accompanying bundle booklet - women.wcha.asn.au · 4 wha accompanying bundle booklet 05.07.2018...

Accompanying Bundle Booklet

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WHA Accompanying Bundle Booklet 05.07.2018

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Contents _Toc499219107

BACKGROUND .................................................................................................................................................................. 4

ABOUT INTERVENTIONS BUNDLES ........................................................................................................................... 5

HOW TO USE THIS BOOKLET ....................................................................................................................................... 6

RISK FACTORS .......................................................................................................................................................................................... 7 PATIENT INFORMATION AND CONSENT ................................................................................................................................................ 7

COMPONENTS OF THE INTERVENTIONS BUNDLE ................................................................................................ 8

FOR ALL WOMEN. ............................................................................................................................................................ 9

1. APPLY WARM PERINEAL COMPRESSES DURING THE SECOND STAGE OF LABOUR AT THE COMMENCEMENT OF PERINEAL

STRETCHING. .................................................................................................................................................................................. 9 2. WITH A SPONTANEOUS VAGINAL DELIVERY, USING GENTLE VERBAL GUIDANCE, TO ENCOURAGE A SLOW CONTROLLED

BIRTH OF THE FETAL HEAD AND SHOULDERS: ........................................................................................................................ 10 a. support the perineum with the dominant hand ....................................................................................................... 10 b. apply counter-pressure on the fetal head with the non-dominant hand ...................................................... 10 c. if shoulders do not deliver spontaneously, apply gentle traction to release the anterior shoulder . 10 d. allow the posterior shoulder to be released following the curve of Carus ................................................... 10

WHEN EPISIOTOMY IS INDICATED ......................................................................................................................... 12

3. EPISIOTOMY SHOULD BE PERFORMED: .................................................................................................................................... 12 a. at crowning of the fetal head ........................................................................................................................................... 12 b. using a medio-lateral incision .......................................................................................................................................... 12 c. at a minimum 60 degree angle from the fourchette .............................................................................................. 12

FOR ALL WOMEN .......................................................................................................................................................... 14

4. GENITO-ANAL EXAMINATION NEEDS TO: ................................................................................................................................. 14 a. be performed by an experienced clinician .................................................................................................................. 14 b. include a PR examination on all women, including those with an intact perineum ............................... 14

5. ALL PERINEAL TRAUMA SHOULD BE ......................................................................................................................................... 15 a. graded according to the RCOG grading guideline .................................................................................................. 15 b. reviewed by a second experienced clinician to confirm the diagnosis & grading .................................... 15

WOMEN’S INVOLVEMENT .......................................................................................................................................... 16

ENSURING CONTINUOUS QUALITY IMPROVEMENT .......................................................................................... 17

DATA COLLECTION, FEEDBACK AND EVALUATION .......................................................................................... 18

MEASURES FOR IMPROVEMENT ........................................................................................................................................................... 18 EVALUATION OF THE CARE BUNDLE .................................................................................................................................................... 19 WHAT THIS MEANS FOR YOU AND YOUR TEAM ................................................................................................................................. 20

REFERENCES .................................................................................................................................................................. 21

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Background

Approximately 75% (n=172,700) of all women who give birth in Australia each year

sustain some form of perineal tear1. More than 3.6% (n=6,365)1 of these women will

sustain third and fourth degree tears which have the potential for long term, or

even lifelong, impact on their wellbeing. Australian data shows a year on year

increase in the number of women who sustain third and fourth degree tears2. This

rising rate of harm from tears is occurring despite a declining vaginal birth rate.

There is considerable variation in rates of third and fourth degree tears between

hospitals. This variation is not specific to different service capabilities. Hospitals

supporting more than 500 births p.a. reported rates of third and fourth degree tear

ranging between 1.3% and 5.6%, with an average of 3.43%3. For hospitals

supporting less than 500 births per annum the rates varied from 0% to 10%, with an

average of 2.46%3. This variability in rates of tears indicates that local practices,

including the grading of tears, have an impact on rates of tears and that there is

potential for improvement to occur.

