Sunteți pe pagina 1din 173

2012

The Womens Health Service

Annual Clinical Report

Women's Health Service


Capital & Coast District Health Board
Riddiford Street, Wellington
Private Bag 7902, Wellington South,
New Zealand
Phone (04) 385 5999

Capital & Coast District Health Board

Project Team

Acknowledgements

This report was prepared by:


Keith Fisher, Data Analyst, Decision Support Unit
Carolyn Coles, Quality Facilitator, Surgery, Women and
Childrens Directorate
Dr Rose Elder, Clinical Leader, Obstetrics
Dr Jackie Hawley, Clinical Leader, Gynaecology
Dr Robyn Maude, Associate Director of Midwifery
Margaret Thomson, Charge Nurse Manager, Ward 4
North Gynaecology

This WHS Annual Clinical Report contains major


changes to the layout and content compared to
previous annual reports. In designing this report the
project team acknowledges use of the layout design of
the National Womens Annual Clinical Report 2011.

Reproduction of material
The Womens Health Service (WHS), Capital and
Coast District Health Board (C&C DHB), permits the
reproduction of material from this publication without
prior notification, provided that the WHS C&C DHB is
acknowledged as the source and any information used
must not be distorted or changed.

Disclaimer
The purpose of this publication is to promote, discuss
and audit outcomes. The opinions expressed in this
publication do not necessarily reflect the official views
of the WHS and C&C DHB.

We would like to acknowledge contributions from the


following:
Dr Peter Abels, Obstetrician and Gynaecologist
Dr Anju Basu, Obstetrician and Gynaecologist
Pauline Bennett-Tamati, Business Services Officer
Denise Braid, Charge Nurse Manager, Womens Clinics
Dr Howard Clentworth, Gynaecological Oncologist
Christina Cuncarr, Charge Midwife Manager, Ward 4
North Maternity
Gill Dawidowski, Charge Nurse Manager, Te Mahoe
Unit
Rosemary Escott, Nurse Manager, Neonatal Intensive
Care Unit
Hazel Irvine, PMMRC/AMOSS Midwife Coordinator
Shelley James, Charge Midwife Manager, Delivery
Suite
Fiona Jones, Clinical Midwife Specialist
Dr Fali Langdana, Obstetrician and Gynaecologist
Dr Elaine Langton, Clinical Leader, Obstetric
Anaesthesia
Dr Dean Maharaj, Obstetrician and Gynaecologist
Stuart McGregor, Charge Sonographer, Womens
Ultrasound Service
Dr Alan McKenzie, Specialist Anaesthetist
Diana Murray, Charge Midwife Manager, Primary
Maternity Care
Justine Plunkett, Operations Manager, Womens Health
Service
Jenny Quinn, Charge Midwife Manager, Kenepuru
Maternity Unit
Noreen Roche, Lead Maternity Carer
Dr Jeremy Tuohy, Clinical Leader, Maternal Fetal
Medicine
Penny Wyatt, Lactation Consultant

REPORT DESIGN AND PRINT PRODUCTION: TBD DESIGN LTD, WELLINGTON


PHOTOGRAPHS: COMMUNICATIONS, CAPITAL & COAST DISTRICT HEALTH BOARD
JENNY QUINN, CHARGE MIDWIFE MANAGER, KENEPURU MATERNITY UNIT
ALISON CURRAN, ACTING CHARGE MIDWIFE MANAGER, PARAPARAUMU MATERNITY UNIT
ISSN 1177-7168
2 |

The Womens Health Service Annual Clinical Report 2012

It is my pleasure to present the 2012 Womens Health Service Annual Clinical Report. This is our 10th report.
In 2012 the focus was on the implementation of the Ministry of Health (MOH) Maternity Quality and Safety
Programme. This is a national framework for DHB quality and safety improvement and reporting and provided us
with guidance for the revised format for this years annual clinical report.
Our primary purpose for producing these reports is to identify and acknowledge our achievements. It is also an
opportunity to identify where improvements can be made to the care provided to women and their babies. This
then allow us to improve the quality and safety of our service.
Thank you to all that have contributed to this report but special thanks must go to Carolyn Coles and Keith Fisher
who have spent many hours in the production of this report.

Justine Plunkett
Operations Manager
Womens Health Service

| 3

Capital & Coast District Health Board

4 |

The Womens Health Service Annual Clinical Report 2012

Contents
1 Introduction

15

1.1

Purpose of this report

15

1.2

Report structure

15

1.3

Clinical indicators

17

1.4

Women and babies included in this report

17

1.5

Data sources

18

1.6

Data quality

18

1.7

Data analysis

19

Service provision

21

2.1

Maternity Services

21

2.2

Lead Maternity Carer Services

25

2.3

Specialist Maternal Mental Health Service

25

2.4

Gynaecology Services

26

2.5

Ultrasound Scanning Service

27

2.6

Quality, Health and Safety

28

2.7

University of Otago

29

2.8

Victoria University of Wellington

29

2.9

Otago Polytechnic

30

Quality, health & safety

31

3.1

Maternity Quality Safety Programme (MQSP) Governance and Objectives

31

3.2

Reportable events

35

3.3

Adverse Serious (SAC2) and Sentinel (SAC1) events

35

3.4

Adverse maternity outcomes

36

3.5

Compliments, complaints and HDC cases

36

3.6

Health and safety

37

3.7 Audits

37

3.8

38

Learning development and research

39

4.1

Quality forum

39

4.2

RANZCOG integrated training programme

39

4.3

Midwife educators

40

4.4

Graduate midwifery programme

41

Controlled documents

| 5

Capital & Coast District Health Board

Summary statistics for 2012

43

5.1

Place of birth

43

5.2

Maternity demographics and outcomes

45

5.3

Neonatal outcomes

47

5.4

ACHS maternal and perinatal clinical indicators

49

5.5

Gynaecology outcomes

51

5.6

ACHS gynaecology clinical indicators

52

Antenatal and postnatal clinics

53

6.1

Obstetric diabetic clinics

55

6.2

Anaesthesia clinics

56

6.3

Pregnancy and parenting education

56

Maternity service demography

57

7.1 Domicile

57

7.2 Age

58

7.3 Ethnicity

61

7.4 Parity

64

7.5 Smoking

65

7.6

Body mass index

67

7.7

Lead maternity carer (LMC) at booking

68

7.8

Hospital Primary Care

70

Antenatal complications

71

8.1

Preterm birth

71

8.2

Multiple pregnancy

74

8.3

Diabetes in pregnancy

76

8.4

Maternal Fetal Medicine service & Ultrasound scan service

78

8.5

Maternal cardiac

81

Labour and birth

83

9.1

Mode of birth

84

9.2

Labour and birth by parity group

87

9.3

Various rates

93

9.4

Induction of labour

95

9.5

Breech presentation and external cephalic version (ECV)

97

9.6

Outcome of selected primipara (ACHS)

99

9.7

Obstetric anaesthesia

100

9.8

Primary maternity units

104

9.8.1

Kenepuru Maternity Unit

104

9.8.2

Paraparaumu Maternity Unit

105

10

Labour and birth outcomes

107

10.1

Perineal trauma

107

10.2

Postpartum haemorrhage

108

10.3

Surgical site infection (ACHS)

109

10.4

Neonatal outcomes

110

10.4.1 Gender

110

10.4.2 Plurality

110

10.4.3

111

6 |

Birth weight

The Womens Health Service Annual Clinical Report 2012

10.4.4

Gestational age

114

10.4.5

Apgar score

115

11

Postnatal care

117

11.1

Postnatal consumer satisfaction survey

117

11.2

Infant feeding

118

11.3

Newborn hearing screening

121

11.4

NICU admissions and outcomes

122

12

Perinatal mortality

123

12.1

Perinatal mortality rates

123

12.2

Perinatal mortality by maternal age and ethnicity

125

12.3

Causes of perinatal deaths

127

13

Maternal mortality and morbidity

131

13.1

Maternal mortality

131

13.2

Severe maternal morbidity

132

13.3

Admissions to the Intensive Care Unit

132

14

Gynaecology Clinics

133

14.1

Gynaecology outpatient service

133

14.2

Colposcopy service

135

14.3

Te Mahoe unit

137

15

Gynaecology Services

141

15.1

Gynaecology inpatient service

141

15.2

Endometriosis service

145

15.3

Urogynaecology service

146

15.4

Gynaecology oncology service

147

15.5

Adverse gynaecological outcomes

149

15.6

ACHS gynaecology clinical indicators

150

16 Appendices

153

16.1

153

16.2 Abbreviations

165

16.3 References

166

16.4

167

Extra data tables

ACHS clinical indicator definitions

| 7

Capital & Coast District Health Board

8 |

The Womens Health Service Annual Clinical Report 2012

tables
Table 1:

Clinical audits approved in 2012

37

Table 2:

Place of birth for the Capital & Coast DHB region for 2012

43

Table 3:

Key demographic statistics for women giving birth in 2012

45

Table 4:

Mode of labour by parity group for 2012

46

Table 5:

Mode of birth by parity group for 2012

46

Table 6:

Various mode of birth rates and postpartum outcomes for 2012

46

Table 7:

Neonatal outcomes for babies in 2012

47

Table 8:

Perinatal mortality for babies in 2012

48

Table 9:

ACHS obstetric clinical indicators for 2012

50

Table 10:

ACHS infection control clinical indicator for 2012

51

Table 11:

ACHS gynaecology clinical indicators for 2012

52

Table 12:

Obstetric outpatient clinic attendances and DNA rates for years 2009 to 2012

54

Table 13:

Ethnicity distribution of women seen at obstetric diabetic outpatient clinics in 2012

55

Table 14:

Domicile by District Health Board (DHB) area and by gestation at birth for 2012

57

Table 15:

Age group distribution by birth facility for 2012

58

Table 16:

Maternal age group distribution for years 2005 to 2012

59

Table 17:

Ethnicity distribution by birth facility for 2012

61

Table 18:

Maternal ethnicity groups for years 2005 to 2012

62

Table 19:

Age group distribution within each ethnicity group for 2012

62

Table 20:

Parity for years 2005 to 2012

64

Table 21:

Grouping by Caesarean Section (CS) history for years 2005 to 2012

64

Table 22:

Rates of smoking at booking time by ethnicity and age groups for 2012

65

Table 23:

Rates of smoking at booking time by ethnicity group for years 2005 to 2012

66

Table 24:

Body mass index (BMI) categories at booking by age group for 2012

67

Table 25:

Body mass index (BMI) categories at booking by ethnicity group for 2012

67

Table 26:

LMC bookings by trimester at time of first visit, for years 2008 to 2012

68

Table 27:

LMC at time of booking by facility of birth for 2012

69

Table 28:

LMC at time of booking for years 2008 to 2012

69

Table 29:

Ethnicity group distribution by booking LMC for 2012

69

Table 30:

Parity group distribution by booking LMC for 2012

70

Table 31:

Parity by ethnicity for women booked with Hospital Midwifery Primary Care for 2012

70

Table 32:

Preterm rates by maternal age group for 2012

72

| 9

Capital & Coast District Health Board

Table 33:

Preterm rates by maternal ethnicity group for 2012

72

Table 34:

Perinatal outcome of preterm births by gestation for 2012

73

Table 35:

Multiple pregnancy numbers and rates for years 2003 to 2012

74

Table 36:

Ethnicity of women with GDM and Type 2 diabetes giving birth in 2012

76

Table 37:

Ethnicity distribution within diabetes type for women attending clinic in 2012

76

Table 38:

Mode of birth by diabetes type for births in 2012 within C&C DHB

77

Table 39:

Referrals to Maternal Fetal Medicine for years 2010 to 2012

78

Table 40:

Ultrasound scanning service volumes for years 2008 to 2012

79

Table 41:

Amniocentesis and CVS indications for years 2008 to 2012

80

Table 42:

Outcomes after amniocentesis and CVS for 2011 and 2012 (Jan-Sep)

81

Table 43:

Mode of birth for years 2003 to 2012

84

Table 44:

Mode of birth by age group for 2012

86

Table 45:

Mode of birth by ethnicity group for 2012

86

Table 46:

Peer group comparison for ACHS obstetric clinical indicator 2.1

93

Table 47:

Various rates for years 2005 to 2012

94

Table 48:

Primary indication for induction of labour by parity and CS history group for 2012

95

Table 49:

Mode of birth after induction of labour for main primary indication groups for 2012

96

Table 50:

Peer group comparison for ACHS obstetric clinical indicators 1.1 to 1.4

99

Table 51:

Summary of neuraxial blocks for years 2011 and 2012

100

Table 52:

Indications for anaesthesia support in 2012

100

Table 53:

Mode of delivery after neuraxial block in labour in 2012

101

Table 54:

Anaesthesia for caesarean section in 2012

101

Table 55:

Urgency of caesarean section for years 2011 and 2012

102

Table 56:

Peer group comparison for ACHS obstetric clinical indicator 4.1

103

Table 57:

Age and ethnicity distribution for the women who gave birth at KMU in 2012

104

Table 58:

Age and ethnicity distribution for the women who gave birth at PMU in 2012

105

Table 59:

Peer group comparison for ACHS obstetric clinical indicators 3.1 to 3.6

107

Table 60:

Peer group comparison for ACHS obstetric clinical indicators 7.1 and 7.2

108

Table 61:

Primary postpartum blood loss for years 2005 to 2012

108

Table 62:

ACHS infection control clinical indicator 1.16

109

Table 63:

Gender for years 2005 to 2012

110

Table 64:

Plurality for years 2005 to 2012

110

Table 65:

Peer group comparison for ACHS obstetric clinical indicator 8.1

111

Table 66:

Birth weights of all babies by maternal age group for 2012

111

Table 67:

Birth weights of all babies by maternal ethnicity group for 2012

112

Table 68:

Birth weights for liveborn babies for years 2005 to 2012

113

Table 69:

Gestational age for liveborn babies for years 2005 to 2012

114

Table 70:

Gestational age groups for liveborn babies for years 2005 to 2012

115

Table 71:

Peer group comparison for ACHS obstetric clinical indicator 9.1

115

Table 72:

Apgar score at 5 minutes for liveborn babies by maternal age group for 2012

116

Table 73:

Apgar score at 5 minutes for liveborn babies by maternal ethnicity group for 2012

116

Table 74:

Apgar scores at 5 minutes for liveborn babies for years 2005 to 2012

116

10 |

The Womens Health Service Annual Clinical Report 2012

Table 75:

Infant feeding at time of initial discharge, by birth facility for 2012

118

Table 76:

Infant feeding at time of initial discharge, by mode of birth for 2012

119

Table 77:

Infant feeding at time of initial discharge, by maternal age for 2012

119

Table 78:

Infant feeding at time of initial discharge, by maternal ethnicity for 2012

120

Table 79:

UNHSEIP volumes for years 2010 to 2012

121

Table 80:

NICU admissions and outcomes for liveborn babies, by gestation group for 2012

122

Table 81:

Peer group comparison for ACHS obstetric clinical indicator 10.1

122

Table 82:

Perinatal mortality numbers and rates for years 2005 to 2012

124

Table 83:

Perinatal mortality rate by maternal age groups for years 2005 to 2012

125

Table 84:

Adjusted perinatal mortality rate by maternal age groups for years 2005 to 2012

125

Table 85:

Perinatal mortality rate by maternal ethnicity groups for years 2005 to 2012

126

Table 86:

Adjusted perinatal mortality rate by maternal ethnicity groups for years 2005 to 2012 126

Table 87:

Summary of factors related to the 23 stillbirths in 2012

127

Table 88:

Stillbirths by perinatal death classification for the years 2006 to 2012

128

Table 89:

Summary of factors related to the 7 early neonatal deaths < 7 days in 2012

129

Table 90:

Early neonatal deaths by perinatal death classification for the years 2006 to 2012

130

Table 91:

Incidence of AMOSS reportable severe maternal morbidities for 2011 and 2012

132

Table 92:

Gynaecology outpatient clinic attendances and DNA rates for years 2009 to 2012

134

Table 93:

Gynaecology waiting time numbers per month for 2012

135

Table 94:

Colposcopy outpatient clinic attendances and DNA rates for years 2009 to 2012

136

Table 95:

Colposcopy waiting time numbers per month for 2012

136

Table 96:

DHB distribution of women attending Te Mahoe unit in years 2007 to 2012

137

Table 97:

Numbers and rates for Te Mahoe for years 2007 to 2012

139

Table 98:

Elective gynaecology surgery volumes for years 2009 to 2012

142

Table 99:

Acute gynaecology surgery volumes for years 2009 to 2012

142

Table 100: Elective gynaecology surgery volumes and breakdown of surgical procedures for 2012 143
Table 101: Acute gynaecology surgery volumes for 2012

144

Table 102: Postnatal readmissions for 2012

144

Table 103: Non-surgical acute admissions for 2012

145

Table 104: Total endometriosis procedures for 2012

146

Table 105: Urogynaecology surgery procedures for years 2008 to 2012

147

Table 106: Gynaecology oncology referral numbers by DHB for years 2009 to 2012

147

Table 107: Histological confirmed gynaecology oncology cases for newly referred women in 2012 148
Table 108: Gynaecology oncology surgery procedures for 2012

148

Table 109: Adverse gynaecologic outcomes for 2012

149

Table 110: Group comparison for ACHS gynaecology clinical indicators for years 2010 to 2012

151

Table 111: Place of birth for the C&C DHB region for the years 2003 to 2012

154

Table 112: Place of birth by C&C DHB birthing facility for the years 2003 to 2012

155

Table 113: Ethnicity group distribution within each age group for 2012

155

Table 114: Parity by age group for 2012

156

Table 115: Parity by ethnicity group for 2012

156

Table 116: Maternal ethnicities within the six ethnicity groups for years 2005 to 2012

157

| 11

Capital & Coast District Health Board

Table 117: Mode of birth group percentages for years 1997 to 2012

158

Table 118: Mode of birth group by age group for all women in 2012

158

Table 119: Mode of birth group by age group for primiparous women in 2012

158

Table 120: Mode of birth group by age group for multiparous women without previous CS in 2012 159
Table 121: Mode of birth group by age group for multiparous women with previous CS in 2012 159
Table 122: ACHS obstetric clinical indicators (Jan-Jun, Jul-Dec 2012) and table notes

160

Table 123: ACHS infection control clinical Indicators (Jan-Jun, Jul-Dec 2012) and table notes

162

Table 124: ACHS gynaecology clinical indicators (Jan-Jun, Jul-Dec 2012) and table notes

163

12 |

The Womens Health Service Annual Clinical Report 2012

figures
Figure 1:

C&C DHB quality framework diagram

28

Figure 2:

WHS Governance Structure

32

Figure 3:

Number of reportable events by month for 2012, with a linear trend line

35

Figure 4:

Age group percentage distribution for years 2005 to 2012

59

Figure 5:

Ethnicity group distribution within each maternal age group for 2012

60

Figure 6:

Age group distribution within each maternal ethnicity group for 2012

63

Figure 7:

Labour and birth branch diagram for all women with multiple pregnancies for 2012

75

Figure 8:

Mode of birth group rates for years 1997 to 2012, for all C&C DHB facilities combined 85

Figure 9:

Labour and birth branch diagram for all women for 2012

Figure 10: Labour and birth branch diagram for primiparous women for 2012

87
88

Figure 11: Labour and birth branch diagram for multiparous women without previous CS for 2012 89
Figure 12: Labour and birth branch diagram for multiparous women with previous CS for 2012

90

Figure 13: Mode of birth group by age group for all women for 2012

91

Figure 14: Mode of birth group by age group for primiparous women for 2012

91

Figure 15: Mode of birth group by age group for multiparous women without previous

CS for 2012

92

Figure 16: Mode of birth group by age group for multiparous women with previous CS for 2012

92

Figure 17: Labour and birth branch diagram for singleton breech presentations for 2012

97

Figure 18: Perinatal mortality rates (perinatal and adjusted) for years 2005 to 2012

124

| 13

Capital & Coast District Health Board

14 |

The Womens Health Service Annual Clinical Report 2012

1. Introduction

1.1 Purpose of this report


The purpose of this WHS Annual Clinical Report is:

To document the services provided within the


Maternity and Gynaecology Services at C&C DHB
during the calendar year.

To demonstrate trends in the population groups,


service provision, interventions and outcomes over
time.

To report on the implementation of the Maternity


Quality Safety Programme and list the planned
actions and expected outputs.

1.2 Report structure


This publication continues the series of annual clinical
reports produced by the WHS with the first report in
the series published in 2004.
The chapters in this report contain discussion and
analysis of data displayed in tables and figures.
Additional data tables relevant to a particular section
are listed in the Appendices section at the end of the
report. The report has the following chapters.
Chapter 1: Introduction
This chapter lists the purpose and structure of
the report, and describes the data sources and
methodology.

Chapter 2: Service provision


This chapter describes the services provided within the
Maternity and Gynaecology Services at C&C DHB.
Chapter 3: Quality, health and safety
The Maternity Quality Safety Programme is described.
Reportable event numbers are reported as are the
recommendations of two serious event reviews.
Common themes are identified in womens feedback
and the outcomes of those clinical audits completed in
2012 highlighted.
Chapter 4: Learning development and research
Learning development and education programmes
within the WHS and allied educational organisations
are described.

| 15

Capital & Coast District Health Board

Chapter 5: Summary statistics for 2012

Chapter 10: Labour and birth outcomes

Summary numbers for the 2012 calendar year are


presented. These include birth numbers, maternal
demographics and outcomes, neonatal outcomes,
and gynaecology outcomes. Clinical indicators
for Obstetrics and Gynaecology as defined by the
Australian Council on Healthcare Standards (ACHS) are
listed.

Outcomes for perineal trauma and postpartum


haemorrhage are discussed. Neonatal outcomes by
gender, plurality, birth weight, gestational age and
Apgar score are presented.

Chapter 6: Antenatal and postnatal clinics


Obstetric antenatal and postnatal outpatient clinics
are discussed. Attendance numbers at these clinics
are tabulated. The obstetric diabetic clinic, the
anaesthesia pre-assessment clinic and pregnancy
parenting and education classes are discussed in detail.
Chapter 7: Maternity Service demography
This chapter contains the demographic characteristics
of the women who gave birth in 2012. Information is
presented on domicile, age, ethnicity, parity, smoking
status at the time of booking, body mass index and
lead maternity carer (LMC) at booking. No analysis of
socioeconomic status by deprivation score is possible
from the current database.

Chapter 11: Postnatal care


Information is presented on a postnatal consumer
satisfaction survey, infant feeding, newborn hearing
screening, and admissions to the Neonatal Intensive
Care Unit (NICU).
Chapter 12: Perinatal mortality
This chapter provides information and analyses those
fetal and neonatal deaths that occurred in C&C DHB
during 2012. Analysis is done by maternal age and
ethnicity.
Chapter 13: Maternal mortality and morbidity
Information on maternal deaths over the last 10
years is discussed. Data reported to the Australasian
Maternity Outcomes Surveillance System (AMOSS) on
severe maternal morbidities is tabulated. Reasons for
admission to ICU are listed.

Chapter 8: Antenatal complications

Chapter 14: Gynaecology clinics

Antenatal complications such as preterm birth,


multiple pregnancy, diabetes in pregnancy and cardiac
problems in pregnancy are discussed. The Maternal
Fetal Medicine service and the Ultrasound scan service
are described.

Gynaecology and colposcopy outpatient clinics are


discussed. Attendance numbers at these clinics are
tabulated. Reports are presented for the colposcopy
services and Te Mahoe unit.
Chapter 15: Gynaecology services

Chapter 9: Labour and birth


This chapter presents labour and mode of birth
numbers and analyses these by maternal age,
ethnicity and parity group. Induction of labour and
breech presentation are discussed. A report on
obstetric anaesthesia is provided by the Department
of Anaesthetics and Pain Management. Reports
are presented from the primary birthing facilities
at Kenepuru and Paraparaumu Maternity Units.
Outcomes for select primipara (ACHS) are tabulated.

16 |

Reports are presented for the gynaecology inpatient,


endometriosis, urogynaecology and gynaecologic
oncology services. Adverse gynaecological outcomes
are discussed. The ACHS gynaecology clinical
indicators are tabulated and discussed.
Chapter 16: Appendices
Extra data tables not presented in the main text of the
report are tabulated here. Abbreviations, references
and the ACHS clinical indicator definitions are listed.

The Womens Health Service Annual Clinical Report 2012

1.3 Clinical indicators


The Australian Council on Healthcare Standards
(ACHS) is an authorised accreditation agency with
the Australian Commission on Safety and Quality in
Health Care. The ACHS Clinical Indicator Program
is a data collection and reporting service that assists
organisations to measure and manage an aspect of
clinical care. ACHS provide customised reporting
enabling single health care organisations to compare
their own performance to other similar organisations.
The WHS has been using this system since 2003 to
benchmark their performance.

and the detailed peer group comparison tables for


2012 are listed in the Appendices (Table 122, Table 123
and Table 124). The peer group comparisons contain
our rate, the 99% confidence interval, the expected
number of events and the number of excess events.
These comparisons can be used to determine areas
for improvement or reassurance regarding the existing
level of performance.

Data was submitted to ACHS for both six month


periods in 2012 for obstetrics, infection surveillance
and gynaecology.

The obstetric peer group comparison is for all


organisations that have a NICU and / or more than
3000 births per year. Comparisons of C&C DHB rates
against the overall ACHS peer group rates for the years
2010 to 2012 are presented in those chapters of the
report to which they pertain.

This is the third time we have tabulated peer group


comparisons.

The gynaecology peer group comparison is with all


organisations submitting data in this category.

The clinical indicator results for the WHS for 2012 are
presented in chapter 5 Summary Statistics for 2012,

Detailed definitions of the ACHS clinical indicators are


listed in the Appendices.

1.4 Women and babies included


in this report
The maternity section of this report includes maternal
and infant data pertaining to women giving birth to
babies at and beyond twenty weeks gestation at any
of the three birthing facilities in the C&C DHB area
during the 2012 calendar year. Also included are those
women who were booked to give birth at a facility but
had an unplanned home birth or gave birth en route to
the birthing facility. Note that data for these women

and babies have not been included in previous annual


reports. Data for years prior to 2012 for these births
before arrival are now included in this report in all
time series tables and figures.
The gynaecology section includes information
on women who received care from the various
gynaecology inpatient and outpatient services.

| 17

Capital & Coast District Health Board

1.5 Data sources


extracted by the Decision Support Unit from the
Patient Management System and Theatres ORSOS
database, the Gynaecology Oncology database,
and data from the Te Mahoe Unit database

The information in this report has been sourced from


the following database systems.

Maternity from PIMS (Perinatal Information


Management System)

Maternal Anaesthesia Department of


Anaesthesia database

Maternal Diabetes PIMS and outpatient data


from C&C DHB Patient Management Systems

Maternal Fetal Medicine and Perinatal Ultrasound


Scan Service Viewpoint database

Gynaecology Outpatient data from C&C DHB


Patient Management Systems, surgery data

1.6 Data quality


Daily and monthly checks, queries and corrections
are done on key data fields in the PIMS maternity
database.
No formal audits have been undertaken to ascertain
the quality or accuracy of the data entered into PIMS
and other data systems, or provided in the individual
reports which have been included here. We expect
that there are limitations in the quality of some of the
data in this report.

18 |

Quality, Health & Safety Decision Support Unit


and C&C DHB Patient Management Systems

The PIMS database is due for replacement within the


next year. A new Maternity Clinical Information System
(MCIS) will be implemented in all District Health Boards
over the next few years. This is a National Health IT
Board (Ministry of Health) project, and C&C DHB will
be one of the first District Health Boards to change to
the new national system.

The Womens Health Service Annual Clinical Report 2012

1.7 Data analysis


The data have been extracted and analysed using
Microsoft Access and Excel. Data tables are formatted
with either column or row percentages as indicated.
Numbers are entered in columns denoted by the
abbreviation No. and percentages in the columns
denoted by %. The table captions indicate the years
for which the data are tabulated.
In 2005 PIMS was implemented at the Paraparaumu
Maternity Unit thus completing 100% collection of all
births occurring within C&C DHB birthing facilities.
The following assumptions have been made for the
maternity data:

The maternal age was calculated as at the time of


the birth.

All babies born from 20 completed weeks


gestation and/or over 400 grams birth weight are
included.

For multiple pregnancies, only one mode of birth


has been assigned to the mother, with the mode
prioritized as caesarean, forceps, Ventouse, vaginal
breech, then normal vaginal birth.

Maternal obstetric and caesarean section (CS)


history was determined from the Parity and CS
history data fields in PIMS.

Vaginal breech births have been included in the


assisted vaginal birth group.

| 19

Capital & Coast District Health Board

20 |

The Womens Health Service Annual Clinical Report 2012

2. Service provision

2.1 Maternity Services


C&C DHB provides primary, secondary, tertiary and
regional maternity services.

REGIONAL SERVICES
Maternal

NATIONAL SERVICES
The Maternal Fetal Medicine (MFM) unit at Wellington
is part of the New Zealand MFM Network and provides
nationwide care for high risk obstetric and fetal
medicine, in concert with Christchurch and Auckland.
Maternal
The WHS is a tertiary level facility that accepts referrals
from around New Zealand if capacity is exceeded in
other tertiary units.

The care and management of women with major


cardiac disease including those who may require
bypass surgery during pregnancy is referred to
Auckland.
Women with liver disease requiring transplant
would also be cared for in Auckland.

Fetal / Neonatal

The WHS is responsible for tertiary maternal transfers


from the central region of New Zealand, which includes
Whanganui, Hawkes Bay, Mid-Central, Wairarapa, Hutt
Valley, and Nelson-Marlborough DHBs.
The multidisciplinary diabetes antenatal clinic provides
tertiary pre-conception counseling and pregnancy care
to women with complex needs residing in the Hutt
Valley and Wairarapa DHBs.
A multidisciplinary team provides care for women
with complex cardiac conditions from the lower North
Island including Hutt Valley, Wairarapa, Mid-Central,
Whanganui and Hawkes Bay DHBs.
Fetal
MFM is a tertiary service whose catchment area
includes the lower North Island and the upper South
Island. An MFM outreach clinic is held in Taranaki DHB
once a month.

The WHS accepts maternal transfers and NICU


provides intensive care to babies from other New
Zealand DHBs, particularly if their units are at capacity.

The MFM service is also a training centre for subspecialists in MFM.

The WHS does not undertake laser ablation for


twin to twin transfusion.

MFM specialise in:


Management and supervision of high risk
screening from screening programmes

| 21

Capital & Coast District Health Board

Provision of antenatal diagnosis by amniocentesis,


cordocentesis and chorionic villous sampling

Management of major fetal anomalies

Transfusions for red blood cell incompatibility

Multifetal reduction

Management of fetal cardiac anomalies that are


unlikely to require immediate cardiac surgery

Management of other cardiac disease

Management of fetal genetic conditions in


pregnancy

Management of fetal surgical conditions in


pregnancy

Telemedicine consultation for the central region.

Newborn
The Neonatal Intensive Care Unit (NICU) is located on
Level 4 of the Wellington Regional Hospital adjacent to
the Delivery Suite and Ward 4 North. NICU provides
heath care services to premature and sick newborns.
NICU works closely with the WHS.
NICU is contracted to provide:

Level 3 neonatal intensive care including surgery,


to the central region of New Zealand including
the Hutt Valley, Wairarapa, Mid-Central, Hawkes
Bay, Whanganui and Nelson-Marlborough DHBs.
Current capacity is 20 level 3 cots.
Level 2 neonatal care for the C&C DHB area
covering Wellington, Porirua and the Kapiti Coast.
Current capacity is 20 level 2 cots.
NICU provides a regional service for babies
requiring surgery and laser treatment for
retinopathy of prematurity.

The newborn service also includes the following


support services:

Neonatal Emergency Transport Service

Neonatal Homecare Service

Specialist Lactation Service

Paediatric Outpatient Service

Child Development Unit (as part of the Child


Health Service).

22 |

DISTRICT SERVICES
The maternity service is comprised of:

Delivery Suite

Ward 4 North - one antenatal and two postnatal


pods

Acute Assessment Unit

Kenepuru Maternity Unit

Paraparaumu Maternity Unit

Specialist antenatal outpatient clinics held at


Wellington, Kenepuru and Paraparaumu and
include:
>

High risk antenatal

>

Secondary antenatal consultation

>

Diabetic antenatal

>

VBAC / OASIS

>

MFM consultation clinic

>

MFM clinic

>

Obstetric anaesthesia pre-assessment clinic.

Wellington Regional Hospital - Delivery Suite


Delivery Suite is a modern, purpose-built, state-ofthe-art birthing suite catering for the needs of women
and their families. There are 12 self-contained, fully
equipped labour and birthing rooms where care can be
provided to low and high risk women alike.
An operating theatre and post anesthetic care unit are
located within the Delivery Suite and it is conveniently
located on the same floor as the NICU and Ward 4
North.
Each birthing room has its own pool or bath providing
women with the opportunity to birth in water. Pain
relief options include entonox, pethidine, epidural and
remifentanyl patient controlled analgesia.
One to one labour and birth care is provided by core
midwives to women whose LMC is the Primary Care
team, the High Risk team, MFM or the Diabetic service.
Core midwives provide labour and birth care to
women who have booked under the care of a private
obstetrician (Shared Care) and to women whose care
has been transferred to secondary or tertiary services
following the identification of a problem. Care can also
be provided by core midwives to midwife LMCs who
require relief.

The Womens Health Service Annual Clinical Report 2012

Wellington Regional Hospital - Ward 4 North


Antenatal and Postnatal

Antenatal, labour and birth care is provided by the


womens LMC.

The antenatal and postnatal ward is divided into three


pods.

Postnatal care is provided by experienced core


midwives in partnership with the womens LMC.

Pod B is an antenatal pod with 15 beds. Two flexi


beds are shared with inpatient gynaecology. The
Pohutakawa room is purpose built and available for
women who have experienced a peripartum loss.

Core midwives provide support and assistance for


labouring women, newborn babies and LMCs as
and when required.

A secondary antenatal consultation clinic is run


once a week allowing women to be seen in their
own community.

Pods C and D each contain 12 postnatal beds.


Postnatal care is provided to primary, secondary and
tertiary women and their babies. Daily breastfeeding
classes are held on the ward.
A lactation consultant is available Monday to Friday for
additional support and advice for those women with
complex breastfeeding issues.
All women and babies who have been reviewed and
are clincially stable have the option of transferring to
one of two outlying maternity units at Kenepuru or
Paraparaumu.
Acute Assessment Unit
The Acute Assessment unit is based on Level 3,
Wellington Regional Hospital. Acute Assessment is
open Monday to Friday from 8am to 6pm and provides
acute care to those women who are more than 20
completed weeks pregnant or recently postpartum.
Pregnant women may require pre-eclamptic screening,
assessment of abdominal pain, vaginal bleeding,
possible deep vein thrombosis and postpartum
infections including mastitis, wound reviews and
endometritis. After hours these assessments are
carried out in Delivery Suite.
Kenepuru Maternity Unit
Kenepuru Maternity Unit is a primary birthing facility
located in the Kenepuru Community Hospital at
Porirua. This unit is situated 20 to 30 minutes drive
north of Wellington.
Kenepuru Maternity Unit provides services to women
living in the Porirua Basin who birth at the unit or who
birth at Wellington Regional Hospital and transfer
postnatally.
The Unit:

Is an eight bed facility with two birthing rooms and


six postnatal rooms.

Is open and staffed by core midwives 24 hours


a day throughout the year. This is a sole charge
position.

Paraparaumu Maternity Unit


Paraparaumu Maternity Unit is a primary birthing
facility situated in a wing of the Kapiti Health Centre in
Paraparaumu. The unit is situated approximately 45 to
60 minutes drive north of Wellington.
Paraparaumu Maternity Unit provides services to
women living on the Kapiti Coast who birth at the
unit or who birth at Wellington Regional Hospital and
transfer postnatally.
The Unit:

Has one birthing room with a birthing pool and


two postnatal rooms.

Is open and staffed by core midwives 24 hours


a day throughout the year. This is a sole charge
position.

Antenatal, labour and birth care is provided by the


womens LMC.

Postnatal care is provided by experienced core


midwives in partnership with the womens LMC.

Core midwives provide support and assistance for


labouring women, newborn babies and LMCs as
and when required.

A secondary antenatal consultation clinic is held


once a fortnight allowing women to be seen in
their own community.

Antenatal and birth preparation classes are also


provided for those women choosing Paraparaumu
Maternity Unit.

Midwifery Teams
The limited availability of midwife LMCs has meant that
C&C DHB have been providing primary maternity care
to some women. The Primary Care team is a group of
midwives who provides antenatal and postnatal care to
these women. Antenatal clinics are held at Wellington
and Kenepuru Hospitals (Monday to Friday). Labour
| 23

Capital & Coast District Health Board

and birth care is undertaken by core midwives in


Delivery Suite.
The Shared Care team provides midwifery antenatal
and postnatal care with a private obstetrician.
Antenatal clinics are held at the obstetricians rooms.
Labour and birth care for these women is undertaken
by core midwives in Delivery Suite.
The High Risk team midwives provide midwifery
antenatal and postnatal care to women attending the
Diabetic, MFM, and High Risk clinics, on occasion
they also care for women attending secondary
consultation clinics at C&C DHB. Labour and birth
care is undertaken by core midwives in Delivery Suite.
The High Risk midwives also provide postnatal care
to women from the Kapiti Coast and outside the
Wellington region who have recently given birth and
the baby requires admission to NICU.
Newborn Hearing Screening Service
The Newborn Hearing Screening service offer hearing
screening to all babies born at C&C DHB. Babies are
screened in the postnatal pods at Wellington Regional
Hospital, and at Kenepuru and Paraparaumu Maternity
Units. Outpatient clinics are also available at each of
these facilities.

COMMUNITY SERVICES
Antenatal education
Free pregnancy and parenting education classes are
provided at Wellington and Kenepuru Hospitals to
women who are not currently accessing antenatal
education. These classes were set up to address
inequities of access to antenatal education
programmes for Mori, Pacific People, women from
ethnic minorities and those on a low income. The
objective is to improve health outcomes for these
women and their families and to increase the number
of first-time pregnant women accessing C&C DHB
funded antenatal education.
Breastfeeding education and support
Free breastfeeding classes are provided by the Clinical
Midwife Specialist Lactation, at Wellington and
Kenepuru Hospitals on a monthly basis. The classes
are run over two days.
Chinese breastfeeding classes are run in conjunction
with Hutt Valley DHB at Petone every two months and
are run over two days.
The Community Breastfeeding Team is comprised of
the community lactation coordinator, Pacific lactation
consultant and two Pacific breastfeeding support
workers who provide lactation consultancy support in
the homes of women and at the Breastfeeding Centre.
A particular focus of the Community Breastfeeding
Team is Mori and Pacific women and those with
complex needs. The Breastfeeding Centre is situated
in the Whanau Centre in Cannons Creek, Porirua, and
is a drop in centre open on Thursdays and Fridays from
10am to 2pm.

