Maternity Services

Report 2014-15

Royal Berkshire Hospital

Reading

Jane Siddall Consultant Obstetrician

2

Contents

Introduction page 3 Glossary page 4 Comparison to national data from RCOG page 6 Trends Overall figures with comparisons to nearby services page 7 National and Local Demographics , including home birth numbers page 9 Bookings for care and delivery, follow-up appointments page 9-10 Demographics and national trends for age, fertility page 14 Rushey report, covering triage, early labour assessment & births page 18 Anaesthetic services page 20 Prenatal screening and diagnostic services page 23 Ultrasound Trends Standards page 26 Congenital malformations page 28 Birth Outcomes across whole service page 33 The RBFT standard primip page 26 Women with more complex health care needs Twins page 44 Singleton breeches page 46 Induction of labour page 47 Augmentation page 49 Outcomes in diabetic pregnancies page 50 Outcomes in women with substance dependency page 51 Perineal trauma page 52 Post partum haemorrhage page 53 Infant feeding page 54 Perinatal loss Perinatal mortality page 56

Introduction Both internal and external bodies are increasingly requiring information from the services on quality of outcome, as well as quantity of care delivered. These include commissioners and the Care Quality Commission, to name two. It is important that we know inform dialogues on service provision and ‘sense check’ figures proffered by these groups as describing either their vision for the future (is it achievable?) or our outcomes (did both parties use the same sets and denominator?). The challenge this year activity by consultant name rather than splitting out specific clinics led on different days by the same consultant. ‘Sense checking’ against historicommissioners to look at historic data alongside current activity as unless there has been significant reconfiguration of a service, data is similar year on year.possible to the report. The data are drawn from a variety of sources; the annual RCOG census returns provides national comparators of birth outcomes as well as medical workforce data, analysis of outpatient activity is collected by the staff in Maternity Records, specialist clinical data come from the teams involved in providing these services, and CMIS the central maternity data collection resource. Julie Sadio extracts data onto spreadsheets from CMIS for me. National demographic material has beOffice for National Statistics website, and is on 2010 registrations. I work on much of the maternity data to produce many of the charts and graphs in the clinical outcomes sections of this report. Sections authored by colleagues haalways to the legions of staff, both clerical and clinical, who prospectively record data so that it can be collated, analysed and presented in this report.. I no longer list audit projects as these are presen

Jane Siddall, FRCOG, Consultant obstetrician

Both internal and external bodies are increasingly requiring information from the services on quality of outcome, as well as quantity of care delivered. These include commissioners and the Care Quality Commission, to name two. It is important that we know what we have done, if nothing else to explain and inform dialogues on service provision and ‘sense check’ figures proffered by these groups as describing either their vision for the future (is it achievable?) or our outcomes (did both parties use the same sets and denominator?). The challenge this year (again) was data on outpatient activity, activity by consultant name rather than splitting out specific clinics led on different days by the same

ense checking’ against historical output can be invaluable and I would urge managers and commissioners to look at historic data alongside current activity as unless there has been significant reconfiguration of a service, data is similar year on year. I have attempted to add such data

The data are drawn from a variety of sources; the annual RCOG census returns provides national comparators of birth outcomes as well as medical workforce data, analysis of outpatient activity is

aternity Records, specialist clinical data come from the teams involved in providing these services, and CMIS the central maternity data collection resource. Julie Sadio extracts data onto spreadsheets from CMIS for me. National demographic material has been extracted from the Office for National Statistics website, and is on 2010 registrations.

I work on much of the maternity data to produce many of the charts and graphs in the clinical outcomes Sections authored by colleagues have been identified as such. I am indebted as

always to the legions of staff, both clerical and clinical, who prospectively record data so that it can be collated, analysed and presented in this report.

I no longer list audit projects as these are presented elsewhere in greater detail.

Jane Siddall, FRCOG, Consultant obstetrician

Both internal and external bodies are increasingly requiring information from the services on quality of outcome, as well as quantity of care delivered. These include commissioners and the Care Quality

what we have done, if nothing else to explain and inform dialogues on service provision and ‘sense check’ figures proffered by these groups as describing either their vision for the future (is it achievable?) or our outcomes (did both parties use the same data

data on outpatient activity, as EPR gives activity by consultant name rather than splitting out specific clinics led on different days by the same

cal output can be invaluable and I would urge managers and commissioners to look at historic data alongside current activity as unless there has been significant

I have attempted to add such data wherever

The data are drawn from a variety of sources; the annual RCOG census returns provides national comparators of birth outcomes as well as medical workforce data, analysis of outpatient activity is

aternity Records, specialist clinical data come from the teams involved in providing these services, and CMIS the central maternity data collection resource. Julie Sadio extracts

en extracted from the

I work on much of the maternity data to produce many of the charts and graphs in the clinical outcomes ve been identified as such. I am indebted as

always to the legions of staff, both clerical and clinical, who prospectively record data so that it can be

4

Glossary Obstetric terms nulliparous no previous livebirths at any gestation, or any stillbirth after 24 weeks multiparous at least one previous livebirth, or a stillbirth after 24 weeks primiparous one delivery after 24 weeks only grand multip at least five previous deliveries maternities number of women delivering a liveborn infant plus all stillbirths occurring after 24 weeks deliveries total number of babies born SVD spontaneous vaginal delivery AVD assisted vaginal delivery (cephalic presentations delivered with ventouse or any

type of forceps) VB or vag.br vaginal delivery of breech presentation Primary LSCS the first LSCS performed on the mother Repeat LSCS any subsequent LSCS delivery, whether in labour or before onset of contractions el LSCS elective Caesarean performed before the onset of labour em LSCS Caesarean section performed in labour VBAC vaginal birth after Caesarean section IUD intrauterine death LB livebirth NND neonatal death TOP termination of pregnancy

CHD congenital heart disease

Units RBH Royal Berkshire Hospital WBCH West Berkshire Community Hospital GWH Great Western Hospital, Swindon JRH John Radcliffe Hospital, Oxford NHH North Hants Hospital, Basingstoke GOSH Great Ormond Street Hospital Workforce terms HETV (Health Education Thames Valley) a postgraduate training area comprising Berkshire, Buckinghamshire, &

Oxfordshire, formerly known as the Oxford Deanery

5

ST3 or higher number) SpR ) Specialist Registrar Staff grade (SG or SD) A doctor not in training for a consultant post of (usually) at least Specialist

Registrar level of clinical skills. Also known as a specialty doctor. Most have MRCOG.

MRCOG Member of the Royal College of Obstetricians and Gynaecologists… an

examination taken after a minimum of four years in O&G. SHO or ST1-2 Senior House Officer: usually a doctor of no more than four postgraduate years of

medical practise VTS Vocational Training Scheme for General Practice (SHO level doctor) F2 A doctor in their second post-graduate year in a foundation programme. An SHO

not yet in a specific specialty training programme IMG International medical graduate, i.e. a doctor who qualified outside the UK or

European Union WTE whole time equivalent. For nursing and midwifery staff this equates to 37.5 hours

per week. For consultant medical staff this equates to 40 hours per week, although RBH consultants work 48. The term is not used for training or non-consultant career grade staff, but most of these work 56 hours per week on a shift system.

Clinical Governance NHSLA NHS Litigation Authority

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How does the Royal Berks compare year on year?

RBFT 2007-8

RBFT 2008-9

RBFT 09-10

RBFT 2010-

11

RBFT 2011-

12

RBFT 12-13

RBFT 13-14

RBFT 2014-

15 Deliveries ie babies born

5968 5946 5935 5963 5917 6081 5689 5681

% home deliveries 4.2 4.9 3.38 3.4

3.0 2.39 1.9 2.6

Stillbirth/ 1000 dels 4.9” 3.8 4.04 4.98 4.4 5.47 2.8 4.4 PNMR / 1000 dels 5.1” 3.87 3.5 8.47 6.7 6.96 4.7 4.7 %SVD all dels 51.6 51.9 52.7 57 57 55.6 58.3 55 % Caesareans all dels

28.4 27.2 29 28 25.8 25.8 27.9 25.1

% of dels which were elective LSCS

10.25 11.33 12.1 11.4 11.2 10.3 13.8 13.3

% forceps all dels 10 7.6 8.7 10.4 9.8 10.1 10.1 11 % ventouse all dels

6.4 6.3 4.1 3.6 5.3 3.8 3.7 3.6

Epidurals in labour as % of all deliveries

22.8 21 No data

No data

20 18 18.8

Number of twins 103 104 107 94 99 100 91 98 Ratio of twins to singletons

56:1 55:1 54:1 62:1 59:1 60:1 63:1 55.1

Number of higher order multiples

1 trip’ts 4 triplet sets

3 triplet sets

2 triplets

1 set triplets

3 sets triplets

1 set triplets

2 sets of

triplets

% LSCS with regional block

93.2 99.7 97.4 95 93.5 97 (cats 3&4) 90

(cats 1&2)

89.6

% singleton vaginal breeches

0.27 0.30 0.43 0.22 0.33 0.32 0.23 0.35

Breeches del by LSCS as % of all births

3.8 3.38 3.2 3.5 2.9 2.8 3.3 3.1

Induction rate % 12.7 12.6 13.4 12.5 15.2π 13.1 17.4 15.5

Please be aware that the denominator is usually BIRTHS /DELIVERIES which is not the same as MATERNITIES * this apparent fall is due to better collection of data on anaesthetics used, but subsequent increase are ‘real’ # a genuine fall, due to change in guidelines “ both on calendar year 2007, not fiscal 07/8

