The Coombe Hospital Annual Report 2023

Report 2023

Advancing Healthcare for Women & Newborns since 1826

The Coombe Hospital

Our History

Our founder, Margaret Boyle, spearheaded the development of our hospital almost 200 years ago, because she wanted to ensure that ALL women had access to the healthcare they needed, and deserved.

We’ve worked hard to deliver on that vision. Our brand represents all the elements that make up who we are, our name, reputation, culture, values, and highlights our unique approach to healthcare.

Advancing Healthcare for all women and newborns at The Coombe Hospital.

Our Purpose

We provide specialist care for women and newborns putting their needs at the heart of everything we do.

Our Vision

To be a nationally and internationally recognised leader in healthcare for women, newborns and their families.

Centuries of Care

Community of Care

Our Values

Empathy for all Teamwork

We listen to each other in order to understand; we always act with kindness and compassion. This is how we treat each other as colleagues, and it’s how we treat every person who walks through our doors.

We all bring unique skills and knowledge to The Coombe and when they are combined, we are at our best. We work as a collective in the best interests of the women, the newborns, the families, staff and all the people who use our services.

Dignity & Respect

We are a diverse team, serving a diverse community. Our different backgrounds, skills and experience make The Coombe a very unique and special place, where we treat everyone with dignity and respect.

People at the heart of everything we do

The women, newborns, families, and all people who use our services are at the heart of everything we do. From a kind word, to a high-tech intervention, we strive to give people the very best possible care, and that’s what makes The Coombe a truly human place.

Always striving to be at our best

We’re passionate about what we do. We give our very best everyday and learn from our experiences with colleagues and those who use our services. This enables us to continually improve what we do, and how we do it.

The Coombe Hospital is dedicated to delivering specialist women’s healthcare, in a holistic, personal and human way

The Coombe Hospital

Introduction

Introduction from The Master

Professor Michael O’Connell - Hospital Master

The Coombe Hospital has been offering care to women and newborns for the past 197 years, furtherance to this legacy it is my great privilege as the 31st Master of The Coombe Hospital to introduce the 2023 Annual Report.

As Master, I continue to be indebted to the Executive Management Team (Anna Deasy, Patrick Donohue, Melissa Lawlor, Ann MacIntyre, John Robinson, Professor Martin White and Annemarie Waldron) for all they contribute and their dedication to living our purpose of providing specialist care for women and newborns putting their needs at the heart of everything we do. I am grateful for the support of the Board (Appendix Three) and in particular to the Chair, Mary Donovan.

In 2023, 6,836 women gave birth to 6,974 babies weighing ≥ 500 grams. The corrected perinatal mortality rate was 4.0 per 1,000 total births. We provided care for 136 liveborn babies weighing ≤ 1,500 grams who were reported to the Vermont Oxford Network (VON).

In 2023, we remained the largest provider of benign gynaecology services in Ireland, performing 6,042 gynaecological surgical procedures. In addition, in 2023 there was a 47% increase in attendances at the Outpatient Hysteroscopy Clinic against 2022, a doubling of numbers seen in the Enhanced Endometriosis Clinic with an additional 861 women seen in the Colposcopy Clinic. Gynaecology waiting list management was prioritised, and to this end The Coombe Hospital was the best performing hospital in the Dublin Midlands Hospital Group (DMHG).

New Service Initiatives in 2023

A specialist Gynaecology Clinic caring for women with fibroids was established by Dr Workineh Tadesse. This clinic occurs once per month and over 100 women have engaged with this service since its establishment. I am indebted to Dr Niall McEniff who provides the embolisation service for the Fibroid Clinic.

Dr Niamh Murphy established a specialist Adolescent Gynaecology Clinic at The Coombe Hospital in January 2023. The clinic accepts referrals nationally, as The Coombe Hospital is one of only three hospitals with a dedicated Paediatric and Adolescent Gynaecology (PAG) service. The PAG team (Consultant and SpR) at The Coombe Hospital also attend the PAG clinic in Children’s Health Ireland (CHI) at Temple Street, where care is offered to younger patients. In the first year of service, 165 new referrals were seen in the clinic and there were 140 return visits. Patients from the age of 12 years and above attended the clinic at The Coombe Hospital, with admission for theatre, where required from the age of 15 years and above, also provided in The Coombe Hospital. In 2023, the PAG service admitted 48 patients for a surgical procedure, 45 of whom were admitted as day cases. The establishment of this clinic fulfils our ambition to provide care from cradle to grave for women and newborns.

Professor Mairead Kennelly established a tertiary referral Fetal Surgical Clinic to offer multidisciplinary assessment, counselling and discussion of surgical and post-operative care for select fetal anomalies. The service is provided by Professor Kennelly (Fetal Medicine Specialist), Mr Brian Sweeney (Paediatric Surgeon CHI), Dr John Kelleher (Consultant Neonatologist) and Felicity Doddy (Prenatal Diagnosis Coordinator).

At a glance:

6,974 babies born weighing ≥ 500 grams

136 babies born weighing ≤ 1,500 grams at birth

861 women seen in the Colposcopy Clinic.

6 new clinical services were established

4.0 per 1,000 total births perinatal mortality rate

47% increase in activity in the Outpatient Hysteroscopy Clinic.

The Daisy Clinic was established to provide antenatal and postnatal care to homeless pregnant women, women who are at risk of homelessness, women living in emergency accommodation and women living in direct provision. This is a joint midwifery and medical social worker clinic with the service provided by a dedicated Clinical Midwife Manager (CMM2) and a social inclusion medical social worker. In the six months after commencement in June 2023, 51 women were referred to the Daisy Clinic.

The Coombe Hospital/HSE Integrated Home Birth Service commenced in October 2023 as the governance was transferred from the HSE to The Coombe Hospital. This service is provided for women who chose a home birth, who fulfil agreed safety criteria, by midwives who are self-employed with the HSE. The service is facilitated by Paula Barry, Designated Midwifery Officer (DMO).

The Bayley Assessment Clinic commenced in 2023. Detailed developmental assessments of high-risk extreme preterm infants and/or those infants with a history of neonatal encephalopathy are performed in this clinic. The assessments are performed by either Dr John Kelleher (Consultant Neonatologist) or Dr Sara Kift (Occupational Therapist). The Bayley assessment is a target for performance at approximately 24 months of age, corrected for prematurity. The aim is to give parents results and feedback the day of the clinic, followed by a formal report which is sent to parents and to healthcare professionals.

During the COVID-19 pandemic the Naas Antenatal Clinic was temporarily transferred to The Coombe Hospital. The Coombe Midland Antenatal Clinic was established in Vista Primary Care in Naas in Q4 2023.

The Emergency Assessment Centre (EAC) which is an amalgamation of the Assessment Unit (AU) attached to the Delivery Suite, and the Emergency Room (ER) in OPD, was opened in September 2023. This development ensures one pathway for all unscheduled care of women presenting at The Coombe Hospital.

All these initiatives occurred despite significant challenges in recruiting midwives and nurses. At the beginning of 2023 the hospital was 50 WTEs (not counting statutory leaves) short in midwifery and nursing. Thanks to the amazing work of Ann MacIntyre (Director of Midwifery and Nursing) and her team,

aided by the national Ministerial intervention whereby newly qualified midwives and nurses were offered permanent contracts, we ended the year with a commitment to fill almost all these vacancies by the end of the first quarter of 2024.

The Coombe Hospital National Cervical Screening Laboratory (NCSL) recommenced screening programme samples in October 2023, following reinstatement of accreditation. I wish to thank Dr Cillian De Gascun Interim Director, for his leadership during this difficult time. Cillian, due to other commitments, left the Interim Director role in October. Dr Corrina Wright successfully interviewed for the Director’s role and as Master I will undertake the Interim Director role until Corrina takes up her post. Other appointments to the service included a Laboratory Manager and a Quality Manager.

During 2023 the Hospital Management Forum met for the first time. The forum allows for updates from each of the Management Committees in the hospital to update the EMT and advise of proposed initiatives.

The Guideline Committee under the chair of Professor Stephen Lindow recommenced formally after the COVID-19 pandemic. This committee aims to update our guidelines and review the new national guidelines in the context of either adopting them in full or adapting them to the hospital where it is not possible to implement in full due to resource limitations.

A new committee, The Audit, Quality Improvement and Research Oversight Committee was constituted in 2023 to ensure that all projects are aligned to the Hospital Strategy.

In January 2023, The Coombe Hospital became the first hospital in Ireland to be accredited by the European Board College of Obstetrics and Gynaecology (EBCOG) for Maternal-Fetal Medicine training. This was a great achievement and aligns to our EBCOG accreditation for General Obstetrics and Gynaecology. Our EBCOG accredited training programme in partnership with the Dublin Midlands Hospital Group (DMHG) commenced with trainees rotating between The Coombe Hospital, Midland Regional Hospital Portlaoise, Tallaght University Hospital and St James’s Hospital. This programme aims to provide a structured programme for those not on the Higher Specialist Training Programme.

Infrastructure

I continued to advocate for the development of the Women’s Health Centre, the theatre block (including the Neonatal Intensive Care Unit and an alongside Birthing Unit) and the purpose-built EAC with the support of DMHG, the Acute Division of HSE and HSE estates. Hopefully, perseverando vinces.

Within the aging building the St Patrick’s Ward refurbishment was completed, which sets the standard for all our wards. We replaced old lighting with LED lights. The pantries and kitchens in Our Lady’s Ward, St Monica’s Ward and St Gerard’s Ward were replaced. The Information and Communication Technology (ICT) upgrade progressed at a pace. This will improve our cybersecurity while enabling the upcoming Maternal and Newborn Clinical Management System (MN-CMS) project. Great credit is due to Serge Panzu and the Engineering team and to Bryan Smyth and the ICT team in progressing these projects whilst attempting to minimise the impact on our services.

Staff

The Coombe Hospital Social Committee was formed in April 2023 and was extremely active across the year with two visits of the ice cream van, a staff BBQ, and a great delegation from the North Pole with Santa, Mrs Claus and the elves paying a long overdue visit to The Coombe Hospital in December.

The Coombe Golf Society was established with five very successful outings. The extra practice ensured that The Coombe Hospital team won the Rotunda Hospital Golf Classic. My thanks to all who take the time to give of their time for us all in making these events so successful.

In the first week of September staff from all departments joined me at 7am each morning to walk our Coombe Camino Challenge around Dublin 8. This offered a great opportunity for staff to meet and chat over our 45 minute walk (albeit a little quicker if you tried to keep up with our physiotherapists!). I was delighted to be joined by Aisling, Kevin, Liz and Steve as we walked the second stages of the Camino Frances in early October. I am pleased to say that we are on target to complete the Camino in time for

the 200th anniversary of The Coombe Hospital in 2026. The Jonathan Swift Garden for staff opened on June 2nd. This is a wonderful initiative with thanks to all involved, but in particular to the Human Resources Department for delivering this project.