The consequences of such injuries include both physical and psychological

morbidities4,5. Long-term complications of perineal tears include anal

incontinence, urinary incontinence, chronic pain and dyspareunia6. This trauma

has been shown to have a detrimental psychosocial impact on women requiring

ongoing intervention. It has also been shown that the trauma of sustaining a

perineal tear and its complications can effect subsequent births choices where a

vaginal birth is forsaken, increasing rates of elective caesarean section7.

The financial impact on the Australian health care system is also substantial. The

overall inpatient cost is estimated to reach $58 million annually. In addition the

estimated cost of outpatient care of the woman with a perineal tear costs

approximately $6 million every year8. In Australia, WHA members have anecdotally

advised that successful claims are typically between $80,000 and $300,000 each.

Costs of litigation arising from third and fourth degree tears is also a consideration.

While Australian data is scarce, in the United Kingdom it has been reported that

between 2000 and 2010 there were 441 successful claims alleging negligence after

women sustained perineal trauma9. The total value of these claims was estimated

to be £31.2 million, and is reported to relate primarily to third and fourth degree

perineal tears.

In England, the rate of third and fourth degree tears has tripled over the last 10

years, increasing from 1.8% to 5.9% in singleton, term, cephalic, vaginal first births10.

The incidence of perineal tears in the UK is 2.9% (range 0—8%), with an incidence

of 6.1% in primiparous and 1.7% in multiparous women11. As a result of the

increasing rates of perineal trauma, the National Health Service has commenced

a national collaborative improvement project which is progressively being rolled

out in maternity services around the UK in 2016 – 2018.

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About interventions bundles

The US Institute for Healthcare Improvement (IHI) developed the concept of a

bundle to describe a collection of interventions needed to reliably deliver the

best possible care and safety for patients. They define an interventions bundle as

a set of evidence-based interventions that, when reliably implemented together

will result in significantly improved outcomes than when implemented

individually12.

A bundle should consist of a small number, usually three to five, of evidence

based interventions. Each of these interventions can be separately implemented

in each episode of care. A bundle brings changes together into a package of

interventions that must be followed for every patient, every single time.

Interventions bundles are effective in ensuring evidence base practices are

consistently performed by all staff within a clinical service. Monitoring compliance

with each component of the bundle enables individual unit to assess the impact

of the intervention bundle within their unit. Women should be informed of the

care bundles prior to their birth.

Care Bundle development

An expert panel was formed with representation from around Australia including

midwives, obstetricians, urogynaecologists and consumer representatives. The

panel met on two occasions to evaluate evidence from current systematic

reviews, source articles and best practice methodology to determine the

interventions that could reliably reduce rates of third and fourth degree tears. In

addition to the quality of evidence, other factors were taking into account in the

selection process including patient acceptability and feasibility.

Testing of the interventions bundle then occurred using QI 1, 3, 5 methodology to

evaluate the ability to implement and evaluate the bundle effectiveness. Initial

testing sites provided input which resulted in continuous improvement to bundle

terminology, measurement and supporting resources. The interventions bundle

was well received by obstetricians, urogynaecologists, midwives and consumers.

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How to use this booklet

This booklet provides information on how to perform all components and

implement the Interventions bundle. The effectiveness of the Bundle is

dependent upon the conscientious application of all components including;

1) the effectiveness of local change leaders,

2) the quality of the educational programme,

3) the compliance with the bundle

The booklet describes the five evidence-based components that form the WHA

National Collaborative Interventions Bundle that when implemented together will

reduce the risk of third and fourth degree tears for women giving birth in

participating hospitals.

Included in the booklet are recommendations on communicating with the woman

about the elements of the bundle and suggested wording for documentation

related to the interventions bundle. The bundle will be supported by an

educational resources package and facilitated coaching by experts in

improvement science that aims to achieve reliable sustained improvements in

patient care.

This booklet is intended for use by all midwives and obstetricians at participating

hospitals and health services. The term ‘clinician’ is used which refers to both

midwives and obstetricians irrespective of the level of experience. Local training

on how to use the care bundle is essential to its success. The accompanying

educational resource package is designed to support participating teams to

increase reliability of implementation. Those championing change within each

service are responsible for ensuring that staff are provided with sufficient training

to enable them to carry out all elements safely and effectively.

