Dimension: Maternity Services

The aim of publishing metrics from each maternity unit in the RCSI Hospital Group is to enable patients, relatives and the general public to view activity in each of the three maternity units in the Group, (Cavan General Hospital, OLOLH and the Rotunda Hospital).

These metrics are comprised of a range of clinical activities, major obstetric events, modes of delivery and rates of attendance at clinical training.

When viewing these metrics, it is important to note that tertiary and referral maternity centres will care for a higher complexity of patients (mothers and babies). Therefore rates of clinical activity and outcomes will be higher and comparisons should not be drawn with units that do not look after complex cases. In addition these figures are not formatted in a way to support comparison with other hospitals or aggregation with other data.

Rationale for measurement

Demonstrates the volume of clinical activity in each organisation and information is reported on the total number of mothers delivered, the total numbers of births, the number of multiple pregnancies, and transfers in and out to hospitals.

Measurement methodology and data sources:

Local extracts submitted monthly and extrapolated for analysis and publication.

Target

These figures are not formatted in a way to support comparison with other hospitals or aggregation with other data.

Performance

(n) = number
Total mothers delivered >500g: Total number of women delivering a baby weighing 500g or more. The infant weight of 500g is an internationally recognised weight measurement for counting numbers of mothers delivered.
Multiple pregnancies:  Number of mothers delivering more than one baby from a single pregnancy. This is a count of mothers, not numbers of babies delivered.
Total births >500g: Total number of babies born, including live births and stillbirths, weighing 500g or more. The weight of 500g is an internationally recognised weight measurement for counting numbers of babies born.
In-utero transfers admitted: Number of pregnant women admitted to a maternity hospital from another hospital prior to delivery for reasons in the fetal/maternal interest.
In-utero transfers sent out: Number of pregnant women transferred from a maternity hospital to another hospital prior to delivery for reasons in the fetal/maternal interest.

 

PERINATAL MORTALITY RATE (ADJUSTED)

Definition

The Adjusted Perinatal Mortality Rate is defined as Stillbirth and early neonatal death > 2500 grams excluding lethal congenital defects/1000 deliveries.

Rationale for measurement

The perinatal mortality rate is recognised as an indicator of the quality and safety of antenatal and perinatal care.

Measurement methodology and data sources:

Local data extracts submitted monthly and extrapolated for analysis and publication.

Target

The figures beneath are not formatted in a way to support comparison with other hospitals or aggregation with other data. Context is provided in the graph below.

Performance

 

PERINATAL DEATHS ≥2.5KG WITHOUT A CONGENITAL ANOMALY (PERINATAL ADJUSTED)

Rationale for measurement

Perinatal mortality Rate –Adjusted (PNMR-A) is defined as the number of perinatal deaths (stillbirths and early neonatal deaths) weighing 2.5kg or more without physiological or structural abnormalities that develop at or before birth and are present at the time of birth per 1,000 births. PNMR-Adjusted is an important indicator of the quality of care provided in Irish maternity services.

Measurement methodology and data sources:

Maternity Units in the Rotunda, Drogheda and Cavan Hospitals submit perinatal mortality data on a monthly basis to the RCSI HG, which in turn is made available to the National Women and Infants Health Programme Clinical Programme Irish Maternity Indicator System (IMIS). The IMIS report is published on an annual basis and allows scrutiny of individual hospital processes and outcomes for women and infants, while bench marking them against national performance.

Variations in PMR – Adjusted between maternity units could potentially be due to random chance or reflect differences in baseline characteristics of the childbearing population. For this reason, funnel plots are used to assess performance outcomes for individual maternity units in comparison to the overall average. The funnel plot is a scatter diagram of individual maternity unit mortality rates against the total number of births within that unit.

In the funnel graph below:-

  • The national rate for PNMR-A is indicated by the solid straight green line for 2018 and by a dashed grey line for 2017
  • The curved dashed lines (the 95% confidence interval for 2018) represent the limits within which 95% of units are expected to lie.
  • The width of the confidence interval is adjusted to allow for meaningful comparison between unit-specific rates and the national rate. The confidence interval is wider for smaller units reflecting the lack of precision in rates calculated based on small numbers. The confidence interval narrows for larger maternity units, giving the diagram a ‘funnel’ shape.

Performance

Note:
Maternity units include in their figures of perinatal deaths babies that are transferred in utero from other units and die in their hospital. Annual rates of perinatal deaths ≥2.5kg without a congenital anomaly should be interpreted with caution.

The Rotunda, Drogheda and Cavan maternity units are all below or slightly above the national average rate for Perinatal Mortality Rate-Adjusted for 2018 (solid straight green line). All are within the 95% confidence interval for 2018 (curved dashed lines). All three Maternity Units are below the national average rate for Perinatal Mortality Rate-Adjusted for 2017 (dashed grey line) for 2017.