On the 19th April we were offered the opportunity not to wear masks – a significant milestone against the challenges of the COVID-19 pandemic. This allowed for my long promise to all who retired during the COVID-19 pandemic to attend a retirement celebration on the 14th September where they were presented with the Master’s Medal.

On 19th October we had a wonderful day beginning with our recently qualified midwives and nurses for the Hospital Midwifery and Nursing graduation, followed by a highly contested Master’s Medal (won by Frances Fallon) for Audit, Quality Improvement and Research, with the day culminating with the presentation of the Master’s Medal to those with 25 years and more service to The Coombe Hospital. The combined service by those honoured was 910 years – absolutely amazing.

On the following day I was delighted to host Professor Zephne van Der Spuy from Cape Town to give the 49th Guinness Lecture, entitled ‘Fertility and Infertility: An African Perspective.’ Zephne gave an amazing lecture which not only demonstrated a lived experience, but in her inimitable humble manner her advocacy for women in the African subcontinent. The lecture series was completed by our Fertility Hub team who outlined the journey of their incredible service development over the past two years.AhighlysuccessfulGuinnessdinnerfollowedthatnight.

Finally

My thanks to all who contributed to this report and in particular to Caoimhe, Emma, Fiona and Julie.

In 2023 we continued to implement our five-year strategy, I would like to extend a big thanks to all who aresupporting and making the strategy happen.

In my 2022 report I thanked all staff who lived our values of empathy for all, teamwork, dignity and respect, people at the heart of everything we do,

and always striving to be at our best. This year following a HIQA inspection, the representatives from HIQA recognised that our values were being truly lived, and informed EMT during the verbal feedback session that they felt the care, kindness, empathy and dignity provided to the patients in The Coombe Hospital was ‘second to none.’ They advised us that this aspect and component of care is by far the most important and was recognised as being at a level which they rarely encounter. They acknowledged that whilst this finding would be difficult to portray in their final report, we should all be very proud of our hospital, our colleagues, our values and that we should all strive to always protect this.

I am delighted to conclude that in 2023 we continued to fulfil our purpose of providing specialist care for women and newborns, putting their needs at the heart of everything we do.

Care, kindness, empathy and dignity provided to the patients in The Coombe Hospital was second to none.

The Coombe Hospital Executive Management Team 2023.

Highlights

First Baby Born 2023

We welcomed our first baby of 2023 at 00:55 on 1st January 2023. I had the pleasure of presenting the Master’s Medal to two-month-old Nicholas Urban, and his family on Monday the 27th of February. The medal celebrates the first baby born at The Coombe Hospital each year.

Guinness Lecture Series

On 19th October we had a wonderful day beginning with our recently qualified midwives and nurses for the Hospital Midwifery and Nursing graduation, followed by a highly contested Master’s Medal (won by Frances Fallon) for Audit, Quality Improvement and Research, with the day culminating with the presentation of the Master’s Medal to those with 25 years and more service to The Coombe Hospital. The combined service by those honoured was 910 years – absolutely amazing.

I was delighted to host Professor Zephne van Der Spuy from Cape Town to give the 49th Guinness Lecture, entitled ‘Fertility and Infertility: An African Perspective.’ Zephne gave an amazing lecture which not only demonstrated a lived experience but in her inimitable humble manner her advocacy for women in the African subcontinent. The lecture series was concluded by our Fertility Hub team who outlined the journey of their incredible service development over the past two years. A highly successful Guinness dinner followed that night.

Opening of Jonathan Swift Garden

The Jonathan Swift Garden for staff opened on 2nd June with a garden party which enjoyed a great staff turnout. The garden was officially opened by the winner of the competition to name the garden, Glen Cusack and Professor Martin J. White. This is a wonderful initiative with thanks to all involved, but in particular to the Human Resources Department for delivering this project.

Year In Review

2023

Obstetrics and Newborns

961

Babies were cared for in NICU and SCBU

27,283

Fetal Medicine and Perinatal scans

6,836 Women gave birth

8,762 Emergency room attendances

6,974

Babies were born

4,101

Early pregnancy assessment unit attendances

2,591

Caesarean sections

137 Multiple Pregnancies

Gynaecology

18,029 Gynaecology outpatient attendences

6,042 Gynaecology surgical procedures

3,633 Uterine surgical procedures

1,735

Outpatient hysteroscopy clinic attendances

1,666

Hysteroscopies

Outpatient hysteroscopic procedures 925

Fertility hub attendances 975

Tubal and ovarian surgeries 887

Laboratory specimens

Hysterectomies

Laparoscopic hysterectomies

of abdominal hysterectomies were laparoscopic

Vaginal hysterectomies

Vaginal repairs (anterior and posterior)

392,984

Director of Midwifery and Nursing Report

Ann MacIntyre

The Midwifery and Nursing objective for 2023 was to ensure that safe, quality evidenced care was provided for all the women, babies and families attending The Coombe Hospital. There was a focus on workforce planning with the recruitment and retention of midwives and nurses. The realisation of this objective within a challenging landscape was enabled by the support provided by The Board of Guardians and Directors, the Master, and the Executive Management Team (EMT).

Vacancy rates increased from 48 Whole Time Equivalent (WTE) posts in January 2023 to a peak of 60 WTE posts in October 2023. The year began with the Christmas recruitment drive, which targeted international midwives, neonatal nurses, theatre nurses and women’s health nurses through social media and via The Coombe Hospital’s webpage. This initiative was supported by the Dublin Midland Hospital Group (DMHG). Applications for midwifery and nursing roles across departments were received from Ireland, Italy, Ghana, Australia and the Philippines.

We were delighted that 17 of our BSc interns took up posts in The Coombe Hospital on qualifying. This was a true reflection of the support they received from the staff midwives and nurses, preceptors and managers in The Coombe Hospital.

The successful integration of recruits across access routes was supported by the Clinical Skills Facilitators (CSFs). The CSFs also supported adaptation midwives employed to work in Midland Regional Hospital Portlaoise. Throughout 2023, 64 WTE and 12 WTE

adaptation midwives commenced, 38 WTE resigned and 10 WTE retired, providing a strong start for 2024.

The achievements listed in the various clinical reports would not have been possible without the dedication and commitment of all staff. The care, support and passion of the midwives, nurses and healthcare assistants to ensure the provision of specialist care for women and newborns throughout 2023 is reflected throughout this annual report and is a demonstration of how they are living The Coombe Hospital values.

Sincere thanks to the ADoMN for their leadership, management, their continued support, and their help and kindness to all the staff throughout the year. A very sincere thanks to all the AMPs, the ANPs and candidates, the Clinical Midwife Managers (CMMs), the Clinical Nurse Managers (CNMs), the Clinical Nurse/Midwife Specialists (CN/MSs), the CSFs, the CPCs, the allocation officer, all the midwives, nurses, student midwives and healthcare assistants for their hard work, dedication and the caring ethos that they bring every day to the women, babies, families and colleagues.

The night duty ADoMN, Ita Burke retired having worked for 32 years in The Coombe Hospital. Ita was an amazing midwife and manager in the Delivery Suite for many years, providing support and kindness to the women, babies, their families and the staff she worked with. We wish her well on her retirement.

The sad loss of a valued member of the Delivery Suite midwifery team, Mary Flood, CMM2 on 3rd July was felt by all her colleagues in Delivery Suite and throughout The Coombe Hospital. Mary was a passionate and caring midwife. Our deepest sympathies, thoughts and prayers are with her husband Ben and sons Alex, Jacob and Samuel as well Christina and the extended family. Mary is sadly missed by us all.

Workforce Planning

The midwifery and nursing team’s focus was to retain and ‘grow our own’ careers within The Coombe Hospital along with attracting and engaging midwives and nurses with The Coombe Hospital. With this objective, the provision of career development opportunities, the development of recruitment and retention strategies, forecasting of attrition via retirements and resignations were undertaken across 2023.

The Midwifery Executive Team, CN/MMs, Human Resources, the Communications Officer and the Marketing Manager worked together to increase recruitment and retention rates. Six agencies were engaged, (both local and international) and The Coombe Hospital’s webpage was utilised to assist to increase the recruitment and retention rates. The team attended three Healthcare Recruitment Fairs. Interviews were organised weekly to ensure all applicants’ CVs were reviewed and shortlisted candidates were interviewed promptly.

Toward career development and retention, a career day was organised in February, with presentations from 12 midwives and nurses representing all grades and a variety of hospital departments. This highlighted the career growth opportunities within The Coombe Hospital and evidenced the supported pathways available across routes such as management and leadership, education, and specialist.

Midwifery and Nursing Education

In October, the HSE Professional Development Plans programme was launched by the Midwifery and Nursing Practice Development Department (MNPDD), with the delivery of the Midwifery and Nursing Career Pathways in The Coombe Hospital Booklet. Thanks to the Human Resources team, the Marketing Manager and the Nursing and Midwifery Planning and Development Unit (NMPDU) for their support.

The internal rotation of midwives continued every nine months along with the midwife sonographer in-house ultrasound training pathway. Rotation increases midwifery knowledge, as well as supporting ‘growing our own’ experienced and knowledgeable

midwives. Third year student midwives continued to provide crucial support to the staff midwives on the wards as midwives assistants (HCAs). A transition programme and mentorship programme were offered to all newly qualified midwives in 2023, with each midwife also afforded an orientation week which was supported by the CSFs.

The DoMN and the MNPDD met with Dr Ray Healy, Director of Registration, Nursing and Midwifery Board of Ireland (NMBI) in June and September to progress discussions on the adaptation programme for staff nurses. This initiative aims to decrease the turnaround time from appointment to registration of the staff nurses. The waiting times for the RCSI adaptation programme have lengthened because of the increased demand nationally. Theatre and gynaecology nurses will be the focus of this adaptation programme. An application to commence the programme in The Coombe Hospital has been submitted to the NMBI.

Monthly meetings with the DoMN, the CMM/NM2s, the CMM/NM3s, the Practice Development Coordinator and the ADoMN on duty commenced in June 2023. These meetings offer a great opportunity to liaise and work collaboratively on recruitment, retention, mandatory training, rotation, personal development plans (PDPs), issues arising, concerns and opportunities, along with organisational and national changes that impact on the care of women and babies.

Professional Development

The Nursing and Midwifery Planning Development Unit (NMPDU) supported and funded 32 midwives and nurses with MSc, postgraduate diplomas and professional certificates in wound management and tissue viability and in urodynamics. This support of midwifery and nursing staff in further education and development, ensures a greater understanding of evidence-based practice and critical thinking, which are all vital ingredients for the provision of quality evidence-based care for the women, babies and families in The Coombe Hospital.

