Royal College of
Obstetricians and
Gynaecologists
•Setting standards to improve women’s health
•Risk Management and Medico-Legal Issues In Women’s Health
•Joint RCOG/ENTER Meeting
•Please turn off all mobile phones and pagers
How can we reduce stillbirth rates
in diabetic pregnancies?
Jo Modder
CEMACH Clinical Director (Obstetrics)
Consultant Obstetrician UCLH NHS Trust
What is a diabetic pregnancy?
• Pregnancy in a woman with pre-existing
diabetes
• Either type 1 or type 2 diabetes that had
been diagnosed at least 1 year before the
woman’s estimated delivery date (EDD)
CEMACH 2005
What is the stillbirth rate in diabetic
pregnancies?
Type 1 diabetes
Type 2 diabetes
35 31.7 32.3
30 29.2 England, Wales &
25.
Northern Ireland
25 8 (2002)
20
15
8.5 9.6 9.5
10
5.7
5 3.6
0
Stillbirth rate* PNMR* Neonatal death
rate**
*per 1000 total births **per 1000 live births
† Source: Confidential Enquiry into Maternal and Child Health: Pregnancy in women with type 1
and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2005.
Possible mechanisms for stillbirth
↑ maternal ↑ fetal
↑ fetal insulin
blood glucose blood glucose
↓ O2 release ↑O2 ↑ fetal basal
from RBC Consumption metabolic rate
Fetal hypoxia
Fetal Fetal
polycythaemia thrombosis
↑ maternal
↑ lactate
blood glucose
↓fetal pO2 ↓fetal pH
Current interventions to
reduce stillbirth rate
• Good glycaemic control
– Early booking
– Frequent antenatal visits
– Multidisciplinary team
• Fetal surveillance
– Frequent ultrasound scans
• Delivery between 38 – 40 weeks
The CEMACH national enquiry
• National survey of diabetes maternity services
• Descriptive study of 3808 pregnancies to women
with diabetes
• Panel enquiry into 442 + 79 additional type 2
pregnancies
– Audit of care
– What factors associated with poor
pregnancy outcome?
– Comparison of type 1 and type 2 diabetes
Causes of stillbirth and neonatal death
Extended Enquiry General p-value
Wigglesworth classification (N=98) maternity
(N=5756)
Congenital defect 18% 19% 0.68
Unexplained antepartum death 59% 44% 0.002
Death from intrapartum causes 10% 8% 0.30
Immaturity 4% 18% 90th centile
Issues underlying suboptimal fetal
monitoring for big babies (n=58)
• Lack of timely follow-up
• Poor interpretation of ultrasound scans
• Incorrect actions taken as a response to
tests
Maternity care factors associated
with death from 20 weeks
Cases Controls ORa [95% CI]
No discussion of mode 12% 2% 5.9 (1.7 – 20.7)
and timing of delivery†
Suboptimal maternity 76% 44% 4.2 (2.3 – 7.4)
care during the
antenatal period
a Adjusted for maternal age and social deprivation
† for women who delivered from 24+0 weeks only
Issues identified by panels underlying
suboptimal maternity care in the antenatal
period
• Suboptimal fetal surveillance
• Poor management of maternal risks
• Problems with the multidisciplinary team
• Need for more senior obstetrician input
• Poor communication between health
professionals
• Inappropriate mode and/or timing of delivery
Discussion of mode and
timing of delivery
• Median 35 weeks (range 5 – 40 weeks)
• Women who did not have a discussion
delivered earlier than those who had a
discussion (median gestation at delivery 35
versus 37 weeks).
Current interventions to
reduce stillbirth rate
• Good glycaemic control
– Early booking
– Frequent antenatal visits
– Multidisciplinary team
• Fetal surveillance
– Frequent ultrasound scans
• Delivery between 38 – 40 weeks
Could we reduce the
stillbirth rate further by:
• Consistent provision of consistent
preconception care?
– Folic acid
– Contraception
– Glycaemic control
– Education of health professionals
Could we reduce the
stillbirth rate further by:
• Consistent provision of maternity care?
