. There was a steady decrease in the number of referrals for invasive diagnostic procedures with 23% fewer tests performed in 2011 than in 2010. The indications for invasive testing in 2012 have remained very similar to those in 2011. Increased combined risk is now the most common indication for an invasive test. Some invasive tests will be performed on the basis of NT alone. This is usually when there is a markedly increased nuchal translucency or cystic hygroma. There has been a slight increase in the number of women having an invasive test for an increased MSS2, but it would appear that the majority of women being screened are having the combined test, which is in line with Ministry of Health recommendations. The steady

decrease in the number of invasive tests at 20 weeks over the last 5 years has plateaued. This was probably due to improved detection of anomalies due to the introduction of first trimester screening.

Although the data from 2012 is very similar to the data from 2011, the rates of invasive testing is highly likely to change with the introduction of Non Invasive Prenatal Diagnosis (NIPD). At present this test is neither publicly funded nor integrated into the screening programme. NIPD has not been validated for a low risk population. The NZ MFM network and RANZCOG have recommended that the test not be introduced in New Zealand (current cost about $2,000) until it is validated for a low risk population and/or integrated into the current screening programme.


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TaBle 41: amniocenTesis anD cvs inDicaTions For years 2008 To 2012

2008 2009 2010 2011 2012

Indication No. % No. % No. % No. % No. %

Increased combined risk 4 1.5 6 2.4 42 22.3 58 39.5 57 36.3

Increased risk on NT 117 42.5 91 36.5 32 17.0 16 10.9 17 10.8

Increased risk on maternal serum screen 2 0.7 26 10.4 31 16.5 4 2.7 10 6.4

Subtotal 123 44.7 123 49.4 105 55.9 78 53.1 84 53.5

Previous chromosomally abnormal child 8 2.9 14 5.6 6 3.2 9 6.1 9 5.7

Advanced maternal age 50 18.2 18 7.2 5 2.7 2 1.4 3 1.9

Maternal anxiety 11 4.0 10 4.0 7 3.7 4 2.7 4 2.5

Subtotal 69 25.1 42 16.9 18 9.6 15 10.2 16 10.2

Carrier of genetic disease 13 4.7 13 5.3 8 4.3 12 8.2 9 5.7

Carrier of balanced translocation 3 1.1 1 0.4 4 2.1 2 1.4 1 0.6

Subtotal 16 5.8 14 5.6 12 6.4 14 9.5 10 6.4

Fetal abnormality 39 14.2 34 13.7 30 16.0 13 8.8 17 10.8

Abnormalities on 20 week scan 15 5.5 19 7.6 16 8.5 10 6.8 13 8.3

Abnormalities on subsequent scan 3 1.1 5 2.0 7 3.7 12 8.2 13 8.3

Subtotal 57 20.7 58 23.3 53 28.2 35 23.8 43 27.4

Other or not specified 10 3.6 12 4.8 5 3.4 4 2.5

Total 275 100 249 100 188 100 147 100 157 100

In 2011 there was one miscarriage after an amniocentesis (0.5%). That was in a twin pregnancy where one of the twins had hydrops and there was a high risk of miscarriage prior to the test. There were three stillbirths after amniocentesis, one with multiple anomalies and two with severe IUGR.

The data for 2012 is incomplete (January to September) as some babies have not been born yet. There were four stillbirths after amniocentesis, one fetus had severe hydrops due to parvovirus, one

Trisomy 13 and two with severe IUGR. There was one woman who had an amniotic fluid leak following amniocentesis but this settled and she delivered at term. There were no pregnancy losses directly attributable to the procedure.

The data does not include multiple pregnancy reduction or complications from other invasive procedures. The data outcomes for women delivering outside C&C DHB remain incomplete.


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TaBle 42: ouTcomes aFTer amniocenTesis anD cvs For 2011 anD 2012 (Jan-sep)

Outcome 2011 2012

No. % No. %

Miscarriage 1 0.5 0 0.0

TOP 42 22.2 34 21.9

Trisomy 21 10 5.3 14 9.0

Trisomy 18 8 4.2 8 5.2

Trisomy 13 2 1.1 3 1.9

Turners 4 2.1 0 0.0

Other 1 0.5 5 3.2

Stillbirth 3 1.6 4 2.6

Livebirth 113 59.8 79 51.0

Not known 5 2.6 8 5.2

Total 189 100 155 100

8.5 maternal cardiac

The obstetric anaesthetic cardiology service was created to streamline the management of maternal cardiac related conditions during pregnancy.

The aetiology of women presenting to this service varies significantly and includes valvular lesions and replacements, cardiomyopathy and dysrhythmias with and without internal cardiac defibrillators. During the latter part of 2012 all women with cardiac conditions were assigned to the same obstetric clinic in order to optimise continuity of care.

The multidisciplinary team meets once a month to discuss referrals and includes three obstetricians dedicated to high risk obstetrics, a MFM specialist, an anaesthetist and two cardiologists.

Over the past few years the number of women being referred to this service has steadily increased from five in 2009 to 33 in 2011. The number of women presenting in 2012 is currently incomplete.

An electronic interdepartmental case review template has recently been created on the Medical Applications Portal. This has significantly improved the accessibility of our management plans and will allow us to enhance the service and improve data collection. The template is currently available to clinicians at Capital and Coast, Wairarapa and Hutt Valley DHBs and is due to be extended to other DHBs in the lower North Island in 2013.

Challenges continue to be:

• Building a national support network to assist clinicians managing these women

• Optimising the care of pregnant women with cardiac conditions

• Increasing the awareness of this service.


82 |


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In this section, labour and mode of birth are analysed by maternal age, ethnicity and parity group. Induction of labour and breech presentation are discussed.

Labour and birth branch diagrams are presented using data for 2012 for the following four parity groups:

• All women

• Primiparous women

• Multiparous women without previous CS

• Multiparous women with previous CS

Each branch diagram shows the number of women whose birth was at term (37+0 weeks and over) or pre-term (under 37+0 weeks gestation). These two groups are further subdivided into the type of labour

experienced (spontaneous, induced, or pre-labour CS). Within each category, mode of birth is detailed.

The three labour categories (spontaneous, induced, and pre-labour CS) used to determine the onset of labour have been defined from two date and time fields in the PIMS database. As there is no specific field in PIMS to define an induction of labour, the time difference between the fields “labour established” and “induction or augmentation started” has been calculated and used for the above categories. The labour category for some women may not be correct because of incomplete data.

After the branch diagrams, figures for mode of birth by age group are presented for each of the parity groups described above.

9. labour and birth


84 |

9.1 mode of birth

Mode of birth statistics are presented in the next table for the years 2003 to 2012. The following figure shows the mode of birth groups (normal, assisted, CS) for the years 1997 to 2012.

The normal birth rate has remained under 60% for the last three years. The caesarean section rate has

remained stable for the last two years at just under 31%. The assisted vaginal birth rate also remains stable at about 11.5%.

TaBle 43: moDe oF BirTh For years 2003 To 2012

Mothers 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Mode of Birth

No. % No. % No. % No. % No. % No. % No. % No. % No. % No. %

Vaginal

Normal 2420 61.6 2270 61.3 2278 60.7 2338 58.9 2413 59.6 2438 61.0 2442 61.1 2300 59.1 2226 56.8 2224 57.8

Forceps 238 6.1 191 5.2 200 5.3 243 6.1 232 5.7 222 5.6 187 4.7 227 5.8 259 6.6 215 5.6

Ventouse 173 4.4 166 4.5 212 5.6 164 4.1 199 4.9 205 5.1 245 6.1 174 4.5 198 5.1 192 5.0

Manual Rotation

4 0.1 1 0.0 1 0.0 2 0.1 0 0.0 1 0.0 0 0.0 0 0.0 1 0.0 1 0.0

Breech 25 0.6 20 0.5 19 0.5 33 0.8 26 0.6 19 0.5 28 0.7 38 1.0 25 0.6 27 0.7

Total Vaginal

2860 72.8 2648 71.5 2710 72.2 2780 70.1 2870 70.9 2885 72.1 2902 72.6 2739 70.4 2709 69.2 2659 69.1

Caesarean

Emergency 707 18.0 743 20.1 722 19.2 787 19.8 790 19.5 735 18.4 686 17.2 717 18.4 780 19.9 758 19.7

Elective 360 9.2 312 8.4 322 8.6 400 10.1 387 9.6 379 9.5 407 10.2 435 11.2 428 10.9 433 11.2

Total Caesarean

1067 27.2 1055 28.5 1044 27.8 1187 29.9 1177 29.1 1114 27.9 1093 27.4 1152 29.6 1208 30.8 1191 30.9

Total 3927 100 3703 100 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100


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Figure 8: moDe oF BirTh group raTes For years 1997 To 2012, For all c&c DhB FaciliTies comBineD

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

80.0 %

70.0 %

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Normal CS Assisted

See Table 117 in the Appendices for the percentages values used in the above figure.

Note that “normal vaginal birth” has been assigned to all the births at Kenepuru Maternity Unit before 2002 and to all births at Paraparaumu Maternity Unit before

2005. This was before the PIMS database was used at these units and numbers of births were collected manually. Some forceps births were done by GP LMCs at Kenepuru Maternity in the years before 2002 but the exact numbers are unknown.


86 |

The following two tables present the mode of birth numbers for 2012 by age group and by ethnicity group.

Mode of birth varied markedly with maternal age. Younger women had the highest rates of normal birth. Total caesarean section rates rose from 20.3%

in those women less than 20 years of age to 47.3% for women aged 40 years and older.

Mode of birth also varied between ethnicity groups. Pacific and Mäori women had the lowest total caesarean section rates of 26.5% and 27.0% respectively.

TaBle 44: moDe oF BirTh By age group For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Mode of birth No. % No. % No. % No. % No. % No. % No. %

Vaginal

Normal 116 67.4 330 66.3 494 59.8 692 57.4 481 53.2 111 45.3 2224 57.8

Forceps 11 6.4 25 5.0 44 5.3 73 6.1 51 5.6 11 4.5 215 5.6

Ventouse 9 5.2 25 5.0 49 5.9 73 6.1 31 3.4 5 2.0 192 5.0

Manual rotation 0 0.0 0 0.0 0 0.0 1 0.1 0 0.0 0 0.0 1 0.0

Breech 1 0.6 1 0.2 7 0.8 9 0.7 7 0.8 2 0.8 27 0.7

137 79.7 381 76.5 594 71.9 848 70.4 570 63.1 129 52.7 2659 69.1

Caesarean

Emergency 32 18.6 89 17.9 158 19.1 218 18.1 191 21.1 70 28.6 758 19.7

Elective 3 1.7 28 5.6 74 9.0 139 11.5 143 15.8 46 18.8 433 11.2

35 20.3 117 23.5 232 28.1 357 29.6 334 36.9 116 47.3 1191 30.9

Total 172 100 498 100 826 100 1205 100 904 100 245 100 3850 100

TaBle 45: moDe oF BirTh By eThniciTy group For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Mode No. % No. % No. % No. % No. % No. % No. %

Vaginal

Normal 1091 57.1 238 51.6 309 64.2 243 67.7 294 55.0 49 48.0 2224 57.8

Forceps 110 5.8 34 7.4 18 3.7 11 3.1 32 6.0 10 9.8 215 5.6

Ventouse 99 5.2 31 6.7 17 3.5 10 2.8 29 5.4 6 5.9 192 5.0

Manual rotation 0 0.0 1 0.2 0 0.0 0 0.0 0 0.0 0 0.0 1 0.0

Breech 14 0.7 3 0.7 7 1.5 0 0.0 3 0.6 0 0.0 27 0.7

1314 68.7 307 66.6 351 73.0 264 73.5 358 66.9 65 63.7 2659 69.1

Caesarean

Emergency 378 19.8 96 20.8 85 17.7 61 17.0 112 20.9 26 25.5 758 19.7

Elective 220 11.5 58 12.6 45 9.4 34 9.5 65 12.1 11 10.8 433 11.2

598 31.3 154 33.4 130 27.0 95 26.5 177 33.1 37 36.3 1191 30.9

Total 1912 100 461 100 481 100 359 100 535 100 102 100 3850 100


| 87

9.2 labour and birth by Parity grouP

Figure 9: laBour anD BirTh Branch Diagram For all Women For 2012

Pre-labour CS 154 / 413 = 37.3%

% of Total No.

CS 154 100.0% 4.0

Pre-term 413 / 3850 = 10.7%


% of Total No.



% of Total No.

NVB 63 54.8% 1.6All Women

Total No. = 3850AVB 20 17.4% 0.5CS 32 27.8% 0.8

NVB 2224 57.8% 115 100% 3.0

AVB 435 11.3%CS 1191 30.9% 3850 100%

Pre-labour CS 448 / 3437 = 13.0%

% of Total No.

CS 448 100% 11.6

Term 3437 / 3850 = 89.3%


% of Total No.


Induced Labour 978 / 3437 = 28.5%

% of Total No.

NVB 537 54.9% 13.9AVB 168 17.2% 4.4CS 273 27.9% 7.1 978 100% 25.4

100

Labour No. %

Spontaneous 2155 56.0Induced 1093 28.4Pre-labour CS 602 15.6Total 3850 100


88 |

Figure 10: laBour anD BirTh Branch Diagram For primiparous Women For 2012

Pre-labour CS 56 / 181 = 30.9%

% of Primip No.

CS 56 100.0% 3.2

Pre-term 181 / 1741 = 10.4%


% of Primip No.



% of Primip No.

NVB 23 43.4% 1.3Primiparous No. = 1741

AVB 10 18.9% 0.6CS 20 37.7% 1.1

NVB 810 46.5% 53 100% 3.0

AVB 342 19.6%CS 589 33.8% 1741 100%

Pre-labour CS 100 / 1560 = 6.4%

% of Primip No.

CS 100 100% 5.7

Term 1560 / 1741 = 89.6%


% of Primip No.


Induced Labour 578 / 1560 = 37.1%

% of Primip No.

NVB 212 36.7% 12.2AVB 138 23.9% 7.9CS 228 39.4% 13.1 578 100% 33.2

100

Labour No. %



| 89

Figure 11: laBour anD BirTh Branch Diagram For mulTiparous Women WiThouT previous cs For 2012

Pre-labour CS 50 / 161 = 31.1%

% of Multip No.

CS 50 100% 3.2

Pre-term 161 / 1541 = 10.4%


% of Multip No.



% of Multip No.

NVB 37 67.3% 2.4Multiparous without

previous CS No. = 1541AVB 8 14.5% 0.5CS 10 18.2% 0.6

NVB 1317 85.5% 55 100% 3.6

AVB 53 3.4%CS 171 11.1% 1541 100%

Pre-labour CS 49 / 1380 = 3.6%

% of Multip No.

CS 49 100% 3.2

Term 1380 / 1541 = 89.6%


% of Multip No.


Induced Labour 357 / 1380 = 25.9%

% of Multip No.

NVB 311 87.1% 20.2AVB 20 5.6% 1.3CS 26 7.3% 1.7 357 100% 23.2

100

Labour No. %



90 |

Figure 12: laBour anD BirTh Branch Diagram For mulTiparous Women WiTh previous cs For 2012

Pre-labour CS 48 / 71 = 67.6%

% of Multip No.

CS 48 100% 8.5

Pre-term 71 / 568 = 12.5%


% of Multip No.



% of Multip No.

NVB 3 42.9% 0.5

Multiparous with previous CS No. = 568

AVB 2 28.6% 0.4

CS 2 28.6% 0.4

NVB 97 17.1% 7 100% 1.2

AVB 40 7.0%CS 431 75.9% 568 100%

Pre-labour CS 299 / 497 = 60.2%

% of Multip No.

CS 299 100% 52.6

Term 497 / 568 = 87.5%


% of Multip No.



% of Multip No.

NVB 14 32.6% 2.5AVB 10 23.3% 1.8CS 19 44.2% 3.3 43 100% 7.6

100

Labour No. %



| 91

Figure 13: moDe oF BirTh group By age group For all Women For 2012

Normal CS Assisted


80.0 %

70.0 %

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

(The numbers and percentages for this figure are in Table 118 in the Appendices).

Figure 14: moDe oF BirTh group By age group For primiparous Women For 2012


70.0 %

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

Normal CS Assisted



92 |

Figure 15: moDe oF BirTh group By age group For mulTiparous Women WiThouT previous cs For 2012


100.0 %

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%


Figure 16: moDe oF BirTh group By age group For mulTiparous Women WiTh previous cs For 2012


100.0 %

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%


NB The 100% CS rate for the “< 20 years” group is for 3 women who have had one or more previous CS.

Normal CS Assisted

Normal CS Assisted


| 93

9.3 various rates

The ACHS clinical indicator tabulated here is for women who have had a vaginal birth following one previous caesarean section (VBAC). C&C DHB rates were above the peer group rates for most six-monthly

periods but the aggregate rates were not outside the 99% confidence intervals.

TaBle 46: peer group comparison For achs oBsTeTric clinical inDicaTor 2.1

C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012

Clinical Indicator Period Rate (%) Rate (%) Rate (%) Rate (%) Rate (%) Rate (%)

2.1 Vaginal delivery following a previous primary caesarean section (N)

Jan-Jun 26.67 20.69 19.89 20.11 19.27 18.55

Jul-Dec 21.74 22.95 27.68 21.87 18.29 19.43

(L) – A low rate is desirable(H) – A high rate is desirable (N) – Desirable rate is unspecified Rates in italic / greyed highlight results that require attention. Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.


94 |

Various other rates are tabulated in the next table.

39.8% of all births in 2012 were “normal births”. These are defined as women who went to term and had a spontaneous labour and had a normal vaginal birth. This rate has remained around 40% for the last four years.

About 55% of all elective CS in 2012 were performed where the indication was a history of one or more previous CS.

The episiotomy rate has been about 14% for each of the last three years.

TaBle 47: various raTes For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Variable *Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

Num. Den.

Rate %

“Normal birth”

1625 43.3 1634 41.2 1709 42.2 1765 44.1 1661 41.6 1586 40.8 1517 38.7 1532 39.8

3754 3967 4047 3999 3995 3891 3917 3850

Elective CS for previous CS

155 48.1 189 47.3 198 51.2 190 50.1 227 55.8 257 59.1 217 50.7 241 55.7

322 400 387 379 407 435 428 433

Emergency CS in established labour

503 69.7 561 71.3 555 70.3 535 72.8 473 69.0 486 67.8 540 69.2 522 68.9

722 787 790 735 686 717 780 758

Primary CS688 21.1 784 22.9 774 22.2 710 20.8 688 19.9 720 21.8 790 23.5 760 23.2

3268 3429 3485 3416 3463 3306 3365 3282

Episiotomy477 12.7 473 11.9 493 12.2 459 11.5 514 12.9 551 14.2 550 14.0 522 13.6

3754 3967 4047 3999 3995 3891 3917 3850

* Definitions:“Normal birth” - defined as women who went to term and had a spontaneous labour and had a normal vaginal birth (see branch diagrams in Labour and Birth section).“Elective CS for previous CS” - Proportion of total elective CS performed when the primary documented indication is an obstetric history of one or more previous CS.“Emergency CS in established labour” - Proportion of total emergency CS performed in established labour “Primary CS” - Number of women having their first CS, divided by total number of women without a previous CS.


| 95

9.4 induction of labour

Postdates, prelabour SRM, abnormal fetal monitoring, hypertension and diabetes were the main indications listed in the database for induction of labour.