π the gestation for IOL in uncomplicated pregnancies moved from 40+14 to 40+12

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Overall Delivery Figures for RBFT Data from CMIS extracted by Julie Sadio and analysed by Jane Siddall 5579 maternities within the service, with 5681 babies born. 161 maternities were outside this hospital (146 planned at home, and 15 deliveries ’elsewhere’’, ie mainly ‘in transit’, all singletons). Births at other hospitals are not routinely captured on CMIS. All babies born outside RBFT were singleton and delivered spontaneously Of the 5576 maternities in this service, 2450 were nulliparae, and 3126 multiparae. Parity was captured for all but 3 mothers this year. Of the 5484babies delivered in hospital 5283 were singletons

• 3086 singletons delivered vaginally (spontaneous)

• 815 vaginal instrumental deliveries

• 3 breech singletons delivered vaginally

• 1409 singletons were delivered by LSCS, of whom 174 were breech presentations. 201 babies were from multiple births

• 98 sets of twins (one twin in one pregnancy was lost as a previable fetus) ,

• 2 sets of triplets (two maternities with all three being delivered at viable gestation), All babies born at home (146) were spontaneous vertex deliveries. There were no singleton breeches born at home, nor twins. Comparison of RBFT services to nearby maternity services It may be interesting to compare some of our data with that nationally, and of nearby services, and across the Thames Valley. These data have come from BirthChoices, and are from the financial year 2013-14. Please note that this report addresses 2014-15 outcomes, where our birth modes are different to 2013-14 rates for the service. The table below describes delivery rates in the whole maternity service in the last few years: overall the rate of LSCS continues to rise. These data were derived from Hospital Episode Statistics (HES) outputs. A ‘unassisted’ birth is defined by HES data as one where there was no induction, there was the option of regional anaesthesia but the delivery was unassisted. The mother may not have sustained an episiotomy . The three units with the highest LSCS rates were Croydon University Hospital at 37%, Chelsea & Westminster at 36.8% and St. Thomas’ London at 34.1%. The lowest three nationally were the Royal Shrewsbury and associated midwifery units (mainly free-standing) at 16.3%, the County Hospital in Stafford at 18.6% and the combined services at Grimsby, Scunthorpe and Goole at 18.9%

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Total births

Induction rate

LSCS rate

AVDs Forceps Ventouse SVDs classified

as ‘unassisted’

England 646904 25% 26.2% 12.8% 6.8 6 44.5% Planned & intrapartum

11% & 15.2%

RBH 5479 18.5 28.2 (13 & 15.2)

14.3 10.5 3.8 57.4

Milton Keynes

3713 22.4 27.9 (12.3 & 15.6)

11.6 6.8 8.3 55.7

Bucks (Stoke M and High

Wycombe)

5299 30.6 25.8 (10.2

&15.6)

18.1 12.8 5.3 56.1

OUHT (John

Radcliffe, Horton,

Wallingford and

Chipping Norton)

8257 24.6 23.5 (11 & 12.4)

16.1 12.6 3.6 60.4

Wexham Park

4413 No data 29.8 (12.4

&17.4)

14.5 6.3 8.3 55.7

Frimley Park

5052 27 24.4 (11.6 & 12.8)

13.1 6.5 6.6 62.5

GWH Swindon

plus associated

free standing MW units

8786 30.2 26.4 (12.3

&14.1)

12.6 No data No data 61

NHH Basingstoke

plus associated

free standing MW units

5723 21.7 24.9 (10.4 & 14.9)

13.5 7.9 5.6 61.6

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The numbers of home births are also captured from ONS data and the Registrar General in Scotland and has been analysed by BirthChoices:

The rate in our Home Birth service is close to the English trend line. Booking for antenatal care and delivery. Pregnancy is a physiological state which becomes complicated by medical or psychological co-morbidities for some women at various points during the pregnancy. Whilst a significant, but growing number, of women have pre-existing health needs which can impact adversely on their pregnancy if they do not receive high quality care and advice, most have relatively transient needs which can be managed without hospital admission. Women can be stratified into ‘low risk’ or ‘more complex needs’ at booking. However, pregnancy is a dynamic and relatively prolonged episode in a woman’s life, and situations can change (for better, or deteriorate) and new concerns may emerge with the passage of time. The booking process, which is managed by Community Midwives within the first trimester, entails a detailed history taking, screening for personal and family histories of note, a review of previous pregnancy outcomes and a huge amount of Health Promoting discussion, covering

Diet Exercise Smoking cessation support Enquiries about domestic violence Preparation for parenthood Availability of screening tests for infections and congenital abnormalities

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The midwives see between 500 and 600 women each month for a booking appointment, and achieve bookings of about 89% of those women known to be pregnant by the end of the first trimester cross the whole area, but this varies by GP practice where the mother is registered. At this stage, about just under a half of women are deemed to be ‘low risk’ and do not require consultant input into their pregnancy care plan. During the course of the pregnancy, approximately 1200 will be referred to a hospital clinic for an obstetric review. This may commonly be for

Management of anaemia not responding to oral iron therapy, Concerns over fetal size maternal abdominal pain (urinary tract and musculo-skeletal problem are most common) hypertensive disorders

but there are referrals for many other indications. Most women do not require admission, but may require additional out-patient care. This can be provided through the Day Assessment Service (please see later). Data from NHS England published in July this year gives a breakdown by GP practice on the numbers of women booked by 12 weeks, breast feeding initiation and continuation rates. Whilst these figures do not necessarily correlate directly with RBH maternity service in all geographical areas, they do offer a measure of pre-pregnancy health, early worries around the pregnancy, the ‘ease of access’ to care and public health promotion around breast feeding. The first set of data relates to bookings and antenatal appointments in the community settings. The ‘take home headlines’ are that the numbers of maternity patients per GP surgery does not correlate with how soon a woman is seen in early pregnancy, and that a significant number of women are seem more than once in primary care before they reach twelve weeks gestation (one surgery in South & West Reading saw 40% of women twice in the first trimester). However, a failure to be booked by twelve weeks seems more prevalent in Newbury and South Reading compared to the practices in Wokingham or North Reading. The reasons for this are likely to be multiple and may include maternal awareness of being pregnant, her awareness of the potential benefits or perceived disadvantages of early booking, preferred place to book for delivery and ease of getting an appointment once she makes the decision to alert health professionals to her pregnancy.

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CCG Numbers of maternities per practice

Consultations, as a % of all maternities registered with practice, before 12+6 weeks this may be a

marker for health concerns in general as well as pregnancy

Not booked for antenatal care and delivery by 12+6

Newbury 53-236 (typical around 130)

124-150% 17% (range 15-21%)

North and West Reading

25-258 (typical around 130)

99 -121% 10% (range 8 – 16%)

South Reading 29-206 (typical 80-90)

97 – 152% 13% (range 0 to 29%)

Wokingham 11- 258 (typical about 140)

84 -125% 8% (range 5-16%)

Data provided by Margaret Love, team leader maternity records, analysis by Jane Siddall Consultant antenatal clinics are held on three sites; the Royal Berks, Wokingham and WBCH, Newbury. Women requiring consultant booking can be referred by their GP or community midwife to any clinic. 2882 women were referred, and seen, for consultant directed antenatal care. These women subsequently required 7528 later hospital appointments.(Previously there were 5029 consultant booked follow-up appointments and a further 1104 women were referred later in pregnancy for an opinion by their midwife or GP to a clinic). There is no obvious, or single, explanation for this jump, as the numbers of mothers booking in the service was similar in these two years. Factors which MAY have influenced this change include the experience of both midwifery staff in the community and non-consultant medical staff in the hospital clinics, and perhaps the appointment of some locum consultants who are ‘new’ to leading their clinical services.

The graph below shows total new appointment for all antenatal clinics in the service, includingall specialised activities such as cardiac, endocrine (inc diabetes), bereaved parents.

Satellite clinics There have been two outreach clinics for over Patients attending these clinics live medical conditions such as diabetes, HIV or cardiac diseases for which there are specialised services at Reading. Substance dependant women can be assessed across the service thanks to the input of a specialist midwife, but are encouraged to attend key appointments in Reading, such as for antenatal anaesthetic assessments and consultations with the consultant who provides care to these women. A separate clinic is held every week for mothers with inseen by both the obstetrician and endocrinologist. On average, a mother with insulin dependant diabetes at conception is seen 10 times in a hospital clinic after her booking consultation.

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RBH 05 RBH 06 RBH 08-

Tues am + diabetes Weds am Thurs am

There have been two outreach clinics for over twenty years at Wokingham and West Berks: Patients attending these clinics live locally and require consult care, but do not have specific medical conditions such as diabetes, HIV or cardiac diseases for which there are specialised services at Reading. Substance dependant women can be assessed across the service thanks

a specialist midwife, but are encouraged to attend key appointments in Reading, such as for antenatal anaesthetic assessments and consultations with the consultant who

A separate clinic is held every week for mothers with insulin dependant diabetes where they are seen by both the obstetrician and endocrinologist. On average, a mother with insulin dependant diabetes at conception is seen 10 times in a hospital clinic after her booking consultation.