– Careful antenatal fetal surveillance
– Identification and management of maternal
risk factors
– Senior obstetrician input into management
– Effective diabetes antenatal multidisciplinary
team
– Good communication?
Questions to be answered
• How can we improve the provision and
uptake of preconception care in the UK?
• What test/s can be used to predict the
fetus of a woman with diabetes who is at
risk of intrauterine death?
• At what gestation should babies of diabetic
mothers be delivered?
• CEMACH recommendations
• NICE Diabetes in Pregnancy guideline
Thank you
www.cemach.org.uk
Royal College of
Obstetricians and
Gynaecologists
•Setting standards to improve women’s health
•Risk Management and Medico-Legal Issues In Women’s Health
•Joint RCOG/ENTER Meeting
•Please turn off all mobile phones and pagers
A DOUBLE BLIND RANDOMISED CONTROLLED TRIAL COMPARING THE
EFFICACY OF INTRAMUSCULAR SYNTOMETRINE AND INTRAVENOUS
SYNTOCINON, IN PREVENTING POST PARTUM HAEMORRHAGE
Mohammed Rashid, Medical Student, Imperial College
Dr Mumtaz, Consultant O&G, James Paget Hospital, Norfolk
Abstract Presentation
Risk Management Conference April 2008
Introduction
• Post partum haemorrhage (PPH) remains the leading
cause of maternal death in the developing world,
accounting for 25-33% of all maternal deaths1
• The most common cause of PPH is uterine atony2
• Prevention of PPH is of great importance in the
pursuit of improved health care for women, even
more so in developing countries where parity, and
therefore the risk of uterine atony, is higher
Existing Knowledge
• Routine prophylactic administration of an oxytocic
during the third stage of labour reduces the risk of
PPH by 40%3
• In the UK and Ireland, intramuscular syntometrine is
most commonly used, while in the rest of Europe,
the USA and Canada, syntocinon is most commonly
used4
• But which is better?
• This study is the first randomised controlled trial
comparing intramuscular syntometrine and
intravenous syntocinon in a population group that
included high risk women.
Method
• Study done in a high risk population in the Gulf
• Patients who were seen in the obstetric clinic at 36
weeks of gestation were invited to participate in the
trial
• Strict inclusion/exclusion criteria
• 686 patients were randomly allocated to receive
either one vial of intramuscular syntometrine or 10
units of intravenous syntocinon
• Each patient received their allocated drug with the
delivery of the anterior shoulder of the baby
Outcome measures
• The primary outcome measure was the amount of
blood loss during delivery
• Secondary outcome measures included other
indicators of blood loss and possible side effects
Quick look at demographics
• 340 women received intramuscular syntometrine
and 346 women received intravenous syntocinon
• 37% of maternities were para four or above, 27%
were para five or above, 16% were para six or above
and the highest parity was thirteen.
Results
Primary outcome measure
Syntometrine Syntocinon Size of estimated 95% CI
n = 340 n = 346 difference*
Average 245.74 (135.86) 248.41 (124.03) 2.68 (-16.82,22.17)
Blood loss p = 0.7877
during
delivery (ml)
Postpartum 8 (2.35) 9 (2.60) 0.90 (0.35,2.32)
haemorrhages p = 0.834
(> 500 ml)
Post partum 6 (1.76) 8 (2.31) 0.76 (0.27,2.18)
haemorrhages p = 0.612
(> 1000 ml)
* The size of the estimated difference is the difference in means for the continuous outcomes and the
relative risk for the binary outcomes
Results
Secondary outcome measures
• There was an increase in the incidence of having a
diastolic blood pressure of between 90 and 100,
thirty minutes after the delivery (p=0.004), with
intramuscular syntometrine
Discussion
• In higher parity women, the myometrium is gradually
replaced by more and more fibrous tissue.