 

NEONATAL ENCEPHALOPATHY (NE)

Rationale for measurement

Neonatal encephalopathy (NE) is a complex disease of a new-born infant and can be defined as clinical findings in three or more of the following domains: level of consciousness, spontaneous activity when awake or aroused, posture, tone, primitive reflexes, and autonomic system. NE can result from a wide variety of causes. Hypoxic Ischaemic Encephalopathy (HIE) is a subset of NE and is the most common cause of NE; however not all encephalopathies have a HIE.

Measurement methodology and data sources:

Maternity Units in the Rotunda, Drogheda and Cavan Hospitals submit perinatal mortality and morbidity data on a monthly basis to the RCSI HG, which in turn is made available to the National Women and Infants Health Programme Clinical Programme Irish Maternity Indicator System (IMIS). The IMIS report is published on an annual basis and allows scrutiny of individual hospital processes and outcomes for women and infants, while bench marking them against national performance.

Variations in Neonatal Encephalopathy (NE) rates between maternity units could potentially be due to random chance or reflect differences in baseline characteristics of the childbearing population. For this reason, funnel plots are used to assess performance outcomes for individual maternity units in comparison to the overall average. The funnel plot is a scatter diagram of individual maternity unit mortality rates against the total number of births within that unit.

In the funnel graph below:-

  • The national rate NE is indicated by the solid straight green line for 2018 and by a dashed grey line for 2017
  • The curved dashed lines (the 95% confidence interval for 2018) represent the limits within which 95% of units are expected to lie.
  • The width of the confidence interval is adjusted to allow for meaningful comparison between unit-specific rates and the national rate. The confidence interval is wider for smaller units reflecting the lack of precision in rates calculated based on small numbers. The confidence interval narrows for larger maternity units, giving the diagram a ‘funnel’ shape.

Performance

Description: All infants with ≥35 weeks’ gestation who, during the first week of life, have either seizures alone and/or signs of neonatal encephalopathy
Caution is advised when dealing with small values
NE rates in RCSI Hospitals are all below the national average for 2017 and 2018 and are within the 95% confidence interval.

Rationale for measurement

These are rare but potentially catastrophic events, which when they occur in obstetric patients can impact on the safety of both mother and baby. The RCSI Hospital Group reports the total combined rate (per 1,000 total mothers delivered) of the following major obstetric events,

  • Eclampsia is a condition in which one or more convulsions occur in a pregnant woman suffering from high blood pressure, often followed by coma and posing a threat to the health of mother and baby.
  • Uterine rupture is a rare but potentially catastrophic event in which the uterus tears open along the scar line from a previous Caesarian-section or major uterine surgery. Hospital incidence of uterine rupture is rare. The main risk factors for uterine rupture are previous caesarean section or induction of labour (using prostaglandins).
  • Peripartum hysterectomy is a hysterectomy which is usually performed following a caesarean section, but also includes hysterectomies performed during pregnancy and/or within seven completed days after delivery. Peripartum hysterectomy is rare and usually only performed in emergency situations, but it is a life-saving procedure in cases of severe haemorrhage.
  • Pulmonary embolism (PE) is a blockage of the lung’s main artery or one of its branches by a substance that travels from elsewhere in the body through the bloodstream.

Measurement methodology and data sources:

Local data extracts submitted monthly and extrapolated retrospectively for analysis and publication.

Numerator: Number of events
Denominator:  per 1,000 total mothers delivered

Target

These figures are not formatted in a way to support comparison with other hospitals or aggregation with other data.

Performance

RATE OF INSTRUMENTAL DELIVERY

Rationale for measurement

Instrumental delivery: Percentage of ‘Mothers delivered ≥500g’ who require instrumental assistance during delivery. Instrumental assistance includes forceps delivery and vacuum extraction, excluding failed forceps and failed vacuum extraction. Also includes assisted breech delivery with forceps to after-coming head and breech extraction with forceps to after-coming head.

Most women aim for spontaneous vaginal delivery. An instrumental delivery may be performed in situations where imminent delivery of the infant is considered to be the safest option for both mother and baby.

Measurement methodology and data sources:

Local data extracts submitted monthly and extrapolated for analysis and publication.

NumeratorRate of instrumental deliveries (%)
Denominator: per 1,000 total mothers delivered

National Performance

National Instrumental Delivery rate = 15% (95% Confidence Intervals 14.7-15.2%), Irish Maternity Indicator System (IMIS) Report 2018.

Performance

Cavan General Hospital

OLOL Hospital

Rotunda Hospital

  • CGH is above and OLOL is below the 2018 national rate for instrumental delivery (August data). Rotunda Hospital (July data) same as the 2018 national rate.