-9 RBH 09-10 RBH 10-11 RBH11 -12 2012-13 2013-14

Thurs am Weds pm and Fri am Thurs pm + cardiac Tues pm

years at Wokingham and West Berks: locally and require consult care, but do not have specific

medical conditions such as diabetes, HIV or cardiac diseases for which there are specialised services at Reading. Substance dependant women can be assessed across the service thanks

a specialist midwife, but are encouraged to attend key appointments in Reading, such as for antenatal anaesthetic assessments and consultations with the consultant who

sulin dependant diabetes where they are seen by both the obstetrician and endocrinologist. On average, a mother with insulin dependant diabetes at conception is seen 10 times in a hospital clinic after her booking consultation.

14 2014-15

Tues pm Newbury

13

Follow up appointments in hospital clinics. The NICE recommendations indicate that a healthy, low risk primigravid woman should not need more than nine antenatal appointments, and a multip just seven. There are no national indicators for the optimum number of appointments for women with more complex maternity needs. The women attending hospital clinics are heterogeneous in their needs, with many requiring a single hospital consultation, and others requiring very close surveillance such as women with diabetes, multiple pregnancy etc. Urgent review outside scheduled clinic appointments The Day Assessment Service is staffed by midwives who work in the hospital, providing antenatal care in clinics and the assessment unit, between 7am and 7pm, Monday to Friday, and on Saturday mornings. Outside these hours, staffing is provided through the delivery suite. The midwifery triage line is staffed 24 hours a day by carefully selected and trained community midwives who take queries from women who either perceive that they may be going into labour, or have some other reason for needing t speak to a midwife. All women who arrive at the clinic following a GP midwife referral, or the assessment unit, have, almost by definition, a pregnancy related concern which require evaluation by a trained professional. There is, however, much debate about whether that professional should always be hospital based, as improved access to primary care facilities might obviate a significant number of attendances. Various QIPP projects have been designed to address this issue.

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Demographics in Maternity Data collated by Jane Siddall Data from the most recent ONS papers for 2014 are presented below: The chart below shows national birth registrations from 1997 for England only.

Data from ONS, July 2015 Maternal age Nationally, this continues to rise, now at 30.2 years. Data collected by the ONS on maternal age for England and Wales is shown in the first image overleaf, then local RBH data.

580

630

680

730

643.1 635.9 622 604.5 594.5 596.1 621.5 639.8 645.8 669.6 689.8 674.7 675.8 723.2 723.9 729 698 695

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Registered births, in thousands, by year, England &Wales

thousand births

15

The fertility of women under twenty years of age has fallen by 10%, and indeed has been falling cross Europe steadily for the last ten years. Fertility rates in the over 35s have, in contrast, risen, but only by about 2.5%. Teenage conceptions have, historically, been reported to be higher in this part of the Thames Valley than the national average, but the number who are still of statutory school age who actually continue with their pregnancy is small, typically around 10-12. In 2014 there were just four girls under 16 who became mothers. Locally, 265 young women under the age of 20 years had babies in the last financial year, a fall of 10% on 2013, and nearly 30% fewer than in 2012. Data for England and Wales, 2014

16

The chart below maps the age trends since 1999 to the present day locally, although it should be noted that the school girl cohort is so small it isn’t visible, and neither if the over 45 years group. Most mothers are aged between 26 and 35:

These demographic shifts, whilst small year on year, steadily impact on the range of services required and provided, such as increasing co-morbidities such as obesity, hypertension and diabetes, all more prevalent in older service users. Trends in maternities, RBH 1990 to 2014-15

50

250

450

650

850

1050

1250

1450

1650

1850

2050

13-

1516-

2021-

2526-

3031-

3536-

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4.5

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6.5

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-4

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-15

maternities

babies born

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The number of babies born will always be greater than the maternities because there are multiple births. The birth rate locally more or less plateaued at around 6000 per annum between 2007 and 2012, but has dropped recently. In England and Wales in 2014 there were 695,233 a drop of 0.5% on the previous year, there having been a steady increase year on year 2009-12, and now a 5% overall fall.. There were, sadly, 3,254 stillbirths in the same period, a rate of 4.7 per thousand birthsfor the second consecutive year. The fall in stillbirths was greater than that seen in total births. The national rate has been 5.1 to 5.2 per thousand for a number of years recently so this continued fall is very welcome. Maternal age has risen again, but slightly to 30.2, increasing by about two and a half months each year in the last 3 to 4. Trends in use of Regional Anaesthesia 2000 to 2014-15 The chart below shows a historical trend line, indicating that over a fifteen year period, the numbers of mothers requesting an epidural, mainly for pain relief in labour has been around 900-1400 per annum, with a maternity rate in the range 5000-6000. In the same period, the use of spinal anaesthesia has increased steadily, with the two types crossing in around 2009 locally. Spinal anaesthesia is a popular option in maternity services, both for elective abdominal delivery and third stage complications, due to the rapid onset of a dense block. Detail on the obstetric anaesthesia services is available later in the report.

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to 09to 10 to11 to12 to13 to14 to 15

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of

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ion

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Regional anaesthesia

Epid

spinal /CSE

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Rushey Birth Centre 2014/15 Annette Weavers August 2015 Over the last year, 1035 women were admitted to Rushey Birth Centre. This is a decrease of 38% on the previous year because of the closure of two rooms (CQC safety recommendation Feb 2014). 788 women delivered their babies on the Birth Centre, accounting for 14% of all births. Overall outcomes for women are good and are comparable with the findings in the Birthplace study (2011). Birth Outcomes (n=1035) 511 primips and 524 multips were admitted. Overall mode of birth outcomes align with national data: 85.6% spontaneous vaginal birth rate and 3.4% caesarean section rate.

For primips who intended to birth on the birth centre, 74% had a spontaneous vaginal birth, slightly lower than national data (76%), however the caesarean section rate was 6%, slightly lower than national data (8%). For multips, 97% achieved a spontaneous vaginal birth with 1% needing a caesarean section. Transfers to Delivery Suite Some women require transfer to DS during labour or in the immediate postnatal period. Theoverall rate for both primips and multipswas 27%, no change from last year and similar to national data at 26%. The data has been separated for primips and multips. ‘Other’indications for transfer include raised blood pressure, breech presentation, pyrexia in labour, haemorrhage or transfer because of birth centre closure which has occurred on times over the year on a shift by shift basis. The overall transfer rate for primips was 43% which is an increase of 2% from last year’s rate. Indications for transfer in primips, presented as numbers are outlined below. Transfers for delay in second stage of labour account for the majority reason (n=71) followed by delay in first stage (n = 36) and meconium stained liquor (n=31).

75%

80%

85%

90%

95%

100%

105%

Birthplace

study

2012/13 2013/14 2014/15

LSCS

AVD

SVD

19

Indications for transfer to Delivery Suite in multiparous women are shown below. Fewer multips(n=65) required transfer in labour, the overall rate was 12% an increase of 1% from last year.The ‘other’ category (n=12) accounts for the main indication for transfer followed by epidural (n=10) and delay in second stage of labour (n=10).

Other data for women who birthed in Rushey n=788:

% of mothers n =788

Use of pool room: Summer 22 Intact perineum rate 28.7 Episiotomy rate 4 Third degree tear rate 1.4

Shoulder Dystocia 0.76 Physiological third stage of labour 7 PPH >1L 1.4

Neonatal outcomes Of the babies born on Rushey, 18 (2.2%) were admitted directly to SCBU for different periods of time and mainly for observations. Two babies were admitted for Apgars of <7 at 5 minutes.

0 10 20 30 40 50 60 70 80

First stage delay

Epidural

Fetal Distress

Retained placenta

Other

Reasons for transfer to DS:primips

0 2 4 6 8 10 12 14

First stage delay

Epidural

Fetal Distress

Retained placenta

Other

Reasons for transfer to DS: multips

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Anaesthetic services for the Maternity Unit This section has been compiled by Dr Guy Jackson, lead for Obstetric Anaesthesia. The data has been taken from the obstetric anaesthetic database and may have different information to that captured by CMIS. Anaesthetic Antenatal Assessments We hold an obstetric anaesthetic clinic on every Wednesday morning for both antenatal and postnatal women at the Royal Berkshire Hospital. In the antenatal period we review women with more complex needs (eg: previous back surgery, clotting disorders, raised body mass index > 40, drug dependency and general medical conditions). The aim is to make plans for delivery in advance of labour or Caesarean section to inform the women of the options available and to communicate these plans to the anaesthetic staff. A new secure computer program with antenatal assessment record and labour procedure database has been designed and implemented to improve communication between anaesthetists and provide documentation for women to keep in handheld notes as well as hospital notes. We also review women in the postnatal period if there have been any complications such as dural puncture headaches. 366 formal antenatal assessments with management plans were completed this year Analgesia for labour and delivery We provide epidural and combined spinal epidural (CSE) analgesia for labour in addition to the analgesia offered and led by the midwifery services. Between April 2014 – April 2015: We inserted 927 epidurals, We inserted 126 combined spinal epidurals Our epidural rate (based on 5579 maternities during the year) = 1053/5579 = 18.9% Anaesthesia for elective and emergency LSCS The vast majority of mothers having a planned Caesarean section are delivered using spinal anaesthesia, whereas mothers having an intrapartum Caesarean section have either spinal, epidural (top up) or general anaesthesia. See tables below:

ELECTIVE CAESAREAN SECTION (cat 4 and cat 3)

Number Percentage

Spinal 484 88% Epidural 7 1% Combined spinal epidural 44 8% General anaesthetic 16 3% Total 551

21

EMERGENCY CAESAREAN SECTION (cats 1 and 2)

Number Percentage

Spinal 471 53% Epidural top up 266 30% Combined spinal epidural 14 16% General anaesthetic 93 11% Total 884

Complications from regional anaesthesia Low pressure headaches caused by dural puncture often require a blood patch to resolve symptoms.