Syntocinon contracts the myometrium, but has little
effect on fibrous tissue thus theoretically making it
less effective in such women, however this was not
supported by our study
• The superior effect of intravenous syntocinon
compared its intramuscular counterpart may be
related to the earlier onset of action expected when
using an intravenous administration
Discussion continued
• The increased incidence of having diastolic
hypertension was demonstrated (>90 mm Hg thirty
minutes after delivery) in the syntometrine group,
was supported by findings in other studies5,6 and is
thought to be due to the vasoconstriction effect of
syntometrine
Strengths and Weaknesses
+ The researchers, the patients and the midwives were
blinded
+ Midwives were carefully instructed on how to
properly measure blood loss
+ Every measurement was repeated
- Visual estimation of blood loss is known to be
inaccurate
Conclusion
• Intramuscular syntometrine and intravenous
syntocinon are equally effective in preventing
postpartum haemorrhage, in a high risk population.
There is an increased risk of diastolic hypertension
after the delivery with intramuscular syntometrine.
References
1. Duffy S. Global perspective Obstetric haemorrhage in Gimbie, Ethiopia. TOG 2007;9:121-
126.
2. Lewis, G. The Confidential Enquiry into Maternal and Child Health (CEMACH) ‘Saving
mother’s lives: Reviewing maternal deaths to make motherhood safer’-2003-2005. The
seventh report on Confidential Enquiry into Maternal Deaths in the United Kingdom.
2007, London. CEMACH.
3. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third
stage of labour. Cochrane Database Syst Rev 2003:CD000007.
4. Winter C, Macfarlane A, Deneux-Tharaux C, Zhang WH, Alexander S, Brocklehurst P,
Bouvier-Colle MH, Prendiville W, Cararach V, van Roosmalen J, Berbik I, Klein M, Ayres-
de-Campos D, Erkkola R, Chiechi LM, Langhoff-Roos J, Stray-Pedersen B, Troeger C.
Variations in policies for management of the third stage of labour and the immediate
management of postpartum haemorrhage in Europe. BJOG 2007;114(7) :845-54.
5. Choy CMY, Lau WC, Tam WH, Yuen PM. A Randomised controlled trial of intramuscular
syntometrine and intravenous oxytocin in the management of the third stage of labour.
BJOG 2002;109 (2):173-177.
6. Khan G Q, John I S, Chan T, Wani S, Hughes A O, Stirrat G M. Abu Dhabi third stage
trial: oxytocin versus Syntometrine in the active management of the third stage of labour.
Eur J Obstet Gynecol Reprod Biol 1995; 58(2):147-51.
Questions & Answers
Thank you for listening
Flowchart
Recruitment Statistics
Total number of deliveries in 6950
the hospital
Number of women delivered 686
within the trial
Number of women delivered 5095
not in the trial
Number not fulfilling the 2021
criteria
Number who refused 870
Language barrier 2104
Characteristics of the study population
Syntometrine Syntocinon
n = 340 n = 346
Age in years 29.43 (5.64) 29.17 (6.41)
Gestation at delivery (weeks) 39.25 (1.14) 39.43 (1.08)
Nulliparity 56 (16.47) 59 (17.05)
Average parity 3.03 (2.40) 3.03 (2.47)
Parity of 4 or more 91 (26.77) 97 (28.52)
Previous Caesarean Section (1 missing) 28 (8.26) 30 (8.67)
Previous manual removal of placenta 7 (2.06) 7 (2.02)
Spontaneous onset of labour 280 (82.35) 296 (85.55)
Augmentation with Syntocinon 198 (58.24) 189 (54.62)
Spontaneous vaginal delivery 319 (93.82) 322 (93.06)
Episiotomy 39 (11.47) 47 (13.58)
Genital tract trauma 189 (55.59) 192 (55.49)
Instumental Delivery 319 (93.82) 322 (93.06)
Birthweight (g) 3230.33 (445.33) 3247.56 (442.25)
Values are shown as mean (standard deviation) or n (%)