The Interventions Bundle is compatible with clinician discretion and does not

replace reasonable clinical judgement. The interventions should be implemented

with consideration of local policies and procedures related to, but not limited to:

operative vaginal births

maternal position

Informed consent

communication

episiotomy

perineal assessment, and

management of tears.

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Risk Factors

Clinicians must be aware of the risk factors for sustaining a third and fourth degree

perineal tear (included in table 1 below). However, it should also be remembered

that even without these specific risk factors, a woman may sustain a perineal tear

and therefore the Interventions Bundle should still be applied.

Antenatal Risk factors:

Nulliparous

Asian/ Indian ethnicity

Posterior fourchette to mid-anus < 2.5cm

Previous 3rd and 4th degree tear

Previous shoulder dystocia

Intrapartum Risk Factors

This baby in OP position at delivery

Birthweight estimated at delivery > 4 kgs

Shoulder dystocia at delivery

Table 1 Risk factors for third and fourth degree tears14:

Information for Women and consent

An information leaflet for Women has been finalised for use. It is envisaged that it

will be provided to all women at an antenatal appointment between 32-36

weeks. The clinician should explain the Interventions bundle and respond to any

questions or concerns the woman may have. It is envisaged that in the future

copies of this leaflet be displayed and available at services frequented by

prenatal women including ultrasound departments, antenatal clinics and

consultant waiting rooms.

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COMPONENTS OF THE INTERVENTIONS BUNDLE

Perineal support should be able to be applied in most positions women choose to

adopt for birth. With the exception of a birthing stool or water immersion, all other

positions should allow the clinician to visualise the perineum and use their hands

to support it at the time of birth. Women should be encouraged to mobilize freely

during labour and to choose their preferred position for birth. A woman can be

advised of their increased risk of tears in their chosen position but should not be

FOR ALL WOMEN.

1. Apply warm perineal compresses during the second stage of

labour at the commencement of perineal stretching.

2. With a spontaneous vaginal delivery, using gentle verbal

guidance, to encourage a slow controlled birth of the fetal head

and shoulders:

a. support the perineum with the dominant hand

b. apply counter-pressure on the fetal head with the non-

dominant hand

c. if the shoulders do not deliver spontaneously, apply

gentle traction to release the anterior shoulder

d. Allow the posterior shoulder to be released following the

curve of Carus

WHEN EPISIOTOMY IS INDICATED

3. Episiotomy should be performed:

a. at crowning of the fetal head

b. using a medio-lateral incision

c. at a minimum 60 degree angle from the fourchette NB: An episiotomy is indicated for all women requiring a forceps or vacuum assisted delivery having their

first vaginal birth

FOR ALL WOMEN

4. Genito-anal examination following birth needs to:

a. be performed by an experienced clinician

b. include a PR examination on all women, including those

with an intact perineum

5. All perineal trauma should be

a. graded according to the RCOG grading guideline

b. reviewed by a second experienced clinician to confirm

the diagnosis & grading


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prevented from adopting this position. If an instrumental delivery is required a

women will need to adopt a suitable position for this to occur.

FOR ALL WOMEN.

1. Apply warm perineal compresses during the second stage of labour

at the commencement of perineal stretching.

Warm packs applied during the second stage of labour reduce the risk of third

and fourth degree tears16 and intrapartum perineal pain16, 17. The use of a

standard hospital perineal pad with water of a safe temperature should be

applied to all women at the commencement of perineal stretching, with the

exception of women having a water birth.

Temperature of the warm compress

Ensure water is the correct temperature by:

1. Adding 300mls of boiling water to 300mls of cold tap water (cold water

should be added first for safety)

Or

2. Using a temperature controlled tap that has been tested to deliver water

between 38-44oC

3. Prior to application test water temperature in the same way a baby’s bath

water is checked

4. Replace water entirely every 15 minutes to ensure a correct temperature is

maintained

5. Do NOT ‘top up’ or add hot water as a correct temperature cannot be

maintained

6. Check the colour of the skin after application for signs of excessive heat.

Communication

Provision of information about the benefits of reducing perineal tears should be

provided. It is important to warn the woman about the risk of overheating and

ask her to report any discomfort. If a women requests to remove the warm

compress at any stage their preferences should be followed. It is reasonable to

suggest reapplying a warm compress at a later stage with consent of the

labouring women. The amount of time the compress was in place and any

reasons for removal should be documented in the patient notes.