The Coombe Hospital’s Midwifery and Nursing Celebration Day

The Coombe Hospital midwifery and nursing celebration day was held on 9th May in the Rita Kelly Conference Centre. There was an attendance of 60 nurses and midwives, HCAs and staff from the medical social work department, the Physiotherapy Department, the Pastoral Care Department and administrative staff throughout the day. There were two guest speakers; Ann Mulhall (former Midwife Manager and Practice Development Coordinator and Director of the CME) who presented on ‘The History of The Coombe’ and Margaret Dunlea, Assistant Professor in Midwifery, TCD who presented on ‘Midwifery from the time of the Famine.’ We had many wonderful presentations from The Coombe Hospital midwives and nurses. Mary McMorrow (CMM2) and Anne O’Sullivan (ANNP) were each presented with a vase and flowers as ‘Outstanding Inspirational Staff’ who truly live by The Coombe Hospital’s values and are a valuable support to their colleagues. Thanks to the chefs and catering staff who supplied a wonderful cake and lunch for all those who attended. Thanks to the EMT and the DMHG for funding the day and the awards.

National Events

Fourteen midwives and the DoMN from The Coombe Hospital attended the National Women and Infants Health Programme (NWIHP) International Day of the Midwife Conference in the Aviva Stadium. The DoMN and seven midwives from The Coombe Hospital attended the DMHG nursing and midwifery inaugural conference on 10th May. The CMM2 in Parent Education presented on the Antenatal Education Component of ‘Birth Dynamics’ at this conference. The CMM2 in Parent Education was invited to attend the South Dublin City ‘Infant Mental Health Wellbeing, first 1,000 days’ celebration and networking event in October 2023.

The CMM2 and CMM3 in Community were invited by the ONMSD to present the Daisy Clinic Initiative at the National Mental Health Study Day in November. The Community Midwifery team have joined a breastfeeding for vulnerable women steering group with PHNs and voluntary groups. The DoMN attended the IDNAM Conference in Sligo on 5th October and participated in a top table discussion on the Professional Development Plans for midwives and nurses.

Internal Events

The Practice Development Team organised an Open Day for Registered Nurses in March and September ‘An Introduction to the HDip in Midwifery.’ In December an information session was given by two members of staff from the Dochas Centre to the multidisciplinary team in the Rita Kelly Conference Centre. The feedback was very positive, and the event was well attended. The theatre CMM3 and team introduced the Safety Pause and Surgical Safety Checklist in Theatre in line with the National Policy and Procedure for Safe Surgery, HSE.

During National Breastfeeding week from 2nd to 7th October 2023, the infant feeding team organised posters and information leaflets in the front hall for women attending The Coombe Hospital along with staff education sessions throughout the week and a quiz. The Parent Education Team organised a celebration for mothers and community breastfeeding support workers in the Wisdom Centre. In November 2023, the NNU Clinical Midwife/Nurse Specialists in lactation support presented at the 2nd International Conference on Midwifery and Neonatal Care in Dubai (see Appendix Two for details of the presentation).

Midwifery and Nursing Graduation and Student Community

The midwifery and nursing graduation took place in The Rita Kelly Conference Centre on 19th October 2023. Thirty-five midwives and two neonatal nurses who completed their PGDip in Neonatal Intensive Care attended with family and friends. Deborah Kehoe and Melissa Ward, Clinical Midwife Managers in the Delivery Suite were presented with the Clinical Lead Educator awards by the midwifery graduates.

Student Council meetings continued throughout 2023. Feedback was positive, students felt supported in all areas and enjoyed their clinical placements. They felt supported by their preceptors, staff midwives, CPCs and CMMs. This was reflected in the 17 BSc interns who took up posts as staff midwives on completion of their studies. This certainly reflects our aim of ‘retaining and growing our own.’ Ten student nurses from Tallaght University Hospital and St James’s Hospital continued with their two-week placements throughout the year. 2023 was our

first year to have UCD College, Public Health Nurse (PHN) student placements in The Coombe Hospital. We received very positive feedback from these students. Thanks to the Practice Development Team and the CMMs and midwives for supporting the students and the programme.

Quality and Improvement

Our Designated Midwifery Officer (DMO) for The Coombe Hospital/HSE Integrated Home Birth Service commenced in October 2023 as the governance was transferred from the HSE to The Coombe Hospital. The DMO facilitated meetings with the DoMN and the Self-Employed Community Midwives (SECMs) as part of a collaboration and communication strategy. The DMO liaised closely with the obstetricians and the Pharmacy Department to ensure that all the SECMs were supported, and standard operating procedures (SOPs) were in place as required. The DMO in the Midland Regional Hospital Portlaoise spent a day with Paula Barry (The Coombe Hospital DMO), looking at pathways and processes.

The Daisy Clinic for international displaced and homeless women commenced in the Wisdom Centre in June, facilitated by the CMM2 community and Medical Social Worker. This clinic facilitates booking visits, organises

follow-up appointments with all members of the multidisciplinary as well as postnatal visits within the catchment area. The Daisy Clinic is closely linked with the multidisciplinary antenatal clinics in The Coombe Hospital. Administrative support is provided to the clinic. Women and midwives have access to translating services. This clinic ensures a safe pathway, continuity of care and carer, and supports for the most vulnerable pregnant women attending The Coombe Hospital. Sincere thanks to the NMPDU for funding and support.

The Emergency Assessment Centre (EAC) which consisted of the amalgamation of the assessment unit (AU) attached to the Delivery Suite and the emergency room (ER) in OPD was opened on the ground floor in September 2023. This ensured one pathway for all unscheduled care for all women. The establishment of the EAC reflects teamwork and collaboration, people at the heart of everything we do, dignity and respect and always striving to be at our best. All the staff at The Coombe Hospital including household, administration, midwifery and nursing, HCAs, consultant obstetricians and NCHDs worked closely to make the EAC a success for the women attending The Coombe Hospital.

Dublin Maternity Hospitals - Combined Clinical Data, 2023

The following tables have been agreed to form the common elements of the Three Dublin Maternity Hospitals Report.

1. Women who attended The Coombe Hospital in pregnancy

≥ 500 grams

* Does not include all spontaneous miscarriages

2. Maternal deaths, n = 1

3. Babies born weighing ≥ 500g

* Excludes three babies weighing < 500 grams

4. Obstetric outcome

* Excludes terminations of pregnancy and outborn babies

■ Antepartum deaths

■ Intrapartum deaths

■ Stillbirths

■ Early neonatal deaths ■ Late neonatal deaths ■ Congenital anomalies

Four stillbirths, seven early neonatal deaths and two late neonatal deaths

Perinatal mortality rates

Per 1,000 total births

■ Overall perinatal mortality rate

■ Perinatal mortality rate corrected for lethal congenital anomalies

■ Perinatal mortality rate including late neonatal deaths

■ Perinatal mortality rate excluding women unbooked

■ Corrected perinatal mortality rate excluding women unbooked

■ Corrected perinatal mortality rate excluding women initially booked elsewhere

8. Parity

7. Age

9.

Country of birth and nationality

10. Birth weight

11. Gestational age

12. Perineal injury after spontaneous vaginal birth (SVB) Perineal

May be recorded in more than one category

13. Third degree tears

Third degree tears

14. Perinatal mortality in normally formed stillborn infants, n = 17

15. Perinatal deaths in infants with congenital anomalies*

*Four stillbirths and seven early neonatal deaths

16. Early and late neonatal deaths ≥ 500g*

*Twenty early neonatal deaths and ten late neonatal deaths

17. Overall perinatal autopsy rate = 57%

18. Hypoxic ischaemic encephalopathy (Grade II and III) inborn infants, n = 5

19. Severe maternal morbidity, n = 36

* Defined as an estimated blood loss ≥ 2.5 litres and/or transfusion with ≥ 5 units of red cell concentrate

† A number followed by a number in brackets indicate that the woman is already included in an organ dysfunction category

In January 2023, The Coombe Hospital became the first hospital in Ireland to be accredited by the European Board College of Obstetrics and Gynaecology for Maternal-Fetal Medicine sub-speciality training

Section 1

Obstetrics and Midwifery

1.1 General Obstetric Medical Report

Professor Michael O’Connell

The number of women who gave birth to babies weighing greater than or equal to 500 grams increased from 6,786 in 2022 to 6,836 in 2023 (Table 1.1.1). In 2023, 6,974 babies weighing greater than or equal to 500 grams were born in The Coombe Hospital compared with 6,914 babies in 2022 (Appendix One). This is a reversal of the decrease in the number of births at The Coombe Hospital between 2021 and 2022. The birth rate nationally continued to decrease in 2023. The number of women with multiple pregnancies who gave birth in The Coombe Hospital decreased between 2017 and 2021 and increased from 129 in 2022 to 137 in 2023 (Table 1.1.1). There have been no quadruplet pregnancies since 2020. Twelve women had triplet pregnancies in 2023 and 2021 compared with three women in 2022.

The rate of hypoxic ischaemic encephalopathy (HIE) (grades II and III) in infants was 0.72 per 1,000 live births in 2023 compared with 1.45 per 1,000 live births in 2022 (Appendix One). A small increase or decrease in absolute numbers can have a disproportionate impact on HIE rates. In 2023, as in 2022, 20% (1/5) of cases of HIE grades II and III were associated with placental abruption.

The overall Perinatal Mortality Rate (PMR) in 2023 was 5.9 per 1,000 total births compared with 5.1 per 1,000 total births in 2022 and 4.0 per 1,000 total births in 2021 (Appendix One). At less than 26+0 weeks’ gestation, there were 15 perinatal deaths in 2023 (Appendix One) compared with five, seven and five perinatal deaths at this gestation in 2022, 2021 and 2020, respectively. Four of the 15 perinatal deaths in 2023 were antepartum

stillbirths (all at less than or equal to 25+0 weeks’ gestation). Five of the 15 perinatal deaths in 2023 were at less than or equal to 23+6 weeks’ gestation (Appendix One) and all were early neonatal deaths (ENNDs).

No perinatal deaths in 2023 were due to COVID-19 placentitis. The corrected PMR in 2023 was 4.2 per 1,000 total births (Appendix One). The corrected PMR excluding women initially booked elsewhere was 4.0 per 1,000 total births (Appendix One). The adjusted PMR of normally formed babies at greater than or equal to 34 weeks’ gestation weighing greater than or equal to 2.5 kg was 1.4 per 1,000 (Appendix One). Similar to the HIE rate, a small increase or decrease in absolute numbers can have a disproportionate impact on this rate (Appendix One).

The PMR for mothers aged 35 - 39 years was 6.3 per 1,000 total births in 2023 (Appendix One). It ranged between 2.7 per 1,000 total births in 2022 and 5.9 per 1,000 total births in 2020 (Appendix One). The PMR for mothers aged greater than or equal to 40 years was 8.6 per 1,000 total births in 2023 (Appendix One). It ranged between 1.5 per 1,000 total births in 2021 and 6.3 per 1,000 total births in 2022 (Appendix One). A small increase or decrease in absolute numbers can have a disproportionate impact on PMR. Of note, the PMRs in these two aged cohorts of women increased in 2023. It will be important to monitor this in the future, to see if this trend continues.

The perinatal autopsy rate at The Coombe Hospital increased following the enactment of the Coroners (Amendment) Act 2019 when the mandatory reporting of any death of a stillborn child or infant death became a legal requirement. The perinatal autopsy rate was 48% in 2019. It peaked at 71% in 2021, decreased to 54% in 2022 and increased to 57% in 2023.