Primary outcome measures
Syntometrine Syntocinon Size of estimated 95% CI
n = 340 n = 346 difference*
Average Blood 245.74 (135.86) 248.41 (124.03) 2.68 (-16.82,22.17)
loss during p = 0.7877
delivery (ml)
Postpartum 8 (2.35) 9 (2.60) 0.90 (0.35,2.32)
haemorrhages p = 0.834
(> 500 ml)
Post partum 6 (1.76) 8 (2.31) 0.76 (0.27,2.18)
haemorrhages p = 0.612
(> 1000 ml)
* The size of the estimated difference is the difference in means for the continuous outcomes and the
relative risk for the binary outcomes
Sub-group analysis of blood loss during
delivery by parity
Syntometrine Syntocinon
n = 340 n = 346
Parity p = 0.0074
0–1 287.48 250.27 (112.72) p = 0.0478
(160.74)
2 -5 233.66 246.44 p = 0.3318
(118.57) (126.78)
>5 200.88 250.847 p = 0.0329
(109.99) (137.24)
Other indicators of blood loss
Syntometrine Syntocinon Relative risk 95% CI
n = 340 n = 346
Duration of third 5.90 (4.75) 6.14 (8.24) -0.24 (-0.78,1.24)
stage p = 0.651
Prolonged third 4 (1.18) 3 (0.87) 1.36 (0.31,6.02)
stage p = 0.249
(greater than
30 minutes)
Repeated 35 (10.29) 34 (9.83) 1.05 (0.67,1.64)
syntocinon p = 0.839
Post delivery 10.86 (1.32) 10.86 (1.38) -0.01 (-0.21,0.20)
haemoglobin p = 0.9490
Blood transfusion 6 (1.76) 2 (0.58) 3.05 (0.62, 15.02)
needed p = 0.148
Secondary PPH 0 1 - 1.000
Blood pressure
Syntometrine Syntocinon Relative risk 95% CI
n = 340 n = 346
Immediately after delivery
SBP > 140 24 (7.06) 30 (8.67) 0.81 p = 0.433
(0.49,1.36)
SBP > 150 2 (0.59) 4 (1.16) 0.51 p = 0.425
(0.09,2.76)
DBP > 90 7 (2.06) 10 (2.89) 0.71 p = 0.484
(0.27,1.85)
DBP > 100 0 0 - -
30 minutes after delivery
SBP > 140 9 (2.65) 12 (3.47) 0.76 p = 0.532
(0.33,1.79)
SBP > 150 4 (1.18) 3 (0.87) 1.36 p =0.687
(0.31,6.02)
DBP > 90 15 (4.41) 3 (0.87) 5.09 p = 0.004
(1.49,17.42)
DBP > 100 0 0 - -
Other side effects
Syntometrine Syntocinon Relative risk 95% CI
n = 340 n = 346
Headache 2 (0.59) 2 (0.58) 1.02 p = 1.000
(0.14, 7.18)
Nausea 12 (3.53) 10 (2.89) 1.22 p = 0.670
(0.53,2.79)
Vomiting 4 (1.18) 1 (0.29) 4.07 (0.46,36.23( p = 0.213
Chest pain 2 (0.59) 3 (0.87) 0.68 p = 1.000
(0.11,4.03)
Shortness 0 0 - -
of
breath
Manual 0 1 (0.29) - p = 1.000
removal
of
placenta
Royal College of
Obstetricians and
Gynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s Health
Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers
Audit of decision to delivery interval for
emergency caesarean sections in 2007
Michelle Judd
Consultant Obstetrician
rural location
Bury St Edmunds
market town
2500 deliveries per year
25% CS rate
Aims and objectives
To ensure that the urgency of an emergency CS is
documented in a standardised way
To use timing standards which have been agreed
between obstetric and anaesthetic staff
To review decision to delivery interval for all
emergency CS
Required audit for the unit’s CNST Level 3
assessment
Audit standards
CS Indication Decision to delivery
grade interval (minutes)
1 Immediate threat to life of 30
woman or fetus
2 Maternal or fetal compromise, 60
not immediately life threatening
3 Needing early delivery but no To be delivered within
maternal or fetal compromise an acceptable time
4 Elective cases Booked on elective CS
lists
Audit method
Review decision to delivery interval for all emergency
CS
Data collected monthly using emergency CS diary
Diary recorded
– Reason for CS
– Grade of CS
– Decision time for CS
– Time of delivery
Results presented at monthly Clinical Governance
meetings
Emergency CS decision to delivery interval
% standard achieved in 2007
100
90
80
70
60
50 grade 1 CS
40 grade 2 CS
30
20
10
0
J F M A M J J A S O N D