TaBle 48: primary inDicaTion For inDucTion oF laBour By pariTy anD cs hisTory group For 2012


previous CS

Multiparous, with previous

CSTotal

Primary indication No. % No. % No. % No. %

Postdates 168 26.6 104 25.2 14 28.0 286 26.2

Prelabour SRM 101 16.0 55 13.3 10 20.0 166 15.2

Hypertension 63 10.0 20 4.9 1 2.0 84 7.7

Diabetes 53 8.4 28 6.8 2 4.0 83 7.6

Maternal disease 30 4.8 25 6.1 1 2.0 56 5.1

Maternal request 2 0.3 16 3.9 1 2.0 19 1.7

Antepartum haemorrhage 6 1.0 2 0.5 1 2.0 9 0.8

Multiple gestation 10 1.6 5 1.2 0 0.0 15 1.4

IUGR 42 6.7 34 8.3 1 2.0 77 7.0

Abnormal fetal monitoring 61 9.7 34 8.3 3 6.0 98 9.0

Fetal abnormality 10 1.6 6 1.5 1 2.0 17 1.6

Intrauterine fetal demise 4 0.6 10 2.4 0 0.0 14 1.3

Other 81 12.8 73 17.7 15 30.0 169 15.5

Total 631 100 412 100 50 100 1093 100

Parity group induction rates 631 1741

36.2412

154126.7

50568

8.810933850

28.4


96 |

TaBle 49: moDe oF BirTh aFTer inDucTion oF laBour For main primary inDicaTion groups For 2012

Mothers Primiparous Multiparous, no

previous CS

Multiparous, with previous

CSTotal

Main IOL indication groups No. % No. % No. % No. %

Postdates

NVB 55 32.7 92 88.5 1 7.1 148 51.7

AVB 36 21.4 5 4.8 4 28.6 45 15.7

CS 77 45.8 7 6.7 9 64.3 93 32.5

168 100 104 100 14 100 286 100

Prelabour SRM

NVB 48 47.5 47 85.5 6 60.0 101 60.8

AVB 17 16.8 3 5.5 1 10.0 21 12.7

CS 36 35.6 5 9.1 3 30.0 44 26.5

101 100 55 100 10 100 166 100

Hypertension

NVB 21 33.3 14 70.0 0 0.0 35 41.7

AVB 20 31.7 2 10.0 0 0.0 22 26.2

CS 22 34.9 4 20.0 1 100.0 27 32.1

63 100 20 100 1 100 84 100

Abnormal fetalmonitoring

NVB 21 34.4 28 82.4 2 66.7 51 52.0

AVB 15 24.6 2 5.9 0 0.0 17 17.3

CS 25 41.0 4 11.8 1 33.3 30 30.6

61 100 34 100 3 100 98 100

Diabetes

NVB 17 32.1 28 100.0 1 50.0 46 55.4

AVB 11 20.8 0 0.0 0 0.0 11 13.3

CS 25 47.2 0 0.0 1 50.0 26 31.3

53 100 28 100 2 100 83 100

All Indications

NVB 235 37.2 348 84.5 17 34.0 600 54.9

AVB 148 23.5 28 6.8 12 24.0 188 17.2

CS 248 39.3 36 8.7 21 42.0 305 27.9

631 100 412 100 50 100 1093 100


| 97

9.5 breech Presentation and external cePhalic version (ecv)

83.3% of all singleton breech births were delivered by caesarean section. Almost 95% of all term singleton breech births were performed by CS.

Figure 17: laBour anD BirTh Branch Diagram For singleTon Breech presenTaTions For 2012

Pre-labour CS 34 / 66 = 51.5%

% of Total No.

CS 34 100% 23.6

Pre-term 66 / 144 = 45.8%


% of Total No.



% of Total No.

NVB 0 0.0% 0.0

All women with singleton breech presentations No. = 144

AVB 13 92.9% 9.0

CS 1 7.1% 0.7

NVB 0 0.0% 14 100% 9.7

AVB 24 16.7%CS 120 83.3% 144 100%

Pre-labour CS 62 / 78 = 79.5%

% of Total No.

CS 62 100% 43.1

Term 78 / 144 = 54.2%


% of Total No.



% of Total No.

NVB 0 0.0% 0.0AVB 1 20.0% 0.7CS 4 80.0% 2.8 5 100% 3.5

100


98 |

external cePhalic version

This is the first time that data has been presented on ECV. C&C DHB’s Decision Support Unit identified 19 women who attempted an ECV in 2012. Fifteen of the 19 ECVs undertaken were successful (78.9%). This rate indicates that the women who were selected were well chosen.

Eighty-seven percent of the women who had a successful ECV achieved a vaginal birth, and this is consistent with the range of rates reported internationally (63–85%). 11 women achieved a normal

vaginal birth (two of which were home births), two women required a Ventouse, and two women required an emergency caesarean section for other reasons.

Of the four unsuccessful ECVs, three women had an elective caesarean section and one woman had an assisted vaginal breech birth.

ECV is a safe procedure that is effective in reducing the number of breech presentations near term. Looking at the rates of women attempting ECV in other DHBs it could be suggested that we should be encouraging this procedure more.


| 99

9.6 outcome of selected PrimiPara (achs)

Refer to section 1.3 for the introduction commentary on ACHS clinical indicators. See the complete table with peer comparisons for 2012 in the Appendices (Table 122).

ACHS clinical indicators 1.1 to 1.4 pertain to a specific group of women called the “selected primipara”. These are defined as:

• a woman who is 20 to 34 years of age at the time of giving birth

• giving birth for the first time at >20 weeks gestation

• singleton pregnancy

• cephalic presentation

• at 37+0 to 41+0 weeks gestation

Indicator 1.1: The rate of spontaneous vaginal birth reported in this group helps control for differences in case mix and increases the validity of those comparisons between organisations. C&C DHBs half yearly rates of 42.05% and 39.15% in 2012 are undesirably lower when compared to the peer organisations and require further attention.

Indicator 1.4: In the second six month period of 2012 the rate for selected primipara undergoing caesarean section was higher than for all organisations. Caesarean section rates for primiparous women are a complex area with multiple contributing factors and are an issue that the WHS are addressing. Regular fetal surveillance education is required of all clinicians employed within C&C DHB and we are working towards holding regular cardiotocograph meetings. In addition, the introduction of the lactate meter and a comprehensive review of the induction of labour process will help to improve outcomes.

TaBle 50: peer group comparison For achs oBsTeTric clinical inDicaTors 1.1 To 1.4

C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012

Clinical Indicator PeriodRate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

1.1 Selected primipara who have a spontaneous vaginal birth (H)

Jan-Jun 42.26 39.92 42.05 51.63 48.90 48.28

Jul-Dec 41.34 39.74 39.15 50.16 48.45 47.62

1.2 Selected primipara who undergo induction of labour (L)

Jan-Jun 29.64 29.75 31.20 30.32 31.48 31.22

Jul-Dec 29.12 25.82 28.49 30.06 32.30 31.95

1.3 Selected primipara who undergo an instrumental vaginal birth (L)

Jan-Jun 20.84 20.54 20.16 24.29 25.25 22.44

Jul-Dec 24.64 24.18 23.16 24.84 25.12 22.28

1.4 Selected primipara undergoing caesarean section (L)

Jan-Jun 24.67 27.83 24.81 21.85 24.12 21.54

Jul-Dec 23.22 26.37 28.13 23.51 24.49 22.45

(L) – A low rate is desirable(H) – A high rate is desirable (N) – Desirable rate is unspecifiedRates in italic / greyed highlight results that require attention.Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.


100 |

9.7 obstetric anaesthesia

The anaesthesia department’s new database was introduced in October 2010. The statistics presented in this report are from this database.

The total number of births in the C&C DHB area has fallen slightly, but the proportion of women using anaesthesia services remains unchanged.

TaBle 51: summary oF neuraxial Blocks For years 2011 anD 2012

2011 2012

No. % No. %

Labour analgesia 1329 33.9 1270 33.0

Caesarean section 1 736 18.8 732 19.0

Total neuraxial blocks 2098 53.6 2080 54.0

Total C&C DHB births 3917 38501 Includes only new blocks for caesarean section and does not include epidurals topped up for caesarean section

Total labour analgesia rate remains constant at 1295 (33.6%) compared with 34.2% in 2011, an insignificant difference. In addition 21 women required neuraxial block for instrumental delivery and 81 for postpartum procedures (EUA, manual removal of placenta, perineal

repair). There were 106 general anaesthetics given (2.8%). In total 2239 women had some anaesthesia intervention (one or more), or 58.2% of all women delivered in C&C DHB (64.5% of women at WRH).

TaBle 52: inDicaTions For anaesThesia supporT in 2012

Anaesthesia procedure

EpiduralSpinal (SAB)

Combined spinal epidural

(CSE)

Total neuraxial

blocks

General anaesthesia

Total requiring

intervention

First block indication

No. No. No. No. % No. No. %

Labour analgesia 1215 23 57 1295 33.6 0 1295 33.6

Caesarean section 12 195 525 732 19.0 85 817 21.2

Forceps / Ventouse 1 13 7 21 0.5 0 21 0.5

Total for delivery 1228 231 589 2048 53.2 85 2133 55.4

Other 4 4 0.1

Cerclage 0 4 0 4 1 5 0.1

Postpartum procedure 0 79 2 81 16 97 2.5

Total 1228 314 591 2133 106 2239

C&C DHB women 3850 55.4 58.2

WRH women 3470 61.5 64.5


| 101

Outcome of labour after neuraxial block for analgesia is documented below. 1270 women received some

form of neuraxial block in labour of whom 1157 have the mode of delivery documented in the database. Of these 43% had a normal vaginal birth.

TaBle 53: moDe oF Delivery aFTer neuraxial Block in laBour in 2012

Outcome 2012

No. %

Normal vaginal birth 499 43.1

Forceps 150 13.0

Ventouse 105 9.1

Caesarean section 403 34.8

Total 1157 100

Combined spinal epidural (CSE) is the technique of choice for elective caesarean section, while subarachnoid block (spinal) was more frequently the choice for emergency caesarean sections. A total of

348 women had epidural top up and a total of 85 had GA, of which 16 had either insufficient time to top up epidural or there was a problem with an existing block.

TaBle 54: anaesThesia For caesarean secTion in 2012

Anaesthesia 2012

No. %

CSE 525 45.1

Spinal 195 16.7

Epidural top up 348 29.9

Epidural for caesarean 12 1.0

General anaesthesia 85 7.3

Total 1165 100

Seven women had CSE for instrumental delivery, providing an option of extending the block if caesarean was required. Fifty seven women had CSE in labour for rapid onset of good analgesia. These figures are relatively unchanged from 2011.

The anaesthesia department documented 1144 women having caesarean section as outcome of anaesthesia procedure, although this differs from the number

cited above and from the official number of caesarean sections at C&C DHB in 2012. Unfortunately mode of delivery was omitted in the records for 68 women. The official C&C DHB figures are 1191 caesarean sections (30.9%) of which 758 were emergencies and 433 elective. Urgency is reported in the table below.


102 |

TaBle 55: urgency oF caesarean secTion For years 2011 anD 2012

CS urgency category 2011 2012

No. % No. %

1 – immediate threat to life of mother or baby 85 7.6 103 9.0

2 – urgent for maternal or fetal compromise 474 42.2 436 38.1

3 – needing early delivery 112 10.0 130 11.4

4 – elective planned at least 24 hrs in advance 333 29.6 298 26.0

No category 120 10.7 177 15.5

Total caesareans (in anaesthesia database) 1124 100 1144 100

Anaesthesia for caesarean section depended on the degree of urgency of caesarean section. Eighty five women had general anaesthesia for caesarean sections, of whom 50 were category one urgency, and 16 had epidurals in situ which were either ineffective or there was insufficient time for a top up. Seven women had general anaesthesia for elective caesarean sections. Three hundred and forty one women (341) had epidurals for labour which were topped up for caesarean section, while 732 women had neuraxial blocks sited specifically for caesarean section (either electively or in labour).

elective caesarean sections

A simple audit of start times (the time the woman arrived in the caesarean theatre) of caesarean sections was carried out in June, July and August 2012. Eighty three elective caesarean sections were audited. In summary, over 50% of first elective caesarean sections started late. Around half of delays were due to system factors such as staff or beds being unavailable or women not being ready, and not due to acute cases pending or occurring. Most delays could be resolved by having an elective caesarean section list in the main operating theatre.

comPlications

Accidental dural puncture remains a rare complication of epidural analgesia with 8 documented cases (0.8%). One woman had postdural puncture headache (PDPH) with spinal alone. Twelve epidural blood patches were performed as treatment for PDPH, of which 3 failed in the first 48 hours, requiring repeat blood patch.

Numbness or weakness lasting longer than expected was reported on 0.1% (1 in 1000) of women receiving neuraxial blocks, while backache requiring analgesia occurred in 1.1% of women. Side effects from spinal

morphine remains a problem for some with 7.7% of women having epidural morphine requiring treatment for itch and 12.4% reporting nausea (compared with 6.9% and 7.9% in 2011). Surprisingly those receiving intrathecal morphine had fewer side effects, with 6.1% having pruritus (12.7% in 2011) and 4.2% having nausea (7.8% in 2011). Naloxone is the most effective treatment for these side effects, but will not decrease the analgesia provided by spinal morphine. However, there seems to be some reluctance to use naloxone and this may be the subject of future education efforts.

satisfaction

Postnatal follow up on the wards, or a phone call at home are an important part of anaesthesia care. Follow up rates are high with 94% of women documented as giving a response. There has been an improvement in satisfaction scores, and a decrease in those reporting intra-operative pain during caesarean section. Fewer women report poor pain relief during second stage (4.8% compared with 6.0% in 2011). It is important to continue use of patient-controlled epidural analgesia (PCEA) throughout labour and the low concentrations used mean women can push adequately and receive adequate analgesia.

Post-caesarean pain relief has continued to be an important focus, and we now provide leaflets on postoperative analgesia to all women having caesarean section, emphasising the use of regular simple analgesics.

conclusions

The anaesthesia department continues to provide an essential service for all women delivering in the Wellington area. As in the past, 58% of women require some form of anaesthesia assistance, so antenatal review is helpful in providing the best service we can.


| 103

achs clinical indicator 4.1, general anaesthesia for caesarean section

The table below shows the 2010 to 2012 rates for caesarean section under GA, comparing C&C DHB with all other sites contributing to ACHS data. The figures provided to the ACHS are calculated by the C&C DHB Decision Support Unit using clinically coded inpatient event data. In 2012 the Decision Support Unit calculated 71 GA sections from this source. The

Department of Anaesthesia calculated 85 GA sections from their stand alone database. The reason for the difference is thought to be inaccurate data entry, which may be occurring in both data sources. There may need to be a cross-check of data to ensure accuracy for future submissions of this particular indicator.

According to the data submitted to ACHS for the second six month period in 2012 the aggregate rate for all organisations was above the 99% confidence interval of the DHBs rate.


C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

4.1Women having a general anaesthetic for a caesarean section (L)

Jan-Jun 7.82 4.82 6.78 7.23 8.64 8.93

Jul-Dec 8.16 6.50 5.18 8.43 7.74 7.97



104 |

9.8 Primary maternity units

9.8.1 kenePuru maternity unit

The following table tabulates the numbers by ethnicity and age groups for the 245 women who gave birth at KMU in 2012.

The largest age group for all C&C DHB women in 2012 was the 30 to 34 year age group (31% of all ethnicities), whereas women giving birth at KMU were in three

distinct groups. These were the 20-24 year old women (43% of Mäori), the 25-29 year old women (37% of Pacific) and the 30-34 year old women (27% of NZ European).

The average age for primiparous women at KMU was 23.5 years (29.6 for all C&C DHB) and 28.8 years for multiparous women (32.7 for all C&C DHB).

TaBle 57: age anD eThniciTy DisTriBuTion For The Women Who gave BirTh aT kmu in 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total


< 20 5 6.8 0 0.0 17 22.1 5 7.7 1 5.9 0 0.0 28 11.4

20 – 24 13 17.8 1 8.3 33 42.9 16 24.6 5 29.4 1 100.0 69 28.2

25 – 29 19 26.0 3 25.0 18 23.4 24 36.9 8 47.1 0 0.0 72 29.4

30 – 34 20 27.4 3 25.0 6 7.8 12 18.5 2 11.8 0 0.0 43 17.6

35 – 39 14 19.2 4 33.3 3 3.9 4 6.2 1 5.9 0 0.0 26 10.6

≥ 40 2 2.7 1 8.3 0 0.0 4 6.2 0 0.0 0 0.0 7 2.9

Total 73 100 12 100 77 100 65 100 17 100 1 100 245 100

Average age No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs

Primips 18 27.1 2 32.2 22 19.8 14 23.3 4 23.8 60 23.5

Multips 55 30.8 10 33.9 55 25.7 51 29.1 13 28.5 1 24.9 185 28.8

Total 73 29.9 12 33.6 77 24.0 65 27.9 17 27.4 1 24.9 245 27.5

There were 31 antenatal transfers from the Kenepuru Maternity Unit to the Wellington Regional Hospital and 20 postnatal transfers to Wellington for women who gave birth at KMU.

There were 497 postnatal admissions for women who gave birth at the Wellington Regional Hospital and who required further postnatal care at Kenepuru. Eight of these women were transferred back to Wellington Regional Hospital for further care.


| 105

9.8.2 ParaParaumu maternity unit

The following table tabulates the numbers by ethnicity and age groups for the 135 women who gave birth at PMU in 2012.

The largest age group for all C&C DHB women in 2012 was the 30 to 34 year age group (31% of all ethnicities),

but the 25-29 year age group prevailed at PMU mainly from the NZ European ethnicity group.

The average age for primiparous women at PMU was 23.4 years (29.6 for all C&C DHB) and 31.0 years for multiparous women (32.7 for all C&C DHB).

TaBle 58: age anD eThniciTy DisTriBuTion For The Women Who gave BirTh aT pmu in 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total


< 20 6 6.7 0 0.0 5 25.0 1 100.0 0 0.0 0 0.0 12 8.9

20 – 24 19 21.1 4 23.5 4 20.0 0 0.0 1 16.7 0 0.0 28 20.7

25 – 29 26 28.9 4 23.5 5 25.0 0 0.0 1 16.7 0 0.0 36 26.7

30 – 34 22 24.4 6 35.3 3 15.0 0 0.0 3 50.0 0 0.0 34 25.2

35 – 39 15 16.7 3 17.6 1 5.0 0 0.0 1 16.7 1 100.0 21 15.6

≥ 40 2 2.2 0 0.0 2 10.0 0 0.0 0 0.0 0 0.0 4 3.0

Total 90 100 17 100 20 100 1 100 6 100 1 100 135 100

Average age No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs No. Yrs

Primips 25 24.0 4 21.2 5 21.3 1 18.5 1 31.9 36 23.4

Multips 65 31.0 13 32.9 15 28.9 5 30.7 1 37.4 99 31.0

Total 90 29.1 17 30.1 20 27.0 1 18.5 6 30.9 1 37.4 135 29.0

There were 19 antenatal transfers from the Paraparaumu Maternity Unit to the Wellington Regional Hospital and 9 postnatal transfers to Wellington for women who gave birth at PMU.

There were 135 postnatal admissions for women who gave birth at the Wellington Regional Hospital and who required further postnatal care at Paraparaumu. Two of these women were transferred back to Wellington Regional Hospital for further care.


106 |


| 107

10.1 Perineal trauma

Indicator 3.4: This reports the rate of episiotomy and sustaining of a perineal tear while giving birth vaginally for selected primipara. The aggregate rate for all organisations is below our 99% CI for the first six

months of 2012 and our rate of 13.4% is undesirably higher than peer organisations. This indicator will continue to be monitored.