It is acceptable to use warm compresses in the presence of an epidural

providing due care in taken to the assessment of the heat of the warm compress

prior to its application as the woman may not be able to necessarily discriminate

the temperature.

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2. With a spontaneous vaginal delivery, using gentle verbal guidance, to

encourage a slow controlled birth of the fetal head and shoulders:


b. apply counter-pressure on the fetal head with the non-dominant

hand

c. if shoulders do not deliver spontaneously, apply gentle traction

to release the anterior shoulder

d. allow the posterior shoulder to be released following the curve of

Carus

Slowing the birth of the fetal head at the time of crowning may reduce the risk of

perineal trauma16. Techniques to control speed of birth can be performed in most

birthing positions that the woman adopts. The following techniques should be used

for all births to reduce rapid expulsive force and encourage birth to occur in a slow

controlled manner 18:

1) Encourage the woman to minimise active pushing using gentle verbal

guidance. The use of controlled slowed or shallow maternal breathing

should be used to birth the baby slowly.

2) Support of the perineum with the dominant hand (* with the exception of

women having a water birth)

3) Applying counter pressure to the fetal head using the non-dominant hand

to control the fetal head15 (* with the exception of women having a water

birth).It is important for the clinician to evaluate the speed at which the

head is progressing to allow the use of appropriate pressure i.e.to allow

progress but prevent uncontrolled expulsion.

4) Once the head has been delivered, wait for restitution to occur.

5) Continue to support the perineum as you encourage the mum to push

gently to birth the shoulders. In the event that the shoulders do not delivery

spontaneously, remove the dominant hand and apply gentle downward

traction or as appropriate to the women’s position e.g. on all fours traction

is upwards, towards the accoucheur. If she is standing and you are in front

of her, the traction is applied anterior or forward etc.

6) Allow the posterior shoulder to be released following the curve of Carus,

protecting the perineum throughout this step.

7) Support is provided to the baby’s body by moving both hands.

Although access to the perineum is necessary for the achievement of perineal

support at crowning, it should never be a reason to restrict a woman’s movement

during the second stage. The clinician may need to adjust their position in order to

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allow visualisation and support of the perineum. Perineal support can be provided

in most positions including semi-recumbent, lateral and ‘all fours’ (hands and

knees). There is no clear evidence that any particular position has a significantly

protective effect on the perineum.

Instrumental Assisted Births

Perineal support should also be used during assisted births when using either

forceps or vacuum. In these instances, the technique for perineal support is

modified. If a single clinician is performing the instrumental procedure, at the point

at which the fetal head is extending, then the clinician should change the hand

controlling the instrument from the dominant hand to the non-dominant hand and

use the dominant hand to support the perineum (including after an episiotomy has

been cut) If two clinicians are available during an instrumental birth, the assistant

will apply support from one hand on the perineum during the birth of the fetal head

(including after the episiotomy has been cut) by the instrument of choice. On

crowning, the clinician should control the speed of the birth of the head and

control the delivery of the shoulders.

Communication

The use of verbal guidance to encourage a slow controlled birth should be used

by encouraging women to slow their breathing and control their pushes on

crowning of the fetal head. This allows the perineum to accommodate the gradual

stretching caused by the head, thereby reducing the risk of tearing by

uncontrolled expulsion.

If a woman has chosen a birthing position which restricts access to the perineum

and the clinician has concerns about a women’s individual risk for a third or fourth

degree tear (see risk factors on page 7) they may recommend that the woman

adopts a position which allows for perineal support.

Unless the baby’s condition is critical, once the head is born, the clinician should

encourage the women to refrain from pushing until restitution occurs (external

rotation of the baby’s head and internal rotation of the shoulders). Due to ongoing

risk to the perineum, care should be taken during the birth of the shoulders and

perineal support should be continued as the shoulders are delivered.