Table

1.1.1

Women who attended The Coombe Hospital in pregnancy, 2017 to 2023

Women who attended The Coombe Hospital

The general demographic characteristics of women who attended The Coombe Hospital between 2017 and 2023 have changed (Table 1.1.2). The percentage of women booking, born in the Republic of Ireland decreased from 70.1% in 2017 to 64.6% in 2023 (Table 1.1.2). The percentage of women booking, born outside the EU or the UK has gradually increased from 13.9% in 2017 to 23.5% in 2023. These changes reflect the evolution of a multicultural society. The percentage of women greater than or equal to 40 years of age at booking has gradually increased from 7.2% in 2017 to 9.2% in 2023, reflecting a societal trend. The percentage of women less than 18 years of age at booking has been stable ranging between 0.3% in 2017 and 0.5% in 2023 (Table 1.1.2).

1.1.2 Women’s profile at booking - general demographic factors, 2017 to 2023

Table

The percentage of women with a healthy body mass index (BMI 18.5 - 24.9 kg/m2) at booking has gradually decreased from 49.3% in 2017 to 42.9% in 2023 (Table 1.1.3). The percentage of women at booking in the categories of overweight, obese class 1 and obese class 2 increased in 2023 compared with 2022. The percentages have all increased compared with 2017. The percentage of women at booking in the obese class 3 category peaked at 2.8% in 2021, decreasing to 2.6% in 2022 and 2.5% in 2023. The increase in the percentage of women in overweight and obese categories impacts service delivery because of the indication to transfer these women from supportive care models to assisted or high-risk models of care. Overweight and obese categories of BMI are associated with an increased incidence of gestational diabetes mellitus (GDM) which in turn is associated with increased rates of induction of labour and Caesarean section. The morbidity associated with these interventions are also increased in these cohorts of women.

The proportion of nulliparous women at booking increased from 39.3% in 2021 to 43.8% in 2022 and to 44.3% in 2023 (Table 1.1.3). This sustained increase reflects confidence in the service provided at The Coombe Hospital. However, it also creates challenges, because in general, the provision of care to nulliparous women require is more intensive than it is to parous women.

The proportion of women who reported being a current smoker at booking has decreased from 9.5% in 2018 to 6.2% in 2023 (Table 1.1.3). This decrease may be associated with an increase in the number of women vaping instead of smoking.

The percentage of women at booking who reported a history of domestic violence remained unchanged (0.9 - 1.0%) between 2017 and 2023 which is not in keeping with the national trend of an increase in domestic violence. This may reflect women’s reluctance to report domestic violence at booking.

CervicalCheck recommends cervical screening from the age of 25 years. The number of women booking who have never had a cervical smear increased from 19.2% in 2017 to 22.9% in 2022 and to 25.0% in 2023 (Table 1.1.3). Since 2017, the percentage of women who gave birth in The Coombe Hospital under the age of 25 years decreased from 10.3% in 2017 to 8.4% in 2023. The booking visit provides an opportunity to educate and encourage this cohort of women to avail of cervical screening.

Almost a quarter of women at booking in 2023 reported a history of mental health conditions (Table 1.1.3). This was almost the same as the reported rate in 2022. The rate has increased from 18.5% in 2017, but it is difficult to determine if this represents a true increase or is due to less stigma associated with reporting a history of mental health conditions.

The percentage of women at booking with two or more previous Caesarean sections decreased from 4.6% in 2022 to 4.3% in 2023 (Table 1.1.3). In contrast, the percentage of women at booking with one Caesarean section increased from 13.4% in 2022 to 14.1% in 2023.

The percentage of nulliparous women who received care in the private system increased from a trough of 12.4% in 2018 and 2020 to a peak of 16.1% in 2023 (Appendix One). In contrast, the percentage of parous women who received care in this system remained stable ranging from 12.8% in 2019 to a peak of 14.2% in 2023 (Appendix One). The percentage of nulliparous women and parous women who attended semi-private clinics has remained stable between 2017 and 2023, ranging between 8.7% and 9.8% and between 6.7% and 7.9%, respectively (Appendix One). The percentage of nulliparous women who received care in the public system between 2017 and 2023 peaked at 78.5% in 2020. This decreased to 74.4% in 2022 and was 74.5% in 2023 (Appendix One). The percentage of parous women who received care in the public system between 2017 and 2023 peaked at 79.6% in 2022 and decreased to 79.1% in 2023 (Appendix One).

Table 1.1.3 Women’s recorded information at booking, 2017 to 2023

Information recorded at booking

The profile of women who gave birth to babies weighing greater than or equal to 500 grams remained relatively unchanged between 2017 and 2023 (Table 1.1.4). No woman developed eclampsia in 2023 or in the preceding six years. No uterine rupture occurred in 2022 and 2023. There was one maternal death (indirect) in 2023. The proportion of women with GDM increased from 10.9% in 2022 to 11.9% in 2023 (Table 1.1.4). The proportion of women who had an antepartum haemorrhage (APH) in 2023 was similar to that in the years prior to 2022 when 9.9% of women had an APH. As the numbers are low, similar to the HIE rate and the PMR, a small increase or decrease in absolute numbers can have a disproportionate impact on the proportion of women with a particular condition, which may explain why the proportion was 9.9% in 2022. The Caesarean section rate increased from 31.8% in 2017, to 36.1% in 2022 to 37.9% in 2023 (Table 1.1.4).

Table 1.1.4 Women’s conditions in index pregnancy (gave birth to babies ≥ 500 grams), 2017 to 2023

The rate of induction of labour decreased from 42.0% in 2022 to 39.9% in 2023 (Table 1.1.5). Compared with 2022, the rate of induction of labour in 2023 decreased by 2.2% in nulliparous women and by 2.9% in parous women (Table 1.1.6). In 2022, there was uncertainty about the impact of the Omicron variant of SARS-CoV-2 on the perinatal mortality rate. However, by 2023 it had been established that the Omicron variant was not associated with an increase in the perinatal mortality rate. This led to a reduction in the rate of induction of labour in 2023. The rate of epidural analgesia in labour decreased slightly

from 40.2% in 2022 to 39.9% in 2023 (Table 1.1.5). Compared with 2022, the rate of epidural analgesia in labour in 2023, decreased by 0.9% in nulliparous women and by 1.4% in parous women which is probably a reflection of the decrease in the rate of induction of labour in 2023 (Table 1.1.6). The rate of prolonged labour ranged between 2.9% in 2018 and 4.0% in 2020 and was 3.6% in 2023 (Table 1.1.5). The rates of prolonged labour in nulliparous (7.3%) women and in parous (0.8%) women were the same in 2022 and 2023 (Table 1.1.6). The rate of fetal blood sampling continued to decline in 2023. It decreased from 8.8% in 2017 to 1.7% in 2023 (Table 1.1.5).

Table 1.1.5 Type of labour, 2017 to 2023

Table 1.1.6 Labour according to parity, 2017 to 2023

The total spontaneous vaginal birth (SVB) rate decreased from 51.6% in 2022 to 50.7% in 2023 (Table 1.1.7). The SVB rate in nulliparous women increased from 38.9% in 2022 to 40.3% in 2023. The SVB rate in parous women decreased from 60.5% in 2022 to 58.9% in 2023 (Table 1.1.7).

The total instrumental (forceps assisted and vacuum assisted) birth rate was 11.6% in 2023 compared with 14.9% in 2017 (Table 1.1.7). The total forceps assisted birth rate decreased from a peak of 5.3% in 2017 to 3.5% in 2020 and 2021 and increased slightly to 3.8% in 2023 (Table 1.1.7). The forceps assisted birth rate in nulliparous women ranged decreased from 11.0% in 2017 to 7.4% in 2020 and 2023 (Table 1.1.7).

The total vacuum assisted birth rate decreased from a peak of 10.2% in 2020 to 7.8% in 2023 (Table 1.1.7). The vacuum assisted birth rate in nulliparous women was 13.7% in 2023 which was lower than the rates in the preceding six years (Table 1.1.7). The vacuum assisted birth rate in parous women ranged between 2.6% in 2019 and 2021 and 4.1% in 2017 and was 3.1% in 2022 and 2023 (Table 1.1.7). Compared with 2022, the Caesarean section rate in 2023 increased by 2.0% in nulliparous and by 1.7% in parous women (Table 1.1.7). In 2023, the total Caesarean section rate increased by 1.8% compared with 2022 (Table 1.1.7).

Table 1.1.7 Mode of delivery according to parity, 2017 to 2023

Table 1.1.8 Episiotomy (total deliveries), 2017 to 2023

The episiotomy rate (total deliveries) in nulliparous women in 2023 was lower than in the preceding six years, decreasing from a peak of 37.7% in 2021 to 30.1% in 2023 (Table 1.1.8). This reduction can be partly explained by the increase in the Caesarean section rate but can mostly be attributed to changes in clinical practice. The episiotomy rate in parous women in 2023 was also lower than the rate in 2022, decreasing by 0.8%. The total episiotomy rate decreased by 5.8% between 2022 and 2023.

Table 1.1.9 Obstetric anal sphincter injuries (all deliveries, including CS) according to parity, 2023

deliveries

Obstetric anal sphincter injuries (OASIS) include third degree and fourth degree perineal tears. The rate of OASIS in all deliveries, according to parity, in 2023 are presented in Table 1.1.9. Table 1.1.10 and Table 1.1.11 present third degree and fourth degree perineal tears from 2017 to 2023, using all deliveries and vaginal deliveries as the denominator, respectively. The rate of OASIS in all deliveries was lower in 2023 (1.1%) than in 2022 (1.2%) and was lower than in the preceding six years (Table 1.1.10). Similarly, the rate of OASIS in vaginal deliveries was lower in 2023 (1.8%) than in 2022 (1.9%) and was lower than in the preceding six years (Table 1.1.11). The decrease in the rate of OASIS reflects the on-going work of the OASIS quality improvement team which recommenced in 2022.

Table 1.1.10 Obstetric anal sphincter injuries (all deliveries, including CS), 2017 to 2023

deliveries

Table 1.1.11 Obstetric anal sphincter injuries (vaginal deliveries only), 2017 to 2023

Table 1.1.12 Shoulder dystocia, 2017 to 2023 Shoulder

The rate of shoulder dystocia continued to decrease in 2023 (Table 1.1.12). It is difficult to draw meaningful conclusions about trends in the number of deliveries complicated by shoulder dystocia when the numbers are small (Table 1.1.13).