TaBle 59: peer group comparison For achs oBsTeTric clinical inDicaTors 3.1 To 3.6

C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

3.1 Selected primipara with intact perineum or unsutured perineal tear (H)

Jan-Jun 17.51 20.74 17.27 13.61 15.15 18.12

Jul-Dec 13.26 17.41 16.11 12.54 14.30 16.09

3.2Selected primipara undergoing episiotomy AND no perineal tear while giving birth vaginally (L)

Jan-Jun 29.44 29.79 27.84 24.33 26.25 25.50

Jul-Dec 34.75 30.60 30.69 25.30 27.76 26.76

3.3 Selected primipara sustaining a perineal tear AND no episiotomy (L)

Jan-Jun 44.92 40.96 41.49 53.45 51.24 50.01

Jul-Dec 42.18 41.04 42.46 51.06 49.26 46.69

3.4Selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally (L)

Jan-Jun 7.36 8.51 13.40 7.14 7.93 8.15

Jul-Dec 8.49 10.95 10.74 8.45 8.42 9.25

3.5 Selected primipara requiring surgical repair of the perineum for third degree tear (L)

Jan-Jun 3.05 3.72 5.67 5.55 7.15 7.45

Jul-Dec 4.51 5.22 7.16 6.70 7.33 6.98

3.6 Selected primipara requiring surgical repair of the perineum for fourth degree tear (L)

Jan-Jun 0.25 0.53 0.00 0.43 0.36 0.36

Jul-Dec 0.27 0.50 0.77 0.42 0.33 0.43

(L) – A low rate is desirable (H) – A high rate is desirable (N) – Desirable rate is unspecified. Rates in italic / greyed highlight results that require attention. Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

10. labour and birth outcomes


108 |

10.2 PostPartum haemorrhage

Multidisciplinary teaching on the recognition and estimation of blood loss may be a contributing factor to the increase in estimates of postpartum haemorrhage (PPH). The rates of women requiring a

blood transfusion do not seem to be increasing and this may indicate that the reported PPH rate may not be related to increased volumes lost. Careful ongoing monitoring of these clinical indicators is required.

TaBle 60: peer group comparison For achs oBsTeTric clinical inDicaTors 7.1 anD 7.2

C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

7.1

Women who give birth vaginally who receive a blood transfusion during the same admission (L)

Jan-Jun 2.16 1.99 1.93 1.67 1.66 1.86

Jul-Dec 1.99 0.91 2.10 1.75 1.56 1.60

7.2

Women who undergo caesarean section who receive a blood transfusion during the same admission (L)

Jan-Jun 5.33 2.25 3.73 2.93 2.69 2.97

Jul-Dec 4.25 2.05 3.01 2.73 2.91 2.16


TaBle 61: primary posTparTum BlooD loss For years 2005 To 2012

Mothers 2005 2006 2007 2008 2009 2010 2011 2012

Total blood loss No. % No. % No. % No. % No. % No. % No. % No. %

≥ 1000ml 95 2.5 137 3.5 127 3.1 104 2.6 139 3.5 158 4.1 171 4.4 203 5.3

≥ 500ml and < 1000ml 757 20.2 862 21.7 865 21.4 790 19.8 682 17.1 743 19.1 905 23.1 876 22.8

< 500ml 2790 74.3 2812 70.9 2890 71.4 2946 73.7 3033 75.9 2888 74.2 2765 70.6 2716 70.5

Not stated 112 3.0 156 3.9 165 4.1 159 4.0 141 3.5 102 2.6 76 1.9 55 1.4

Total 3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100


| 109

10.3 surgical site infection (achs)

This ACHS indicator has been submitted for the last two years. C&C DHB rates are higher than the peer group rates.

The number of deep surgical site infections were four in the first half and six in the second half of 2012.

TaBle 62: achs inFecTion conTrol clinical inDicaTor 1.16

C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012

Clinical Indicator Period Rate (%) Rate (%) Rate (%) Rate (%) Rate (%) Rate (%)

1.16

Deep incisional/organ/space surgical site infection (SSI) in lower segment caesarean section procedures (L)

Jan-Jun 1.29 0.68 0.36 0.21

Jul-Dec 1.55 1.00 1.15 0.50



110 |

10.4 neonatal outcomes

Neonatal outcomes by gender, plurality, birth weight, gestational age and Apgar score are presented in the next sections.

10.4.1 gender

TaBle 63: genDer For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Gender No. % No. % No. % No. % No. % No. % No. % No. %

Male 1940 50.6 2008 49.7 2150 51.9 2057 50.3 2068 50.6 2048 51.4 1988 49.7 2031 51.8

Female 1894 49.4 2032 50.3 1991 48.0 2032 49.7 2016 49.4 1937 48.6 2013 50.3 1889 48.2

Indeterminate 3 0.1 1 0.0 3 0.1 2 0.1 0 0.0 0 0.0 0 0.0 0 0.0

Total 3837 100 4041 100 4144 100 4091 100 4084 100 3985 100 4001 100 3920 100

10.4.2 Plurality

TaBle 64: pluraliTy For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Plurality No. % No. % No. % No. % No. % No. % No. % No. %

Singletons 3672 95.7 3894 96.4 3952 95.4 3909 95.6 3910 95.7 3800 95.4 3836 95.9 3782 96.5

Twins * 162 4.2 144 3.6 186 4.5 176 4.3 162 4.0 176 4.4 156 3.9 132 3.4

Triplets * 3 0.1 3 0.1 6 0.1 6 0.1 12 0.3 9 0.2 9 0.2 6 0.2

Total 3837 100 4041 100 4144 100 4091 100 4084 100 3985 100 4001 100 3920 100

* Numbers not sets


| 111

10.4.3 birth weight

In the second six months of 2012 the aggregate rate from all peer organisations for babies born with birth weights less than 2750g at 40 weeks gestation or

beyond was higher than our upper 99% confidence interval. This indicates than there were fewer term babies born at C&C DHB who were low birth weight.


C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

8.1

Deliveries with birth weight less than 2750g at 40 weeks gestation or beyond (L)

Jan-Jun 1.50 1.07 1.26 2.00 1.78 1.75

Jul-Dec 1.10 1.23 0.76 1.89 1.67 1.63


The next two tables present the birth weights of all babies born in 2012 by maternal age and ethnicity groups.

TaBle 66: BirTh WeighTs oF all BaBies By maTernal age group For 2012

Babies < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Weight (g) No. % No. % No. % No. % No. % No. % No. %

< 500 2 1.2 3 0.6 6 0.7 8 0.7 8 0.9 1 0.4 28 0.7

500 – 999 5 2.9 8 1.6 14 1.7 16 1.3 11 1.2 9 3.6 63 1.6

1000 – 1499 6 3.5 9 1.8 11 1.3 12 1.0 7 0.8 3 1.2 48 1.2

1500 – 1999 2 1.2 13 2.6 20 2.4 25 2.0 20 2.2 5 2.0 85 2.2

2000 – 2499 5 2.9 30 5.9 30 3.6 43 3.5 36 3.9 15 6.0 159 4.1

2500 – 2999 20 11.6 65 12.8 123 14.6 147 12.0 90 9.8 33 13.1 478 12.2

3000 – 3499 55 31.8 149 29.4 263 31.2 356 29.0 302 32.9 68 27.1 1193 30.4

3500 – 3999 58 33.5 158 31.2 255 30.3 431 35.1 293 31.9 71 28.3 1266 32.3

4000 – 4499 19 11.0 62 12.2 106 12.6 162 13.2 127 13.8 41 16.3 517 13.2

4500 – 4999 1 0.6 10 2.0 13 1.5 26 2.1 21 2.3 5 2.0 76 1.9

≥ 5000 0 0.0 0 0.0 1 0.1 2 0.2 4 0.4 0 0.0 7 0.2

Total 173 100 507 100 842 100 1228 100 919 100 251 100 3920 100

Average 3235 3295 3305 3390 3390 3295 3345

Median 3440 3420 3420 3500 3480 3440 3460

Maximum 4780 4950 5220 5415 5080 4860 5415


112 |

TaBle 67: BirTh WeighTs oF all BaBies By maTernal eThniciTy group For 2012

BabiesNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Weight (g) No. % No. % No. % No. % No. % No. % No. %

< 500 15 0.8 2 0.4 5 1.0 1 0.3 5 0.9 0 0.0 28 0.7

500 – 999 27 1.4 9 1.9 17 3.5 5 1.4 4 0.7 1 1.0 63 1.6

1000 – 1499 29 1.5 4 0.8 9 1.8 2 0.5 3 0.6 1 1.0 48 1.2

1500 – 1999 49 2.5 8 1.7 12 2.5 8 2.2 5 0.9 3 2.9 85 2.2

2000 – 2499 72 3.7 15 3.2 19 3.9 11 3.0 32 5.9 10 9.5 159 4.1

2500 – 2999 192 9.8 52 11.0 65 13.3 44 12.1 115 21.3 10 9.5 478 12.2

3000 – 3499 564 28.9 137 29.0 149 30.6 106 29.0 197 36.5 40 38.1 1193 30.4

3500 – 3999 670 34.3 164 34.7 139 28.5 126 34.5 135 25.0 32 30.5 1266 32.3

4000 – 4499 293 15.0 69 14.6 56 11.5 53 14.5 38 7.0 8 7.6 517 13.2

4500 – 4999 37 1.9 11 2.3 15 3.1 7 1.9 6 1.1 0 0.0 76 1.9

≥ 5000 3 0.2 1 0.2 1 0.2 2 0.5 0 0.0 0 0.0 7 0.2

Total 1951 100 472 100 487 100 365 100 540 100 105 100 3920 100

Average 3385 3405 3245 3430 3215 3255 3345

Median 3520 3520 3390 3530 3260 3360 3460

Maximum 5415 5120 5030 5220 4910 4460 5415


| 113

The next table gives the birth weights for liveborn babies born in the years 2005 to 2012.

In 2012, 2.6% of babies weighed less than 1500g, 8.8% weighed less than 2500g and 15.5% weighed more than 4000g.

TaBle 68: BirTh WeighTs For liveBorn BaBies For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Weight (g) No. % No. % No. % No. % No. % No. % No. % No. %

< 500 2 0.0 3 0.1 5 0.1 2 0.0 6 0.1 4 0.1 2 0.1 2 0.1

500 – 999 35 0.9 34 0.9 44 1.1 33 0.8 44 1.1 42 1.1 40 1.0 53 1.4

1000 – 1499 54 1.4 49 1.2 50 1.2 60 1.5 64 1.6 58 1.5 51 1.3 46 1.2

1500 – 1999 62 1.6 46 1.2 62 1.5 72 1.8 58 1.4 68 1.7 92 2.3 84 2.2

2000 – 2499 134 3.5 126 3.2 153 3.7 169 4.2 149 3.7 179 4.5 179 4.5 158 4.1

2500 – 2999 498 13.1 548 13.7 528 12.9 527 13.0 493 12.2 522 13.2 516 13.0 476 12.3

3000 – 3499 1214 32.0 1272 31.9 1270 31.0 1316 32.5 1290 32.0 1254 31.7 1297 32.7 1192 30.7

3500 – 3999 1223 32.2 1318 33.1 1345 32.9 1272 31.4 1315 32.6 1279 32.4 1234 31.2 1266 32.7

4000 – 4499 492 13.0 487 12.2 519 12.7 502 12.4 511 12.7 465 11.8 464 11.7 517 13.3

4500 – 4999 71 1.9 95 2.4 105 2.6 88 2.2 90 2.2 75 1.9 77 1.9 76 2.0

≥ 5000 14 0.4 9 0.2 12 0.3 11 0.3 8 0.2 5 0.1 9 0.2 7 0.2

Total 3799 100 3987 100 4093 100 4052 100 4028 100 3951 100 3961 100 3877 100

Average 3385 3400 3395 3375 3390 3350 3350 3375

Median 3460 3460 3470 3440 3460 3440 3430 3470

Maximum 5650 5180 5880 5520 5370 5680 5300 5415

NB This table includes a few extremely small babies who were neonatal deaths in Delivery Suite soon after birth.


114 |

10.4.4 gestational age

TaBle 69: gesTaTional age For liveBorn BaBies For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Gestation (weeks)

No. % No. % No. % No. % No. % No. % No. % No. %

20

21 1 0.0 1 0.0 3 0.1 1 0.0

22 2 0.1 1 0.0 0 0.0 1 0.0 1 0.0

23 5 0.1 3 0.1 7 0.2 6 0.1 6 0.1 7 0.2 4 0.1 4 0.1

24 2 0.1 6 0.2 10 0.2 6 0.1 10 0.2 12 0.3 5 0.1 8 0.2

25 10 0.3 10 0.3 7 0.2 11 0.3 4 0.1 9 0.2 6 0.2 9 0.2

26 5 0.1 11 0.3 12 0.3 7 0.2 14 0.3 15 0.4 9 0.2 17 0.4

27 15 0.4 5 0.1 10 0.2 14 0.3 15 0.4 6 0.2 12 0.3 13 0.3

28 12 0.3 5 0.1 16 0.4 13 0.3 20 0.5 16 0.4 14 0.4 17 0.4

29 15 0.4 17 0.4 10 0.2 21 0.5 15 0.4 11 0.3 16 0.4 13 0.3

30 22 0.6 19 0.5 15 0.4 11 0.3 23 0.6 23 0.6 24 0.6 26 0.7

31 21 0.6 14 0.4 25 0.6 19 0.5 18 0.4 29 0.7 25 0.6 27 0.7

32 26 0.7 12 0.3 18 0.4 29 0.7 17 0.4 31 0.8 29 0.7 18 0.5

33 23 0.6 29 0.7 24 0.6 27 0.7 27 0.7 24 0.6 31 0.8 32 0.8

34 43 1.1 40 1.0 43 1.1 45 1.1 47 1.2 37 0.9 61 1.5 42 1.1

35 64 1.7 69 1.7 61 1.5 90 2.2 70 1.7 91 2.3 80 2.0 66 1.7

36 111 2.9 104 2.6 110 2.7 113 2.8 119 3.0 121 3.1 132 3.3 134 3.5

37 226 5.9 244 6.1 290 7.1 258 6.4 248 6.2 302 7.6 279 7.0 267 6.9

38 616 16.2 659 16.5 633 15.5 655 16.2 595 14.8 647 16.4 604 15.2 583 15.0

39 881 23.2 961 24.1 959 23.4 953 23.5 994 24.7 939 23.8 966 24.4 1008 26.0

40 999 26.3 991 24.9 1035 25.3 1037 25.6 1018 25.3 941 23.8 996 25.1 923 23.8

41 641 16.9 710 17.8 754 18.4 674 16.6 707 17.6 638 16.1 627 15.8 622 16.0

42 60 1.6 73 1.8 50 1.2 59 1.5 55 1.4 47 1.2 40 1.0 46 1.2

43 0 0.0 3 0.1 3 0.1 4 0.1 3 0.1 4 0.1 1 0.0

Total 3799 100 3987 100 4093 100 4052 100 4028 100 3951 100 3961 100 3877 100

NB This table includes a few extremely small babies who were neonatal deaths in Delivery Suite soon after birth.


| 115

TaBle 70: gesTaTional age groups For liveBorn BaBies For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Gestation No. % No. % No. % No. % No. % No. % No. % No. %

20+0 – 23+6 weeks 7 0.2 5 0.1 8 0.2 6 0.1 9 0.2 8 0.2 5 0.1 5 0.1

24+0 – 27+6 weeks 32 0.8 32 0.8 39 0.9 38 0.9 43 1.1 42 1.1 32 0.8 47 1.2

28+0 – 31+6 weeks 70 1.8 55 1.4 66 1.6 64 1.6 76 1.9 79 2.0 79 2.0 83 2.1

32+0 – 36+6 weeks 267 7.0 254 6.4 256 6.3 304 7.5 280 7.0 304 7.7 333 8.4 292 7.5

All preterm 376 9.9 346 8.7 369 9.0 412 10.2 408 10.1 433 11.0 449 11.3 427 11.0

37+0 – 41+6 weeks 3363 88.5 3565 89.4 3671 89.7 3577 88.3 3562 88.4 3467 87.7 3472 87.7 3403 87.8

≥ 42+0 weeks 60 1.6 76 1.9 53 1.3 63 1.6 58 1.4 51 1.3 40 1.0 47 1.2

Total 3799 100 3987 100 4093 100 4052 100 4028 100 3951 100 3961 100 3877 100

10.4.5 aPgar score

In the second six months of 2012 at C&C DHB there were a significantly lower number of term babies born with an Apgar score of less than 7 at five minutes post delivery.

The aggregate rate of 1.66% for all peer organisations was above our upper 99% confidence interval value of 1.43%.


C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

9.1

Term babies born with an Apgar score of less than 7 at five minutes post delivery (L)

Jan-Jun 0.92 1.64 1.66 1.59 1.62 1.82

Jul-Dec 1.60 1.69 0.86 1.58 1.44 1.66



116 |

TaBle 72: apgar score aT 5 minuTes For liveBorn BaBies By maTernal age group For 2012

Babies < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Apgar score No. % No. % No. % No. % No. % No. % No. %

< 5 0 0.0 0 0.0 2 0.2 3 0.2 3 0.3 2 0.8 10 0.3

5 or 6 2 1.2 15 3.0 10 1.2 11 0.9 16 1.8 8 3.2 62 1.6

7 or 8 14 8.2 34 6.8 58 6.9 92 7.6 69 7.6 19 7.7 286 7.4

9 or 10 154 90.6 454 90.3 767 91.6 1107 91.3 818 90.3 219 88.3 3519 90.8

Total 170 100 503 100 837 100 1213 100 906 100 248 100 3877 100

TaBle 73: apgar score aT 5 minuTes For liveBorn BaBies By maTernal eThniciTy group For 2012

BabiesNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total

Apgar score No. % No. % No. % No. % No. % No. % No. %

< 5 6 0.3 0 0.0 2 0.4 1 0.3 0 0.0 1 1.0 10 0.3

5 or 6 32 1.7 3 0.6 13 2.7 5 1.4 5 0.9 4 3.8 62 1.6

7 or 8 149 7.7 28 6.0 40 8.3 26 7.2 32 6.0 11 10.5 286 7.4

9 or 10 1745 90.3 436 93.4 425 88.5 328 91.1 496 93.1 89 84.8 3519 90.8

Total 1932 100 467 100 480 100 360 100 533 100 105 100 3877 100

TaBle 74: apgar score aT 5 minuTes For liveBorn BaBies For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 2012

Apgar score No. % No. % No. % No. % No. % No. % No. % No. %

< 5 24 0.6 26 0.7 19 0.5 15 0.4 18 0.4 13 0.3 21 0.5 10 0.3

5 or 6 40 1.1 42 1.1 31 0.8 35 0.9 42 1.0 63 1.6 59 1.5 62 1.6

7 or 8 184 4.8 194 4.9 159 3.9 201 5.0 245 6.1 251 6.4 209 5.3 286 7.4

9 or 10 3551 93.5 3725 93.4 3884 94.9 3801 93.8 3723 92.4 3624 91.7 3672 92.7 3519 90.8

Total 3799 100 3987 100 4093 100 4052 100 4028 100 3951 100 3961 100 3877 100


| 117

11.1 Postnatal consumer satisfaction survey

In September 2012 all women who received postnatal inpatient care at Wellington Regional Hospital, Kenepuru and/or Paraparaumu Maternity Units were invited to complete an anonymous survey. The survey commenced on 1st of September and concluded on the 30th September. 316 women gave birth during this period and feedback was received from 114 women, a response rate of 36%. Generally speaking the feedback received was very positive. Areas where the service scored highly included courtesy and respect, timely attendance, timely analgesia administration, and an ideal length of stay.

Areas where the service scored higher than 10% in the disagree or strongly disagree sections were identified as areas where the service should focus their attention. These included information about the wards (the location of the toilets, the call bell system, meal and visiting times), practical assistance with baby bathing,

safe positioning of baby in the cot and safety issues related to bed sharing.

In 2013 the service plans to employ a media student to prepare an audio visual aid for women. This will include:

• a virtual tour of all maternity facilities

• information on safe sleeping practices

• baby bathing

• breastfeeding

• immunisations.

Audio visual information will be made available to women via C&C DHBs free to air TV channels and will run as a two-hour continuous loop. An on-screen menu will be provided so that women can select the information most relevant to their needs.

11. Postnatal care


118 |

11.2 infant feeding

The following are the New Zealand Ministry of Health breastfeeding definitions used in this section:

• Exclusive breastfeeding: The infant has never, to the mother's knowledge, had any water, formula or other liquid or solid food. Only breast milk, from the breast or expressed, and prescribed medicines have been given from birth.

• Fully breastfeeding: The infant has taken breast milk only, no other liquids or solids except a minimal amount of water or prescribed medicines, in the past 48 hours.

• Partial breastfeeding: The infant has taken some breast milk and some infant formula or other solid food in the past 48 hours.

• Artificial feeding: The infant has had no breast milk but has had alternative liquid such as infant formula with or without solid food in the past 48 hours.