Audit results -Standards achieved for 2007
Grade 1 CS – target achieved 98%
Grade 2 CS – target achieved 78%
Grade 3 CS – target achieved 100%
Results: reason for delay
Reason for delay No. %
Anaesthetic difficulty 12 24
Surgical difficulty 3 6
Delay in transfer to theatre 15 28
Another obstetric case in theatre 12 24
Lack of staff/awaiting arrival staff 6 11
Patient needed time to make decision 2 4
Unknown (notes missing) 1 2
Results: length of delay
Delay Anaesthetic Delay in Other obstetric Other
(min) problem transfer to case in theatre causes
theatre
1-10 4 11 4 6
11-20 5 2 - 2
21-30 2 - 1 2
>3060 - - 4 -
Results: length of delay
Delay (minutes) Number %
1-10 25 49
11-20 9 18
21-30 5 10
>3060 4 7
Summary of delays
Anaesthetic difficulties
– Unavoidable delay
– Most related to maternal obesity
– Use of regional anaesthesia is safest option
Delay in transfer to theatre
– Avoidable delay
– CDS Coordinator to be responsible for timely transfer to
theatre
Lack of obstetric theatre
– Avoidable delay
– Feasibility of providing another theatre when there is a
second obstetric emergency
BMI at booking appointment
BMI Midwifery-led care Consultant-led care
18.5-24.9 56% 40%
25-29.9 30% 20%
30-34.9 7% 20%
35 or greater - 10%
Not recorded 7% 10%
Summary of delays
Anaesthetic difficulties
– Unavoidable delay
– Most related to maternal obesity
– Use of regional anaesthesia is safest option
Delay in transfer to theatre
– Avoidable delay
– CDS Coordinator to be responsible for timely transfer to
theatre
Lack of obstetric theatre
– Avoidable delay
– Feasibility of providing another theatre when there is a
second obstetric emergency
….and finally
Level 1 CNST in March 2004
Level 2 CNST in March 2006
Level 3 CNST in January 2008
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Obstetricians and
Gynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s Health
Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers
National Maternity Hospital Dublin
Postpartum Urinary Retention
R.C.O.G. Risk Management & Medico Legal
Issues in Woman’s Health
30th April 2008
M. Jacob MSc BSc RGN RCN RM FFNMRCSI
Midwife Prescriber
29 November 2011 71
Definition of Postpartum Urinary Retention
No uniform definition exists
Has been classified into ‘overt’ or ‘covert’
categories
Rane and Frazer, (1999) 0bs &Gynae 1 (4): 311-313
29 November 2011 72
Overt Retention
Is the inability to pass urine within six hours
after delivery requiring catheterisation with
removal of a volume equal to or greater than
normal bladder capacity
Rane and Frazer (1999) 0bs &Gynae 1 (4): 311-313
29 November 2011 73
Covert Retention
More difficult to define
Clinically can be described as failure of the bladder
to empty properly where a catheter yields at least
50% of normal bladder capacity or a post void
residual bladder volume of 150 ml
Yip et al., (1998) Effect of duration of labour on postpartum post void residual
bladder volume (Gynaecol Obstet Invest 45, 3: 177-180)
29 November 2011 74
Consequences of Postpartum Urinary
Retention
In short term, may lead to atonic bladder
and infection if not identified and relieved
Page (2005)
29 November 2011 75
Consequences of Postpartum Urinary
Retention
Single episode of bladder over-distension
(Not diagnosed and treated early may cause
persistent postpartum urinary retention and
irreversible damage to the detrusor muscle
with recurrent urinary tract infections and
permanent voiding difficulties
Hinman, 1976; Versi, 1987; Mills, 1998)
29 November 2011 76
Pathophysiology
Poorly understood
Nervousness, modesty & similar factors causing
inhibition by the CNS.
