‘You only know what you measure and what you cannot measure must be made measurable’.
Gallileo
Introduction
From the available literature it is clear that intrapartum care is provided in many different ways and with variable outcomes, for which there will be many reasons. The intention of this chapter is not to suggest one way of providing care but rather persuade professionals that we should standardize the way we examine the quality of care that we provide so we can improve it. We need to encourage midwives and obstetricians to know more about events and outcomes in their own unit. Clinically relevant information is needed on a continuous and timely basis in order to rationalize decision-making. To do this we need to introduce the concept of a Multidisciplinary Quality Assurance Programme (MDQAP) for labour and delivery.
Multidisciplinary Quality Assurance Programme
Figure 3-1 describes this concept in the context of labour and delivery. Similar programmes have been suggested elsewhere. Quality Assurance should be applied to the subject as a whole. Audit, classification of information, assessing management and modifying management, when applicable, should be applied to the processes involved in achieving it. All these components are crucial to achieving quality, but accurate and complete information collection is paramount. At the present time, setting standards and benchmarking interventions and outcomes are used as assessment of quality in a healthcare organization. Good information collection itself must be the first quality standard. Information must be easily available, quality controlled and validated.
Audit
Audit is defined as the formal examination and recording of the results and is divided into structure (representing resources), process (the way that resources are applied) and outcome (the result of intervention). Recently more emphasis has been placed on auditing processes rather than outcomes, but patients are primarily interested in outcome. Quality is related to outcome and this will guide processes. A more practical definition of audit is continuously looking at your outcomes in a standardized way at the most senior level on a regular basis, resulting in a formal written annual report documenting the quantity and quality of care.
High-quality audit has long been undervalued as a guide for the development and support of clinical practice, as opposed to other forms of evidence-based medicine. The reason is that audit requires time, resources, discipline and leadership. The challenge from a practical point of view is to combine routine documentation of notes with audit and the ability to use them for teaching, education and research without duplication of effort. The information needs to be relevant, carefully defined, accurately collected, timely and available. Information collection needs adequate resources and meticulous organization.
Information Collection
No judgement or assessment of management, indeed no knowledge of what is actually taking place in a delivery unit is possible unless a reliable system to collect information is in place.
The information collection system must not depend on individuals but must be part of a general organizational approach to the labour ward. A senior midwife and obstetrician should be responsible for organization of information collection.
Information collection must be carefully planned and certain principles must be remembered. To ensure quality information the amount of information collected needs to be continually reviewed so that the quantity does not exceed the resources required to collect it. The information must be collected by people who understand the relevance and importance of the information. A team approach is essential and the collection shared between staff.
Information collection still depends upon manual collection in many cases and the partogram is commonly used for that purpose. The partogram can be reproducible so that one copy can be kept on the labour ward for inspection and the other kept in the medical record. Collection of information is usually contemporaneous and is only transferred to an electronic register after delivery.
Computer software programmes have been designed to collect information contemporaneously but the programmes still need to be designed to satisfy the principles of information collection previously described. Otherwise there will be no benefit. The advantages of being able to review cases with partograms, fetal and maternal monitoring simultaneously, as well as all the events and outcomes recorded will be significant if used appropriately. However, a standard way of recording, retrieving and analysing is needed so that a large number of cases can be quickly and easily reviewed. The software programmes need to be ‘ user tempting ’ to ensure that they are embraced by users. There should also be simple ways of checking complete information collection and accuracy. Analysis of the information collected using classification systems will help achieve this.
Finally, apart from collection of physical outcome of mothers and babies there needs to be some method of integrating the mother’s satisfaction about the care provided into the software programme.
Information Retrieval, Presentation and Dissemination
Most clinicians require standard clinical information to assess the quality of care, resolve clinical problems and identify any changes in outcome as a result of modifications of guidelines or methods of care.
The information therefore needs to be presented in a standard way on a regular basis with flexibility for more detailed investigation. An annual clinical report including detailed information on labour and delivery as well as neonatal outcome is essential. International standardization will enable learning from each other but only when a common language has been developed.