24 |

The Womens Health Service Annual Clinical Report 2012

2.2 Lead Maternity Carer Services


Midwife LMCs
Lead Maternity Carers in the Wellington region are
almost exclusively midwife LMCs. There are a small
number of obstetricians and no general practitioners
providing LMC care.
Midwife LMCs are self employed and tend to work in
supportive group practices. Midwife LMCs provide
care for pregnant women residing throughout the
Wellington region from as far north as Otaki to Island
Bay in the south. Midwife LMCs have an access
agreement with C&C DHB that allows them to provide
care to women in the hospitals facilities.
Women choose a midwife LMC and enter into a
partnership with continuity of care planned accordingly.
The midwife LMC is responsible for the planning
and provision of maternity services at no cost to the
woman.
Antenatal care is provided in the community either
in clinic rooms or at the womans home. The woman
is supported to birth wherever is appropriate for her
(hospital or home) and postnatal care is provided for
up to six weeks in the womans home.

If the womans care moves out of the midwifes scope


of practice then care is negotiated with the obstetric
team to ensure appropriate management and
continuity meet the womans needs. These three way
discussions usually take place in antenatal consultation
clinics held in Paraparaumu, Kenepuru or Wellington
Regional Hospital.
LMC midwives are paid via Section 88 of The Public
Health and Disability Act. Payments are made at the
completion of each module of care.
Each year a number of midwife LMCs mentor newly
graduated midwives into LMC practice through the
Midwifery First Year of Practice Programme whereby
ensuring growth and capacity in the community setting.

Obstetrician LMCs
There are two obstetric LMCs in the Wellington area.
They provide antenatal care in community clinics and
employ midwives to provide antenatal and postnatal
midwifery care. Labour care is provided by core
midwives. LMC obstetricians are also funded via
Section 88 but there is an additional charge to the
woman for this private service.

2.3 Specialist Maternal Mental Health


Service
The specialist maternal mental health service (SMMHS)
is the only C&C DHB service delivering maternal
mental health services. The team consists of 5.3 full
time equivalent staff who provide clinical services to
women residing in the Wellington, Porirua, Kapiti Coast
and Hutt Valley areas.
The SMMHS also provide case consulting and training
to all central region DHBs including the Hutt Valley,
Wairarapa, Hawkes Bay, Whanganui, Mid-Central and
Tairawhiti.
The criteria for referral to the SMMHS are the
existence of a moderate to severe mood or psychotic

disorder which is associated with pregnancy. Referrals


are accepted antenatally and up to nine months
postpartum. The average wait-time for women to be
seen by the SMMHS is two weeks.

In 2012 there were 267 referrals made to SMMHS.


One hundred and thirty three referrals (49.8%) were
made by general practitioners, and midwives referred
43 women (16.1%). Ninety-one referrals (34.1%) were
made by DHB clinicians including obstetricians, social
workers and other community mental health services.
A similar number of women were referred in 2011.

| 25

Capital & Coast District Health Board

2.4 Gynaecology Services


C&C DHBs gynaecology service provides care to
women referred by general practitioners or other
specialties, who have gynaecological symptoms,
dysfunctions and / or diseases of the female
reproductive system or genital tract.

REGIONAL SERVICES
C&C DHBs gynaecology service provides:

Gynaecological oncology services and support


to the Mid-Central, Hawkes Bay, Wairarapa and
Nelson-Marlborough DHBs. The Christchurch
gynaecology oncology service provides collegial
support and backup to the gynaecology oncology
team in Wellington.

An extended regional service for all vulval skin


disorders.

Urogynaecology support to Mid-Central and


Nelson-Marlborough DHBs.

Tairawhiti second trimester service

Hawkes Bay second trimester service

Nelson-Marlborough second trimester service

Wairarapa second trimester service.

DISTRICT SERVICES
The gynaecology service is comprised of:

Ward 4 North one gynaecology pod

Acute Assessment Unit

Day stay surgery

Specialist gynaecology outpatient clinics held


at Wellington, Kenepuru and Paraparaumu and
include:
> General gynaecology
> Gynaecology oncology

Wellington Regional Hospital - Te Mahoe Unit

> Gynaecology skin

Te Mahoe provides comprehensive pregnancy


counselling as well as first and second trimester
termination of pregnancy services for women between
5 and 19+1 weeks gestation.

> Urogynaecology

The Te Mahoe social work / counselling team provides


as appropriate the following services:

Pre-decision counselling

Pre-abortion couple/family counselling

Post abortion counselling

Pregnancy or pregnancy loss counselling for


woman, couples and family

MFM counselling services are available upon


request

Support services referral

Further counselling if required

Te Mahoe is contracted to provide termination of


pregnancy services to the following DHBs:

Mid-Central first and second trimester service

Whanganui first and second trimester service

Hutt Valley first and second trimester service

26 |

> Colposcopy
> Infertility (non-tertiary)
> Endometriosis.
Wellington Regional Hospital - Ward 4 North
Inpatient Gynaecology
Ward 4 North Pod A provides the inpatient
gynaecology acute and elective services for C&C DHB.
The service has provision for 14 beds with twelve beds
in Pod A and two in Pod B. There are also two flexibeds in Pod B for use as and when required.
Pod A downsizes to ten beds on weekends and public
holidays. The gynaecology pod also provides an acute
after hours assessment service for women requiring
urgent attention.
Admissions to Pod A include acute non-surgical
gynaecology (including women with chronic pain),
elective gynaecology surgery, urogynaecology surgery,
tertiary gynaecology oncology services, and acute
early pregnancy care for women who are less than
20 weeks pregnant, readmissions greater than 10
days postpartum and after hours Te Mahoe inpatient
admissions.

The Womens Health Service Annual Clinical Report 2012

Surgical Admissions Units


The Surgical Admissions Unit (Wellington Regional
Hospital), the Kenepuru Surgical Medical Unit and the
Surgical Medical Ward (Kenepuru Hospital) provide
additional beds for elective gynaecology surgery.
All women are admitted as day of surgery admissions
to the surgical admissions units, day cases will be
discharged home from the second stage recovery area.
Women having surgical procedures requiring a longer
length of stay are transferred postoperatively to the
inpatient wards.
Operating Theatre Availability
There are 10 half day operating lists each week
at Wellington Regional Hospital for elective
gynaecological surgery, two of these lists are
designated for gynaecological malignancy. There are
also two lists each week at Kenepuru for less complex
women where a large proportion of surgeries are
laparoscopic (key-hole) minimally invasive day case
procedures.
Acute Assessment Unit
The Acute Assessment unit is based on Level 3,
Wellington Regional Hospital. Acute Assessment
is open Monday to Friday from 8am to 6pm and
provides acute care to those women who are not

pregnant and those who are pregnant but less than


20 completed weeks gestation. Women are seen in
Acute Assessment with undiagnosed abdominal pain,
for review of a Bartholins abscess, acute dysfunctional
uterine bleeding, postoperative complications,
suspected or confirmed ectopic pregnancy,
hyperemesis gravidarum and miscarriage management.
A small number of women require inpatient admission
but many are managed by regular outpatient review or
booked for day case surgery. Women requiring urgent
after hours assessment are seen in Ward 4 North, Pod
A.
The Acute Assessment unit is staffed by two nursemidwives, a house officer and a registrar. From
October 2012 a change to the Resident Medical
Officers (RMO) roster resulted in a registrar being
allocated to the Acute Assessment unit from Monday
to Friday. This registrar is responsible for the acute
theatre list for women requiring evacuation of
retained products of conception (ERPOC). They also
help with the triaging of referrals being sent to the
service by answering calls from GPs, LMCs and other
services within the hospital about early pregnancy or
gynaecology issues.

2.5 Ultrasound Scanning Service


The perinatal ultrasound service plays a critical role
in the evaluation and monitoring of women with
gynaecological and obstetric problems.
The gynaecological team is supported through the
provision of detailed pelvic scanning for patients
attending clinics and those admitted acutely.
The service provides imaging support to high risk
antenatal and diabetic clinics for regular monitoring of
these at-risk pregnancies.

| 27

Capital & Coast District Health Board

2.6 Quality, Health and Safety


Improving healthcare outcomes and patient safety is
a priority for C&C DHB. As part of the DHB Clinical
Governance infrastructure the Womens Health Clinical
Governance Group ensures that systems are in place to
enable managers and clinicians to share responsibility
and accountability for patient safety, to minimise risks
to consumers and to continuously monitor and improve
the quality of clinical care.

This is supported by a Quality Facilitator (0.7FTE),


whose role is to coordinate the Maternity Quality
Safety Programme and assist in the effective
application of the C&C DHB Quality Framework across
the WHS.

Figure 1: C&C DHB quality framework diagram

28 |

The Womens Health Service Annual Clinical Report 2012

2.7 University of Otago


Collaborations in research between the Department
of Obstetrics and Gynaecology, University of Otago
(Wellington) and C&C DHB are ongoing, with university
staff supporting and mentoring Royal Australian and
New Zealand College of Obstetrics and Gynaecology
(RANZCOG) Integrated Training Programme (ITP)
trainees. University staff are also involved with registrar
teaching and training.

and 6th years they have clinical placements and


training within the WHS.
Collaborations already exist between members of the
University of Otago and the Womens Health Research
Unit (WHRU, Department of Primary Care), the New
Zealand College of Midwives, Victoria University of
Wellington (VUW), and the WHS clinical audit and
research committee.

Medical students are trained via the University of


Otago, Wellington School of Medicine. In their 5th

2.8 Victoria University of Wellington


The Graduate School of Nursing, Midwifery and
Health (GSNMH) is located at Wellington Regional
Hospital and is part of Victoria University's Faculty of
Humanities and Social Sciences. The school specialises
in postgraduate qualifications for nurses, midwives
and health professionals. Qualifications range from
postgraduate certificates and diplomas to Master's
degrees and PhDs.
The GSNMH vision is to shape the health and future of
Aotearoa/New Zealand by:

leading to improvements in health outcomes

building leaders in research, policy and practice

providing expertise in nursing, midwifery and


health.

The GSNMH programmes have been developed


through extensive consultation with clinicians,

managers, current and potential students, and are


internationally benchmarked. The framework for
the qualifications has a straightforward yet flexible
structure of progression. Through a building blocks
approach our programmes will enable clinicans to gain
qualifications that reflect their knowledge, skills and
clinical experience.
Over the last few years many C&C DHB nurses
and midwives have commenced and completed
study programmes at VUW. The WHS has a close
relationship with the GSNMH and has provided
clinical placement for midwives engaged in the Health
Workforce New Zealand (HWNZ) funded postgraduate
certificate in Midwifery (Complex Care) since 2009.
In 2012 C&C DHB had approximately 20 midwives
engaged in study and the Associate Director of
Midwifery, who is seconded to the GSNMH, completed
a PhD in Midwifery.

| 29

Capital & Coast District Health Board

2.9 Otago Polytechnic


The Bachelor of Midwifery at Otago Polytechnic
leads to registration as a midwife in New Zealand.
Meeting the Midwifery Council of New Zealands new
standards for midwifery education, it also aligns with
the midwifery education requirements of the European
Union and the United Kingdom.
Otago Polytechnic uses a blend of face to face and
distance-learning allowing students to study where
they live. There are a number of satellite sites available
throughout the country, including Wellington, that are
staffed with midwifery lecturers who provide individual

30 |

support, run tutorials and coordinate local midwifery


practice. Otago Polytechnic midwifery students
from the Wellington satellite have had their clinical
placements within C&C DHB maternity services for
three years now and several graduates have joined our
staff through the one year graduate midwife orientation
programme. C&C DHB welcomes the opportunity to
be involved in supporting locally grown midwives and
look forward to seeing them flourish as practitioners of
the future.

The Womens Health Service Annual Clinical Report 2012

3. Quality, Health & Safety

3.1 Maternity Quality Safety Programme


(MQSP) Governance and Objectives
BACKGROUND

OBJECTIVES

In 2009, the New Zealand Government agreed to


the development of the Maternity Quality Initiative,
including work to improve the collection and reporting
of maternity data. Representatives from midwifery,
obstetrics, anaesthesia, paediatrics, general practice
and maternity consumers worked together with the
Ministry of Health to develop the National Maternity
Quality and Safety Programme (MQSP).

In April 2012 the WHS outlined their planned


approach to ensuring that a comprehensive MQSP was
established to ensure the ongoing quality improvement
and systematic review of maternity services.

In 2012, the MQSP was rolled out across all DHBs


supported by the development of the New Zealand
Maternity Standards, New Zealand Maternity Clinical
Indicators, the Revised Referral Guidelines and
Maternity Service Specifications.
The MQSP involves ongoing, systematic review by local
multidisciplinary teams that work together to identify
potential improvements to maternity services and work
to implement those improvements. The programme is
driven by local midwifery and medical leaders working
together, with consumers, midwife LMCs and other
community groups to monitor and improve maternity
care at C&C DHB.
The intent of the programme is to bring together
professional and consumer stakeholders to
collaboratively monitor and improve maternity care for
women, their babies and their families.

The WHS objectives were to:


Ensure representation and involvement of midwife


LMCs and primary care providers in MQSP
improvement activities.

Improve mechanisms for the discussion and


dissemination of data, guidance or guidelines,
innovative practice, new research and local
initiatives to midwife LMCs and other communitybased maternity practitioners.

Ensure consumer representation and involvement


in MQSP improvement activities.

Improve on and support seamless, collaborative


maternity care with integrated hospital and
community-based clinicians and services.

Improve communication and maternity care


teamwork across the region.

| 31

Capital & Coast District Health Board

GOVERNANCE STRUCTURE
The WHS has a governance structure that has
been in existence and working effectively for a
number of years. The structure consists of monthly
multidisciplinary meetings that focus on quality and risk
review, clinical audit and research and overall clinical
governance.
The MQSP is governed by a Maternity Quality
and Safety Programme Governance group, who
report to the WHS Clinical Governance group. This
multidisciplinary governance group includes the WHS

operations manager, clinical leader obstetrics, associate


director of midwifery, quality facilitator surgery women
and childrens directorate, two midwife LMC liaison
representatives (including a Mori and Pacifica focus),
two maternity consumer representatives, and a Mori
representative (see attached Governance Structure).
Representation from other health professionals will be
invited as required (for example, a neonatologist).
The MQSP Governance group meets monthly
to oversee and guide the implementation of the
programme.

Figure 2: WHS governance structure

32 |

The Womens Health Service Annual Clinical Report 2012

MQSP STRATEGIC PLAN


DELIVERABLES 2012

Implementation of shared or interdisciplinary


training and education opportunities (including the
management of obstetric emergencies).

In addition to the diabetic antenatal clinic held


in Wellington a second diabetic antenatal clinic
commenced at Kenepuru Hospital. The addition
of this clinic has seen the did not attend rates
reduce significantly.

Work has been undertaken with the DHB


psychologist to evaluate the wellbeing of
relationships between midwives and obstetric staff
within the DHB. A six monthly interface meeting
between senior midwives and senior medical staff
has been formalised to improve communication
and an escalation plan has been put in place to
provide a system for contacting additional senior
medical staff if required urgently. The psychologist
has also worked with clinicians of the WHS to
optimise interactions at the perinatal education
meeting to encourage functional communication.

Following reportable event and adverse outcome


trend monitoring a safe sleep campaign for babies
was initiated. Micro-teaching sessions were
undertaken with midwifery staff and an on-line
audio-visual education tool called through the
tubes installed. Safe sleeping banners, posters
and cot cards were sourced and standardised
throughout the WHS. A retrospective clinical audit
looking for evidence of safe sleeping discussions
with parents has commenced and a prospective
re-audit will commence in March 2013 to assess
the effectiveness of this campaign.

The Maternity Support Services Specification


was rewritten with the assistance of the MQSP
Governance group.

Additional resources are in place to support the


current monitoring systems for more timely SAC
1 and SAC 2 event reviews. Midwife LMCs and
maternity consumers will be co-opted where and
when appropriate.

Information pertaining to ACHS (2011) and


Ministry of Health (2009) clinical indicators were
sent to all C&C DHB maternity staff including
links to the Health Quality and Safety Commission
website.

Senior medical officers who are on call for


delivery suite and the acute services are no longer
assigned concurrent clinical responsibilities and
their allocated time has increased from four to
eight hours.

An anonymous postnatal inpatient survey was


undertaken during September. An explanation of
how the survey was conducted, the response rate
and copies of the survey results were sent to the
MQSP Governance group.

A fully automated point of care lactate meter was


sourced for delivery suite. The meter is easy to
use and the results are more reliable. Results are
able to be directly uploaded into the Medical
Applications Portal.

In 2012 a gap analysis was undertaken of the current


quality improvement systems within C&C DHB and
the WHS. An implementation plan was subsequently
developed that provided the MQSP with specific
actions, deliverables, timelines and measures to
address the identified gaps. This was summarised
in the WHS strategic plan that was submitted to the
Ministry of Health and approved in September 2012.

MQSP DELIVERABLES ACHIEVED


IN 2012
Setting up the overarching multidisciplinary MQSP
Governance group within WHS:

Ensuring Mori and Pacific representation is


included on the MQSP Governance group

Ensuring that consumer representation is in place


as per the Governance groups agreed Terms of
Reference

Ensuring that Midwife LMC representation is in


place as per Governance groups agreed Terms of
Reference

Facilitating linkages between all community and


hospital-based practitioners, consumers and
advocacy groups

Budget approved by Governance group and


endorsed by C&C DHB general manager and chief
executive Planning and Funding

The first MQSP Governance group meeting was


convened on 24 July 2012.

Service delivery was strengthened by the following


quality and safety initiatives.

Other changes made to the medical roster include


increasing the number of antenatal clinics and
the availability of senior medical staff during post
surgical rounds.

| 33

Capital & Coast District Health Board

A fully automated point of care urinalysis machine


was sourced for womens clinics. The use of
the machine removes subjectivity, enhances
consistency and reduces false positive results.
Results are able to be directly uploaded into the
Medical Applications Portal.

- Handover from LMC to core midwifery staff.


- Handover of clinical responsibility to the on call
registrar and consultant when an IOL is being
performed overnight in Pod B.
- Clarification of the policy for CTG monitoring in
early labour.

MQSP DELIVERABLES TO BE
UNDERTAKEN 2013

- Regular fetal surveillance and CTG monitoring


meetings will be reinstated.

There are several major pieces of work to be


undertaken by the service in 2013.

- The outcomes of women who received cervical


priming in Pod B during 2012 will be audited.

- Consideration will be given to the use of a Foley


catheter for cervical ripening.

To ensure the collection of comprehensive and


consistent maternity data, the Ministry of Health
will be implementing a new national Maternity
Clinical Information System. The successful
vendor Clevermed and the National Clinical
Reference group are currently making the system
suitable for New Zealand maternity services. C&C
DHB has been selected as an early adopter site for
the Clevermed system and anticipates a go live
date of November 2013.

A multidisciplinary implementation group


will determine what is required from a DHB
perspective to enable the Clevermed system to
go live.

Implementation and training for the Clevermed


system will be required for all hospital based
medical and midwifery staff and LMCs using the
system throughout C&C DHBs maternity services.

Implementation and training of core midwives in


the use of the lactate meter.

Following receipt of the WHS ACHS clinical


indicator report (2012) and New Zealand maternity
clinical indicator report (2011) a multidisciplinary
working group will be convened to improve
the current induction of labour (IOL) policy and
process. This will include:
- The communication and assessment process
required to book an IOL.
- Communication required with the on call
registrar regarding the womans cervical status
prior to prostaglandin insertion.

34 |

The second clinical indicator that the service


intends to review pertains to blood transfusion
during the birth admission.
- A review of the WHS postpartum haemorrhage
rates will be undertaken.
- A clinical audit will also be undertaken looking
at whether iron deficiency anaemia prior to an
elective or emergency caesarean section affects
womens blood transfusion requirements and
recovery outcomes postoperatively.

The credentialing for all resident medical officers


will be formalised earlier in their placement.

Evaluate the changes made in October 2012 to


the medical roster.

The content and layout of the 2012 WHS annual


clinical report will be revised to expand upon
previously identified areas for improvement.

Implement mechanisms for discussion and


dissemination of data, guidance or guidelines,
innovative practice, new research and local
initiatives to midwife LMCs and other communitybased maternity practitioners.

Local data communication out to community


including consultation with Iwi. This deliverable
was carried over from 2012.

An anonymous antenatal, intrapartum and


postnatal inpatient satisfaction survey will be
undertaken.

The Womens Health Service Annual Clinical Report 2012

3.2 Reportable events


At C&C DHB all healthcare incidents are entered into
an electronic reportable events system (RL6). Lower
level events are generally resolved at the Charge
Midwife / Nurse Manager level. All events are
reviewed at the Quality and Patient Safety meeting the
following month. There were 213 reportable events
entered during 2012.

Figure 3: Number of reportable events by month for 2012,


with a linear trend line
30

25

20

15

10

0
Jan 12

Feb 12

Mar 12

Apr 12

May 12

Jun 12

Jul 12

Aug 12

Sep 12

Oct 12

Nov 12

Dec 12

3.3 Adverse Serious (SAC2) and Sentinel


(SAC1) events
Two reportable events were reviewed and considered
serious (SAC2) events. The first occurred in June and
the second in August. Both events were thoroughly
investigated using appropriate review methodologies
and the following recommendations were made:

Re-educate all staff regarding C&C DHBs


Obstetrics Surgery / Procedures Trial policy.

Review obstetric registrar orientation and


credentialing to ensure that levels of competence,
supervision and teaching required are widely
known to on-call obstetricians.

Review the indications for initiating the obstetric


senior medical officer escalation plan.

Review the C&C DHB Induction of Labour policy


and process.

Send a memo to all WHS clinicians in acute areas


reminding them of the importance of attending
handover.

Ensure that all medical staff who see women who


are being assessed for VBAC antenatally, clearly
document the management plan which has been
agreed with the couple and the LMC.

Clearly document any specific issues or concerns


identified during the antenatal period as this will
assist staff when the LMC is not present.

| 35

Capital & Coast District Health Board

Undertake a documentation audit of the current


VBAC consenting practices. Once common
themes are identified registrar teaching sessions
will be initiated.

All recommendations are assigned to named clinicians.


Progress is monitored monthly via the patient quality
and safety meeting until all actions have been
completed.

3.4 Adverse maternity outcomes


For a number of years the maternity service has
collected information on adverse maternity outcomes.
The adverse maternity outcome data collection form
requires completion by clinicians prior to transferring
women and babies to the postnatal pods.
A specific list of variables allows the service to monitor
trends. However if the clinician completing the
adverse maternity outcome form is concerned about

some other aspect of care and requests a review then


this information can be entered on the form. The
adverse outcome rates are reported at the quarterly
multidisciplinary quality forums and occur alongside
reportable event reporting. In some near miss
cases a learning opportunity is recognised and direct
feedback is given to the appropriate person by either
the clinical leader of obstetrics or the associate director
of midwifery.

3.5 Compliments, complaints and


HDC cases
The WHS regularly receives feedback about womens
experiences via the C&C DHB Patient Liaison Office
and the Health and Disability Commissioners
(HDC) Office. Feedback provides the WHS with an
opportunity to learn about and improve the services
we provide.
In 2012 the WHS received 150 written compliments.
The two most consistently identified themes pertained
to respect, dignity and support, and the standard of
clinical care received. During this same period the
service also received 49 complaints. The three most

36 |

common concerns raised by women related to the


standard of clinical care they received, respect, dignity
and support, communication and information. There
were 2 HDC cases reported during this time.
All feedback received by the WHS is taken seriously
and we seek to resolve all complaints in a fair and
effective way. Concerns raised by women about
aspects of the care they received may be discussed
with clinicians on a case by case basis, or more
generally via micro teaching sessions, perinatal
education meetings, midwifery and quality forums.

The Womens Health Service Annual Clinical Report 2012

3.6 Health and safety


All hazard registers and environmental inspections
were completed as per health and safety schedules for
all departments within the WHS. Monthly health and
safety topics were displayed throughout the service
and staff were encouraged to be cognisant of each
months topic.
The WHS took an active role in the influenza
vaccination campaign with a champion from
gynaecology inpatients training as a vaccinator.
Overall, the number of staff from within the WHS who
were vaccinated showed some improvement.

Staff from within the WHS also took part in Earthquake


Shake out day and on-line ChemWatch training to
ensure that all chemical inventories are entered onto an
electronic database.

Significant Health and


Safety Issues
There were no significant health and safety issues
identified during 2012.

3.7 Audits
In 2012, 8 audits were approved by the clinical audit
and research committee. Clinicians who submit a
proposal to the committee do so on the understanding
that they will be required to submit a copy of their final
report to the committee upon completion and present
their audit findings at a quality forum.

Three of the eight clinical audits approved in 2012


were completed that same year. Progress on the
five remaining audits is monitored monthly and it is
anticipated that all will be completed in 2013.

Table 1: Clinical audits approved in 2012


Audit title

Author

1.

How many babies born between 35 and 37 weeks gestation are admitted
directly to the postnatal ward and cared for as per policy Management of
babies 35-37 weeks gestation or 2.0-2.5 kg on the postnatal ward?

Gail Austin (ACMM)


Therese Hungerford-Morgan (Midwife)
Angela Saunders (Registered Nurse)

2.

Neonatal Weight Loss.

Jennifer Petrovich
Midwife

3.

Induction of labour for suspected fetal macrosomia: are we adherent to


current evidence based best practice standards?

Sam Lepine
Obstetric Senior House Officer

4.

Is the daily baby check for babies on the postnatal pods being completed
once every 24 hours during their postnatal stay?

Pip Penhey
Midwife

5.

Is the current fetal femur length normative scale applicable to the


New Zealand population?

Laura Neuss
Ultrasonographer

6.

Are safe sleep and sudden unexpected death in infancy (SUDI) education
conversations with parents being undertaken and documented in hospital
records?

Carol McCord
Midwife

7.

How many patients failed to complete a successful trial of void in 2011 and
what factors contributed to this?

Kerri Gunn
Registered Nurse

8.

Review of anatomy scans detection rate of major cardiac abnormalities

Jeremy Tuohy
Obstetrician

| 37

Capital & Coast District Health Board

Clinical Audit One: How many babies born


between 35 and 37 weeks gestation are
admitted directly to the postnatal ward and
cared for as per policy?

The auditor recommended:


Reminding staff about the correct timeframe when


babies should be weighed

Midwives working in the postnatal pods are caring for


considerably more late preterm low birth weight babies
than they did in 2010. Overall compliance with the
policy is very good.

Annual re-auditing to ensure maximum compliance


with policy.

The audit team recommended:


Annual re-auditing to ensure maximum compliance


with policy

Developing a comprehensive observation chart for


preterm low birth weight babies being cared for
on the postnatal pods.

Plotting baby weights on customised GROW


charts to determine whether babies are growth
restricted or constitutionally small.

Clinical Audit Three: Induction of labour for


suspected fetal macrosomia: are we adherent to
current evidence based best practice standards?
There is no evidence that a systematic policy of
labour induction for suspected fetal macrosomia in
non-diabetic women can reduce maternal or neonatal
morbidity.
The auditor recommended:

Routine induction of labour (IOL) for suspected


macrosomia is not recommended

Vigilance on the part of both referrers and


accepting clinicians in non-validated indications
for induction

Increased use of GROW charts

Clinical Audit Two: Neonatal weight loss.


This audit identified that 15.9% of the babies audited
were not weighed within the correct timeframe. Of
those babies who were eligible for weighing prior to
discharge 8.4% were not weighed. Weighing babies
is a non-invasive assessment that can alert clinicians to
potential problems that can be dealt with in a timely
manner. Weighing can also identify lactation difficulties
that with early correction, support and guidance could
result in successful and ongoing lactation for most
women.

All reports and recommendations made are tabled at


the clinical audit and research committees monthly
meeting. All accepted recommendations are
monitored monthly for progress.

3.8 Controlled documents


In 2012 the Ministry of Healths Guidelines for
Consultation with Obstetric and Related Medical
Services (Referral Guidelines) were published. As
a result of this publication a new protocol entitled
Emergency transfer from Kenepuru or Paraparaumu
primary maternity facilities to Wellington Regional
Hospital was developed.
Document owners were notified of the new referral
guidelines and the MQSP Governance group will
ensure that all existing documents are aligned as and
when they come up for renewal.
At the end of 2012 the WHS had:

38 |

190 policies, procedures, protocols and guidelines


in use (including the obstetric quick references)

92 patient information brochures / sheets.

The obstetric and gynaecology HealthPoint web pages


(www.healthpoint.co.nz) allow women to obtain up
to date information on services the WHS provides
24 hours a day, 7 days a week. This information is
reviewed regularly and can be downloaded onto a
Smartphone or iPad.

The Womens Health Service Annual Clinical Report 2012

4. Learning development
and research

4.1 Quality forum


The quality forum enables nursing, midwifery and
medical staff to present the outcomes of interesting
obstetric and gynaecology case reviews, adverse

outcomes, trend monitoring and the results of recently


completed clinical audit activities. Attendance is
voluntary and scheduled at three monthly intervals.

4.2 RANZCOG Integrated Training


Programme
RANZCOG offers postgraduate training in obstetrics
and gynaecology. Membership / fellowship training
involves six years of postgraduate hospital-based
training and assessment. The first four years are called
the ITP and the last two years are the Electives.
The four-year ITP includes the following:

Rotation through a minimum of three different


hospitals, with at least 12 months in a tertiary
hospital and 6 months in a rural hospital

Logged clinical work in obstetrics and


gynaecology resulting in attainment of prescribed
competency levels in specified procedures

Utilising the resources of Trainee Connect via the


online.ranzcog e-learning platform

Experience in gynaecological oncology

Assessment through various methods (both


formative and summative).

In New Zealand the three regions for training are


Northern, Central and Southern.
C&C DHB is part of the central rotation for ITP. Other
hospitals in this rotation are in the Hutt Valley, MidCentral and Hawkes Bay DHBs. C&C DHB is the
tertiary centre that trainees rotate through. Each
year Wellington also takes one or two first year ITP
candidates.
C&C DHB has eight registrars at any given time at
various levels of training. Senior registrars in their fifth
and sixth year of training (electives) do sub-speciality
training in the areas of infertility, MFM, gynaecologic
oncology, laparoscopic surgery and urogynaecology.

| 39

Capital & Coast District Health Board

At C&C DHB there are two training supervisors and a


coordinator for central regional training. A teaching
session is held once a week and the registrars partake
in training and learning requirements stipulated by
RANZCOG.

4.3 Midwife educators


The midwifery education team consists of a clinical
midwife specialist and two clinical midwife educators.
A core midwife also supported the education team.
The midwifery educators facilitated and participated
in 61 study days in 2012. The midwife educators
coordinated the Graduate Midwifery Programme for
eight midwives, the Return to Practice Programme for
one midwife and provided orientation programmes for
27 midwives and nurses who were new to the service.
Orientation days for new LMC midwives were also
provided.

PROMPT Course
Three PROMPT (Practical Obstetric Multi-Professional
Training) days were run by the clinical midwife
specialist, the clinical leader obstetrics and the clinical
leader obstetric anaesthesia. The course is designed
to improve teamwork and communication during an
obstetric emergency. Emergencies are simulated with
the use of actors. The emergencies take place in the
unit, using real equipment, ensuring that the simulation
occurs in real time. The midwives and doctors
practise in their normal clinical roles. Five courses
were run in 2012. For the first time, two courses were
delivered at the primary maternity units. Paramedics
and call takers from Wellington Free Ambulance also
participated at the days run in the primary maternity
facilities.
One of the advantages of these days, is that systems
that do not work when trialled are examined and
rectified if at all feasible.

Technical Skills days for


Midwives
The Midwifery Council determines the content of these
days and requires all midwives to attend two technical
skill days over a three year period. The midwife
educators develop these days in collaboration with

40 |

other midwife educators within the lower North Island


region. Sixteen days were provided in 2012. These
days are available to both core and LMC midwives.

Core days for Midwives and


Nurses
Fourteen core days were provided in 2012. These
days consist of emergency management training,
manual handling, adult CPR and newborn resuscitation.
Attendance at this day is a compulsory annual
requirement. 180 nurses and midwives attended these
days in 2012.

CPR and Newborn


Resuscitation
These days were designed to enable LMC midwives
to achieve their annual CPR and newborn resuscitation
requirements in accordance with the Midwifery
Council recertification programme. Four courses were
provided and forty three LMC midwives attended.

Epidural Days for Midwives


Three epidural study days were facilitated by the
midwife educators and a specialist anaesthetist. Thirty
seven core and LMC midwives attended.

Newborn Life Support


Course
Nine newborn life support courses were offered in
2012. These were coordinated by the NICU clinical
nurse educator. The course is taught jointly by NICU
staff and midwives from the WHS. Core and LMC
midwives, nurses and doctors from NICU, and staff
from other areas of the DHB who may require newborn
resuscitation skills also attended the course.

The Womens Health Service Annual Clinical Report 2012

Perineal Suturing Workshops

Midwifery Forums

Three perineal suturing workshops for midwives were


run this year. These are open to both hospital and
community based midwives. There were thirty six
participants.

Two midwifery forums were run in 2012. Guest


speakers were invited. Ethical issues and difficulties
encountered in midwifery practice were presented and
discussed. Both core and LMC midwives attended
these days.

Diabetes Management for


Midwives
Two courses were facilitated by the clinical nurse
specialist diabetes and a clinical midwife educator.
This day was designed to give midwives a refresher
on the pathophysiology of diabetes, and the current
management of pregnant women with diabetes.

Preceptor Day for Midwives


One day is provided each year to ensure that midwives
understand the requirements of student midwives,
graduate midwives, midwives returning to practice, and
midwives commencing work within the WHS.

The Quality and Leadership


Programme for Midwives
The quality and leadership programme is the midwifery
career pathway. There are three domains, competent,
confident and leadership. All midwives are considered
to be in the competent domain, until they have applied
to progress to the confident or leadership domain. In
2012 seven midwives progressed to the confident level
and six midwives progressed to the leadership level.

4.4 Graduate Midwifery Programme


The graduate midwifery orientation programme
runs for twelve months and is aimed at the midwife
developing and consolidating their midwifery
knowledge and practice within a supportive
environment working across the scope of practice in
primary, secondary and tertiary maternity services.
There is an initial two week orientation programme
to start, and planned study days throughout the year
and the graduate midwife rotates through our primary
services, Kenepuru, Delivery Suite, and the antenatal/
postnatal areas.

midwives who are assigned to support the graduate


midwives during their orientation time for each rotation
and continue to support them further in their day to
day practice as they gain confidence.
Throughout the programme the graduate midwives
participate in facilitated informal group discussions
providing them with an opportunity to share
experiences, ideas, good times and difficulties with
their peers in a safe environment.
At the completion of the programme the graduate
midwife participates in a formal appraisal.

The programme is facilitated by a dedicated clinical


midwife educator who is a clinical and non-clinical
resource. In addition, each area has experienced

| 41

Capital & Coast District Health Board

42 |

The Womens Health Service Annual Clinical Report 2012

5. Summary statistics for 2012

Key statistics for maternity, gynaecology, and the


ACHS clinical indicators are documented here to give a
snapshot of what happened in 2012. Brief analysis is

provided and more in-depth analysis is in the following


chapters of this report.

5.1 Place of birth


There were 3920 babies born to 3850 women in
2012. 28 (0.7%) of these births were to women who
had booked to give birth at a birthing facility but had
an unplanned home birth or a birth in-transit before
admission to a facility. 20 of the 28 births before
arrival were subsequently admitted to Wellington
Regional Hospital. There were five births before
arrival admitted to Kenepuru Maternity Unit and three
admitted to Paraparaumu Maternity Unit.

Planned home birth numbers are not collected in the


DHBs maternity database. The New Zealand Ministry
of Health collates these numbers based on LMC claims
for service. The number of homebirths for 2012 is
not currently available but is likely to be similar to the
number in 2011 when there were 127 planned home
births in C&C DHB. This number was 3.1% of the total
births in 2011.

Table 2: Place of Birth for the Capital & Coast DHB region for 2012
Mothers
Place of Birth

Babies
No.

Wellington Delivery Suite

3450

89.6

Kenepuru Maternity Unit

240

Paraparaumu Maternity Unit


Births before arrival
Total

Place of Birth

No.

Wellington Delivery Suite

3520

89.8

6.2

Kenepuru Maternity Unit

240

6.1

132

3.4

Paraparaumu Maternity Unit

132

3.4

28

0.7

Births before arrival

28

0.7

3850

100

3920

100

Total

| 43

Capital & Coast District Health Board

See Table 111 for the place of birth numbers for the
last 10 years 2003 to 2012. Table 112 has the number
of births by birthing facility for 2003 to 2012, with the
births before arrival included in the birthing facility to
which they were admitted.

44 |

The number of births which occurred in 2012 were the


lowest since 2005. There were an average of 3905
mothers and 3992 babies over the last ten years.

The Womens Health Service Annual Clinical Report 2012

5.2 Maternity demographics and


outcomes
Table 3: Key demographic statistics for women giving birth in 2012
Variable

Category

Ethnicity *

NZ European

Age

Lead Maternity
Carer (at booking)

Parity **

Smoking rates
by ethnicity (at
booking)

Number

Of Total

1912

49.7

Other European

461

12.0

Mori

481

12.5

Pacific Peoples

359

9.3

Asian

535

Other

102

13.9

< 20 years

172

4.5

20 24

498

12.9

25 29

826

21.5

30 34

1205

31.3

35 39

904

23.5

40

245

Average age for all women

31.3

Average age for first time mothers

29.6

Midwife LMC

2835

73.6

Hospital Midwifery Primary Care

320

8.3

Obstetrician & Midwife LMC

144

3.7

Obstetrician & Hospital Midwifery Shared Care

229

5.9

Hospital Secondary / Tertiary

322

3850

3850

3850

2.6

6.4

8.4

Primiparous

1741

45.2

Multiparous with no previous Caesarean Section (CS)

1541

40.0

Multiparous with 1 previous CS

465

12.1

Multiparous with more than 1 previous CS

103

3850

2.7

NZ European

119

1912

6.2

11

461

2.4

197

481

41.0

67

359

18.7

Asian

535

1.3

Other

102

1.0

402

3850

10.4

Other European
Mori
Pacific Peoples

Total

* The ethnicity groups used in this report contain the following ethnicities. The method by which ethnicity is determined is explained in section
7.3.
NZ European: New Zealand European/Pakeha.
Other European: Other European, European not further defined.
Mori: New Zealand Mori.
Pacific Peoples: Cook Island Mori, Fijian, Niuean, Samoan, Tokelauan, Tongan, Pacific Island not further defined, Other Pacific Island.
Asian: Chinese, Indian, Southeast Asian, Asian not further defined, Other Asian.
Other: African, Latin American/Hispanic, Middle Eastern, Other, Not stated.
** Parity:
Primiparous: A woman who has not previously given birth from 20 completed weeks gestation. (Also called nulliparous or Para 0)
Multiparous: A woman who has previously given birth from 20 completed weeks gestation.

| 45

Capital & Coast District Health Board

Table 4: Mode of labour by parity group for 2012


Mothers

Primiparous

Labour

No.

Multiparous, no
previous CS

No.

Multiparous, with
previous CS
No.

Total

No.

Spontaneous

954

54.8

1030

66.8

171

30.1

2155

56.0

Induced

631

36.2

412

26.7

50

8.8

1093

28.4

Pre-labour CS

156

9.0

99

6.4

347

61.1

602

15.6

1741

100

1541

100

568

100

3850

100

Total

Table 5: Mode of birth by parity group for 2012


Mothers
Mode

Primiparous
No.