All C&C DHB maternity facilities maintained good exclusive breastfeeding rates (EBR) during 2012, above the minimum 75% required by the Baby Friendly Hospital Initiative (BFHI). Over the past 4 years the EBR has slowly reduced, year on year, from 81.2% to 79.6%. A number of factors influenced this including maternal age, mode of birth and ethnicity. Although not considered in the scope of this report, many other factors (such as the mode of labour, diabetes, family support, obesity and smoking) also impact on breastfeeding success.

TaBle 75: inFanT FeeDing aT Time oF iniTial Discharge, By BirTh FaciliTy For 2012

Babies Wellington Kenepuru Paraparaumu C&C DHB

Feeding * No. % No. % No. % No. %

Exclusive 2396 78.6 204 83.3 128 94.8 2728 79.6

Full 114 3.7 2 0.8 0 0.0 116 3.4

Partial 456 15.0 22 9.0 5 3.7 483 14.1

Artificial 83 2.7 17 6.9 2 1.5 102 3.0

Total 3049 100 245 100 135 100 3429 100

* Numbers are for babies discharged from Delivery Suite, Ward 4 North, Kenepuru Maternity and Paraparaumu Maternity.

The EBR for women who had normal births remained excellent at 87.1%. However, the rate of normal births has trended down year on year from 61.1% in 2009 to 57.8% in 2012.

There has been an increase in the caesarean section rate from 27.4% in 2009 to 30.9% in 2012. Caesarean section has a negative impact on breastfeeding. These women have missed out on the full hormones of labour, in addition to them coping with the impact of abdominal surgery and delayed lactation. It may be

worth considering extending the program of antenatal milk expressing to those women for whom an elective caesarean section is planned.

Although the EBR for babies born by Ventouse is almost as high as that for normal births, this is unusual. In previous years the EBR for these babies has been over 10% lower, close to that for babies born by forceps. It will be interesting to review this next year. The EBR for breech births is difficult to interpret due to the small numbers involved.


| 119

TaBle 76: inFanT FeeDing aT Time oF iniTial Discharge, By moDe oF BirTh For 2012

Babies Normal Forceps Ventouse Breech Emerg. CS Elect. CS Total

Feeding * No. % No. % No. % No. % No. % No. % No. %

Exclusive 1810 87.1 137 71.7 152 86.4 3 42.9 378 64.0 248 64.1 2728 79.6

Full 41 2.0 10 5.2 5 2.8 0 0.0 35 5.9 25 6.5 116 3.4

Partial 167 8.0 39 20.4 16 9.1 3 42.9 163 27.6 95 24.5 483 14.1

Artificial 59 2.8 5 2.6 3 1.7 1 14.3 15 2.5 19 4.9 102 3.0

Total 2077 100 191 100 176 100 7 100 591 100 387 100 3429 100


Although younger (<20 years) women’s breasts may lactate well, often other issues such as self-confidence, social influences and lack of breastfeeding education impact on their success.

Women over 40 years experience more difficulty initiating lactation because the breast tissue is less productive. EBR across the age ranges 20 to 39 years are fairly consistent.

TaBle 77: inFanT FeeDing aT Time oF iniTial Discharge, By maTernal age For 2012

Babies < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total


Exclusive 112 76.2 355 81.1 603 81.3 878 80.0 629 78.6 151 73.7 2728 79.6

Full 4 2.7 9 2.1 26 3.5 38 3.5 31 3.9 8 3.9 116 3.4

Partial 18 12.2 54 12.3 95 12.8 157 14.3 120 15.0 39 19.0 483 14.1

Artificial 13 8.8 20 4.6 18 2.4 24 2.2 20 2.5 7 3.4 102 3.0

Total 147 100 438 100 742 100 1097 100 800 100 205 100 3429 100


Asian women consistently have the lowest EBR. Breastfeeding classes in Mandarin were introduced in July 2012. The remainder of the Asian group are Indian, South East Asian, Japanese, Korean and Filipino. Although this group requires special support, it is difficult to devise an initiative that takes account of their disparate cultural experiences and attitudes.

The other group is made up of women from Africa, Latin America, the Middle East and women who do not fit into another ethnic group. This group have experienced an increase in exclusive breastfeeding rate from 62.5% in 2011 to 80.4% in 2012. There is no obvious explanation for this although it is a relatively small number of women, so individuals have a disproportionate influence on the percentages.

Despite a consistently above average rate of normal vaginal births Pacific People often experience poorer breastfeeding outcomes. Possible negative influences are diabetes, poor attendance at antenatal education, smoking and a lack of written information in appropriate languages. The Pacific breastfeeding team is addressing this by providing increased support antenatally and following discharge. The rate has increased since 2011.

One initiative for increasing breastfeeding success is antenatal milk expression for diabetic pregnant women. As this process becomes more widespread, diabetic mothers and babies may be enabled to stay together on the postnatal wards. This may lead to better EBR on discharge.


120 |

It is notable that the Mäori EBR is good on leaving hospital, but then declines at a greater rate than average in the first 6 weeks. The peer support counsellor programme aims to address this.

Good linkage between the hospital and the community for women requiring breastfeeding support is provided by the community lactation consultant, the Pacific breastfeeding teams and the breastfeeding centre.

TaBle 78: inFanT FeeDing aT Time oF iniTial Discharge, By maTernal eThniciTy For 2012

BabiesNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total


Exclusive 1428 84.5 339 81.7 332 80.8 255 77.0 300 61.2 74 80.4 2728 79.6

Full 44 2.6 10 2.4 12 2.9 12 3.6 36 7.3 2 2.2 116 3.4

Partial 185 10.9 52 12.5 39 9.5 46 13.9 146 29.8 15 16.3 483 14.1

Artificial 33 2.0 14 3.4 28 6.8 18 5.4 8 1.6 1 1.1 102 3.0

Total 1690 100 415 100 411 100 331 100 490 100 92 100 3429 100



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11.3 newborn hearing screening

In New Zealand approximately 3 in 1000 babies born have mild to profound hearing loss. Before the commencement of the Universal Newborn Hearing Screening and Early Intervention Programme (UNHSEIP) in New Zealand the average age of detection was 45 months. Effective screening, referral to audiology and diagnostic procedures can detect permanent congenital hearing loss soon after birth. Early medical and educational intervention before 6 months can maintain language, social and emotional development matching their physical development.

The parents of all babies born in C&C DHB are offered newborn hearing screening and in 2012 0.5% declined. 54 babies (1.5% of babies screened) were referred to audiology for assessment and diagnosis. 7

(13%) of these referred babies were diagnosed with a permanent/congenital hearing loss. Non attendance issues are being addressed with planning for an audiology diagnostic clinic at Kenepuru in process.

From audiology, 10 babies were referred to the ENT specialist, 2 were referred for hearing aids and no babies required cochlear implants in 2012. The advisor for deaf children attended the diagnostic appointments and 6 required her follow up.

At C&C DHB in 2012 approximately two babies per thousand screened were diagnosed with a permanent congenital hearing loss within the first few months of life and interventions commenced.

TaBle 79: unhseip volumes For years 2010 To 2012

2010 2011 2012

Newborn Hearing Screening No. No. No.

Offered screening 3988 3882 3903

Declined screening 68 32 19

Screening completed by end of year 3779 3677 3619

Screening not completed by end of year 52 2 3

Missed babies (not offered screening) 18 15 2

Screened at outpatient clinics 1585 1466 1443

Requiring targeted follow-up by Audiologist at 18 months 239 163 218

Referred for Audiology Assessment 71 45 54

Audiology Diagnosis

Confirmed sensorineural loss (bilateral - unilateral) 2 - 4 3 - 7 1 - 3

Confirmed conductive loss (bilateral - unilateral) 5 - 2 2 - 1 0 - 1

Confirmed mixed loss (bilateral - unilateral) 1 - 0 3 - 1 1 - 0

Confirmed auditory neuropathy (bilateral - unilateral) 0 - 0 0 - 1 0 - 1

Total (% of referrals) 14 (20%) 18 (40%) 7 (13%)

% diagnosed of babies screened 0.4% 0.5% 0.2%

Early Intervention

Referred to ENT Specialist 7 12 10

Referred for hearing aids 4 4 2

Referred for cochlear implants 2 1 0

Follow-ups by Advisor on deaf children, Ministry of Education 10 6


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11.4 nicu admissions and outcomes

19.2% of all live babies born in 2012 were admitted to the Neonatal Intensive Care Unit and 83.1% of all preterm babies admitted.

98.4% of all babies admitted to NICU were live at discharge, and 97.2% of preterm babies were discharged live.

TaBle 80: nicu aDmissions anD ouTcomes For liveBorn BaBies, By gesTaTion group For 2012

Babies

Total liveborn before

NICU adm.

NICU adms, (No. & % of Total liveborn)

Died in NICU <7 days (%

of NICU adms)

Died in NICU ≥7, <28 days (% of NICU

adms)

Died in NICU ≥28 days

(% of NICU adms)

Live at discharge

(% of NICU adms)

Gestation group

No. No. % No. % No. % No. % No. %

20+0 – 23+6 5 5 100.0 2 40.0 0 0.0 1 20.0 2 40.0

24+0 – 27+6 47 47 100.0 0 0.0 1 2.1 1 2.1 45 95.7

28+0 – 31+6 83 83 100.0 3 3.6 1 1.2 0 0.0 79 95.2

32+0 – 36+6 292 220 75.3 0 0.0 1 0.5 0 0.0 219 99.5

All preterm 427 355 83.1 5 1.4 3 0.8 2 0.6 345 97.2

37+0 – 40+6 2781 317 11.4 1 0.3 0 0.0 0 0.0 316 99.7

≥41+0 669 72 10.8 1 1.4 0 0.0 0 0.0 71 98.6

Total 3877 744 19.2 7 0.9 3 0.4 2 0.3 732 98.4

(NICU = Neonatal Intensive Care Unit)

In the first six months of 2012 the aggregate rate of 10.62% for peer organisations was above C&C DHBs upper 99% confidence interval for the clinical indicator

defined below. This was a favourable outcome for C&C DHB.


C&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012


Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

10.1

Inborn term babies transferred / admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality (L)

Jan-Jun 8.55 9.03 8.33 12.05 11.59 10.62

Jul-Dec 8.32 10.77 11.06 10.69 12.17 11.60



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12.1 Perinatal mortality rates

Fetal death includes stillbirths and terminations of pregnancy. At C&C DHB there were 43 fetal deaths in 2012, 20 of these 43 fetal deaths were terminations. As the DHB provides a termination service for the surrounding DHBs this increases our fetal death rate in comparison to the national rate.

Using the sixth annual PMMRC report of 2010 data the adjusted perinatal mortality rate (stillbirth and early neonatal deaths) was 7.8 per 1000 total babies which compares favorably with our most recent rate of 7.7 per 1000 total babies for 2012.

12. Perinatal mortality


124 |

TaBle 82: perinaTal morTaliTy numBers anD raTes For years 2005 To 2012

Babies 2005 2006 2007 2008 2009 2010 2011 20122005-2012

No. No. No. No. No. No. No. No. No.

Total babies 3837 4041 4144 4091 4084 3985 4001 3920 32102

Liveborn babies 3799 3987 4093 4052 4028 3951 3961 3877 31747

Fetal deaths 1 38 54 51 39 56 34 40 43 355

Stillbirths 17 21 26 19 28 22 20 23 176

Early neonatal deaths 2 17 14 12 5 14 14 13 7 96

Late neonatal deaths 3 0 1 2 1 4 6 1 3 18

PMMRC Rates 4 (per 1000 total babies)

Perinatal mortality rate (Fetal & early neonatal deaths) 14.3 16.8 15.2 10.8 17.1 12.0 13.2 12.8 14.0

Adjusted perinatal mortality rate (Stillbirth & early neonatal deaths)

8.9 8.7 9.2 5.9 10.3 9.0 8.2 7.7 8.5

Perinatal related mortality rate (Fetal & all neonatal deaths)

14.3 17.1 15.7 11.0 18.1 13.6 13.5 13.5 14.6

1 All fetal deaths (Stillbirths and terminations of pregnancy, 20 completed weeks or more, or > 400g birth weight)2 Early neonatal deaths (Liveborn, died < 7 days)3 Late neonatal deaths (Liveborn, died between 7 and < 28 days)4 PMMRC = Perinatal & Maternal Mortality Review Committee

The following figure shows that the perinatal and the adjusted perinatal mortality rates have remained constant over the last three years 2010 to 2012.

Figure 18: perinaTal morTaliTy raTes (perinaTal anD aDJusTeD) For years 2005 To 2012

20.0

18.0

16.0

14.0

12.0

10.0

8.0

6.0

4.0

2.0

0.0

2005 2006 2007 2008 2009 2010 2011 2012

Perinatal Adjusted


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12.2 Perinatal mortality by maternal age and ethnicity

The perinatal and the adjusted perinatal mortality rates are tabulated in this section by maternal age and ethnicity groups for the years 2005 to 2012. Rates for the eight years combined are included in the right hand column of each table. From the adjusted perinatal mortality rate tables, the rates are highest for women under 20 years of age and 40 years and over. Pacific and Mäori women also have the highest adjusted perinatal mortality rates.

Although the numbers are small the peak in adjusted perinatal mortality in 2009 coincided with a decrease in the caesarean section rate during that year. Future plans to decrease the caesarean section rate will need to ensure that there are not adverse implications in other areas.

TaBle 83: perinaTal morTaliTy raTe By maTernal age groups For years 2005 To 2012

2005 2006 2007 2008 2009 2010 2011 20122005-2012

Maternal age

< 20 14.6 0.0 4.5 9.2 45.5 15.9 17.2 17.3 15.8

20 – 24 6.9 20.4 25.3 7.4 25.8 21.1 10.1 7.9 15.7

25 – 29 24.2 19.0 17.5 13.3 21.3 9.0 13.0 7.1 15.5

30 – 34 12.1 20.5 9.5 7.9 11.4 9.3 9.2 12.2 11.6

35 – 39 12.0 12.6 14.2 12.7 9.1 13.2 20.8 18.5 14.1

≥ 40 16.7 9.6 32.8 18.5 24.5 9.3 9.3 19.9 17.9

Total 14.3 16.8 15.2 10.8 17.1 12.0 13.2 12.8 14.0

TaBle 84: aDJusTeD perinaTal morTaliTy raTe By maTernal age groups For years 2005 To 2012

2005 2006 2007 2008 2009 2010 2011 20122005-2012

Maternal age

< 20 9.8 0.0 0.0 9.2 36.4 15.9 11.5 5.8 11.3

20 – 24 2.3 12.2 19.5 1.9 21.9 13.4 6.1 0.0 9.7

25 – 29 16.6 10.8 11.3 3.6 13.0 7.7 7.1 3.6 9.1

30 – 34 6.8 10.2 2.9 6.3 4.5 7.7 3.1 6.5 6.0

35 – 39 7.7 6.3 10.1 8.8 5.0 8.1 16.6 14.1 9.6

≥ 40 11.1 0.0 20.5 4.6 4.9 9.3 9.3 19.9 10.4

Total 8.9 8.7 9.2 5.9 10.3 9.0 8.2 7.7 8.5


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TaBle 85: perinaTal morTaliTy raTe By maTernal eThniciTy groups For years 2005 To 2012

2005 2006 2007 2008 2009 2010 2011 20122005-2012

Maternal ethnicity

NZ European 12.8 16.7 17.2 12.3 14.3 13.0 13.5 12.3 14.1

Other European 14.7 19.7 4.4 11.1 8.5 8.5 11.9 10.6 11.0

Mäori 9.4 10.8 16.0 5.2 30.7 20.4 20.1 16.4 16.1

Pacific Peoples 15.9 15.2 7.6 12.5 24.1 10.2 10.1 13.7 13.7

Asian 31.3 21.1 17.3 9.7 16.9 6.7 10.2 13.0 15.1

Other 8.1 32.6 27.8 6.8 15.4 0.0 9.1 9.5 13.6

Total 14.3 16.8 15.2 10.8 17.1 12.0 13.2 12.8 14.0

TaBle 86: aDJusTeD perinaTal morTaliTy raTe By maTernal eThniciTy groups For years 2005 To 2012

2005 2006 2007 2008 2009 2010 2011 20122005-2012

Maternal ethnicity

NZ European 7.6 8.1 8.8 5.2 5.7 9.5 6.5 7.2 7.3

Other European 2.9 4.9 4.4 8.9 4.3 4.3 6.0 6.4 5.3

Mäori 5.7 5.4 10.7 5.2 23.5 16.7 18.1 8.2 11.6

Pacific Peoples 13.3 15.2 7.6 10.0 19.3 10.2 7.6 13.7 12.1

Asian 22.7 10.6 9.9 4.8 14.5 4.5 8.1 5.6 9.6

Other 8.1 21.7 22.2 0.0 7.7 0.0 9.1 9.5 9.7

Total 8.9 8.7 9.2 5.9 10.3 9.0 8.2 7.7 8.5


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12.3 causes of Perinatal deaths

69.6% of stillbirths in 2012 occurred at less than 28 weeks gestation and 52.2% had birth weights less than 500g.

Almost 22% of the stillbirths were to women who smoked, whereas the overall C&C DHB smoking rate for 2012 was 10.4%.

TaBle 87: summary oF FacTors relaTeD To The 23 sTillBirThs in 2012

Factor No. %

Maternal Ethnicity NZ European 9 39.1


Mäori 3 13.0


Asian 3 13.0

Other 0 0.0

23 100

Maternal Age < 20 years 1 4.3

20 – 24 years 0 0.0

25 – 29 years 2 8.7

30 – 34 years 8 34.8

35 – 39 years 9 39.1

≥ 40 years 3 13.0

23 100

Maternal Parity/CS history Primiparous 8 34.8

Multiparous, no previous CS 13 56.5

Multiparous, with previous CS 2 8.7

23 100

Maternal Domicile C&C DHB 21 91.3

Other DHBs 2 8.7

23 100

Maternal Smoking Yes 5 21.7

No 18 78.3

23 100

Gestational Age 20+0 – 23+6 weeks 10 43.5

24+0 – 27+6 weeks 6 26.1

28+0 – 31+6 weeks 1 4.3

32+0 – 36+6 weeks 2 8.7

37+0 – 40+6 weeks 3 13.0

≥ 41+0 weeks 1 4.3

23 100

Birth Weight <500g 12 52.2

500g-999g 5 21.7

1000g-1499g 1 4.3

1500g-1999g 1 4.3

2000g-2499g 1 4.3

2500g-2999g 2 8.7

3000g-3499g 1 4.3

23 100


128 |

TaBle 88: sTillBirThs By perinaTal DeaTh classiFicaTion For The years 2006 To 2012

2006 2007 2008 2009 2010 2011 20122006-2012

Primary diagnosis (PDC*) No. No. No. No. No. No. No. No.