• There were x dural punctures (during epidural insertion) reported

• 7 women required a blood patch The dural puncture rate during this period was x/y = % This is within the national average. General anaesthetics This table below shows what procedures were undertaken under general anaesthesia in this year:

Procedure Number

Elective (cat 3 or 4) Caesarean section 16 Emergency (cat 1 or 2)Caesarean section 93 Evacuation of retained products of conception (ERPC) 71 Examination under anaesthetic (EUA) 4

Perineal repair 14 Laparotomy 3 Manual removal of placenta (MROP) 20 Cervical suture 1 Breech delivery second twin 1 Total 225

Number of general anaesthetics in comparison to previous years:

General anaesthetics Number 2008-2009 167 2009-2010 188 2010-2011 236 2011-2012 200

2012-2013 204 2013-2014 249 2014-2015 225

22

Follow up We aim to follow up all women following any anaesthetic intervention on the following day. Between April 2014 – April 2015 1806 women were visited in the postnatal period. 93% of women rated their experience of anaesthesia intervention as good or excellent. 2% of women rated their experience as poor or average. 15% of women were not seen in the postoperative period because they had already been discharged prior to review. Whilst clinic appointments are all scheduled, being made by obstetricians, about 110-120 each month are additional ones requested by community midwives or GPs. The balance is different however in the Day Unit, with half of the women having pre-booked appointments scheduled from clinics, and the other half being referred at short notice (2-48 hours) by health professionals, or as ‘self referrals’ routed through the midwifery triage line. Women telephone the unit using the triage line, but those who are not in labour may be directed to the assessment unit if the midwife taking the call obtains information which needs prompt evaluation.

Prenatal screening and Diagnostic Services

Screening:

The ‘standard’ is that 100% of women who are known to the maternity services by 10 weeks are

offered a comprehensive array of screening tests, most are blood tests, but this also includes a

first trimester scan. Women identified after 12+6 weeks of pregnancy are offer a quadruple

blood test as nuchal scanning cannot be offered after this gestation.

Ultrasound Data from Lynn Fulford Trends in ultrasound examinations undertaken in M.U.D. Universal nuchal screening commenced in Nov 2005, which corresponds to the sharp rise in activity in the chart below. These data are thousands of scans per annum:

90

91

92

93

94

95

96

97

98

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

-8

20

08

-9

20

09

-10

20

11

-12

20

12

-13

20

13

-14

20

14

-15

total

scans

obs

scans

Annual maternity services report 2014-15

During 2014-15 26476 ultrasound examinations were performed by the sonographers and senior medical staff

18718 were obstetric scans of which 17541 were at RBH 1177 were obstetric scans at West Berks

Nearly all gynaecological scans are performed in the RBH, although a small number are done at Bracknell, Henley and WBCH, and obstetric examinations are performed only at RBH and at West Berkshire Community Hospital. Doppler velocimetry and pre-natal invasive procedures are only available at RBH of which 47 were on women who underwent amniocentesis 22 were on women who underwent chorionic villus sampling.

0 were for fetal blood sampling. in addition the ultrasound department in the Maternity Block also performs gynaecological scans: 7742 were undertaken of which 1435 were on fertility clinic patients 1915 from gynae. out-patients 61 were on women attending the Family Planning Clinic 3529 were on women attending Sonning ward for the

Early Pregnancy Assessment clinic and emergency gynaecology services

539 Post menopausal bleeding 197 HyFoSy studies and 10 were on patients from the GUM clinic

Annual maternity services report 2014-15

258 examinations were done at WBCH,. A number of fertility patients were scanned elsewhere, 61 at Townlands Hospital in Henley and the 10 at the Bracknell Clinic. As the gynaecological work is a different specialty, I am not able to comment on the changes noted.

Prenatal diagnosis and management of women with fetal abnormalities

Data collected and stratified by Jeanne Harris

There is a monthly combined pre-natal and peri-natal clinic run by Mark Selinger and Anne Gordon where mothers whose fetus has been identified as having an abnormality, and who elect to continue with the pregnancy can be seen, their fetus monitored and a neonatal care plan developed. Not all women choose to have appointments in this service, but all have the offer made if planned neonatologist input is considered to be beneficial.

Diagnostic Standards

The data are presented in this next section, after the RCOG / RCR standards table below. Our sonographers and medical staff who work in

Ultrasound have performed to an impeccably high standard again this year. Data for the years 2001 to 2012 are not shown individually but are

included in cumulative totals

Defect RCOG / RCR standard for detection

2013-14 2014-15 Cumulative detection rate in since 2001

Spina bifida 90% none One detected 100% (47 cases) Anencephaly 99% 100 % (1) 2 detected 100% (33 cases) Major cardiac

defects 25% 89%

(16/18) 10 detected 80% (103 of 129 cases)

Diaphragmatic hernia

60% 100% (4 of 4) none 87% (13 of 15cases)

Abdominal wall defects

90% 100% (4 of 4) 3 detected 100% (42cases)

Major renal problems

85% 100% (4 of 4) 11 detected 100% (86cases)

Missing or shortened limbs

90% none 7 detected 75% ( 33 of 44 cases)

27

The following charts detail the 126 pregnancies where there were abnormalities and show what was diagnosed prior to delivery and what was diagnosed afterwards. If a structural abnormality was noted and karyotyping performed, the fetus is listed as ‘chromosomal’ if the result was positive, and under the relevant organ systems if karyotyping was normal. There were a number fetuses where several abnormalities were noted at delivery, all of which had been diagnosed antenatally, and which are now grouped as ‘miscellaneous’, with two or more defects from at least two body systems identifified. Detection of chromosomal anomalies is part of the National Screening programme, and pregnant women can choose to have a Combined Test (CT) at the end of the first trimester, which comprises both blood testing for three analytes and a nuchal scan, a Nuchal Translucency Scan (NT) alone, or neither. The Harmony Test is not available on the NHS, and analyses cell free DNA in the maternal blood. It is claimed that 99% of babies with Down syndrome (T21), 97% of Edwrad’s Syndrome (T18) and 92% of Patau (T13) can be diagnosed with this test. The diagnostic tests remain invasive; either a chorion villus biopsy (CVS) or an amniocentesis are offered during pregnancy. Testing after birth is by fetal blood sampling. Other abnormalities can be detected by ultrasound: the scan at the end of the first trimester can lead to some diagnoses, but the majority are detected around 20 weeks. It should be borne in mind that not abnormalities can be detected by ultrasound, and that not all pathology has evolved by 20 weeks.

28

The tables below are for mothers screened at RBH in the last financial year.

Chromosomal defects (25) . (Trisomy 21 = 18 cases, T18 = 5 cases, 2 ‘others’) Maternal age Gestation Defect Screening

test Diagnostic

test Pregnancy outcome

33 16 T21 CT Amnio ToP 40 16 T21 CT Amnio ToP

33 12 T21 NT CVS ToP

39 12 T21 CT NT CVS ToP

42 12 T21 declined CVS ToP

35 16 T21 NT Amnio LB 41 16 T21 CT NT Amnio ToP 29 22 T21 CT Amnio ToP 37 13 T21 CT NT CVS ToP

35 16 T21 CT Amnio ToP

43 18 T21 CT harmony Amnio ToP

38 19 T21 CT harmony Amnio ToP

39 29 T21 Abnormal USS

Amnio ToP

46 12 T21 CT NT CVS ToP

30 Birth T21 Very low risk CT

Blood LB

38 Bith T21 Declined Blood LB 35 Birth T21 Declined Blood LB 28 Birth T21 Declined Blood LB

39 15 T18 CT Harmony Amnio ToP 36 13 T18 USS

Harmony Amnio ToP

46 12 T18 NT Harmony CVS ToP

41 32 T18 USS Amnio ToP

26 28 T18 NT USS ToP

27 20 Deletion chromosome

16

USS Gastroschisis

Amnio ToP

27 12 Deletion chromosome

12

NT CVS ToP

29

Central Nervous System (18)

35 13 Encephalocele USS ToP

23 18 Microcephaly, absent cavum septum pelucidum, (CSP)

cerebellar hypoplasia

USS LB

31 22 Absent CSP USS ToP 34 12 Acrania USS ToP 34 36 Enlarged cisterna magna USS LB 16 20 Right sided ventriculomegaly USS LB 31 32 Bilateral ventriculomegaly,

absent CSP USS LB

28 19 Bilateral severe ventriculomegaly

USS ToP

28 25* Schizencepahly USS Delivered LB in Finland

42 17 Dandy Walker malformation USS ToP 28 32 Enlarged cavum vigae, absent

corpus callosum USS LB

34 21 Moderate ventriculomegaly USS LB 24 22 Lumbosacral spina bifida USS Moved away and

lost to follow up 35 29 Mild VM in one twin USS LB 30 21 Bilateal ventriculomegaly USS LB 27 20 Lumbosacral spina bifida USS ToP 32 12 Anencephaly in one twin USS Selective fetocide 33 20 Mild unilateral ventriculomegaly USS LB