Multiparous, no
previous CS
No.

Multiparous, with
previous CS

No.

Total
No.

Vaginal
Normal

810

46.5

1317

85.5

97

17.1

2224

57.8

Forceps

179

10.3

25

1.6

11

1.9

215

5.6

Ventouse

153

8.8

15

1.0

24

4.2

192

5.0

0.0

0.1

0.0

0.0

Manual rotation
Breech

10

0.6

12

0.8

0.9

27

0.7

1152

66.2

1370

88.9

137

24.1

2659

69.1

502

28.8

116

7.5

140

24.6

758

19.7

Caesarean
Emergency
Elective
Total

87

5.0

55

3.6

291

51.2

433

11.2

589

33.8

171

11.1

431

75.9

1191

30.9

1741

100

1541

100

568

100

3850

100

Table 6: Various mode of birth rates and postpartum outcomes


for 2012
Variable

Number

Of Total

1532

3850

39.8

Elective CS with indication of a previous CS

241

433

55.7

Emergency CS performed in established labour

522

758

68.9

Primary CS (first CS for women without a previous CS)

760

3282

23.2

Episiotomy

522

3850

13.6

86

2659

3.2

117

1191

9.8

Normal birth (at term and spontaneous labour and normal birth)

Postpartum haemorrhage of 1000mls or more after a vaginal birth


Postpartum haemorrhage of 1000mls or more after a CS birth

46 |

The Womens Health Service Annual Clinical Report 2012

5.3 Neonatal outcomes


Table 7: Neonatal outcomes for babies in 2012
Variable

Category

Gender

Female

1889

Male

2031

Single

3782

96.5

Twins

132

3.4

Plurality

Triplets
Gestation

3920

3920

51.8

0.2

24 27 weeks

57

1.5

28 31 weeks

84

2.1

32 36 weeks

294

7.5

All preterm

466

11.9

3407

86.9

+6
+6
+6
+6

37+0 41+6 weeks


42+0 weeks
<500g

47

3920

1.2

0.1

500g-999g

53

1.4

1000g-1499g

46

1.2

1500g-1999g

84

2.2

2000g-2499g

158

4.1

2500g-2999g

476

12.3

3000g-3499g

1192

30.7

3500g-3999g

1266

32.7

4000g-4499g

517

13.3

4500g-4999g

76

2.0

5000g

Breastfeeding at discharge
(excludes discharges from NICU)

48.2

0.8

+0

Admissions to the Neonatal ICU


(Some discharged from Ward 4 North)

31

+0

Apgar < 7 at 5 minutes for liveborn *

Of Total

20 23 weeks
+0
+0

Birth weights for liveborn

Number

Average weight

3375g

Maximum weight

5415g

3877

0.2

Preterm

31

427

7.3

Term

41

3450

1.2

Total

72

3877

1.9

Preterm

355

427

83.1

Term

389

3450

11.3

Total

744

3877

19.2

Exclusive

2728

79.6

Full

116

3.4

Partial

483

14.1

Artificial

102

3429

3.0

* Apgar: Numerical score used to evaluate the infants condition at one and five minutes after birth. Five variables are scored: heart rate,
breathing, muscle tone, reactivity to stimulation and colour. Values of 0, 1 or 2 are assigned to each variable, with 10 being the maximum Apgar
score.

| 47

Capital & Coast District Health Board

Table 8: Perinatal mortality for babies in 2012


Babies

Number

Total babies

3920

Liveborn babies

3877

Rate

Fetal deaths (stillbirths and TOPs, 20 completed weeks gestation or more)

43

10.97 / 1000 total babies

Stillbirths

23

5.87 / 1000 total babies

Early neonatal deaths (died < 7 days)

1.81 / 1000 liveborn babies

Late neonatal deaths (died between 7 and < 28 days)

0.77 / 1000 liveborn babies

10

2.58 / 1000 liveborn babies

Perinatal mortality (fetal and early neonatal deaths)

50

12.76 / 1000 total babies

Adjusted perinatal mortality (stillbirth and early neonatal deaths)

30

7.65 / 1000 total babies

Perinatal related mortality (fetal and all neonatal deaths)

53

13.52 / 1000 total babies

All neonatal deaths (died < 28 days)


PMMRC Rates *

* PMMRC = Perinatal & Maternal Mortality Review Committee

48 |

The Womens Health Service Annual Clinical Report 2012

5.4 ACHS maternal and perinatal


clinical indicators
Overall the maternity services clinical indicators
compared favourably with other organisations
submitting data within Australasia. Our rates for
selected primipara who have a spontaneous vaginal
birth selected primipara undergoing caesarean
section and selected primipara undergoing
episiotomy and sustaining a perineal tear while giving
birth vaginally do however require further attention.
These results demonstrate that C&C DHB is statistically
significantly different to all other organisations
submitting data for these particular indicators and
where our results are undesirably lower or higher than
the expected rates.

Selected primipara undergoing caesarean section

Selected primipara sustaining a perineal tear and


no episiotomy

Selected primipara undergoing episiotomy and


sustaining a perineal tear while giving birth
vaginally

Women having a general anaesthetic for a


caesarean section

Babies with birth weight less than 2750g at 40


weeks gestation or beyond

Term babies born with an Apgar score of less than


7 at five minutes post delivery

The 2012 peer group comparison data has also


identified eight clinical indicators where the aggregate
rate is outside our 99% confidence interval. C&C
DHB is statistically significantly different to all other
organisations submitting data for the following
indicators:

Inborn term babies transferred / admitted to


a neonatal intensive care nursery or special
care nursery for reasons other than congenital
abnormality.

Selected primipara who have a spontaneous


vaginal birth

To view the complete table with peer comparisons for


2012 refer to Table 122.

| 49

Capital & Coast District Health Board

Table 9: ACHS Obstetric Clinical Indicators for 2012


Indicator Number and Description

2012

Numerator

Denominator

Rate (%)

Jan-Jun

217

516

42.05

Jul-Dec

213

544

39.15

Jan-Jun

161

516

31.20

Jul-Dec

155

544

28.49

Jan-Jun

104

516

20.16

Jul-Dec

126

544

23.16

Jan-Jun

128

516

24.81

Jul-Dec

153

544

28.13

1.1

Selected primipara who have a spontaneous vaginal


birth (H)

1.2

Selected primipara who undergo induction of labour (L)

1.3

Selected primipara who undergo an instrumental


vaginal birth (L)

1.4

Selected primipara undergoing caesarean section (L)

2.1

Vaginal delivery following a previous primary caesarean


section (N)

Jan-Jun

35

176

19.89

Jul-Dec

49

177

27.68

3.1

Selected primipara with intact perineum or unsutured


perineal tear (H)

Jan-Jun

67

388

17.27

Jul-Dec

63

391

16.11

3.2

Selected primipara undergoing episiotomy AND no


perineal tear while giving birth vaginally (L)

Jan-Jun

108

388

27.84

Jul-Dec

120

391

30.69

3.3

Selected primipara sustaining a perineal tear AND


no episiotomy (L)

Jan-Jun

161

388

41.49

Jul-Dec

166

391

42.46

3.4

Selected primipara undergoing episiotomy AND


sustaining a perineal tear while giving birth vaginally (L)

Jan-Jun

52

388

13.40

Jul-Dec

42

391

10.74

3.5

Selected primipara requiring surgical repair of the


perineum for third degree tear (L)

Jan-Jun

22

388

5.67

Jul-Dec

28

391

7.16

3.6

Selected primipara requiring surgical repair of the


perineum for fourth degree tear (L)

Jan-Jun

388

0.00

Jul-Dec

391

0.77

4.1

Women having a general anaesthetic for a caesarean


section (L)

Jan-Jun

40

590

6.78

Jul-Dec

31

598

5.18

7.1

Women who give birth vaginally who receive a blood


transfusion during the same admission (L)

Jan-Jun

25

1295

1.93

Jul-Dec

28

1336

2.10

7.2

Women who undergo caesarean section who receive a


blood transfusion during the same admission (L)

Jan-Jun

22

590

3.73

Jul-Dec

18

598

3.01

8.1

Deliveries with birth weight less than 2750g at 40


weeks gestation or beyond (L)

Jan-Jun

10

793

1.26

Jul-Dec

789

0.76

9.1

Term babies born with an Apgar score of less than 7


at five minutes post delivery (L)

Jan-Jun

28

1685

1.66

Jul-Dec

15

1742

0.86

Inborn term babies transferred / admitted to a


10.1 neonatal intensive care nursery or special care nursery
for reasons other than congenital abnormality (L)

Jan-Jun

137

1644

8.33

Jul-Dec

188

1700

11.06

(L) A low rate is desirable (H) A high rate is desirable (N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

50 |

The Womens Health Service Annual Clinical Report 2012

Table 10: ACHS Infection Control Clinical Indicator for 2012


Indicator Number and Description
1.16

Deep incisional/organ/space surgical site infection (SSI)


in lower segment caesarean section procedures (L)

2012

Numerator

Denominator

Rate (%)

Jan-Jun

586

0.68

Jul-Dec

598

1.00

5.5 Gynaecology outcomes


There has been an overall increase in the number of
women attending gynaecology clinics within the WHS
in 2012. Attendances at general gynaecology clinics
increased 11.1% from 2011 and total gynaecology
clinic attendances increased 9.2% from 2011. There
was also an 8.2% increase in attendance to all
colposcopy clinics from 2011 to 2012.
A concerted effort was made to reduce the waiting
times for gynaecology first specialist assessments
(FSA).

There has been an increase in both elective and acute


surgery volumes from 2011 to 2012 mainly because
of increased use of theatre time for Wellington day
surgeries.
There has been a 27.8% decline in the number of
terminations of pregnancy between 2007 and 2012.
There has been a steady decline in the number
of terminations performed each year with an 11%
reduction in numbers from 2011 to 2012.

This was achieved by July 2012 with no women waiting


more than 4 months for a FSA.

| 51

Capital & Coast District Health Board

5.6 ACHS gynaecology clinical indicators


Overall the gynaecology services clinical indicators compared favourably with other organisations submitting data
within Australasia. See the complete table with peer comparisons in the Appendices (Table 124).

Table 11: ACHS Gynaecology Clinical Indicators for 2012


Indicator Number and Description

2012

Numerator

Denominator

Rate (%)

1.1

Patients receiving an unplanned blood transfusion


during their hospital admission for any type of
gynaecological surgery for benign disease (L)

Jan-Jun

10

390

2.56

Jul-Dec

429

1.86

1.2

Patients receiving an unplanned blood transfusion


during their hospital admission for any type of
gynaecological surgery for malignant disease (L)

Jan-Jun

57

8.77

Jul-Dec

61

8.20

2.1

Patients suffering injury to a major viscus with repair,


during an gynaecological operative procedure or
subsequently up to 2 weeks post-operatively (L)

Jan-Jun

412

1.70

Jul-Dec

455

0.44

Jan-Jun

245

0.00

3.1

Patients suffering an injury to a major viscus with


repair, during a laparoscopic gynaecological operative
procedure or subsequently up to 2 weeks postoperatively (L)

Jul-Dec

271

0.74

Patients receiving an injury to a ureter at the time


of a laparoscopic hysterectomy with repair during
the procedure or subsequently up to 2 weeks postoperatively (L)

Jan-Jun

15

0.00

Jul-Dec

12

0.00

Patients receiving a bladder injury at the time of a


laparoscopic hysterectomy with repair during the
procedure or subsequently up to 2 weeks postoperatively (L)

Jan-Jun

15

0.00

Jul-Dec

12

0.00

Jan-Jun

15

16

93.75

Jul-Dec

12

14

85.71

3.2

3.3

4.1

Laparoscopic management of an ectopic pregnancy (H)

5.1

Patients receiving injury to a major viscus with repair,


during a pelvic floor repair procedure or subsequently
up to 2 weeks post-operatively (L)

Jan-Jun

51

0.00

Jul-Dec

70

0.00

5.2

Patients receiving a ureter injury at the time of a pelvic


floor repair procedure with repair during the procedure
or subsequently up to 2 weeks post-operatively (L)

Jan-Jun

51

0.00

Jul-Dec

70

0.00

5.3

Patients receiving a bladder injury at the time of a pelvic


floor repair procedure with repair during the procedure
or subsequently up to 2 weeks post-operatively (L)

Jan-Jun

51

0.00

Jul-Dec

70

0.00

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified

52 |

The Womens Health Service Annual Clinical Report 2012

6. Antenatal and
postnatal clinics

The following table lists the attendance volumes and


did not attend rates for all medical and midwifery
outpatient clinics for the last four years 2009 to 2012.

| 53

Capital & Coast District Health Board

Table 12: Obstetric outpatient clinic attendances and DNA rates


for years 2009 to 2012
Attendance volumes
Obstetric Clinic

Did not attend rates

2009

2010

2011

2012

2009

2010

2011

2012

No.

No.

No.

No.

Antenatal

1889

2154

2306

2484

9.3

10.3

9.0

7.3

Diabetic

1038

1714

1845

1555

12.5

11.0

12.3

6.8

High risk

1075

939

1109

1297

8.7

7.3

12.7

11.3

MFM counselling

985

1156

1013

907

5.3

3.3

2.4

1.8

Acute assessment

1904

3059

2738

2564

0.2

Preassessment

394

466

540

581

12.2

12.0

11.1

11.4

Pre-20 weeks

533

857

877

185

11.4

8.3

8.1

7.0

Medical

VBAC antenatal

65

VBAC pre-20 weeks

3.1

Virtual MFM

Virtual - Obstetric

Total - Medical

0.3

7818

10345

10432

52
9695

7.2

6.2

7.1

5.5

Midwifery
MFM antenatal

MFM postnatal

15

High risk antenatal

227

175

108

128

High risk antenatal community

430

413

373

473

High risk postnatal

190

139

138

122

High risk postnatal community

1050

1163

1383

1353

0.3

0.2

Primary antenatal

2820

2520

2368

2232

8.7

13.4

341

224

13

43

37

663

175

166

613

2064

2910

2491

1959

0.1

0.0

Primary pre-20 week

430

564

481

389

9.8

9.6

8.9

Shared care antenatal

22

34

1004

835

847

802

0.2

0.2

259

181

149

203

2062

1678

1618

1717

Total - Midwifery

11245

10807

10516

10275

2.6

3.7

3.4

3.3

Grand Total - Obstetric

19063

21152

20948

19970

4.5

4.9

5.2

4.4

Primary antenatal education class


Primary antenatal community
Primary postnatal
Primary postnatal community

Shared care antenatal community


Shared care postnatal
Shared care postnatal community

54 |

0.1
9.6

10.4

24.6

33.5

0.2

4.9

The Womens Health Service Annual Clinical Report 2012

6.1 Obstetric diabetic clinics


The analysis in this section is based on data for women
who attended obstetric diabetic outpatient clinics
during 2012. This data was sourced from the patient
management systems of C&C DHB and a database
kept in clinic.

The clinics were attended by 272 women. 241 women


had diabetes and 31 women had other endocrine
disorders. 253 (93%) of the 272 women were C&C
DHB domiciled, 8 (3%) from the Hutt Valley DHB and
the rest were from other DHBs.

Table 13: Ethnicity distribution of women seen at obstetric


diabetic outpatient clinics in 2012
NZ
European

Other
European

Pacific
Peoples

No.

No.

No.

No.

No.

No.

No.

GDM

72

64.9

16

88.9

13

56.5

23

59.0

59

80.8

87.5

190

69.9

Type 1

18

16.2

5.6

4.3

5.1

1.4

0.0

23

8.5

Type 2

4.5

0.0

30.4

10

25.6

8.2

0.0

28

10.3

14

12.6

5.6

4.3

5.1

8.2

12.5

25

9.2

Other

1.8

0.0

4.3

5.1

1.4

0.0

2.2

Total

111

100

18

100

23

100

39

100

73

100

100

272

100

Mori

Asian

Other

Total

Diabetes

Other
Thyroid

There is an increase in the incidence of diabetes in


the community and this will be occurring in women
of reproductive age. Diabetes nurses and midwife
educators have been doing training sessions and
diabetes has been discussed in forums such as the
perinatal education meeting. There seems to be an
increased awareness with regard to screening and the
risks of untreated diabetes in pregnancy. However
communication from the PMMRC indicated that rates
of screening could still be improved.
The weekly diabetes antenatal clinic provides
antenatal care for women with pre-existing diabetes
or gestational diabetes, and for women with other

endocrine disorders. In early 2012 a second diabetes


clinic was initiated at Kenepuru. Our clinic population
was divided evenly between the two areas. Having
to come into Wellington Regional Hospital was
inconvenient and costly for women living in the Porirua
and Kapiti Coast areas so a clinic closer to them was
seen as appropriate. Establishing scanning facilities
adjacent to the clinic at Kenepuru has also improved
access and care for these women and their babies.
Table 12 shows that attendance volumes have
decreased and DNA rates have dropped dramatically
from 12.3% in 2011 to 6.8% in 2012.

| 55

Capital & Coast District Health Board

6.2 Anaesthesia clinics


Two anaesthesia clinics are held per week, one on
Wednesdays for women requiring elective caesarean
section and one on Thursdays for women with more
complex medical conditions. An average of 50 women
per month attend these, but late referrals often make
it difficult for women to be seen in a timely manner.
There is a possibility of an additional monthly clinic
at Kenepuru to reduce the travel for women from the
Kapiti Coast. As much of the anaesthesia assessment
consists of examining women for adequate airway and
appropriate spinal mobility, phone assessments are not
usually possible.

581 women were seen in clinics in 2012 and an


additional 66 women (11%) did not attend their
appointments. If a woman is referred to the
anaesthesia clinic it is important that she is informed
that she has been referred, knows the reason for the
referral and some effort is made to ensure she attends.
With the review of midwifery roles in the outpatient
department it is hoped that this will improve the
attendance rate.

6.3 Pregnancy and parenting education


Wellington Hospital
Antenatal Education Class
This class is used by women who are being cared for
by the primary care team, the high risk team or have
a midwife LMC, but have not been able to source free
antenatal education elsewhere. 45 women and their
families attended.

Wellington Hospital
Antenatal Assessment and
Education Class
These education classes are structured to run alongside
antenatal assessments so enabling the majority of
women attending to have their antenatal assessment
prior to the education class commencing. 66 women
and their families attended.

56 |

Kenepuru Hospital Antenatal


Assessment and Education
Class
This clinic was run using the same format as the
Wellington clinic. Feedback from women attending
the antenatal assessment and education class was that
the classes were helpful, but attendance was low. The
frequency of these classes and attendance numbers
were reviewed. In July the class was changed to a one
day education only class once a month. 54 women and
their families attended.
The number of women attending education classes
run by the C&C DHB has increased from 152 in 2011
to 171 in 2012. There were women from 14 different
ethnic groups attending classes in 2012.
There has been a definite increase in the number of
first-time pregnant women accessing C&C DHB funded
antenatal education classes. There has also been an
increase in the number of families attending classes
in order to support women through their learning
experience.

The Womens Health Service Annual Clinical Report 2012

7. Maternity Service demography

This chapter describes the demographic characteristics


of the women giving birth at C&C DHB birthing
facilities in 2012.

7.1 Domicile
93% of all births were to women from the local catchment
area. 275 women were from other DHBs with most being
from the Hutt Valley and Mid-Central DHBs.

Table 14: Domicile by District Health Board (DHB) area and by


gestation at birth for 2012
Mothers
DHB *

< 28 weeks

28+0 31+6

32+0 36+6

No.

No.

No.

35

44.3

29

40.3

211

80.5

Hutt Valley

7.6

14

19.4

16

Hawkes Bay

12

15.2

5.6

Wairarapa

3.8

Whanganui

6.3

Mid Central

Nelson Marlborough

Term
37+0 40+6

Total

No.

2655

96.0

645

96.3

3575

92.9

6.1

67

2.4

15

2.2

118

3.1

1.5

0.3

0.0

27

0.7

5.6

2.7

0.2

0.1

20

0.5

6.9

1.1

0.1

0.0

16

0.4

11.4

2.8

2.7

22

0.8

1.3

49

1.3

6.3

11.1

1.1

0.2

0.0

21

0.5

Other North Island

5.1

8.3

10

3.8

0.1

0.0

23

0.6

Other South Island

0.0

0.0

0.4

0.0

0.0

0.0

79

100

72

100

262

100

100

670

100

3850

100

Capital and Coast

Total

No.

Post term
41+0

2767

No.

* Domicile determined from patient address.

| 57

Capital & Coast District Health Board

7.2 Age
The median age of New Zealand women giving birth in
2012 is 30 years (Statistics New Zealand, 2013) whereas
C&C DHBs median age was 31.9 years.
The proportion of women (40 years of age and over)
giving birth at C&C DHB is 6.4% compared with
4.1% of the New Zealand birthing population. The
proportion of women (35 years of age and over) giving
birth at C&C DHB is almost 29.8% compared with
21.5% of the New Zealand birthing population. In
2012 the MoH published the Report on Maternity

from 2010 national data and reported that the


percentage of normal vaginal births decreased with
advanced maternal age. A rate of 74.0% was reported
for women less than 20 years of age compared
with 51.9% for women aged 40 years and over.
The opposite trend was seen in women who had a
caesarean section rate of 14.2% if less than 20 years of
age compared with 38.5% for women aged 40 years
and over. There are implications for older women in
C&C DHB that are reflected in our intervention rates
and outcomes.

Table 15: Age group distribution by birth facility for 2012


Mothers

Wellington

Kenepuru

Age

No.

No.

No.

No.

No.

< 20

132

3.8

28

11.4

12

8.9

172

4.5

4582

7.1

20 24

401

11.6

69

28.2

28

20.7

498

12.9

12121

18.8

25 29

718

20.7

72

29.4

36

26.7

826

21.5

16113

25.0

30 34

1128

32.5

43

17.6

34

25.2

1205

31.3

17782

27.6

35 39

857

24.7

26

10.6

21

15.6

904

23.5

11190

17.4

40

234

6.7

2.9

3.0

245

6.4

2669

4.1

0.0

0.0

0.0

0.0

28

0.0

3470

100

245

100

135

100

3850

100

Not stated
Total

Paraparaumu

C&C DHB

Average age

31.7

27.5

29.0

31.3

Median age

32.3

27.2

28.7

31.9

(Report on Maternity 2010, NZ Ministry of Health, 2012).


* NZ median age for 2012 (www.stats.govt.nz)

The average age for all women and for first time
mothers has remained fairly constant over the last eight
years since 2005 (see next table).

58 |

2010 (NZ)

64485

30.0 *

100

The Womens Health Service Annual Clinical Report 2012

Table 16: Maternal age group distribution for years 2005 to 2012
Mothers

2005

Age

No.

2006

183

%
4.6

No.
219

2008

%
5.4

No.
212

2009

No.

5.3

2010

216

No.

5.4

187

2011

No.

4.8

172

2012

No.

4.4

< 20

202

20 24

427 11.4

484 12.2

508 12.6

531 13.3

492 12.3

512 13.2

487 12.4

498 12.9

25 29

768 20.5

730 18.4

783 19.3

811 20.3

832 20.8

762 19.6

823 21.0

826 21.5

30 34

5.4

No.

2007

172

4.5

1288 34.3 1435 36.2 1342 33.2 1238 31.0 1292 32.3 1263 32.5 1285 32.8 1205 31.3

35 39

893 23.8

928 23.4

959 23.7

997 24.9

967 24.2

959 24.6

937 23.9

904 23.5

40

176

207

236

210

196

208

213

245

Total

4.7

5.2

5.8

5.3

4.9

5.3

5.4

6.4

3754 100 3967 100 4047 100 3999 100 3995 100 3891 100 3917 100 3850 100

Average age
All mothers

31.2

31.4

31.2

31.1

31.2

31.3

31.3

31.3

First time mothers

29.4

29.8

29.5

29.2

29.4

29.6

29.8

29.6

Figure 4: Age group percentage distribution for years 2005 to


2012
<20

40.0 %

20-24

25-29

30-34

35-39

>=40

35.0 %
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%

2005

2006

2007

2008

2009

2010

2011

2012

The following figure plots the ethnicity distribution for


each age group for 2012. Refer to Table 113 in the
Appendices for the underlying data. Mori and Pacific
women are over-represented in the under 25 year age
groups.

| 59

Capital & Coast District Health Board

Figure 5: Ethnicity group distribution within each maternal


age group for 2012
70.0 %

60.0 %

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

< 20 yrs

20 - 24 yrs

NZ European

60 |

25 - 29 yrs

Other European

30 - 34 yrs
Mori

35 - 39 yrs
Pacific Peoples

40 yrs
Asian

Total
Other

The Womens Health Service Annual Clinical Report 2012

7.3 Ethnicity
Reporting of ethnicity is complex and different systems
are used in various reports. The New Zealand Ministry
of Health uses a prioritised ethnicity classification
system. The prioritised ethnicity classification system
works by an individual choosing multiple ethnicities
based on their preferences or self-concept. The
classification system then determines the ethnicity
group value for multiple ethnicities using a hierarchical
system of 21 ethnicity descriptions. This is based on
the following priority: Mori, Pacific peoples, Asian,
other groups except NZ European, NZ European.
Thus, any person who selects Mori as one of their
three ethnicities will be recorded as Mori. (Hospital
based Maternity events 2006, NZ Ministry of Health,

2010). Therefore any comparison between C&C DHB


and New Zealand percentage distribution values needs
to be treated with caution.
The method of ethnicity reporting used in this report
is the sole classification method. Three ethnicity
descriptions can be collected in the PIMS database but
90% of women giving birth at C&C DHB facilities in
2012 indicated one ethnicity only. For the remaining
10% with multiple ethnicities, the first selected ethnicity
value has been used.
Women of different ethnic groups vary in their
utilisation of available maternity services. This
influences their pregnancy risk factors and outcomes.

Table 17: Ethnicity distribution by birth facility for 2012


Mothers

Wellington

Kenepuru

Ethnicity

No.

NZ European

1749

50.4

73

29.8

Other European

432

12.4

12

Mori

384

11.1

Pacific Peoples

293

Asian

No.

Paraparaumu
No.

C&C DHB

2010 (NZ)

No.

No.

90

66.7

1912

49.7

26184

40.6

4.9

17

12.6

461

12.0

6138

9.5

77

31.4

20

14.8

481

12.5

16348

25.4

8.4

65

26.5

0.7

359

9.3

7536

11.7

512

14.8

17

6.9

4.4

535

13.9

6966

10.8

Other

100

2.9

0.4

0.7

102

2.6

1313

2.0

Total

3470

100

245

100

135

100

3850

100

64485

100

(Report on Maternity 2010, NZ Ministry of Health, 2012).

| 61

Capital & Coast District Health Board

Changes in maternal ethnicity over time show an


increase in the Asian group (9.1% in 2005 to 13.9% in
2012) and the Other European group (8.8% in 2005 to
12.0% in 2012). The New Zealand European group has
declined from 55.1% in 2005 to 49.7% in 2012.

Table 18: Maternal ethnicity groups for years 2005 to 2012


Mothers

2005

2006

2007

2008

2009

2010

2011

2012

Ethnicity

No.

No.

No.

No.

No.

No.

No.

No.

NZ
European

2069

55.1

2169

54.7

2089

51.6

2059

51.5

2058

51.5

1946

50.0

1954

49.9

1912

49.7

Other
European

331

8.8

401

10.1

440

10.9

440

11.0

462

11.6

456

11.7

497

12.7

461

12.0

Mori

519

13.8

543

13.7

553

13.7

562

14.1

531

13.3

525

13.5

488

12.5

481

12.5

Pacific
Peoples

370

9.9

393

9.9

394

9.7

389

9.7

407

10.2

387

9.9

385

9.8

359

9.3

Asian

343

9.1

373

9.4

400

9.9

405

10.1

412

10.3

440

11.3

486

12.4

535

13.9

Other

122

3.2

88

2.2

171

4.2

144

3.6

125

3.1

137

3.5

107

2.7

102

2.6

Total

3754

100

3967

100

4047

100

3999

100

3995

100

3891

100

3917

100

3850

100

The distribution of each ethnicity within each of these


six ethnicity groups for years 2005 to 2012 is tabulated
in Table 116 in the Appendices.

The average age varies between ethnicity groups but


Mori and Pacific women are younger on average.
Both NZ European and Other European groups were
older on average. The figure below shows the age
distribution in each ethnicity group.

Table 19: Age group distribution within each ethnicity group


for 2012
Mothers

NZ
European

Other
European

Age

No.

No.

< 20

52

2.7

0.7

76

15.8

35

9.7

0.4

20 24

196

10.3

17

3.7

140

29.1

85

23.7

47

25 29

352

18.4

55

11.9

116

24.1

107

29.8

30 34

640

33.5

186

40.3

70

14.6

75

35 39

540

28.2

159

34.5

62

12.9

40

132

6.9

41

8.9

17

Total

1912

100

461

100

481

Average

32.3

62 |

34.0

Mori
No.

27.1

Pacific
Peoples
No.

No.

Other

No.

3.9

172

4.5

8.8

13

12.7

498

12.9

169

31.6

27

26.5

826

21.5

20.9

206

38.5

28

27.5

1205

31.3

39

10.9

81

15.1

23

22.5

904

23.5

3.5

18

5.0

30

5.6

6.9

245

6.4

100

359

100

535

100

102

100

3850

100

31.4

No.

Total

28.2

Asian

31.0

31.3

The Womens Health Service Annual Clinical Report 2012

Figure 6: Age group distribution within each maternal


ethnicity group for 2012
50.0 %
45.0 %
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
NZ European

< 20 yrs

Other
European

20 - 24 yrs

Mori

Pacific Peoples

25 - 29 yrs

Asian

30 - 34 yrs

Other

35 - 39 yrs

Total
40 yrs

| 63

Capital & Coast District Health Board

7.4 Parity
The parity rates for all women have remained
consistent for the last 8 years. Tables for 2012 of parity
by age group and parity by ethnicity group are listed in
the Appendices (Table 114 and Table 115).

Table 20: Parity for years 2005 to 2012


Mothers

2005

2006

No.

No.

44.8 1813

45.7 1844

45.6 1854

46.4 1828

45.8 1717

44.1 1787

45.6 1741

45.2

1249

33.3 1321

33.3 1372

33.9 1273

31.8 1299

32.5 1285

33.0 1327

33.9 1294

33.6

513

13.7

503

12.7

524

12.9

528

13.2

533

13.3

574

14.8

491

12.5

528

13.7

182

4.8

183

4.6

167

4.1

200

5.0

189

4.7

183

4.7

178

4.5

163

4.2

73

1.9

88

2.2

82

2.0

66

1.7

73

1.8

83

2.1

64

1.6

79

2.1

>4

57

1.5

59

1.5

58

1.4

78

2.0

73

1.8

49

1.3

70

1.8

45

1.2

100 3850

100

100 3995

This next table shows the distribution of previous CS


history for women who gave birth in each year from
2005 to 2012. About 45% of women are primiparous

No.

100 3891

No.

2012

1680

100 3999

2011

100 4047

2010

100 3967

No.

2009

No.

3754

2008

Parity

Total

No.

2007

100 3917

No.

and about 15% are multiparous with one or more


previous CS. This table does not indicate the birth
outcome for these groups of women.

Table 21: Grouping by Caesarean Section (CS) history for years


2005 to 2012
Mothers

2005

2006

2007

2008

2009

2010

2011

2012

Parity
grouping

No.

Primipara

1680

44.8 1813

45.7 1844

45.6 1854

46.4 1828

45.8 1717

44.1 1787

45.6 1741

45.2

42.3 1616

40.7 1641

40.5 1562

39.1 1635

40.9 1589

40.8 1578

40.3 1541

40.0

No.

No.

No.

No.

No.

No.

No.

Multipara, with :
0 previous
CS

1588

1 previous
CS

391

10.4

456

11.5

477

11.8

471

11.8

431

10.8

464

11.9

460

11.7

465

12.1

95

2.5

82

2.1

85

2.1

112

2.8

101

2.5

121

3.1

92

2.3

103

2.7

100 3850

100

>1
previous
CS
Total

64 |

3754

100 3967

100 4047

100 3999

100 3995

100 3891

100 3917

The Womens Health Service Annual Clinical Report 2012

7.5 Smoking
The Ministry of Health have defined a 90% target for
women who identify as smokers at the time of their
pregnancy confirmation. These women should be
offered advice and support to quit smoking when
booking with their LMC or visiting their general
practitioner.

Fewer than 0.5% of women had missing data. There


are four data options in PIMS to identify the number
of cigarettes smoked per day. These have been
combined in the following analysis to denote if a
woman was a smoker. The category given up has
been assigned to the non-smoking group.

There is strong evidence that advice however brief is


effective in prompting quit smoking attempts and longterm quit smoking success.

The following table gives the smoking rates within each


age group for each of the ethnicity groups. Numbers
in each age - ethnicity group cell are the number of
women smoking, the total number of women, and their
rate. For example, in the < 20 years, NZ European
group, 14 of 52 women smoked which is a rate of
26.9%.

Before registration documentation is accepted by the


WHS for data entry to the PIMS database a smoking
dependence and cessation referral record for the
pregnant woman must be completed by their LMC.
This form collects information on the womans smoking
status at the time of booking. Women who indicate
that they would like help to stop smoking are provided
with information about the cessation support options
currently available. The support options include
nicotine replacement therapy, consultation with the
C&C DHB smoking cessation coordinator or referral
to one of four cessation support programmes. The
programmes are Quitline, Aukati Kai Paipa, Pacific
Smoking Cessation or Quit Smoking Service.

The smoking rate for all women in 2012 was 10.4%, but
Mori women had a rate of 41% and Pacific women a
rate of 18.7%. In 2011 National Womens reported an
overall rate of 6.6% at booking and rates of 34.5% for
Mori women and 13.5% for Pacific women (Auckland
District Health Board 2012).
Young women under 25 years had high smoking rates
with a combined rate of 30.3%. National Womens
reported a rate of 19.8% in 2011 for all women 25
years and younger.

Data on smoking is recorded in the PIMS database


and in the C&C DHB patient management system.

Table 22: Rates of smoking at booking time by ethnicity and age


groups for 2012
Mothers

< 20

20 24

25 29

30 34

35 39

40

Total

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

NZ
European

14

26.9

48

24.5

24

6.8

18

2.8

11

2.0

3.0

119

6.2

Other
European

Ethnicity

Mori
Pacific
Peoples
Asian

Other

Total

52

196
0.0

3
41

53.9

22.9

50.0

172

23

0.0

27.1

139
498

45

20

2.1

38.8

18.7

97
826

21

12

1.8

30.0

16.0

56
1205

15

1.0

24.2

7.7

33
904

0.0

47.1

5.6

13
245

197

41.0

67

18.7

359
0.0

1.3

535
0.0

7
3.7

2.4

481

30
0.0

11
461

18

23
4.6

0.0

17

81
0.0

1912

41

39

28
11.7

2.5

62

206
3.7

132

159

75

27
27.9

1.6

70

169
0.0

540

186

107

13
37.2

7.3

116

47

4
64

47.9

85

2
0

67

640

55

140

35
1

0.0

17

76
8

352

1.0

102
5.3

402

10.4

3850

| 65

Capital & Coast District Health Board

Detailed booking data has been collected since 2005


for births at all three C&C DHB birthing facilities. The
next table shows the overall smoking rates for each
ethnicity group from 2005 to 2012.

The rate for Mori women has reduced from 46% in


2005 to 41% in 2012.
The issue of smoking rates will become a priority to be
addressed. The development of further strategies and
interventions and the implementation of these will be
required.

The smoking rates for all women have gradually


declined from 14.6% in 2005 to 10.4% in 2012.

Table 23: Rates of smoking at booking time by ethnicity group


for years 2005 to 2012
Mothers
Ethnicity
NZ
European
Other
European
Mori
Pacific
Peoples
Asian

Other

Total

66 |

2005

2006

2007

2008

2009

2010

2011

2012

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

Num
Den

Rate
%

185

8.9

196

9.0

201

9.6

169

8.2

158

7.7

154

7.9

141

7.2

119

6.2

2069
12

2169
3.6

331
238

45.9

27.3

2.0

3754

81

4.9

20.6

550
3967

243

103

2.1

43.9

26.1

581
4047

248

89

2.0

11

44.1

22.9

536
3999

236

92

2.7

44.4

22.6

510
3995

236

83

2.2

45.0

21.4

492
3891

193

87

0.9

39.5

22.8

448
3917

197

41.0

67

18.7

359
1.0

1.3

535
1.9

107
12.6

2.4

481

486
3.6

11
461

385

137
12.8

4.0

488

440
4.0

20

1912

497

387

125
13.4

2.2

525

412
3.5

10

1954

456

407

144
14.4

2.2

531

405
4.1

10

1946

462

389

171
13.9

3.2

562

400
2.3

14

2058

440

394

88
14.6

4.3

553

373

122
549

44.6

393

343
6

242

19

2059

440

543

370
7

5.2

401

519
101

21

2089

1.0

102
11.4

402
3850

10.4

The Womens Health Service Annual Clinical Report 2012

7.6 Body mass index


Maternal weight gain in pregnancy has implications on
intervention rates and outcomes. There is an increased
risk of pre-eclampsia, gestational diabetes, fetal
macrosomia, and caesarean section (PMMRC, 2012).
Information and recommendations on healthy weight
gain in pregnancy are available.

Table 24: Body mass index (BMI) categories at booking by age


group for 2012
Mothers
BMI *
< 19

< 20
No.

20 24
%

No.

25 29
No.

30 34
No.

35 39
No.

40
No.

Total
%

No.

4.6

18

3.9

39

4.9

41

3.5

17

1.9

1.7

126

3.4

19 25

76

50.3

201

43.4

384

48.6

669

56.8

476

53.8

115

48.9

1921

51.9

26 30

47

31.1

127

27.4

199

25.2

298

25.3

245

27.7

76

32.3

992

26.8

31 35

14

9.3

64

13.8

89

11.3

106

9.0

86

9.7

24

10.2

383

10.3

36 40

2.6

34

7.3

47

5.9

42

3.6

28

3.2

3.8

164

4.4

41 45

1.3

14

3.0

17

2.2

10

0.8

24

2.7

1.7

71

1.9

> 45

0.7

1.1

15

1.9

12

1.0

1.0

1.3

45

1.2

151

100

463

100

790

100

1178

100

885

100

235

100

3702

100

Total

* BMI = Weight (kg) / Height (m ). BMI calculated from booking weights and heights. Missing data is excluded from the table
(3.9% of the total women for 2012)
2

Table 25: Body mass index (BMI) categories at booking by


ethnicity group for 2012
Mothers

NZ
European

Other
European

BMI *

No.

No.

< 19

Pacific
Peoples

Mori
No.

No.

Asian
No.

Other

No.

Total

No.