Congenital anomaly 5 8 0 2 2 4 1 22

Perinatal infection 1 3 0 0 0 0 2 6

Hypertension 0 1 0 0 3 0 1 5

Antepartum haemorrhage 3 0 1 1 3 4 2 14

Maternal conditions 2 1 1 1 1 2 2 10

Specific perinatal conditions 2 6 4 12 7 5 7 43

Hypoxic peripartum death 1 1 0 1 1 0 0 4

Fetal growth restriction 2 2 3 5 1 0 3 16

Spontaneous preterm delivery 2 1 6 1 1 2 3 16

Unexplained 3 3 4 5 3 3 2 23

No obstetric antecedent 0 0 0 0 0 0 0 0

Total 21 26 19 28 22 20 23 159

Post Mortems (PM) 20 13 13 12 9 9 12 88

Post Mortem rate (%) 95.2 50.0 68.4 42.9 40.9 45.0 52.2 55.3

* Perinatal Society of Australia and New Zealand - Perinatal Death Classification


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TaBle 89: summary oF FacTors relaTeD To The 7 early neonaTal DeaThs < 7 Days in 2012

Factor No. %

Maternal Ethnicity NZ European 5 71.4


Mäori 1 14.3


Asian 0 0.0

Other 1 14.3

7 100

Maternal Age < 20 years 0 0.0

20 – 24 years 0 0.0

25 – 29 years 1 14.3

30 – 34 years 0 0.0

35 – 39 years 4 57.1

≥ 40 years 2 28.6

7 100

Maternal Parity/CS history Primiparous 1 14.3

Multiparous, no previous CS 3 42.9

Multiparous, with previous CS 3 42.9

7 100

Maternal Domicile C&C DHB 4 57.1

Other DHBs 3 42.9

7 100

Maternal Smoking Yes 1 14.3

No 6 85.7

7 100

Gestational Age 20+0 – 23+6 weeks 2 28.6

24+0 – 27+6 weeks 0 0.0

28+0 – 31+6 weeks 3 42.9

32+0 – 36+6 weeks 0 0.0

37+0 – 40+6 weeks 1 14.3

≥ 41+0 weeks 1 14.3

7 100

Birth Weight <500g 0 0.0

500g-999g 3 42.9

1000g-1499g 0 0.0

1500g-1999g 2 28.6

2000g-2499g 0 0.0

2500g-2999g 0 0.0

3000g-3499g 2 28.6

7 100


130 |

TaBle 90: early neonaTal DeaThs By perinaTal DeaTh classiFicaTion For The years 2006 To 2012

2006 2007 2008 2009 2010 2011 20122006-2012

Primary diagnosis (PDC*) No. No. No. No. No. No. No. No.


Perinatal infection 2 0 0 1 0 1 1 5

Hypertension 0 0 0 0 1 2 0 3

Antepartum haemorrhage 6 2 0 0 3 0 1 12

Maternal conditions 0 0 0 1 0 1 2 4

Specific perinatal conditions 1 5 1 4 2 1 0 14

Hypoxic peripartum death 0 0 2 0 0 1 0 3

Fetal growth restriction 0 0 1 0 0 0 1 2

Spontaneous preterm delivery 2 3 0 5 4 1 1 16

Unexplained 0 0 0 0 0 0 0 0

No obstetric antecedent 2 0 0 0 0 0 0 2

Total 14 12 5 14 14 13 7 79

Primary diagnosis (NDC*) No. No. No. No. No. No. No. No.


Extreme prematurity 4 6 0 7 3 1 0 21

Cardio-respiratory disorders 0 1 1 2 1 1 0 6

Infection 3 1 0 2 2 2 0 10

Neurological 4 1 3 0 2 2 5 17

Gastrointestinal 0 0 0 0 0 0 0 0

Other 0 1 0 0 0 1 1 3

Total 14 12 5 14 14 13 7 79

Post Mortems (PM) 12 6 5 6 8 4 4 45

Post Mortem rate (%) 85.7 50.0 100.0 42.9 57.1 30.8 57.1 57.0

* Perinatal Society of Australia and New Zealand - Perinatal Death Classification & Neonatal Death Classification


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13.1 maternal mortality

From 2003 to 2012 there has been one direct (in 2007) and three indirect maternal deaths (in 2003, 2004 and 2009) at C&C DHB (see definitions below).

The maternal mortality ratio is the number of maternal-related deaths per 100,000 maternities and for C&C DHB it was 10.2 per 100,000 women over the 2003 to 2012 period.

This rate is comparable to the ratio reported in the United Kingdom between 2006 and 2008 of 11.4 per 100,000 (Lewis, 2007). The Perinatal and Maternal Mortality Review Committee (PMMRC) reported a New Zealand national ratio of 17.8 per 100,000 for the five years 2006-2010 (PMMRC, Sixth Annual Report, table 35).

definitions

Maternal deaths are defined according to the World Health Organisation (WHO) definition as: “Deaths of women while pregnant or within 42 days of birth,miscarriage or termination of pregnancy, from any

cause related to, or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (NZ HIS, 2007).

Maternal deaths are further subdivided into two groups defined by WHO as:

• Direct - deaths resulting from obstetric complications of the pregnant state, from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

• Indirect - deaths resulting from previous existing disease that developed during pregnancy and which was not due to direct obstetric causes, but was aggravated by the physiological effects of pregnancy.

The Denominator for the ratio calculation is “the number of women with pregnancies that resulted in a live birth or stillbirth occurring at or after 20 completed weeks gestation” (PMMRC, 2012).

13. maternal mortality and morbidity


132 |

13.2 severe maternal morbidity

AMOSS (Australasian Maternity Outcomes Surveillance System) has been set up in New Zealand under the auspices of the PMMRC. Monthly reports are obtained from coding data and cases are entered in the AMOSS database for current studies.

Previous studies include extreme morbid obesity – BMI >50 (completed 2010), influenza requiring ICU admission (completed 2011), eclampsia (completed

2010), placenta accreta (completed 2012) and peripartum hysterectomy (completed 2012). Data collection continues for ongoing studies on amniotic fluid embolism and antenatal pulmonary embolism. New studies on rheumatic heart disease in pregnancy and gestational breast cancer commenced in 2012.

There were no maternal deaths among the severe morbidities reported in 2012.

TaBle 91: inciDence oF amoss reporTaBle severe maTernal morBiDiTies For 2011 anD 2012

2011 2012

Study No. Rate per 1000 No. Rate per 1000

Placenta accreta/percreta/increta 2 0.51 4 1.04

Peripartum hysterectomy 2 0.51 3 0.78

Influenza requiring ICU admission 1 0.26

Amniotic fluid embolism 0 0.00 0 0.00

Antenatal pulmonary embolism 1 0.26 2 0.52

Rheumatic heart disease in pregnancy 2 0.52

Gestational breast cancer 0 0.00

13.3 admissions to the intensive care unit

There were seven admissions to ICU of postpartum women during 2012.

All were post caesarean section either for high level observation or management of complications.

Admission reasons included pneumothorax (1), massive postpartum haemorrhage (1), bowel complications (2), morbid obesity with BMI >70 (1), uterine rupture (1), and uterine tear (1).


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14.1 gynaecology outPatient service

There has been an overall increase in the number of women attending gynaecology clinics within the WHS in 2012 (see table on following page).

General gynaecology had 4845 visits which was an increase of 484 visits (11.1%) from 2011. Total gynaecology volumes were 8830 for 2012 which was an increase of 9.2% from 2011.

The OASIS clinic was introduced with the commencement of the new medical roster in October 2012. These women were previously seen in the pelvic floor or general gynaecology clinics.

Preassessment volumes in 2012 (1558) have increased by 35.8% since 2009 (1147). Nurse led preassessment clinics for fit and healthy women who do not require

assessment by medical staff have been introduced over this period.

The volumes for acute assessments have increased by 6.3% from 1142 in 2011 to 1214 in 2012.

There has been a 7.9% decrease from 2011 to 2012 in the number of women attending clinic at Kenepuru, and a 13.6% decrease over the four years from the 850 in 2009 to the 748 in 2012.

DNA (did not attend) rates have dropped for most gynaecology clinics which is largely due to the introduction of telephone and text reminders. The booking centre staff work hard to reschedule those who are unable to attend and fill clinic vacancies with other women waiting to attend.

14. gynaecology clinics


134 |

TaBle 92: gynaecology ouTpaTienT clinic aTTenDances anD Dna raTes For years 2009 To 2012


Gynaecology Clinic 2009 2010 2011 2012 2009 2010 2011 2012

No. No. No. No. % % % %

Gynaecology - General

Wellington 3187 3247 3380 3846 9.2 9.1 9.8 7.8

Kenepuru 850 843 812 748 15.5 12.2 11.6 11.8

Kapiti 349 198 169 246 5.4 11.6 14.8 5.3

Hastings 2 34 5 0.0 14.7 0.0 0.0

Total - General 4388 4322 4361 4845 10.1 9.9 10.3 8.3

Gynaecology - Other

Acute assessment 2337 1541 1142 1214 0.5 0.1 0.5 0.6

Preassessment 1147 1299 1415 1558 5.8 3.5 3.1 3.9

High cost treatment 56 46 50 82 7.1 15.2 8.0 1.2

Infertility 290 237 280 300 10.0 8.4 8.9 6.3

Oncology 523 667 592 461 8.0 6.1 7.4 11.1

PCC 18 29 47 59 16.7 17.2 6.4 8.5

Pelvic floor 55 64 50 27 3.6 7.8 2.0 0.0

PMB 5 66 116 6.1 3.4

Skin 93 80 84 75 5.4 12.5 4.8 5.3

Urogynaecology 78 10.3

OASIS 15 0.0

Total - Other 4519 3968 3726 3985 3.6 3.4 3.6 4.0

Grand Total – Gynaecology 8907 8290 8087 8830 6.8 6.8 7.2 6.3

During 2012 a concerted effort has been made by the WHS and the outpatient booking centre to reduce the waiting times for gynaecology FSAs (First Specialist Assessment). This was achieved by July 2012 with no

women waiting for more than 4 months for an FSA. At the same time in 2011 31 women were waiting up to 8 months for an FSA.


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TaBle 93: gynaecology WaiTing Time numBers per monTh For 2012

2012Maximum waiting

time for FSANumbers waiting

> 6 monthsNumbers waiting

< 6 months

Jan 10 months 22 847

Feb 9 months 17 851

Mar 8 months 14 894

Apr 6 months 5 884

May 6 months 2 767

Jun 8 months 7 644

Jul 5 months 0 544

Aug 6 months 1 471

Sep 6 months 0 469

Oct 5 months 1 492

Nov 4 months 0 581

Dec 4 months 0 574

14.2 colPoscoPy service

colPoscoPy satisfaction survey

Since 2009 the WHS have asked women who require colposcopy to participate in a satisfaction survey. In 2012 the survey commenced on 1st of June and concluded on the 30th June. 123 women required colposcopy during this period and feedback was received from 39 women, a response rate of 31.7%. Generally speaking the feedback received was very positive. Women felt they were treated with respect, given adequate opportunity to ask questions and receive information.

The main area identified by women as needing improvement pertained to information about their up and coming treatment. A copy of the National Cervical Screening leaflet is now posted out to all women requiring colposcopy as previously only new patients received the leaflet. This leaflet accompanies the scheduled appointment letter. Women attending the colposcopy service will be resurveyed in June and November 2013.

colPoscoPy service monitoring

The colposcopy service is monitored by the National Screening Unit of the Ministry of Health with a monthly colposcopy service monitoring report. There are strict criteria that govern the timeframes in which women with abnormal cervical smears are seen for FSA at colposcopy.

These are:

• Suspicion of cancer - within 1 week

• High grade - within 4 weeks

• Low grade - within 26 weeks

There are also criteria to ensure that women who require treatment for their biopsy proven cervical abnormalities have this carried out within the appropriate times. These are:

• High grade - within 8 weeks

• Low grade - within 26 weeks


136 |

If the women are not seen within these timeframes the reason for this is documented in the service monitoring report. In 2012 there were three main reasons why women were not seen on time for FSA and treatment in colposcopy.

First Specialist Assessment:

• 19 women declined an appointment offered within the timeframe

• 4 women had a medical reason

• 3 women were not seen due to doctor unavailability

Treatment:

• 10 women declined an appointment offered

• 23 women were not seen due to doctor unavailability

C&C DHBs contracted volumes for 2012 were:

• 1200 new and follow up colposcopy and LLETZ follow ups

• 200 LLETZ treatments

These volumes were exceeded in 2012 which can be seen in the table below.

There was an 8.2% increase in visits to all colposcopy clinics from 1536 in 2011 to 1662 in 2012. The colposcopy did not attend rate of 12.5% for 2012 is within the accepted rate of less than 15% which is monitored by the National Cervical Screening Programme.

TaBle 94: colposcopy ouTpaTienT clinic aTTenDances anD Dna raTes For years 2009 To 2012


Colposcopy Clinic 2009 2010 2011 2012 2009 2010 2011 2012

No. No. No. No. % % % %

Colposcopy 1184 1200 1144 1294 15.2 14.6 16.7 14.1

LLETZ 315 328 392 368 15.9 9.1 9.2 6.5

Total – Colposcopy 1499 1528 1536 1662 15.3 13.4 14.8 12.5

TaBle 95: colposcopy WaiTing Time numBers per monTh For 2012

2012 Maximum waiting time for FSA Numbers waiting > 6 months Numbers waiting < 6 months

Jan 9 months 8 256

Feb 10 months 12 217

Mar 9 months 6 196

Apr 9 months 3 226

May 10 months 3 244

Jun 7 months 5 206

Jul 6 months * 230

Aug 6 months 3 227

Sep 7 months 4 227

Oct 7 months 2 221

Nov 7 months 4 182

Dec 8 months 7 122

* Not available


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14.3 te mahoe unit

Te Mahoe provides comprehensive pregnancy counselling as well as first and second trimester termination of pregnancy (TOP) services for women between 5 and 19+1 weeks gestation.

The following table tabulates the distribution of women who attended Te Mahoe by DHB of origin over the last six years.

There are slight variations in the DHB distribution of TOPs. During 2012 there was a slight decrease in the Capital and Coast and Hutt Valley DHB figures, as well as an increase in the number of non-residents seeking a TOP.

TaBle 96: DhB DisTriBuTion oF Women aTTenDing Te mahoe uniT in years 2007 To 2012

2007 2008 2009 2010 2011 2012

DHB % % % % % %

Capital & Coast 46.0 44.5 44.0 41.0 44.0 40.5

Hutt Valley 23.0 23.0 24.0 22.8 23.2 21.6

Mid-Central 19.3 20.0 19.0 19.1 19.0 19.4

Whanganui 6.8 7.4 7.0 9.0 8.4 9.2

Hawkes Bay 1.1 0.6 0.7 0.8 0.4 0.9

Wairarapa 0.4 0.5 0.7 0.8 0.7 1.5

Nelson Marlborough 0.6 0.7 0.5 0.5 0.8 0.8

Other non-central region DHBs 0.7 0.7 0.2 1.2 0.8 0.5

Non-residents 2.1 2.5 4.0 4.7 2.7 5.7

100 100 100 100 100 100


138 |

The next table shows the total number of TOPs performed in the unit for the years 2007 to 2012, the percentage distributions for various medical and demographic variables, and the complication rates.

There continues to be a decrease in the number of women having a TOP in Te Mahoe. There was an 11% reduction in the number of TOPs performed from 2011 to 2012.

Of the TOP appointments scheduled in 2012, 2.5% of women did not attend and 2.6% phoned and cancelled their appointment.

During 2012, 1958 counselling appointments were made but 10% did not attend.

44.3% of women had some form of long acting reversible contraception (LARC) inserted following their TOP during 2012. Of those 6.6% were the mirena intrauterine system, 23.3% were a multiload cu 375 intrauterine device and 14.4% were the jadelle contraceptive implant. There was a 10% decrease in the number of jadelle implants inserted post TOP in 2012 as compared to 2011.

There was a slight decrease in the number of women choosing to have a medical TOP procedure. A contributing factor to this might have been the early availability of surgical TOP appointments. During 2012, 81% of women having an early medical TOP procedure chose to return home after taking the misoprostol and continued the process at home.

During 2012, 18 women from the MFM team were admitted to Te Mahoe for a TOP. Fifteen of these women had their TOP performed under general anaesthetic and three under local anaesthetic. These figures are not included in the Te Mahoe data.

According to the Abortion Supervisory Committee statistics, Te Mahoe continues to perform terminations at earlier gestations than the majority of units within New Zealand, with 55% being performed at less than nine weeks.

There are slight variations in the ethnicity distributions of women seeking a TOP.

Of note there was a 4% decrease in TOPs performed in the 19 to 24 year age group, otherwise there was no significant change in the age distribution of women referred.

There was no significant change between the 2011 and 2012 surgical TOP known complications. When comparing the 2011 and 2012 medical TOP known complications, there was a slight increase in retained products of conception (RPOC) and a 3% increase in women requiring hospital admissions, with the majority of those requiring an evacuation of RPOC. Two women had ongoing pregnancies following a medical TOP with one repeated as a general anaesthetic TOP and the other choosing to continue the pregnancy.


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TaBle 97: numBers anD raTes For Te mahoe For years 2007 To 2012

2007 2008 2009 2010 2011 2012

Total number of TOPs 3078 2872 2781 2691 2497 2221

Procedure % % % % % %

Local anaesthetic 88.0 86.0 90.0 89.0 89.0 91.6

General anaesthetic 5.0 5.0 5.0 5.0 4.8 3.8

Early medical terminations 6.5 7.0 5.0 6.0 6.0 4.4

Induction of labour 0.5 1.0 0.1 0.1 0.04

MFM induction of labour 1.0

Gestation % % % % % %

Less than 9 weeks 40.0 47.0 48.0 50.0 50.0 54.8

9 – 11 weeks 41.0 37.0 35.0 33.0 34.0 29.6

12 – 15 weeks 15.0 12.0 14.0 14.0 12.0 12.8

16 weeks and over 4.0 4.0 3.0 3.0 4.0 2.6

Repeat TOPs % % % % % %

None 63.0 62.0 61.0 62.0 62.0 58.8

1 prior TOP 24.0 23.0 25.0 25.0 25.0 26.4

2 prior TOPs 8.0 10.0 8.0 9.0 9.0 9.3

3 prior TOPs 3.0 4.0 4.0 3.0 3.0 3.4

4 prior TOPs 2.0 1.0 2.0 1.0 1.0 2.0

Ethnicity % % % % % %

NZ European 49.0 50.0 46.0 49.0 49.0 48.8

Mäori 24.0 25.0 25.0 25.0 24.5 26.2

Samoan 5.0 6.0 6.0 6.0 6.5 6.4

Other Pacific Peoples 2.4 4.4 4.0 4.0 5.0 0.2

Asian 5.0 4.4 4.0 3.0 4.5 0.1

Other 14.6 10.2 15.0 13.0 10.5 18.2

Age % % % % % %

< 14 years 0.2 0.4 0.0 0.0 0.0 0.0

14 – 15 years 2.2 1.6 2.0 1.0 1.5 1.1

16 – 18 years 16.2 15.0 16.0 12.0 10.2 9.9

19 – 24 years 37.9 40.0 40.0 40.0 44.2 40.2

25 – 29 years 17.3 19.3 19.0 21.0 19.5 21.8

30 – 35 years 15.2 14.0 14.0 15.0 14.3 15.8

36 – 40 years 8.7 7.6 7.0 8.0 8.0 8.3

> 40 years 2.3 2.1 2.0 3.0 2.3 2.8

STOP complication rates % % % % % %

RPOC 1.1 1.3 0.6 0.8

Endometritis 1.45 0.8 0.8 0.5

Requiring hospital admission 0.8 0.9 0.4 0.6

Failed TOP 0.2 0.3 0.0 0.04

Perforation 0.04 0.1 0.08 0.04

PPH 0.0 0.04

Ongoing pregnancy 0.0 0.04

Early MTOP complication rates % % % % % %

RPOC 3.9 5.3 2.0 3.1

Endometritis 1.3 0.5 0.6 1.0

Requiring hospital admission 2.6 3.0 2.0 5.2

Failed TOP 1.2 1.3 2.0

PPH 0.6 1.0


140 |


| 141

15.1 gynaecology inPatient service

Gynaecology inpatient services in pod A of Ward 4 North continued to maintain its acute and elective services in 2012.

Acute admissions to the inpatient ward are via the Acute Assessment service Monday to Friday 8am to 6pm. After hours, the majority of admissions are via the Emergency Department (ED). In order to meet the 6 hour rule in ED, women are triaged according to a defined triage protocol. If their condition is stable and meets the set criteria, after discussion with the on-call registrar the women are fast tracked to the inpatient ward for assessment. Women with an unstable condition will remain in ED until they are assessed by the obstetric and gynaecology registrar and their condition stablised prior to admission to the inpatient ward.

66 women admitted acutely required evacuation of retained products of conception (ERPOC) and were admitted directly from ED to an operating theatre or from Ward 4 North to theatre. 159 women had an arranged ERPOC procedure in a day stay bed in the Surgical Admissions Unit. Refer to Table 101.