*This mother relocated to Finland during her pregnancy

Cardio-thoracic (14)

31 35 Cardiomyopathy USS LB but NND

31 18 Transposition with VSD

USS LB surgery So’ton

28 23 Anomalous drainage

USS LB

34 27 Fallot’s tetralogy USS LB 20 22 VSD USS LB 26 20 Dilated

cardiomyopathy USS LB, no anomaly

42 24 ASD + VSD USS LB 31 21 Truncus

arteriosus USS LB

28 21 VSD overriding aorta (also had Down’s)

USS ToP

36 20 Left sided superior vena cava

USS Lost to F/U as moved away

26 24 VSD USS ToP

30

28 20 Large dilated heart with mediastinal shift

USS LB

33 21 Right CCAM USS LB 32 21 Left CCAM USS LB

Face (6)

25 20 Arrhinia / severely Hypoplastic nose

USS LB very flat nasal bridge

32 21 Bilateral cleft lip +/_ palate USS LB 37 16 Bilateral cleft lip +/_ palate USS LB 34 20 Unilateral cleft lip +/_ palate USS LB 22 20 R cleft lip only USS LB 30 22 Unilateral cleft lip +/_ palate USS LB

Limb Defects (14)

29 20 Shortened forearm, absent R hand

USS LB

21 20 Skeletal dysplasia USS SB 38 weeks

27 20 Bilateral talipes USS LB

37 11 Skeletal dysplasia one twin USS LB

28 20 R talipes USS LB

31 22 ? osteogenesis imperfecta USS LB no anomaly

28 L talipes USS LB no anomaly

32 26 L talipes USS Delivered elsewhere and lost to follow-up

30 20 Arthrogryphosis multiplex USS LB but NND at 3 weeks

26 31 Bilateral talipes USS LB

22 20 Arthrogryphosis multiplex USS ToP

32 25 Shortened and bowed femurs USS LB

38 19 One twin with unilateral talipes USS LB

35 21 Bowed leg with fracture (mother has osteogenesis)

USS LB

Renal (21)

35 20 Bilateral pelvi-calyceal dilation, bright cortex

USS Moved before delivery, lost to F/U

32 19 Unilateral pelvi-calyceal dilatation

USS LB with anomaly

36 19 ? absent R kidney USS LB with anomaly

31

36 28 Bilateral PCD &? Posterior urethral valves

USS LB with anomaly

33 20 Unilateral PCD in one twin USS LB with anomaly 32 12 Megacystis USS ToP 29 20 absent R kidney USS LB with anomaly 32 20 Mild PCD USS LB anomaly

resolved 32 22 Unilateral PCD USS LB with anomaly 25 20 Bilaterally enlarged kidneys

assoc with oligohydramnios USS IUD 34 weeks

20 21 Hyeprechoic renal cortex USS LB with anomaly 27 27 Twins with megacystsis USS LB with anomaly 29 21 ? abnormal bladder USS LB anomaly

resolved 31 20 Absent R kidney USS LB with anomaly 26 20 L cystic dysplastic kidney USS LB 30 18 Posterior urethral valves,

enlarged bladder USS ToP

37 18 Anydramnios, dysplastic kidneys, ? Potters

USS ToP

35 20 Bilateral PCD + hydronephrosis

USS LB with anomaly

40 20 Bilateral PCD USS LB with anomaly 36 20 Absent R kidney USS LB

Gastro-intestinal (8)

40 31 ? duodenal atresia USS IUD at 32 weeks

27 14 Gastrocshisis USS ToP 33 30 Fetal cyst USS Moved out of

area, lost to F/U 22 32 Fetal ovarian cyst USS LB with anomaly 24 12 Gastroschisis USS Del JRH 39 29 Duodenal atresia with

abnormal heart (also T21) USS ToP

29 20 Fetal cyst USS LB 38 12 Gastroschisis USS ToP

32

Multiple / miscellaneous (20)

25 20 Absent cavum septum pellucidum, cranial

ventriculomegaly plus cardiac ventricular septal defect and

over-riding aorta

USS IUD 34 weeks

36 21 Twin to twin transfusion syndrome in monochorionic

twins

USS LB 30 weeks

34 12 Abnormal nuchal screening in one twin

USS Selective invasivetesting at UCH but both twins died in early second trimester

36 21 Chorioangioma USS LB with abnormal placenta

21 20 Micrognathia, pleural effusions, absent stomach

bubble

USS ToP

26 20 Bilateral ventriculomegaly, absent corpus callosum,

bilateral cleft lip and palate, abnormal legs, no feet

USS ToP

24 20 Absent CC abnormal nose lip and palate. Sacral scolioisis

USS IUD prior to planned ToP

31 22 Unilateral shortening of lower limb

USS LB with abnormality

37 12 Cystic hygroma USS ToP

34 12 One twin with abnormal nuchal scan

USS LB, both normal

37 12 NT of >7mm USS IUD 20 weeks

32 14 Pseudohyperaldosteronism CVS ToP

30 16 Early onset severe IUGR. Normal chromosomes

USS IUD 23 weeks

32 20 Early onset IUGR and pelvic kidney

USS IUD 25 weeks

28 12 Large anterior abdominal wall defect containing liver

USS ToP (later confirmed T18)

30 12 Cystic hygroma USS ToP

35 13 Cystic hygroma USS ToP

34 12 Cystic hygroma USS ToP

34 21 Cystic hygroma, echogenic bowel, tricuspid regurgitation

USS unknown

33

Birth Outcomes across the whole service The chart below describes modes, the relative proportions within the cohort, of the various modes of delivery, for singletons. It should be noted that the total number of births varies year by year, so whilst the absolute number of deliveries completed by any means may rise or fall in any year, this should not be taken in isolation. The most striking feature is the shift away from ventouse to forceps deliveries (red and bright blue bars), and there has been a small but sustained fall in the numbers of emergency LSCS (royal blue bar) since 2009-10. The emergency LSCS rate is currently at 13.0 % for singletons, and 12.7% for all maternities. As this rate was 17.8% in 2007, this would suggest a sustained, although small, change in the intrapartum management. Overall, 74.4 % of mothers achieved a vaginal delivery, a small increase on last year (72.2%).

34

‘Low risk’ woman at the point of admission for delivery The RBH ‘standard’ primipare (SP) Analysis by Jane Siddall In 1998 we adopted a model to describe the group of relatively homogenous women who are healthy and expecting their first baby. This sub-set is the model for women with low risk for medical complications, and has predominantly midwifery led care during pregnancy and at delivery. Our definition (derived from Paterson et al at St. Mary’s in London, 1991) is

• no previous pregnancy (any outcome)

• over 18 years of age but under 35

• presents in spontaneous labour between 37 and 42 weeks gestation, with a singleton in the vertex presentation

In addition, there is no history of any of the following

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

VB

em LSCS

el LSCS

SVD

AVDf

AVDv

35

• cervical cerclage

• antepartum haemorrhage

• epilepsy

• diabetes

• hypertension

• renal disease

• cardiac disease In the last financial year there were 1354 SPs. The group is now 52% of all primigravid women, having run at 35-37% until about four years ago. There is no obvious explanation for this demographic shift. The numbers of unassisted vaginal deliveries (whether or not the labour was augmented) was 813 (60.3% of the cohort, another rise, now 3% higher than in 2011-12). Those women who required assistance to deliver, with either forceps or ventouse was 339 (25%), All LSCS performed on the group have to be, by definition for inclusion in the cohort, emergency procedures. There were 202 (14.9%).

The chart below shows the proportions of each type of delivery experienced by our standard primip over the years since she was first described in 1998. Overall 1 in 7will be delivered by LSCS after labour has started.

12

13

14

15

16

17

18

2010- 2011- 2012= 2013- 2014-

% LSCS

% LSCS

36

Higher risk or more complex maternities Caesarean Section The CS data have been analysed by Jane Siddall National data The rates of LSCS vary across the four Home Nations of the United Kingdom and there does not appear to be a clear reason for this difference. I am indebted to BirthChoices for the following data: The calculations from HES data by BirthChoices for 2013 / 2014 are as follows:

Cats 3 and 4 (%)

Cats 1&2 (%) Total (%)

England 2013 10.7% 14.7 25.4 Scotland 2013 12.8 15.7 28.4 Wales 2014 11.7 15.3 26.9 N Ireland 2014 14.5 14.6 29.1

37

BirthChoices also provides historical data on elective LSCS rates by hospital trust, derived from HES data, as shown below.

births 2009 2010 2011 2012 2013 2014 England 9.8% 10% 10% 10.2% 10.7% 11%

RBH 5800 12 13 12 12 12 13 Milton Keynes

3700 11 11 11 11 11 12.3

Stoke Mandeville + High Wycombe

5200 11 12 12 11 11 10.2

JRH Oxford 6500 11 10 10 11 10 11 Horton (Banbury)

1700 11 12 12 12 11

Wexham Park Slough

4700 11 11 11 11 14 12.4

Frimley Park 5300 12 13 11 12 12 11.6 Great Western Swindon

4500 11 10 10 11 11 12.3

NHH Basingstoke

3100 7 7 9 8 9 10.4

.