Table 1.1.13 Shoulder dystocia according to parity and birthweight, 2017 to 2023

The rate of primary postpartum haemorrhage (10 PPH) increased slightly from 21.7% in 2022 to 21.9% in 2023 (Table 1.1.14). It has ranged between a trough of 21.6% in 2018 and a peak of 22.7% in 2020. In 2023, the rate of 10 PPH increased in nulliparous women and in parous women who went into spontaneous labour and in those whose labour was induced. The rate of 10 PPH in all forceps assisted births increased by 7.7% in 2023 compared with 2022 (Table 1.14.1). The rate also increased by 7.7% in nulliparous women. It increased by 5.8% in parous women. The rate of 10 PPH in all Caesarean sections increased from 42.4% in 2022 to 49.0% in 2023. The increase was higher in parous women (6.9%) than it was in nulliparous women (5.4%). Unsurprisingly, the increase was higher in emergency Caesarean sections (7.2%) than in elective Caesarean sections (5.8%). The rate of 10 PPH in women with a twin pregnancy increased from 46.9% in 2022 to 62.4% in 2023. The increase was higher in parous women (20.6%) than it was in nulliparous women (9.1%). The Caesarean section rate in twin pregnancies was lower in 2023 (67.7%) than it was in 2022 (70.3%) (Table 1.1.18) therefore, the increase in the rate of 10 PPH in twin pregnancies in 2023 was not due to an in increase in the twin pregnancy Caesarean section rate.

Table 1.1.14 Primary postpartum haemorrhage, 2017 to 2023

The rate of manual removal of retained placenta (MROP) ranged between 1.0% in 2017 and 2023 and 1.3% in 2019 (Table 1.1.15). The rate of 10 PPH associated with MROP increased from 64.5% in 2022 to 69.0% in 2023. It ranged between 62.3% in 2017 and 71.4% in 2021.

Table 1.1.15 Manual removal of retained placenta (MROP) and primary PPH, 2017 to 2023

As the number of mothers who receive a transfusion is low each year, it is difficult to draw meaningful conclusions about trends in maternal transfusion rates (Table 1.1.16). A small increase or decrease in absolute numbers can have a disproportionate impact on the rate. In 2023, 58 more mothers received a transfusion than in 2022, yet the rate increased from 2.5% in 2022 to 3.7% in 2023.

Table 1.1.16 Maternal transfusion, 2017 to 2023

* Red cell concentrate

The total Caesarean section rate in women with a singleton breech presentation ranged from 93.2% in 2022 to 95.6% in 2023 (Table 1.1.17). The rate in nulliparous women was 92.9% in 2023, the lowest rate between 2017 and 2023. Prior to 2023, the rate in parous women remained stable ranging between 92.5% in 2018 and 2020 and 93.8% in 2021, however the rate increased to 98.2%in 2023 (Table 1.1.17).

Table 1.1.17 Caesarean section - singleton breech presentation, 2017 to 2023

The total Caesarean section rate in women with a twin pregnancy decreased from 70.3% in 2022 to 67.7% in 2023 (Table 1.1.18). The rate in nulliparous women decreased from 87.3% in 2022 to 72.7% in 2023, which was the lowest rate between 2017 and 2023 with the highest rate (87.8%) occurring in 2021. The rate in parous women increased from 57.5% in 2022 to 64.1% in 2023, the highest rate between 2017 and 2023 with the lowest rate (53.5%) occurring in 2021 (Table 1.1.18). However, a small increase or decrease in absolute numbers can have a disproportionate impact on the Caesarean section rate.

Table 1.1.18 Caesarean section - twin pregnancy, 2017 to 2023

The Robson Ten Group Classification System 2018 to 2023 is presented in Appendix One (Caesarean section rates, size of groups and contribution of each group to the total Caesarean rate). The size of the Robson Ten Groups has changed between 2018 and 2023 (Appendix One). Change in a group’s size affects the contribution a group makes to the total Caesarean section rate.

The Group 1 Caesarean section rate increased slightly from 12.6% in 2022 to 12.8% in 2023 (Appendix One and Table 1.1.19). The size of Group 1 ranged from 11.8% in 2021 to 15.9% in 2018 and was 13.3% in 2023 (Appendix One and Table 1.1.19). The contribution Group 1 made to the total Caesarean section rate ranged from 3.3% in 2021 to 5.7% in 2018 and was 4.5% in 2023 (Appendix One and Table 1.1.19).

The Group 2 Caesarean section rate ranged from 39.5% in 2020 to 44.2% in 2018 and was 44.9% in 2023 (Appendix One and Table 1.1.19). The Group 2a Caesarean section rate was 36.8% in 2018. It decreased to a trough of 30.2% in 2020 and increased to 34.4% in 2023 (Appendix One and Table 1.1.19). The size of Group 2 increased gradually from 20.8% in 2018 to 25.5% in 2023 (Appendix One and Table 1.1.19). During this time, the size of Group 2a increased by 3% while the size of Group 2b increased by 1.6% (Appendix One). Despite the increase in the size of Group 2a the contribution this group made to the total Caesarean section rate in 2023 (19.4%) was lower than in 2018 (20.0%) (Appendix One and Table 1.1.19). Whereas the contribution Group 2b made to the total Caesarean section increased from 7.3% in 2018 to 10.8% in 2023 (Appendix One and Table 1.1.19) which is probably a reflection of increased maternal choice (e.g. nulliparous women requesting delivery by elective Caesarean section at term).

The Group 3 Caesarean section rate decreased from a peak of 2.3% in 2021 and 2022 to 1.2% in 2023 (Appendix One and Table 1.1.19). The size of Group 3 ranged from 16.1% in 2023 to 19.8% in 2023 (Appendix One and Table 1.1.19). The contribution Group 3 made to the total Caesarean section rate ranged from a trough of 0.4% in 2020 to a peak of 1.2% in 2019 and was 0.5% in 2023 (Appendix One and Table 1.1.19).

The Group 4 Caesarean section rate ranged from a trough of 12.0% in 2022 to a peak of 20.8% in 2021 and was 15.7% in 2023 (Appendix One and Table 1.1.19). The Group 4a Caesarean section rate peaked at 5.8% in 2018, fell to a trough of 3.2% in 2022 and was 5.7% in 2023 (Appendix One and Table 1.1.19). The size of Group 4 ranged between 17.7% in 2018 and 20.8% in 2021 and was 18.1% in 2023 (Appendix

One and Table 1.1.9). Unlike Group 2, the size of Group 4 has remained stable since 2018. Therefore, the contribution Groups 4a and 4b made to the total Caesarean section rate has remained stable. The former ranged from 1.7% in 2020 to 2.8% in 2018 and was 2.4% in 2023 while the latter ranged from 4.4% in 2022 to 5.8% in 2021 and was 5.1% in 2023 (Appendix One and Table 1.1.19).

The Group 5 Caesarean section rate increased slightly from 85.2% in 2022 to 85.7% in 2023 (Appendix One and Table 1.1.19). The size of Group 5 ranged from 14.7% in 2018 and 2019 to 16.3% in 2021 (Appendix One). Interestingly, it decreased to 15.3% in 2023 which is probably a reflection of the decrease in number of parous women who gave birth in The Coombe Hospital in 2023 (58.8% of obstetric population in 2023 compared with 60.6% in 2021) (Appendix One). Group 5 was the highest contributor to the total Caesarean section rate between 2018 and 2023. Its contribution peaked at 39.5% in 2021 and decreased to 34.5% in 2023 (Appendix One and Table 1.1.19).

The Group 8 Caesarean section rate increased from a trough of 64.4% in 2020 to a peak of 70.5% in 2022 and was 68.6% in 2023 (Appendix One and Table 1.1.19).

The size of Group 8 ranged from a trough of 1.6% in 2021 to a peak of 2.3% in 2019 and was 2.0% in 2023 (Appendix One and Table 1.1.19). The contribution Group 8 made to the total Caesarean section rate ranged from a trough of 3.0% in 2021 to a peak of 5.0% in 2019 and was 3.6% in 2023 (Appendix One and Table 1.1.19).

The Group 10 Caesarean section rate increased gradually from a trough of 47.1% in 2018 to a peak of 53.6% in 2023 (Appendix One and Table 1.1.19). The size of Group 10 ranged from a trough of 4.2% in 2020 to a peak of 5.1% in both 2022 and 2023 (Appendix One and Table 1.1.19). The increase in the Caesarean section rate and the increase in the size of the group reflect recent changes in neonatal resuscitation practice. The contribution Group 10 made to the total Caesarean section rate ranged from a trough of 6.2% in 2018 to a peak of 7.4% in 2022 and was 7.1% in 2023 (Appendix One and Table 1.1.19).

As expected, the Caesarean section rates in Groups 6 and 7 are high (Appendix One and Table 1.1.19). However, as these groups are small, their contribution to the total Caesarean section rate is low and has remained stable (Appendix One and Table 1.1.19). A Caesarean section rate of 100.0% in Group 9 is a data quality assurance (Appendix One and Table 1.1.19).

Table 1.1.19 Caesarean section - Robson Ten Group Classification, 2023 Groups

(excl.

Singleton, cephalic, < 37 weeks (incl. prev. CS)

The proportion of women with one previous lower segment Caesarean section who underwent a pre-labour Caesarean section increased from 62.9% in 2020 to 76.1% in 2023 (Table 1.1.20). In women with one previous delivery, the rate increased from 69.8% in 2020 to 82.6% in 2023 (Table 1.1.20). In women with two or more previous deliveries, one of which was a lower segment Caesarean section, the pre-labour Caesarean section rate increased from 37.4% in 2020 to 54.5% in 2023 (Table 1.1.20). The overall proportion of women with one previous lower segment Caesarean section who attempted vaginal birth after Caesarean section (VBAC) decreased from 37.0% in 2020 to 23.9% in 2023 (Table 1.1.20). The percentage decrease was higher (16.7%) in women with two or more previous deliveries than it was in women with one previous delivery (12.8%) (Table 1.1.20). However, the percentage of women with one previous delivery who achieved a VBAC increased from 49.4% in 2020 to 63.7% in 2023 (Table 1.1.20). It increased from 76.7% in 2020 to 87.5% in 2023 in women with two or more previous deliveries (Table 1.1.20). These data suggest that in 2023, VBAC was attempted in a more appropriate cohort of women than in 2020.

Table 1.1.20 Mode of delivery with one previous lower segment Caesarean section, 2020 to 2023

The rate of VBAC after one previous lower segment Caesarean section (all women with one previous Caesarean section as the denominator) decreased from a peak of 25.0% in 2017 to a trough of 17.6% in 2021. It increased to 18.7% in 2022 and decreased by 1% in 2023 (Table 1.1.21).

Table 1.1.21 Vaginal birth with one previous lower segment Caesarean section, 2017 to 2023

Neonatal outcome data are presented in Table 1.1.22. The rate of babies with an Apgar score less than 7 at 5 minutes remained stable ranging from 0.8% to 0.9% between 2017 and 2023. The percentage of babies with an arterial cord pH less than 7 also remained stable ranging from 0.4% to 0.6% between 2017 and 2023. The rate of admission to the Neonatal Unit of babies greater than or equal to 38 weeks’ gestation decreased from 5.4% in 2022 to 4.4% in 2023. This decrease was due to a streamlining of services and decreased access to beds due to the renovation work which took place in 2023. The percentage of babies born before arrival of the mother at The Coombe Hospital was 0.2% in 2023, the lowest percentage between 2017 and 2023.