There were 484 non-surgical gynaecology admissions in 2012. The diagnoses for 289 of these women are detailed in Table 103. There were also 104 antenatal admissions of women who were under 20 weeks gestation, of which 68 had hyperemesis and 36 other conditions such as urinary tract infection, pylonephritis,

urinary retention, abdominal pain and breast abscess. A further 91 postpartum women were readmitted more than 10 days after giving birth.

The perioperative unit at Wellington Regional Hospital, the day surgery unit and the surgical medical unit at Kenepuru Hospital provide additional beds for elective surgery. The gynaecology service has an allocated 10 surgical sessions per week, with three sessions at Kenepuru Hospital. A total of 1177 women had elective surgery at Wellington Regional Hospital and 384 women at Kenepuru Hospital.

The increase in day case numbers at Wellington reflects the available use of theatre time for additional gynaecology operating lists. Preparation for discharge commences at the preassessment visit when women are informed of their expected length of stay in the inpatient ward. This process has increased the number of women being discharged from the inpatient ward in the expected timeframes. All day of surgery admissions including gynaecology oncology are admitted to the surgical admissions unit and transferred to the inpatient ward postoperatively. This enables improved bed utilisation.

In 2012 the gynaecology service used the mobile surgical bus at the Kapiti Health Centre for seven elective surgical lists. Procedures carried out included dilation and curettage, hysteroscopy, laparoscopic sterilisation, excision of Bartholins abscess and

15. gynaecology services


142 |

insertion of mirena. This was a nurse-led initiative. The list was arranged by the gynaecology nurse care coordinator with postoperative follow-up by nursing staff. This service meant that women did not have to travel to Wellington for surgery. The service plans to continue using the mobile surgical bus in 2013.

TaBle 98: elecTive gynaecology surgery volumes For years 2009 To 2012

2009 2010 2011 2012

Surgery location No. No. No. No.

Wellington Inpatient 866 848 777 835

Wellington Day Surgery Unit (SAU) 358 242 270 342

Kenepuru Surgical Medical Unit 470 318 393 384

Total 1694 1408 1440 1561

TaBle 99: acuTe gynaecology surgery volumes For years 2009 To 2012

2009 2010 2011 2012

Surgery location No. No. No. No.

Wellington Inpatient 92 157 147 198

Wellington Day Surgery Unit 211 188 143 169

Total 303 345 290 367


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TaBle 100: elecTive gynaecology surgery volumes anD BreakDoWn oF surgical proceDures For 2012

Surgical ProcedureWellington Inpatient

Wellington day patient

Kenepuru Total

TAH +/- BSO 43 12 55

Sub-total hysterectomy 9 4 13

Vaginal hysterectomy 11 5 16

Laparoscopic assisted vaginal hysterectomy 32 4 36

Laparoscopic ovarian cystectomy/BSO/oopherectomy 46 19 65

Laparotomy oopherectomy/BSO 21 2 23

Laparoscopic sterilisation 31 22 53

Dilation & curettage, hysteroscopy, polypectomy 168 95 263

Insertion of Mirena 78 32 110

Insertion of Mirena as part of another procedure**** 33 8 41

Myomectomy 1 2 3

Endoscopic endometrial ablation 65 22 87

Large loop excision of the transformation zone (LLETZ) 13 2 15

Cone biopsy 13 4 17

Laparoscopic cerclage 5 5

Incision & drainage Bartholins abscess 18 2 20

Fenton’s procedure 4 1 5

Urogynaecology surgery * 152 32 184

Endometriosis surgery ** 239 124 363

Gynaecology Oncology Service *** 228 228

Total 835 342 384 1561

* See section on Urogynaecology for breakdown of surgical procedures** See section on Endometriosis for breakdown of surgical procedures*** See section on Gynaecology Oncology for breakdown of surgical procedures**** Not counted in total numbers as part of another procedure


144 |

TaBle 101: acuTe gynaecology surgery volumes For 2012

Surgical ProcedureWellington Inpatient

Wellington day patient

Total

Laparoscopic salpingectomy/salpingostomy (ectopic pregnancy)* 32 32

Evacuation retained products of conception (dilation & curettage) 66 159 225

Laparoscopic ovarian cyst/abscess 37 37

Diagnostic laparoscopy 13 13

Laparotomy torted ovarian cyst/hemorrhagic cyst 12 12

Incision & drainage of Bartholins abscess 27 10 37

Total abdominal hysterectomy (following caesarean section) 4 4

Cervical cerclage 4 4

Wound debridement 3 3

Total 198 169 367

* Of the 32 women with ectopic pregnancy, there were 7 ruptured ectopic and 2 corneal ectopic.

The following table lists the reasons for postnatal readmission. Women who have recently given birth are able to have their baby stay to encourage breastfeeding and bonding.

On discharge the women are referred back to their LMC for ongoing postnatal care or to their GP if they are 4 to 6 weeks postpartum.

TaBle 102: posTnaTal reaDmissions For 2012

Diagnosis Total

Retained products of conception 6

Endometritis 23

Caesarean section wound infection 14

Mastitis 14

Breast abscess 7

Unwell / sepsis 6

Urinary retention 6

Pain +/- endometritis 15

Total 91

Of the 45 women who presented with chronic pain (endometriosis) there were 12 women who presented between two and five times. Further discussion is provided in the Endometriosis Service report.


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TaBle 103: non-surgical acuTe aDmissions For 2012

Diagnosis Total

Complete / incomplete miscarriage (conservative management ) 76

Conservative management ectopic (Methotrexate) 14

Ovarian hyperstimulation 4

Tubal / ovarian abscess 5

Labial / vulval cellulitis 15

Pelvic inflammatory disease 21

Genital herpes 5

PV bleeding / menorrhagia 37

PV bleeding / infection post TOP 14

Post-operative readmissions (Public & Private) 53

Chronic pain (Endometriosis) 45

Total 289

15.2 endometriosis service

There is a dedicated fortnightly specialist endometriosis clinic. Women are referred from other specialists and general practitioners. Various management options are discussed with the women and if surgery is warranted this is explained in detail.

In most cases we are able to treat the endometriosis at the time of the initial laparoscopy thereby saving women an additional operative procedure.

The service carried out elective surgery on 199 women at Wellington Regional Hospital and 164 women at Kenepuru Hospital. Length of stay for these women is usually overnight with discharge home planned for 11am the next morning. Most women having a diagnostic laparoscopy and dye studies are able to be discharged home on the day of surgery.

Most clinicians perform excisional treatment and histological confirmation is obtained. The majority of ovarian endometriomas were treated by cystectomy and tissue was sent for histology.

The service also provides an acute service for those women who present with exacerbation of their

endometriosis pain. In 2012 there were 45 acute admissions for exacerbation of endometriosis pain. With input from the chronic pain service, no women required a patient controlled analgesia system (PCAS) to assist in controlling their pain.

Those women who had not previously been referred to the chronic pain service were referred during their admission for assistance with pain management, with an outpatient referral for follow-up and ongoing management.

Women who are under the chronic pain service and continue to have multiple presentations to the Emergency Department have an agreed analgesia management plan for their pain management. The chronic pain clinical nurse specialist visits the women on a daily basis whilst they are inpatients, in order to assist with early discharge and follow up in the community. Some complex cases of chronic pelvic pain are discussed at the multidisciplinary team meetings with gynaecologic input which we plan to make a more regular feature.


146 |

TaBle 104: ToTal enDomeTriosis proceDures For 2012

Sites excised * Total

Laparoscopic excision of endometriosis (includes excision of endometriosis from broad ligaments, pelvic side walls, uterosacral, rectovaginal, bladder, bowel tubes & ovaries)** 267

Laparoscopy & dye studies 46

Ovarian drilling 13

Ovarian endometrioma 36

Converted to open procedure 1

Total 363

* Some women have multiple sites of disease, therefore there may be 3-4 sites excised in one procedure. ** Total volumes represent each case not each procedure.

15.3 urogynaecology service

Women with symptoms of pelvic floor disorder are seen in a range of gynaecology clinics in Wellington and Kenepuru. Women with more complex problems such as recurrent prolapse, previously treated stress incontinence and ICS stage 4 vault prolapse, are referred to the pelvic floor clinic. There is now a dedicated combined pelvic floor clinic with three clinicians with sub-speciality interest managing these women.

The urogynaecology service is supported by a team of pelvic floor physiotherapists. Patients for urodynamics are referred to the Urology Department. Occasional referrals are also made to colorectal specialists.

Challenges in urogynaecology continue to be:

• Optimising care at a time of increasing demand because of the ageing population, increased public awareness and the need to improve quality of life

• Steady increase in number of women requiring surgery for pelvic organ prolapse (POP) and urinary incontinence

• Individualising surgical approach: improving outcomes while minimising risks

• Current medico legal environment.

Bilateral sacrospinous fixation for vault prolapse continues to be utilised widely as part of a combined procedure.

Grafts to reinforce tissues have been used in selected cases. There is now a trend towards reduced graft related problems as our understanding of preoperative,

postoperative care and surgical techniques improve. With new FDA regulations there has been a change in the type of synthetic grafts available for transvaginal mesh repair.

There is a clear shift from retropubic procedures to transobturator procedures for the surgical treatment of stress incontinence related to safety and technical ease of the latter. Retropubic TVT is reserved for a select few cases.

As the proportion of women in the 50-85 year age group increases so will the need for prolapse surgery. Nationwide data of surgical numbers is not available in New Zealand for comparison. There is a steady increase in surgical volumes noted. As life expectancy increases and more women opt for surgery for want of better quality of life and with a 29% failure rate for traditional prolapse repair the need for repeat surgery will increase as well.

We need to continue focusing on pelvic floor physiotherapy both pre and postoperatively, along with advising women on life style interventions to reduce the recurrence rate.

Excellent support is provided by our gynaecology ward nursing staff for management of postoperative bladder and bowel care. Postoperative bladder management has been further refined with use of retrograde fill of bladder postoperatively. This avoids some of the unsuccessful trial of voids and re-catherisation. The gynaecology inpatient charge nurse manager in Ward 4 North remains actively involved in continuous education of the nursing staff.


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TaBle 105: urogynaecology surgery proceDures For years 2008 To 2012

Procedure * 2008 2009 2010 2011 2012

No. No. No. No. No.

Vaginal repair with sacrospinous fixation 16 13 50 30 29

Native tissue vaginal repair 63 85 88 78 74

Vaginal repair with Prolift 23 7 5 8

Mesh vaginal repair with Gynaecare mesh 15 7 1 3 1

Vaginal hysterectomy for prolapse 4 4 20 15 27

Sling procedures for SUI 56 49 60 58 36

Revision of mesh 4 4 2 1 5

Abdominal sacrocolpopexy 1 1 2 5 4

Total 159 186 230 195 184

* Some women have had more than one procedure at the same operative episode. The surgical numbers for 2012 were reliant on ORSOS and surgical lists. The actual procedure may be different from proposed therefore possibly affecting accuracy of surgical procedures for 2012.

15.4 gynaecology oncology service

The service continues to develop a model based on the Central Cancer Network and the framework for providing gynaecologic oncology service developed by the New Zealand Gynaecology Cancer group.

Multidisciplinary meetings now include our colleagues at Mid-Central DHB and with more resources available both at Wellington and at other locations the service can continue to evolve.

TaBle 106: gynaecology oncology reFerral numBers By DhB For years 2009 To 2012

2009 2010 2011 2012

District Health Board No. No. No. No.

Capital and Coast 98 102 94 120

Hutt Valley * 16 19

Hawkes Bay 48 38 28 36

Taranaki 29 36 27 23

Whanganui 0 0 15 2

Mid Central 8 16 21 13

Wairarapa 20 10 9 13

Nelson Marlborough 1 2 1 2

Other North Island 2 1 3 0

Other South Island 1 0 0 0

Total 207 205 214 228

* Hutt Valley DHB numbers included in C&C DHB numbers for 2009 and 2010.


148 |

TaBle 107: hisTological conFirmeD gynaecology oncology cases For neWly reFerreD Women in 2012

Gynaecology Malignant Neoplasm Total

Malignant neoplasm of ovary 38

Malignant neoplasm of endometrium 44

Malignant neoplasm of cervix uteri, unspecified 56

Malignant neoplasm of vulva, unspecified 31

Malignant neoplasm of vagina 5

Malignant neoplasm of placenta 0

Malignant neoplasm of fallopian tube 0

Total 174

TaBle 108: gynaecology oncology surgery proceDures For 2012

Surgical Procedure Total

Total abdominal hysterectomy bilateral salpingo-oopherectomy, para-aortic lymph node sampling 38

Total abdominal hysterectomy, bilateral salpingo-oopherectomy, omentectomy, para-aortic lymph node sampling 44

Radical abdominal hysterectomy with radical excision of pelvic lymph nodes 5

Trachlectomy 1

Dilation & curettage of uterus, D&C, hysteroscopy, +/- polypectomy 24

EUA, staging 50

Cone biopsy of cervix 12

Biopsy of vagina 5

Wide local excision vulva 18

Wide local excision vulva bilateral groin node dissection 8

Radical vulvectomy 5

Laparoscopic bilateral salpingo-oopherectomy 4

Other procedures 17

Total 231


| 149

15.5 adverse gynaecological outcomes

Definition: An adverse outcome is an unintended and/or unexpected significant gynaecological injury or complication that results in a prolonged length of stay, disability or death.

Outcome monitoring is performed under the following headings:

• Trend monitoring

• Case review

• Reportable event

The process of monitoring adverse outcomes commenced in May 2004, with 2012 being our eighth year of formal reporting.

The WHS clinical outcomes committee meets regularly to ensure that adverse gynaecology outcomes, in relation to trends tracking and clinical indicators are identified, analysed and reviewed. All trend monitoring is measured against the ACHS clinical indicators. The objective of adverse outcome monitoring is to minimise risk to women, staff and the

organisation. Data, trends and adverse outcome case studies are presented at our quality forums, in order to review and engage clinicians in discussion. This enables all clinicians to focus on potential areas of risk and to identify systems that can help to improve care and outcomes for women accessing our service.

Advantages of the process:

• No worrying trends have been identified

• This is an educational, supportive forum

• This is well received by senior medical officers, junior medical and nursing staff

• Data presented at quarterly quality forums.

A brief summary of the adverse outcomes for 2012 are in the following table. Some women had more than one adverse outcome.

The total number of adverse outcomes reported in 2010 was 104. Sixty-five adverse outcomes were reported in 2011 and 81 in 2012 indicating there is some fluctuation year to year.

TaBle 109: aDverse gynaecologic ouTcomes For 2012

Adverse outcomeBenign

GynaecologyGynaecology / Oncology

Blood transfusion intraoperatively 3 1

Blood transfusion postoperatively 5 3

Major vascular injury or bowel or urinary tract requiring over sewing/repair 9 6

Uterine perforation requiring surgical intervention 7 1

Major wound dehiscence 0 1

Unexpected admission to ICU 0 0

Major postoperative sepsis 0 0

Major wound infection 0 0

Transfer from Kenepuru 9 0

Return to theatre within 7 days 5 0

Postoperative death 0 0

Readmission within 1 month 20 2

Length of stay over 10 days postoperatively 0 9

Urinary tract obstruction requiring catheterisation postoperatively 0 0

Total Adverse Outcomes 58 23

Total Women 53 22


150 |

15.6 achs gynaecology clinical indicators

The gynaecology ACHS clinical indicator peer report provides a useful tool for comparing intra and postoperative complications with like organisations throughout New Zealand and Australia who submitted data. In total, 33 organisations submitted data in the first half of 2012, and 34 organisations submitted data in the second half (see Table 124).

Overall the gynaecology service is comparable to other units within Australasia. Complication rates compared favourably for laparoscopic and urogynaecological procedures and in the surgical management of ectopic pregnancies.

In 2012 there were three indicators where the gynaecology service did not meet the benchmark.

The most notable is the rate of unplanned blood transfusions for women admitted for gynaecological surgery for benign disease (indicator 1.1). 18 women were transfused in 2012 compared to the expected

number of 10. The rate of transfusion of women admitted for gynaecological surgeries (indicator 1.2) was also marginally higher than expected by the peer group comparison.

In the first six months, there were seven cases where operative injuries to major viscus occurred. These cases included gynaecological malignancies. This pattern did not continue in the latter part of the year. No viscus injuries were reported for laparoscopic surgeries.

One of the ACHS clinical indicators is laparoscopic management of ectopic pregnancies (indicator 4.1). 27 of 30 ectopics managed surgically at C&C DHB in 2012 were managed laparoscopically. This indicates that the acute services are functioning well enabling timely diagnosis and access to surgeons with the necessary skills and training.


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TaBle 110: group comparison For achs gynaecology clinical inDicaTors For years 2010 To 2012

Clinical IndicatorC&C 2010

C&C 2011

C&C 2012

ACHS 2010

ACHS 2011

ACHS 2012

PeriodRate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

1.1

Patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecological surgery for benign disease (L)

Jan-Jun 3.05 1.74 2.56 0.99 1.35 1.46

Jul-Dec 1.42 2.34 1.86 1.09 1.03 1.01

1.2

Patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecological surgery for malignant disease (L)

Jan-Jun 8.96 19.12 8.77 9.41 8.36 6.01

Jul-Dec 19.12 14.81 8.20 10.48 6.01 7.03

2.1

Patients suffering injury to a major viscus with repair, during an gynaecological operative procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 1.59 1.37 1.70 0.47 0.51 0.63

Jul-Dec 0.79 1.11 0.44 0.46 0.58 0.40

3.1

Patients suffering an injury to a major viscus with repair, during a laparoscopic gynaecological operative procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0.00 0.50 0.00 0.63 0.99 0.78

Jul-Dec 0.00 1.52 0.74 0.73 1.03 0.82

3.2

Patients receiving an injury to a ureter at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0.00 0.00 0.00 0.43 0.43 0.00

Jul-Dec 0.00 0.00 0.00 0.43 0.00 1.00

3.3

Patients receiving a bladder injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0.00 0.00 0.00 0.00 0.00 0.36

Jul-Dec 0.00 0.00 0.00 0.00 0.31 1.00

4.1 Laparoscopic management of an ectopic pregnancy (H)

Jan-Jun 87.50 69.23 93.75 83.57 80.76 82.41

Jul-Dec 92.86 94.44 85.71 82.75 82.82 82.58

5.1

Patients receiving injury to a major viscus with repair, during a pelvic floor repair procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 1.85 1.45 0.00 0.91 1.43 1.78

Jul-Dec 0.00 0.00 0.00 1.52 1.18 1.39

5.2

Patients receiving a ureter injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0.00 0.00 0.00 0.00 0.28 0.00

Jul-Dec 0.00 0.00 0.00 0.14 0.27 0.36

5.3

Patients receiving a bladder injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively (L)

Jan-Jun 0.00 0.00 0.00 0.66 0.42 0.68

Jul-Dec 0.00 0.00 0.00 0.42 0.68 0.60

(L) – A low rate is desirable(H) – A high rate is desirable (N) – Desirable rate is unspecifiedRates in italic / greyed highlight results that require attention.Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.


152 |


| 153

16.1 extra data tables

The following are data tables not included in the main text.

16. aPPendices


154 |

Ta

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263

6.7

234

6.3

264

7.0

254

6.4

266

6.6

273

6.8

232

5.8

203

5.2

245

6.3

240

6.2

Para

para

umu

992.

598

2.6

110

2.9

131

3.3

154

3.8

162

4.1

157

3.9

156

4.0

127

3.2

132

3.4

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240.

619

0.5

180.

526

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631

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038

9110

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1710

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2003

2004

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2006

2007

2008

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.836

3089

.837

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.8

Kene

puru

263

6.5

234

6.2

264

6.9

254

6.3

266

6.4

273

6.7

232

5.7

203

5.1

245

6.1

240

6.1

Para

para

umu

992.

598

2.6

110

2.9

131

3.2

154

3.7

162

4.0

157

3.8

156

3.9

127

3.2

132

3.4

Birt

h be

fore

arr

ival

240.

619

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180.

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0.6

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0


| 155

TaBle 112: place oF BirTh By c&c DhB BirThing FaciliTy For The years 2003 To 2012

Mothers 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Birth Facility No. No. No. No. No. No. No. No. No. No.