Labour Events and Outcome
In collecting information about labour and delivery there are two main types of information and Table 3-1 summarizes some basic information that is useful to collect: firstly, epidemiological data such as age, height, body mass index, medical conditions, ethnicity and other case-mix variables; secondly, there is what is commonly known as interventions , which refer to events (or outcomes) carried out by professionals involved in the mothers’ care. Although these are performed with the intention of improving care, many interpret them as interference with a normal physiological process. The difficulty with a generic term like interventions is that there is no distinction in how the mother, midwife or medical staff perceive the particular event or outcome in question. Even more confusing is the fact that what may be an intervention to one woman may not be an intervention to another; indeed it may be a desired event or outcome. In order to clarify matters the term intervention should be avoided. Instead, all events that take place should be recorded whether they are processes carried out by professionals or occur as a result of the care provided. Some labour events are also labour outcomes, in that the mother, midwife or medical staff consider them to affect the health or satisfaction of either the mother or baby. All events and outcomes need to be defined in a standard way.
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Caesarean section is a case in point; an event that may take place in the process of labour and delivery. It may also be an outcome either negative or positive or indeed neither, depending on the circumstances of the delivery. Induction of labour, artificial rupture of membranes, use of oxytocin and length of labour are other examples of events that may also be outcomes or may affect the incidence of other outcomes.
The third type of information that is collected in labour and delivery is information used to classify the epidemiological data and the events and outcomes.
Indications
While recording numbers of events and outcomes should be straightforward, recording why we carry out certain procedures has been less successful. This needs to be clarified if we are to improve care. The most common examples in labour and delivery are induction of labour and caesarean section; their indications have been difficult to define and implement consistently. A further problem is the increase in numbers of indications used. This presents a problem for classification and obtaining an overview of care; in particular why the procedures are being carried out and whether they can be justified in terms of other outcomes.
If an appropriate caesarean section rate is to be described, then indications for caesarean section have to be standardized. Pre-labour caesarean sections should ideally be classified into fetal, maternal or no medical indication. If more than one indication exists then one main indication should be chosen, with the other indications added in a hierarchical manner.
A definition for no medical indication or maternal request is required. Practically it might be best defined as ‘at the time of the request by the woman, in the opinion of the obstetrician there is a greater relative risk of a significant adverse outcome to mother or baby by carrying out a caesarean section than awaiting spontaneous labour and delivery or inducing labour’.
A medical indication for a caesarean section must be one that is used consistently in similar circumstances. Otherwise the indication should be recorded as maternal request. This does not mean to say it is inappropriate care to carry out a caesarean section after counselling the woman, but only that it should be classified as maternal request and also include the reason for that request. Variances in the application of indications can be studied by analysing them in different groups of women. Importantly though, it is not inconceivable that an indication for caesarean section recorded as maternal request today may well, with change in practice and outcomes from labour and delivery, become a medical indication in the future and also vice-versa.
The terms elective and emergency caesarean section are difficult to define and are rarely applied in a standard way. An elective caesarean section might best be defined as a planned procedure (greater than 24 hours), carried out during routine working hours, at greater than 39 weeks, in a woman who is neither in labour nor has had labour induced. All other caesarean sections would be audited as emergency or possibly more appropriately as non-elective caesarean sections. The reasons why they were recorded as non-elective could be recorded using the rationale described above. This adds an organizational element as well as clinical to the definition of elective and emergency and would be helpful in assessing an appropriate caesarean section rate.
Indications for caesarean sections in labour need to be simple, replicable and allow for improvement of care. Management of labour depends on ensuring fetal wellbeing and achieving efficient uterine action and they are also the reasons why caesarean sections are carried out in labour. It is therefore logical that indications for caesarean sections in labour might be classified into fetal or dystocia so that management can be assessed. A fetal indication would be defined by convention when a caesarean section is carried out for suspected fetal distress (for whatever reason), but without the use of oxytocin. All other caesarean sections performed in labour are classified as a form of dystocia. No formal definition of dystocia is suggested as each delivery unit will have their own interpretation but this will not preclude them from using the following classification. Rather, the subclassification of dystocia will depend upon whether the progress in labour had been less than 1 cm/hour (inefficient uterine action) or more than 1 cm/hour (efficient uterine action). Inefficient uterine action is then subdivided into poor response (despite maximum treatment with oxytocin), inability to treat adequately (for fetal reasons), inability to treat adequately (because of the uterus overcontracting) or lastly no treatment (oxytocin not given because thought to be inappropriate: for example in labour with a malpresentation, in a woman with a previous caesarean section, when a woman declines oxytocin or indeed declines labour itself).
This classification, shown in Table 3-2 , differentiates between suspected fetal distress without oxytocin as opposed to suspected fetal distress after oxytocin was started, but when the primary problem was dystocia.