Table 1.1.22 Neonatal outcomes, 2017 to 2023

Data on obstetric surgical procedures in theatre between 2017 and 2023 is presented in Table 1.1.23. In 2023, 3,649 such procedures were performed, the highest number since 2018 when 3,748 procedures were performed.

Table 1.1.23 Obstetric surgical procedures in theatre, 2017 to 2023

* Two peripartum hysterectomies were conducted in St James’s Hospital

† Numbers corrected due to misclassification errors in 2021 and 2022

1.2 Addiction and Infectious Diseases Clinic

Deirdre Carmody, Emma Flynn and Professor Michael O’Connell

Addiction Clinic

In 2023, 38 women attended the multidisciplinary team, including one woman who was transferred to the Multiple Birth Clinic (Table 1.2.1), an increase of eight women compared with 2022. In addition, the Drug Liaison Midwife (DLM) contacted 15 women that reported stopping smoking cannabis early in pregnancy and chose to remain on another obstetrical team. Two women were referred to the DLM in the postnatal period because of a late discloser of drug or alcohol use.

Table 1.2.1

Number of women who attended the Addiction Clinic, 2017 to 2023

Women (n) 5040383638 26 38

Twenty-two (57.9%) of the women who attended had opiate use disorder (OUD) and were already attending an opiate substitute treatment programme. Twenty women were prescribed methadone, and two women were prescribed buprenorphine (subutex). A further 16 women who had non-opiate use disorder reported cocaine, cannabis, alcohol or benzodiazepines as their choice of drug.

Eight (21.1%) women who attended reported taking heroin in pregnancy. One of these women reported intravenous use. Twenty-two (57.8%) women reported taking cocaine in pregnancy, 12 women of whom smoked crack cocaine.

Thirty-six (94.7%) women gave a history of past and/or current mental health issues at the booking visit, including

depression, bipolar, anxiety, panic attacks, schizophrenia and previous suicide attempts. Twenty-one (55.3%) women agreed to be referred to the Specialist Perinatal Mental Health Service in The Coombe Hospital. Eight women were admitted to residential drug stabilisation treatment programmes in the Community Addiction Service.

Seven (18.4%) women delivered preterm (less than 37 weeks’ gestation) including one woman with a twin pregnancy. Nine babies of mothers with OUD were admitted to the Special Care Baby Unit (SCBU). Three of these babies required pharmacological treatment for neonatal abstinence syndrome.

The number of women using cocaine increased from 14 women in 2022 to 22 women in 2023. Nine women reported smoking crack cocaine in 2022 compared with 12 women in 2023. As we are reliant on women self-reporting their drug use, illicit drug use in pregnancy, particularly cocaine, alcohol, cannabis and prescription drug use, may be higher than recorded in this report.

In 2023, 22 (57.9%) women who attended identified as living in homeless accommodation.

Past and/or current mental health issues were reported by 94.7% of women.

The DLM continues to work with the team and the Addiction Service to support women with drug dependency and to help provide a comprehensive care plan to meet the needs of this group of vulnerable women.

Infectious Diseases Clinic

All women booked for antenatal care in The Coombe Hospital are routinely tested for human immunodeficiency virus (HIV), hepatitis B, hepatitis C and syphilis serology. In 2023, over 200 women attended the Infectious Diseases Clinic in The Coombe Hospital. Most of these patients attended for full antenatal and postnatal care within the service. Many other antenatal and gynaecological women also attended for consultations for diagnosis, treatment and followup care of sexually transmitted infections such as chlamydia, gonorrhoea, genital warts, mycoplasma genitalium and herpes simplex. Eighteen women who booked for antenatal care in 2023 tested positive for HIV.

Eight women originated from Africa, four from Ireland, five from Eastern Europe and one from Asia. Of these 18 women, three were counselled and educated about a new diagnosis and commenced on treatment. Two of the newly diagnosed women were also coinfected with syphilis. Seven women were delivered by Caesarean section. All women artificially fed their babies.

Ten women were hepatitis C antibody positive at booking. None of these women tested PCR (polymerase chain reaction) positive on booking. Six of the ten women had been successfully treated for hepatitis C prior to pregnancy. Six women originated from Eastern Europe, three from Ireland and one from Asia. Four women were delivered by Caesarean section, and three women opted to artificially feed their babies.

Seven women were found to be hepatitis B surface antigen positive at booking while a further five women were hepatitis B core antibody positive at booking. One new diagnosis of hepatitis B surface antibody was made in 2023. Of the seven hepatitis B surface antigen positive women, three originated from Eastern Europe, two originated from Asia and two originated from Africa. No delivery by Caesarean section was required for those who gave birth in 2023. One woman opted to artificially feed her baby.

Six women tested positive for syphilis (treponema pallidum) at booking in 2023. Of these women, four had been previously and adequately treated prior to pregnancy. Two women required treatment for latent syphilis. No woman was treated for early syphilis in 2023. Four women originated from Eastern Europe, one from Africa and one from Ireland. Two women were delivered by Caesarean section. Two women opted to artificially feed their babies.

Sixty-six women with a current or history of genital herpes simplex virus (HSV) were also cared for by the Infectious Diseases Clinic. Fifty-three women had either a positive PCR or were antibody positive for HSV-1. Twenty-four women had a positive PCR or were antibody positive for HSV-2. Samples from nine women could not have type specific testing performed.

Seventy-seven women required follow up and/or repeat testing due to indeterminate serology which was attributed to cross-reactivity in pregnancy.

There was no recorded incidence of mother-to-child transmission of an infectious disease in 2023.

The diagnosis and management of an infectious disease in pregnancy challenges the healthcare provider with a myriad of complexities in the provision of antenatal and follow-up care. The Infectious Diseases Clinic is specifically designed to ensure individualised education and care-planning, specialised counselling as well as disclosure and support services. Women are provided with a specific pathway into specialist on-going care, ensuring treatment and monitoring thereby often preventing disease progression, mother to child transmission and significantly reducing future healthcare costs in this highrisk patient cohort.

Specialist services were also provided for additional women with high-risk pregnancies e.g. loss in pregnancy, serodiscordant couples, current sexually transmitted infection and tuberculosis. Couples continued to be seen in the Infectious Diseases Conception Clinic, which provides fertility investigations for both seropositive and serodiscordant couples attempting to optimise conception, while safeguarding the risk of transmission of HIV.

In 2023, the Infectious Diseases midwife continued to provide ongoing education session to all staff members and higher diploma midwifery students.

Louise Kelly, HIV Clinical Nurse Specialist, St James’s Hospital who facilitates the joint clinic in The Coombe Hospital completed her Masters in Advanced Practice in June 2023. Louise continues to provide care to women in the joint clinic.

Publications

See Appendix Two for the details of a peer reviewed publication from the Addiction team in 2023 listed under The Master’s Office Research Report.

1.3 Adult Outpatient Department and Perinatal Centre

Gráinne Sullivan

The adult Outpatient Department (OPD) facilitates public and semi-private antenatal clinics and public gynaecology clinics. The OPD provides supported, assisted and specialised care pathways in maternity care reflecting the principles of the 'National Maternity Strategy - Creating a Better Future Together 2016-2026.' Women are offered choice regarding their preferred pathway in line, with safety, their clinical needs, and best practice.

The Emergency Room (ER) was housed in the adult OPD until September 2023. Until this time, women up to 24 weeks’ gestation and those with postnatal and gynaecology complications attended the ER and women at greater than or equal to 24 weeks’ gestation attended the Assessment Unit (AU).

Table 1.3.1 presents the attendances at OPD clinic appointments and ER from 2019 to 2023. A decline is seen in all subcategories in line with a decrease in overall births at The Coombe Hospital. There was a significant decrease (33.5%), in the number of antenatal booking appointments in OPD. However, this correlated with an increased demand for community-based midwife booking clinics. Multidisciplinary team involvement is at the heart of delivering high quality antenatal care in OPD. To enhance care, additional day care services are provided in collaboration with the Perinatal Centre (PNC) team.

* Including addiction and infectious disease clinic, epilepsy clinic, rhesus, renal, haematology, multiple birth clinic and preterm birth prevention clinic

† Midwives’ antenatal clinics and anti-D prophylaxis clinic as per TRAADP which commenced in 2021

‡ The Emergency Assessment Centre opened on 20th September 2023

Table 1.3.1 Attendances at clinics in the adult OPD (excluding gynaecology clinics), 2019 to 2023

On 20th September 2023, the ER and AU amalgamated with the opening of the Emergency Assessment Centre (EAC). The successful relocation of these two departments to a purpose-built centre on the ground floor allows emergency care to be provided at one location in The Coombe Hospital. Triage and assessment of all acute unscheduled pregnancy, postnatal and gynaecology presentations occur in the EAC. The existing ER room began refurbishment in late 2023 for the development of a urodynamics suite in anticipation of providing a five-day service in 2024. For details about the numbers and categories of attendances at the EAC between 20th September and 31st December 2023 see subsection 1.7. 2023 saw Dr Alison DeMaio join the Advanced Endometriosis team with Alison Bowes, Endometriosis CMS. Dr Chris Morris’ Gynaecology Clinic with Dr Niamh Murphy’s Adolescent Gynaecology Clinic commenced in 2023.

In September 2023, Grainne Sullivan was appointed CMM3 of the adult Outpatient Department, the Perinatal Centre and the EAC. I would like to take this opportunity to wish

our previous CMM3 Mary McDonald every success in her retirement and to thank her and her fellow retiree Mary O’Toole for their continued support to the EAC by providing phone triage in the EAC.

In 2023, there were 7,955 attendances at the Perinatal Centre (PNC) (Table 1.3.2) In May 2023 the PNC relocated from the third floor to what was previously the COVID-19 assessment unit. In 2023, there were 3,291 attendances at this new location.

Glucose tolerance tests (GTTs) and fasting and post-prandial (FPP) testing continued to be provided on the third floor. Table 1.3.3 presents attendances for GTTs and FPP testing from 2019 to 2023. In September 2023, Rosemary Corcoran was appointed CMM1 of the PNC. With extended opening hours, the PNC is paving the way to compliment the EAC in the provision of in tandem scheduled and unscheduled care.

Table 1.3.2 Attendances at the Perinatal Centre, 2022 and 2023 Indication for attendance (n)

* Different data collection formats were used in 2022 and 2023. Other include GP referrals, referrals from the adult Outpatient Department, COVID-19 and influenza swabs.

Table 1.3.3 Attendances at the Perinatal Centre for GTTs or FPP testing, 2019 to 2023

1.4 Community Midwifery Service

Kate Johnson

In 2023, the Community Midwifery Service facilitated community antenatal booking and follow-up clinics, the Early Transfer Home (ETH) service and the DOMINO service.

Kildare midwifery services continued in the Newbridge Health Centre and Celbridge Health Centre. The Coombe Midlands antenatal clinic opened in December 2023 in the Vista Primary Care Campus in Naas. This clinic offers a weekly consultant antenatal clinic and plans to commence maternity scanning services in 2024.

