Stillbirth in Australia 2: Working together to reduce stillbirth in Australia: The Safer Baby Bundle initiative.

The rate of late gestation stillbirth in Australia is unacceptably high. Up to one third of stillbirths are preventable, particularly beyond 28 weeks' gestation. The aim of this second paper in the Stillbirth in Australia series is to highlight one key national initiative, the Safer Baby Bundle (SBB), which has been led by the Centre of Research Excellence in Stillbirth in partnership with state health departments. Addressing commonly identified evidence practice gaps, the SBB contains five elements that, when implemented together, should result in better outcomes than if performed individually. This paper describes the development of the SBB, what the initiative aims to achieve, and progress to date. By collaborating with Departments of Health and other partners to amplify uptake of the SBB, we anticipate a reduction of at least 20% in Australia's stillbirth rate after 28 weeks' gestation is achievable.

Comparison of group O Rh(D)- red blood cell use in pregnant women across hospitals of various sizes and obstetric capabilities prior to the introduction of patient blood management guidelines.

BACKGROUND: O Rh(D)- red blood cell (RBC) units can generally be transfused to most patients regardless of their ABO blood type and are frequently used during emergency situations. Detailed usage patterns of O Rh(D)- RBC units in obstetric populations have not been well characterised. With the introduction of patient blood management guidelines, historical usage patterns are important for providing comparative data. AIMS: To determine how the use of O Rh(D)- RBC units in pregnant women differs between hospitals of different sizes and obstetric capabilities prior to patient blood management guidelines. METHODS: Data from 67 New South Wales public hospital blood banks were linked with hospital and perinatal databases to identify RBC transfusions during pregnancy, birth and postnatally between July 2006 and December 2010. RBC transfusions were divided into O Rh(D)- or other blood types. Hospitals were classified according to birth volume, obstetric capability and location, with transfusions classified by timing and diagnosis. RESULTS: Of the 12 078 RBC units transfused into pregnant women, 1062 (8.8%) were O Rh(D)-. Higher use of O Rh(D)- RBC units was seen in antenatal transfusions, preterm deliveries and in regional or smaller hospitals. There was wide variation in rates of O Rh(D)- RBC transfusion among hospitals. CONCLUSIONS: The rate of O Rh(D)- RBC unit use in obstetrics was lower during the period assessed than the nationally reported usage. It is encouraging that O Rh(D)- RBCs were more commonly used in emergency or specialised situations, or in facilities where holding a large blood inventory is not feasible.

Uptake of external cephalic version for term breech presentation: an Australian population study, 2002-2012.

BACKGROUND: The safety, efficacy, and cost-effectiveness of external cephalic version (ECV) for term breech presentation has been demonstrated. Clinical guidelines recommend ECV for all eligible women, but the uptake of this procedure in the Australian healthcare setting is unknown. This study aimed to describe ECV uptake in New South Wales, the most populous state of Australia, during 2002 to 2012. METHODS: Data from routine hospital and birth records were used to identify ECVs conducted at ≥36 weeks' gestation. Women with ECV were compared to women who were potentially eligible for but did not have ECV. Eligibility for ECV was based on clinical guidelines. For those with ECV, birth outcomes following successful and unsuccessful procedures were examined. RESULTS: In N = 32,321 singleton breech pregnancies, 10.5% had ECV, 22.3% were ineligible, and 67.2% were potentially eligible but did not undergo ECV. Compared to women who were eligible but who did not attempt ECV, those who had ECV were more likely to be older, multiparous, overseas-born, public patients at delivery, and to deliver in tertiary hospitals in urban areas (p < 0.01). Fewer women who underwent ECV smoked during pregnancy, fewer were morbidly obese, and fewer had a hypertensive disorder of pregnancy, compared to those who were eligible. Caesarean section occurred in 25.9% of successful compared to 95.6% of unsuccessful ECVs. Infant outcomes did not differ by ECV success. CONCLUSIONS: The majority of women with a breech presentation did not receive ECV. It is unclear whether this is attributable to issues with service provision or low acceptability among women. Policies to improve access to and information about ECV appear necessary to improve uptake among women with term breech presentation. Improved data collection around the diagnosis of breech presentation, ECV attempts, and outcomes may help to identify specific barriers to ECV uptake.

Induction of labour practices in New South Wales hospitals: Before and after a statewide policy.

Midwifery Unit Managers completed surveys in 2008 and 2014 to determine methods of induction of labour. There was an increase in balloon catheter use for cervical ripening (rate difference 37%, P = 0.007). Currently, all respondent hospitals have an oxytocin protocol; district hospitals had a significant increase in use of post-maturity protocols (rate difference = 40%, P = 0.01) but there was no change in use of prostaglandin protocols.