49

2.6

17

3.8

1.4

0.3

49

9.4

4.0

126

3.4

19 25

1045

56.1

272

60.7

151

34.7

51

15.2

347

66.9

55

54.5

1921

51.9

26 30

492

26.4

113

25.2

147

33.8

106

31.6

100

19.3

34

33.7

992

26.8

31 35

170

9.1

31

6.9

70

16.1

87

26.0

19

3.7

5.9

383

10.3

36 40

61

3.3

2.0

35

8.0

57

17.0

0.4

0.0

164

4.4

41 45

28

1.5

1.1

15

3.4

21

6.3

0.2

1.0

71

1.9

> 45
Total

19

1.0

0.2

11

2.5

12

3.6

0.2

1.0

45

1.2

1864

100

448

100

435

100

335

100

519

100

101

100

3702

100

* BMI = Weight (kg) / Height2 (m2). BMI calculated from booking weights and heights. Missing data is excluded from the table (3.9% of the
total women for 2012)

| 67

Capital & Coast District Health Board

7.7 Lead maternity carer (LMC) at


booking
The PMMRC recommendations regarding early
booking have been made to enable early antenatal
screening, to detect underlying maternal medical
conditions and risk factors and to provide advice and
support with respect to lifestyle choices.
Improved rates of booking in the first trimester of
pregnancy have been noted over the last five years
within the C&C DHB region.
C&C DHB had a long standing contract with a service
provider to assist women looking for a midwife LMC.
However the number of women who accessed this
service and successfully found an LMC had decreased
over recent years. C&C DHB recently reviewed the
service specification and as a result decided to contract
for a revised service.

Developing close working relationships with


primary health organisations and their general
practitioner members, C&C DHB, the College of
Midwives and the Ministry of Health to ensure that
midwife LMC information is accurate and up to
date within the Capital and Coast district

Creating an electronic website that provides


information on maternity services within the
district with links to relevant websites

Producing information pamphlets which will


provide key messages and the step by step
process for finding a midwife.

The WHS will tender for two sections of the proposal


enabling and supporting women in their decision to
find a midwife LMC and early antenatal education.

The new service components will include:

Table 26: LMC bookings by trimester at time of first visit, for


years 2008 to 2012
Mothers

2008

2009

2010

2011

2012

Trimester at booking

No.

No.

No.

No.

No.

First (0 13+6 weeks)

2122

53.1

2267

56.7

2256

58.0

2339

59.7

2444

63.5

Second (14+0 26+6 weeks)

1282

32.1

1184

29.6

1126

28.9

1124

28.7

931

24.2

Third (27 40 weeks)

274

6.9

232

5.8

222

5.7

186

4.7

195

5.1

Gestation at first visit not stated

321

8.0

312

7.8

287

7.4

268

6.8

280

7.3

3999

100

3995

100

3891

100

3917

100

3850

100

+0

Total

68 |

The Womens Health Service Annual Clinical Report 2012

Table 27: Lead Maternity Carer (LMC) at time of booking by


facility of birth for 2012
Mothers

Wellington

LMC at booking

No.

No.

No.

No.

2455

70.7

245

100.0

135

100.0

2835

73.6

Hospital Midwifery Primary Care

320

9.2

320

8.3

Obstetrician & Midwife LMC

144

4.1

144

3.7

Obstetrician & Hospital Midwifery Shared Care

229

6.6

229

5.9

Hospital Secondary / Tertiary

322

9.3

322

8.4

3470

100

3850

100

Midwife LMC

Total

The number of women booking with a midwife LMC


has remained fairly constant at about 70% over the last
five years. There has however been a decline in the

Kenepuru

245

Paraparaumu

100

135

100

C&C DHB

number of women cared for by a private obstetrician


and midwife LMC combination. This was due to a
number of obstetricians giving up private practice.

Table 28: Lead Maternity Carer (LMC) at time of booking for


years 2008 to 2012
Mothers

2008

LMC at Booking

2009

2010

2011

2012

No.

No.

No.

No.

No.

2812

70.3

2813

70.4

2683

68.9

2660

67.9

2835

73.6

Hospital MW Primary Care

264

6.6

371

9.3

396

10.2

361

9.2

320

8.3

Obst. & Midwife LMC

404

10.1

300

7.5

300

7.7

261

6.7

144

3.7

Obst. & Hosp. MW Shared

219

5.5

165

4.1

159

4.1

253

6.5

229

5.9

Hospital Secondary/Tertiary

300

7.5

346

8.7

353

9.1

382

9.8

322

8.4

3999

100

3995

100

3891

100

3917

100

3850

100

Midwife LMC

Total

Table 29: Ethnicity group distribution by booking LMC for 2012


Mothers

Midwife LMC

Hospital
Midwifery
Primary Care

Obstetrician
& Midwife
LMC

Obstetrician
& Hospital
Midwifery
Shared Care

Ethnicity

No.

NZ European

1397

49.3

108

33.8

101

70.1

159

69.4

Other European

334

11.8

40

12.5

19

13.2

36

Mori

371

13.1

29

9.1

0.7

Pacific Peoples

280

9.9

46

14.4

Asian

384

13.5

83

25.9

Other

69

2.4

14

Total

2835

100

320

No.

No.

No.

Hospital
Secondary /
Tertiary
No.

Total

No.

147

45.7

1912

49.7

15.7

32

9.9

461

12.0

2.2

75

23.3

481

12.5

0.7

0.0

32

9.9

359

9.3

17

11.8

23

10.0

28

8.7

535

13.9

4.4

3.5

2.6

2.5

102

2.6

100

144

100

229

100

322

100

3850

100

| 69

Capital & Coast District Health Board

Table 30: Parity group distribution by booking LMC for 2012


Hospital
Midwifery
Primary
Care

Midwife
LMC

Mothers
Parity

No.

Primiparous

1284

45.3

160

50.0

66

45.8

105

45.9

Multip. & no CS

1173

41.4

109

34.1

53

36.8

87

38.0

378

13.3

51

15.9

25

17.4

37

2835

100

320

100

144

100

229

Multip. prev. CS
Total

No.

Obstetrician
& Hospital
Midwifery
Shared Care

Obstetrician
& Midwife
LMC

No.

No.

Hospital
Secondary /
Tertiary

No.

Total

No.

126

39.1

1741

45.2

119

37.0

1541

40.0

16.2

77

23.9

568

14.8

100

322

100

3850

100

7.8 Hospital Primary Care


The primary care team are a group of midwives who
provide antenatal and postnatal care to women who
have been unable to locate an LMC. Antenatal clinics
are held at Wellington Regional Hospital and Kenepuru

Hospital Monday to Friday. Labour and birth care is


undertaken by core midwives in delivery suite.
Midwives working within the primary care team are
employees of C&C DHB.

Table 31: Parity by ethnicity for women booked with Hospital


Midwifery Primary Care for 2012
Mothers

NZ
European

Other
European

Parity

No.

No.

Mori
No.

Pacific
Peoples
No.

Asian
No.

Other

No.

Total

No.

52

48.1

20

50.0

11

37.9

23

50.0

46

55.4

57.1

160

50.0

40

37.0

14

35.0

27.6

19.6

28

33.7

14.3

101

31.6

13

12.0

10.0

20.7

15.2

9.6

14.3

40

12.5

0.9

5.0

3.4

8.7

1.2

0.0

2.8

1.9

0.0

3.4

6.5

0.0

7.1

2.2

>4

0.0

0.0

6.9

0.0

0.0

7.1

0.9

108

100

40

100

29

100

46

100

83

100

14

100

320

100

Total

70 |

The Womens Health Service Annual Clinical Report 2012

8. Antenatal complications

8.1 Preterm birth


In 2012, 413 women (10.7%) had a preterm birth
at C&C DHB. The preterm birth rate for C&C DHB
domiciled women was 7.7% (275/3575) and 50.2%
(138/275) for women from other DHBs.
The number of births under 37 weeks has remained
stable at just under 11% of pregnancies for the last
three years. Although this rate is similar to other
tertiary units in New Zealand, comparisons to other
units and other countries is difficult as the local data
includes women transferred in from secondary units
around the region and other tertiary units. In addition
the data does not differentiate between spontaneous
and iatrogenic preterm births. National Womens
reports both iatrogenic and spontaneous preterm
births to monitor these rates over time.
The rate of preterm birth in the local population is
7.7%. This is similar to the rate in Australia (8%) and
in Europe (6.2%). The highest rates of preterm birth
were in Africa and North America 11.9% and 10.6%
of all births, respectively (Bulletin of the World Health
Organization).

The advent of progesterone therapy for the prevention


of preterm labour has the potential to decrease the
rate of preterm delivery. Unfortunately the overall
impact of this therapy is limited, as it is currently used
for women at increased risk of preterm birth and
the majority of women who deliver preterm have no
recognisable risk factors.
The survival rate for babies born prematurely is
excellent. Accurate assessment of gestational age is
necessary to ensure reliable data. Small changes in
gestational age around the time of viability can result in
a significant change in outcome. It is important to note
that all of the babies born alive at 24 weeks gestation
survived for more than 28 days. Early recognition of
preterm labour allows the extremely preterm neonate
to be born in optimal condition with a good chance of
survival even at 24 weeks.
Preterm birth remains the leading cause of neonatal
death, and is second only to congenital anomaly as
a cause of perinatal death (PMMRC, 2012). Mori
women remain more likely to deliver preterm than
women of other ethnicities. The PMMRC has identified
that access to care and poverty are risk factors which
are associated with perinatal death.

| 71

Capital & Coast District Health Board

Table 32: Preterm rates by maternal age group for 2012


Mothers
Gestation

< 20

20 24

25 29

30 34

35 39

40

Total

No.

No.

No.

No.

No.

No.

No.

< 24 weeks

1.7

0.6

0.8

11

0.9

0.7

0.0

30

0.8

24 27

1.2

1.6

10

1.2

13

1.1

1.0

2.9

49

1.3

28 31

4.1

13

2.6

16

1.9

15

1.2

14

1.5

2.9

72

1.9

+6

32 35

3.5

16

3.2

33

4.0

39

3.2

32

3.5

12

4.9

138

3.6

36+0 36+6

2.3

20

4.0

29

3.5

28

2.3

34

3.8

3.7

124

3.2

All < 32 weeks

12

7.0

24

4.8

33

4.0

39

3.2

29

3.2

14

5.7

151

3.9

All < 37 weeks

22

12.8

60

12.0

95

11.5

106

8.8

95

10.5

35

14.3

413

10.7

+0
+0
+0

+6
+6

Table 33: Preterm rates by maternal ethnicity group for 2012


Mothers

NZ
European

Other
European

Gestation

No.

No.

No.

No.

No.

No.

No.

< 24 weeks

13

0.7

0.2

1.9

0.6

0.9

0.0

30

0.8

24+0 27+6

26

1.4

1.3

12

2.5

0.6

0.6

0.0

49

1.3

28+0 31+6

31

1.6

10

2.2

15

3.1

1.9

1.1

2.9

72

1.9

32+0 35+6

71

3.7

11

2.4

18

3.7

15

4.2

17

3.2

5.9

138

3.6

36 36

58

3.0

1.3

16

3.3

12

3.3

28

5.2

3.9

124

3.2

All < 32 weeks

70

3.7

17

3.7

36

7.5

11

3.1

14

2.6

2.9

151

3.9

All < 37 weeks

199

10.4

34

7.4

70

14.6

38

10.6

59

11.0

13

12.7

413

10.7

+0

72 |

+6

Pacific
Peoples

Mori

Asian

Other

Total

The Womens Health Service Annual Clinical Report 2012

Table 34: Perinatal outcome of preterm births by gestation for


2012
Gestation

Total
births

Fetal
deaths

Live
births

% Live births
of Total

Neonatal deaths
< 28 days

% of live births
surviving 28 days

20

0.0

0.0

21

0.0

0.0

22

12

11

8.3

0.0

23

44.4

75.0

24

11

72.7

100.0

25

11

81.8

100.0

26

21

17

91.0

100.0

27

14

13

92.9

92.3

28

17

17

100.0

88.2

29

13

13

100.0

100.0

30

27

26

96.3

96.2

31

27

27

100.0

96.3

32

19

18

94.7

100.0

33

32

32

100.0

100.0

34

43

42

97.7

97.6

35

66

66

100.0

100.0

36

134

134

100.0

100.0

Total

466

39

427

91.6

98.1

| 73

Capital & Coast District Health Board

8.2 Multiple pregnancy


Birth rates for multiple pregnancies have remained
stable. At term there were no multiple pregnancies
that had a spontaneous labour. Not awaiting labour
is supported by a study undertaken by JM Dodd et al,
2012. Further data considering other outcomes for
multiple pregnancies may be worthwhile.

There were no births in 2012 where there was a vaginal


birth for the first twin followed by a caesarean section
for the second twin.

Table 35: Multiple pregnancy numbers and rates for years


2003 to 2012
Mothers
Multiple
pregnancies
Twin

2003
No.

2004
%

No.

2005
%

No.

2006
%

No.

2007
%

No.

2008
%

No.

2009
%

No.

2010
%

No.

2011
%

No.

2012
%

No.

84 2.14

91 2.46

81 2.16

72 1.81

93 2.30

88 2.20

81 2.03

88 2.26

78 1.99

66 1.71

Triplet

4 0.10

3 0.08

1 0.03

1 0.03

2 0.05

2 0.05

4 0.10

3 0.08

3 0.08

2 0.05

Total

88 2.24

94 2.54

82 2.18

73 1.84

95 2.35

90 2.25

85 2.13

91 2.34

81 2.07

68 1.77

74 |

The Womens Health Service Annual Clinical Report 2012

Figure 7: Labour and birth branch diagram for all women with
multiple pregnancies for 2012
Pre-labour CS
31 / 51 = 60.8%
CS
Pre-term
51 / 68 = 75.0%
NVB
AVB
CS

31

Spontaneous Labour
41 / 51 = 27.5%

5
9

9.8%
17.6%

NVB
AVB

37

72.5%

CS

51 100%

All Women with multiple


pregnancies No. = 68
NVB 7 10.3%
AVB
14
20.6%

100.0%

45.6
% of
Total No.

4
7

26.8%
50.0%

5.9
10.3

21.4%

4.4
20.6

14 100%

% of
Total No.

Induced Labour
6 / 51 = 11.8%

% of
Total No.

NVB
1
16.7%
AVB
2
33.3%
CS
3
50.0%
6 100%

1.5
2.9
4.4
8.8

Pre-labour CS
6 / 17 = 35.3%

% of
Total No.

8.8

CS 47 69.1%

68 100%

CS
Term
17 / 68 = 25.0%
NVB
AVB
CS

2 11.8%
5
29.4%
10
58.8%
17 100%

100%

Spontaneous Labour
0 / 17 = 0.0%

% of
Total No.

NVB 0 0.0%
AVB
0
0.0%

0.0
0.0

CS

0 0%

0.0
0.0

0.0%

Induced Labour
11 / 17 = 64.7%
NVB
AVB
CS

% of
Total No.

2
5

18.2%
45.5%

2.9
7.4

36.4%

5.9
16.2

11 100%

100

| 75

Capital & Coast District Health Board

8.3 Diabetes in pregnancy


4.8% (185 / 3850) of women who gave birth in 2012
at C&C DHB had a diagnosis of pre-existing or
gestational diabetes. 4.1% (158 / 3850) had GDM,

0.3% (12 / 3850) Type 1 diabetes, and 0.4% (15 / 3850)


Type 2 diabetes.

Table 36: Ethnicity of women with GDM and Type 2 diabetes


giving birth in 2012
GDM
Ethnicity

Type 2

Number

Of total births

Number

Of total births

NZ European

58

1912

3.0

1912

0.1

Other European

15

461

3.3

461

0.0

Mori

10

481

2.1

481

1.0

Pacific Peoples

18

359

5.0

359

1.4

Asian

51

535

9.5

535

0.6

Other

102

5.9

102

0.0

Total

158

3850

4.1

15

3850

0.4

Table 37: Ethnicity distribution within diabetes type for women


attending clinic in 2012
GDM
Ethnicity

Type 1

Type 2

Total

No.

No.

No.

No.

NZ European

72

37.9

18

78.3

17.9

95

39.4

Other European

16

8.4

4.3

0.0

17

7.1

Mori

13

6.8

4.3

25.0

21

8.7

Pacific Peoples

23

12.1

8.7

10

35.7

35

14.5

Asian

59

31.1

4.3

21.4

66

27.4

Other

3.7

0.0

0.0

2.9

Total

190

100

23

100

28

100

241

100

Given the number of Pacific Peoples with Type 2


diabetes it is surprising to see the relatively low rates
of gestational diabetes (GDM) in this ethnic group. As
GDM is often seen as a precursor to Type 2 diabetes
it could be expected that the rate of GDM in Pacific
Peoples would mirror the rate of Type 2 diabetes
in that ethnic group. This may be related to them
not being screened, having a false negative screen
(Sacks et al, 1989) or reflect the need for ethnically
appropriate cut offs for the 50g glucose screen (Nahum

76 |

and Huffaker, 1993), (Esakof et al, 2005). National


Womens Annual Report (2011) noted a similar
trend with Pacific women and has seen this group
over-represented in a group in their clinic that were
diagnosed using HbA1c with a normal OGTT. They
found 90% of this group needed treatment. Certain
ethnic groups are at risk of diabetes. Our women with
diabetes reflect the higher rates in Pacific and Asian
groups.

The Womens Health Service Annual Clinical Report 2012

Table 38: Mode of birth by diabetes type for births in 2012


within C&C DHB
Mothers
Mode

Gestational

Type 1
No.

Type 2

No.

Normal

71

44.9

16.7

Forceps

5.7

Ventouse

3.2

Manual rotation

Breech

No.

Total
%

No.

40.0

79

42.7

0.0

0.0

4.9

0.0

0.0

2.7

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

85

53.8

16.7

40.0

93

50.3

Emergency

45

28.5

25.0

26.7

52

28.1

Elective

28

17.7

58.3

33.3

40

21.6

73

46.2

10

83.3

60.0

92

49.7

158

100

12

100

15

100

185

100

Vaginal

Caesarean

Total

Generally for the diabetes population there is a


caesarean rate of 40-50%. Women with pre-existing
diabetes often are reported with caesarean section
rates around 50-67% (Jensen et al, 2004), (Gunton et
al, 2000), (Bell et al, 2008).
There is a high caesarean section rate in women with
Type 1 diabetes although the numbers of women with
Type 1 diabetes is small.

| 77

Capital & Coast District Health Board

8.4 Maternal Fetal Medicine Service &


Ultrasound Scan Service
The number of referrals to the MFM service and the
origin of those referrals have remained relatively stable
over the last three years. The service also provides
outreach clinics at Taranaki District Health Board once
a month. These referrals are not included in the C&C
DHB data.
Over the last three years women have been identified
by referral category at the initial consultation. The
categories have been designed to reflect the two main
functions of the service, namely screening and fetal
anomaly management, but also several specific fetal

conditions which require either protracted follow-up


(twins and RBC antibodies) or considerable interregional coordination (cardiac conditions).
With the advent of tele-radiology there have been an
increasing number of women managed remotely. This
can often be very effective, but is mostly limited by the
quality of the ultrasound examination at the referring
centre. The MFM service has run educational sessions
in the Hawkes Bay and Taranaki to improve the quality
of referrals and increase the number of women who are
managed locally.

Table 39: Referrals to Maternal Fetal Medicine for years


2010 to 2012
2010

2011

Category

No.

Screening

153

29.4

Multiple pregnancy

22

Red blood cell antibodies


Cardiac

No.

93

17.7

104

21.7

4.2

38

7.2

15

3.1

13

2.5

15

2.9

1.3

21

4.0

27

5.1

29

6.1

New (Others)

312

59.9

322

61.2

294

61.4

Telemedicine

0.0

31

5.9

31

6.5

Total women referred

521

100

526

100

479

100

Follow up visits

737

718

695

Average visits per patient

3.1

2.4

3.0

The perinatal ultrasound unit provides MFM


ultrasound services for the central region. It also
undertakes obstetric and gynaecology scanning for
women referred to the WHS. The service undertakes
approximately 5,000 obstetric and MFM scans a year
and 1500 gynaecology scans and this number has
remained relatively constant.

78 |

No.

2012

The Womens Health Service Annual Clinical Report 2012

Table 40: Ultrasound Scanning Service volumes for years 2008


to 2012
2008

2009

2010

2011

2012

Scan or procedure

No.

No.

No.

No.

No.

Early pregnancy scan

863

20.5

750

18.8

460

13.3

410

12.1

507

14.0

2707

64.3

2578

64.5

2461

71.4

2483

73.3

2555

70.9

Morphology scan

643

15.3

668

16.7

528

15.3

496

14.6

544

15.1

Total Obstetrics

4213

100

3996

100

3449

100

3389

100

3606

100

MFM scan

1081

76.8

1426

83.5

1327

83.8

1354

87.4

1151

86.2

186

13.2

172

10.1

133

8.4

102

6.6

105

7.9

89

6.3

77

4.5

55

3.5

45

2.9

52

3.9

Fetal blood sampling

0.3

0.1

0.4

0.1

0.1

Intrauterine blood transfusion

0.6

0.5

21

1.3

13

0.8

0.3

Amnio drainage

0.5

0.5

19

1.2

13

0.8

0.5

Amnio infusion

0.0

0.1

0.1

0.0

0.0

Platelet transfusion

0.1

0.1

0.3

0.0

0.1

Shunt

0.1

0.0

0.1

0.1

0.0

Embryo reduction/fetocide

0.6

0.4

10

0.6

12

0.8

11

0.8

20

1.4

0.2

0.4

0.5

0.2

Total MFM

1407

100

1708

100

1584

100

1549

100

1335

100

Gynaecology

1475

Growth scan ( 20 weeks)

Amniocentesis
Chorionic villus sampling

Other sampling

1485

The screening programme for Down syndrome and


other conditions was introduced in 2010. There was a
steady decrease in the number of referrals for invasive
diagnostic procedures with 23% fewer tests performed
in 2011 than in 2010. The indications for invasive
testing in 2012 have remained very similar to those
in 2011. Increased combined risk is now the most
common indication for an invasive test. Some invasive
tests will be performed on the basis of NT alone. This
is usually when there is a markedly increased nuchal
translucency or cystic hygroma. There has been a
slight increase in the number of women having an
invasive test for an increased MSS2, but it would
appear that the majority of women being screened
are having the combined test, which is in line with
Ministry of Health recommendations. The steady

1547

1451

1456

decrease in the number of invasive tests at 20 weeks


over the last 5 years has plateaued. This was probably
due to improved detection of anomalies due to the
introduction of first trimester screening.
Although the data from 2012 is very similar to the
data from 2011, the rates of invasive testing is
highly likely to change with the introduction of Non
Invasive Prenatal Diagnosis (NIPD). At present this
test is neither publicly funded nor integrated into the
screening programme. NIPD has not been validated
for a low risk population. The NZ MFM network and
RANZCOG have recommended that the test not be
introduced in New Zealand (current cost about $2,000)
until it is validated for a low risk population and/or
integrated into the current screening programme.

| 79

Capital & Coast District Health Board

Table 41: Amniocentesis and CVS indications for years 2008 to


2012
2008
Indication
Increased combined risk

No.

2009
%

No.

2010
%

No.

2011
%

No.

2012
%

No.

1.5

2.4

42

22.3

58

39.5

57

36.3

117

42.5

91

36.5

32

17.0

16

10.9

17

10.8

0.7

26

10.4

31

16.5

2.7

10

6.4

123

44.7

123

49.4

105

55.9

78

53.1

84

53.5

Previous chromosomally
abnormal child

2.9

14

5.6

3.2

6.1

5.7

Advanced maternal age

50

18.2

18

7.2

2.7

1.4

1.9

Maternal anxiety

11

4.0

10

4.0

3.7

2.7

2.5

Subtotal

69

25.1

42

16.9

18

9.6

15

10.2

16

10.2

Carrier of genetic disease

13

4.7

13

5.3

4.3

12

8.2

5.7

1.1

0.4

2.1

1.4

0.6

Subtotal

16

5.8

14

5.6

12

6.4

14

9.5

10

6.4

Fetal abnormality

39

14.2

34

13.7

30

16.0

13

8.8

17

10.8

Abnormalities on 20 week
scan

15

5.5

19

7.6

16

8.5

10

6.8

13

8.3

1.1

2.0

3.7

12

8.2

13

8.3

57

20.7

58

23.3

53

28.2

35

23.8

43

27.4

3.4

2.5

188

100

147

100

157

100

Increased risk on NT
Increased risk on maternal
serum screen
Subtotal

Carrier of balanced
translocation

Abnormalities on
subsequent scan
Subtotal
Other or not specified
Total

10

3.6

12

4.8

275

100

249

100

In 2011 there was one miscarriage after an


amniocentesis (0.5%). That was in a twin pregnancy
where one of the twins had hydrops and there was a
high risk of miscarriage prior to the test. There were
three stillbirths after amniocentesis, one with multiple
anomalies and two with severe IUGR.
The data for 2012 is incomplete (January to
September) as some babies have not been born
yet. There were four stillbirths after amniocentesis,
one fetus had severe hydrops due to parvovirus, one

80 |

Trisomy 13 and two with severe IUGR. There was


one woman who had an amniotic fluid leak following
amniocentesis but this settled and she delivered
at term. There were no pregnancy losses directly
attributable to the procedure.
The data does not include multiple pregnancy
reduction or complications from other invasive
procedures. The data outcomes for women delivering
outside C&C DHB remain incomplete.

The Womens Health Service Annual Clinical Report 2012

Table 42: Outcomes after Amniocentesis and CVS for 2011 and
2012 (Jan-Sep)
Outcome

2011

2012

No.

No.

0.5

0.0

TOP

42

22.2

34

21.9

Trisomy 21

10

5.3

14

9.0

Trisomy 18

4.2

5.2

Trisomy 13

1.1

1.9

Turners

2.1

0.0

Other

0.5

3.2

Stillbirth

1.6

2.6

Livebirth

113

59.8

79

51.0

2.6

5.2

189

100

155

100

Miscarriage

Not known
Total

8.5 Maternal Cardiac


The obstetric anaesthetic cardiology service was
created to streamline the management of maternal
cardiac related conditions during pregnancy.
The aetiology of women presenting to this service
varies significantly and includes valvular lesions and
replacements, cardiomyopathy and dysrhythmias with
and without internal cardiac defibrillators. During the
latter part of 2012 all women with cardiac conditions
were assigned to the same obstetric clinic in order to
optimise continuity of care.
The multidisciplinary team meets once a month to
discuss referrals and includes three obstetricians
dedicated to high risk obstetrics, a MFM specialist, an
anaesthetist and two cardiologists.
Over the past few years the number of women being
referred to this service has steadily increased from
five in 2009 to 33 in 2011. The number of women
presenting in 2012 is currently incomplete.

An electronic interdepartmental case review template


has recently been created on the Medical Applications
Portal. This has significantly improved the accessibility
of our management plans and will allow us to enhance
the service and improve data collection. The template
is currently available to clinicians at Capital and Coast,
Wairarapa and Hutt Valley DHBs and is due to be
extended to other DHBs in the lower North Island in
2013.
Challenges continue to be:

Building a national support network to assist


clinicians managing these women

Optimising the care of pregnant women with


cardiac conditions

Increasing the awareness of this service.

| 81

Capital & Coast District Health Board

82 |

The Womens Health Service Annual Clinical Report 2012

9. Labour and birth

In this section, labour and mode of birth are analysed


by maternal age, ethnicity and parity group. Induction
of labour and breech presentation are discussed.
Labour and birth branch diagrams are presented using
data for 2012 for the following four parity groups:

All women

Primiparous women

Multiparous women without previous CS

Multiparous women with previous CS

Each branch diagram shows the number of women


whose birth was at term (37+0 weeks and over) or
pre-term (under 37+0 weeks gestation). These two
groups are further subdivided into the type of labour

experienced (spontaneous, induced, or pre-labour CS).


Within each category, mode of birth is detailed.
The three labour categories (spontaneous, induced,
and pre-labour CS) used to determine the onset of
labour have been defined from two date and time
fields in the PIMS database. As there is no specific
field in PIMS to define an induction of labour, the time
difference between the fields labour established
and induction or augmentation started has been
calculated and used for the above categories. The
labour category for some women may not be correct
because of incomplete data.
After the branch diagrams, figures for mode of birth by
age group are presented for each of the parity groups
described above.

| 83

Capital & Coast District Health Board

9.1 Mode of birth


Mode of birth statistics are presented in the next table
for the years 2003 to 2012. The following figure shows
the mode of birth groups (normal, assisted, CS) for the
years 1997 to 2012.

remained stable for the last two years at just under


31%. The assisted vaginal birth rate also remains
stable at about 11.5%.

The normal birth rate has remained under 60% for


the last three years. The caesarean section rate has

Table 43: Mode of birth for years 2003 to 2012


Mothers
Mode of
Birth

2003
No.

2004
No.

2005
No.

2006
No.

2007
No.

2008
No.

2009
No.

2010
No.

2011
No.

2012
No.

Vaginal
Normal

2420 61.6 2270 61.3 2278 60.7 2338 58.9 2413 59.6 2438 61.0 2442 61.1 2300 59.1 2226 56.8 2224 57.8

Forceps

238

6.1

191

5.2

200

5.3

243

6.1

232

5.7

222

5.6

187

4.7

227

5.8

259

6.6

215

5.6

Ventouse

173

4.4

166

4.5

212

5.6

164

4.1

199

4.9

205

5.1

245

6.1

174

4.5

198

5.1

192

5.0

Manual
Rotation

0.1

0.0

0.0

0.1

0.0

0.0

0.0

0.0

0.0

0.0

Breech

25

0.6

20

0.5

19

0.5

33

0.8

26

0.6

19

0.5

28

0.7

38

1.0

25

0.6

27

0.7

Total
Vaginal

2860 72.8 2648 71.5 2710 72.2 2780 70.1 2870 70.9 2885 72.1 2902 72.6 2739 70.4 2709 69.2 2659 69.1

Caesarean
Emergency

707 18.0

743 20.1

722 19.2

787 19.8

790 19.5

735 18.4

686 17.2

717 18.4

780 19.9

758 19.7

Elective

360

312

322

400 10.1

387

379

407 10.2

435 11.2

428 10.9

433 11.2

9.2

8.4

8.6

9.6

9.5

Total
1067 27.2 1055 28.5 1044 27.8 1187 29.9 1177 29.1 1114 27.9 1093 27.4 1152 29.6 1208 30.8 1191 30.9
Caesarean
Total

84 |

3927

100 3703

100 3754

100 3967

100 4047

100 3999

100 3995

100 3891

100 3917

100 3850

100

The Womens Health Service Annual Clinical Report 2012

Figure 8: Mode of birth group rates for years 1997 to 2012, for
all C&C DHB facilities combined
Normal

80.0 %

CS

Assisted

70.0 %

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
1997

1998

1999

2000 2001 2002 2003

See Table 117 in the Appendices for the percentages


values used in the above figure.
Note that normal vaginal birth has been assigned to
all the births at Kenepuru Maternity Unit before 2002
and to all births at Paraparaumu Maternity Unit before

2004 2005 2006

2007

2008

2009

2010 2011

2012

2005. This was before the PIMS database was used


at these units and numbers of births were collected
manually. Some forceps births were done by GP LMCs
at Kenepuru Maternity in the years before 2002 but the
exact numbers are unknown.

| 85

Capital & Coast District Health Board

The following two tables present the mode of birth


numbers for 2012 by age group and by ethnicity
group.

in those women less than 20 years of age to 47.3% for


women aged 40 years and older.
Mode of birth also varied between ethnicity
groups. Pacific and Mori women had the lowest
total caesarean section rates of 26.5% and 27.0%
respectively.

Mode of birth varied markedly with maternal age.


Younger women had the highest rates of normal birth.
Total caesarean section rates rose from 20.3%

Table 44: Mode of birth by age group for 2012


Mothers
Mode of birth

< 20

20 24

25 29

30 34

40

35 39

Total

No.

No.

No.

No.

No.

No.

No.

Normal

116

67.4

330

66.3

494

59.8

692

57.4

481

53.2

111

45.3

2224

57.8

Forceps

11

6.4

25

5.0

44

5.3

73

6.1

51

5.6

11

4.5

215

5.6

Ventouse

5.2

25

5.0

49

5.9

73

6.1

31

3.4

2.0

192

5.0

Manual rotation

0.0

0.0

0.0

0.1

0.0

0.0

0.0

Breech

0.6

0.2

0.8

0.7

0.8

0.8

27

0.7

137

79.7

381

76.5

594

71.9

848

70.4

570

63.1

129

52.7

2659

69.1

32

18.6

89

17.9

158

19.1

218

18.1

191

21.1

70

28.6

758

19.7

1.7

28

5.6

74

9.0

139

11.5

143

15.8

46

18.8

433

11.2

35

20.3

117

23.5

232

28.1

357

29.6

334

36.9

116

47.3

1191

30.9

172

100

498

100

826

100

1205

100

904

100

245

100

3850

100

Vaginal

Caesarean
Emergency
Elective

Total

Table 45: Mode of birth by ethnicity group for 2012


Mothers

NZ
European

Other
European

Mode

No.

No.

No.

No.

No.

Normal

1091

57.1

238

51.6

309

64.2

243

67.7

294

55.0

Forceps

110

5.8

34

7.4

18

3.7

11

3.1

32

Ventouse

99

5.2

31

6.7

17

3.5

10

2.8

0.0

0.2

0.0

14

0.7

0.7

1.5

1314

68.7

307

66.6

351

Emergency

378

19.8

96

20.8

Elective

220

11.5

58

598

31.3

1912

100

Mori

Pacific
Peoples

Asian

Other
No.

Total

No.

49

48.0

2224

57.8

6.0

10

9.8

215

5.6

29

5.4

5.9

192

5.0

0.0

0.0

0.0

0.0

0.0

0.6

0.0

27

0.7

73.0

264

73.5

358

66.9

65

63.7

2659

69.1

85

17.7

61

17.0

112

20.9

26

25.5

758

19.7

12.6

45

9.4

34

9.5

65

12.1

11

10.8

433

11.2

154

33.4

130

27.0

95

26.5

177

33.1

37

36.3

1191

30.9

461

100

481

100

359

100

535

100

102

100

3850

100

Vaginal

Manual rotation
Breech

Caesarean

Total

86 |

The Womens Health Service Annual Clinical Report 2012

9.2 Labour and birth by parity group

Figure 9: Labour and birth branch diagram for all women for
2012
Pre-labour CS
154 / 413 = 37.3%
CS
Pre-term
413 / 3850 = 10.7%
155
42

37.5%
10.2%

NVB
AVB

CS

216

52.3%

CS

All Women
Total No. = 3850
NVB 2224 57.8%
AVB
435
11.3%

100.0%

Spontaneous Labour
144 / 413 = 34.9%

NVB
AVB

413 100%

154

4.0
% of
Total No.

92
22

63.9%
15.3%

2.4
0.6

30

20.8%

0.8
3.7

144 100%

% of
Total No.

Induced Labour
115 / 413 = 27.8%

% of
Total No.

NVB
63
54.8%
AVB
20
17.4%
CS
32
27.8%
115 100%

1.6
0.5
0.8
3.0

Pre-labour CS
448 / 3437 = 13.0%

% of
Total No.

CS 1191 30.9%

3850 100%

CS
Term
3437 / 3850 = 89.3%

448

100%

Spontaneous Labour
2011 / 3437 = 58.5%

11.6
% of
Total No.

NVB 2069 60.2%


AVB
393
11.4%

NVB 1532
AVB
225

76.2%
11.2%

39.8
5.8

CS

CS

12.6%

6.6
52.2

975
28.4%
3437 100%

254

2011 100%

Induced Labour
978 / 3437 = 28.5%
NVB
AVB

% of
Total No.

537
168

54.9%
17.2%

13.9
4.4

CS

273

27.9%

978 100%

7.1
25.4
100

Labour

No.

Spontaneous
Induced

2155
1093

56.0
28.4

Pre-labour CS
Total

602
3850

15.6
100

| 87

Capital & Coast District Health Board

Figure 10: Labour and birth branch diagram for primiparous


women for 2012
Pre-labour CS
56 / 181 = 30.9%
CS
Pre-term
181 / 1741 = 10.4%

56

Spontaneous Labour
72 / 181 = 39.8%

NVB
AVB

69
22

38.1%
12.2%

NVB
AVB

CS

90

49.7%

181 100%

Primiparous
No. = 1741
NVB 810 46.5%
AVB
342
19.6%

100.0%

% of
Primip No.
3.2
% of
Primip No.

46
12

63.9%
16.7%

2.6
0.7

CS

14

19.4%

72 100%

0.8
4.1

Induced Labour
53 / 181 = 29.3%

% of
Primip No.

NVB
23
43.4%
AVB
10
18.9%
CS
20
37.7%
53 100%

1.3
0.6
1.1
3.0

Pre-labour CS
100 / 1560 = 6.4%

% of
Primip No.

CS 589 33.8%

1741 100%

CS

100

100%

5.7

Term
1560 / 1741 = 89.6%

Spontaneous Labour
882 / 1560 = 56.5%

% of
Primip No.

NVB 741 47.5%


AVB
320
20.5%

NVB 529 60.0%


AVB
182
20.6%

30.4
10.5

CS

CS

171

882 100%

9.8
50.7

499
32.0%
1560 100%

19.4%

Induced Labour
578 / 1560 = 37.1%
NVB
AVB

% of
Primip No.

212
138

36.7%
23.9%

12.2
7.9

CS

228

39.4%

578 100%

13.1
33.2
100

Labour

No.

Spontaneous
Induced

954
631

54.8
36.2

Pre-labour CS
Total

156
1741

9.0
100

88 |

The Womens Health Service Annual Clinical Report 2012

Figure 11: Labour and birth branch diagram for multiparous


women without previous CS for 2012
Pre-labour CS
50 / 161 = 31.1%
CS
Pre-term
161 / 1541 = 10.4%

50

Spontaneous Labour
56 / 161 = 34.8%

NVB
AVB

78
14

48.4%
8.7%

NVB
AVB

CS

69

42.9%

CS

161 100%

Multiparous without
previous CS No. = 1541
NVB 1317 85.5%
AVB
53
3.4%

100%

3.2
% of
Multip No.

41
6

73.2%
10.7%

2.7
0.4

16.1%

0.6
3.6

56 100%

% of
Multip No.

Induced Labour
55 / 161 = 34.2%

% of
Multip No.

NVB
37
67.3%
AVB
8
14.5%
CS
10
18.2%
55 100%

2.4
0.5
0.6
3.6

Pre-labour CS
49 / 1380 = 3.6%

% of
Multip No.

CS 171 11.1%

1541 100%

CS

49

100%

3.2

Term
1380 / 1541 = 89.6%

Spontaneous Labour
974 / 1380 = 70.6%

% of
Multip No.

NVB 1239 89.8%


AVB
39
2.8%

NVB 928 95.3%


AVB
19
2.0%

60.2
1.2

CS

CS

1.8
63.2

102
7.4%
1380 100%

27

2.8%

974 100%

Induced Labour
357 / 1380 = 25.9%
NVB
AVB
CS

% of
Multip No.

311
20

87.1%
5.6%

20.2
1.3

26

7.3%

1.7
23.2

357 100%

100
Labour

No.

Spontaneous
Induced

1030
412

66.8
26.7

Pre-labour CS
Total

99
1541

6.4
100

| 89

Capital & Coast District Health Board

Figure 12: Labour and birth branch diagram for multiparous


women with previous CS for 2012
Pre-labour CS
48 / 71 = 67.6%
CS
Pre-term
71 / 568 = 12.5%
NVB
AVB
CS

48

Spontaneous Labour
16 / 71 = 22.5%

8
6

11.3%
8.5%

NVB
AVB

57

80.3%

CS

71 100%

Multiparous with
previous CS No. = 568
NVB 97 17.1%
AVB
40
7.0%

100%

8.5
% of
Multip No.

