Perinatal Audit in Labour and Delivery: Safety, Quality and Consistency

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 to embrace different ways of providing care and persuade professionals that we should standardize the way we examine the quality of care and learn from each other so that we can improve it. Eventually, it would not be unreasonable to expect that the different ways of providing care will gradually merge. We need to encourage midwives and obstetricians to know more about labour, delivery 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 43.1 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, standards, 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. The second measure of quality care is enabling the ability to interpret the results, comparing them with other delivery units and then improving the quality of care.

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 and testing different processes using randomized controlled trials (RCTs) rather than continuously auditing outcomes, but women and their families 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 outcomes in a standardized way at the most senior level on a regular basis, resulting in a formal written annual Clinical Report documenting the quantity and quality of care.

The purpose of the Clinical Report is to enable delivery units to drive quality care and be aware of outcomes, using classification systems that help to interpret the outcomes. It is important to stratify and use appropriate denominator data as otherwise the analysis may be open to misinterpretation. The frequency of the report will depend on the number of deliveries in the labour and delivery unit. The maternity dashboard, which is used by many units, serves a similar purpose but is more of an overview without a lot of the detail. Both of them should include organizational issues such as activity, workforce and available resources.

High-quality labour and delivery 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, in particular RCTs. 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.

Perinatal audit is not recognized as an entity or specialist area, or even at all useful (a poor relation of RCTs). Collection of routine quality data is resource dependent, requiring total organizational commitment. At the moment, there are no accepted terminology, classifications, core event and outcome definitions, principles or training programmes.

Labour and delivery is a complex process. At the present time, there are two competing but ultimately complementary philosophies to evidence-based care – RCTs and perinatal audit. RCTs are considered the highest form of evidence and undoubtedly often are. However, in complex situations such as labour and delivery, perinatal audit in an organized and structured way with adequate training may become more useful.

It is interesting to look at organizations outside medicine (e.g. in business or sport) that are also trying to achieve and maintain quality. They depend more on analyzing their routine data. These organizations are rapidly developing and improving their methods of routine data collection and, in particular, the analysis of their data using sophisticated analytical systems. There is no doubt that there are lessons that could be learnt here.

Ultimately the solution will be an electronic patient record that incorporates all aspects of patient care, including all clinical documentation, order communication, medications, anaesthesia and theatre. It will be a system primarily designed to make the patient journey both easier and safer by improving communication, access to the chart and legibility. However, it also will provide for the better collection of routine data, both clinical and organizational, with the potential for designing the most cost-effective models of care and establishing an epidemiological database to be proud of.

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 and analysis 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. Information collection and analysis should be led by professionals who understand the relevance and importance of the information. A team approach is essential though, and it is important to emphasize this to all involved in the care of the pregnant woman.

Information collection still depends upon manual collection on paper in many labour and delivery units and the partogram is commonly used for that purpose. The partogram can be made 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 information is only transferred to an electronic register after delivery, in most cases by the midwife and not by the doctor. If an electronic register is not available then the amount of detailed information that can be recorded is more limited and will require more human resources. This would be especially true for retrieving information, but with good organization and determination then much useful information can be made available, for example, the Ten Group Classification results looking at caesarean section results.

A big change in relation to information collection is occurring in many delivery units in those countries that have the resources and the expertise, and that is the move to the electronic patient record. Although to some it may seem a simple, obvious and inevitable step, in actual fact it is one of the biggest stress tests that will occur in a labour and delivery unit. For obvious reasons, it is not possible here to go into much detail, but an understanding of certain principles are important.

Principles of an Electronic Patient Record for Labour and Delivery

Computer software programmes and the electronic patient record should be designed to collect information contemporaneously. This will be a big change in most organizations, as the medical staff will become a lot more involved in recording information, requesting investigations and prescribing electronically. This, in many organizations, will be a big departure from previous practice and will need to be carefully managed. The future reward though will be that a lot more detailed information will be recorded electronically than previously, which can be analyzed in more detail, providing the information has been carefully recorded. The electronic software still needs 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 and 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 analyzing 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 recognized and accepted classification systems will help achieve this.

Finally, apart from collection of information on 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.