PPH at NW

•

Post partum haemorrhage

Indicator WHA NW 2010 N=7709

NW Public 2010N=2329

PPH 1000-1500 Vaginal births

1.91-2.43

3.1 4

PPH >1500 Vaginal births

1.35-1.7

2.7 4

PPH 500-1500 CS

49.4 67 74.6

TransfusionAll births

1.63-2.1

2.5 3.8

Good at identifying low risk women

Physiological

Syntocinon Syntometrine

SVD 10.2 46.8 40.9

Operative vaginal delivery

61 36

Previous CS 48.9 44.2

Syntocinon vs Syntometrine

Physiological

Syntocinon Syntometrine

SVD 10.2 46.8 40.9

Operative vaginal delivery

61 36

Previous CS 48.9 44.2

PPH at NW

• Primary PPH rate (>500ml) was 36%• 16% with vaginal delivery• 78% for emergency caesarean

section• Role to audit blood loss by staff

member?

Individual audit at an Australian public hospital

• Registrars advised that a: – Junior (ITP) with a mean blood loss >500ml

would result in borderline for surgical skills on assessment form and mean >600ml a fail.

– Senior registrar with a mean blood loss >400ml would result in borderline for surgical skills on assessment form and mean >500ml a fail.

• Consultants (Lead maternity care providers) were advised they would be audited against background rates.

Quinlivan JA et al, Unpublished data JHC Q&S, 2011

Dear Dr Smith,Comment: Your PPH results are significantly poorer than our benchmark.

Smith Hospital

Number of deliveries

135 3990

% PPH total (>500ml)

48% 36%

% PPH SVD (>500ml)

42% 30%

PPH CS (>500ml)

77% 49%

PPH at JHC 2011 6 months

Mean blood lossBaseline cohort

Pre warning(ml)

Mean blood loss follow up cohort

Post warning(ml)

ITP2 690 510

ITP3 640 440

Senior Reg 440 420

CMO 400 400

Consultant 410 385

Quinlivan JA et al, Unpublished data JHC Q&S, 2011

Misopristol• Lancet RCT of 1422 women.• Randomised to Misopristol or Placebo.• No difference in rate of PPH (>500ml

loss).• More women receiving Misopristol had

shivering (65% vs 32%) and a body temperature >380C (43% vs 15%).

• Findings do not support the use of Misopristol in addition to standard uterotonics for treatment of PPH.

Widmer M et al. Lancet 2010; 375: 1808-

NW Strategies to reduce PPH

• New guidelines for PPH late 2009– Expected to result in an increased use of

syntometrine for prevention of PPH in women at risk and a more consistent approach to calling for help.

– Overall reduction in blood transfusion 3.3% (2009) to 2.6% (2010).

• New checklist for PPH in 2010– Hospital wide strategy to reassess need for

a second bag of blood.

Other strategies to consider...• Delivery suite:

– Ensure routine active management strategies are being implemented correctly

– Ensure PPH is being recognised early– Axe use of Misopristol– Audit PPH rate by LMC provider for SVD and

give feedback.

• Operating theatre:– Consider using a long acting syntocinon– Audit PPH rate by LMC provider and

registrar for CS and give feedback.

Induction of Labour•

IOL at NW

• More than 1 in 3 nulliparous women were induced.

• Post dates pregnancy and term PROM were the most common reasons for IOL

• When post dates was the primary reason for IOL, 11% occurred BEFORE 41 weeks gestation.

Diagnosis of term PROM

• Need to confirm diagnosis through history, examination and testing (amnicator/ultrasound).

• Consider waiting 24 hours if GBS negative.

Post dates IOL

• Restrict access to postdates IOL until AFTER 41 weeks.

• Ensure dates are confirmed by early US before booking.

• Introduce offer of routine membrane sweeping at 38 and 39 weeks to reduce post dates IOL.

Sweeping membranes

• Meta analysis of RCT concluded that a policy of offering routine sweeping of membranes at 38 or 39 weeks reduces the number of women progressing to post term gestation and the need for formal labour induction.

• Boulvain M eta al. Cchrane database of systematic reviews 2005; CD000451.

Urogynaecology

Urogynaecology• 209 had

urogynaecology procedure.

• 40 women had a hysterectomy at the same time as their urogynaecology procedure.

• Complication rate was 10.5% overall

Urogynaecology complications

Significant post operative infection

1

Unplanned return to theatre 3.4

Failure to complete surgery 0.5

Intra operative injury to internal organ

0.5

Blood transfusion 1

Other significant complication 3.8

Readmission to hospital 9.1

• 300,000 operations performed annually in US.

• Sacrocolpopexy considered the gold-standard.

• Vaginal approach to prolapse repair common.• Surgical outcomes for vaginal native tissue

repair of prolapse are poor– Nearly 1 in 3 women undergo repeat surgery.

• Lifetime risk of reoperation– Mean interval to reoperation was 12.5 years.

– Clark AL. AJOG 2001; 184: 1357-1364.

Urogynaecology and Prolapse

Should you be using Vaginal mesh outside a trial setting?

Rogers RG, Obstet Gynecol 2011; 118: 1-2

• Prompted by adverse reports, in October 2008 FDA issued safety advisory regarding the use of mesh for treatment of incontinence and vaginal prolapse.

• Issued advice that more detailed information to be collected.

• New FDA advisory released July 2011 states that there are serious concerns over the use vaginal mesh for the treatment of vaginal prolapse and incontinence.

Concern over use of vaginal mesh

FDA Advisory• “The occurrence of serious complications with

the use of vaginal mesh is not rare and mesh use is not proven to provide improved outcomes when compared with native tissue repairs.”

• “Update prompted by an increase in the number of reports made to the Manufacturer and User Facility Device Experience database, including common reports of exposure, erosion, and protrusion of mesh into the vagina and new reports of mesh contractions.”

• US Food & Drug Administration 2011

How are devices cleared?• FDA

– Class I (low risk)– Class II (Mesh, contact lens solution, external hearing

aid)– Class III (high risk)

• Process– Premarket approval required (Clinical trials required -

expensive)– 510k process which clears for market (does not

approve)

• Withdrawal from market 2005 to 2009• 113 items withdrawn or recalled• 71% were Class II, 510k devices!

Some excellent results

• General– Breast feeding– Quit campaign

• Low complication rates in – General Gynaecology– Gynaecology Oncology

• Obstetrics– HIE (below benchmark)– VBAC (above benchmark)

Thankyou•