“CLOSING THE LOOP”

National Women’s HealthAuckland District Health Board

The Annual Clinical Report Day

16th August 2011

National Women’s History

• 1906 the first Auckland St Helen’s Hospital opens

• 1946 first baby born at Cornwall Hospital

• 1958 construction of NWH at Green Lane

• 1962 99% of women birth in hospital

• 1962 first successful pre-birth transfusion in the world by Sir William Liley

• 1964 new NWH opening ceremony

National Women’s History• 1968 Red Cross volunteers offer beauty

care to women in NWH

• 1971 Obstetric Flying Squad established

• 1978 NWH granted licence to provide termination of pregnancy service

• 1979 Dr Rutter publicly criticises women for pressing for free access to NWH for those with private obstetrician or GP

• 1979 Rob Muldoon announces private maternity hospitals are a thing of the past

National Women’s History• 1979 A hospital directive issued “If

husbands are present at the delivery they must be placed on a stool on the mother’s right, at the head of the table. They must not be standing or walking around theatre.”

• 1981 St Helen’s 75th birthday

• 1983 Dr Fisher “the attitude at NWH was that anyone with a normal pregnancy should have a normal birth”

National Women’s History• 1983 Dr’s at NWH use IVF for the first time

in New Zealand

• 1984 SMO’s at St Helen’s set up the Mortality and Morbidity Review Committee

• 1984 Arson attack at Warborough Ave

• 1986 Teen antenatal clinics set up

• 1987 Inquiry instigated into treatment of cervical cancer at NWH

• 1992 First Annual Clinical Report presented

External Commentators in 2010

• Dr Sue Belgrave, Clinical Director, Women’s Health, Waitemata District Health Board

• Dr Phil Weston, Clinical Unit Leader, Child Health, Waikato Hospital

Women’s Health – Sue Belgrave• Understand PPH rates especially in

association with Caesarean section• CS rate is high

– Prevent primary caesarean– Reduce IOL– Increase PBAC– Increase ECV

• Unbooked status + smoking + perinatal mortality

• BMI and GDM among Indian mothers• Audit double instrumental birth

Understand PPH especially in association with Caesarean section

What we’ve done…• Improved documentation

antenatally of women at risk: Electronic Clinical Record project risk plan may assist

• Improved utilisation of drugs by implementing the PPH check list

• Improved notification of senior staff

High Caesarean Section Rate

• Prevent primary caesarean sections

• Reduce IOL• Increase VBAC• Increase ECV

Actions:• A project to review processes

around induction initiated• PBAC clinic launched 2011

Unbooked status + smoking + perinatal mortality

BMI and GDM among Indian mothers

• Noted

• No specific action

Audit Double Instrumental Birth

• Audited in 2010

• Rate within WHA average in 2010

• Maternal and baby outcomes similar to single instrumental births (other than increased proportion with 3rd/4th degree tears)

Neonatal Commentary – Phil Weston• Is there a problem with NEC rates?

– (Waikato rate 2%)

• Monitor Perinatal Mortality rate by DHB nationally

• Monitor Chronic Lung Disease by home oxygen

• Monitor infection rates• Monitor outcomes in 23 weekers

across the country• Review the increase in ventilation at

term for respiratory distress

Is there a problem with NEC rates?(Waikato rate 2%)

• 2010 rate is consistent with 2008 and 2009 rates (3-5% overall) but absolute numbers are low

• Ongoing research in the unit as part of a multicentre study looking at probiotics to decrease rates

Monitor Perinatal Mortality Rate by DHB nationally

Monitor CLD by home oxygenMonitor infection rates

Monitor outcomes in 23 weekers across the country• Perinatal mortality reported by

DHB of residence annually by PMMRC

• No specific local action required

Review the increase in assisted ventilation at term for respiratory

distress

• New process introduced 1st July for booking of elective caesarean sections. Aiming to eliminate the need for elective caesarean without fetal or maternal compromise prior to 39 weeks

Points raised in other presentations• Consistently low rates of

hysterectomy (and especially vaginal and laparoscopic hysterectomy) at ADHB.

Actions:• Audit: Hysterectomy by abdominal

route generally indicated• Ongoing investigation of pathway of

care for women referred to NW with abnormal bleeding

Points raised in other presentations

• High parity (4+) and increasing BMI are independently associated with late (>=28 wks) stillbirth; not ethnicity or age

Actions:

• The Big Day Out: workshop on interventions for obesity in pregnancy

Points raised in other presentations

• Fetal fibronectin audit– Exclusion criteria not adhered to– Could avoid transfer of woman by

sending swab first– Implement a strict policy of not

giving steroids or tocolysis with negative result

Action:• Referred to CONCORD for

assistance with this project

Gynaecology• Note made of high re-admission rate

following inpatient gynaecology surgery.

Actions:• Audit showed high rate of admission

with pain and constipation• Audit of discharge medication• Information sheet developed for

discharge following abdominal procedures

• Readmission rate 6.3% 2010 cf 8.3% in 2009

Acknowledgements

• External Commentators and Speakers

• Women’s Health Intelligence Team

• Annual Clinical Report committee members

• National Women’s Staff

• Our patient’s and their families