1. PPH at NW

2. Post partum haemorrhage IndicatorWHANW 2010 N=7709 NW Public 2010 N=2329 PPH 1000-1500 Vaginal births 1.91- 2.43 3.14 PPH >1500 Vaginal births 1.35-1.72.74 PPH 500-1500 CS 49.46774.6 Transfusion All births 1.63-2.12.53.8

3. Good at identifying low risk women PhysiologicalSyntocinonSyntometrine SVD10.246.840.9 Operative vaginal delivery 6136 Previous CS 48.944.2

4. Syntocinon vs Syntometrine PhysiologicalSyntocinonSyntometrine SVD10.246.840.9 Operative vaginal delivery 6136 Previous CS 48.944.2

5. PPH at NW Primary PPH rate (>500ml) was 36% 16% with vaginal delivery 78% for emergency caesarean section Role to audit blood loss by staff member?

6. Individual audit at an Australian public hospital Registrars advised that a: –Junior (ITP) with a mean blood loss >500ml would result in borderline for surgical skills on assessment form and mean >600ml a fail. –Senior registrar with a mean blood loss >400ml would result in borderline for surgical skills on assessment form and mean >500ml a fail. Consultants (Lead maternity care providers) were advised they would be audited against background rates. Quinlivan JA et al, Unpublished data JHC Q&S, 2011

7. Dear Dr Smith, Comment: Your PPH results are significantly poorer than our benchmark. SmithHospital Number of deliveries 1353990 % PPH total (>500ml) 48%36% % PPH SVD (>500ml) 42%30% PPH CS (>500ml) 77%49%

8. PPH at JHC 2011 6 months Mean blood loss Baseline cohort Pre warning (ml) Mean blood loss follow up cohort Post warning (ml) ITP2690510 ITP3640440 Senior Reg440420 CMO400 Consultant410385 Quinlivan JA et al, Unpublished data JHC Q&S, 2011

9. Misopristol Lancet RCT of 1422 women. Randomised to Misopristol or Placebo. No difference in rate of PPH (>500ml loss). More women receiving Misopristol had shivering (65% vs 32%) and a body temperature >38 0 C (43% vs 15%). Findings do not support the use of Misopristol in addition to standard uterotonics for treatment of PPH. Widmer M et al. Lancet 2010; 375: 1808-

10. NW Strategies to reduce PPH New guidelines for PPH late 2009 –Expected to result in an increased use of syntometrine for prevention of PPH in women at risk and a more consistent approach to calling for help. –Overall reduction in blood transfusion 3.3% (2009) to 2.6% (2010). New checklist for PPH in 2010 –Hospital wide strategy to reassess need for a second bag of blood.

11. Other strategies to consider... Delivery suite: –Ensure routine active management strategies are being implemented correctly –Ensure PPH is being recognised early –Axe use of Misopristol –Audit PPH rate by LMC provider for SVD and give feedback. Operating theatre: –Consider using a long acting syntocinon –Audit PPH rate by LMC provider and registrar for CS and give feedback.

12. Induction of Labour

13. IOL at NW More than 1 in 3 nulliparous women were induced. Post dates pregnancy and term PROM were the most common reasons for IOL When post dates was the primary reason for IOL, 11% occurred BEFORE 41 weeks gestation.

14. Diagnosis of term PROM Need to confirm diagnosis through history, examination and testing (amnicator/ultrasoun d). Consider waiting 24 hours if GBS negative.

15. Post dates IOL Restrict access to postdates IOL until AFTER 41 weeks. Ensure dates are confirmed by early US before booking. Introduce offer of routine membrane sweeping at 38 and 39 weeks to reduce post dates IOL.

16. Sweeping membranes Meta analysis of RCT concluded that a policy of offering routine sweeping of membranes at 38 or 39 weeks reduces the number of women progressing to post term gestation and the need for formal labour induction. Boulvain M eta al. Cchrane database of systematic reviews 2005; CD000451.

17. Urogynaecology

18. 209 had urogynaecology procedure. 40 women had a hysterectomy at the same time as their urogynaecology procedure. Complication rate was 10.5% overall

19. Urogynaecology complications Significant post operative infection1 Unplanned return to theatre3.4 Failure to complete surgery0.5 Intra operative injury to internal organ 0.5 Blood transfusion 1 Other significant complication3.8 Readmission to hospital9.1

20. 300,000 operations performed annually in US. Sacrocolpopexy considered the gold- standard. Vaginal approach to prolapse repair common. Surgical outcomes for vaginal native tissue repair of prolapse are poor –Nearly 1 in 3 women undergo repeat surgery. Lifetime risk of reoperation –Mean interval to reoperation was 12.5 years. –Clark AL. AJOG 2001; 184: 1357-1364. Urogynaecology and Prolapse

21. Should you be using Vaginal mesh outside a trial setting? Rogers RG, Obstet Gynecol 2011; 118: 1-2

22. Prompted by adverse reports, in October 2008 FDA issued safety advisory regarding the use of mesh for treatment of incontinence and vaginal prolapse. Issued advice that more detailed information to be collected. New FDA advisory released July 2011 states that there are serious concerns over the use vaginal mesh for the treatment of vaginal prolapse and incontinence. Concern over use of vaginal mesh

23. FDA Advisory “The occurrence of serious complications with the use of vaginal mesh is not rare and mesh use is not proven to provide improved outcomes when compared with native tissue repairs.” “Update prompted by an increase in the number of reports made to the Manufacturer and User Facility Device Experience database, including common reports of exposure, erosion, and protrusion of mesh into the vagina and new reports of mesh contractions.” US Food & Drug Administration 2011

24. How are devices cleared? FDA –Class I (low risk) –Class II (Mesh, contact lens solution, external hearing aid) –Class III (high risk) Process –Premarket approval required (Clinical trials required - expensive) –510k process which clears for market (does not approve) Withdrawal from market 2005 to 2009 113 items withdrawn or recalled 71% were Class II, 510k devices!

25. Some excellent results General –Breast feeding –Quit campaign Low complication rates in –General Gynaecology –Gynaecology Oncology Obstetrics –HIE (below benchmark) –VBAC (above benchmark)

26. Thankyou