Unnatural posture
Lack of elasticity of bladder
Injury, swelling of vulva, urethra and bladder trigone.
Reflex spasm of external urethral sphincter from
tears & incisions in perineum.
An unspecified temporary derangement of the
neuromuscular mechanism of bladder & urethra
Francis, W.J. J. Obstet Gynaecol Br. Emp (1960) 67: 353-366.
29 November 2011 77
Pathophysiology
Hormones and contractile responses of bladder –
hormone-responsive organ & functions may be
subjected to fluctuations of hormones during
pregnancy & postpartum period.
Injured bladder innervation – urinary retention
occurs when neurological lesions occur below the
spinal reflex arc, at or below the level of the outlet of
sacral nerves – hypotonic or acontractile bladder.
Pudendal nerve, with afferent nerve branches (S2-4)
supplying the bladder is damaged during pelvic
surgery & vaginal delivery – 1st pregnancy
significant pelvic floor tissue stretching & pudendal
nerve damage.
29 November 2011 78
Yip et al. (2004) Acta Obstet Gynecol Scand 83: 881-891
Literature Review
Dearth of studies
Limited urodynamic studies in women
following postpartum urinary retention
Bladder remains a largely neglected organ
29 November 2011 79
Literature Review
Voiding dysfunction after delivery 10-15% (Bennets,
1941)
Positive correlation between epidural
anaesthesia and postpartum urinary retention
irrespective of the mode of delivery (Weil et al., 1983;
Tapp et al., 1987; Yip et al., 1997)
29 November 2011 80
Literature Review
Urinary retention occurred in about 0.05% of pts.
could last as long as 30 – 40 days (Watson, 1991)
2 pts had prolonged urinary retention 10-15
days. 1 pt had persistent urgency, frequency and
strenuous voiding 9 months postpartum
(Watson,1991).
43% women abnormal postpartum voiding (Ramsay
& Tarbet, 1993)
29 November 2011 81
Literature Review
Voiding difficulties during labour and in
immediate postpartum period could be
associated with epidurals.
Early resort to ultrasound scan & supra pubic
catheter to estimate the residual volume
Kulkarni R, Bradford WP, Forster SJ, James ED (1994) Aust N Z J Ostet Gynaecol
34 (1): 107-8
29 November 2011 82
Literature Review
4 patients with prolonged postpartum urinary
retention who had U.D.S. 1 month after the
symptoms of retention ceased, 1 pt had S.U.I.
and 1 pt had urgency & urge incontinence (Groutz et
al. 2001)
Increased use of epidural analgesia and
instrumental deliveries (Ching Chung et al. 2002; Carey, 2002)
29 November 2011 83
National Survey for Intrapartum &
Postpartum Bladder Care U.K.
189 maternity units in England and Wales hospitals
Findings: Majority of units were non-compliant with
limited RCOG recommendations.
All units should be timing & measuring the voided
volume and ideally checking first post-void residual
volume.
Further research needed to develop evidence-
based guidelines.
Zaki M., Pandit M., Jackson S. (2004) British Journal Obst & Gynae 111 (8):
874-6.
29 November 2011 84
Use of epidural anesthesia and risk of acute
postpartum urinary retention
Sample – 2,000 women delivered at 3 primary
hospitals.
Findings: APUR may lead to serious short term and
long term problems – changes in detrusor
contractility and increased incidence of lower or
upper U.T.I.s.
Increased risk for APUR - prolonged 2nd stage
labour, instrumental delivery, perineal damage or
use of narcotics during delivery.