5
4

31.3%
25.0%

0.9
0.7

43.8%

1.2
2.8

16 100%

% of
Multip No.

Induced Labour
7 / 71 = 9.9%

% of
Multip No.

NVB
AVB

3
2

42.9%
28.6%

0.5
0.4

CS

28.6%

7 100%

0.4
1.2

Pre-labour CS
299 / 497 = 60.2%

% of
Multip No.

CS 431 75.9%

568 100%

CS

299

100%

52.6

Term
497 / 568 = 87.5%

Spontaneous Labour
155 / 497 = 31.2%

% of
Multip No.

NVB 89 17.9%
AVB
34
6.8%

NVB 75 48.4%
AVB
24
15.5%

13.2
4.2

CS

CS

9.9
27.3

374
75.3%
497 100%

56

36.1%

155 100%

Induced Labour
43 / 497 = 8.7%
NVB
AVB

% of
Multip No.

14
10

32.6%
23.3%

2.5
1.8

CS

19

44.2%

43 100%

3.3
7.6
100

Labour

No.

Spontaneous
Induced

171
50

30.1
8.8

Pre-labour CS
Total

347
568

61.1
100

90 |

The Womens Health Service Annual Clinical Report 2012

Figure 13: Mode of birth group by age group for all women
for 2012
80.0 %

Normal

CS

Assisted

70.0 %
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

< 20 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

40 yrs

(The numbers and percentages for this figure are in Table 118 in the Appendices).

Figure 14: Mode of birth group by age group for primiparous


women for 2012
Normal

70.0 %

CS

Assisted

60.0%
50.0%

40.0%

30.0%

20.0%
10.0%

0.0%

< 20 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

40 yrs

(The numbers and percentages for this figure are in Table 119 in the Appendices).

| 91

Capital & Coast District Health Board

Figure 15: Mode of birth group by age group for multiparous


women without previous CS for 2012
Normal

100.0 %

CS

Assisted

90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

< 20 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

40 yrs

(The numbers and percentages for this figure are in Table 120 in the Appendices).

Figure 16: Mode of birth group by age group for multiparous


women with previous CS for 2012
Normal

100.0 %

CS

Assisted

90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%

< 20 yrs

20 - 24 yrs

25 - 29 yrs

30 - 34 yrs

35 - 39 yrs

(The numbers and percentages for this figure are in Table 121 in the Appendices).
NB The 100% CS rate for the < 20 years group is for 3 women who have had one or more previous CS.

92 |

40 yrs

The Womens Health Service Annual Clinical Report 2012

9.3 Various rates


The ACHS clinical indicator tabulated here is for
women who have had a vaginal birth following one
previous caesarean section (VBAC). C&C DHB rates
were above the peer group rates for most six-monthly

periods but the aggregate rates were not outside the


99% confidence intervals.

Table 46: Peer group comparison for ACHS Obstetric clinical


indicator 2.1
C&C
2010

2.1

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Clinical Indicator

Period

Rate (%) Rate (%) Rate (%) Rate (%) Rate (%) Rate (%)

Vaginal delivery following a previous


primary caesarean section (N)

Jan-Jun

26.67

20.69

19.89

20.11

19.27

18.55

Jul-Dec

21.74

22.95

27.68

21.87

18.29

19.43

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 93

Capital & Coast District Health Board

Various other rates are tabulated in the next table.


39.8% of all births in 2012 were normal births. These
are defined as women who went to term and had a
spontaneous labour and had a normal vaginal birth.
This rate has remained around 40% for the last four
years.

About 55% of all elective CS in 2012 were performed


where the indication was a history of one or more
previous CS.
The episiotomy rate has been about 14% for each of
the last three years.

Table 47: Various rates for years 2005 to 2012


Mothers
Variable *

Normal
birth

Elective CS
for previous
CS
Emergency
CS in
established
labour

2005

2006

2007

2008

2009

2010

2011

2012

Num.
Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate Num.
% Den.

Rate
%

1625

43.3

41.2

42.2

44.1

41.6

40.8

38.7

39.8

3754
155

3967
48.1

322
503

189

69.7

561

47.3

784

198

71.3

555

51.2

774

190

70.3

535

50.1

710

227

72.8

473

55.8

688

257

69.0

486

59.1

720

217

67.8

540

50.7

790

241

55.7

433
69.2

780
21.8

1532
3850

428

717
19.9

1517
3917

435

686
20.8

1586
3891

407

735
22.2

1661
3995

379

790
22.9

1765
3999

387

787
21.1

1709
4047

400

722
688

1634

522

68.9

758
23.5

760

23.2

Primary CS
3268
477

3429
12.7

473

3485
11.9

493

3416
12.2

459

3463
11.5

514

3306
12.9

551

3365
14.2

550

3282
14.0

522

13.6

Episiotomy
3754

3967

4047

3999

3995

3891

3917

3850

* Definitions:
Normal birth - defined as women who went to term and had a spontaneous labour and had a normal vaginal birth (see branch diagrams in
Labour and Birth section).
Elective CS for previous CS - Proportion of total elective CS performed when the primary documented indication is an obstetric history of one
or more previous CS.
Emergency CS in established labour - Proportion of total emergency CS performed in established labour
Primary CS - Number of women having their first CS, divided by total number of women without a previous CS.

94 |

The Womens Health Service Annual Clinical Report 2012

9.4 Induction of labour


Postdates, prelabour SRM, abnormal fetal monitoring,
hypertension and diabetes were the main indications
listed in the database for induction of labour.

Table 48: Primary indication for induction of labour by parity


and CS history group for 2012
Mothers

Primiparous

Multiparous, no
previous CS

Multiparous,
with previous
CS

Total

Primary indication

No.

No.

No.

No.

Postdates

168

26.6

104

25.2

14

28.0

286

26.2

Prelabour SRM

101

16.0

55

13.3

10

20.0

166

15.2

Hypertension

63

10.0

20

4.9

2.0

84

7.7

Diabetes

53

8.4

28

6.8

4.0

83

7.6

Maternal disease

30

4.8

25

6.1

2.0

56

5.1

Maternal request

0.3

16

3.9

2.0

19

1.7

Antepartum haemorrhage

1.0

0.5

2.0

0.8

Multiple gestation

10

1.6

1.2

0.0

15

1.4

IUGR

42

6.7

34

8.3

2.0

77

7.0

Abnormal fetal monitoring

61

9.7

34

8.3

6.0

98

9.0

Fetal abnormality

10

1.6

1.5

2.0

17

1.6

0.6

10

2.4

0.0

14

1.3

81

12.8

73

17.7

15

30.0

169

15.5

631

100

412

100

50

100

1093

100

36.2

412
1541

26.7

50
568

8.8

1093
3850

28.4

Intrauterine fetal demise


Other
Total
Parity group induction rates

631
1741

| 95

Capital & Coast District Health Board

Table 49: Mode of birth after induction of labour for main


primary indication groups for 2012
Mothers

Primiparous

Main IOL indication groups

Postdates

Prelabour SRM

Hypertension

Abnormal fetal
monitoring

Diabetes

All Indications

96 |

Multiparous, no
previous CS

Multiparous,
with previous
CS

Total

No.

No.

No.

No.

NVB

55

32.7

92

88.5

7.1

148

51.7

AVB

36

21.4

4.8

28.6

45

15.7

CS

77

45.8

6.7

64.3

93

32.5

168

100

104

100

14

100

286

100

NVB

48

47.5

47

85.5

60.0

101

60.8

AVB

17

16.8

5.5

10.0

21

12.7

CS

36

35.6

9.1

30.0

44

26.5

101

100

55

100

10

100

166

100

NVB

21

33.3

14

70.0

0.0

35

41.7

AVB

20

31.7

10.0

0.0

22

26.2

CS

22

34.9

20.0

100.0

27

32.1

63

100

20

100

100

84

100

NVB

21

34.4

28

82.4

66.7

51

52.0

AVB

15

24.6

5.9

0.0

17

17.3

CS

25

41.0

11.8

33.3

30

30.6

61

100

34

100

100

98

100

NVB

17

32.1

28

100.0

50.0

46

55.4

AVB

11

20.8

0.0

0.0

11

13.3

CS

25

47.2

0.0

50.0

26

31.3

53

100

28

100

100

83

100

NVB

235

37.2

348

84.5

17

34.0

600

54.9

AVB

148

23.5

28

6.8

12

24.0

188

17.2

CS

248

39.3

36

8.7

21

42.0

305

27.9

631

100

412

100

50

100

1093

100

The Womens Health Service Annual Clinical Report 2012

9.5 Breech presentation and external


cephalic version (ECV)
83.3% of all singleton breech births were delivered by
caesarean section. Almost 95% of all term singleton
breech births were performed by CS.

Figure 17: Labour and birth branch diagram for singleton


breech presentations for 2012
Pre-labour CS
34 / 66 = 51.5%
CS
Pre-term
66 / 144 = 45.8%

34

Spontaneous Labour
18 / 66 = 27.3%

NVB
AVB

0
20

0.0%
30.3%

NVB
AVB

CS

46

69.7%

66 100%

100%

NVB 0
AVB
24

0.0%
16.7%

CS 120

83.3%

23.6
% of
Total No.

0
7

0.0%
38.9%

0.0
4.9

CS

11

61.1%

18 100%

7.6
12.5

Induced Labour
14 / 66 = 21.2%
NVB
AVB

All women with singleton breech


presentations No. = 144

% of
Total No.

% of
Total No.

0
13

0.0%
92.9%

0.0
9.0

7.1%

14 100%

0.7
9.7

Pre-labour CS
62 / 78 = 79.5%

% of
Total No.

CS

144 100%

CS

62

100%

43.1

Term
78 / 144 = 54.2%

Spontaneous Labour
11 / 78 = 14.1%

% of
Total No.

NVB 0 0.0%
AVB
4
5.1%

NVB 0 0.0%
AVB
3
27.3%

0.0
2.1

CS

CS

5.6
7.6

74
94.9%
78 100%

72.7%

11 100%
Induced Labour
5 / 78 = 6.4%

% of
Total No.

0
1

0.0%
20.0%

0.0
0.7

CS

80.0%

5 100%

2.8
3.5

NVB
AVB

100

| 97

Capital & Coast District Health Board

External cephalic version


This is the first time that data has been presented on
ECV. C&C DHBs Decision Support Unit identified 19
women who attempted an ECV in 2012. Fifteen of the
19 ECVs undertaken were successful (78.9%). This rate
indicates that the women who were selected were well
chosen.
Eighty-seven percent of the women who had a
successful ECV achieved a vaginal birth, and this
is consistent with the range of rates reported
internationally (6385%). 11 women achieved a normal

98 |

vaginal birth (two of which were home births), two


women required a Ventouse, and two women required
an emergency caesarean section for other reasons.
Of the four unsuccessful ECVs, three women had an
elective caesarean section and one woman had an
assisted vaginal breech birth.
ECV is a safe procedure that is effective in reducing the
number of breech presentations near term. Looking
at the rates of women attempting ECV in other DHBs
it could be suggested that we should be encouraging
this procedure more.

The Womens Health Service Annual Clinical Report 2012

9.6 Outcome of selected primipara


(ACHS)
Refer to section 1.3 for the introduction commentary
on ACHS clinical indicators. See the complete table
with peer comparisons for 2012 in the Appendices
(Table 122).
ACHS clinical indicators 1.1 to 1.4 pertain to a specific
group of women called the selected primipara.
These are defined as:

a woman who is 20 to 34 years of age at the time


of giving birth

giving birth for the first time at >20 weeks


gestation

singleton pregnancy

cephalic presentation

at 37+0 to 41+0 weeks gestation

Indicator 1.1: The rate of spontaneous vaginal birth


reported in this group helps control for differences
in case mix and increases the validity of those
comparisons between organisations. C&C DHBs
half yearly rates of 42.05% and 39.15% in 2012
are undesirably lower when compared to the peer
organisations and require further attention.
Indicator 1.4: In the second six month period of
2012 the rate for selected primipara undergoing
caesarean section was higher than for all organisations.
Caesarean section rates for primiparous women are a
complex area with multiple contributing factors and
are an issue that the WHS are addressing. Regular
fetal surveillance education is required of all clinicians
employed within C&C DHB and we are working
towards holding regular cardiotocograph meetings.
In addition, the introduction of the lactate meter and
a comprehensive review of the induction of labour
process will help to improve outcomes.

Table 50: Peer group comparison for ACHS Obstetric clinical


indicators 1.1 to 1.4
C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Clinical Indicator

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

1.1

Selected primipara who have a


spontaneous vaginal birth (H)

Jan-Jun

42.26

39.92

42.05

51.63

48.90

48.28

Jul-Dec

41.34

39.74

39.15

50.16

48.45

47.62

1.2

Selected primipara who undergo


induction of labour (L)

Jan-Jun

29.64

29.75

31.20

30.32

31.48

31.22

Jul-Dec

29.12

25.82

28.49

30.06

32.30

31.95

1.3

Selected primipara who undergo


an instrumental vaginal birth (L)

Jan-Jun

20.84

20.54

20.16

24.29

25.25

22.44

Jul-Dec

24.64

24.18

23.16

24.84

25.12

22.28

1.4

Selected primipara undergoing


caesarean section (L)

Jan-Jun

24.67

27.83

24.81

21.85

24.12

21.54

Jul-Dec

23.22

26.37

28.13

23.51

24.49

22.45

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 99

Capital & Coast District Health Board

9.7 Obstetric anaesthesia


The anaesthesia departments new database was
introduced in October 2010. The statistics presented
in this report are from this database.

The total number of births in the C&C DHB area has


fallen slightly, but the proportion of women using
anaesthesia services remains unchanged.

Table 51: Summary of neuraxial blocks for years 2011 and 2012
2011

2012

No.

No.

1329

33.9

1270

33.0

736

18.8

732

19.0

Total neuraxial blocks

2098

53.6

2080

54.0

Total C&C DHB births

3917

Labour analgesia
Caesarean section 1

3850

Includes only new blocks for caesarean section and does not include epidurals topped up for caesarean section

Total labour analgesia rate remains constant at 1295


(33.6%) compared with 34.2% in 2011, an insignificant
difference. In addition 21 women required neuraxial
block for instrumental delivery and 81 for postpartum
procedures (EUA, manual removal of placenta, perineal

repair). There were 106 general anaesthetics given


(2.8%). In total 2239 women had some anaesthesia
intervention (one or more), or 58.2% of all women
delivered in C&C DHB (64.5% of women at WRH).

Table 52: Indications for anaesthesia support in 2012


Anaesthesia
procedure
First block
indication
Labour analgesia
Caesarean section
Forceps / Ventouse
Total for delivery

Epidural

Spinal
(SAB)

Combined
spinal epidural
(CSE)

Total
neuraxial
blocks

General
anaesthesia

Total
requiring
intervention

No.

No.

No.

No.

No.

No.

1215

23

57

1295

33.6

1295

33.6

12

195

525

732

19.0

85

817

21.2

13

21

0.5

21

0.5

1228

231

589

2048

53.2

85

2133

55.4

0.1

Other
Cerclage

0.1

Postpartum
procedure

79

81

16

97

2.5

1228

314

591

2133

106

2239

Total
C&C DHB women

3850

55.4

58.2

WRH women

3470

61.5

64.5

100 |

The Womens Health Service Annual Clinical Report 2012

Outcome of labour after neuraxial block for analgesia is


documented below. 1270 women received some

form of neuraxial block in labour of whom 1157 have


the mode of delivery documented in the database. Of
these 43% had a normal vaginal birth.

Table 53: Mode of delivery after neuraxial block in labour in


2012
Outcome

2012
No.

Normal vaginal birth

499

43.1

Forceps

150

13.0

Ventouse

105

9.1

Caesarean section

403

34.8

1157

100

Total

Combined spinal epidural (CSE) is the technique


of choice for elective caesarean section, while
subarachnoid block (spinal) was more frequently the
choice for emergency caesarean sections. A total of

348 women had epidural top up and a total of 85 had


GA, of which 16 had either insufficient time to top up
epidural or there was a problem with an existing block.

Table 54: Anaesthesia for caesarean section in 2012


Anaesthesia

2012
No.

CSE

525

45.1

Spinal

195

16.7

Epidural top up

348

29.9

Epidural for caesarean

12

1.0

General anaesthesia

85

7.3

1165

100

Total

Seven women had CSE for instrumental delivery,


providing an option of extending the block if caesarean
was required. Fifty seven women had CSE in labour
for rapid onset of good analgesia. These figures are
relatively unchanged from 2011.
The anaesthesia department documented 1144 women
having caesarean section as outcome of anaesthesia
procedure, although this differs from the number

cited above and from the official number of caesarean


sections at C&C DHB in 2012. Unfortunately mode of
delivery was omitted in the records for 68 women. The
official C&C DHB figures are 1191 caesarean sections
(30.9%) of which 758 were emergencies and 433
elective. Urgency is reported in the table below.

| 101

Capital & Coast District Health Board

Table 55: Urgency of caesarean section for years 2011 and 2012
CS urgency category

2011
No.

2012
%

No.

85

7.6

103

9.0

2 urgent for maternal or fetal compromise

474

42.2

436

38.1

3 needing early delivery

112

10.0

130

11.4

4 elective planned at least 24 hrs in advance

333

29.6

298

26.0

No category

120

10.7

177

15.5

1124

100

1144

100

1 immediate threat to life of mother or baby

Total caesareans (in anaesthesia database)

Anaesthesia for caesarean section depended on


the degree of urgency of caesarean section. Eighty
five women had general anaesthesia for caesarean
sections, of whom 50 were category one urgency, and
16 had epidurals in situ which were either ineffective
or there was insufficient time for a top up. Seven
women had general anaesthesia for elective caesarean
sections. Three hundred and forty one women (341)
had epidurals for labour which were topped up for
caesarean section, while 732 women had neuraxial
blocks sited specifically for caesarean section (either
electively or in labour).

Elective caesarean sections


A simple audit of start times (the time the woman
arrived in the caesarean theatre) of caesarean sections
was carried out in June, July and August 2012. Eighty
three elective caesarean sections were audited. In
summary, over 50% of first elective caesarean sections
started late. Around half of delays were due to system
factors such as staff or beds being unavailable or
women not being ready, and not due to acute cases
pending or occurring. Most delays could be resolved
by having an elective caesarean section list in the main
operating theatre.

Complications
Accidental dural puncture remains a rare complication
of epidural analgesia with 8 documented cases (0.8%).
One woman had postdural puncture headache (PDPH)
with spinal alone. Twelve epidural blood patches were
performed as treatment for PDPH, of which 3 failed in
the first 48 hours, requiring repeat blood patch.
Numbness or weakness lasting longer than expected
was reported on 0.1% (1 in 1000) of women receiving
neuraxial blocks, while backache requiring analgesia
occurred in 1.1% of women. Side effects from spinal
102 |

morphine remains a problem for some with 7.7% of


women having epidural morphine requiring treatment
for itch and 12.4% reporting nausea (compared with
6.9% and 7.9% in 2011). Surprisingly those receiving
intrathecal morphine had fewer side effects, with
6.1% having pruritus (12.7% in 2011) and 4.2% having
nausea (7.8% in 2011). Naloxone is the most effective
treatment for these side effects, but will not decrease
the analgesia provided by spinal morphine. However,
there seems to be some reluctance to use naloxone
and this may be the subject of future education efforts.

Satisfaction
Postnatal follow up on the wards, or a phone call
at home are an important part of anaesthesia
care. Follow up rates are high with 94% of women
documented as giving a response. There has been an
improvement in satisfaction scores, and a decrease in
those reporting intra-operative pain during caesarean
section. Fewer women report poor pain relief during
second stage (4.8% compared with 6.0% in 2011). It
is important to continue use of patient-controlled
epidural analgesia (PCEA) throughout labour and
the low concentrations used mean women can push
adequately and receive adequate analgesia.
Post-caesarean pain relief has continued to be an
important focus, and we now provide leaflets on
postoperative analgesia to all women having caesarean
section, emphasising the use of regular simple
analgesics.

Conclusions
The anaesthesia department continues to provide
an essential service for all women delivering in the
Wellington area. As in the past, 58% of women require
some form of anaesthesia assistance, so antenatal
review is helpful in providing the best service we can.

The Womens Health Service Annual Clinical Report 2012

ACHS clinical indicator 4.1,


general anaesthesia for
caesarean section
The table below shows the 2010 to 2012 rates for
caesarean section under GA, comparing C&C DHB
with all other sites contributing to ACHS data. The
figures provided to the ACHS are calculated by the
C&C DHB Decision Support Unit using clinically coded
inpatient event data. In 2012 the Decision Support
Unit calculated 71 GA sections from this source. The

Department of Anaesthesia calculated 85 GA sections


from their stand alone database. The reason for the
difference is thought to be inaccurate data entry, which
may be occurring in both data sources. There may
need to be a cross-check of data to ensure accuracy for
future submissions of this particular indicator.
According to the data submitted to ACHS for the
second six month period in 2012 the aggregate rate
for all organisations was above the 99% confidence
interval of the DHBs rate.

Table 56: Peer group comparison for ACHS Obstetric clinical


indicator 4.1

Clinical Indicator

4.1

Women having a
general anaesthetic for a
caesarean section (L)

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Jan-Jun

7.82

4.82

6.78

7.23

8.64

8.93

Jul-Dec

8.16

6.50

5.18

8.43

7.74

7.97

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 103

Capital & Coast District Health Board

9.8 Primary maternity units


9.8.1 Kenepuru Maternity Unit
The following table tabulates the numbers by ethnicity
and age groups for the 245 women who gave birth at
KMU in 2012.
The largest age group for all C&C DHB women in 2012
was the 30 to 34 year age group (31% of all ethnicities),
whereas women giving birth at KMU were in three

distinct groups. These were the 20-24 year old women


(43% of Mori), the 25-29 year old women (37% of
Pacific) and the 30-34 year old women (27% of NZ
European).
The average age for primiparous women at KMU was
23.5 years (29.6 for all C&C DHB) and 28.8 years for
multiparous women (32.7 for all C&C DHB).

Table 57: Age and ethnicity distribution for the women who
gave birth at KMU in 2012
Mothers

NZ
European

Other
European

Age

No.

No.

No.

No.

No.

No.

No.

< 20

6.8

0.0

17

22.1

7.7

5.9

0.0

28

11.4

20 24

13

17.8

8.3

33

42.9

16

24.6

29.4

100.0

69

28.2

25 29

19

26.0

25.0

18

23.4

24

36.9

47.1

0.0

72

29.4

30 34

20

27.4

25.0

7.8

12

18.5

11.8

0.0

43

17.6

35 39

14

19.2

33.3

3.9

6.2

5.9

0.0

26

10.6

2.7

8.3

0.0

6.2

0.0

0.0

2.9

73

100

12

100

77

100

65

100

17

100

100

245

100

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

Primips

18

27.1

32.2

22

19.8

14

23.3

23.8

60

23.5

Multips

55

30.8

10

33.9

55

25.7

51

29.1

13

28.5

24.9

185

28.8

Total

73

29.9

12

33.6

77

24.0

65

27.9

17

27.4

24.9

245

27.5

40
Total
Average age

Pacific
Peoples

Mori

There were 31 antenatal transfers from the Kenepuru


Maternity Unit to the Wellington Regional Hospital and
20 postnatal transfers to Wellington for women who
gave birth at KMU.

104 |

Asian

Other

Total

There were 497 postnatal admissions for women who


gave birth at the Wellington Regional Hospital and
who required further postnatal care at Kenepuru. Eight
of these women were transferred back to Wellington
Regional Hospital for further care.

The Womens Health Service Annual Clinical Report 2012

9.8.2 Paraparaumu Maternity


Unit

but the 25-29 year age group prevailed at PMU mainly


from the NZ European ethnicity group.

The following table tabulates the numbers by ethnicity


and age groups for the 135 women who gave birth at
PMU in 2012.

The average age for primiparous women at PMU was


23.4 years (29.6 for all C&C DHB) and 31.0 years for
multiparous women (32.7 for all C&C DHB).

The largest age group for all C&C DHB women in 2012
was the 30 to 34 year age group (31% of all ethnicities),

Table 58: Age and ethnicity distribution for the women who
gave birth at PMU in 2012
Mothers

NZ
European

Other
European

Age

No.

No.

< 20

6.7

0.0

25.0

100.0

0.0

0.0

12

8.9

20 24

19

21.1

23.5

20.0

0.0

16.7

0.0

28

20.7

25 29

26

28.9

23.5

25.0

0.0

16.7

0.0

36

26.7

30 34

22

24.4

35.3

15.0

0.0

50.0

0.0

34

25.2

35 39

15

16.7

17.6

5.0

0.0

16.7

100.0

21

15.6

40

Mori
No.

Pacific
Peoples
No.

Asian
No.

Other
No.

Total
No.

2.2

0.0

10.0

0.0

0.0

0.0

3.0

90

100

17

100

20

100

100

100

100

135

100

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

No.

Yrs

Primips

25

24.0

21.2

21.3

18.5

31.9

36

23.4

Multips

65

31.0

13

32.9

15

28.9

30.7

37.4

99

31.0

Total

90

29.1

17

30.1

20

27.0

30.9

37.4

135

29.0

Total
Average age

There were 19 antenatal transfers from the


Paraparaumu Maternity Unit to the Wellington Regional
Hospital and 9 postnatal transfers to Wellington for
women who gave birth at PMU.

18.5

There were 135 postnatal admissions for women who


gave birth at the Wellington Regional Hospital and who
required further postnatal care at Paraparaumu. Two
of these women were transferred back to Wellington
Regional Hospital for further care.

| 105

Capital & Coast District Health Board

106 |

The Womens Health Service Annual Clinical Report 2012

10. Labour and birth outcomes

10.1 Perineal trauma


Indicator 3.4: This reports the rate of episiotomy
and sustaining of a perineal tear while giving birth
vaginally for selected primipara. The aggregate rate
for all organisations is below our 99% CI for the first six

months of 2012 and our rate of 13.4% is undesirably


higher than peer organisations. This indicator will
continue to be monitored.

Table 59: Peer group comparison for ACHS Obstetric clinical


indicators 3.1 to 3.6

Clinical Indicator

Period

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

3.1

Selected primipara with intact perineum or


unsutured perineal tear (H)

Jan-Jun

17.51

20.74

17.27

13.61

15.15

18.12

Jul-Dec

13.26

17.41

16.11

12.54

14.30

16.09

3.2

Selected primipara undergoing episiotomy


AND no perineal tear while giving birth
vaginally (L)

Jan-Jun

29.44

29.79

27.84

24.33

26.25

25.50

Jul-Dec

34.75

30.60

30.69

25.30

27.76

26.76

3.3

Selected primipara sustaining a perineal


tear AND no episiotomy (L)

Jan-Jun

44.92

40.96

41.49

53.45

51.24

50.01

Jul-Dec

42.18

41.04

42.46

51.06

49.26

46.69

3.4

Selected primipara undergoing episiotomy


AND sustaining a perineal tear while giving
birth vaginally (L)

Jan-Jun

7.36

8.51

13.40

7.14

7.93

8.15

Jul-Dec

8.49

10.95

10.74

8.45

8.42

9.25

3.5

Selected primipara requiring surgical repair


of the perineum for third degree tear (L)

Jan-Jun

3.05

3.72

5.67

5.55

7.15

7.45

Jul-Dec

4.51

5.22

7.16

6.70

7.33

6.98

3.6

Selected primipara requiring surgical repair


of the perineum for fourth degree tear (L)

Jan-Jun

0.25

0.53

0.00

0.43

0.36

0.36

Jul-Dec

0.27

0.50

0.77

0.42

0.33

0.43

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified. Rates in italic / greyed highlight results
that require attention. Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 107

Capital & Coast District Health Board

10.2 Postpartum haemorrhage


Multidisciplinary teaching on the recognition and
estimation of blood loss may be a contributing
factor to the increase in estimates of postpartum
haemorrhage (PPH). The rates of women requiring a

blood transfusion do not seem to be increasing and


this may indicate that the reported PPH rate may not
be related to increased volumes lost. Careful ongoing
monitoring of these clinical indicators is required.

Table 60: Peer group comparison for ACHS Obstetric clinical


indicators 7.1 and 7.2

Clinical Indicator

7.1

7.2

Women who give birth


vaginally who receive a
blood transfusion during
the same admission (L)
Women who undergo
caesarean section
who receive a blood
transfusion during the
same admission (L)

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Jan-Jun

2.16

1.99

1.93

1.67

1.66

1.86

Jul-Dec

1.99

0.91

2.10

1.75

1.56

1.60

Jan-Jun

5.33

2.25

3.73

2.93

2.69

2.97

Jul-Dec

4.25

2.05

3.01

2.73

2.91

2.16

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

Table 61: Primary postpartum blood loss for years 2005 to 2012
Mothers
Total blood loss
1000ml
500ml and
< 1000ml
< 500ml
Not stated
Total

108 |

2005
No.
95

%
2.5

757 20.2

2006
No.
137

%
3.5

862 21.7

2007
No.
127

%
3.1

865 21.4

2008
No.
104

%
2.6

790 19.8

2009
No.
139

%
3.5

682 17.1

2010
No.
158

%
4.1

743 19.1

2011
No.
171

%
4.4

905 23.1

2012
No.
203

%
5.3

876 22.8

2790 74.3 2812 70.9 2890 71.4 2946 73.7 3033 75.9 2888 74.2 2765 70.6 2716 70.5
112
3754

3.0

156

100 3967

3.9

165

100 4047

4.1

159

100 3999

4.0

141

100 3995

3.5

102

100 3891

2.6

76

100 3917

1.9

55

1.4

100 3850

100

The Womens Health Service Annual Clinical Report 2012

10.3 Surgical site infection (ACHS)


This ACHS indicator has been submitted for the last
two years. C&C DHB rates are higher than the peer
group rates.

The number of deep surgical site infections were four


in the first half and six in the second half of 2012.

Table 62: ACHS Infection Control clinical indicator 1.16

Clinical Indicator

1.16

Deep incisional/organ/
space surgical site
infection (SSI) in lower
segment caesarean section
procedures (L)

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

Rate (%)

Jan-Jun

1.29

0.68

0.36

0.21

Jul-Dec

1.55

1.00

1.15

0.50

Period

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 109

Capital & Coast District Health Board

10.4 Neonatal outcomes


Neonatal outcomes by gender, plurality, birth weight,
gestational age and Apgar score are presented in the
next sections.

10.4.1 Gender
Table 63: Gender for years 2005 to 2012
Babies

2005

2006

1894 49.4 2032 50.3 1991 48.0 2032 49.7 2016 49.4 1937 48.6 2013 50.3 1889 48.2

Total

3837

100 4041

No.

0.1

100 4144

No.

0.1

100 4091

No.

0.0

100 4084 100 3985

No.

0.0

2012

Female

0.0

2011

1940 50.6 2008 49.7 2150 51.9 2057 50.3 2068 50.6 2048 51.4 1988 49.7 2031 51.8

No.

2010

Male

0.1

2009

No.

No.

2008

Gender

Indeterminate

2007

100 4001

0.0

No.

0.0

100 3920 100


10.4.2 Plurality
Table 64: Plurality for years 2005 to 2012
Babies

2005

No.

No.

2009

No.

2010

No.

2011

No.

2012

Singletons

3672 95.7 3894 96.4 3952 95.4 3909 95.6 3910 95.7 3800 95.4 3836 95.9 3782 96.5

Total

2008

No.

Triplets *

No.

2007

Plurality

Twins *

2006

No.

162

4.2

144

3.6

186

4.5

176

4.3

162

4.0

176

4.4

156

3.9

132

3.4

0.1

0.1

0.1

0.1

12

0.3

0.2

0.2

0.2

100 3920

100

3837

100 4041

100 4144

100 4091

100 4084

100 3985

100 4001

* Numbers not sets

110 |

The Womens Health Service Annual Clinical Report 2012

10.4.3 Birth weight


In the second six months of 2012 the aggregate rate
from all peer organisations for babies born with birth
weights less than 2750g at 40 weeks gestation or

beyond was higher than our upper 99% confidence


interval. This indicates than there were fewer term
babies born at C&C DHB who were low birth weight.

Table 65: Peer group comparison for ACHS Obstetric clinical


indicator 8.1
C&C
2010
Clinical Indicator

8.1

Deliveries with birth


weight less than 2750g
at 40 weeks gestation or
beyond (L)

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Jan-Jun

1.50

1.07

1.26

2.00

1.78

1.75

Jul-Dec

1.10

1.23

0.76

1.89

1.67

1.63

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

The next two tables present the birth weights of all


babies born in 2012 by maternal age and ethnicity
groups.

Table 66: Birth weights of all babies by maternal age group


for 2012
Babies
Weight (g)

< 20
No.

20 24
%

No.

25 29
No.

30 34
No.

35 39
No.

40
No.

Total
%

No.

< 500

1.2

0.6

0.7

0.7

0.9

0.4

28

0.7

500 999

2.9

1.6

14

1.7

16

1.3

11

1.2

3.6

63

1.6

1000 1499

3.5

1.8

11

1.3

12

1.0

0.8

1.2

48

1.2

1500 1999

1.2

13

2.6

20

2.4

25

2.0

20

2.2

2.0

85

2.2

2000 2499

2.9

30

5.9

30

3.6

43

3.5

36

3.9

15

6.0

159

4.1

2500 2999

20

11.6

65

12.8

123

14.6

147

12.0

90

9.8

33

13.1

478

12.2

3000 3499

55

31.8

149

29.4

263

31.2

356

29.0

302

32.9

68

27.1

1193

30.4

3500 3999

58

33.5

158

31.2

255

30.3

431

35.1

293

31.9

71

28.3

1266

32.3

4000 4499

19

11.0

62

12.2

106

12.6

162

13.2

127

13.8

41

16.3

517

13.2

4500 4999

0.6

10

2.0

13

1.5

26

2.1

21

2.3

2.0

76

1.9

5000

0.0

0.0

0.1

0.2

0.4

0.0

0.2

Total

173

100

507

100

842

100

1228

100

919

100

251

100

3920

100

Average

3235

3295

3305

3390

3390

3295

3345

Median

3440

3420

3420

3500

3480

3440

3460

Maximum

4780

4950

5220

5415

5080

4860

5415

| 111

Capital & Coast District Health Board

Table 67: Birth weights of all babies by maternal ethnicity


group for 2012
Babies

NZ
European

Other
European

Weight (g)

No.

No.

Mori
No.

Pacific
Peoples
No.

Asian
No.

Other

No.

Total
No.

< 500

15

0.8

0.4

1.0

0.3

0.9

0.0

28

0.7

500 999

27

1.4

1.9

17

3.5

1.4

0.7

1.0

63

1.6

1000 1499

29

1.5

0.8

1.8

0.5

0.6

1.0

48

1.2

1500 1999

49

2.5

1.7

12

2.5

2.2

0.9

2.9

85

2.2

2000 2499

72

3.7

15

3.2

19

3.9

11

3.0

32

5.9

10

9.5

159

4.1

2500 2999

192

9.8

52

11.0

65

13.3

44

12.1

115

21.3

10

9.5

478

12.2

3000 3499

564

28.9

137

29.0

149

30.6

106

29.0

197

36.5

40

38.1

1193

30.4

3500 3999

670

34.3

164

34.7

139

28.5

126

34.5

135

25.0

32

30.5

1266

32.3

4000 4499

293

15.0

69

14.6

56

11.5

53

14.5

38

7.0

7.6

517

13.2

4500 4999

37

1.9

11

2.3

15

3.1

1.9

1.1

0.0

76

1.9

0.2

0.2

0.2

0.5

0.0

0.0

0.2

Total

1951

100

472

100

487

100

365

100

540

100

105

100

3920

100

Average

3385

3405

3245

3430

3215

3255

3345

Median

3520

3520

3390

3530

3260

3360

3460

Maximum

5415

5120

5030

5220

4910

4460

5415

5000

112 |

The Womens Health Service Annual Clinical Report 2012

The next table gives the birth weights for liveborn


babies born in the years 2005 to 2012.
In 2012, 2.6% of babies weighed less than 1500g, 8.8%
weighed less than 2500g and 15.5% weighed more
than 4000g.

Table 68: Birth weights for liveborn babies for years 2005 to
2012
Babies
Weight (g)
< 500

2005
No.

2006
No.

2007
No.

2008
No.

2009
No.

2010
No.

2011
No.

2012
No.

0.0

0.1

0.1

0.0

0.1

0.1

0.1

0.1

500 999

35

0.9

34

0.9

44

1.1

33

0.8

44

1.1

42

1.1

40

1.0

53

1.4

1000 1499

54

1.4

49

1.2

50

1.2

60

1.5

64

1.6

58

1.5

51

1.3

46

1.2

1500 1999

62

1.6

46

1.2

62

1.5

72

1.8

58

1.4

68

1.7

92

2.3

84

2.2

2000 2499

134

3.5

126

3.2

153

3.7

169

4.2

149

3.7

179

4.5

179

4.5

158

4.1

2500 2999

498

13.1

548

13.7

528

12.9

527

13.0

493

12.2

522

13.2

516

13.0

476

12.3

3000 3499

1214

32.0 1272

31.9 1270

31.0 1316

32.5 1290

32.0 1254

31.7 1297

32.7 1192

30.7

3500 3999

1223

32.2 1318

33.1 1345

32.9 1272

31.4 1315

32.6 1279

32.4 1234

31.2 1266

32.7

4000 4499

492

13.0

487

12.2

519

12.7

502

12.4

511

12.7

465

11.8

464

11.7

517

13.3

4500 4999

71

1.9

95

2.4

105

2.6

88

2.2

90

2.2

75

1.9

77

1.9

76

2.0

5000

14

0.4

0.2

12

0.3

11

0.3

0.2

0.1

0.2

0.2
100

Total

3799

100 3987

100 4093

100 4052

100 4028

100 3951

100 3961

100 3877

Average

3385

3400

3395

3375

3390

3350

3350

3375

Median

3460

3460

3470

3440

3460

3440

3430

3470

Maximum

5650

5180

5880

5520

5370

5680

5300

5415

NB This table includes a few extremely small babies who were neonatal deaths in Delivery Suite soon after birth.

| 113

Capital & Coast District Health Board

10.4.4 Gestational age


Table 69: Gestational age for liveborn babies for years 2005 to
2012
Babies
Gestation
(weeks)

2005
No.

2006
No.

2007
No.

2008
No.

2009
No.

2010
No.

2011
No.

2012
No.

20
21

0.0

0.0

0.1

22

0.1

0.0

0.0

23

0.1

0.1

0.2

0.1

0.1

24

0.1

0.2

10

0.2

0.1

10

0.2

25

10

0.3

10

0.3

0.2

11

0.3

26

0.1

11

0.3

12

0.3

0.2

27

15

0.4

0.1

10

0.2

14

28

12

0.3

0.1

16

0.4

29

15

0.4

17

0.4

10

30

22

0.6

19

0.5

31

21

0.6

14

32

26

0.7

33

23

34

0.0
1

0.0

0.0

0.2

0.1

0.1

12

0.3

0.1

0.2

0.1

0.2

0.2

0.2

14

0.3

15

0.4

0.2

17

0.4

0.3

15

0.4

0.2

12

0.3

13

0.3

13

0.3

20

0.5

16

0.4

14

0.4

17

0.4

0.2

21

0.5

15

0.4

11

0.3

16

0.4

13

0.3

15

0.4

11

0.3

23

0.6

23

0.6

24

0.6

26

0.7

0.4

25

0.6

19

0.5

18

0.4

29

0.7

25

0.6

27

0.7

12

0.3

18

0.4

29

0.7

17

0.4

31

0.8

29

0.7

18

0.5

0.6

29

0.7

24

0.6

27

0.7

27

0.7

24

0.6

31

0.8

32

0.8

43

1.1

40

1.0

43

1.1

45

1.1

47

1.2

37

0.9

61

1.5

42

1.1

35

64

1.7

69

1.7

61

1.5

90

2.2

70

1.7

91

2.3

80

2.0

66

1.7

36

111

2.9

104

2.6

110

2.7

113

2.8

119

3.0

121

3.1

132

3.3

134

3.5

37

226

5.9

244

6.1

290

7.1

258

6.4

248

6.2

302

7.6

279

7.0

267

6.9

38

616

16.2

659

16.5

633

15.5

655

16.2

595

14.8

647

16.4

604

15.2

583

15.0

39

881

23.2

961

24.1

959

23.4

953

23.5

994

24.7

939

23.8

966

24.4

1008 26.0

40

999

26.3

991

24.9

1035 25.3

1037 25.6

1018 25.3

941

23.8

996

25.1

923

23.8

41

641

16.9

710

17.8

754

18.4

674

16.6

707

17.6

638

16.1

627

15.8

622

16.0

42

60

1.6

73

1.8

50

1.2

59

1.5

55

1.4

47

1.2

40

1.0

46

1.2

0.0

0.1

0.1

0.1

0.1

0.1

0.0

43
Total

3799 100

3987 100

4093 100

4052 100

4028 100

3951 100

NB This table includes a few extremely small babies who were neonatal deaths in Delivery Suite soon after birth.