In 2023, 266 women gave birth under the DOMINO service. The spontaneous vaginal birth rate, the instrumental birth

rate and the Caesarean section rate were 71%, 15% and 13.5% respectively. The Caesarean section rate for women in Robson Group 1 in the DOMINO service was 4.4% compared with an overall rate of 12.8%.

The community activity increased in 2023 compared to 2022. Community booking appointments increased by 12%, contributing to 33% of the overall bookings in The Coombe Hospital. The number of community followup antenatal appointments increased by 58%, contributing to 16% of all the follow-up antenatal appointments in The Coombe Hospital.

Two of the community midwives qualified as International Board Certified Lactation Consultants in 2023 which contributes to our team’s commitment to support mothers and families in the early days of breastfeeding.

The community midwifery service continued to promote, advertise and seek funding opportunities to expand our community-based services and improve awareness and improve awareness and uptake of the DOMINO service.

In 2023 a new community clinic, the Daisy Clinic, was established to provide antenatal and postnatal care to pregnant homeless women, women who are at risk of homelessness, women living in emergency accommodation and women living in direct provision. This is a joint midwifery and medical social worker clinic based in the Wisdom Centre, a short walk from The Coombe Hospital. The service has a dedicated Clinical Midwife Manager 2 and a social inclusion medical social worker. Continuity of midwifery antenatal care, postnatal home visits in the ETH areas and medical social worker support are provided. The Daisy Clinic commenced on the 21st June 2023. Between June and December, 51 women were referred to the Daisy Clinic. Nine emergency booking appointments and follow-up antenatal appointments were provided. Forty postnatal follow-up appointments were provided, and these varied between home visits, postnatal ward visits and phone calls.

1.5 Delivery Suite

Elizabeth Johnson

The tables referred to in this report are in the General Obstetric Medical Report.

In 2023, there was a small increase in the total number of women giving birth in The Coombe Hospital, as compared to 2022, with 6,836 women giving birth to 6,974 babies weighing greater than or equal to 500 grams (Table 1.1.1). This was on a background of midwifery staffing challenges, which was experienced nationally.

The induction of labour rate decreased from 42.0% in 2022 to 39.9% in 2023 (Table 1.1.5). The rate decreased for nulliparous women from 51.9% in 2022 to 49.7% in 2023 and for parous women from 35.0% in 2022 to 32.1% in 2023 (Table 1.1.6). This was the first reduction in rates observed following the gradual increase in rates since 2017 (Tables 1.1.5 and 1.1.6).

The total spontaneous vaginal birth (SVB) rate in 2023 was 50.7%, a slight decrease from 51.6% in 2022 (Table 1.1.7).

The SVB rate in nulliparous women was 40.3% in 2023, the highest rate between 2017 and 2023 (Table 1.1.7). In contrast, the SVB rate in parous women was 58.9%, the lowest rate between 2017 and 2023 (Table 1.1.7). The total instrumental birth rate in 2023 was 11.6% compared with 12.5% in 2022 and 14.9% in 2017 (Table 1.1.7). The total forceps assisted birth rate, and the total vacuum assisted birth rate have been relatively stable since 2021, ranging between 3.5% and 3.8% and between 7.8% and 8.8%, respectively (Table 1.1.7).

In 2023, the rate of obstetric anal sphincter injuries (OASIS) in vaginal births was 1.8% (Table 1.1.11). The OASIS rate has continued to decrease from 2.2% in 2021 and 1.9% in 2022 (Table 1.1.11), reflecting the continued work of the OASIS quality improvement team which recommenced in 2022.

Following the reintroduction in 2022 of water immersion for labour and delivery at The Coombe Hospital, 47.4% of women who availed of the birthing pool in 2023 proceeded to experience an underwater birth.

The total Caesarean section rate in 2023 was 37.9%, compared with 36.1% in 2022 and 35.5% in 2021 (Table 1.1.7).

The Robson Group 1 Caesarean rate increased slightly to 12.8% in 2023 (Appendix One and Table 1.1.19). The increase in this rate from 9.8% in 2021 to 12.6% in 2022 was attributed to the significant challenge associated with the provision of one-to-one midwifery care in the context of staff shortages, which remained a challenge in 2023 (Appendix One). The Robson Group 1 Caesarean rate continued to be monitored weekly to identify any concerns and to enable ongoing learning from practice. The size of Robson Group 2 continued to increase and was 25.5% in 2023 compared with 20.8% in 2018 (Appendix One and Table 1.1.19).

The Robson Group 2 Caesarean rate was 44.9% in 2023, an increase of 4.3% from the rate in 2022 (Appendix One and Table 1.1.19). The Robson Group 4 Caesarean rate increased from 12.0% in 2022 to 15.7% in 2023, however it remained below the rate of 20.8% in 2021 (Appendix One and Table 1.1.19). The size of Group 5 decreased from 16.1% in 2022 to 15.3% in 2023 (Appendix One and Table 1.1.19). The Robson Group 5 Caesarean rate ranged from 81.6% in 2018 to 86.2% in 2021 with a rate of 85.6% in 2023 (Appendix One and Table 1.1.19). The overall rate of pre-labour Caesarean section in Robson Group 5 in 2023 was 76.1% compared with 62.9% in 2020, 68.4% in 2021 and 65.6% in 2022 (Table 1.1.20). In 2023, the overall rate of pre-labour Caesarean section in women

with one previous lower segment Caesarean section was 82.6% compared with 69.8% in 2020 (Table 1.1.20). Overall, vaginal birth after Caesarean section (VBAC) was achieved in 74.1% of women with one previous lower uterine segment Caesarean section who attempted a VBAC in 2023 compared with 57.3% in 2020, 55.7% in 2021 and 54.4% in 2022 (Table 1.1.20). In 2023, VBAC was achieved in 63.7% of women with one previous delivery and in 87.5% of women with two or more previous deliveries, the highest rates between 2020 and 2023 (Table 1.1.20). While the number of women who attempted VBAC in 2023 declined, reassuringly the percentage of women who achieved a VBAC increased. Detailed analysis of the Robson Ten Group Classification is presented in the General Obstetric Medical Report.

During 2023, 127 women who delivered in The Coombe Hospital required higher level care (Table 1.19.2). These women received multidisciplinary high dependency care within the Delivery Suite. In 2021, 161 women received this level of care compared with 119 women in 2022.

During 2023, the Quiet Room within the Delivery Suite was refurbished. This dedicated space facilitates the presence of additional family members to support bereaved parents, allowing them to wait in a non-clinical environment when not with the bereaved parents. Staff are also able to utilise the Quiet Room for reflection and debrief, away from the busy clinical environment.

Within the challenges of midwifery staffing, the dedication and commitment of the staff of the Delivery Suite was fundamental in maintaining the high standard of care provided to women and their families in 2023.

1.6 Early Pregnancy Assessment Unit

There was a total of 4,101 attendances at the Early Pregnancy Assessment Unit (EPAU) in 2023 (Table 1.6.1). Attendances included women who had more than one visit to the EPAU. Diagnoses made at EPAU attendances in 2023 are presented in Table 1.6.2.

Table 1.6.1 EPAU attendances, 2020 to 2023

Dr Mary Anglim

Table 1.6.2 Diagnoses made at EPAU attendances, 2023

* Excludes women who were admitted directly to theatre from the Emergency Room or the Emergency Assessment Centre or women who were diagnosed outside of normal working hours.

Table 1.6.3 Management of women with delayed or incomplete miscarriage, 2020 to 2023

In 2023, 674 women had a delayed or incomplete miscarriage (Table 1.6.3). Surgical management was the most frequent type of management in 2022 and 2023. Medical management was the most common in 2020 (49.9%) and 2021 (36.6%) in 2021. This may have been due to women’s reluctance to attend for a procedure during the COVID-19 pandemic.

In 2023, 54.7% of women with an ectopic pregnancy who attended the EPAU were managed surgically compared with 43.8% in 2022 and 22.5% in 2021 (Table 1.6.4). Conservative management decreased from 61.2% in 2021 to 34.9% in 2023.

Table 1.6.4 Management of women with ectopic pregnancy, 2021 to 2023

Staff in the EPAU provided training to NCHDs, GPs and to midwife sonographers for the UCD Early Pregnancy Module.

Publications

See Appendix Two for a list of peer reviewed publications from the EPAU team in 2023.

1.7 Emergency Assessment Centre

Nóirín Farrelly

The Emergency Assessment Centre (EAC) was officially opened on 20th September 2023. The EAC is a single-entry point for all unscheduled and/or emergency presentations to The Coombe Hospital. The EAC is an amalgamation of the Emergency Room (ER), which was previously based in the adult Outpatient Department, and the Assessment Unit (AU). Staff from both the ER and the AU expressed interest

Table 1.7.1

in working in the new EAC and this was the beginning of a successful alignment of services. The recruitment of a clinical skills facilitator (CSF) and an advanced midwife practitioner (AMP) ensured the level of upskilling of staff required was achieved prior to the opening of the EAC. The service was enhanced by having a senior decision maker (registrar in attendance from 8am to 8pm Monday to Friday) and dedicated consultant sessions.

There was a total of 4,584 attendances at the EAC between the 20th and 31st December 2023, 71.2% of which occurred between 7.30am and 7.59pm (Table 1.7.1). Women at greater than or equal to 24 weeks’ gestation were the commonest (46.8%) category seen followed by women at less than 24 weeks’ gestation (36.2%).

Attendances at the Emergency Assessment Centre, by time and category

* Attendances from 20th September 2023

Standard operating procedures and relevant clinical guidelines were completed prior to the opening of the EAC. The EAC has dedicated medical cover for 12 hours each day with an additional 12 hours of on-call medical cover thus ensuring efficient processing of patient care and services. An improved triage system was introduced for all women attending the EAC. An ultrasound service is available within the EAC. At the initiation of the CSF and the AMP, weekly multidisciplinary skills and drills are held. Student midwives are facilitated to spend time in the EAC as part of their clinical placements.

Many thanks to all the staff involved in the development of the EAC, including Planning Committee members, Dr Jennifer Hogan (Group chair), Dr Niamh Murphy, Dr Eimear McSherry, Dr Amaliya Morgan-Brown, Mary McDonald CMM3 Adult Outpatient Department and Liz Johnson, CMM3 Delivery Suite.

1.8 Epilepsy Clinic

Dr Jennifer Hogan

The obstetric epilepsy service, which was established in 2022, is a multidisciplinary service. The service has an obstetric outpatient clinic weekly with an alongside Advanced Nurse Practitioner (ANP) epilepsy clinic twice monthly. Women are reviewed antenatally, postnatally

and prior to conception in person at the clinic. There were 354 attendances at the clinic in 2023. The type and number of outpatient attendances are presented in Table 1.8.1. In addition, virtual review occurs between clinic visits to facilitate anti-seizure medication (ASM) adjustments. Prior to the service commencing, a baseline audit took place assessing compliance with the national standards from the epilepsy in pregnancy guideline. We are looking forward to reauditing the service with the specialist clinic in operation.