Risk of developing APUR after epidural analgesia
during labour may increase by up to 3-fold
29 November 2011 85
Musselwhite et al., 2007 Am J Obstet Gynaecol)
Acute Postpartum Urinary Retention in Calgary
Health Region’s Policy & Procedures
Need for at least 1 catheterisation within first 24
hours postpartum
Patient did not void within 6 hours postpartum.
Voiding frequently in small amounts.
Urge to void but unable to do so
Musselwhite et al., 2007 Am J Obstet Gynaecol)
29 November 2011 86
Background
Large numbers of clinical incident report
forms relating to urinary retention
Add to the body of knowledge already
existing on the subject of urinary retention
29 November 2011 87
Definition of Clinical Audit
A quality improvement process that seeks
to improve patient care and outcomes
through systematic review of care against
explicit criteria and the implementation of
change
National Institute for Clinical Excellence (2002) Principles for Best Practice in Clinical
Audit.
29 November 2011 88
Results of NMH audit of patients with postpartum
urinary retention (volumes >1,000ml)
Action research cycle methodology
Retrospective medical records review of women
March 2006 – April 2007
Data recorded
Parity, birth weight, type of delivery, epidural,
bladder scan, Foley catheter, residuals,
supra pubic catheter, time post delivery,
intermittent self catheterisation.
29 November 2011 89
Action Research Cycle
Coughlan, D. & Brannick, T. (2001) Doing Action Research in Your Own Organisation.
Sage pg 17
Diagnosing
Evaluation Planning Action
Taking Action
29 November 2011 90
NMH audit of patients with postpartum
urinary retention
Total sample 91 – 3 pts without epidural
11 patients had second Foley Catheter
3 patients had Supra Pubic Catheter
1 patient required intermittent self
catheterisation
29 November 2011 91
Birth Weight Range
Drop Page Fields Here
Total
Count of BW Range (g)
45
40
35
30
25 Drop Series Fields Here
Total
20
15
10
5
0
2500 - 2999 3000 - 3499 3500 - 3999 4000 - 4449 4500 - 4999 Unknow n (blank)
Number
BW Range (g)
29 November 2011 92
Parity
Drop Page Fields Here
Total
Count of Parity
60
50
40
Drop Series Fields Here
30
Total
20
10
0
1+0 1+1 1+2 1+3 2+0 2+1 2+2 2+3 3+0 3+1 3+2 (blank)
Parity
29 November 2011 93
Primips
Number in cohort 62/91: 68.1%
Number of primips 2006 3579/7986: 44.8%
Chi squared test for proportions 18.8
(p2.5lts :6
• ITU admissions : 2 (+3 PPH)
• Eclampsia :1
• Rupture uterus :1
• CVA (Cerebellar bleed) :1
(not delivered)
RCOG 131
MOH (APH+PPH) – TT
MOH (APH+PPH) – BF
Judged Appropriate
RCOG 132
PPH – CJ
PPH – SL
Judged Appropriate
RCOG 133
PPH - SJ
Judged substandard - Minor
RCOG 134
PPH- NM
Judged Substandard - Incidental
RCOG 135
ITU – Ruptured Cornual
Pregnancy-SL
Judged Substandard Minor
RCOG 136
ITU – Sepsis /Abruption-EL
Judged Appropriate
RCOG 137
Rupture uterus - CH
Judged Substandard Major
RCOG 138
Eclampsia + HELLP -NS
Judged Appropriate
RCOG 139
RSH
• Total number of LW deliveries : 3660
• Incidence of 1:332 deliveries
• Total number of maternal deaths : 2
• One maternal death - RTA
• Total number of near-misses : 11
• Near-miss: death ratio of 11:1
RCOG 140
Quality of Care
• Appropriate :6
• Substandard – Incidental :1
• Substandard – Minor :2
• Substandard – Major :1
RCOG 141
Lessons learnt…
• Documentation
• Electronic database
• System errors
– Referral pathway from peripheral units
– Busy shifts
– Treating coagulopathy secondary to abruption
– Treating liver rupture
RCOG 142
Thank you
143
Royal College of
Obstetricians and
Gynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s Health
Joint RCOG/ENTER Meeting
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