114 |

3961 100

3877 100

The Womens Health Service Annual Clinical Report 2012

Table 70: Gestational age groups for liveborn babies for years
2005 to 2012
Babies

2005

Gestation

No.

2006
No.

2007
No.

2008
No.

2009
No.

2010
No.

2011
No.

2012
No.

20 23 weeks

0.2

0.1

0.2

0.1

0.2

0.2

0.1

0.1

24 27 weeks

32

0.8

32

0.8

39

0.9

38

0.9

43

1.1

42

1.1

32

0.8

47

1.2

28 31 weeks

70

1.8

55

1.4

66

1.6

64

1.6

76

1.9

79

2.0

79

2.0

83

2.1

32 36 weeks

267

7.0

254

6.4

256

6.3

304

7.5

280

7.0

304

7.7

333

8.4

292

7.5

All preterm

376

9.9

346

8.7

369

9.0

412 10.2

+0
+0
+0
+0

+6
+6
+6
+6

408 10.1

433 11.0

449 11.3

427 11.0

37 41 weeks 3363 88.5 3565 89.4 3671 89.7 3577 88.3 3562 88.4 3467 87.7 3472 87.7 3403 87.8
+0

+6

42+0 weeks
Total

60

1.6

76

1.9

53

1.3

63

1.6

58

1.4

51

1.3

40

1.0

47

1.2

3799 100 3987 100 4093 100 4052 100 4028 100 3951 100 3961 100 3877

100

10.4.5 Apgar Score


In the second six months of 2012 at C&C DHB there
were a significantly lower number of term babies born
with an Apgar score of less than 7 at five minutes post
delivery.

The aggregate rate of 1.66% for all peer organisations


was above our upper 99% confidence interval value of
1.43%.

Table 71: Peer group comparison for ACHS Obstetric clinical


indicator 9.1

Clinical Indicator

9.1

Term babies born with an


Apgar score of less than
7 at five minutes post
delivery (L)

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Jan-Jun

0.92

1.64

1.66

1.59

1.62

1.82

Jul-Dec

1.60

1.69

0.86

1.58

1.44

1.66

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 115

Capital & Coast District Health Board

Table 72: Apgar score at 5 minutes for liveborn babies by


maternal age group for 2012
Babies
Apgar score

< 20

20 24

25 29

30 34

40

35 39

Total

No.

No.

No.

No.

No.

No.

No.

<5

0.0

0.0

0.2

0.2

0.3

0.8

10

0.3

5 or 6

1.2

15

3.0

10

1.2

11

0.9

16

1.8

3.2

62

1.6

7 or 8

14

8.2

34

6.8

58

6.9

92

7.6

69

7.6

19

7.7

286

7.4

9 or 10

154

90.6

454

90.3

767

91.6

1107

91.3

818

90.3

219

88.3

3519

90.8

Total

170

100

503

100

837

100

1213

100

906

100

248

100

3877

100

Table 73: Apgar score at 5 minutes for liveborn babies by


maternal ethnicity group for 2012
Babies

NZ
European

Other
European

Apgar score

No.

No.

No.

No.

No.

No.

No.

0.3

0.0

0.4

0.3

0.0

1.0

10

0.3

5 or 6

32

1.7

0.6

13

2.7

1.4

0.9

3.8

62

1.6

7 or 8

149

7.7

28

6.0

40

8.3

26

7.2

32

6.0

11

10.5

286

7.4

9 or 10

1745

90.3

436

93.4

425

88.5

328

91.1

496

93.1

89

84.8

3519

90.8

Total

1932

100

467

100

480

100

360

100

533

100

105

100

3877

100

<5

Pacific
Peoples

Mori

Asian

Other

Total

Table 74: Apgar score at 5 minutes for liveborn babies for


years 2005 to 2012
Babies

2005

2006
%

No.

2007
%

No.

2008
%

No.

2009
%

No.

2010
%

No.

2011
%

No.

2012

Apgar score

No.

No.

<5

24

0.6

26

0.7

19

0.5

15

0.4

18

0.4

13

0.3

21

0.5

10

0.3

5 or 6

40

1.1

42

1.1

31

0.8

35

0.9

42

1.0

63

1.6

59

1.5

62

1.6

7 or 8

184

4.8

194

4.9

159

3.9

201

5.0

245

6.1

251

6.4

209

5.3

286

7.4

9 or 10

3551 93.5

3725 93.4

3884 94.9

3801 93.8

3723 92.4

3624 91.7

3672 92.7

3519 90.8

Total

3799 100

3987 100

4093 100

4052 100

4028 100

3951 100

3961 100

3877 100

116 |

The Womens Health Service Annual Clinical Report 2012

11. Postnatal care

11.1 Postnatal consumer satisfaction


survey
In September 2012 all women who received postnatal
inpatient care at Wellington Regional Hospital,
Kenepuru and/or Paraparaumu Maternity Units were
invited to complete an anonymous survey. The survey
commenced on 1st of September and concluded on
the 30th September. 316 women gave birth during this
period and feedback was received from 114 women,
a response rate of 36%. Generally speaking the
feedback received was very positive. Areas where the
service scored highly included courtesy and respect,
timely attendance, timely analgesia administration, and
an ideal length of stay.

safe positioning of baby in the cot and safety issues


related to bed sharing.

Areas where the service scored higher than 10% in the


disagree or strongly disagree sections were identified
as areas where the service should focus their attention.
These included information about the wards (the
location of the toilets, the call bell system, meal and
visiting times), practical assistance with baby bathing,

In 2013 the service plans to employ a media student


to prepare an audio visual aid for women. This will
include:

a virtual tour of all maternity facilities

information on safe sleeping practices

baby bathing

breastfeeding

immunisations.

Audio visual information will be made available to


women via C&C DHBs free to air TV channels and
will run as a two-hour continuous loop. An on-screen
menu will be provided so that women can select the
information most relevant to their needs.

| 117

Capital & Coast District Health Board

11.2 Infant feeding


The following are the New Zealand Ministry of Health
breastfeeding definitions used in this section:

Exclusive breastfeeding: The infant has never, to


the mother's knowledge, had any water, formula or
other liquid or solid food. Only breast milk, from
the breast or expressed, and prescribed medicines
have been given from birth.

Fully breastfeeding: The infant has taken breast


milk only, no other liquids or solids except a
minimal amount of water or prescribed medicines,
in the past 48 hours.

Partial breastfeeding: The infant has taken some


breast milk and some infant formula or other solid
food in the past 48 hours.

Artificial feeding: The infant has had no breast


milk but has had alternative liquid such as infant
formula with or without solid food in the past 48
hours.

All C&C DHB maternity facilities maintained good


exclusive breastfeeding rates (EBR) during 2012, above
the minimum 75% required by the Baby Friendly
Hospital Initiative (BFHI). Over the past 4 years the
EBR has slowly reduced, year on year, from 81.2% to
79.6%. A number of factors influenced this including
maternal age, mode of birth and ethnicity. Although
not considered in the scope of this report, many
other factors (such as the mode of labour, diabetes,
family support, obesity and smoking) also impact on
breastfeeding success.

Table 75: Infant feeding at time of initial discharge, by birth


facility for 2012
Babies

Wellington

Kenepuru

Paraparaumu

C&C DHB

Feeding *

No.

No.

No.

No.

Exclusive

2396

78.6

204

83.3

128

94.8

2728

79.6

Full

114

3.7

0.8

0.0

116

3.4

Partial

456

15.0

22

9.0

3.7

483

14.1

83

2.7

17

6.9

1.5

102

3.0

3049

100

245

100

135

100

3429

100

Artificial
Total

* Numbers are for babies discharged from Delivery Suite, Ward 4 North, Kenepuru Maternity and Paraparaumu Maternity.

The EBR for women who had normal births remained


excellent at 87.1%. However, the rate of normal births
has trended down year on year from 61.1% in 2009 to
57.8% in 2012.
There has been an increase in the caesarean section
rate from 27.4% in 2009 to 30.9% in 2012. Caesarean
section has a negative impact on breastfeeding. These
women have missed out on the full hormones of
labour, in addition to them coping with the impact of
abdominal surgery and delayed lactation. It may be

118 |

worth considering extending the program of antenatal


milk expressing to those women for whom an elective
caesarean section is planned.
Although the EBR for babies born by Ventouse is
almost as high as that for normal births, this is unusual.
In previous years the EBR for these babies has been
over 10% lower, close to that for babies born by
forceps. It will be interesting to review this next year.
The EBR for breech births is difficult to interpret due to
the small numbers involved.

The Womens Health Service Annual Clinical Report 2012

Table 76: Infant feeding at time of initial discharge, by mode of


birth for 2012
Babies

Normal

Forceps

Ventouse

Breech

Emerg. CS

Elect. CS

Total

Feeding *

No.

No.

No.

No.

No.

No.

No.

Exclusive

1810

87.1

137

71.7

152

86.4

42.9

378

64.0

248

64.1

2728

79.6

41

2.0

10

5.2

2.8

0.0

35

5.9

25

6.5

116

3.4

167

8.0

39

20.4

16

9.1

42.9

163

27.6

95

24.5

483

14.1

59

2.8

2.6

1.7

14.3

15

2.5

19

4.9

102

3.0

2077

100

191

100

176

100

100

591

100

387

100

3429

100

Full
Partial
Artificial
Total

* Numbers are for babies discharged from Delivery Suite, Ward 4 North, Kenepuru Maternity and Paraparaumu Maternity.

Although younger (<20 years) womens breasts may


lactate well, often other issues such as self-confidence,
social influences and lack of breastfeeding education
impact on their success.

Women over 40 years experience more difficulty


initiating lactation because the breast tissue is less
productive. EBR across the age ranges 20 to 39 years
are fairly consistent.

Table 77: Infant feeding at time of initial discharge, by


maternal age for 2012
Babies

< 20

20 24

25 29

30 34

40

35 39

Total

Feeding *

No.

No.

No.

No.

No.

No.

No.

Exclusive

112

76.2

355

81.1

603

81.3

878

80.0

629

78.6

151

73.7

2728

79.6

2.7

2.1

26

3.5

38

3.5

31

3.9

3.9

116

3.4

Partial

18

12.2

54

12.3

95

12.8

157

14.3

120

15.0

39

19.0

483

14.1

Artificial

13

8.8

20

4.6

18

2.4

24

2.2

20

2.5

3.4

102

3.0

147

100

438

100

742

100

1097

100

800

100

205

100

3429

100

Full

Total

* Numbers are for babies discharged from Delivery Suite, Ward 4 North, Kenepuru Maternity and Paraparaumu Maternity.

Asian women consistently have the lowest EBR.


Breastfeeding classes in Mandarin were introduced
in July 2012. The remainder of the Asian group
are Indian, South East Asian, Japanese, Korean and
Filipino. Although this group requires special support,
it is difficult to devise an initiative that takes account of
their disparate cultural experiences and attitudes.
The other group is made up of women from Africa,
Latin America, the Middle East and women who do
not fit into another ethnic group. This group have
experienced an increase in exclusive breastfeeding
rate from 62.5% in 2011 to 80.4% in 2012. There
is no obvious explanation for this although it is a
relatively small number of women, so individuals have a
disproportionate influence on the percentages.

Despite a consistently above average rate of normal


vaginal births Pacific People often experience
poorer breastfeeding outcomes. Possible negative
influences are diabetes, poor attendance at antenatal
education, smoking and a lack of written information
in appropriate languages. The Pacific breastfeeding
team is addressing this by providing increased support
antenatally and following discharge. The rate has
increased since 2011.
One initiative for increasing breastfeeding success
is antenatal milk expression for diabetic pregnant
women. As this process becomes more widespread,
diabetic mothers and babies may be enabled to stay
together on the postnatal wards. This may lead to
better EBR on discharge.
| 119

Capital & Coast District Health Board

It is notable that the Mori EBR is good on leaving


hospital, but then declines at a greater rate than
average in the first 6 weeks. The peer support
counsellor programme aims to address this.

Good linkage between the hospital and the community


for women requiring breastfeeding support is provided
by the community lactation consultant, the Pacific
breastfeeding teams and the breastfeeding centre.

Table 78: Infant feeding at time of initial discharge, by


maternal ethnicity for 2012
Babies

NZ
European

Other
European

Feeding *

No.

No.

No.

No.

No.

No.

No.

Exclusive

1428

84.5

339

81.7

332

80.8

255

77.0

300

61.2

74

80.4

2728

79.6

44

2.6

10

2.4

12

2.9

12

3.6

36

7.3

2.2

116

3.4

185

10.9

52

12.5

39

9.5

46

13.9

146

29.8

15

16.3

483

14.1

33

2.0

14

3.4

28

6.8

18

5.4

1.6

1.1

102

3.0

1690

100

415

100

411

100

331

100

490

100

92

100

3429

100

Full
Partial
Artificial
Total

Pacific
Peoples

Mori

Asian

Other

* Numbers are for babies discharged from Delivery Suite, Ward 4 North, Kenepuru Maternity and Paraparaumu Maternity.

120 |

Total

The Womens Health Service Annual Clinical Report 2012

11.3 Newborn hearing screening


In New Zealand approximately 3 in 1000 babies
born have mild to profound hearing loss. Before
the commencement of the Universal Newborn
Hearing Screening and Early Intervention Programme
(UNHSEIP) in New Zealand the average age of
detection was 45 months. Effective screening, referral
to audiology and diagnostic procedures can detect
permanent congenital hearing loss soon after birth.
Early medical and educational intervention before 6
months can maintain language, social and emotional
development matching their physical development.
The parents of all babies born in C&C DHB are
offered newborn hearing screening and in 2012 0.5%
declined. 54 babies (1.5% of babies screened) were
referred to audiology for assessment and diagnosis. 7

(13%) of these referred babies were diagnosed with a


permanent/congenital hearing loss. Non attendance
issues are being addressed with planning for an
audiology diagnostic clinic at Kenepuru in process.
From audiology, 10 babies were referred to the ENT
specialist, 2 were referred for hearing aids and no
babies required cochlear implants in 2012. The advisor
for deaf children attended the diagnostic appointments
and 6 required her follow up.
At C&C DHB in 2012 approximately two babies per
thousand screened were diagnosed with a permanent
congenital hearing loss within the first few months of
life and interventions commenced.

Table 79: UNHSEIP volumes for years 2010 to 2012

Newborn Hearing Screening


Offered screening

2010

2011

2012

No.

No.

No.

3988

3882

3903

68

32

19

3779

3677

3619

Screening not completed by end of year

52

Missed babies (not offered screening)

18

15

1585

1466

1443

239

163

218

71

45

54

Confirmed sensorineural loss (bilateral - unilateral)

2-4

3-7

1-3

Confirmed conductive loss (bilateral - unilateral)

5-2

2-1

0-1

Confirmed mixed loss (bilateral - unilateral)

1-0

3-1

1-0

Confirmed auditory neuropathy (bilateral - unilateral)

0-0

0-1

0-1

14 (20%)

18 (40%)

7 (13%)

0.4%

0.5%

0.2%

Referred to ENT Specialist

12

10

Referred for hearing aids

Referred for cochlear implants

10

Declined screening
Screening completed by end of year

Screened at outpatient clinics


Requiring targeted follow-up by Audiologist at 18 months
Referred for Audiology Assessment
Audiology Diagnosis

Total (% of referrals)
% diagnosed of babies screened
Early Intervention

Follow-ups by Advisor on deaf children, Ministry of Education

| 121

Capital & Coast District Health Board

11.4 NICU admissions and outcomes


19.2% of all live babies born in 2012 were admitted
to the Neonatal Intensive Care Unit and 83.1% of all
preterm babies admitted.

98.4% of all babies admitted to NICU were live


at discharge, and 97.2% of preterm babies were
discharged live.

Table 80: NICU admissions and outcomes for liveborn babies, by


gestation group for 2012
Total
liveborn
before
NICU adm.

Babies
Gestation
group

No.

20+0 23+6

NICU adms,
(No. & %
of Total
liveborn)
No.

Died in NICU
<7 days (%
of NICU
adms)
No.

Died in NICU
7, <28 days
(% of NICU
adms)
No.

Died in NICU
28 days
(% of NICU
adms)

No.

Live at
discharge
(% of NICU
adms)

No.

100.0

40.0

0.0

20.0

40.0

24 27

+6

47

47

100.0

0.0

2.1

2.1

45

95.7

28 31

+6

83

83

100.0

3.6

1.2

0.0

79

95.2

32 36

+6

292

220

75.3

0.0

0.5

0.0

219

99.5

427

355

83.1

1.4

0.8

0.6

345

97.2

2781

317

11.4

0.3

0.0

0.0

316

99.7

+0
+0
+0

All preterm
37 40
+0

41

+6

+0

669

72

10.8

1.4

0.0

0.0

71

98.6

Total

3877

744

19.2

0.9

0.4

0.3

732

98.4

(NICU = Neonatal Intensive Care Unit)

In the first six months of 2012 the aggregate rate of


10.62% for peer organisations was above C&C DHBs
upper 99% confidence interval for the clinical indicator

defined below. This was a favourable outcome for


C&C DHB.

Table 81: Peer group comparison for ACHS Obstetric clinical


indicator 10.1

Clinical Indicator

10.1

Inborn term babies transferred /


admitted to a neonatal intensive
care nursery or special care nursery
for reasons other than congenital
abnormality (L)

Period

C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Jan-Jun

8.55

9.03

8.33

12.05

11.59

10.62

Jul-Dec

8.32

10.77

11.06

10.69

12.17

11.60

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

122 |

The Womens Health Service Annual Clinical Report 2012

12. Perinatal mortality

12.1 Perinatal mortality rates


Fetal death includes stillbirths and terminations of
pregnancy. At C&C DHB there were 43 fetal deaths in
2012, 20 of these 43 fetal deaths were terminations.
As the DHB provides a termination service for the
surrounding DHBs this increases our fetal death rate in
comparison to the national rate.

Using the sixth annual PMMRC report of 2010 data the


adjusted perinatal mortality rate (stillbirth and early
neonatal deaths) was 7.8 per 1000 total babies which
compares favorably with our most recent rate of 7.7
per 1000 total babies for 2012.

| 123

Capital & Coast District Health Board

Table 82: Perinatal mortality numbers and rates for years 2005
to 2012
2005

2006

2007

2008

2009

2010

2011

2012

20052012

No.

No.

No.

No.

No.

No.

No.

No.

No.

3837

4041

4144

4091

4084

3985

4001

3920

32102

3799

3987

4093

4052

4028

3951

3961

3877

31747

38

54

51

39

56

34

40

43

355

17

21

26

19

28

22

20

23

176

17

14

12

14

14

13

96

18

14.3

16.8

15.2

10.8

17.1

12.0

13.2

12.8

14.0

Adjusted perinatal mortality


rate (Stillbirth & early neonatal
deaths)

8.9

8.7

9.2

5.9

10.3

9.0

8.2

7.7

8.5

Perinatal related mortality rate


(Fetal & all neonatal deaths)

14.3

17.1

15.7

11.0

18.1

13.6

13.5

13.5

14.6

Babies

Total babies
Liveborn babies
Fetal deaths

Stillbirths
Early neonatal deaths
Late neonatal deaths

2
3

PMMRC Rates (per 1000 total babies)


4

Perinatal mortality rate (Fetal


& early neonatal deaths)

1
2
3
4

All fetal deaths (Stillbirths and terminations of pregnancy, 20 completed weeks or more, or > 400g birth weight)
Early neonatal deaths (Liveborn, died < 7 days)
Late neonatal deaths (Liveborn, died between 7 and < 28 days)
PMMRC = Perinatal & Maternal Mortality Review Committee

The following figure shows that the perinatal and


the adjusted perinatal mortality rates have remained
constant over the last three years 2010 to 2012.

Figure 18: Perinatal mortality rates (perinatal and adjusted)


for years 2005 to 2012
Perinatal

20.0

Adjusted

18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0

2005

124 |

2006

2007

2008

2009

2010

2011

2012

The Womens Health Service Annual Clinical Report 2012

12.2 Perinatal mortality by maternal


age and ethnicity
The perinatal and the adjusted perinatal mortality
rates are tabulated in this section by maternal age and
ethnicity groups for the years 2005 to 2012. Rates
for the eight years combined are included in the
right hand column of each table. From the adjusted
perinatal mortality rate tables, the rates are highest
for women under 20 years of age and 40 years and
over. Pacific and Mori women also have the highest
adjusted perinatal mortality rates.

Although the numbers are small the peak in adjusted


perinatal mortality in 2009 coincided with a decrease
in the caesarean section rate during that year. Future
plans to decrease the caesarean section rate will need
to ensure that there are not adverse implications in
other areas.

Table 83: Perinatal mortality rate by maternal age groups


for years 2005 to 2012
2005

2006

2007

2008

2009

2010

2011

2012

20052012

14.6

0.0

4.5

9.2

45.5

15.9

17.2

17.3

15.8

20 24

6.9

20.4

25.3

7.4

25.8

21.1

10.1

7.9

15.7

25 29

24.2

19.0

17.5

13.3

21.3

9.0

13.0

7.1

15.5

30 34

12.1

20.5

9.5

7.9

11.4

9.3

9.2

12.2

11.6

35 39

12.0

12.6

14.2

12.7

9.1

13.2

20.8

18.5

14.1

40

16.7

9.6

32.8

18.5

24.5

9.3

9.3

19.9

17.9

Total

14.3

16.8

15.2

10.8

17.1

12.0

13.2

12.8

14.0

Maternal age
< 20

Table 84: Adjusted perinatal mortality rate by maternal age


groups for years 2005 to 2012
2005

2006

2007

2008

2009

2010

2011

2012

20052012

< 20

9.8

0.0

0.0

9.2

36.4

15.9

11.5

5.8

11.3

20 24

2.3

12.2

19.5

1.9

21.9

13.4

6.1

0.0

9.7

25 29

16.6

10.8

11.3

3.6

13.0

7.7

7.1

3.6

9.1

30 34

6.8

10.2

2.9

6.3

4.5

7.7

3.1

6.5

6.0

35 39

7.7

6.3

10.1

8.8

5.0

8.1

16.6

14.1

9.6

Maternal age

40

11.1

0.0

20.5

4.6

4.9

9.3

9.3

19.9

10.4

Total

8.9

8.7

9.2

5.9

10.3

9.0

8.2

7.7

8.5

| 125

Capital & Coast District Health Board

Table 85: Perinatal mortality rate by maternal ethnicity


groups for years 2005 to 2012
2005

2006

2007

2008

2009

2010

2011

2012

20052012

NZ European

12.8

16.7

17.2

12.3

14.3

13.0

13.5

12.3

14.1

Other
European

14.7

19.7

4.4

11.1

8.5

8.5

11.9

10.6

11.0

9.4

10.8

16.0

5.2

30.7

20.4

20.1

16.4

16.1

Pacific Peoples

15.9

15.2

7.6

12.5

24.1

10.2

10.1

13.7

13.7

Asian

31.3

21.1

17.3

9.7

16.9

6.7

10.2

13.0

15.1

Other

8.1

32.6

27.8

6.8

15.4

0.0

9.1

9.5

13.6

Total

14.3

16.8

15.2

10.8

17.1

12.0

13.2

12.8

14.0

Maternal ethnicity

Mori

Table 86: Adjusted perinatal mortality rate by maternal


ethnicity groups for years 2005 to 2012
2005

2006

2007

2008

2009

2010

2011

2012

20052012

NZ European

7.6

8.1

8.8

5.2

5.7

9.5

6.5

7.2

7.3

Other
European

2.9

4.9

4.4

8.9

4.3

4.3

6.0

6.4

5.3

Mori

5.7

5.4

10.7

5.2

23.5

16.7

18.1

8.2

11.6

Pacific Peoples

13.3

15.2

7.6

10.0

19.3

10.2

7.6

13.7

12.1

Asian

22.7

10.6

9.9

4.8

14.5

4.5

8.1

5.6

9.6

Other

8.1

21.7

22.2

0.0

7.7

0.0

9.1

9.5

9.7

Total

8.9

8.7

9.2

5.9

10.3

9.0

8.2

7.7

8.5

Maternal ethnicity

126 |

The Womens Health Service Annual Clinical Report 2012

12.3 Causes of perinatal deaths


69.6% of stillbirths in 2012 occurred at less than 28
weeks gestation and 52.2% had birth weights less than
500g.

Almost 22% of the stillbirths were to women who


smoked, whereas the overall C&C DHB smoking rate
for 2012 was 10.4%.

Table 87: Summary of factors related to the 23 stillbirths in


2012
Factor
Maternal Ethnicity

Maternal Age

Maternal Parity/CS history

No.
NZ European

39.1

Other European

13.0

Mori

13.0

Pacific Peoples

21.7

Asian

13.0

Other

0.0

23

100

< 20 years

4.3

20 24 years

0.0

25 29 years

8.7

30 34 years

34.8

35 39 years

39.1

40 years

13.0

Primiparous
Multiparous, no previous CS
Multiparous, with previous CS

Maternal Domicile

C&C DHB
Other DHBs

Maternal Smoking

Gestational Age

23

100

34.8

13

56.5

8.7

23

100

21

91.3

8.7

23

100

Yes

21.7

No

18

78.3

23

100

20 23 weeks

10

43.5

24+0 27+6 weeks

26.1

28+0 31+6 weeks

4.3

32+0 36+6 weeks

8.7

37 40 weeks

13.0

41+0 weeks

4.3

23

100

+0

+0

Birth Weight

+6

+6

<500g

12

52.2

500g-999g

21.7

1000g-1499g

4.3

1500g-1999g

4.3

2000g-2499g

4.3

2500g-2999g

8.7

3000g-3499g

4.3

23

100

| 127

Capital & Coast District Health Board

Table 88: Stillbirths by Perinatal Death Classification for the


years 2006 to 2012
2006

2007

2008

2009

2010

2011

2012

20062012

No.

No.

No.

No.

No.

No.

No.

No.

Congenital anomaly

22

Perinatal infection

Hypertension

Antepartum haemorrhage

14

Maternal conditions

10

Specific perinatal conditions

12

43

Hypoxic peripartum death

Fetal growth restriction

16

Spontaneous preterm
delivery

16

Unexplained

23

Primary diagnosis (PDC*)

No obstetric antecedent

Total

21

26

19

28

22

20

23

159

Post Mortems (PM)

20

13

13

12

12

88

95.2

50.0

68.4

42.9

40.9

45.0

52.2

55.3

Post Mortem rate (%)

* Perinatal Society of Australia and New Zealand - Perinatal Death Classification

128 |

The Womens Health Service Annual Clinical Report 2012

Table 89: Summary of factors related to the 7 early neonatal


deaths < 7 days in 2012
Factor
Maternal Ethnicity

Maternal Age

Maternal Parity/CS history

Maternal Domicile

Maternal Smoking

Gestational Age

No.
NZ European

71.4

Other European

0.0

Mori

14.3

Pacific Peoples

0.0

Asian

0.0

Other

14.3

100

< 20 years

0.0

20 24 years

0.0

25 29 years

14.3

30 34 years

0.0

35 39 years

57.1

40 years

28.6

100

Primiparous

14.3

Multiparous, no previous CS

42.9

Multiparous, with previous CS

42.9

100

C&C DHB

57.1

Other DHBs

42.9

100

Yes

14.3

No

85.7

100

20 23 weeks

28.6

24 27 weeks

0.0

28 31 weeks

42.9

32 36 weeks

0.0

37+0 40+6 weeks

14.3

41+0 weeks

14.3

100

<500g

0.0

500g-999g

42.9

1000g-1499g

0.0

1500g-1999g

28.6

2000g-2499g

0.0

2500g-2999g

0.0

3000g-3499g

28.6

100

+0
+0
+0
+0

Birth Weight

+6
+6
+6
+6

| 129

Capital & Coast District Health Board

Table 90: Early neonatal deaths by Perinatal Death


Classification for the years 2006 to 2012
2006

2007

2008

2009

2010

2011

2012

20062012

No.

No.

No.

No.

No.

No.

No.

No.

Congenital anomaly

18

Perinatal infection

Hypertension

Antepartum haemorrhage

12

Maternal conditions

Specific perinatal conditions

14

Hypoxic peripartum death

Fetal growth restriction

Spontaneous preterm delivery

16

Unexplained

No obstetric antecedent

14

12

14

14

13

79

No.

No.

No.

No.

No.

No.

No.

No.

Congenital anomaly

22

Extreme prematurity

21

Cardio-respiratory disorders

Infection

10

Neurological

17

Gastrointestinal

Other

Total

14

12

14

14

13

79

Post Mortems (PM)

12

45

85.7

50.0

100.0

42.9

57.1

30.8

57.1

57.0

Primary diagnosis (PDC*)

Total
Primary diagnosis (NDC*)

Post Mortem rate (%)

* Perinatal Society of Australia and New Zealand - Perinatal Death Classification & Neonatal Death Classification

130 |

The Womens Health Service Annual Clinical Report 2012

13. Maternal mortality


and morbidity

13.1 Maternal mortality


From 2003 to 2012 there has been one direct (in 2007)
and three indirect maternal deaths (in 2003, 2004 and
2009) at C&C DHB (see definitions below).

cause related to, or aggravated by the pregnancy or


its management, but not from accidental or incidental
causes (NZ HIS, 2007).

The maternal mortality ratio is the number of maternalrelated deaths per 100,000 maternities and for C&C
DHB it was 10.2 per 100,000 women over the 2003 to
2012 period.

Maternal deaths are further subdivided into two groups


defined by WHO as:

This rate is comparable to the ratio reported in the


United Kingdom between 2006 and 2008 of 11.4 per
100,000 (Lewis, 2007). The Perinatal and Maternal
Mortality Review Committee (PMMRC) reported a New
Zealand national ratio of 17.8 per 100,000 for the five
years 2006-2010 (PMMRC, Sixth Annual Report, table
35).

Definitions
Maternal deaths are defined according to the World
Health Organisation (WHO) definition as: Deaths
of women while pregnant or within 42 days of
birth,miscarriage or termination of pregnancy, from any

Direct - deaths resulting from obstetric


complications of the pregnant state, from
interventions, omissions, incorrect treatment, or
from a chain of events resulting from any of the
above.

Indirect - deaths resulting from previous existing


disease that developed during pregnancy and
which was not due to direct obstetric causes, but
was aggravated by the physiological effects of
pregnancy.

The Denominator for the ratio calculation is the


number of women with pregnancies that resulted in a
live birth or stillbirth occurring at or after 20 completed
weeks gestation (PMMRC, 2012).

| 131

Capital & Coast District Health Board

13.2 Severe maternal morbidity


AMOSS (Australasian Maternity Outcomes Surveillance
System) has been set up in New Zealand under the
auspices of the PMMRC. Monthly reports are obtained
from coding data and cases are entered in the AMOSS
database for current studies.
Previous studies include extreme morbid obesity
BMI >50 (completed 2010), influenza requiring ICU
admission (completed 2011), eclampsia (completed

2010), placenta accreta (completed 2012) and


peripartum hysterectomy (completed 2012). Data
collection continues for ongoing studies on amniotic
fluid embolism and antenatal pulmonary embolism.
New studies on rheumatic heart disease in pregnancy
and gestational breast cancer commenced in 2012.
There were no maternal deaths among the severe
morbidities reported in 2012.

Table 91: Incidence of AMOSS reportable severe maternal


morbidities for 2011 and 2012
2011
Study

2012

No.

Rate per 1000

No.

Rate per 1000

Placenta accreta/percreta/increta

0.51

1.04

Peripartum hysterectomy

0.51

0.78

Influenza requiring ICU admission

0.26

Amniotic fluid embolism

0.00

0.00

Antenatal pulmonary embolism

0.26

0.52

Rheumatic heart disease in pregnancy

0.52

Gestational breast cancer

0.00

13.3 Admissions to the Intensive Care


Unit
There were seven admissions to ICU of postpartum
women during 2012.
All were post caesarean section either for high
level observation or management of complications.

132 |

Admission reasons included pneumothorax (1), massive


postpartum haemorrhage (1), bowel complications (2),
morbid obesity with BMI >70 (1), uterine rupture (1),
and uterine tear (1).

The Womens Health Service Annual Clinical Report 2012

14. Gynaecology Clinics

14.1 Gynaecology Outpatient Service


There has been an overall increase in the number of
women attending gynaecology clinics within the WHS
in 2012 (see table on following page).
General gynaecology had 4845 visits which was
an increase of 484 visits (11.1%) from 2011. Total
gynaecology volumes were 8830 for 2012 which was
an increase of 9.2% from 2011.
The OASIS clinic was introduced with the
commencement of the new medical roster in October
2012. These women were previously seen in the pelvic
floor or general gynaecology clinics.
Preassessment volumes in 2012 (1558) have increased
by 35.8% since 2009 (1147). Nurse led preassessment
clinics for fit and healthy women who do not require

assessment by medical staff have been introduced over


this period.
The volumes for acute assessments have increased by
6.3% from 1142 in 2011 to 1214 in 2012.
There has been a 7.9% decrease from 2011 to 2012 in
the number of women attending clinic at Kenepuru,
and a 13.6% decrease over the four years from the 850
in 2009 to the 748 in 2012.
DNA (did not attend) rates have dropped for most
gynaecology clinics which is largely due to the
introduction of telephone and text reminders. The
booking centre staff work hard to reschedule those
who are unable to attend and fill clinic vacancies with
other women waiting to attend.

| 133

Capital & Coast District Health Board

Table 92: Gynaecology outpatient clinic attendances and DNA


rates for years 2009 to 2012
Attendance volumes
Gynaecology Clinic

Did not attend rates

2009

2010

2011

2012

2009

2010

2011

2012

No.

No.

No.

No.

Wellington

3187

3247

3380

3846

9.2

9.1

9.8

7.8

Kenepuru

850

843

812

748

15.5

12.2

11.6

11.8

Kapiti

349

198

169

246

5.4

11.6

14.8

5.3

Gynaecology - General

Hastings

34

0.0

14.7

0.0

0.0

4388

4322

4361

4845

10.1

9.9

10.3

8.3

Acute assessment

2337

1541

1142

1214

0.5

0.1

0.5

0.6

Preassessment

1147

1299

1415

1558

5.8

3.5

3.1

3.9

56

46

50

82

7.1

15.2

8.0

1.2

Infertility

290

237

280

300

10.0

8.4

8.9

6.3

Oncology

523

667

592

461

8.0

6.1

7.4

11.1

PCC

18

29

47

59

16.7

17.2

6.4

8.5

Pelvic floor

55

64

50

27

3.6

7.8

2.0

0.0

66

116

6.1

3.4

80

84

75

4.8

5.3

Total - General
Gynaecology - Other

High cost treatment

PMB
Skin

93

5.4

12.5

Urogynaecology

78

10.3

OASIS

15

0.0

Total - Other

4519

3968

3726

3985

3.6

3.4

3.6

4.0

Grand Total Gynaecology

8907

8290

8087

8830

6.8

6.8

7.2

6.3

During 2012 a concerted effort has been made by the


WHS and the outpatient booking centre to reduce the
waiting times for gynaecology FSAs (First Specialist
Assessment). This was achieved by July 2012 with no

134 |

women waiting for more than 4 months for an FSA. At


the same time in 2011 31 women were waiting up to 8
months for an FSA.

The Womens Health Service Annual Clinical Report 2012

Table 93: Gynaecology waiting time numbers per month for 2012
2012

Maximum waiting
time for FSA

Numbers waiting
> 6 months

Numbers waiting
< 6 months

Jan

10 months

22

847

Feb

9 months

17

851

Mar

8 months

14

894

Apr

6 months

884

May

6 months

767

Jun

8 months

644

Jul

5 months

544

Aug

6 months

471

Sep

6 months

469

Oct

5 months

492

Nov

4 months

581

Dec

4 months

574

14.2 Colposcopy Service


Colposcopy Satisfaction
Survey

Colposcopy Service
Monitoring

Since 2009 the WHS have asked women who require


colposcopy to participate in a satisfaction survey. In
2012 the survey commenced on 1st of June and
concluded on the 30th June. 123 women required
colposcopy during this period and feedback was
received from 39 women, a response rate of 31.7%.
Generally speaking the feedback received was very
positive. Women felt they were treated with respect,
given adequate opportunity to ask questions and
receive information.

The colposcopy service is monitored by the National


Screening Unit of the Ministry of Health with a monthly
colposcopy service monitoring report. There are strict
criteria that govern the timeframes in which women
with abnormal cervical smears are seen for FSA at
colposcopy.

The main area identified by women as needing


improvement pertained to information about their
up and coming treatment. A copy of the National
Cervical Screening leaflet is now posted out to all
women requiring colposcopy as previously only new
patients received the leaflet. This leaflet accompanies
the scheduled appointment letter. Women attending
the colposcopy service will be resurveyed in June and
November 2013.

These are:

Suspicion of cancer - within 1 week

High grade - within 4 weeks

Low grade - within 26 weeks

There are also criteria to ensure that women who


require treatment for their biopsy proven cervical
abnormalities have this carried out within the
appropriate times. These are:

High grade - within 8 weeks

Low grade - within 26 weeks

| 135

Capital & Coast District Health Board

If the women are not seen within these timeframes the


reason for this is documented in the service monitoring
report. In 2012 there were three main reasons why
women were not seen on time for FSA and treatment
in colposcopy.

