“CLOSING THE LOOP” National Women’s Health Auckland District Health Board

1. “CLOSING THE LOOP”National Women’s HealthAuckland District Health Board The Annual Clinical Report Day 16th August 2011

2. National Women’s History • 1906 the first Auckland St Helen’s Hospital opens • 1946 first baby born at Cornwall Hospital • 1958 construction of NWH at Green Lane • 1962 99% of women birth in hospital • 1962 first successful pre-birth transfusion in the world by Sir William Liley • 1964 new NWH opening ceremony

3. National Women’s History • 1968 Red Cross volunteers offer beauty care to women in NWH • 1971 Obstetric Flying Squad established • 1978 NWH granted licence to provide termination of pregnancy service • 1979 Dr Rutter publicly criticises women for pressing for free access to NWH for those with private obstetrician or GP • 1979 Rob Muldoon announces private maternity hospitals are a thing of the past

4. National Women’s History • 1979 A hospital directive issued “If husbands are present at the delivery they must be placed on a stool on the mother’s right, at the head of the table. They must not be standing or walking around theatre.” • 1981 St Helen’s 75th birthday • 1983 Dr Fisher “the attitude at NWH was that anyone with a normal pregnancy should have a normal birth”

5. National Women’s History • 1983 Dr’s at NWH use IVF for the first time in New Zealand • 1984 SMO’s at St Helen’s set up the Mortality and Morbidity Review Committee • 1984 Arson attack at Warborough Ave • 1986 Teen antenatal clinics set up • 1987 Inquiry instigated into treatment of cervical cancer at NWH • 1992 First Annual Clinical Report presented

6. External Commentators in 2010 • Dr Sue Belgrave, Clinical Director, Women’s Health, Waitemata District Health Board • Dr Phil Weston, Clinical Unit Leader, Child Health, Waikato Hospital

7. Women’s Health – Sue Belgrave • Understand PPH rates especially in association with Caesarean section • CS rate is high • Prevent primary caesarean • Reduce IOL • Increase PBAC • Increase ECV • Unbooked status + smoking + perinatal mortality • BMI and GDM among Indian mothers • Audit double instrumental birth

8. Understand PPH especially in association with Caesarean section What we’ve done… • Improved documentation antenatally of women at risk: Electronic Clinical Record project risk plan may assist • Improved utilisation of drugs by implementing the PPH check list • Improved notification of senior staff

9. High Caesarean Section Rate • Prevent primary caesarean sections • Reduce IOL • Increase VBAC • Increase ECV Actions: • A project to review processes around induction initiated • PBAC clinic launched 2011

10. Unbooked status + smoking + perinatal mortality BMI and GDM among Indian mothers • Noted • No specific action

11. Audit Double Instrumental Birth • Audited in 2010 • Rate within WHA average in 2010 • Maternal and baby outcomes similar to single instrumental births (other than increased proportion with 3rd/4th degree tears)

12. Neonatal Commentary – Phil Weston • Is there a problem with NEC rates? • (Waikato rate 2%) • Monitor Perinatal Mortality rate by DHB nationally • Monitor Chronic Lung Disease by home oxygen • Monitor infection rates • Monitor outcomes in 23 weekers across the country • Review the increase in ventilation at term for respiratory distress

13. Is there a problem with NEC rates?(Waikato rate 2%) • 2010 rate is consistent with 2008 and 2009 rates (3-5% overall) but absolute numbers are low • Ongoing research in the unit as part of a multicentre study looking at probiotics to decrease rates

14. Monitor Perinatal Mortality Rate by DHB nationallyMonitor CLD by home oxygenMonitor infection ratesMonitor outcomes in 23 weekers across the country • Perinatal mortality reported by DHB of residence annually by PMMRC • No specific local action required

15. Review the increase in assisted ventilation at term for respiratory distress • New process introduced 1st July for booking of elective caesarean sections. Aiming to eliminate the need for elective caesarean without fetal or maternal compromise prior to 39 weeks

16. Points raised in other presentations • Consistently low rates of hysterectomy (and especially vaginal and laparoscopic hysterectomy) at ADHB. Actions: • Audit: Hysterectomy by abdominal route generally indicated • Ongoing investigation of pathway of care for women referred to NW with abnormal bleeding

17. Points raised in other presentations • High parity (4+) and increasing BMI are independently associated with late (>=28 wks) stillbirth; not ethnicity or age Actions: • The Big Day Out: workshop on interventions for obesity in pregnancy

18. Points raised in other presentations • Fetal fibronectin audit • Exclusion criteria not adhered to • Could avoid transfer of woman by sending swab first • Implement a strict policy of not giving steroids or tocolysis with negative result Action: • Referred to CONCORD for assistance with this project

19. Gynaecology • Note made of high re-admission rate following inpatient gynaecology surgery. Actions: • Audit showed high rate of admission with pain and constipation • Audit of discharge medication • Information sheet developed for discharge following abdominal procedures • Readmission rate 6.3% 2010 cf 8.3% in 2009

20. Acknowledgements • External Commentators and Speakers • Women’s Health Intelligence Team • Annual Clinical Report committee members • National Women’s Staff • Our patient’s and their families