IMPORTANT PRINCIPLES ARE:

• Coaching the mum to avoid sudden expulsive push

• Maintaining gradual progress during the birth of the head

• No undue downward traction during delivery of the shoulders

• Support the perineum throughout the whole birth Royal College of Obstetricians and Gynaecologists , OASIS Care Bundle19

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WHEN EPISIOTOMY IS INDICATED

3. Episiotomy should be performed:

a. at crowning of the fetal head

b. using a medio-lateral incision

c. at a minimum 60 degree angle from the fourchette

There is evidence that selective use of episiotomy reduces the risk of third and

fourth degree tears during instrumental delivery19. All primiparous women,

including women having the first vaginal birth ie VBAC who require a forceps or

vacuum assisted delivery should have an episiotomy.

An episiotomy should be performed at a 60-degree angle on the woman’s right as

the baby’s head is crowning. Due to stretching and distortion of the perineum

during the second stage, an episiotomy cut at less than 60o results in a episiotomy

suture line closer to 45o angle, which has been shown to increase the risk of a third

and fourth degree tear20. All midwives and obstetricians should have the

performance of an episiotomy within their scope of practice.

Episiotomy should only be considered after clinical assessment of the fetal and

maternal risks for multiparous women and for women not requiring forceps or

vacuum assisted deliveries.

It is important to remember that 16% of women report severe pain levels during

perineal procedures21. It is therefore important to ensure adequate pain relief prior

to and during the procedure (e.g. lignocaine infiltration, nitrous gas inhalation, or

epidural):

1) Explain the rational for performing the episiotomy and obtain the woman’s

informed consent

2) Ensure adequate analgesia and check that it is effective prior to procedure

3) Cut an episiotomy by starting at the fourchette and directing the incision

away from the perineal midline at an angle of 60 degrees22.

Tools should be used and training provided to facilitate achievement of the 60

degree angle. Alternatively if available the use of scissors that indicate the correct

episiotomy angle can be used29.

In the context of this care bundle, episiotomy is indicated in cases of suspected or

confirmed fetal compromise, delayed second stage of labour, instrumental

delivery, and in cases when a severe perineal tear is judged to be imminent (feel

digitally for remaining space/stretch), for example where the blood flow to the

perineum is significantly reduced, or if 'button-holing' is occurring during the

second stage of labour.

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Communication

It is important that the clinician communicates the reason why an episiotomy is

being considered with the woman. For example, if the episiotomy is being

performed when there are no immediate concerns about fetal wellbeing and the

episiotomy is only being performed in an attempt to protect the perineum, the

woman should be made aware of the equivocal nature of the evidence for this

intervention.

As with any intervention, the woman should give her agreement before an

episiotomy is performed.

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FOR ALL WOMEN

4. Genito-anal examination needs to:

a. be performed by an experienced clinician

b. include a PR examination on all women, including those with an

intact perineum

Accurate diagnosis and effective care of perineal injuries requires systematic

perineal assessment23. Following ALL BIRTHS, a thorough examination of the

perineum should be carried out by an experienced clinician. This assessment

must include a rectal examination as recommended by NICE 24 and should be

carried out even when the perineum appears intact as visual examination alone

often results in underestimation of the degree of trauma25.

It is often difficult to determine if the internal anal sphincter is damaged. Careful

inspection by an experienced clinician is required. We recommended that a rectal

examination is performed using the following technique25.

1. Insert the index finger into the anus and ask the woman to squeeze:

The separated ends of a torn external anal sphincter will retract

backwards and a distinct gap will be felt anteriorly

When regional analgesia affects muscle power, assess for gaps or

inconsistencies in the muscle bulk of the sphincter by placing the

index finger in the anal canal and the thumb in the vagina and

palpate by performing a ‘pill-rolling motion’

2. Assess the anterior rectal wall for overt or occult tears by palpating and

gently stretching the rectal mucosa with the index finger

Any tears should be classified according to the RCOG and documented in the

client notes.