38

Caesarean Sections : local data The total number of Caesareans was 1379 for singletons, 47 for both twins, (two being for a second twin) and two for triplets. Thus 1428 maternities were completed by LSCS. Of the singleton ones, 174 were for breech presentations. Caesarean is recorded as being in one of four categories: Category 1 is a potentially life threatening emergency Category 2 is urgent Category 3 is an expedited delivery of a previously planned delivery Category 4 is elective Thus most deliveries intrapartum should be in category 2 and most deliveries without labour would be a category 4. The data recorded on CMIS by midwives suggests that this nomenclature is still being embedded. Overall 690 mothers of singletons and 15 mothers of twins had category 1 or 2 LSCS. 689 mothers of singletons had a planned LSCS, of which 131 were ‘expedited’, and 34 mothers of twins. The triplet deliveries were classified as category 3. 25.6% of all maternities were caesarean deliveries. 723 mothers had planned deliveries which is 50.6% of all caesareans, and the proportion of all deliveries which are by elective LSCS was 12.9 %

39

The numbers of planned LSCS varies by month, and would be expected to be broadly in line with the numbers of maternities each month, which is known to have a bimodal curve with a broad peak around March-April and a higher, longer peak from late August through to early October. The graph below shows data for the fifteen months to March 2015 from the internal monthly LSCS audit to monitor indications and CMIS data entry quality. It is striking that the numbers were low in the autumn, which is counter-intuitive and for which there is no clear explanation.

30

35

40

45

50

55

2009-10 2010-11 2011-12 2012-13 2013-14 2014-15

Percentage of LSCS which are elective procedures at RBFT

percentage

0

10

20

30

40

50

60

Numbers elective (cat 4) LSCS

No eLSCS

To determine the number of primary LSCS performed: 616 nulliparae with singletons had a caesarean delivery and about all twins conceived by nulliparae)primary LSCS on nullips 297 mothers who had previously had one or more Caesarean delabdominally so from 1428 caesareans, deduct 641 nulliparae, then 663 mothers who had had at least one prior LSCS and 26 multips with sets of twins whose mothers were multips,the number of multips having their first LSCS is 98: The number of primary LSCS is thus 714 (616 plus 98) 12.9% (previously, which was within the primary LSCS rate for England & Wales at 17although this rate was derived as part of the Sentinel LSCS Audit in 2002).

The graph below shows the absolute numbers of primary nulliparous and multiparous women. The data on primigravid women is encouraging, but on multips, the data since the Nov 2011 NICE guidance hints that this publication had an impact on both clinicians and service users, with an initial surge in requests, perhaps now falling again with the advent of ‘next birth’ and /or VBAC clinics led by specifically trained midwives, in addition to a longstanding consultant obstetrician delivered service to debrief those with significant complications / concerns around previous deliveries

0

100

200

300

400

500

600

700

800

900

nullips

To determine the number of primary LSCS performed:

nulliparae with singletons had a caesarean delivery and about 25 (assumed half of all twins conceived by nulliparae) with twins were delivered by LSCS in 2013

297 mothers who had previously had one or more Caesarean deliveries were delivered

1428 caesareans, deduct 641 nulliparae, then 663 mothers who had had at least one prior LSCS and 26 multips with sets of twins whose mothers were multips,the number of multips having their first LSCS is 98:

The number of primary LSCS is thus 714 (616 plus 98) 12.9% (cf 17- previously, which was within the primary LSCS rate for England & Wales at 17although this rate was derived as part of the Sentinel LSCS Audit in 2002).

the absolute numbers of primary LSCS performed on both nulliparous and multiparous women. The data on primigravid women is encouraging, but on multips, the data since the Nov 2011 NICE guidance hints that this publication had an

s and service users, with an initial surge in requests, perhaps now falling again with the advent of ‘next birth’ and /or VBAC clinics led by specifically trained midwives, in addition to a longstanding consultant obstetrician delivered service

f those with significant complications / concerns around previous deliveries

multips

40

(assumed half of with twins were delivered by LSCS in 2013-14, so 641

iveries were delivered

1428 caesareans, deduct 641 nulliparae, then 663 mothers who had had at least one prior LSCS and 26 multips with sets of twins whose mothers were multips,

19.2% previously, which was within the primary LSCS rate for England & Wales at 17-19%, although this rate was derived as part of the Sentinel LSCS Audit in 2002).

LSCS performed on both nulliparous and multiparous women. The data on primigravid women is encouraging, but on multips, the data since the Nov 2011 NICE guidance hints that this publication had an

s and service users, with an initial surge in requests, perhaps now falling again with the advent of ‘next birth’ and /or VBAC clinics led by specifically trained midwives, in addition to a longstanding consultant obstetrician delivered service

f those with significant complications / concerns around previous deliveries.

2007-8

2008-9

2009-10

2010-11

2011-12

2012-13

2013-14

2014-15

41

Percentage within cohort of both nullips and mutlips having a first (primary) LSCS over time

Women delivering > 20 weeks after NICE guidance on maternal request for LSCS Repeat LSCS There has been an ‘urban myth’ that once a mother has had a caesarean delivery she will continue to be advised to have further children this way. In the calendar year 2014, we performed 124 elective repeats before 41 weeks’ gestation where maternal choice was the prime factor in the decision making process. A second assumption is that maternal cultural preferences might lead to a bias in the making of a request: an audit on these mothers found that overall, in the ‘planned LSCS’ group, 104 British women had an elective LSCS and 42 (28%) non British enjoyed a similar care plan. Some women were first time mothers, most had one older child whose delivery had been abdominal. The Office for National Statistics published data on maternal origin most recently for the year 2013. 0f the 698,512 births registered, 513,411 (73.5%) were to mothers born in Britain. 68,407 (9.8%) were to mothers of European (EU and non-EU) origin and 40,604 (5.8%) to mothers from India, Pakistan and Bangladesh. In the South East of England, 23.3% of mothers were born outside the UK, being most in Slough at 59.9% of that population, and least likely in the Isle of Wight at 9%. The distribution in the Unitary Authorities in the parts of Berkshire where the majority of

0

5

10

15

20

25

30

35

2008-9 2009- 2010- 2011- 2012- 2013- 2014-

nullips

multips

42

mothers deliver in this unit shows a total of 6156 registered births, where 1915 were to overseas born women,(31%) .Reading has 44.9% of it’s mothers born outside the UK, Wokingham 24.6% and W Berkshire 17.1% . These data do not indicate an excess of mothers born overseas requesting, and getting, an elective LSCS relative to UK born residents. A ‘repeat LSCS’ can only be performed on multips who have had at least one previous LSCS. There were 563 women with only one previous LSCS who had a repeat LSCS for some reason (19 cat 1, 105 cat 2, 55 cat 3 and 384 cat 4). This is an increase of about 30 mothers compared to both of the preceding two years. The group where there is an opportunity to listen, educate and probably influence, are mothers who have only had one caesarean delivery for a non-recurrent indication (such as, but not only, fetal distress, placenta praevia) Once a mother has had two caesarean deliveries, most will have subsequent children delivered by the surgical method. We recommend that women who have had more than two previous LSCS are delivered abdominally; there were 138 in 2014-15 The graph below shows the numbers of women having their third caesarean (left hand column) or fourth or more (right hand column) since we started collecting these data.

Previous Caesarean delivery The VBAC data show that 746 (an small increase of about 30 on 2013-14) multips carrying a singleton, with no more than just one previous baby born by LSCS, booked

0

20

40

60

80

100

120

140

2003 2006 2009- 2012-

2

>3

43

for delivery in the last financial year. Not all of these mothers could have been offered a ‘medically appropriate chance of VBAC’. Of these, 439 had an elective repeat procedure, as noted above, 124 of whom cited a maternal preference not to labour. The other 307 presented with an intention to deliver vaginally, of whom 183 achieved this aspiration. 124 had an intrapartum LSCS. The ‘Intention to achieve VBAC’ group actual birth outcomes (as percentages) are shown below:

It can be seen that the prospect of achieving a vaginal delivery has increased by some 50% from 2007 when just over 4/10 achieved a vaginal birth to 2014-15 where 6/10 did. Various ‘success rates’ are quoted in the literature, with rates of >70% achieving a VBAC being claimed in some maternity units. Data collected by BirthChoices for the UK paint a rather different picture with 50% of the potentially eligible cohort not attempting labour, and about 40% of those who do, have an intrapartum LSCS. Thus a VBAC rate of 60% of the cohort attempting it at best would seem typical across the UK. The RBH rate for the full year was 59.6%

0

10

20

30

40

50

60

70

Achieved VBAC as percentage of those who tried

VBAC

44

Twins and higher order multiple pregnancies Analysis by Jane Siddall UK national data shows that premature (ie before 37 weeks) delivery is six times more likely in a twin pregnancy and up to nine times more likely in higher order multiple pregnancies. This may be spontaneous or iatrogenic due to complications demanding early delivery. At all gestations, fetuses within twin pregnancies are more vulnerable to complications than singletons. Most dramatically they are at an increased risk of death when compared to singleton pregnancies. Although nationally, rates have fallen considerably in the last decade, they are significantly higher than for singletons. Rates between 3 and 7 x higher have been reported in the literature. Mothers with triplet pregnancies are at an even higher risk of fetal loss, with a stillbirth rate nationally approximately 6 times higher than that for singletons. This year we had two sets of triplets, all of whom survived. Given the relatively low numbers of multiple births in any one year in this unit, rates have been calculated over several years to be meaningful:

• In 2012 one set underwent feticide at 24+4 weeks due to twin to twin transfusion syndrome; one succumbed in utero at 25 weeks, another at 30, both with surviving co-twins. A second set both died in utero at 26+ weeks due to severe IUGR associated with severe PET, and the twin who sibling was lost at 19 weeks was born at 24 weeks, only to die shortly afterwards. Thus, the loss of potentially viable twins totalled 7 infants.