Long-term childhood outcomes of breech presentation by intended mode of delivery: a population record linkage study.

INTRODUCTION: There is a lack of information on long-term outcomes by mode of delivery for term breech presentation. We aimed to compare childhood mortality, cerebral palsy, hospitalizations, developmental, and educational outcomes associated with intended vaginal breech birth (VBB) with planned cesarean section. MATERIAL AND METHODS: Population birth and hospital records from New South Wales, Australia, were used to identify women with non-anomalous pregnancies eligible for VBB during 2001-2012. Intended mode of delivery was inferred from labor onset and management. Death, hospital, and education records were used for follow up until 2014. Cox proportional hazards regression and modified Poisson regression were used for analysis. RESULTS: Of 15 281 women considered eligible for VBB, 7.7% intended VBB, 74.2% planned cesarean section, and intention was uncertain for 18.1%. Intended VBB did not differ from planned cesarean section on infant mortality (Fisher's exact p = 0.55), childhood mortality (Fisher's exact p = 0.50), cerebral palsy (Fisher's exact p = 1.00), hospitalization in the first year of life [adjusted hazard ratio (HR) 1.04; 95% CI 0.90-1.20], hospitalization between the first and sixth birthdays (HR 0.92; 95% CI 0.82-1.04), being developmentally vulnerable [adjusted relative risk (RR) 1.22; 95% CI 0.48-1.69] or having special needs status (RR 0.95; 95% CI 0.48-1.88) when aged 4-6, or scoring more than 1 standard deviation below the mean on tests of reading (RR 1.10; 95% CI 0.87-1.40) and numeracy (RR 1.04; 95% CI 0.81-1.34) when aged 7-9. CONCLUSIONS: Planned VBB confers no additional risks for child health, development or educational achievement compared with planned cesarean section.

Contribution of changing risk factors to the trend in breech presentation at term.

BACKGROUND: Recent population-wide changes in perinatal risk factors may affect rates of breech presentation at birth, and have implications for the provision of breech services and training in breech management. AIMS: To investigate whether changes in maternal and pregnancy characteristics explain the observed trend in breech presentation at term. MATERIALS AND METHODS: All singleton term (≥37 week) births in New South Wales during 2002-2012 were identified through birth and associated hospital records. Annual rates of breech presentation were determined. Logistic regression modelling was used to predict expected rates of breech presentation and these were compared with observed rates over time. A priori predictors included maternal age, country of birth, parity, smoking during pregnancy, diabetes, pregnancy hypertension, placenta praevia, previous singleton term breech, previous caesarean section, infant sex, gestational age, birthweight and congenital anomalies. Hospital and Medicare data were used to assess concomitant trends in external cephalic version. RESULTS: Among 914 147 singleton term births, 3.1% were breech at delivery. Rates of breech presentation declined from 3.6% in 2002 to 2.7% in 2012 (test for trend P < 0.001), but was predicted to increase from 3.6% in 2002 to 4.3% in 2012 because of increased maternal age, nulliparity, maternal diabetes, history of breech presentation and previous caesarean section. However, use of external cephalic version appears to have increased over time. CONCLUSIONS: Breech presentation at delivery has decreased in New South Wales. Increased use of external cephalic version likely accounts for this decline, as changes in risk factors do not.

Outcomes of breech birth by mode of delivery: a population linkage study.

BACKGROUND: Trial evidence supports a policy of caesarean section for singleton breech presentations at term, but vaginal breech birth is considered a safe option for selected women. AIMS: To provide recent Australian data on outcomes associated with intended mode of delivery for term breech singletons in women who meet conservative eligibility criteria for vaginal breech birth. MATERIALS AND METHODS: Birth and hospital records from 2009 to 2012 in New South Wales were used to identify women with nonanomalous pregnancies who would be considered eligible for vaginal breech birth. Intended mode of delivery was inferred from labour onset and management. RESULTS: Of 10 133 women with term breech singleton pregnancies, 5197 (51.3%) were classified as eligible for vaginal breech delivery. Of these, 6.8% intended vaginal breech birth, 76.4% planned caesarean section and intention could not be determined for 16.8%. Women intending vaginal delivery had higher rates of neonatal morbidity (6.0% vs 2.1%), neonatal birth trauma (7.4% vs 0.9%), Apgar <4 at one minute (10.5% vs 1.1%), Apgar <7 at five minutes (4.3% vs 0.5%) and neonatal intensive care unit/special care nursery admissions (16.2% vs 6.6%) than those planning caesarean section. Increased perinatal risks remained after adjustment for maternal characteristics. Severe maternal morbidity (1.4% vs 0.7%) and post-partum readmission (4.6% vs 4.0%) were higher in the intended vaginal compared to planned caesarean births, but these differences were not statistically significant. CONCLUSIONS: In a population of women classified as being eligible for vaginal breech birth, intended vaginal delivery was associated with higher rates of neonatal morbidity than planned caesarean section.