Communication

The clinician should explain to the women the reason why the examination is being

performed and how they will do it. The clinician should ensure that the woman is

comfortable with adequate analgesia .e.g entonox. Consideration of the cultural

needs of the women and their right to privacy should be considered. The woman’s

preferred support person should be present if she desires this, to provide support to

the woman and her baby.

If a tear is identified, and following its appropriate repair, a detailed discussion and

the provision of written information is required. Follow up should be offered for any

women assessed as receiving a third or fourth degree tear.

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5. All perineal trauma should be

a. graded according to the RCOG grading guideline

b. reviewed by a second experienced clinician to confirm the

diagnosis & grading

Perineal injuries sustained during childbirth are most often classified by the

degree to which the perineum tears. It is important that assessment and grading

is performed by an experienced clinician trained in perineal assessment and alert

to risk factors25. A second clinician should review any tear to confirm the

diagnosis and the extent of the injury25. Refer to table 2 below regarding grading

of tears.

Table 2. Grading of perineal tears

Degree of perineal tear13

First-degree tear: Injury to perineal skin and/or vaginal mucosa.

Second-degree tear: Injury to perineum involving perineal muscles

but not involving the anal sphincter.

Third-degree tear: Injury to perineum involving the anal sphincter

complex:

Grade 3a tear: Less than 50% of external anal sphincter (EAS)

thickness torn.

Grade 3b tear: More than 50% of EAS thickness torn.

Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.

Fourth-degree tear: Injury to perineum involving the anal sphincter

complex (EAS and IAS) and anorectal mucosa.

For grading purposes an episiotomy should NOT be graded as a second degree

perineal tear.

A perineal tear that goes beyond the planned episiotomy incision, should be

recorded as an episiotomy with extension and graded according to the degree

of perineal trauma.

For example;

1) A women who has been given an episiotomy prior to vaginal birth and

ends up with a tear that exposes the fat in ischio-rectal fossa with both

sphincters intact, should be graded as both an episiotomy with extension

and a grade 2 tear.

2) A women who has a planned episiotomy who has both EAS and internal

anal sphincter (IAS) torn should be graded as both an episiotomy with

extension and a grade 3c tear.

3) An episiotomy that does not extend should be graded as No Tear.

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Where indicated repair should occur as soon as practicable after birth. There

should be consideration of the needs of the women and support of uninterrupted

skin-to-skin contact post birth with the risk of infection and blood loss. It is

important that staff are trained in the diagnosis and repair of tears. Senior

obstetricians should be consulted for any grade 3 or 4 injuries. Refer to local

procedures techniques for perineal repair.

Communication

Following perineal examination, a discussion with the woman of the findings and

proposed treatment should occur. Written information should also be provided

and an appropriate level of follow up arranged.

Women’s involvement

It is important that all women giving birth in your maternity unit are aware of the

interventions bundle and how this influences their care. An information leaflet has

been developed that should be provided at an antenatal visit from 32-36 weeks.

It will also be provided as part of the interventions bundle paperwork to help inform

the women at the time of delivery if feasible. It will be important to discuss the

interventions bundle with the woman: identify any potential risk factors; outline how

the bundle will influence their care; and answer any questions they may have.

The involvement of women in the process of quality improvement is very important

to ensure techniques implemented are acceptable to the patient population. The

WHA involved female consumers in many aspects of planning and development

of the Collaborative. Feedback was particularly valuable in the development of

educational resources and the development of the evaluation framework.

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Ensuring Continuous Quality Improvement

To improve healthcare and the way it is delivered, change must occur. Not all

changes result in improvement, but all improvement starts with acknowledging

that change is needed. Reliable processes are those that occur every time, for

every woman, tailored to each woman’s preferences. When using intervention

bundles and all-or-none measurements, care is changed in important ways27. This

includes:

challenging the assumption that evidence-based care is being delivered

reliably

promoting awareness that the entire care team work together in a system

designed for reliability

promoting the use of improvement methods to redesign care processes27

The use of quality improvement methods to facilitate the implementation of the

interventions bundle in your maternity unit will be supported through training in

improvement methodology and 1:1 coaching.