• In 2013 apparently there were no losses.

45

• In 201-5 we lost six twins from four pregnancies: there was one twin with complex multiple malformations, one of a pair from twin to twin transfusion, one pair from TTS and a second pair from acute fatty liver of pregnancy (a single gene mutation)

The perinatal mortality rate for multiple births in the three years 2010 to end March 2015 was

14 / 596 (289 twin and 6 triplet pregnancies delivered after 24 weeks) = 23.5 per thousand twin births

There were no ‘preventable’ or ‘unexpected’ twin losses around birth, and the figure includes one set where feticide was performed after 24 weeks.

Delivery by gestation for twins:

The key messages from the chart above, is that there is a swift downturn in the numbers of continuing pregnancies (or sharp increase in the number of deliveries) from

0

20

40

60

80

100

120

140

160

180

200

<24 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

undelivered twins by advancing gestation

undelivered twins

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30 weeks and that 50% of mothers will be delivered by 37 weeks. This si in stark contast to singletons, where about 1in 15 are delivered by 37 weeks. About 1/2 of mothers with twins are delivered by scheduled LSCS, and of those who labour, half again will have an intrapartum LSCS. A section for the second twin is alone may appear uncommon, occurring 33 times in the last fifteen years, but in fact this equates to a 1 in 13-15 chance overall after a vaginal deliver of the first twin. The triplets were delivered by LSCS. Singleton Breeches Analysis by Jane Siddall 194 women arrived for delivery with a singleton breech presentation. None were dead on admission. The chance of a breech presentation is inversely related to the gestation. Four mothers had a vaginal breech delivery of a baby at less than 24 weeks gestation. Six mothers delivered between 24 and 28 weeks, seven between 29 and 32 weeks. 127 women had category 3 or 4 Caesareans. A further 47 women were delivered by categories 1 or 2 LSCS. 20 women delivered a singleton breech vaginally, across all gestations. This chart shows the proportions of breeches born by each method

Inductions of labour Analysis by Jane Siddall Induction is defined as the artificial stimulation of uterine contractions leading to the progressive effacement of, and dilatation of the cervix. It does not include women requiring oxytocic agents to augment precontractions. This group are being augmented and are described in a separate section. To date, we have been unable to tease out women who present with a term prelabour spontaneous rupture of membranes from those who undergo ARM followed by syntocinon, although changes to the database means this should become available next year. The induction rate has varied between 17.2 and 11.7% since 2001. There was a change in the policy surrounding induction for women with an uncomplicated singleton pregnancy, from 42 weeks to 40+12 following evidence from NICE. This has necessarily increased the numbers of women e

Historically the IOL rate in Reading compares very well with the national average of 21%. It is worth, however, considering the consequences of induction and the impact on type of delivery, whether for nulliparous or

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Induction is defined as the artificial stimulation of uterine contractions leading to the effacement of, and dilatation of the cervix. It does not include women

requiring oxytocic agents to augment pre-existing short frequency or weak spontaneous contractions. This group are being augmented and are described in a separate section.

ave been unable to tease out women who present with a term prelabour spontaneous rupture of membranes from those who undergo ARM followed by syntocinon, although changes to the database means this should become available next

varied between 17.2 and 11.7% since 2001. There was a change in the policy surrounding induction for women with an uncomplicated singleton pregnancy, from 42 weeks to 40+12 following evidence from NICE. This has necessarily increased the numbers of women eligible to be offered induction.

Historically the IOL rate in Reading compares very well with the national average of 21%. It is worth, however, considering the consequences of induction and the impact on type of delivery, whether for nulliparous or multiparous women.

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Induction is defined as the artificial stimulation of uterine contractions leading to the effacement of, and dilatation of the cervix. It does not include women

existing short frequency or weak spontaneous contractions. This group are being augmented and are described in a separate section.

ave been unable to tease out women who present with a term prelabour spontaneous rupture of membranes from those who undergo ARM followed by syntocinon, although changes to the database means this should become available next

varied between 17.2 and 11.7% since 2001. There was a change in the policy surrounding induction for women with an uncomplicated singleton pregnancy, from 42 weeks to 40+12 following evidence from NICE. This has necessarily

Historically the IOL rate in Reading compares very well with the national average of 21%. It is worth, however, considering the consequences of induction and the impact on

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% women whose labours were induced, singletons only

Singletons

870 women were induced with a singleton cephalic presentation in 2014-15.

78 mothers were induced before 37 weeks for PET, significant fetal growth restriction or other maternal disease, where the ‘trade off’ of a high rate of interventional delivery may be appropriate. This is similar to previous years with the exception of 2013-14. 190 women were induced within seven days of their estimated date for delivery (EDD) for a variety of diverse indications, with 291 more after 41 to 42 weeks of pregnancy. This seems to have been a change in practice.81 women were apparently induced at 42 weeks, and two went significantly over this gestation (although one is clearly a data entry problem at 50 weeks!) Overall 469 were nulliparous and 401 multiparous.

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Nulliparae have a greater than1 in 3 chance of having a caesarean section following induction. This may be justified, depending on the indication for the induction. 62 multips had a caesarean delivery (c 15%) and 33 had an assisted vaginal delivery (c 8%), which may be worth considering when booking inductions for ‘softer’ indications, as if admitted in labour, the chance of LSCS and AVD combined is around 5% for multiparous women. Some of these multips will be ones whose prior obstetric history included a caesarean delivery, but it must not be assumed most are in this cohort. Augmentation of labour Analysis by Jane Siddall 763 women with a singleton had their labour augmented, 551 being nulliparae. Outcomes in pregnancies in diabetic women These data have been compiled by Rachel Crowley, specialist midwife for women with diabetes In 2014-15 there were 210 women seen by the Diabetic Ante-Natal team of whom six miscarried in the first trimester. There were six twin pregnancies, and one stillbirth in a mother whose baby was known to have a lethal malformation The number with pre-existing type 1 diabetes (IDDM) was 10, and the number with type 2 (NIDDM) was 17, or who two were managed by diet alone. 183 women were identified during pregnancy as having gestational diabetes.

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Numbers of mothers with diabetes Overall this group of women had 195 livebirths, 99 of whom had a vaginal delivery. 37 had a scheduled (cat 3 or 4) LSCS and 59 a 6 infants were born weighing more than 4.5kg Mode of delivery, all diabetic cases

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Overall this group of women had 195 livebirths, 99 of whom had a vaginal delivery. 37 had a scheduled (cat 3 or 4) LSCS and 59 an unplanned (cat 1or 2) LSCS.

6 infants were born weighing more than 4.5kg

Mode of delivery, all diabetic cases:

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Overall this group of women had 195 livebirths, 99 of whom had a vaginal delivery. 37 n unplanned (cat 1or 2) LSCS.

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Substance dependant mothers These data have been compiled by Jo Pendennis, specialist midwife for mothers with substance dependency There were 56 mothers referred with ‘problem use’ of which

- 18 high risk women -38 low risk women -4 women referred to the hepatitis C service And another 37 referrals where there was an anxiety from the community midwife about use in the partner or a single peri-conception use. These women are risk assessed y the Specialist Midwife and details may be held in the ‘back of the (her caseload) book’. As might be expected, most disclosed substance misuse is among women living in Reading, rather than in the smaller towns of, and villages around, Newbury and Wokingham.

Of the high risk women

• All were under the Poppy Team

• 2 women had terminations after 12 weeks

• 3 women miscarried, 2 had very chaotic lives and were admitted to ICU after miscarrying.

Most infants whose mothers were on a treatment regimen were also exposed to illicit drugs and/or alcohol. Some women stabilised when they realised they were pregnant. This was sometimes not until the second trimester.

After birth, 4 infants were taken into care, 1 infant was subject to a court order, but went to a mother and baby unit and 8 infants went home with their mother, one of whom had

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chaotic drug use up to 22/40. At the Initial Child Protection Conference for this infant

the chair decreed the child should be subject to a Child in Need Plan. The mother relapsed postnatally and the baby is now with another family member.

Of the lower risk referrals One infant whose mother reported high alcohol intake, but stopping by booking was born in poor condition. A diagnosis of HIE grade 2 was made. As in previous years, little disclosure of designer drug use. Cannabis is the most common drug of choice, but there seems to be an increase in disclosure of alcohol use. This may be improved screening techniques.

‘Back of the Book’ Of the 37 referrals

• 4 were for midwife support when a woman had delivered at another unit

• 6 women disclosed their partners used drugs

• 4 women were chaotic drug users where there were rumours of pregnancy, found to be false

• 20 women delivered with no detectable problems

• 1 woman had suspected cannabis use and delivered an IUD at 20/40

• 3 women were deemed high risk child protection. 1 woman miscarried. 2 women had other medical issues and we were able to offer continuity at ANC and add to effective communication with Children’s Services. The 3 infants of these two women were removed into care.

