Quality at CM Health

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“I remember starting to feel really tired all the time. I was always sleeping. My midwife said it was probably because my iron was low. I tried taking the iron tablets but they did not work. I moved a few times so lost things. My midwife suggested I have an iron injection straight into my blood. This had to be done in hospital. I wouldn’t have gone as I am frightened of needles and did not know what to expect. The community health worker picked me up and put me at ease so I felt ok going with her. When I got to the hospital my midwife was waiting for me on the ward. It took about 3 – 4 hours so I was a bit bored but my midwife kept me talking then I had a sleep…”

Third and Fourth Degree Tears Perineal trauma is one of the most common complications of childbirth. Obstetric anal sphincter injuries (OASIS), further defined as 3a, 3b, 3c or 4th degree tears, can have a major impact on women’s lives, both in the postpartum period and longer term. The MoH Clinical Indicators 6-9 (see Appendix 3) reflect the degree of damage to the lower genital tract from vaginal birth among standard primiparae. Each of the indicators is intended to reflect different issues and encourages reflection by DHBs on what can be done to improve rates of intact lower genital tract, assess risks to mother and infant

before undertaking an episiotomy (i.e. support restricted rather than routine use of episiotomies) and consider factors related to labour management that might impact on third and fourth degree tears. After reviewing the clinical indicator data for 2012 it was noted that: • Women living in Counties Manukau or delivering at Middlemore Hospital were significantly less likely to have an intact lower genital tract post-delivery compared to a standard primiparae (Clinical Indicator 6, intact lower genital tract). • A lower percentage of women living in Counties Manukau or birthing at a CM Health facility had an episiotomy and no

Table 13. Anal Sphincter injuries for all women delivering at CMH facilities, 2003-2014 YEAR

3RD DEGREE TEARS

2007 2008 2009 2010 2011 2012 2013 2014

141 154 143 142 148 189 185 130

% TOTAL 4TH % TOTAL TOTAL VAGINAL DEGREE VAGINAL VAGINAL BIRTHS TEARS BIRTHS BIRTHS 2.1% 2.3% 2.1% 2.1% 2.3% 3.0% 3.2% 2.3%

6 15 14 14 17 14 7 8

0.09% 0.22% 0.21% 0.21% 0.26% 0.22% 0.12% 0.14%

6867 6817 6720 6618 6534 6333 5725 5610

3RD & 4TH TEARS % OF VAGINAL BIRTHS 2.1% 2.5% 2.3% 2.4% 2.5% 3.2% 3.4% 2.5%

third or fourth degree tear after giving birth vaginally compared to the New Zealand average (Clinical indicator 7) • Women living in Counties Manukau Area or birthing at a CM Health facility had a higher, but not statically significantly higher, percentage of a third or fourth degree tears with no episiotomy following a vaginal birth. This was consistent with the New Zealand average for having both an episiotomy and third or fourth degree tear (Clinical Indicator 9). We have also examined our local Healthware data for all women birthing at a CM facility in terms of 3rd and 4th degree tears (Table 13). In 2014, 2.3% of women who had a vaginal birth had a 3rd degree tear while 0.14% of women had a 4th degree tear. A review of births complicated by 3rd and 4th degree tears showed 26% were assisted births (instrumental deliveries either ventouse or forceps) with the reminder occurring after spontaneous vaginal deliveries. Of the assisted deliveries, 77% had an episiotomy. This is encouraging as the practice of episiotomy when performed at an assisted primiparae delivery significantly reduces the risk of an anal sphincter injury.22,23 In addition we have also a looked at episiotomies for women who birthed at Middlemore Hospital (ie not including primary units) in 2014. A higher percentage of Indian women had an episiotomy than other ethnic groups (Table 15).

Source : Healthware ICD 10 code of O702 or O703. Extracted by Health Intelligence and Informatics 2015Vaginal births include normal and operative. 22 Baghestan E, Irgens LM, Børdahl PE, Rasmussen S. Trends in Risk Factors for Obstetric Anal Sphincter Injuries in Norway. Obstet gynecol 2010; 116: 25-33. 23 Jango H, Langhoff-Roos J., Rosthoj S.. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: A population-based cohort study. AJOG. Jan 2014. 59-61.