LEARNIN

G SESSIO

N ONE

29TH OCTOBER 2013

MATERNITY QUALITY IMPROVEMENT

FORMAT FOR TODAY

10.10 – 11.00 – Dr A Hamilton and Dr J Cartmill – QI Methodology

11.00 – 11.30 – Ms Ann Rath – National Maternity Hospital Dublin

11.30 – 11.50 – TEA /COFFEE

11.50 – 12.35 – Dr Mike Robson - National Maternity Hospital Dublin

12.35 – 13.00 – Q&A session

13.00 – 13.45 – LUNCH

13.45 – 15.20 – Trust Presentations

15.20 – 16.00 – Team time with Tea/coffee

16.00 – 16.30 – Feedback and next steps

YOUR SUCCESSES TO DATE

WORK IN PROGRESS

ANTENATAL CTG EVALUATION - NOT FOR USE IN WOMEN LESS THAN 28 WEEKS GESTATION Reason for CTG Maternal Pulse Membranes Intact Y/N

If NO, date and time & colour of liquor

Gestation

CTG FEATURES Reassuring Non – Reassuring Abnormal Baseline (BPM)

110 – 160 100 – 109 161 - 181

<100 >180 Sinusoidal pattern for >10 minutes

A rising baseline rate even within normal range may be of concern if other non- reassuring features are present Variability (BPM)

>5 bpm for 20 minutes <5 bpm for 20 - 30 minutes <5 bpm for 30 minutes or no variability for 15 minutes

Accelerations Present ≤ 2 for 20 – 30 minutes Absent for 30 minutes Decelerations None 2 provoked (related to uterine

tightening not in labour) with quick recovery

More than 2 provoked or any unprovoked decelerations within 20 minutes The presence of any decelerations in the antenatal period is of concern.

OVERALL OPINION NORMAL CTG SUSPICIOUS CTG PATHOLOGICAL CTG All four features reassuring One non – reassuring feature only Two or more non – reassuring or

one or more abnormal feature RECOMMENDED ACTIONS

Midwife to discontinue CTG

Senior Midwifery review Medical review (ST3 or above) Continue trace until review

Urgent medical review (ST3 or above) Continue Trace If review is delayed consider transfer to delivery suite asap. Inform Consultant Consider delivery

ACTION TAKEN Signature: Print Name: Designation : Date: September 2013 Adapted from PROMPT and a version of an antenatal CTG sticker developed by the SHSCT

Vaginal Examination Number Agreed Indication

Abdominal Palpation Fundus Lie Presentation Position 5ths palpable

Cervix Position Presenting part Anterior Length Station Right Left Consistency Caput Posterior Dilatation Position Moulding Comments on pelvic outlet

Membranes Intact Hindwater leak

Ruptured during VE ARM Accidental ROM

Forewaters Already ruptured ARM SROM

Liquor None Clear Blood stained Light meconium Thick meconium

Fetal Heart rate after VE:

Pinard Sonicaid Phono Fetal scalp electrode

Summary of Findings: Plan of care:

Signature: Chaperone: Date and time:

STRATEGIC CONTEXT

MATERNITY STRATEGY IN A DRIVER DIAGRAM

Sepsis Run Charts

SepsisRun Charts

St Luke’s Day Symposium 2013

Intermountain Healthcare Delivery Research Unit: ATP Course - Dr Brent James

• Care that works

• Care that is safe

• Care that leaves no one behind

St Luke’s Day Symposium 2013

Obstet Gynecol 2009;114:1254

The Gestational Age that Women Considered a Baby to be Full Term

Obstet Gynecol 2009;114:1254

The Gestational Age that Women Considered it Safe to Deliver

Obstet Gynecol 2009;114:1254

Weeks of Gestation

Morbidity of Late Preterm Infants in Massachusetts

• Late preterm infants: 22.2% vs Term infants: 3%• Sample: Term (377,638), Late Preterm (26,170)

• Morbidity rates doubled for each gestational week earlier than 38 weeks40 wks: 2.5%39 wks: 2.6%38 wks: 3.3%37 wks: 5.9%36 wks: 12.1%35 wks: 25.6%34 wks: 51.9%

Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121:e223–e232

2.47% 2.65%3.36% 3.44% 4.26%

6.66%

0%

2%

4%

6%

8%

10%

37th Week(8,001)

38th Week(18,988)

39th Week(33,185)

40th Week(19,601)

41st Week(4,505)

42nd Week(258)

Gestational Weeks

Pe

rce

nt

NICU Admissions By Weeks Gestation Deliveries Without Complications, 2000-2003

Oshiro et al. Obstet Gynecol 2009;113:804-811.

NICU Admissions

1.92%

0.78%0.67%0.41%0.42%

0.68%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

37th Week(8,001)

38th Week(18,988)

39th Week(33,185)

40th Week(19,601)

41st Week(4,505)

42nd Week(258)

Gestational Weeks

Pe

rce

nt

RDS By Weeks GestationDeliveries Without Complications, 2000-2003

Oshiro et al. Obstet Gynecol 2009;113:804-811.

RDS

What Do We Need to Get Started?

MAP-IT• Mobilize• Assess• Plan• Implement• Track

Guidry, M., Vischi, T., Han, R., & Passons, O. Healthy people in healthy communities: A community planning guide using healthy people 2010. Washington, D.C.: U.S. Department of Health and Human Services. The Office of Disease Prevention and Health Promotion.