 

RATE OF INDUCTION OF LABOUR

National Performance

National rate for induction of labour = 31.5% (95% Confidence Intervals of 31.1-31.9%), Irish Maternity Indicator System (IMIS) Report  2018

Performance

Cavan General Hospital

OLOL Hospital

Rotunda Hospital

  • CGH is below and OLOL is above the 2018 national rate for induction of labour (August data). The Rotunda Hospital is above the 2018 national rate for induction of labour (July data).

 

RATE OF CAESAREAN SECTION

Rationale for measurement

Caesarean delivery, also known as a C-section, is a surgical procedure used to deliver a baby through incisions in the mother’s abdomen and uterus. When medically justified, a Caesarean Section can reduce problems/complications for mother and baby (mortality and morbidity). Recovery from a C-section takes longer than does recovery from a vaginal birth. Like other types of major surgery, C-sections also carry risks. It is acknowledged that Caesarean rates are on the rise in many developed countries. Ireland’s National Maternity Strategy (2016) identifies a number of possible reasons for this – including “reductions in the risk of Caesarean delivery, increasing litigation, increases in first births among older women and the rise in multiple births resulting from assisted reproduction.”

Measurement methodology and data sources:

Local data extracts submitted monthly and extrapolated for analysis and publication

National Performance

National rate for Caesarian Section = 33.8% (95% Confidence Intervals 33.4-34.1%), Irish Maternity Indicator System (IMIS) Report, 2018

Performance

Cavan General Hospital


OLOL Hospital


Rotunda Hospital

  • CGH and OLOL are above the 2018 national rate for Caesarian Section (August data). The Rotunda Hospital is above the 2018 national rate (July data).

COMPETENCY TRAINING

The delivery of safe, evidence-based care in maternity services ultimately depends on the competency of clinical staff. Consequently the RSCI Hospital Group will be measuring attendance rates at training in two key areas cardiotocography and neonatal resuscitation.

CARDIOTOCOGRAPHY (CTG) TRAINING 

Rationale for measurement

CTG is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy. CTG monitoring is used to assess fetal wellbeing and allows early detection of fetal distress. The inappropriate use or interpretation of fetal surveillance can contribute to adverse obstetric outcomes therefore accurate interpretation of the CTG is a core skill for all staff providing antenatal and intrapartum care.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator: No of staff trained (Expressed as %)
Denominator: No of staff eligible for training (Expressed as %)

Target

100% of relevant clinical staff are up to date with CTG training within the 2 year period.

Performance

Performance data for Q2 2020 reporting period (data provided quarterly):

*relevant clinical staff who have not completed the CTG training will be supervised when involved with CTG (Cavan: Consultants n=1; OLOL: Consultants n=1, NCHDs n=1, Midwives n=2; Rotunda: Consultants n=1, NCHDs n=1, Midwives n=1)

 

RESUSCITATION TRAINING

The Neonatal Resuscitation Programme® (NRP®) was developed by the American Heart Association and the American Academy of Pediatrics. The course conveys an evidence-based approach to care of the newborn at birth and facilitates effective team-based care for healthcare professionals who care for newborns at the time of delivery.

Rationale for measurement

Over 90% of babies born make the transition from life in the womb to life outside the womb at delivery, perfectly smoothly. A small percentage will require assistance. The NRP is intended to optimise the skills of staff in caring for these babies.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Target

100% of relevant clinical staff are up to date with NRP certification (or UK equivalent) within the 2 year period.

Performance

Performance data for Q2 2020 reporting period (data provided quarterly):

*relevant clinical staff who have not completed the NRP training will be supervised when involved with NRP (OLOL: Midwives n=1; Rotunda: Consultants n=2, NCHDs n=2, Neonatal nurses n=3, Labour Ward & Midwife Led Unit n=16)

Introduction

The fetal anomaly scan is a detailed scan carried out in pregnant women at about 20 week’s gestation (mid pregnancy) to check if the baby is developing normally. Prenatal scanning is of great importance as it contributes to appropriate management of the baby both during and after the pregnancy. Fetal anomaly scanning is very accurate but unfortunately it cannot identify all birth defects.

Rationale for measurement

Prior to November 2017, Fetal Anomaly Scanning for women in the North East was available only if they were referred to the Rotunda Hospital or if they chose to access this service privately.

A fetal anomaly scanning services has now commenced in Louth Hospitals and Cavan/Monaghan Hospitals. The initial service is criteria led with plans to expand into a more comprehensive service as the skilled workforce is developed and/or recruited to increase the service capacity. The RCSI Hospital Group intends to monitor the numbers of women availing of this service across the three maternity units of the RCSI Hospital Group, Cavan, Monaghan, Louth Hospitals and the Rotunda Hospital.

Measurement methodology and data sources

(1) number of women booked and

(2) number of fetal anomaly scans performed – Local Hospital data extrapolated for analysis and publication

Performance