The numbers of high risk women for this year is low, but the level of chaos for some of the 18 is noticeably higher than previous years. Breast feeding statistics continue to be below average. Perineal Trauma Analysis by Jane Siddall Data on perineal trauma continues to be more complete this year, again with only 25 hospital deliveries not having any data entered, and was recorded on 5382 maternities in the hospital service. Data on home confinements continues to not be collected through CMIS.. As 2363 women were recorded as having an intact perineum, one should assume that all mothers having elective LSCS (1379+45 mulitple births) and probably all but one or two women delivered by LSCS in the second stage of labour did not sustain perineal damage. This means that at around 940 women had a vaginal delivery with an intact perineum. This is in accord with findings in previous years. The RCOG estimate that up to 90% of women having a vaginal delivery will have either an episiotomy or perineal tear, whereas the incidence within this maternity

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service is closer to 82%. 3859 women delivered vaginally, 3019 sustaining some perineal damage. 161 women had a third degree tear according to CMIS (153 according to the theatre registers), some despite having had an episiotomy cut. Episiotomy does not prevent a recurrence of such tears in women with a previous history. Although numerically more women have a third degree tear following a spontaneous vaginal delivery, the relative risk is at least two fold higher if the baby is delivered with the assistance of obstetric instruments. Post-Partum Haemorrhage Analysis by Jane Siddall As previously, a loss in excess of 1000ml has been taken as significant. During 2014-15 415 women were recorded as having lost >1 litre of blood, of whom 125 of these were delivered by emergency (cats 1&2) LSCS and 92 by elective (cats 3&4) LSCS. In 50 deliveries the loss was described as a ‘major obstetric haemorrhage’ (MOH), where the protocol was called and deployed. In these 41 were thought to have lost 2-3 litres by the time the bleeding was fully under control, 3-4 litres in eightand over 4 litres in four. The chart below shows the percentages of women experiencing a significant PPH by mode of delivery. The denominator for each bar is the total number of deliveries by that mode this year Assisted vaginal delivery (green bars) presents less morbidity from haemorrhage than an emergency LSCS at any point in time, and must continue to be actively considered as a viable means of delivery for many parturients in the second stage of labour. It also shows an increase in the absolute rates of PPH since 2007-8, which may be due in part to better ascertainment of loss by all health professionals. This chart can be used to demonstrate the relative risk of PPH with each mode of delivery compared to the risk with a spontaneous vaginal delivery (the biggest group in the cohort and the one where there should be least trauma). The use of the long acting uterotonic, Carbeprost was introduced in November 2012, initially for women having elective LSCS deliveries. Since 2013-14 this has been used routinely at all LSCS deliveries.

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In cases of MOH the factors are often multifactorial, but the main causes identified are

• Atonic uterus

• Retained products (such as membranes or small fragments of placenta not a whole placenta)

• Retained placenta

• Extensive vaginal trauma

• Placenta praevia Placental abruption

• Ruptured uterus

• Third and fourth degree perineal tears and delay in getting women sutured in theatre

• Multiple pregnancy

• Acute uterine inversion Breast feeding Initiation and Continuation by GP practices within CCGs

Breastfeeding inititation rates vary across the four main CCGs from around 60 to over 90%, and continuation at 6 weeks (full or partial breastfeeding) is shown in the lower chart at 40-70%. Data is incomplete for some areas, particularly breast feeding continuation in Wokingham.

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Continuation of breast feeding by CCG, order as above

Infant feeding Team Report 2014-15 This report has been written by Claire Carter RM Infant Feeding Lead During the last financial year this hospital passed stage 3 of the Baby Friendly Initiative (BFI) and achieved full accreditation in August 2014. The community of Berkshire West, (Health visitors and their support workers) achieved full accreditation in the September. This is an internationally recognised quality standard, demonstrating commitment to promoting sound infant feeding practices and we are proud and delighted to receive this award. I want to congratulate each and every midwife, maternity care worker, nursery nurse, paediatric nurse, breastfeeding network volunteers, other volunteers, paediatricians, doctors, midwifery administrative staff and our managers who supported the Trust in what was a more taxing and lengthy process than we first thought,(we began the process in April 2011). It was a fitting legacy for the project lead, Rosemary Tilbury, to leave us, as she retired in February after more than 30 years in dedicated service and we thank her for all that she achieved.

South Reading Wokingham Newbury N Reading

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The current infant feeding team remain as Fidelma Lee, Gwyneth Rudman, Rayanne Napper-Bonney and Claire Carter (who is the newly appointed lead) who are working hard to meet the new challenges ahead.BFI have recommended that we concentrate on offering timely help with feeding, and support parents to recognise when their baby’s feeding well. They strongly recommended that we continue with our “Topping up Audit” and aim to offer full discussion and choice prior to giving formula to breastfed babies. The team will introduce the new Baby Friendly standards and values over the coming months, supporting the staff in implementing them. Effectiveness will be measured by on-going audit. Monitoring the trust targets of improving Breastfeeding Initiation rates, and reducing numbers of babies who are readmitted, continues. The team currently offer: training for new doctors and maternity staff; feeding discussion sessions on Marsh most mornings for new parents; assistance with care planning; a hospital based Breastfeeding clinic, open to mothers each weekday morning; a regular frenulotomy clinic provides a service for tongue tie related feeding problems, which is supported by Mr Flannery (ENT paediatric consultant); information to pregnant women about feeding and nurturing, through a variety of workshops, in the Reading Wokingham and Newbury areas. Once home, mothers are also supported by community midwives, maternity care assistants, and the Breastfeeding Network volunteer service. We value and are grateful for all this help and look forward to continued collaborative working in the future.

Perinatal Mortality Analysis by Jane Siddall Statistical analysis would suggest that a unit such as RBFT, delivering 5700- 6000 mothers, would see 35-39 babies overall succumb as a perinatal loss if our practice was typical of the national mean rate of 6.8 perinatal deaths per thousand births. It is known that the risk varies according to factors such as ethnicity with Asian and Black mothers (UK born or born overseas), and both teenagers and women over 40 being more at risk of a stillbirth or neonatal loss. The infographic below is from MMBRACE.

The Office for National Statistics published data on maternal origin most recently for the year 2013. 0f the 698,512 births registered, 513,411 (73.5%) were to mothers born in Britain. 68,407 (9.8%) were to mothers of European (EU and non-EU) origin and 40,604 (5.8%) to mothers from India, Pakistan and Bangladesh. In the South East of England, 23.3% of mothers were born outside the UK. The distribution in the Unitary Authorities in the parts of Berkshire where the majority of mothers deliver in this unit shows a total of 6156 registered births, where 1915 were to overseas born women,(31%) .Reading has 44.9% of it’s mothers born outside the UK, Wokingham 24.6% and W Berkshire 17.1% The table below was drawn by Helen Allott from the families who were bereaved in 2014-5 and attended her clinic for post-natal follow-up (n=33). This suggests that ‘non-

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White British’ mothers in this area are indeed at a significantly higher risk of perinatal loss as predicted from national data sets.

Stillbirth Extended Perinatal Death (<28 days)

White British 52% (13) 33% (3) Asian 24% (6) 22% (2) White other 8% (2) 11% (1) Black African 0% 11% (1) Black Caribbean 4% (1) 11% (1)

Oriental 4% (1) Black other 4% (1) 11% (1) In 2014-15 a total of 36 infants were delivered at potentially viable gestations, either stillborn (25), or died within the perinatal period (2). There were two ToPs for abnormalities incompatible with life before 24 weeks and another 2 after 24 weeks, and 7 infants born before 24 weeks who had some signs of life but died soon after delivery. These fetuses are not counted as perinatal losses. Within this cohort we lost six twins from four pregnancies, one with twin to twin transfusion at 31 weeks, one with a prenatally diagnosed series of complex malformations at 33+5, both twins as 34 weeks with acute fatty liver of pregnancy (a single gene mutation) and another pair after an acute TTS at 35 weeks. The corrected SB rate 25/5681, excluding those born before 24 weeks and those where a termination for lethal malformation was performed is thus 4.4 per thousand deliveries. Perinatal rates include all stillborns and all early neonatal deaths, calculated per thousand births, but excluding those with lethal malformations or born before 24 weeks gestation. The rate is therefore (25+2) / total births The perinatal rate for RBFT is thus 27/ 5681 = 4.7 per thousand births The multiple birth specific PNMR calculated from the last three years is 14/596 = 23.4 per thousand infants from multiple births. Increased rates of perinatal loss are known to be higher in twin or triplet pregnancies, and are associated with a three fold risk based on multiple pregnancy and a ten fold risk based on prematurity birth when compared to singletons nationally, which translates overall to 5-7x higher risk. One of the ‘issues’ around perinatal and stillbirth rates is that small numerical increases in the numbers of cases born in any unit can lead to significant upswings or downturns in the local rate from year to year.

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This can make it difficult to determine, without detailed enquiry, whether any change is ‘real’ and is an accurate reflection of the care given. Funnel plots can help tease out some of the data to compare the expected versus observed rates, and those below (prepared by Dr Foster organisation) are for three of the quarters last financial year. (A funnel plot is a scatter plot of the effect estimates from individual studies against some measure of each study’s size or precision). The RBH is the black plot.

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What they do show is that the perinatal losses reported at RBH are within the range seen in individual units around the country, neither significantly better nor worse. National data from MMBRACE 2014 report is shown below. The stillbirth line is the middle one on the image. It can be seen that the local rate (next graph), at 6-4 losses per thousand births, sits within the yellow band added below:

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Jane Siddall, Consultant Obstetrician, Sept 2015

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