Wellington 3558 3365 3379 3574 3622 3560 3603 3520 3537 3470

Kenepuru 270 240 265 262 271 277 234 213 251 245

Paraparaumu 99 98 110 131 154 162 158 158 129 135

Total 3927 3703 3754 3967 4047 3999 3995 3891 3917 3850

Babies 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Birth Facility No. No. No. No. No. No. No. No. No. No.

Wellington 3650 3462 3462 3648 3719 3652 3692 3614 3621 3540

Kenepuru 270 240 265 262 271 277 234 213 251 245

Paraparaumu 99 98 110 131 154 162 158 158 129 135

Total 4019 3800 3837 4041 4144 4091 4084 3985 4001 3920

(NB The “births before arrival” tabulated separately in the previous table are included in this table in the birthing facility to which they were admitted).

TaBle 113: eThniciTy group DisTriBuTion WiThin each age group For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Ethnicity No. % No. % No. % No. % No. % No. % No. %

NZ European 52 30.2 196 39.4 352 42.6 640 53.1 540 59.7 132 53.9 1912 49.7

Other European 3 1.7 17 3.4 55 6.7 186 15.4 159 17.6 41 16.7 461 12.0

Mäori 76 44.2 140 28.1 116 14.0 70 5.8 62 6.9 17 6.9 481 12.5

Pacific Peoples 35 20.3 85 17.1 107 13.0 75 6.2 39 4.3 18 7.3 359 9.3

Asian 2 1.2 47 9.4 169 20.5 206 17.1 81 9.0 30 12.2 535 13.9

Other 4 2.3 13 2.6 27 3.3 28 2.3 23 2.5 7 2.9 102 2.6

Total 172 100 498 100 826 100 1205 100 904 100 245 100 3850 100


156 |

TaBle 114: pariTy By age group For 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total


0 143 83.1 285 57.2 420 50.8 552 45.8 272 30.1 69 28.2 1741 45.2

1 23 13.4 160 32.1 228 27.6 437 36.3 362 40.0 84 34.3 1294 33.6

2 6 3.5 44 8.8 110 13.3 137 11.4 184 20.4 47 19.2 528 13.7

3 0 0.0 5 1.0 38 4.6 52 4.3 48 5.3 20 8.2 163 4.2

4 0 0.0 4 0.8 18 2.2 19 1.6 27 3.0 11 4.5 79 2.1

> 4 0 0.0 0 0.0 12 1.5 8 0.7 11 1.2 14 5.7 45 1.2

Total 172 100 498 100 826 100 1205 100 904 100 245 100 3850 100

TaBle 115: pariTy By eThniciTy group For 2012

MothersNZ

EuropeanOther

EuropeanMäori

Pacific Peoples

Asian Other Total


0 877 45.9 214 46.4 190 39.5 133 37.0 281 52.5 46 45.1 1741 45.2

1 697 36.5 172 37.3 126 26.2 88 24.5 178 33.3 33 32.4 1294 33.6

2 263 13.8 55 11.9 76 15.8 60 16.7 60 11.2 14 13.7 528 13.7

3 59 3.1 14 3.0 36 7.5 36 10.0 14 2.6 4 3.9 163 4.2

4 13 0.7 4 0.9 31 6.4 27 7.5 2 0.4 2 2.0 79 2.1

> 4 3 0.2 2 0.4 22 4.6 15 4.2 0 0.0 3 2.9 45 1.2

Total 1912 100 461 100 481 100 359 100 535 100 102 100 3850 100


| 157

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9.9

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2.7

112

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0.2

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0.2

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Mid

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491.

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2.2

171

4.2

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3.6

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3.1

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3.5

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6710

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158 |

TaBle 117: moDe oF BirTh group percenTages For years 1997 To 2012

Mothers 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Mode of birth group % % % % % % % % % %

Normal 66.5 66.9 65.6 65.6 64.4 64.0 61.6 61.3 60.7 58.9

Caesarean section 21.0 22.0 24.2 26.6 24.0 25.1 27.2 28.5 27.8 29.9

Assisted 12.5 11.1 10.3 7.8 11.6 10.9 11.2 10.2 11.5 11.1

Total 100 100 100 100 100 100 100 100 100 100

Mothers 2007 2008 2009 2010 2011 2012

Mode of birth group % % % % % %

Normal 59.6 61.0 61.1 59.1 56.8 57.8

Caesarean 29.1 27.9 27.4 29.6 30.8 30.9

Assisted 11.3 11.2 11.5 11.3 12.3 11.3

Total 100 100 100 100 100 100

TaBle 118: moDe oF BirTh group By age group For all Women in 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total

Mode group No. % No. % No. % No. % No. % No. % No. %

Normal 116 67.4 330 66.3 494 59.8 692 57.4 481 53.2 111 45.3 2224 57.8

CS 35 20.3 117 23.5 232 28.1 357 29.6 334 36.9 116 47.3 1191 30.9

Assisted 21 12.2 51 10.2 100 12.1 156 12.9 89 9.8 18 7.3 435 11.3

Total 172 100 498 100 826 100 1205 100 904 100 245 100 3850 100

TaBle 119: moDe oF BirTh group By age group For primiparous Women in 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total


Normal 95 66.4 165 57.9 209 49.8 238 43.1 87 32.0 16 23.2 810 46.5

CS 28 19.6 75 26.3 124 29.5 192 34.8 126 46.3 44 63.8 589 33.8

Assisted 20 14.0 45 15.8 87 20.7 122 22.1 59 21.7 9 13.0 342 19.6

Total 143 100 285 100 420 100 552 100 272 100 69 100 1741 100


| 159

TaBle 120: moDe oF BirTh group By age group For mulTiparous Women WiThouT previous cs in 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total


Normal 21 80.8 155 89.6 266 85.5 420 89.2 368 82.0 87 78.4 1317 85.5

CS 4 15.4 14 8.1 35 11.3 35 7.4 63 14.0 20 18.0 171 11.1

Assisted 1 3.8 4 2.3 10 3.2 16 3.4 18 4.0 4 3.6 53 3.4

Total 26 100 173 100 311 100 471 100 449 100 111 100 1541 100

TaBle 121: moDe oF BirTh group By age group For mulTiparous Women WiTh previous cs in 2012

Mothers < 20 20 – 24 25 – 29 30 – 34 35 – 39 ≥ 40 Total


Normal 0 0.0 10 25.0 19 20.0 34 18.7 26 14.2 8 12.3 97 17.1

CS 3 100.0 28 70.0 73 76.8 130 71.4 145 79.2 52 80.0 431 75.9

Assisted 0 0.0 2 5.0 3 3.2 18 9.9 12 6.6 5 7.7 40 7.0

Total 3 100 40 100 95 100 182 100 183 100 65 100 568 100


160 |

Ta

Bl

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22

: a

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s o

Bs

Te

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To

rs

(Ja

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20

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Org

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910

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Both

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sub

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Pu

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Peer

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ompa

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with

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for t

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Firs

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18

Ind

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Num

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Yo

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No

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Ag

gre

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thes

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isat

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1.1

Sele

cted

pri

mip

ara

who

hav

e a

spon

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ous

vag

inal

bir

th (

H)

Jan-

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217

516

42.0

5%(3

4.47

-47.

64)

249

-32

1348

.28%

Jul-D

ec21

354

439

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(33.

78-4

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)25

9-4

613

47.6

2%

1.2

Sele

cted

prim

ipar

a w

ho u

nder

go in

duct

ion

of

labo

ur (

L)

Jan-

Jun

161

516

31.2

0%(2

5.96

-36.

44)

161

012

31.2

2%

Jul-D

ec15

554

428

.49%

(23.

52-3

3.47

)17

4-1

912

31.9

5%

1.3

Sele

cted

prim

ipar

a w

ho u

nder

go a

n in

stru

men

tal

vagi

nal b

irth

(L)

Jan-

Jun

104

516

20.1

6%(1

5.62

-24.

69)

116

-12

1322

.44%

Jul-D

ec12

654

423

.16%

(18.

51-2

7.81

)12

15

1322

.28%

1.4

Sele

cted

pri

mip

ara

und

erg

oing

cae

sare

an

sect

ion

(L)

Jan-

Jun

128

516

24.8

1%(1

9.92

-29.

69)

111

1714

21.5

4%

Jul-D

ec15

354

428

.13%

(23.

17-3

3.08

)12

231

1422

.45%

2.1

Vagi

nal d

eliv

ery

follo

win

g a

prev

ious

prim

ary

caes

area

n se

ctio

n (N

)

Jan-

Jun

3517

619

.89%

(12.

15-2

7.62

)33

212

18.5

5%

Jul-D

ec49

177

27.6

8%(1

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33)

3415

1319

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3.1

Sele

cted

prim

ipar

a w

ith in

tact

per

ineu

m o

r un

sutu

red

perin

eal t

ear (

H)

Jan-

Jun

6738

817

.27%

(12.

34-2

2.20

)70

-314

18.1

2%

Jul-D

ec63

391

16.1

1%(1

1.33

-20.

89)

630

1416

.09%

3.2

Sele

cted

prim

ipar

a un

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oing

epi

siot

omy

AN

D

no p

erin

eal t

ear w

hile

giv

ing

birt

h va

gina

lly (L

)

Jan-

Jun

108

388

27.8

4%(2

1.99

-33.

68)

999

1425

.50%

Jul-D

ec12

039

130

.69%

(24.

70-3

6.68

)10

515

1326

.76%


| 161

3.3

Sele

cted

pri

mip

ara

sust

aini

ng a

per

inea

l tea

r A

ND

no

epis

ioto

my

(L)

Jan-

Jun

161

388

41.4

9%(3

5.07

-47.

92)

194

-33

1450

.01%

Jul-D

ec16

639

142

.46%

(36.

03-4

8.88

)18

3-1

712

46.6

9%

3.4

Sele

cted

prim

ipar

a un

derg

oing

epi

siot

omy

AN

D

sust

aini

ng a

per

inea

l tea

r w

hile

giv

ing

birt

h va

gina

lly (L

)

Jan-

Jun

5238

813

.40%

(8.9

6-17

.85)

3220

148.

15%

Jul-D

ec42

391

10.7

4%(6

.72-

14.7

7)36

613

9.25

%

3.5

Sele

cted

prim

ipar

a re

quiri

ng s

urgi

cal r

epai

r of

the

perin

eum

for t

hird

deg

ree

tear

(L)

Jan-

Jun

2238

85.

67%

(2.6

5-8.

69)

29-7

157.

45%

Jul-D

ec28

391

7.16

%(3

.81-

10.5

1)27

114

6.98

%

3.6

Sele

cted

prim

ipar

a re

quiri

ng s

urgi

cal r

epai

r of

the

perin

eum

for f

ourt

h de

gree

tear

(L)

Jan-

Jun

038

80.

00%

(0.0

0-0.

92)

1-1

150.

36%

Jul-D

ec3

391

0.77

%(0

.00-

1.90

)2

114

0.43

%

4.1

Wom

en h

avin

g a

gen

eral

ana

esth

etic

for

a

caes

area

n se

ctio

n (L

)

Jan-

Jun

4059

06.

78%

(4.1

2-9.

44)

53-1

317

8.93

%

Jul-D

ec31

598

5.18

%(2

.85-

7.51

)48

-17

167.

97%

7.1

Wom

en w

ho g

ive

birt

h va

gina

lly w

ho re

ceiv

e a

bloo

d tr

ansf

usio

n du

ring

the

sam

e ad

mis

sion

(L)

Jan-

Jun

2512

951.

93%

(0.9

5-2.

91)

241

171.

86%

Jul-D

ec28

1336

2.10

%(1

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3.10

)21

716

1.60

%

7.2

Wom

en w

ho u

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go c

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rean

sec

tion

who

re

ceiv

e a

bloo

d tra

nsfu

sion

durin

g th

e sa

me

adm

issio

n (L

)

Jan-

Jun

2259

03.

73%

(1.7

2-5.

73)

175

162.

97%

Jul-D

ec18

598

3.01

%(1

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4.81

)13

516

2.16

%

8.1

Del

iver

ies

wit

h b

irth

wei

ght

less

tha

n 27

50g

at

40 w

eeks

ges

tati

on o

r b

eyon

d (

L)

Jan-

Jun

1079

31.

26%

(0.2

4-2.

28)

14-4

161.

75%

Jul-D

ec6

789

0.76

%(0

.00-

1.56

)13

-715

1.63

%

9.1

Term

bab

ies

bor

n w

ith

an A

pg

ar s

core

of

less

th

an 7

at

five

min

utes

pos

t d

eliv

ery

(L)

Jan-

Jun

2816

851.

66%

(0.8

6-2.

46)

31-3

171.

82%

Jul-D

ec15

1742

0.86

%(0

.29-

1.43

)29

-14

161.

66%

10.1

Inb

orn

term

bab

ies

tran

sfer

red

/ a

dm

itte

d t

o a

neon

atal

inte

nsiv

e ca

re n

urse

ry o

r sp

ecia

l ca

re n

urse

ry f

or r

easo

ns o

ther

tha

n co

ngen

ital

ab

norm

alit

y (L

)

Jan-

Jun

137

1644

8.33

%(6

.58-

10.0

9)17

5-3

814

10.6

2%

Jul-D

ec18

817

0011

.06%

(9.1

0-13

.01)

197

-914

11.6

0%

(L) –

A lo

w ra

te is

des

irabl

e (H

) – A

hig

h ra

te is

des

irabl

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s in

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gre

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orga

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tion

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r org

anis

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fiden

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terv

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indi

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ll ot

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isat

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sub

mitt

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data

for t

hat p

artic

ular

in

dica

tor.


162 |

Ta

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: a

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-499

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for t

he s

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sub

mitt

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for t

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30

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mit

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gre

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) in

low

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ent c

aesa

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se

ctio

n pr

oced

ures

(L)

Jan-

Jun

458

60.

68%

(0.0

0-1.

56)

13

150.

21%

Jul-D

ec6

598

1.00

%(0

.00-

2.05

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39

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%

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A lo

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te is

des

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hig

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tor.


| 163

Ta

Bl

e 1

24

: a

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yn

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co

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gy

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all

orga

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ateg

ory

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t)To

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r of o

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gre

gat

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nts

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46%

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nts

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nant

dis

ease

(L)

Jan-

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557

8.77

%(0

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18.4

0)3

215

6.01

%

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618.

20%

(0.0

0-17

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41

177.

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2.1

Patie

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suffe

ring

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ry to

a m

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vis

cus

with

re

pair,

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ure

or s

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quen

tly u

p to

2 w

eeks

pos

t-op

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ivel

y (L

)

Jan-

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741

21.

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(0.0

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34)

34

250.

63%

Jul-D

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455

0.44

%(0

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026

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%

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nts

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to a

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or

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pos

t-op

erat

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y (L

)

Jan-

Jun

024

50.

00%

(0.0

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45)

2-2

250.

78%

Jul-D

ec2

271

0.74

%(0

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2.07

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0.82

%

3.2

Patie

nts

rece

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g an

inju

ry to

a u

rete

r at t

he

time

of a

lapa

rosc

opic

hys

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y w

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pair

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g th

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tly u

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2

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ks p

ost-

oper

ativ

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(L)

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Jun

015

0.00

%(0

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22.3

1)0

017

0.00

%

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120.

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(0.0

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00

151.

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3.3

Patie

nts

rece

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y at

the

time

of a

lapa

rosc

opic

hys

tere

ctom

y w

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ks p

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%(0

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22.3

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%

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00%

(0.0

0-27

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00

151.

00%


164 |

4.1

Lapa

rosc

opic

man

agem

ent o

f an

ecto

pic

preg

nanc

y (H

)

Jan-

Jun

1516

93.7

5%(7

8.20

-10

0.00

)13

222

82.4

1%

Jul-D

ec12

1485

.71%

(61.

68-

100.

00)

120

2082

.58%

5.1

Patie

nts

rece

ivin

g in

jury

to a

maj

or v

iscu

s w

ith

repa

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urin

g a

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ic fl

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re o

r su

bseq

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ly u

p to

2 w

eeks

pos

t-op

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ivel

y (L

)

Jan-

Jun

051

0.00

%(0

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6.87

)1

-120

1.78

%

Jul-D

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700.

00%

(0.0

0-5.

03)

1-1

211.

39%

5.2

Patie

nts

rece

ivin

g a

uret

er in

jury

at t

he ti

me

of a

pel

vic

floor

repa

ir pr

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with

repa

ir du

ring

the

proc

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e or

sub

sequ

ently

up

to 2

w

eeks

pos

t-op

erat

ivel

y (L

)

Jan-

Jun

051

0.00

%(0

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6.87

)0

018

0.00

%

Jul-D

ec0

700.

00%

(0.0

0-5.

03)

00

200.

36%

5.3

Patie

nts

rece

ivin

g a

blad

der i

njur

y at

the

time

of a

pel

vic

floor

repa

ir pr

oced

ure

with

repa

ir du

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the

proc

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e or

sub

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up

to 2

w

eeks

pos

t-op

erat

ivel

y (L

)

Jan-

Jun

051

0.00

%(0

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6.87

)0

019

0.68

%

Jul-D

ec0

700.

00%

(0.0

0-5.

03)

00

210.

60%

(L) –

A lo

w ra

te is

des

irabl

e (H

) – A

hig

h ra

te is

des

irabl

e

(N) –

Des

irabl

e ra

te is

uns

peci

fied

Rate

s in

ital

ic /

gre

yed

high

light

resu

lts th

at re

quire

att

entio

n. T

hese

resu

lts d

emon

stra

te w

here

an

orga

nisa

tion

is s

tatis

tical

ly s

igni

fican

tly “

diffe

rent

” to

all

othe

r org

anis

atio

ns s

ubm

ittin

g da

ta fo

r tha

t par

ticul

ar in

dica

tor a

nd w

here

th

e re

sults

are

und

esira

bly

low

er o

r hig

her t

han

the

expe

cted

rate

.Ra

tes

in b

old

high

light

resu

lts w

here

the

aggr

egat

e ra

te is

out

side

the

99%

con

fiden

ce in

terv

al.