Variation in hospital caesarean section rates for preterm births.

BACKGROUND: Evidence about optimal mode of delivery for preterm birth is lacking, and there is thought to be considerable variation in practice. OBJECTIVE: To assess whether variation in hospital preterm caesarean section rates (Robson Classification Group 10) and outcomes are explained by casemix, labour or hospital characteristics. MATERIALS AND METHODS: Population-based cohort study in NSW, 2007-2011. Births were categorised according to degree of prematurity and hospital service capability: 26-31, 32-33 and 34-36 weeks' gestation. Hospital preterm caesarean rates were investigated using multilevel logistic regression models, progressively adjusting for casemix, labour and hospital factors. The association between hospital caesarean rates, and severe maternal and neonatal morbidity rates was assessed. RESULTS: At 26-31 weeks' gestation, the caesarean rate was 55.2% (seven hospitals, range 43.4-58.4%); 50.9% at 32-33 weeks (12 hospitals, 43.4-58.1%); and 36.4% at 34-36 weeks (51 hospitals, 17.4-48.3%). At 26-31 weeks and 32-33 weeks' gestation, 81% and 59% of the variation between hospitals was explained with no hospital significantly different from the state average after adjustment. At 34-36 weeks' gestation, although 59% of the variation was explained, substantial unexplained variation persisted. Hospital caesarean rates were not associated with severe maternal morbidity rates at any gestational age. At 26-31 weeks' gestation, medium and high caesarean rates were associated with higher severe neonatal morbidity rates, but there was no evidence of this association ≥32 weeks. CONCLUSION: Both casemix and practice differences contributed to the variation in hospital caesarean rates. Low preterm caesarean rates were not associated with worse outcomes.

Rate of spontaneous onset of labour before planned repeat caesarean section at term.

BACKGROUND: Guidelines recommend that, in the absence of compelling medical indications (low risk) elective caesarean section should occur after 38 completed weeks gestation. However, implementation of these guidelines will mean some women go into labour before the planned date resulting in an intrapartum caesarean section. The aim of this study was to determine the rate at which low-risk women planned for repeat caesarean section go into spontaneous labour before 39 weeks. METHODS: We conducted a population-based cohort study of women who were planned to have an elective repeat caesarean section (ERCS) at 39-41 weeks gestation in New South Wales Australia, 2007-2010. Labour, delivery and health outcome information was obtained from linked birth and hospital records for the entire population. Women with no pre-existing medical or pregnancy complications were categorized as 'low risk'. The rate of spontaneous labour before 39 weeks was determined and variation in the rate for subgroups of women was examined using univariate and multivariate analysis. RESULTS: Of 32,934 women who had ERCS as the reported indication for caesarean section, 17,314 (52.6%) were categorised as 'low-risk'. Of these women, 1,473 (8.5% or 1 in 12) had spontaneous labour or prelabour rupture of the membranes before 39 weeks resulting in an intrapartum caesarean section. However the risk of labour <39 weeks varied depending on previous delivery history: 25% (1 in 4) for those with spontaneous preterm labour in a prior pregnancy; 15% (1 in 7) for women with a prior planned preterm birth (by labour induction or prelabour caesarean) and 6% (1 in 17) among those who had only previously had a planned caesarean section at term. Smoking in pregnancy was also associated with spontaneous labour. Women with spontaneous labour prior to a planned CS in the index pregnancy were at increased risk of out-of-hours delivery, and maternal and neonatal morbidity. CONCLUSIONS: These findings allow clinicians to more accurately determine the likelihood that a planned caesarean section may become an intrapartum caesarean section, and to advise their patients accordingly.

Unexplained variation in hospital caesarean section rates.

OBJECTIVES: To assess recent hospital caesarean section (CS) rates in New South Wales, adjusted for case mix; to quantify the amount of variation that can be explained by case mix differences; and to examine the potential impact on the overall CS rate of reducing variation in practice. DESIGN AND SETTING: Population-based record linkage study of births in 81 hospitals in New South Wales, 2009-2010, using the Robson classification to categorise births, and multilevel logistic regression to examine variation in hospital CS rates within Robson groups. MAIN OUTCOME MEASURES: Hospital CS rates. RESULTS: The overall CS rate was 30.9%, ranging from 11.8% to 47.4% (interquartile range, 23.9%-33.1%) among hospitals. The three groups contributing most to the overall CS rate all comprised women with a single cephalic pregnancy who gave birth at term, including: those who had had a previous CS (36.4% of all CSs); nulliparous women with an elective delivery (prelabour CS or labour induction, 23.4%); and nulliparous women with spontaneous labour (11.1%). After adjustment for case mix, marked unexplained variation in hospital CS rates persisted for: nulliparous women at term; women who had had a previous CS; multifetal pregnancies; and preterm births. If variation in practice was reduced for these risk-based groups by achieving the "best practice" rate, this would lower the overall rate by an absolute reduction of 3.6%, from 30.9% to 27.3%. CONCLUSION: Understanding hospital heterogeneity in performing CS and implementing evidence-based practices may result in improved maternity care. We have identified five risk-based groups as priority targets for reducing practice variation in CS rates.