Changes do not need to be implemented in their entirety overnight. ‘Plan Do Study

Act’ (PDSA) cycles are used to test changes, to assess their impact and to ensure

that new ideas improve quality and safety of care before implementation on a

wider scale28. In this project, facilitated PDSA cycles will be used to support your

team with the implementation of the bundle in your maternity unit. This means that

we will introduce the care bundle to a small cohort of women initially, then review

and modify the approach before implementing it with a larger group of women,

and so forth until the intervention is fit for purpose and implementation among all

agreeing women. Incremental roll-out allows for the introduction of new systems

without disrupting existing systems28.

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Data collection, feedback and evaluation

Measures for improvement

Measurement is critical to quality improvement and allows us to determine

whether changes made result in benefit or improvement.

Many quality improvement initiatives involve making changes to processes, and

performing them in a consistent and reliable way, in order to positively influence

outcome and establish reliable sustained improvements29. Balancing measures are

used to monitor whether a change that is designed to improve one part of the

system has unforeseen impacts on another part of the system29.

This Collaborative aims to improve outcomes for women by reducing the rate of

avoidable third and fourth degree tears. A set of measures will be used in this

Collaborative to evaluate the care bundle used to try to achieve this aim [Figure

1]. Your team will learn more about project measures, how they will be collected,

and how to use the measures to support change and improvement in your

maternity unit in Learning Set 1.

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Evaluation of the care bundle

To better understand whether changes are resulting in improvement to outcomes,

we will also ask teams to collect data on maternal characteristics (e.g. age, BMI,

parity) and intra partum care (induction of labour, mode of delivery, epidural use

and shoulder dystocia) to adjust for case mix and risk factors. Rates of Caesarean

section will also be examined.

Implementation outcomes will be evaluated through evidence of integration of

the care bundle into routine practice i.e. reliability and sustainability, as well as an

assessment of acceptability and feasibility of the interventions.

Evaluation measures for Collaborative

Risk Factors Antenatal

Parity Mode of birth

Asian/ Indian ethnicity Epidural analgesia

Posterior fourchette to mid-

anus < 2.5cm

Episiotomy rate

Previous 3rd degree tear Caesarean section rate

Previous shoulder dystocia

Intrapartum Risk Factors

Length of 2nd stage

(primp/Multip)

O-P position at birth Number of deliveries/ unit

Shoulder dystocia at birth

Birthweight at delivery > 4kgs

Compliance

Compliance with Implementation of Bundle

Provision of patient information leaflet (%

Women who receive)

Post partum referral for third or fourth degree

tear

Figure 1

Type What is measured? Frequency of reporting

Outcome Rate of third and fourth degree

perineal tears in vaginal births

Monthly

Process % Compliance with each

component of bundle

% Compliance with all

components of bundle

Weekly

Balancing Caesarean Section Rate

Episiotomy Rate

Monthly

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What this means for you and your team

The Collaborative implementation period will run from November 2017 through to

December 2018. During this time, your team will be asked to submit de-identified

patient data. An excel data template is available for baseline data collection. This

template will automatically generate run charts and pareto charts which will be

used by the Improvement Advisor to guide your initial coaching session.

A separate template (that auto-generates charts) will be provided for continuous

data collection to monitor ongoing improvement. The Improvement Advisor will

refer to these on a monthly basis. The charts can also be used to provide feedback

to staff in your birthing unit and other key people in your organisation, including

your executive sponsor.

A clinician operated quality improvement platform (QUIDS) is available to support

the quality improvement activities, create driver diagrams, record PDSA and share

learning/experiences across the participating hospitals.

Implementation outcomes will be evaluated through evidence of integration of

the care bundle into routine practice i.e. reliability and sustainability of system

improvement, as well as an assessment of acceptability and feasibility of the

interventions.

Monitoring and feedback during roll-out

A process of continuous data collection, evaluation and feedback will be used to

support implementation within participating hospitals. A clinician operated data

platform will be utilised that supports entry of de identified patient data. The data

platform allows real time evaluation of run charts and facilitates the preparation

of monthly reports. Monthly reporting will be utilised by clinical units to feedback

improvement on key process and outcome measures to clinical teams and

Executive sponsors.

21


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