This

indi

cate

s th

at th

e or

gani

satio

n is

sta

tistic

ally

sig

nific

antly

“di

ffere

nt”

to a

ll ot

her o

rgan

isat

ions

sub

mitt

ing

data

for t

hat p

artic

ular

in

dica

tor.


| 165

16.2 abbreviations

ACHS Australian Council on Healthcare StandardsACMM Associate charge midwife managerAMOSS Australasian Maternity Outcomes Surveillance

SystemAVB Assisted vaginal birthBFHI Baby Friendly Hospital InitiativeBMI Body mass indexBSO Bilateral salpingo-oophorectomyC&C DHB Capital and Coast District Health BoardCI Confidence intervalCPR Cardiopulmonary resuscitationCS Caesarean sectionCSE Combined spinal-epiduralCVS Chorionic villus samplingD&C Dilation and curettageDHB District Health BoardDNA Did not attendEBR Exclusive breastfeeding rateECV External cephalic versionENT Ear, Nose and ThroatERPOC Evacuation of retained products of conceptionEUA Examination under anaestheticFDA Food and Drug AdministrationFSA First Specialist AssessmentFTE Full time equivalentGA General anaesthesiaGDM Gestational Diabetes MellitusGP General PractitionerGROW Gestation related optimal weightGSNMH Graduate School of Nursing, Midwifery and

HealthHDC Health and Disability CommissionerHIS Health Information ServiceHWNZ Health Workforce New ZealandICS International Continence SocietyICU Intensive Care UnitIOL Induction of labourITP Integrated training programmeIUD Intra-uterine deviceIUGR Intrauterine growth restrictionKMU Kenepuru Maternity UnitLA Local anaesthesiaLARC Long acting reversible contraceptionLLETZ Large loop excision of the transformation

zoneLMC Lead Maternity CarerMCIS Maternity clinical information systemMFM Maternal fetal medicineMOH Ministry of HealthMQSP Maternity Quality Safety ProgrammeMSS2 Second trimester maternal serum screeningMTOP Medical termination of pregnancyMW Midwife

NBHS Newborn hearing screeningNCSP National Cervical Screening ProgrammeNDC Neonatal death classificationNICU Neonatal Intensive Care UnitNIPD Non invasive prenatal diagnosisNT Nuchal translucencyNVB Normal vaginal birthOASIS Obstetric anal sphincter injuriesOGTT Oral glucose tolerance testPCC Preconceptual counselling clinicPCEA Patient-controlled epidural analgesiaPDC Perinatal death classificationPDPH Postdural puncture headachePIMS Perinatal Information Management SystemPM Post mortemPMB Post menopausal bleedingPMMRC Perinatal & Maternal Mortality Review

Committee PMU Paraparaumu Maternity UnitPOP Pelvic organ prolapsePPH Post-partum haemorrhagePROMPT Practical obstetric multi-professional trainingPSANZ Perinatal Society of Australia & New ZealandPV Per vaginumRANZCOG Royal Australian and New Zealand College of

Obstetricians and GynaecologistsRBC Red blood cellRPOC Retained products of conceptionSAB Subarachnoid block – (‘spinal’ anaesthesia)SAC1 Severity assessment code 1SAC2 Severity assessment code 2SAU Surgical Admissions UnitSB StillbornSMMHS Specialist Maternal Mental Health ServiceSRM Spontaneous rupture of membranesSSI Surgical site infectionSTOP Surgical termination of pregnancySUDI Sudden unexpected death in infancySUI Stress urinary incontinenceTAH Total abdominal hysterectomyTMU Te Mahoe UnitTOP Termination of pregnancyTVT Tension free vaginal tapeUNHSEIP Universal Newborn Hearing Screening and

Early Intervention ProgrammeUSS Ultrasound scanVBAC Vaginal birth after CSVUW Victoria University of WellingtonWHO World Health OrganisationWHRU Women’s Health Research UnitWHS Women’s Health ServiceWRH Wellington Regional Hospital


166 |

16.3 references

Auckland District Health Board 2012. National Women’s Annual Clinical Report 2011.

Bell R, Bailey K, Cresswell T, Hawthorne G, Critchley J, Lewis-Barned N, Northern Diabetic Pregnancy Survey Steering Group. 2008. Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes. BJOG: An International Journal of Obstetrics and Gynaecology. March 2008. 115, 4. 445-452.

Bulletin of the World Health Organisation. January 2010. Vol. 88 (1), ISSN 0042-9686.

Dodd JM, Crowther CA, Haslam RR, Robinson JS, Twins Timing of Birth Trial Group. 2012. Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial. BJOG: An International Journal of Obstetrics and Gynaecology. July 2012. 119, 8. 964-974.

Esakof TF, Cheng YW, Caughey AB. 2005. Screening for gestational diabetes: different cut-offs for different ethnicities? American Journal of Obstetrics and Gynecology. 193 (3 Pt 2):1040-1044.

Gunton JE, McElduff A, Sulway M, Shiel J, Kelso I, Boyce S, Fulcher G, Robinson B, Clifton-Bligh P, Wilmhurst E. 2000. Outcome of pregnancies complicated by pre-gestational diabetes mellitus. Australian and New Zealand Journal of Obstetrics and Gynaecology. 200; 40: 1:38-43.

Jensen DM, Damm P, Moelsted-Pederson L, Ovesen P, Westergaard JG, Moeller M, Beck-Nielsen H. 2004. Outcomes in Type 1 diabetic pregnancies. Diabetes Care, December 2004. 27: 2819-2823.

Lewis G. (ed) 2007. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer – 2003-2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. (www.cemach.org.uk)

Nahum EG, Huffaker BJ. 1993. Racial differences in oral glucose screening test results: establishing race-specific criteria for abnormality in pregnancy. American Journal of Obstetrics and Gynecology. April 1993. 81 (4):517-522.

New Zealand Health Information Service, 2007. Report on Maternity: Maternal and Newborn Information 2004. Wellington: NZ Ministry of Health.

New Zealand Ministry of Health, 2010. Hospital-based Maternity Events 2006. Wellington: NZ Ministry of Health.

New Zealand Ministry of Health. 2012. New Zealand Maternity Clinical Indicators 2009: Revised June 2012. Wellington: NZ Ministry of Health

New Zealand Ministry of Health. 2012. Report on Maternity, 2010. Wellington: NZ Ministry of Health.

PMMRC. 2012. Sixth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2010. (www.hqsc.govt.nz)

Sacks DA, Abu-Fadil S, Greenspoon JS, Fotheringham N. 1989. How reliable is the fifty-gram, one-hour glucose screening test? American Journal of Obstetrics and Gynecology. 161 (3):642-5.

Statistics New Zealand. 2013. Births and Deaths: Year ended December 2012. (www.stats.govt.nz)

The Australian Council on Healthcare Standards. 2012. Clinical Indicator Users’ Manual 2012. (www.achs.org.au)


| 167

16.4 achs clinical indicator definitions

Reprinted from the Clinical Indicator User Manual, 2012, The Australian Council on Healthcare Standards, ACHS, 2011. (Obstetrics, Version 7; Gynaecology, Version 6; Infection Control Version 3.1).

indicator area 1: obstetrics

Indicator Topic: Outcome of selected primipara.

Rationale: The selected primipara represents an uncomplicated pregnancy whereby intervention and complication rates should be low and consistent across hospitals.

Use of the selected primipara (rather than all women giving birth) as the basis for inter-hospital comparison of maternity care controls for differences in case mix and increases the validity of those comparisons.

A “cascade” effect of birthing interventions has been described, particularly with primiparous women, which starts with induction of labour, increasing the risk of operative vaginal birth or caesarean section. By reducing the number of nulliparous women who have induced labour, the number of women undergoing unnecessary operative birth and other interventions will be reduced.

Type of Indicator: These are rate-based indicators addressing the process of patient care.

Desired Rate:

1.1 – High

1.2 – Low

1.3 – Low

1.4 – Low

Definitions of Terms: For the purpose of these indicators:

• Selected primipara is defined as:

• A woman who is 20–34 years of age at the time of giving birth

• giving birth for the first time at >20 weeks of gestation



• at 370 to 410 weeks gestation

• Spontaneous vaginal birth is defined as a vaginal birth (regardless of onset of labour) that is not assisted by forceps or vacuum and is not a vaginal breech delivery.

• Induction of labour is defined as surgical and / or medical induction.

• Instrumental vaginal birth is defined as forceps or vacuum.

indicator data format:

Ci. 1.1

• Numerator - Total number of selected primipara who have a spontaneous vaginal birth.

• Denominator - The total number of selected primipara who give birth.

Ci. 1.2

• Numerator - Total number of selected primipara who undergo induction of labour (as defined in the manual).


Ci. 1.3

• Numerator - Total number of selected primipara who undergo an instrumental vaginal birth (as defined in the manual).


Ci. 1.4

• Numerator - Total number of selected primipara undergoing caesarean section.



Indicator Topic: The rate of vaginal birth following primary caesarean section (VBAC).

Rationale: This indicator monitors mode of birth in those women who have had a previous primary (first) caesarean section and no other vaginal births. There is evidence that repeat caesarean section can be associated with significant morbidity for women but VBAC carries increased risks for the baby when compared with repeat elective caesarean section.


168 |

Type of Indicator: This is a rate-based indicator addressing the process (management) and outcome of patient care.

Desired Rate:

Not specified

Definitions of Terms: For the purpose of this indicator:

This indicator relates to those women giving birth vaginally following a previous primary (first) caesarean section and having NO intervening pregnancies greater than twenty weeks gestation.


Ci. 2.1

• Numerator - Total number of women giving birth vaginally following a previous primary caesarean section, as defined in the manual.

• Denominator - Total number of women giving birth who have had a previous primary caesarean section and NO intervening pregnancies greater than twenty weeks gestation.


Indicator Topic: Incidence of an intact perineum in primiparous women giving birth vaginally and degree of damage to the perineum.

Rationale: Vaginal birth is the most common cause of anal sphincter injuries in women and as such obstetric anal sphincter injury is considered a major complication of vaginal birth - a complication that can have a significant impact on a woman’s quality of life.

Type of Indicator: These are rate-based indicators addressing the process (management) and outcome of patient care.

Desired Rate:

3.1 – High

3.2 – Low

3.3 – Low

3.4 – Low

3.5 – Low

3.6 – Low


• Selected primipara is defined as:

• A woman who is 20–34 years of age at the time of giving birth

• giving birth for the first time at >20 weeks of gestation



• at 370 to 410 weeks gestation


Ci. 3.1

• Numerator - Total number of selected primipara with an intact perineum or unsutured perineal tear.

• Denominator - Total number of selected primipara giving birth vaginally.

Ci. 3.2

• Numerator - Total number of selected primipara undergoing episiotomy (as defined in the manual) and NO perineal tear (as defined in the manual) while giving birth vaginally.


Ci. 3.3

• Numerator - Total number of selected primipara sustaining a perineal tear and NO episiotomy.


Ci. 3.4

• Numerator - Total number of selected primipara undergoing episiotomy AND sustaining a perineal tear while giving birth vaginally.


Ci. 3.5

• Numerator - Total number of selected primipara undergoing surgical repair of the perineum for third degree tear (as defined in the manual).



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Ci. 3.6

• Numerator - Total number of selected primipara undergoing surgical repair of the perineum for fourth degree tear (as defined in the manual).



Indicator Topic: General anaesthesia for caesarean section

Rationale: This indicator monitors the number of women who have a caesarean section performed under general anaesthesia. There is now evidence that women who are having a caesarean section should be offered regional anaesthesia rather than general anaesthesia because it is safer and results in less maternal and neonatal morbidity.

Type of Indicator: This is a rate-based indicator addressing the process of patient care.

Desired Rate:

Low


General anaesthetic includes women undergoing a primary general anaesthetic and includes conversions from regional to general anaesthetic where intubation is required to control the airway.


Ci. 4.1

• Numerator - Total number of women having a general anaesthetic (as defined in the manual) for a caesarean section.

• Denominator - Total number of women having a caesarean section.


Indicator Topic: Incidence of postpartum haemorrhage and blood transfusions after vaginal birth and caesearean section.

Rationale: Postpartum haemorrhage (PPH) is a potentially life threatening complication of birth that occurs in about 3-5% of vaginal births. The condition remains a leading cause of maternal morbidity and mortality.

Type of Indicator: These are rate-based indicators addressing the outcome of patient care.

Desired Rate:

7.1 – Low

7.2 – Low


• Blood transfusion is required following massive blood loss of equal to/or more than 1000mL or in response to a postpartum haemoglobin level of less than 80g/L.


Ci. 7.1

• Numerator - Total number of women who give birth vaginally who receive a blood transfusion during the same admission.

• Denominator - Total number of women who give birth vaginally.

Ci. 7.2

• Numerator - Total number of women who undergo caesarean section who receive a blood transfusion during the same admission.

• Denominator - Total number of women who undergo caesarean section.


Indicator Topic: Identification of babies with severe intrauterine growth restriction (IUGR), babies less than the 3rd centile delivered after 400 weeks.

Rationale: Profound IUGR is a major cause of perinatal mortality and morbidity with mortality increasing with IUGR in late pregnancy.

Type of Indicator: This is a rate-based indicator addressing the process and outcome of antenatal care.

Desired Rate:

Low


Severe IUGR is defined as babies less than the 3rd centile at 400 weeks gestation. Whilst recognising that birth weight varies with maternal height, weight, parity,


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ethnicity and foetal sex this is impractical to collect at present. A surrogate measure of birth weight less than 2750 grams after 400 weeks gestation is used.


Ci. 8.1

• Numerator - Total number of deliveries with birth weight less than 2750g at 400 weeks gestation or beyond.

• Denominator - Total number of deliveries at 400 weeks gestation or beyond.


Indicator Topic: Apgar score of term babies.

Rationale: The five minute Apgar score measures how well the infant is adapting to the new environment and is an assessment of how the baby responds to resuscitation, should it be required.

Type of Indicator: This is a rate-based indicator addressing the outcome of patient care.

Desired Rate:

Low


• The Apgar score is calculated at one and five minutes after the baby is born, and is determined by five characteristics – heart rate, respiratory effort, muscle tone, reflex irritability and colour. Each characteristic is rated from zero to two. The sum of the five characteristics is the total Apgar score.

• Term refers to gestation of equal to or greater than 370 weeks gestation.

• Fetal demise at any stage after the onset of labour / caesarean section is to be included.

• Fetal death in-utero diagnosed prior to commencement (onset) of labour / caesarean section is excluded.

• Onset of labour refers to “first stage of labour begins when uterine contractions reach sufficient frequency, intensity and duration to initiate readily demonstrable effacement and dilatation of the cervix". (Williams Obstetrics 2010, 23rd edition).


Ci. 9.1

• Numerator - Total number of term babies born with an Apgar score of less than 7 at five minutes post delivery.

• Denominator - The total number of term babies born.


Indicator Topic: Term babies transferred or admitted to a Neonatal Intensive Care Nursery (NICN) or Special Care Nursery (SCN) for reasons other than congenital abnormality.

Rationale: This indicator is included to determine whether the rate of admission of inborn term infants to NICN or SCN for reasons other than birth defects is principally due to non-avoidable factors. Inborn term babies without birth defects are not normally expected to be admitted to a SCN or NICN.

Type of Indicator: This is a rate-based indicator, which addresses the outcome of patient care.

Desired Rate:

Low


• Term refers to gestation of equal to or greater than 370 weeks gestation.

• Inborn baby is defined as an infant born at the reporting hospital.

• Admissions due to congenital abnormality are excluded.


Ci. 10.1

• Numerator - Total number of inborn term babies transferred/admitted to a neonatal intensive care nursery or special care nursery for reasons other than congenital abnormality

• Denominator - Total number of inborn term live babies.


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indicator area 1: infection surveillance

Indicator Topic: Surgical site infection (SSI).

Rationale: The National Strategy to Address Health Care Associated Infections, July 2003 suggests that between 2% and 13% of patients suffer from SSI. The attributable and human costs of SSI are therefore significant.

Type of Indicator: These are rate-based indicators addressing the outcome of patient care in terms of infection.

Desired Rate:

1.16 – Low

Definitions of Terms: For the purpose of indicator 1.16

A surgical site infection (SSI) is defined by the anatomical location of the infection (superficial, deep or organ space) however, due to the difficulty of distinguishing between these categories the indicators have been separated to measure two categories: superficial and deep organ or space.

Note:

• Lower segment caesarean sections include emergency and elective procedures.


Ci. 1.16

• Numerator - Total number of deep incisional/organ/space SSI in lower segment caesarean section procedures performed, during the 6 month time period.

• Denominator - The total number of lower segment caesarean section procedures performed, during the 6 month time period.

indicator area 1: gynaecology

Indicator Topic: Blood transfusion for gynaecology surgery.

Rationale: This indicator is included as a general measure of surgical management.

Type of Indicator: These are comparative rate-based indicators addressing the process and outcome of patient care.

Desired Rate:

1.1 – Low

1.2 – Low

Definitions of Terms: For the purpose of these indicators

• Gynaecology surgery includes all procedures, however named, as defined by the gynaecologist and detailed in coding systems.

• The classification of benign or malignant disease is based on the operative/histological findings.

• Blood transfusion – whole blood or packed cells not plasma products or platelets.

Note:

• Autologous blood transfusions are included.

• Hysterectomies following caesarean section (in the same admission) and emergency hysterectomies are excluded.


Ci. 1.1

• Numerator - Total number of patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecology surgery for benign disease, during the 6 month time period.

• Denominator - Total number of patients undergoing gynaecology surgery for benign disease, during the 6 month time period.

Ci. 1.2

• Numerator - Total number of patients receiving an unplanned blood transfusion during their hospital admission for any type of gynaecological surgery for malignant disease, during the 6 month time period.

• Denominator - Total number of patients undergoing gynaecology surgery for malignant disease, during the 6 month time period.


Indicator Topic: Injury to a major viscus, with repair during a gynaecological operative procedure, or subsequently during the same admission.


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Rationale: This indicator has been included as an index of unintentional intra-operative morbidity associated with gynaecological procedures.

Type of Indicator: This is a comparative rate-based indicator addressing the outcome of patient care.

Desired Rate:

Low

Definitions of Terms: For the purpose of this indicator

• Major viscus is defined as vascular, urological or gastrointestinal.

• Subsequently up to 2 weeks post-operatively includes patients who require readmission and / or further surgery at the same health care organisation.

• This indicator excludes perforation of the uterus as this rarely causes a problem. The main problems relate to small or large bowel or bladder injuries, as they cause the majority of serious morbidities.

• This indicator also excludes laparoscopic procedures.


Ci. 2.1

• Numerator - Total number of patients suffering injury to a major viscus with repair, during a gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

• Denominator - Total number of patients undergoing any type of gynaecology surgery, during the 6 month time period.


Indicator Topic: Laparoscopic gynaecological surgery.

Rationale: These indicators have been included as an index of the utilisation of a laparoscopic approach for gynaecological surgery.

Type of Indicator: These are comparative rate-based indicators addressing the process of patient care.

Desired Rate:

3.1 – Low

3.2 – Low

3.3 – Low


• Laparoscopic gynaecological operative procedure refers to any laparoscopic definitive procedure.

• Subsequently up to 2 weeks post-operatively includes patients who require readmission and / or further surgery.

Note:

• Only those procedures, which have been completed laparoscopically, are to be included in the indicator.

• Procedures, which have converted to an abdominal procedure from a laparoscopic procedure, are excluded from the indicator.


Ci. 3.1

• Numerator - Total number of patients receiving an injury to a major viscus with repair, during a laparoscopic gynaecological operative procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

• Denominator - Total number of patients undergoing laparoscopic gynaecological operative procedure, during the 6 month time period.

Ci. 3.2

• Numerator - Total number of patients receiving a ureter injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

• Denominator - Total number of patients undergoing laparoscopic hysterectomy, during the 6 month time period.

Ci. 3.3

• Numerator - Total number of patients receiving a bladder injury at the time of a laparoscopic hysterectomy with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

• Denominator - Total number of patients undergoing laparoscopic hysterectomy, during the 6 month time period.


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Indicator Topic: Laparoscopic management of an ectopic pregnancy.

Rationale: This indicator has been included as an index of the utilisation of a laparoscopic approach in the management of ectopic pregnancy.

Type of Indicator: This is a comparative rate-based indicator addressing the process of patient care.

Desired Rate:

High

Definitions of Terms: For the purpose of this indicator

• Laparoscopic management refers to any laparoscopic definitive procedure.

Note:

• Only those procedures that have been completed laparoscopically are to be included in the indicator.

• Procedures, which have converted to an abdominal procedure from a laparoscopic procedure, are excluded from the indicator.

• Patients who require a blood transfusion in the same admission are excluded.


Ci. 4.1

• Numerator - Total number of patients having laparoscopic management following an ectopic pregnancy, during the 6 month time period.

• Denominator - Total number of patients presenting with an ectopic pregnancy who are managed surgically, during the 6 month time period.


Indicator Topic: Urogynaecology.

Rationale: This indicator provides an index of unintentional intraoperative morbidity associated with pelvic floor repair procedures.

Type of Indicator: These are comparative rate-based indicators addressing the outcomes of patient care.

Desired Rate:

5.1 – Low

5.2 – Low

5.3 – Low


• Subsequently up to 2 weeks post-operatively includes patients who require readmission and / or further surgery.

• All pelvic floor repair procedures are included.


Ci. 5.1

• Numerator - Total number of patients receiving injury to a major viscus with repair, during a pelvic floor repair procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.

• Denominator - Total number of patients undergoing a pelvic floor repair procedure, during the 6 month time period.

Ci. 5.2

• Numerator - Total number of patients receiving a ureter injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.


Ci. 5.3

• Numerator - Total number of patients receiving a bladder injury at the time of a pelvic floor repair procedure with repair during the procedure or subsequently up to 2 weeks post-operatively, during the 6 month time period.


ccdhb 2012 womens annual clinical report.pdf

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