Predicting date of birth and examining the best time to date a pregnancy.

OBJECTIVE: To compare the estimated date of birth (eDOB) from the last menstrual period (LMP) and ultrasound scans at varying gestations (<7(0), 7(0)-10(6), 11(0)-14(0), 14(1)-19(6), and 20(0)-27(6)weeks) with the actual date of birth (aDOB). METHODS: In a retrospective study, data were analyzed from 18 708 women with spontaneous labor who delivered a single neonate without major anomalies in a local health district in Australia between 2007 and 2011. Data were sourced from a computerized population birth database. The study outcomes were duration of pregnancy expressed as total days, and the difference between aDOB and eDOB by dating method. RESULTS: Only 5% of births occurred on the eDOB, regardless of the dating method or timing of the dating. Approximately 66% of births occurred within 7days of the eDOB, and there was little difference among the ultrasound examinations performed at varying gestational weeks. The ultrasound scans at 11(0)-14(0)weeks of gestation performed as well as ultrasound scans conducted at other gestational ages. CONCLUSION: On a population basis, there were no meaningful differences in the prediction of date of birth by ultrasound scan date. An early dating scan (≤10weeks) is unnecessary if LMP is reliable.

Trends in planned early birth: a population-based study.

OBJECTIVE: The purpose of this study was to describe trends and outcomes of planned births. STUDY DESIGN: Data from linked birth and hospital records for 779,521 singleton births at ≥33 weeks' gestation from 2001-2009 were used to determine trends in planned births (prelabor cesarean section and labor inductions). Adverse outcomes were composite indicators of maternal and neonatal morbidity/death. RESULTS: From 2001-2009, there were increases in labor inductions and prelabor cesarean deliveries at <40 weeks' gestation, but no decrease in the stillbirth rate (trend P = .34). By 2009, 14.9% of live births at ≥33 weeks' gestation were prelabor cesarean deliveries before the due date; 11.4% were inductions. As planned births increased, maternal risks shifted, which included a decline in inductions with maternal hypertension from 31.9-23.9%. Earlier birth was contemporaneous with increases (trend P < .001) in neonatal and maternal morbidity rates from 3.0-3.2% and 1.1-1.5%, respectively. CONCLUSION: Planned birth before the due date is increasing without a contemporaneous reduction of stillbirths.

Getting evidence into obstetric practice: appropriate timing of elective caesarean section.

There is considerable variation in the timing of elective pre-labour caesarean section at term where there is no immediate threat to the life of the mother or baby. Given the outcomes, elective or pre-labour caesarean section ought not be offered or performed before 39 completed weeks' gestation. Primary data sources indicated that the rate of term elective caesarean sections with no medical indication undertaken before 39 weeks' gestation at our institution was ~30% in 2005 and 2006. A project was undertaken during the 6-month period from March 2007 to August 2007 with the aim of reducing this rate to 10%. Over the 6-month period, the rate of elective caesarean section with no medical indication done before 39 weeks' gestation in the target group fell to 10%. Over the same timeframe the number of admissions to the neonatal nursery of term babies born by caesarean section at less than 39 weeks fell to zero. Although the numbers are small and not statistically significant, this work suggests implementation across larger jurisdictions or states could result in significant improvements in clinical outcomes.

Getting evidence into obstetric and midwifery practice: reducing perineal trauma.

PROBLEM: Frequent obstetric perineal morbidity in a hospital setting with service providers inexperienced in getting evidence into practice. DESIGN: Clinical practice improvement methodology in a tertiary referral obstetric unit. STRATEGIES FOR CHANGE: To cease active instruction to push in the second stage of labour; encourage the adoption of the left lateral position when delivering on a bed; use of the vacuum extractor rather than forceps where instrumental delivery indicated. EFFECTS OF CHANGE: Improved perineal outcomes with a 21.5% increase in intact perineum rate and a 100% reduction in fourth degree perineal tears. LESSONS LEARNED: Clinical practice improvement methodology is a useful tool for getting evidence into practice, resulting in improved clinical outcomes.