C&C DHBs contracted volumes for 2012 were:


1200 new and follow up colposcopy and LLETZ


follow ups

200 LLETZ treatments

First Specialist Assessment:


19 women declined an appointment offered within


the timeframe

4 women had a medical reason

3 women were not seen due to doctor


unavailability

These volumes were exceeded in 2012 which can be


seen in the table below.
There was an 8.2% increase in visits to all colposcopy
clinics from 1536 in 2011 to 1662 in 2012. The
colposcopy did not attend rate of 12.5% for 2012
is within the accepted rate of less than 15% which
is monitored by the National Cervical Screening
Programme.

Treatment:

23 women were not seen due to doctor


unavailability

10 women declined an appointment offered

Table 94: Colposcopy outpatient clinic attendances and DNA


rates for years 2009 to 2012
Attendance volumes
Colposcopy Clinic

Colposcopy
LLETZ
Total Colposcopy

Did not attend rates

2009

2010

2011

2012

2009

2010

2011

2012

No.

No.

No.

No.

1184

1200

1144

1294

15.2

14.6

16.7

14.1

315

328

392

368

15.9

9.1

9.2

6.5

1499

1528

1536

1662

15.3

13.4

14.8

12.5

Table 95: Colposcopy waiting time numbers per month for 2012
2012

Maximum waiting time for FSA

Numbers waiting > 6 months

Numbers waiting < 6 months

Jan

9 months

256

Feb

10 months

12

217

Mar

9 months

196

Apr

9 months

226

May

10 months

244

Jun

7 months

206

Jul

6 months

230

Aug

6 months

227

Sep

7 months

227

Oct

7 months

221

Nov

7 months

182

Dec

8 months

122

* Not available

136 |

The Womens Health Service Annual Clinical Report 2012

14.3 Te Mahoe Unit


Te Mahoe provides comprehensive pregnancy
counselling as well as first and second trimester
termination of pregnancy (TOP) services for women
between 5 and 19+1 weeks gestation.
The following table tabulates the distribution of women
who attended Te Mahoe by DHB of origin over the last
six years.

There are slight variations in the DHB distribution of


TOPs. During 2012 there was a slight decrease in the
Capital and Coast and Hutt Valley DHB figures, as well
as an increase in the number of non-residents seeking
a TOP.

Table 96: DHB distribution of women attending Te Mahoe Unit in


years 2007 to 2012
2007
DHB

2008

2009

2010

2011

2012

Capital & Coast

46.0

44.5

44.0

41.0

44.0

40.5

Hutt Valley

23.0

23.0

24.0

22.8

23.2

21.6

Mid-Central

19.3

20.0

19.0

19.1

19.0

19.4

Whanganui

6.8

7.4

7.0

9.0

8.4

9.2

Hawkes Bay

1.1

0.6

0.7

0.8

0.4

0.9

Wairarapa

0.4

0.5

0.7

0.8

0.7

1.5

Nelson Marlborough

0.6

0.7

0.5

0.5

0.8

0.8

Other non-central region DHBs

0.7

0.7

0.2

1.2

0.8

0.5

Non-residents

2.1

2.5

4.0

4.7

2.7

5.7

100

100

100

100

100

100

| 137

Capital & Coast District Health Board

The next table shows the total number of TOPs


performed in the unit for the years 2007 to 2012,
the percentage distributions for various medical and
demographic variables, and the complication rates.
There continues to be a decrease in the number of
women having a TOP in Te Mahoe. There was an 11%
reduction in the number of TOPs performed from 2011
to 2012.
Of the TOP appointments scheduled in 2012, 2.5% of
women did not attend and 2.6% phoned and cancelled
their appointment.
During 2012, 1958 counselling appointments were
made but 10% did not attend.
44.3% of women had some form of long acting
reversible contraception (LARC) inserted following
their TOP during 2012. Of those 6.6% were the
mirena intrauterine system, 23.3% were a multiload
cu 375 intrauterine device and 14.4% were the jadelle
contraceptive implant. There was a 10% decrease in
the number of jadelle implants inserted post TOP in
2012 as compared to 2011.
There was a slight decrease in the number of women
choosing to have a medical TOP procedure. A
contributing factor to this might have been the early
availability of surgical TOP appointments. During
2012, 81% of women having an early medical TOP
procedure chose to return home after taking the
misoprostol and continued the process at home.

138 |

During 2012, 18 women from the MFM team were


admitted to Te Mahoe for a TOP. Fifteen of these
women had their TOP performed under general
anaesthetic and three under local anaesthetic. These
figures are not included in the Te Mahoe data.
According to the Abortion Supervisory Committee
statistics, Te Mahoe continues to perform terminations
at earlier gestations than the majority of units within
New Zealand, with 55% being performed at less than
nine weeks.
There are slight variations in the ethnicity distributions
of women seeking a TOP.
Of note there was a 4% decrease in TOPs performed
in the 19 to 24 year age group, otherwise there was
no significant change in the age distribution of women
referred.
There was no significant change between the 2011
and 2012 surgical TOP known complications. When
comparing the 2011 and 2012 medical TOP known
complications, there was a slight increase in retained
products of conception (RPOC) and a 3% increase in
women requiring hospital admissions, with the majority
of those requiring an evacuation of RPOC. Two women
had ongoing pregnancies following a medical TOP with
one repeated as a general anaesthetic TOP and the
other choosing to continue the pregnancy.

The Womens Health Service Annual Clinical Report 2012

Table 97: Numbers and rates for Te Mahoe for years 2007 to 2012
Total number of TOPs
Procedure
Local anaesthetic

2007

2008

2009

2010

2011

2012

3078

2872

2781

2691

2497

2221

88.0

86.0

90.0

89.0

89.0

91.6

General anaesthetic

5.0

5.0

5.0

5.0

4.8

3.8

Early medical terminations

6.5

7.0

5.0

6.0

6.0

4.4

Induction of labour

0.5

1.0

0.1

0.1

0.04

Less than 9 weeks

40.0

47.0

48.0

50.0

50.0

54.8

9 11 weeks

41.0

37.0

35.0

33.0

34.0

29.6

12 15 weeks

MFM induction of labour


Gestation

1.0

15.0

12.0

14.0

14.0

12.0

12.8

16 weeks and over

4.0

4.0

3.0

3.0

4.0

2.6

Repeat TOPs

None

63.0

62.0

61.0

62.0

62.0

58.8

1 prior TOP

24.0

23.0

25.0

25.0

25.0

26.4

2 prior TOPs

8.0

10.0

8.0

9.0

9.0

9.3

3 prior TOPs

3.0

4.0

4.0

3.0

3.0

3.4

4 prior TOPs

2.0

1.0

2.0

1.0

1.0

2.0

Ethnicity

NZ European

49.0

50.0

46.0

49.0

49.0

48.8

Mori

24.0

25.0

25.0

25.0

24.5

26.2

Samoan

5.0

6.0

6.0

6.0

6.5

6.4

Other Pacific Peoples

2.4

4.4

4.0

4.0

5.0

0.2

Asian

5.0

4.4

4.0

3.0

4.5

0.1

Other

14.6

10.2

15.0

13.0

10.5

18.2

Age

< 14 years

0.2

0.4

0.0

0.0

0.0

0.0

14 15 years

2.2

1.6

2.0

1.0

1.5

1.1

16 18 years

16.2

15.0

16.0

12.0

10.2

9.9

19 24 years

37.9

40.0

40.0

40.0

44.2

40.2

25 29 years

17.3

19.3

19.0

21.0

19.5

21.8

30 35 years

15.2

14.0

14.0

15.0

14.3

15.8

36 40 years

8.7

7.6

7.0

8.0

8.0

8.3

> 40 years

2.3

2.1

2.0

3.0

2.3

2.8

STOP complication rates

RPOC

1.1

1.3

0.6

0.8

1.45

0.8

0.8

0.5

Requiring hospital admission

0.8

0.9

0.4

0.6

Failed TOP

0.2

0.3

0.0

0.04

Perforation

0.04

0.1

0.08

0.04

0.0

0.04

0.0

0.04

Endometritis

PPH
Ongoing pregnancy
Early MTOP complication rates

RPOC

3.9

5.3

2.0

3.1

Endometritis

1.3

0.5

0.6

1.0

Requiring hospital admission

2.6

3.0

2.0

5.2

1.2

1.3

2.0

0.6

1.0

Failed TOP
PPH

| 139

Capital & Coast District Health Board

140 |

The Womens Health Service Annual Clinical Report 2012

15. Gynaecology Services

15.1 Gynaecology Inpatient Service


Gynaecology inpatient services in pod A of Ward 4
North continued to maintain its acute and elective
services in 2012.

urinary retention, abdominal pain and breast abscess.


A further 91 postpartum women were readmitted more
than 10 days after giving birth.

Acute admissions to the inpatient ward are via the


Acute Assessment service Monday to Friday 8am to
6pm. After hours, the majority of admissions are via
the Emergency Department (ED). In order to meet the
6 hour rule in ED, women are triaged according to a
defined triage protocol. If their condition is stable and
meets the set criteria, after discussion with the on-call
registrar the women are fast tracked to the inpatient
ward for assessment. Women with an unstable
condition will remain in ED until they are assessed
by the obstetric and gynaecology registrar and their
condition stablised prior to admission to the inpatient
ward.

The perioperative unit at Wellington Regional Hospital,


the day surgery unit and the surgical medical unit at
Kenepuru Hospital provide additional beds for elective
surgery. The gynaecology service has an allocated
10 surgical sessions per week, with three sessions
at Kenepuru Hospital. A total of 1177 women had
elective surgery at Wellington Regional Hospital and
384 women at Kenepuru Hospital.

66 women admitted acutely required evacuation of


retained products of conception (ERPOC) and were
admitted directly from ED to an operating theatre or
from Ward 4 North to theatre. 159 women had an
arranged ERPOC procedure in a day stay bed in the
Surgical Admissions Unit. Refer to Table 101.
There were 484 non-surgical gynaecology admissions
in 2012. The diagnoses for 289 of these women are
detailed in Table 103. There were also 104 antenatal
admissions of women who were under 20 weeks
gestation, of which 68 had hyperemesis and 36 other
conditions such as urinary tract infection, pylonephritis,

The increase in day case numbers at Wellington


reflects the available use of theatre time for additional
gynaecology operating lists. Preparation for discharge
commences at the preassessment visit when women
are informed of their expected length of stay in
the inpatient ward. This process has increased
the number of women being discharged from the
inpatient ward in the expected timeframes. All day of
surgery admissions including gynaecology oncology
are admitted to the surgical admissions unit and
transferred to the inpatient ward postoperatively. This
enables improved bed utilisation.
In 2012 the gynaecology service used the mobile
surgical bus at the Kapiti Health Centre for seven
elective surgical lists. Procedures carried out included
dilation and curettage, hysteroscopy, laparoscopic
sterilisation, excision of Bartholins abscess and

| 141

Capital & Coast District Health Board

insertion of mirena. This was a nurse-led initiative.


The list was arranged by the gynaecology nurse care
coordinator with postoperative follow-up by nursing
staff. This service meant that women did not have to
travel to Wellington for surgery. The service plans to
continue using the mobile surgical bus in 2013.

Table 98: Elective gynaecology surgery volumes for years


2009 to 2012
2009

2010

2011

2012

Surgery location

No.

No.

No.

No.

Wellington Inpatient

866

848

777

835

Wellington Day Surgery Unit (SAU)

358

242

270

342

Kenepuru Surgical Medical Unit


Total

470

318

393

384

1694

1408

1440

1561

Table 99: Acute gynaecology surgery volumes for years 2009


to 2012
2009

2010

2011

2012

No.

No.

No.

No.

92

157

147

198

Wellington Day Surgery Unit

211

188

143

169

Total

303

345

290

367

Surgery location
Wellington Inpatient

142 |

The Womens Health Service Annual Clinical Report 2012

Table 100: Elective gynaecology surgery volumes and


breakdown of surgical procedures for 2012
Surgical Procedure
TAH +/- BSO

Wellington
Inpatient

Wellington
day patient

Kenepuru

Total

43

12

55

13

Vaginal hysterectomy

11

16

Laparoscopic assisted vaginal hysterectomy

32

36

Laparoscopic ovarian cystectomy/BSO/oopherectomy

46

19

65

Laparotomy oopherectomy/BSO

21

23

31

22

53

168

95

263

Insertion of Mirena

78

32

110

Insertion of Mirena as part of another procedure****

33

41

22

87

Sub-total hysterectomy

Laparoscopic sterilisation
Dilation & curettage, hysteroscopy, polypectomy

Myomectomy

Endoscopic endometrial ablation

65

Large loop excision of the transformation zone (LLETZ)

13

15

Cone biopsy

13

17

Laparoscopic cerclage
Incision & drainage Bartholins abscess

18

20

Urogynaecology surgery *

152

32

184

Endometriosis surgery **

239

124

363

Gynaecology Oncology Service ***

228

Total

835

Fentons procedure

228
342

384

1561

* See section on Urogynaecology for breakdown of surgical procedures


** See section on Endometriosis for breakdown of surgical procedures
*** See section on Gynaecology Oncology for breakdown of surgical procedures
**** Not counted in total numbers as part of another procedure

| 143

Capital & Coast District Health Board

Table 101: Acute gynaecology surgery volumes for 2012


Wellington
Inpatient

Surgical Procedure

Wellington
day patient

Total

Laparoscopic salpingectomy/salpingostomy (ectopic pregnancy)*

32

32

Evacuation retained products of conception (dilation & curettage)

66

Laparoscopic ovarian cyst/abscess

37

37

Diagnostic laparoscopy

13

13

Laparotomy torted ovarian cyst/hemorrhagic cyst

12

12

Incision & drainage of Bartholins abscess

27

159

225

10

37

Total abdominal hysterectomy (following caesarean section)

Cervical cerclage

Wound debridement

Total

198

169

367

* Of the 32 women with ectopic pregnancy, there were 7 ruptured ectopic and 2 corneal ectopic.

The following table lists the reasons for postnatal


readmission. Women who have recently given
birth are able to have their baby stay to encourage
breastfeeding and bonding.

On discharge the women are referred back to their


LMC for ongoing postnatal care or to their GP if they
are 4 to 6 weeks postpartum.

Table 102: Postnatal readmissions for 2012


Diagnosis
Retained products of conception

Total
6

Endometritis

23

Caesarean section wound infection

14

Mastitis

14

Breast abscess

Unwell / sepsis

Urinary retention

Pain +/- endometritis

15

Total

91

Of the 45 women who presented with chronic pain


(endometriosis) there were 12 women who presented
between two and five times. Further discussion is
provided in the Endometriosis Service report.

144 |

The Womens Health Service Annual Clinical Report 2012

Table 103: Non-surgical acute admissions for 2012


Diagnosis

Total

Complete / incomplete miscarriage (conservative management )

76

Conservative management ectopic (Methotrexate)

14

Ovarian hyperstimulation

Tubal / ovarian abscess

Labial / vulval cellulitis

15

Pelvic inflammatory disease

21

Genital herpes

PV bleeding / menorrhagia

37

PV bleeding / infection post TOP

14

Post-operative readmissions (Public & Private)

53

Chronic pain (Endometriosis)

45

Total

289

15.2 Endometriosis Service


There is a dedicated fortnightly specialist
endometriosis clinic. Women are referred from
other specialists and general practitioners. Various
management options are discussed with the women
and if surgery is warranted this is explained in detail.

endometriosis pain. In 2012 there were 45 acute


admissions for exacerbation of endometriosis pain.
With input from the chronic pain service, no women
required a patient controlled analgesia system (PCAS)
to assist in controlling their pain.

In most cases we are able to treat the endometriosis


at the time of the initial laparoscopy thereby saving
women an additional operative procedure.

Those women who had not previously been referred


to the chronic pain service were referred during their
admission for assistance with pain management,
with an outpatient referral for follow-up and ongoing
management.

The service carried out elective surgery on 199 women


at Wellington Regional Hospital and 164 women at
Kenepuru Hospital. Length of stay for these women
is usually overnight with discharge home planned
for 11am the next morning. Most women having a
diagnostic laparoscopy and dye studies are able to be
discharged home on the day of surgery.
Most clinicians perform excisional treatment and
histological confirmation is obtained. The majority of
ovarian endometriomas were treated by cystectomy
and tissue was sent for histology.
The service also provides an acute service for those
women who present with exacerbation of their

Women who are under the chronic pain service


and continue to have multiple presentations to the
Emergency Department have an agreed analgesia
management plan for their pain management. The
chronic pain clinical nurse specialist visits the women
on a daily basis whilst they are inpatients, in order
to assist with early discharge and follow up in the
community. Some complex cases of chronic pelvic pain
are discussed at the multidisciplinary team meetings
with gynaecologic input which we plan to make a more
regular feature.

| 145

Capital & Coast District Health Board

Table 104: Total endometriosis procedures for 2012


Sites excised *

Total

Laparoscopic excision of endometriosis (includes excision of endometriosis from broad ligaments,


pelvic side walls, uterosacral, rectovaginal, bladder, bowel tubes & ovaries)**

267

Laparoscopy & dye studies

46

Ovarian drilling

13

Ovarian endometrioma

36

Converted to open procedure

Total

363

* Some women have multiple sites of disease, therefore there may be 3-4 sites excised in one procedure.
** Total volumes represent each case not each procedure.

15.3 Urogynaecology Service


Women with symptoms of pelvic floor disorder are
seen in a range of gynaecology clinics in Wellington
and Kenepuru. Women with more complex problems
such as recurrent prolapse, previously treated stress
incontinence and ICS stage 4 vault prolapse, are
referred to the pelvic floor clinic. There is now a
dedicated combined pelvic floor clinic with three
clinicians with sub-speciality interest managing these
women.
The urogynaecology service is supported by a team of
pelvic floor physiotherapists. Patients for urodynamics
are referred to the Urology Department. Occasional
referrals are also made to colorectal specialists.
Challenges in urogynaecology continue to be:

Optimising care at a time of increasing demand


because of the ageing population, increased
public awareness and the need to improve quality
of life

Steady increase in number of women requiring


surgery for pelvic organ prolapse (POP) and urinary
incontinence

Individualising surgical approach: improving


outcomes while minimising risks

Current medico legal environment.

Bilateral sacrospinous fixation for vault prolapse


continues to be utilised widely as part of a combined
procedure.
Grafts to reinforce tissues have been used in selected
cases. There is now a trend towards reduced graft
related problems as our understanding of preoperative,
146 |

postoperative care and surgical techniques improve.


With new FDA regulations there has been a change in
the type of synthetic grafts available for transvaginal
mesh repair.
There is a clear shift from retropubic procedures to
transobturator procedures for the surgical treatment of
stress incontinence related to safety and technical ease
of the latter. Retropubic TVT is reserved for a select
few cases.
As the proportion of women in the 50-85 year age
group increases so will the need for prolapse surgery.
Nationwide data of surgical numbers is not available
in New Zealand for comparison. There is a steady
increase in surgical volumes noted. As life expectancy
increases and more women opt for surgery for want
of better quality of life and with a 29% failure rate for
traditional prolapse repair the need for repeat surgery
will increase as well.
We need to continue focusing on pelvic floor
physiotherapy both pre and postoperatively, along with
advising women on life style interventions to reduce
the recurrence rate.
Excellent support is provided by our gynaecology ward
nursing staff for management of postoperative bladder
and bowel care. Postoperative bladder management
has been further refined with use of retrograde fill
of bladder postoperatively. This avoids some of the
unsuccessful trial of voids and re-catherisation. The
gynaecology inpatient charge nurse manager in
Ward 4 North remains actively involved in continuous
education of the nursing staff.

The Womens Health Service Annual Clinical Report 2012

Table 105: Urogynaecology surgery procedures for years 2008


to 2012
Procedure *

2008

2009

2010

2011

2012

No.

No.

No.

No.

No.

Vaginal repair with sacrospinous fixation

16

13

50

30

29

Native tissue vaginal repair

63

85

88

78

74

23

15

20

15

27

56

49

60

58

36

Revision of mesh

Abdominal sacrocolpopexy

159

186

230

195

184

Vaginal repair with Prolift


Mesh vaginal repair with Gynaecare mesh
Vaginal hysterectomy for prolapse
Sling procedures for SUI

Total

* Some women have had more than one procedure at the same operative episode. The surgical numbers for 2012 were reliant on ORSOS and
surgical lists. The actual procedure may be different from proposed therefore possibly affecting accuracy of surgical procedures for 2012.

15.4 Gynaecology Oncology Service


The service continues to develop a model based on
the Central Cancer Network and the framework for
providing gynaecologic oncology service developed by
the New Zealand Gynaecology Cancer group.

Multidisciplinary meetings now include our colleagues


at Mid-Central DHB and with more resources available
both at Wellington and at other locations the service
can continue to evolve.

Table 106: Gynaecology Oncology referral numbers by DHB for


years 2009 to 2012
District Health Board
Capital and Coast

2009

2010

2011

2012

No.

No.

No.

No.

98

102

Hutt Valley *

94

120

16

19

Hawkes Bay

48

38

28

36

Taranaki

29

36

27

23

Whanganui

15

Mid Central

16

21

13

20

10

13

Nelson Marlborough

Other North Island

Other South Island

207

205

214

228

Wairarapa

Total
* Hutt Valley DHB numbers included in C&C DHB numbers for 2009 and 2010.

| 147

Capital & Coast District Health Board

Table 107: Histological confirmed gynaecology oncology cases


for newly referred women in 2012
Gynaecology Malignant Neoplasm

Total

Malignant neoplasm of ovary

38

Malignant neoplasm of endometrium

44

Malignant neoplasm of cervix uteri, unspecified

56

Malignant neoplasm of vulva, unspecified

31

Malignant neoplasm of vagina

Malignant neoplasm of placenta

Malignant neoplasm of fallopian tube

Total

174

Table 108: Gynaecology oncology surgery procedures for 2012


Surgical Procedure

Total

Total abdominal hysterectomy bilateral salpingo-oopherectomy, para-aortic lymph node sampling

38

Total abdominal hysterectomy, bilateral salpingo-oopherectomy, omentectomy, para-aortic lymph


node sampling

44

Radical abdominal hysterectomy with radical excision of pelvic lymph nodes

Trachlectomy

Dilation & curettage of uterus, D&C, hysteroscopy, +/- polypectomy

24

EUA, staging

50

Cone biopsy of cervix

12

Biopsy of vagina
Wide local excision vulva

5
18

Wide local excision vulva bilateral groin node dissection

Radical vulvectomy

Laparoscopic bilateral salpingo-oopherectomy

Other procedures
Total

148 |

17
231

The Womens Health Service Annual Clinical Report 2012

15.5 Adverse gynaecological outcomes


Definition: An adverse outcome is an unintended
and/or unexpected significant gynaecological injury or
complication that results in a prolonged length of stay,
disability or death.
Outcome monitoring is performed under the following
headings:

Trend monitoring

Case review

Reportable event

The process of monitoring adverse outcomes


commenced in May 2004, with 2012 being our eighth
year of formal reporting.
The WHS clinical outcomes committee meets regularly
to ensure that adverse gynaecology outcomes, in
relation to trends tracking and clinical indicators
are identified, analysed and reviewed. All trend
monitoring is measured against the ACHS clinical
indicators. The objective of adverse outcome
monitoring is to minimise risk to women, staff and the

organisation. Data, trends and adverse outcome case


studies are presented at our quality forums, in order
to review and engage clinicians in discussion. This
enables all clinicians to focus on potential areas of risk
and to identify systems that can help to improve care
and outcomes for women accessing our service.
Advantages of the process:

No worrying trends have been identified

This is an educational, supportive forum

This is well received by senior medical officers,


junior medical and nursing staff

Data presented at quarterly quality forums.

A brief summary of the adverse outcomes for 2012 are


in the following table. Some women had more than
one adverse outcome.
The total number of adverse outcomes reported in
2010 was 104. Sixty-five adverse outcomes were
reported in 2011 and 81 in 2012 indicating there is
some fluctuation year to year.

Table 109: Adverse gynaecologic outcomes for 2012


Adverse outcome

Benign
Gynaecology

Gynaecology
/ Oncology

Blood transfusion intraoperatively

Blood transfusion postoperatively

Major vascular injury or bowel or urinary tract requiring over sewing/repair

Uterine perforation requiring surgical intervention

Major wound dehiscence

Unexpected admission to ICU

Major postoperative sepsis

Major wound infection

Transfer from Kenepuru

Return to theatre within 7 days

Postoperative death

20

Readmission within 1 month


Length of stay over 10 days postoperatively
Urinary tract obstruction requiring catheterisation postoperatively

Total Adverse Outcomes

58

23

Total Women

53

22

| 149

Capital & Coast District Health Board

15.6 ACHS Gynaecology clinical


indicators
The gynaecology ACHS clinical indicator peer
report provides a useful tool for comparing intra and
postoperative complications with like organisations
throughout New Zealand and Australia who submitted
data. In total, 33 organisations submitted data in the
first half of 2012, and 34 organisations submitted data
in the second half (see Table 124).
Overall the gynaecology service is comparable to other
units within Australasia. Complication rates compared
favourably for laparoscopic and urogynaecological
procedures and in the surgical management of ectopic
pregnancies.
In 2012 there were three indicators where the
gynaecology service did not meet the benchmark.
The most notable is the rate of unplanned blood
transfusions for women admitted for gynaecological
surgery for benign disease (indicator 1.1). 18 women
were transfused in 2012 compared to the expected

150 |

number of 10. The rate of transfusion of women


admitted for gynaecological surgeries (indicator 1.2)
was also marginally higher than expected by the peer
group comparison.
In the first six months, there were seven cases where
operative injuries to major viscus occurred. These
cases included gynaecological malignancies. This
pattern did not continue in the latter part of the year.
No viscus injuries were reported for laparoscopic
surgeries.
One of the ACHS clinical indicators is laparoscopic
management of ectopic pregnancies (indicator 4.1). 27
of 30 ectopics managed surgically at C&C DHB in 2012
were managed laparoscopically. This indicates that
the acute services are functioning well enabling timely
diagnosis and access to surgeons with the necessary
skills and training.

The Womens Health Service Annual Clinical Report 2012

Table 110: Group comparison for ACHS Gynaecology clinical


indicators for years 2010 to 2012
C&C
2010

C&C
2011

C&C
2012

ACHS
2010

ACHS
2011

ACHS
2012

Period

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Rate
(%)

Patients receiving an unplanned blood


transfusion during their hospital admission
for any type of gynaecological surgery for
benign disease (L)

Jan-Jun

3.05

1.74

2.56

0.99

1.35

1.46

Jul-Dec

1.42

2.34

1.86

1.09

1.03

1.01

Patients receiving an unplanned blood


transfusion during their hospital admission
for any type of gynaecological surgery for
malignant disease (L)

Jan-Jun

8.96

19.12

8.77

9.41

8.36

6.01

Jul-Dec

19.12

14.81

8.20

10.48

6.01

7.03

Patients suffering injury to a major viscus


Jan-Jun
with repair, during an gynaecological
operative procedure or subsequently up to 2
Jul-Dec
weeks post-operatively (L)

1.59

1.37

1.70

0.47

0.51

0.63

0.79

1.11

0.44

0.46

0.58

0.40

Patients suffering an injury to a major


Jan-Jun
viscus with repair, during a laparoscopic
gynaecological operative procedure or
subsequently up to 2 weeks post-operatively Jul-Dec
(L)

0.00

0.50

0.00

0.63

0.99

0.78

0.00

1.52

0.74

0.73

1.03

0.82

Patients receiving an injury to a ureter at the


time of a laparoscopic hysterectomy with
repair during the procedure or subsequently
up to 2 weeks post-operatively (L)

Jan-Jun

0.00

0.00

0.00

0.43

0.43

0.00

Jul-Dec

0.00

0.00

0.00

0.43

0.00

1.00

Patients receiving a bladder injury at the


time of a laparoscopic hysterectomy with
repair during the procedure or subsequently
up to 2 weeks post-operatively (L)

Jan-Jun

0.00

0.00

0.00

0.00

0.00

0.36

Jul-Dec

0.00

0.00

0.00

0.00

0.31

1.00

Jan-Jun

87.50

69.23

93.75

83.57

80.76

82.41

Jul-Dec

92.86

94.44

85.71

82.75

82.82

82.58

Patients receiving injury to a major viscus


with repair, during a pelvic floor repair
procedure or subsequently up to 2 weeks
post-operatively (L)

Jan-Jun

1.85

1.45

0.00

0.91

1.43

1.78

Jul-Dec

0.00

0.00

0.00

1.52

1.18

1.39

Patients receiving a ureter injury at the time


of a pelvic floor repair procedure with repair
during the procedure or subsequently up to
2 weeks post-operatively (L)

Jan-Jun

0.00

0.00

0.00

0.00

0.28

0.00

Jul-Dec

0.00

0.00

0.00

0.14

0.27

0.36

Patients receiving a bladder injury at the


time of a pelvic floor repair procedure with
repair during the procedure or subsequently
up to 2 weeks post-operatively (L)

Jan-Jun

0.00

0.00

0.00

0.66

0.42

0.68

Jul-Dec

0.00

0.00

0.00

0.42

0.68

0.60

Clinical Indicator

1.1

1.2

2.1

3.1

3.2

3.3

4.1

5.1

5.2

5.3

Laparoscopic management of an ectopic


pregnancy (H)

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval.

| 151

Capital & Coast District Health Board

152 |

The Womens Health Service Annual Clinical Report 2012

16. Appendices

16.1 Extra data tables


The following are data tables not included in the main
text.

| 153

154 |

4019

100

0.6

2.5

6.5

90.4

100

0.6

2.5

6.7

3800

19

98

234

3449

No.

100

0.5

2.6

6.2

90.8

100

0.5

2.6

6.3

90.5

2004

3703

19

98

234

3352

No.

2004

3837

18

110

264

3445

No.

100

0.5

2.9

6.9

89.8

100

0.5

2.9

7.0

89.6

2005

3754

18

110

264

3362

No.

2005

4041

26

131

254

3630

No.

100

0.6

3.2

6.3

89.8

100

0.7

3.3

6.4

89.6

2006

3967

26

131

254

3556

No.

2006

4144

23

154

266

3701

No.

100

0.6

3.7

6.4

89.3

100

0.6

3.8

6.6

89.1

2007

4047

23

154

266

3604

No.

2007

4091

31

162

273

3625

No.

100

0.8

4.0

6.7

88.6

100

0.8

4.1

6.8

88.3

2008

3999

31

162

273

3533

No.

2008

4084

20

157

232

3675

No.

100

0.5

3.8

5.7

90.0

100

0.5

3.9

5.8

89.8

2009

3995

20

157

232

3586

No.

2009

3985

39

156

203

3587

No.

100

1.0

3.9

5.1

90.0

100

1.0

4.0

5.2

89.8

2010

3891

39

156

203

3493

No.

2010

4001

27

127

245

3602

No.

100

0.7

3.2

6.1

90.0

100

0.7

3.2

6.3

89.8

2011

3917

27

127

245

3518

No.

2011

3920

28

132

240

3520

No.

100

0.7

3.4

6.1

89.8

100

0.7

3.4

6.2

89.6

2012

3850

28

132

240

3450

No.

2012

Total

24

Birth before arrival

263

Kenepuru

99

3633

Wellington

Paraparaumu

No.

90.2

2003

3927

Place of birth

Babies

Total

24

Birth before arrival

263

Kenepuru

99

3541

Wellington

Paraparaumu

No.

2003

Place of birth

Mothers

Table 111: Place of birth for the C&C DHB region for the years 2003 to 2012

Capital & Coast District Health Board

The Womens Health Service Annual Clinical Report 2012

Table 112: Place of birth by C&C DHB birthing facility for the
years 2003 to 2012
Mothers

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Birth Facility

No.

No.

No.

No.

No.

No.

No.

No.

No.

No.

Wellington

3558

3365

3379

3574

3622

3560

3603

3520

3537

3470

Kenepuru

270

240

265

262

271

277

234

213

251

245

99

98

110

131

154

162

158

158

129

135

3927

3703

3754

3967

4047

3999

3995

3891

3917

3850

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

No.

No.

No.

No.

No.

No.

No.

No.

No.

No.

Wellington

3650

3462

3462

3648

3719

3652

3692

3614

3621

3540

Kenepuru

270

240

265

262

271

277

234

213

251

245

99

98

110

131

154

162

158

158

129

135

4019

3800

3837

4041

4144

4091

4084

3985

4001

3920

Paraparaumu
Total

Babies
Birth Facility

Paraparaumu
Total

(NB The births before arrival tabulated separately in the previous table are included in this table in the birthing facility to which they were
admitted).

Table 113: Ethnicity group distribution within each age group


for 2012
Mothers
Ethnicity

< 20

25 29

30 34

35 39

40

Total

No.

No.

No.

No.

No.

No.

52

30.2

196

39.4

352

42.6

640

53.1

540

59.7

132

53.9

1912

49.7

1.7

17

3.4

55

6.7

186

15.4

159

17.6

41

16.7

461

12.0

Mori

76

44.2

140

28.1

116

14.0

70

5.8

62

6.9

17

6.9

481

12.5

Pacific Peoples

35

20.3

85

17.1

107

13.0

75

6.2

39

4.3

18

7.3

359

9.3

Asian

1.2

47

9.4

169

20.5

206

17.1

81

9.0

30

12.2

535

13.9

Other

2.3

13

2.6

27

3.3

28

2.3

23

2.5

2.9

102

2.6

Total

172

100

498

100

826

100 1205

100

904

100

245

100

3850

100

NZ European
Other European

No.

20 24

| 155

Capital & Coast District Health Board

Table 114: Parity by age group for 2012


Mothers

< 20

20 24

25 29

30 34

Parity

No.

No.

No.

No.

No.

143

83.1

285

57.2

420

50.8

552

45.8

272

30.1

23

13.4

160

32.1

228

27.6

437

36.3

362

3.5

44

8.8

110

13.3

137

11.4

0.0

1.0

38

4.6

52

0.0

0.8

18

2.2

>4

0.0

0.0

12

1.5

172

100

498

100

826

Total

40

35 39

No.

Total
%

No.

69

28.2

1741

45.2

40.0

84

34.3

1294

33.6

184

20.4

47

19.2

528

13.7

4.3

48

5.3

20

8.2

163

4.2

19

1.6

27

3.0

11

4.5

79

2.1

0.7

11

1.2

14

5.7

45

1.2

100 1205

100

904

100

245

100

3850

100

Table 115: Parity by ethnicity group for 2012


Mothers

NZ
European

Other
European

Parity

No.

No.

No.

No.

No.

No.

No.

877

45.9

214

46.4

190

39.5

133

37.0

281

52.5

46

45.1

1741

45.2

697

36.5

172

37.3

126

26.2

88

24.5

178

33.3

33

32.4

1294

33.6

263

13.8

55

11.9

76

15.8

60

16.7

60

11.2

14

13.7

528

13.7

59

3.1

14

3.0

36

7.5

36

10.0

14

2.6

3.9

163

4.2

13

0.7

0.9

31

6.4

27

7.5

0.4

2.0

79

2.1

>4
Total

156 |

Pacific
Peoples

Mori

Asian

Other

Total

0.2

0.4

22

4.6

15

4.2

0.0

2.9

45

1.2

1912

100

461

100

481

100

359

100

535

100

102

100

3850

100

Fijian

Niuean

Pacific Island nfd

3754

Total

11

122

Other

Not stated

49

Middle Eastern

Other

Latin American

49

African

343

Asian

Asian nfd

32

Other Asian

114

Indian

90

103

Chinese

Southeast Asian

370

Pacific Peoples

14

16

Tongan

Other Pacific Island

40

Tokelauan

221

Samoan

68

519

Mori

Cook Island Mori

331

Other European

17

314

Other European

European nfd

2069

No.

2005

NZ European

Ethnicity

Mothers

| 157

100

3.2

0.3

0.1

1.3

0.2

1.3

9.1

0.1

0.9

2.4

3.0

2.7

9.9

0.4

0.0

0.2

0.1

0.4

1.1

1.8

5.9

13.8

8.8

0.5

8.4

55.1

3967

88

27

41

373

11

43

76

131

112

393

13

13

19

34

57

245

543

401

91

310

2169

No.

2006

100

2.2

0.2

0.1

0.7

0.2

1.0

9.4

0.3

1.1

1.9

3.3

2.8

9.9

0.3

0.1

0.2

0.3

0.5

0.9

1.4

6.2

13.7

10.1

2.3

7.8

54.7

4047

171

30

41

43

17

40

400

12

78

74

110

126

394

21

12

12

34

63

244

553

440

59

381

2089

No.

2007

100

4.2

0.7

1.0

1.1

0.4

1.0

9.9

0.3

1.9

1.8

2.7

3.1

9.7

0.5

0.0

0.1

0.3

0.3

0.8

1.6

6.0

13.7

10.9

1.5

9.4

51.6

3999

144

25

18

40

20

41

405

18

67

88

123

109

389

19

21

18

36

53

228

562

440

57

383

2059

No.

2008

100

3.6

0.6

0.5

1.0

0.5

1.0

10.1

0.5

1.7

2.2

3.1

2.7

9.7

0.5

0.2

0.2

0.5

0.5

0.9

1.3

5.7

14.1

11.0

1.4

9.6

51.5

3995

125

17

20

37

43

412

22

72

97

101

120

407

19

11

11

11

42

54

253

531

462

62

400

2058

No.

2009

100

3.1

0.4

0.5

0.9

0.2

1.1

10.3

0.6

1.8

2.4

2.5

3.0

10.2

0.5

0.2

0.3

0.3

0.3

1.1

1.4

6.3

13.3

11.6

1.6

10.0

51.5

3891

137

24

48

12

52

440

23

77

86

114

140

387

26

20

19

38

52

219

525

456

72

384

1946

No.

2010

100

3.5

0.6

0.0

1.2

0.3

1.3

11.3

0.6

2.0

2.2

2.9

3.6

9.9

0.7

0.2

0.1

0.5

0.5

1.0

1.3

5.6

13.5

11.7

1.9

9.9

50.0

3917

107

12

42

10

41

486

13

93

98

131

151

385

22

15

16

32

50

240

488

497

56

441

1954

No.

2011
%

100

2.7

0.3

0.1

1.1

0.3

1.0

12.4

0.3

2.4

2.5

3.3

3.9

9.8

0.6

0.1

0.2

0.4

0.4

0.8

1.3

6.1

12.5

12.7

1.4

11.3

49.9

Table 116: Maternal ethnicities within the six ethnicity groups for years 2005 to 2012

3850

102

31

23

46

535

15

62

125

151

182

359

10

17

23

33

47

223

481

461

36

425

1912

No.

2012

100

2.6

0.0

0.0

0.8

0.6

1.2

13.9

0.4

1.6

3.2

3.9

4.7

9.3

0.3

0.0

0.1

0.4

0.6

0.9

1.2

5.8

12.5

12.0

0.9

11.0

49.7

The Womens Health Service Annual Clinical Report 2012

Capital & Coast District Health Board

Table 117: Mode of birth group percentages for years 1997 to


2012
Mothers

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Mode of birth group

Normal

66.5

66.9

65.6

65.6

64.4

64.0

61.6

61.3

60.7

58.9

Caesarean section

21.0

22.0

24.2

26.6

24.0

25.1

27.2

28.5

27.8

29.9

Assisted

12.5

11.1

10.3

7.8

11.6

10.9

11.2

10.2

11.5

11.1

Total

100

100

100

100

100

100

100

100

100

100

Mothers

2007

2008

2009

2010

2011

2012

Mode of birth group

Normal

59.6

61.0

61.1

59.1

56.8

57.8

Caesarean

29.1

27.9

27.4

29.6

30.8

30.9

Assisted

11.3

11.2

11.5

11.3

12.3

11.3

Total

100

100

100

100

100

100

Table 118: Mode of birth group by age group for all women in
2012
Mothers

< 20

20 24

25 29

30 34

35 39

40

Total

Mode group

No.

No.

No.

No.

No.

No.

No.

Normal

116

67.4

330

66.3

494

59.8

692

57.4

481

53.2

111

45.3

2224

57.8

CS

35

20.3

117

23.5

232

28.1

357

29.6

334

36.9

116

47.3

1191

30.9

Assisted

21

12.2

51

10.2

100

12.1

156

12.9

89

9.8

18

7.3

435

11.3

172

100

498

100

826

100

1205

100

904

100

245

100

3850

100

Total

Table 119: Mode of birth group by age group for primiparous


women in 2012
Mothers
Mode group

< 20

20 24

25 29

30 34

35 39

40

Total

No.

No.

No.

No.

No.

No.

No.

Normal

95

66.4

165

57.9

209

49.8

238

43.1

87

32.0

16

23.2

810

46.5

CS

28

19.6

75

26.3

124

29.5

192

34.8

126

46.3

44

63.8

589

33.8

Assisted

20

14.0

45

15.8

87

20.7

122

22.1

59

21.7

13.0

342

19.6

143

100

285

100

420

100

552

100

272

100

69

100

1741

100

Total

158 |

The Womens Health Service Annual Clinical Report 2012

Table 120: Mode of birth group by age group for multiparous


women without previous CS in 2012
Mothers
Mode group

< 20

20 24

25 29

30 34

35 39

40

Total

No.

No.

No.

No.

No.

No.

No.

21

80.8

155

89.6

266

85.5

420

89.2

368

82.0

87

78.4

1317

85.5

CS

15.4

14

8.1

35

11.3

35

7.4

63

14.0

20

18.0

171

11.1

Assisted

3.8

2.3

10

3.2

16

3.4

18

4.0

3.6

53

3.4

26

100

173

100

311

100

471

100

449

100

111

100

1541

100

Normal

Total

Table 121: Mode of birth group by age group for multiparous


women with previous CS in 2012
Mothers
Mode group

< 20
No.

20 24
%

No.

25 29
No.

30 34
No.

35 39
No.

40
No.

Total
%

No.

Normal

0.0

10

25.0

19

20.0

34

18.7

26

14.2

12.3

97

17.1

CS

3 100.0

28

70.0

73

76.8

130

71.4

145

79.2

52

80.0

431

75.9

Assisted

0.0

5.0

3.2

18

9.9

12

6.6

7.7

40

7.0

Total

100

40

100

95

100

182

100

183

100

65

100

568

100

| 159

160 |

Selected primipara who have a spontaneous


vaginal birth (H)

Selected primipara who undergo induction of


labour (L)

Selected primipara who undergo an instrumental


vaginal birth (L)

Selected primipara undergoing caesarean


section (L)

Vaginal delivery following a previous primary


caesarean section (N)

Selected primipara with intact perineum or


unsutured perineal tear (H)

Selected primipara undergoing episiotomy AND


no perineal tear while giving birth vaginally (L)

1.1

1.2

1.3

1.4

2.1

3.1

3.2

Indicator Number / Description

Your
numerator

217
213
161
155
104
126
128
153
35
49
67
63
108
120

2012

Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec
Jan-Jun
Jul-Dec

391

388

391

388

177

176

544

516

544

516

544

516

544

516

Your
denominator

(19.92-29.69)

(18.51-27.81)

(15.62-24.69)

(23.52-33.47)

(25.96-36.44)

30.69%

27.84%

16.11%

17.27%

27.68%

19.89%

(24.70-36.68)

(21.99-33.68)

(11.33-20.89)

(12.34-22.20)

(19.04-36.33)

(12.15-27.62)

28.13% (23.17-33.08)

24.81%

23.16%

20.16%

28.49%

31.20%

39.15% (33.78-44.53)

42.05% (34.47-47.64)

Your
rate

99%
Confidence
Interval for
your rate

Peer Group Comparison Obstetrics Indicators Version 7


Australasia
Public Facility
ACHS Organisation Code: 910012 Both Halves 2012 submitted
Peer Group: Comparison with all organisations who have a NICU and/or more than 3000 births annually
Total Number of organisations for the selected category submitting data for this set: First Half 2012: 18, Second Half 2012: 18

105

99

63

70

34

33

122

111

121

116

174

161

259

249

Your
expected
number
of events

15

-3

15

31

17

-12

-19

-46

-32

(excess events)

Your
observed
minus
expected

Table 122: ACHS Obstetric Clinical Indicators (Jan-Jun, Jul-Dec 2012) and table notes

13

14

14

14

13

12

14

14

13

13

12

12

13

13

No. of
organisations
submitting
data

26.76%

25.50%

16.09%

18.12%

19.43%

18.55%

22.45%

21.54%

22.28%

22.44%

31.95%

31.22%

47.62%

48.28%

Aggregate
rate for these
organisations

Capital & Coast District Health Board

Selected primipara requiring surgical repair of


the perineum for third degree tear (L)

Selected primipara requiring surgical repair of


the perineum for fourth degree tear (L)

Women having a general anaesthetic for a


caesarean section (L)

Women who give birth vaginally who receive a


blood transfusion during the same admission (L)

Women who undergo caesarean section who


receive a blood transfusion during the same
admission (L)

Deliveries with birth weight less than 2750g at


40 weeks gestation or beyond (L)

Term babies born with an Apgar score of less


than 7 at five minutes post delivery (L)

Inborn term babies transferred / admitted to


a neonatal intensive care nursery or special
care nursery for reasons other than congenital
abnormality (L)

3.5

3.6

4.1

7.1

7.2

8.1

9.1

10.1
Jul-Dec

188

137

15

Jul-Dec
Jan-Jun

28

28

Jul-Dec

Jan-Jun

25

Jan-Jun

31

Jul-Dec

Jul-Dec

40

Jan-Jun

10

Jul-Dec

Jan-Jun

Jan-Jun

18

28

Jul-Dec

Jul-Dec

22

Jan-Jun

22

42

Jul-Dec

Jan-Jun

52

166

Jul-Dec
Jan-Jun

161

Jan-Jun

1700

1644

1742

1685

789

793

598

590

1336

1295

598

590

391

388

391

388

391

388

391

388

11.06%

8.33%

0.86%

1.66%

0.76%

1.26%

3.01%

3.73%

2.10%

1.93%

5.18%

6.78%

0.77%

0.00%

7.16%

5.67%

10.74%

13.40%

42.46%

(9.10-13.01)

(6.58-10.09)

(0.29-1.43)

(0.86-2.46)

(0.00-1.56)

(0.24-2.28)

(1.21-4.81)

(1.72-5.73)

(1.09-3.10)

(0.95-2.91)

(2.85-7.51)

(4.12-9.44)

(0.00-1.90)

(0.00-0.92)

(3.81-10.51)

(2.65-8.69)

(6.72-14.77)

(8.96-17.85)

(36.03-48.88)

41.49% (35.07-47.92)

197

175

29

31

13

14

13

17

21

24

48

53

27

29

36

32

183

194

-9

-38

-14

-3

-7

-4

-17

-13

-1

-7

20

-17

-33

14

14

16

17

15

16

16

16

16

17

16

17

14

15

14

15

13

14

12

14

11.60%

10.62%

1.66%

1.82%

1.63%

1.75%

2.16%

2.97%

1.60%

1.86%

7.97%

8.93%

0.43%

0.36%

6.98%

7.45%

9.25%

8.15%

46.69%

50.01%

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention. These results demonstrate where an organisation is statistically significantly different to all other organisations submitting data for that particular indicator and where
the results are undesirably lower or higher than the expected rate.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval. This indicates that the organisation is statistically significantly different to all other organisations submitting data for that particular
indicator.

Selected primipara undergoing episiotomy AND


sustaining a perineal tear while giving birth
vaginally (L)

3.4

Selected primipara sustaining a perineal tear


AND no episiotomy (L)

3.3

The Womens Health Service Annual Clinical Report 2012

| 161

162 |

Deep incisional/organ/space surgical site


infection (SSI) in lower segment caesarean
section procedures (L)

4
6

Jan-Jun
Jul-Dec

2012

598

586

Your
denominator

1.00%

0.68%

Your
rate

(0.00-2.05)

(0.00-1.56)

99%
Confidence
Interval for
your rate

Your
expected
number
of events

(excess events)

Your
observed
minus
expected

15

No. of
organisations
submitting
data

0.50%

0.21%

Aggregate
rate for these
organisations

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention. These results demonstrate where an organisation is statistically significantly different to all other organisations submitting data for that particular indicator and where
the results are undesirably lower or higher than the expected rate.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval. This indicates that the organisation is statistically significantly different to all other organisations submitting data for that particular
indicator.

1.16

Indicator Number / Description

Your
numerator

Peer Group Comparison Infection Control Indicators Version 3.1


Both Halves 2012 submitted Australasia
Public Facility
ACHS Organisation Code: 910012
Peer Group: Comparison of your results with all organisations in selected category submitting data where total number of beds at this site, location or campus: 200-499 beds
Total Number of organisations for the selected category submitting data for this set: First Half 2012: 33, Second Half 2012: 30

Table 123: ACHS Infection Control Clinical Indicators (Jan-Jun, Jul-Dec 2012) and table notes

Capital & Coast District Health Board

Patients receiving an unplanned blood


transfusion during their hospital admission for
any type of gynaecological surgery for benign
disease (L)

Patients receiving an unplanned blood


transfusion during their hospital admission
for any type of gynaecological surgery for
malignant disease (L)

Patients suffering injury to a major viscus with


repair, during an gynaecological operative
procedure or subsequently up to 2 weeks postoperatively (L)

Patients suffering an injury to a major


viscus with repair, during a laparoscopic
gynaecological operative procedure or
subsequently up to 2 weeks post-operatively
(L)

Patients receiving an injury to a ureter at the


time of a laparoscopic hysterectomy with repair
during the procedure or subsequently up to 2
weeks post-operatively (L)

Patients receiving a bladder injury at the time


of a laparoscopic hysterectomy with repair
during the procedure or subsequently up to 2
weeks post-operatively (L)

1.1

1.2

2.1

3.1

3.2

3.3

Indicator Number / Description

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

2012

10

Your
numerator

12

15

12

15

271

245

455

412

61

57

429

390

Your
denominator

0.00%

0.00%

0.00%

0.00%

0.74%

0.00%

0.44%

1.70%

8.20%

8.77%

1.86%

2.56%

Your
rate

(0.00-27.46)

(0.00-22.31)

(0.00-27.46)

(0.00-22.31)

(0.00-2.07)

(0.00-1.45)

(0.00-1.24)

(0.06-3.34)

(0.00-17.22)

(0.00-18.40)

(0.19-3.54)

(0.51-4.62)

99%
Confidence
Interval for
your rate

Peer Group Comparison Gynaecology Indicators Version 6


Both Halves 2012 submitted Australasia
Public Facility
ACHS Organisation Code: 910012
Peer Group: Comparison with all organisations submitting data in this category (no peer group defined for this set)
Total Number of organisations for the selected category submitting data for this set: First Half 2012: 33, Second Half 2012: 34

Your
expected
number
of events

-2

(excess events)

Your
observed
minus
expected

15

15

15

17

24

25

26

25

17

15

23

22

No. of
organisations
submitting
data

Table 124: ACHS Gynaecology Clinical Indicators (Jan-Jun, Jul-Dec 2012) and table notes

1.00%

0.36%

1.00%

0.00%

0.82%

0.78%

0.40%

0.63%

7.03%

6.01%

1.01%

1.46%

Aggregate
rate for these
organisations

The Womens Health Service Annual Clinical Report 2012

| 163

164 |

Patients receiving injury to a major viscus with


repair, during a pelvic floor repair procedure or
subsequently up to 2 weeks post-operatively
(L)

Patients receiving a ureter injury at the time


of a pelvic floor repair procedure with repair
during the procedure or subsequently up to 2
weeks post-operatively (L)

Patients receiving a bladder injury at the time


of a pelvic floor repair procedure with repair
during the procedure or subsequently up to 2
weeks post-operatively (L)

5.1

5.2

5.3

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

Jan-Jun

Jul-Dec

12

15

70

51

70

51

70

51

14

16

0.00%

0.00%

0.00%

0.00%

0.00%

0.00%

85.71%

93.75%

(0.00-5.03)

(0.00-6.87)

(0.00-5.03)

(0.00-6.87)

(0.00-5.03)

(0.00-6.87)

(61.68100.00)

(78.20100.00)

12

13

-1

-1

21

19

20

18

21

20

20

22

0.60%

0.68%

0.36%

0.00%

1.39%

1.78%

82.58%

82.41%

(L) A low rate is desirable


(H) A high rate is desirable
(N) Desirable rate is unspecified
Rates in italic / greyed highlight results that require attention. These results demonstrate where an organisation is statistically significantly different to all other organisations submitting data for that particular indicator and where
the results are undesirably lower or higher than the expected rate.
Rates in bold highlight results where the aggregate rate is outside the 99% confidence interval. This indicates that the organisation is statistically significantly different to all other organisations submitting data for that particular
indicator.

Laparoscopic management of an ectopic


pregnancy (H)

4.1

Jan-Jun

Capital & Coast District Health Board

The Womens Health Service Annual Clinical Report 2012

16.2 Abbreviations
ACHS
ACMM
AMOSS

Australian Council on Healthcare Standards


Associate charge midwife manager
Australasian Maternity Outcomes Surveillance
System
AVB
Assisted vaginal birth
BFHI
Baby Friendly Hospital Initiative
BMI
Body mass index
BSO
Bilateral salpingo-oophorectomy
C&C DHB
Capital and Coast District Health Board
CI
Confidence interval
CPR
Cardiopulmonary resuscitation
CS
Caesarean section
CSE
Combined spinal-epidural
CVS
Chorionic villus sampling
D&C
Dilation and curettage
DHB
District Health Board
DNA
Did not attend
EBR
Exclusive breastfeeding rate
ECV
External cephalic version
ENT
Ear, Nose and Throat
ERPOC
Evacuation of retained products of conception
EUA
Examination under anaesthetic
FDA
Food and Drug Administration
FSA
First Specialist Assessment
FTE
Full time equivalent
GA
General anaesthesia
GDM
Gestational Diabetes Mellitus
GP
General Practitioner
GROW
Gestation related optimal weight
GSNMH
Graduate School of Nursing, Midwifery and
Health
HDC
Health and Disability Commissioner
HIS
Health Information Service
HWNZ
Health Workforce New Zealand
ICS
International Continence Society
ICU
Intensive Care Unit
IOL
Induction of labour
ITP
Integrated training programme
IUD
Intra-uterine device
IUGR
Intrauterine growth restriction
KMU
Kenepuru Maternity Unit
LA
Local anaesthesia
LARC
Long acting reversible contraception
LLETZ
Large loop excision of the transformation
zone
LMC
Lead Maternity Carer
MCIS
Maternity clinical information system
MFM
Maternal fetal medicine
MOH
Ministry of Health
MQSP
Maternity Quality Safety Programme
MSS2
Second trimester maternal serum screening
MTOP
Medical termination of pregnancy
MW Midwife

NBHS
NCSP
NDC
NICU
NIPD
NT
NVB
OASIS
OGTT
PCC
PCEA
PDC
PDPH
PIMS
PM
PMB
PMMRC

Newborn hearing screening


National Cervical Screening Programme
Neonatal death classification
Neonatal Intensive Care Unit
Non invasive prenatal diagnosis
Nuchal translucency
Normal vaginal birth
Obstetric anal sphincter injuries
Oral glucose tolerance test
Preconceptual counselling clinic
Patient-controlled epidural analgesia
Perinatal death classification
Postdural puncture headache
Perinatal Information Management System
Post mortem
Post menopausal bleeding
Perinatal & Maternal Mortality Review
Committee
PMU
Paraparaumu Maternity Unit
POP
Pelvic organ prolapse
PPH
Post-partum haemorrhage
PROMPT
Practical obstetric multi-professional training
PSANZ
Perinatal Society of Australia & New Zealand
PV
Per vaginum
RANZCOG Royal Australian and New Zealand College of
Obstetricians and Gynaecologists
RBC
Red blood cell
RPOC
Retained products of conception
SAB
Subarachnoid block (spinal anaesthesia)
SAC1
Severity assessment code 1
SAC2
Severity assessment code 2
SAU
Surgical Admissions Unit
SB Stillborn
SMMHS
Specialist Maternal Mental Health Service
SRM
Spontaneous rupture of membranes
SSI
Surgical site infection
STOP
Surgical termination of pregnancy
SUDI
Sudden unexpected death in infancy
SUI
Stress urinary incontinence
TAH
Total abdominal hysterectomy
TMU
Te Mahoe Unit
TOP
Termination of pregnancy
TVT
Tension free vaginal tape
UNHSEIP
Universal Newborn Hearing Screening and
Early Intervention Programme
USS
Ultrasound scan
VBAC
Vaginal birth after CS
VUW
Victoria University of Wellington
WHO
World Health Organisation
WHRU
Womens Health Research Unit
WHS
Womens Health Service
WRH
Wellington Regional Hospital

| 165

Capital & Coast District Health Board

16.3 References
Auckland District Health Board 2012. National Womens Annual Clinical Report 2011.
Bell R, Bailey K, Cresswell T, Hawthorne G, Critchley J, Lewis-Barned N, Northern Diabetic Pregnancy Survey
Steering Group. 2008. Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and
type II diabetes. BJOG: An International Journal of Obstetrics and Gynaecology. March 2008. 115, 4. 445-452.
Bulletin of the World Health Organisation. January 2010. Vol. 88 (1), ISSN 0042-9686.
Dodd JM, Crowther CA, Haslam RR, Robinson JS, Twins Timing of Birth Trial Group. 2012. Elective birth at 37
weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins
Timing of Birth Randomised Trial. BJOG: An International Journal of Obstetrics and Gynaecology. July 2012.
119, 8. 964-974.
Esakof TF, Cheng YW, Caughey AB. 2005. Screening for gestational diabetes: different cut-offs for different
ethnicities? American Journal of Obstetrics and Gynecology. 193 (3 Pt 2):1040-1044.
Gunton JE, McElduff A, Sulway M, Shiel J, Kelso I, Boyce S, Fulcher G, Robinson B, Clifton-Bligh P, Wilmhurst E.
2000. Outcome of pregnancies complicated by pre-gestational diabetes mellitus. Australian and New Zealand
Journal of Obstetrics and Gynaecology. 200; 40: 1:38-43.
Jensen DM, Damm P, Moelsted-Pederson L, Ovesen P, Westergaard JG, Moeller M, Beck-Nielsen H. 2004.
Outcomes in Type 1 diabetic pregnancies. Diabetes Care, December 2004. 27: 2819-2823.
Lewis G. (ed) 2007. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers
Lives: reviewing maternal deaths to make motherhood safer 2003-2005. The Seventh Report on Confidential
Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. (www.cemach.org.uk)
Nahum EG, Huffaker BJ. 1993. Racial differences in oral glucose screening test results: establishing race-specific
criteria for abnormality in pregnancy. American Journal of Obstetrics and Gynecology. April 1993. 81 (4):517522.
New Zealand Health Information Service, 2007. Report on Maternity: Maternal and Newborn Information 2004.
Wellington: NZ Ministry of Health.
New Zealand Ministry of Health, 2010. Hospital-based Maternity Events 2006. Wellington: NZ Ministry of Health.
New Zealand Ministry of Health. 2012. New Zealand Maternity Clinical Indicators 2009: Revised June 2012.
Wellington: NZ Ministry of Health
New Zealand Ministry of Health. 2012. Report on Maternity, 2010. Wellington: NZ Ministry of Health.
PMMRC. 2012. Sixth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting
mortality 2010. (www.hqsc.govt.nz)
Sacks DA, Abu-Fadil S, Greenspoon JS, Fotheringham N. 1989. How reliable is the fifty-gram, one-hour glucose
screening test? American Journal of Obstetrics and Gynecology. 161 (3):642-5.
Statistics New Zealand. 2013. Births and Deaths: Year ended December 2012. (www.stats.govt.nz)
The Australian Council on Healthcare Standards. 2012. Clinical Indicator Users Manual 2012. (www.achs.org.au)

166 |

The Womens Health Service Annual Clinical Report 2012

16.4 ACHS Clinical Indicator definitions


Spontaneous vaginal birth is defined as a vaginal


birth (regardless of onset of labour) that is not
assisted by forceps or vacuum and is not a vaginal
breech delivery.

Induction of labour is defined as surgical and / or


medical induction.

Indicator Topic: Outcome of selected primipara.

Rationale: The selected primipara represents an


uncomplicated pregnancy whereby intervention and
complication rates should be low and consistent across
hospitals.

Instrumental vaginal birth is defined as forceps or


vacuum.

INDICATOR DATA FORMAT:

Reprinted from the Clinical Indicator User Manual,


2012, The Australian Council on Healthcare Standards,
ACHS, 2011. (Obstetrics, Version 7; Gynaecology,
Version 6; Infection Control Version 3.1).

INDICATOR AREA 1: OBSTETRICS

Use of the selected primipara (rather than all women


giving birth) as the basis for inter-hospital comparison
of maternity care controls for differences in case mix
and increases the validity of those comparisons.
A cascade effect of birthing interventions has been
described, particularly with primiparous women, which
starts with induction of labour, increasing the risk
of operative vaginal birth or caesarean section. By
reducing the number of nulliparous women who have
induced labour, the number of women undergoing
unnecessary operative birth and other interventions will
be reduced.
Type of Indicator: These are rate-based indicators
addressing the process of patient care.

CI. 1.1

Numerator - Total number of selected primipara


who have a spontaneous vaginal birth.

Denominator - The total number of selected


primipara who give birth.

CI. 1.2

Numerator - Total number of selected primipara


who undergo induction of labour (as defined in
the manual).

Denominator - The total number of selected


primipara who give birth.

CI. 1.3

Numerator - Total number of selected primipara


who undergo an instrumental vaginal birth (as
defined in the manual).

Denominator - The total number of selected


primipara who give birth.

Desired Rate:
1.1 High
1.2 Low
1.3 Low
1.4 Low
Definitions of Terms: For the purpose of these
indicators:

Selected primipara is defined as:

A woman who is 2034 years of age at the time of


giving birth

giving birth for the first time at >20 weeks of


gestation

singleton pregnancy

cephalic presentation

at 370 to 410 weeks gestation

CI. 1.4

Numerator - Total number of selected primipara


undergoing caesarean section.

Denominator - The total number of selected


primipara who give birth.

INDICATOR AREA 2: OBSTETRICS


Indicator Topic: The rate of vaginal birth following
primary caesarean section (VBAC).
Rationale: This indicator monitors mode of birth
in those women who have had a previous primary
(first) caesarean section and no other vaginal births.
There is evidence that repeat caesarean section can
be associated with significant morbidity for women
but VBAC carries increased risks for the baby when
compared with repeat elective caesarean section.
| 167

Capital & Coast District Health Board

Type of Indicator: This is a rate-based indicator


addressing the process (management) and outcome of
patient care.

Definitions of Terms: For the purpose of these


indicators:

Selected primipara is defined as:

A woman who is 2034 years of age at the time of


giving birth

Definitions of Terms: For the purpose of this


indicator:

giving birth for the first time at >20 weeks of


gestation

This indicator relates to those women giving birth


vaginally following a previous primary (first) caesarean
section and having NO intervening pregnancies greater
than twenty weeks gestation.

singleton pregnancy

cephalic presentation

at 370 to 410 weeks gestation

INDICATOR DATA FORMAT:

INDICATOR DATA FORMAT:

CI. 2.1

CI. 3.1

Desired Rate:
Not specified

Numerator - Total number of women giving


birth vaginally following a previous primary
caesarean section, as defined in the manual.

Numerator - Total number of selected primipara


with an intact perineum or unsutured perineal
tear.

Denominator - Total number of women giving


birth who have had a previous primary caesarean
section and NO intervening pregnancies greater
than twenty weeks gestation.

Denominator - Total number of selected primipara


giving birth vaginally.

CI. 3.2

Numerator - Total number of selected primipara


undergoing episiotomy (as defined in the manual)
and NO perineal tear (as defined in the manual)
while giving birth vaginally.

Denominator - Total number of selected primipara


giving birth vaginally.

INDICATOR AREA 3: OBSTETRICS


Indicator Topic: Incidence of an intact perineum in
primiparous women giving birth vaginally and degree
of damage to the perineum.
Rationale: Vaginal birth is the most common cause of
anal sphincter injuries in women and as such obstetric
anal sphincter injury is considered a major complication
of vaginal birth - a complication that can have a
significant impact on a womans quality of life.
Type of Indicator: These are rate-based indicators
addressing the process (management) and outcome of
patient care.

CI. 3.3

Numerator - Total number of selected primipara


sustaining a perineal tear and NO episiotomy.

Denominator - Total number of selected primipara


giving birth vaginally.

CI. 3.4

Numerator - Total number of selected primipara


undergoing episiotomy AND sustaining a
perineal tear while giving birth vaginally.

Denominator - Total number of selected primipara


giving birth vaginally.

Desired Rate:
3.1 High
3.2 Low
3.3 Low

CI. 3.5

3.4 Low

Numerator - Total number of selected primipara


undergoing surgical repair of the perineum for
third degree tear (as defined in the manual).

Denominator - Total number of selected primipara


giving birth vaginally.

3.5 Low
3.6 Low

168 |

The Womens Health Service Annual Clinical Report 2012

CI. 3.6

Numerator - Total number of selected primipara


undergoing surgical repair of the perineum for
fourth degree tear (as defined in the manual).
Denominator - Total number of selected primipara
giving birth vaginally.

INDICATOR AREA 4: OBSTETRICS


Indicator Topic: General anaesthesia for caesarean
section
Rationale: This indicator monitors the number of
women who have a caesarean section performed
under general anaesthesia. There is now evidence that
women who are having a caesarean section should
be offered regional anaesthesia rather than general
anaesthesia because it is safer and results in less
maternal and neonatal morbidity.

Type of Indicator: These are rate-based indicators


addressing the outcome of patient care.
Desired Rate:
7.1 Low
7.2 Low
Definitions of Terms: For the purpose of these
indicators:

INDICATOR DATA FORMAT:


CI. 7.1

Numerator - Total number of women who give


birth vaginally who receive a blood transfusion
during the same admission.

Denominator - Total number of women who give


birth vaginally.

Type of Indicator: This is a rate-based indicator


addressing the process of patient care.
Desired Rate:
Low

Blood transfusion is required following massive


blood loss of equal to/or more than 1000mL or in
response to a postpartum haemoglobin level of
less than 80g/L.

CI. 7.2

Definitions of Terms: For the purpose of this


indicator:

General anaesthetic includes women undergoing a


primary general anaesthetic and includes conversions
from regional to general anaesthetic where intubation
is required to control the airway.

Numerator - Total number of women who


undergo caesarean section who receive a blood
transfusion during the same admission.

Denominator - Total number of women who


undergo caesarean section.

INDICATOR DATA FORMAT:


CI. 4.1

Numerator - Total number of women having a


general anaesthetic (as defined in the manual) for
a caesarean section.
Denominator - Total number of women having a
caesarean section.

INDICATOR AREA 7: OBSTETRICS


Indicator Topic: Incidence of postpartum haemorrhage
and blood transfusions after vaginal birth and
caesearean section.
Rationale: Postpartum haemorrhage (PPH) is a
potentially life threatening complication of birth that
occurs in about 3-5% of vaginal births. The condition
remains a leading cause of maternal morbidity and
mortality.

INDICATOR AREA 8: OBSTETRICS


Indicator Topic: Identification of babies with severe
intrauterine growth restriction (IUGR), babies less than
the 3rd centile delivered after 400 weeks.
Rationale: Profound IUGR is a major cause of perinatal
mortality and morbidity with mortality increasing with
IUGR in late pregnancy.
Type of Indicator: This is a rate-based indicator
addressing the process and outcome of antenatal care.
Desired Rate:
Low
Definitions of Terms: For the purpose of this
indicator:
Severe IUGR is defined as babies less than the 3rd
centile at 400 weeks gestation. Whilst recognising that
birth weight varies with maternal height, weight, parity,

| 169

Capital & Coast District Health Board

ethnicity and foetal sex this is impractical to collect at


present. A surrogate measure of birth weight less than
2750 grams after 400 weeks gestation is used.

INDICATOR DATA FORMAT:


CI. 8.1

Numerator - Total number of deliveries with birth


weight less than 2750g at 400 weeks gestation or
beyond.

Denominator - Total number of deliveries at 400


weeks gestation or beyond.

INDICATOR AREA 9: OBSTETRICS


Indicator Topic: Apgar score of term babies.
Rationale: The five minute Apgar score measures how
well the infant is adapting to the new environment
and is an assessment of how the baby responds to
resuscitation, should it be required.
Type of Indicator: This is a rate-based indicator
addressing the outcome of patient care.
Desired Rate:
Low
Definitions of Terms: For the purpose of this
indicator:

The Apgar score is calculated at one and five


minutes after the baby is born, and is determined
by five characteristics heart rate, respiratory
effort, muscle tone, reflex irritability and colour.
Each characteristic is rated from zero to two. The
sum of the five characteristics is the total Apgar
score.

Term refers to gestation of equal to or greater


than 370 weeks gestation.

Fetal demise at any stage after the onset of labour


/ caesarean section is to be included.

Fetal death in-utero diagnosed prior to


commencement (onset) of labour / caesarean
section is excluded.

Onset of labour refers to first stage of labour


begins when uterine contractions reach sufficient
frequency, intensity and duration to initiate readily
demonstrable effacement and dilatation of the
cervix". (Williams Obstetrics 2010, 23rd edition).

170 |

INDICATOR DATA FORMAT:


CI. 9.1

Numerator - Total number of term babies


born with an Apgar score of less than 7 at five
minutes post delivery.

Denominator - The total number of term babies


born.

INDICATOR AREA 10: OBSTETRICS


Indicator Topic: Term babies transferred or admitted
to a Neonatal Intensive Care Nursery (NICN) or Special
Care Nursery (SCN) for reasons other than congenital
abnormality.
Rationale: This indicator is included to determine
whether the rate of admission of inborn term infants
to NICN or SCN for reasons other than birth defects is
principally due to non-avoidable factors. Inborn term
babies without birth defects are not normally expected
to be admitted to a SCN or NICN.
Type of Indicator: This is a rate-based indicator, which
addresses the outcome of patient care.
Desired Rate:
Low
Definitions of Terms: For the purpose of this
indicator:

Term refers to gestation of equal to or greater


than 370 weeks gestation.

Inborn baby is defined as an infant born at the


reporting hospital.

Admissions due to congenital abnormality are


excluded.

INDICATOR DATA FORMAT:


CI. 10.1

Numerator - Total number of inborn term babies


transferred/admitted to a neonatal intensive
care nursery or special care nursery for reasons
other than congenital abnormality

Denominator - Total number of inborn term live


babies.

The Womens Health Service Annual Clinical Report 2012

INDICATOR AREA 1: INFECTION


SURVEILLANCE

Desired Rate:
1.1

Low

Indicator Topic: Surgical site infection (SSI).

1.2

Low

Rationale: The National Strategy to Address Health


Care Associated Infections, July 2003 suggests that
between 2% and 13% of patients suffer from SSI. The
attributable and human costs of SSI are therefore
significant.

Definitions of Terms: For the purpose of these


indicators

Type of Indicator: These are rate-based indicators


addressing the outcome of patient care in terms of
infection.

Gynaecology surgery includes all procedures,


however named, as defined by the gynaecologist
and detailed in coding systems.

The classification of benign or malignant disease is


based on the operative/histological findings.

Desired Rate:

Blood transfusion whole blood or packed cells


not plasma products or platelets.

1.16 Low
Definitions of Terms: For the purpose of indicator
1.16
A surgical site infection (SSI) is defined by the
anatomical location of the infection (superficial, deep
or organ space) however, due to the difficulty of
distinguishing between these categories the indicators
have been separated to measure two categories:
superficial and deep organ or space.
Note:

Lower segment caesarean sections include


emergency and elective procedures.

INDICATOR DATA FORMAT:

Note:

Autologous blood transfusions are included.

Hysterectomies following caesarean section (in the


same admission) and emergency hysterectomies
are excluded.

INDICATOR DATA FORMAT:


CI. 1.1

Numerator - Total number of patients receiving an


unplanned blood transfusion during their hospital
admission for any type of gynaecology surgery for
benign disease, during the 6 month time period.

Denominator - Total number of patients


undergoing gynaecology surgery for benign
disease, during the 6 month time period.

CI. 1.16

Numerator - Total number of deep incisional/


organ/space SSI in lower segment caesarean
section procedures performed, during the 6 month
time period.

CI. 1.2

Numerator - Total number of patients receiving


an unplanned blood transfusion during their
hospital admission for any type of gynaecological
surgery for malignant disease, during the 6
month time period.

Denominator - Total number of patients


undergoing gynaecology surgery for malignant
disease, during the 6 month time period.

Denominator - The total number of lower


segment caesarean section procedures performed,
during the 6 month time period.

INDICATOR AREA 1:
GYNAECOLOGY
Indicator Topic: Blood transfusion for gynaecology
surgery.
Rationale: This indicator is included as a general
measure of surgical management.
Type of Indicator: These are comparative rate-based
indicators addressing the process and outcome of
patient care.

INDICATOR AREA 2:
GYNAECOLOGY
Indicator Topic: Injury to a major viscus, with repair
during a gynaecological operative procedure, or
subsequently during the same admission.

| 171

Capital & Coast District Health Board

Rationale: This indicator has been included as an index


of unintentional intra-operative morbidity associated
with gynaecological procedures.
Type of Indicator: This is a comparative rate-based
indicator addressing the outcome of patient care.

3.3 Low
Definitions of Terms: For the purpose of these
indicators

Laparoscopic gynaecological operative


procedure refers to any laparoscopic definitive
procedure.

Subsequently up to 2 weeks post-operatively


includes patients who require readmission and / or
further surgery.

Desired Rate:
Low
Definitions of Terms: For the purpose of this
indicator

Major viscus is defined as vascular, urological or


gastrointestinal.
Subsequently up to 2 weeks post-operatively
includes patients who require readmission and
/ or further surgery at the same health care
organisation.

Note:

Only those procedures, which have been


completed laparoscopically, are to be included in
the indicator.

Procedures, which have converted to an


abdominal procedure from a laparoscopic
procedure, are excluded from the indicator.

This indicator excludes perforation of the uterus as


this rarely causes a problem. The main problems
relate to small or large bowel or bladder injuries,
as they cause the majority of serious morbidities.

INDICATOR DATA FORMAT:

This indicator also excludes laparoscopic


procedures.

Numerator - Total number of patients receiving


an injury to a major viscus with repair, during a
laparoscopic gynaecological operative procedure
or subsequently up to 2 weeks post-operatively,
during the 6 month time period.

Denominator - Total number of patients


undergoing laparoscopic gynaecological operative
procedure, during the 6 month time period.

CI. 3.1

INDICATOR DATA FORMAT:


CI. 2.1

Numerator - Total number of patients suffering


injury to a major viscus with repair, during
a gynaecological operative procedure or
subsequently up to 2 weeks post-operatively,
during the 6 month time period.

CI. 3.2

Numerator - Total number of patients receiving


a ureter injury at the time of a laparoscopic
hysterectomy with repair during the procedure
or subsequently up to 2 weeks post-operatively,
during the 6 month time period.

Denominator - Total number of patients


undergoing laparoscopic hysterectomy, during the
6 month time period.

Denominator - Total number of patients


undergoing any type of gynaecology surgery,
during the 6 month time period.

INDICATOR AREA 3:
GYNAECOLOGY
Indicator Topic: Laparoscopic gynaecological surgery.
Rationale: These indicators have been included as an
index of the utilisation of a laparoscopic approach for
gynaecological surgery.

CI. 3.3

Numerator - Total number of patients receiving


a bladder injury at the time of a laparoscopic
hysterectomy with repair during the procedure
or subsequently up to 2 weeks post-operatively,
during the 6 month time period.

Denominator - Total number of patients


undergoing laparoscopic hysterectomy, during the
6 month time period.

Type of Indicator: These are comparative rate-based


indicators addressing the process of patient care.
Desired Rate:
3.1 Low
3.2 Low
172 |

The Womens Health Service Annual Clinical Report 2012

INDICATOR AREA 4:
GYNAECOLOGY

Desired Rate:

Indicator Topic: Laparoscopic management of an


ectopic pregnancy.

5.2 Low

Rationale: This indicator has been included as an index


of the utilisation of a laparoscopic approach in the
management of ectopic pregnancy.

Definitions of Terms: For the purpose of these


indicators

Type of Indicator: This is a comparative rate-based


indicator addressing the process of patient care.
Desired Rate:
High
Definitions of Terms: For the purpose of this
indicator

Laparoscopic management refers to any


laparoscopic definitive procedure.

5.1 Low

5.3 Low

Subsequently up to 2 weeks post-operatively


includes patients who require readmission and / or
further surgery.

All pelvic floor repair procedures are included.

INDICATOR DATA FORMAT:


CI. 5.1

Only those procedures that have been completed


laparoscopically are to be included in the
indicator.

Numerator - Total number of patients receiving


injury to a major viscus with repair, during a
pelvic floor repair procedure or subsequently up to
2 weeks post-operatively, during the 6 month time
period.

Procedures, which have converted to an


abdominal procedure from a laparoscopic
procedure, are excluded from the indicator.

Denominator - Total number of patients


undergoing a pelvic floor repair procedure, during
the 6 month time period.

CI. 5.2

Note:

Patients who require a blood transfusion in the


same admission are excluded.

Numerator - Total number of patients receiving


a ureter injury at the time of a pelvic floor repair
procedure with repair during the procedure or
subsequently up to 2 weeks post-operatively,
during the 6 month time period.

Denominator - Total number of patients


undergoing a pelvic floor repair procedure, during
the 6 month time period.

INDICATOR DATA FORMAT:


CI. 4.1

Numerator - Total number of patients having


laparoscopic management following an ectopic
pregnancy, during the 6 month time period.

Denominator - Total number of patients


presenting with an ectopic pregnancy who are
managed surgically, during the 6 month time
period.

INDICATOR AREA 5:
GYNAECOLOGY
Indicator Topic: Urogynaecology.

CI. 5.3

Numerator - Total number of patients receiving a


bladder injury at the time of a pelvic floor repair
procedure with repair during the procedure or
subsequently up to 2 weeks post-operatively,
during the 6 month time period.

Denominator - Total number of patients


undergoing a pelvic floor repair procedure, during
the 6 month time period.

Rationale: This indicator provides an index of


unintentional intraoperative morbidity associated with
pelvic floor repair procedures.
Type of Indicator: These are comparative rate-based
indicators addressing the outcomes of patient care.

| 173

S-ar putea să vă placă și