Table 1.8.1 Type and number of outpatient attendances, 2023

In 2023, 32 women with epilepsy attended the service. Details about the type of epilepsy are presented in Table 1.8.2.

Table 1.8.2 Epilepsy diagnosis, 2023

Of the 32 women with epilepsy who attended the service, four (12.5%) women did not require ASM, 22 (68.8%) women were treated with one ASM and the remaining six (18.7%) women were treated with two ASMs. Demographic and obstetric data are presented in Table 1.8.3.

Table 1.8.3 Demographic and obstetric data, 2023

1.9 Fetal Cardiology National (All-Ireland) Service

Dr Caoimhe Lynch

The Fetal Cardiology Service continued to be provided by Professor Orla Franklin, Consultant Fetal and Paediatic Cardiologist, Dr Caoimhe Lynch, Consultant Obstetrician and Fetal Medicine Specialist and Felicity Doddy, CMM2 Prenatal Diagnosis Coordinator.

The Department of Fetal Cardiology continued to provide rapid access and expert opinion to women whose

Table 1.9.1 Congenital heart disease, 2023

pregnancy was complicated by congenital heart disease. In total, 126 women attended the clinic. Structural cardiac anomalies were detected in 78 cases and an abnormality of cardiac rhythm detected in a further 10 pregnancies (Table 1.9.1). Fourteen structural cardiac anomalies were associated with a chromosomal abnormality that was confirmed antenatally. The service continued to attract referrals from 11 sites across Ireland including the cross-border referral group from Northern Ireland. Fifty-three cardiac anomalies were detected in women who were originally booked to deliver outside The Coombe Hospital. The team co-ordinated combined antenatal care with their local hospital with planed delivery at The Coombe Hospital. Site of delivery was dictated by the likely need for urgent cardiac surgical or catheter intervention in the immediate postnatal visit.

Coarctation of the aorta/arch hypoplasia/interrupted aortic arch2

The Fetal Cardiology Clinic is a diagnostic clinic that serves to define a diagnosis of congenital heart disease that has typically originally been made in one of our many referring units. As such we would like to acknowledge the contribution of the fetal medicine specialists and obstetric sonographers from all over Ireland who contribute to the ongoing success of this department.

In 2023, Christina Mc Loughlin was appointed Fetal Cardiac Advanced Midwife Practitioner, developing the fetal echo screening service and the interval fetal cardiac monitoring, growth and wellbeing service in the setting of a known congenital cardiac anomaly.

1.10 Fetal Medicine and Perinatal Ultrasound

Dr Carmen Regan and Dr Caoimhe Lynch

A total of 27,283 ultrasound examinations were performed in 2023 (Table 1.10.1).

Table 1.10.1 Ultrasound scans, 2020 to 2023

* Number underreported in 2022 as ultrasounds on evenings lists were excluded

Table 1.10.2 Indications for ultrasound scans in 2023

wellbeing

(third trimester and follow up scans)

(performed in The Coombe Hospital)

Table 1.10.3 Invasive procedures, 2020 to 2023

Table 1.10.4 Chromosomal anomalies detected, 2020 to 2023

Table 1.10.5 Diagnosis of chromosomal anomalies in 2023

Chromosomal anomaly (n)

Trisomy 21 (15)

Trisomy 18 (7)

Trisomy 13 (2)

* Non-invasive prenatal testing

Indication for invasive testing (n)

High risk NIPT* (6)

Cystic hygroma (3)

Structural abnormality (2)

Increased nuchal fold (1)

Cardiac abnormality (3)

High risk NIPT (2)

Cystic hygroma (2)

Structural abnormality (3)

High risk NIPT (1)

Structural abnormality/maternal balanced translocation (1)

Table 1.10.6 Structural fetal anomalies detected antenatally in 2023

Category of fetal anomaly (n)

Neural tube defects (10)

Cystic hygroma

Facial (6)

Cardiac (88)

Thorax (9)

Abdominal wall defects (6)

Renal (35)

Skeletal (7)

Neurological

Total (n)

Type of fetal anomaly (n)

Spina bifida (3)

Anencephaly (6)

Exencephaly (1)

23

Facial cleft (6)

Structural cardiac abnormality (78)

Cardiac arrythmia (10)

Diaphragmatic hernia (8)

Cystic lung lesion (1)

Gastroschisis (3)

Exomphalos (3)

Renal tract abnormality (32)

Renal agenesis (3)

Skeletal dysplasia (2)

Isolated talipes (5)

28

212

Service provision in 2023

• Dating scan to all women booked in The Coombe Hospital in line with the international standard of care.

• Anatomy scan at 20 - 22 weeks’ gestation all women in line with the international standard of care.

• Third trimester fetal assessment scans for growth and placental localisation in line with national guidelines.

• Clinical Midwife Specialist-led high-risk list: when concerns about fetal growth are identified women are triaged to this list for continuity, expertise and close liaison with the Fetal Medicine team.

• New screening echocardiography service delivered by the Fetal Cardiac, Advanced Midwife Practitioner (AMP).

• Dedicated fetal echocardiography service.

• Dedicated Rhesus Clinic.

• Dedicated twin ultrasound service.

• Dedicated screening for preterm birth service.

• Newly established Fetal Surgical Clinic.

• Access to NIPT service based in The Coombe Hospital and follow up with Fetal Medicine team as indicated.

• Ready access to a ‘Walk in’ ultrasound referral service for obstetric clinical concerns.

• Timely access to specialist fetal medicine expertise daily and within timeframe set out by the national guidelines.

• Weekly multidisciplinary team meetings for complex fetal conditions/extreme prematurity life limiting conditions requesting termination of pregnancy under Section 11 of the Health (Regulation of Termination of Pregnancy) Act 2018.

• Provision of a weekly Naas ultrasound service at The Coombe Hospital.

Fetal Medicine Service

The Fetal Medicine Service has six Fetal Medicine Specialists who support the midwife sonographers and provide comprehensive care to patients with identified fetal abnormalities or concerns as detailed above. Ready access to non-invasive prenatal testing (NIPT),

non-invasive prenatal diagnosis (NIPD) and prenatal diagnosis is available and provided. NIPT is not yet funded for patients but may be in the future.

Regular departmental meetings are held to coordinate activities and assist with resource planning and development.

Weekly perinatal meetings are convened with obstetrics, neonatology, pathology, bereavement and palliative care to discuss the management of ongoing cases of neonatal concern.

Felicity Doddy and Heather McLoughlin are the Prenatal Diagnosis Coordinators. They provide an excellent support service to patients carrying babies with complex fetal abnormalities. As part of a tertiary referral service, they provide support and coordinated shared care with other maternity units nationally for infants who require planned delivery in Dublin. Following delivery, they coordinate transfer to paediatric surgical centres or specialised neonatal care units. We have a multidisciplinary network of neonatology, paediatric subspecialties in Children’s Health Ireland (CHI), clinic genetics, radiology, medical social work and bereavement support to provide comprehensive care to women and their families following a prenatal diagnosis of a fetal abnormality.

Twenty-six families received a diagnosis of a fatal fetal abnormality/life limiting condition in 2023. Two had inutero fetal demise, two received perinatal palliative care and 22 had a termination of pregnancy.

Christina McLoughlin was the first Fetal Cardiac, AMP in Ireland registered with the Nursing and Midwifery Board of Ireland (NMBI). Christina registered in October 2023 following one year as a candidate Fetal Cardiac, AMP. Christina who trained at The Coombe Hospital and following completion of her Masters in Ultrasound worked as a clinical midwife specialist in the Ultrasound Department before commencing her post as candidate Fetal Cardiac, AMP in October 2022. As AMP she provides an expanding screening echocardiography service and follows any babies with antenatal cardiac anomalies from diagnosis to the postnatal period. The Fetal Cardiac, AMP is involved in teaching current midwife sonographers. It is hoped that this teaching role will be expanded to referral centres nationally in the future.

Linda Heuston, CMM1, completed her Masters in Ultrasound in 2023 and Emma Thompson, CMM1, commenced her Masters in Ultrasound in September 2023. There is continued support for ultrasound training and career progression of midwife sonographers. Trainee midwife sonographers have access to the Graduate Certificate in Ultrasound.

In 2023, quarterly educational meetings commenced within the department with educational pieces on fetal cardiology, placenta accrete spectrum and new guideline recommendations.

The Coombe Hospital’s ‘Fetal Anatomy Ultrasound’ guideline was revised following the development of the new National Clinical Practice Guideline by the National Women and Infants Health Programme. All guidelines are evidence based and are available for viewing on The Coombe Hospital Q pulse system.

In 2023, a Fetal Surgical referral clinic was established at The Coombe Hospital. This consultant-led clinic was set up to offer multidisciplinary assessment, counselling and discussion of surgical and post-operative care for select fetal anomalies. Fetal anomalies referred include congenital diaphragmatic hernia, abdominal wall defects, suspected tracheoesophageal fistula/oesophageal atresia, intra-abdominal cysts, choledochal cysts. The clinic receives referrals nationally and offers a shared care or transfer of care service. We aim to prepare prospective parents for delivery, the stabilisation required in the postnatal period, possible admission to Neonatal Intensive Care Unit, transfer to Children’s Health Ireland (CHI) and the Paediatric Intensive Care Unit, neonatal surgery and the neonatal recovery period and beyond. Our proximity to CHI is advantageous for the timely transfer of fetal surgical cases. The clinic is run by Professor Mairead Kennelly (Fetal Medicine Specialist), Mr Brian Sweeney (Consultant Paediatric Surgeon, CHI), Dr John Kelleher (Consultant Neonatologist) and Felicity Doddy (Prenatal Diagnosis Coordinator). The Fetal Surgical Clinic offers ongoing care of fetal surgical cases originally diagnosed in our referring units and we thank our colleagues for their collaboration to achieve optimal outcomes for their patients.

The Coombe Hospital is to become one of three tertiary sites to deliver the National Perinatal Genomics Service, to be branded as the National Perinatal Genomics Service at The Coombe Hospital. This will be resourced with

Clinical Genetics sessions, a full-time genetic counsellor and administrative support.

In 2023, The Coombe Hospital received accreditation for a European Board and College of Obstetrics and Gynaecology (EBCOG) Fellowship in Maternal Fetal Medicine. Dr Sarah McDonnell was successfully recruited to this post and will commence her Fellowship in July 2024.

Acknowledgements

Activity within the Ultrasound Department remains high year on year. Access to ultrasound and fetal medicine specialist expertise is paramount to improving care for our patients and we continue to endeavour to maintain a high standard of care. The figures however do not reflect the increasing demand on the service in terms of provision of high-level care, accurate diagnosis and intervention. The national anatomy guideline includes new elements which increase the workload further. New mandated images increase the duration of each scan. Ready access to a Fetal Medicine Service is emphasised. Informed consent prior to the procedure should be documented. These requirements further stretch resources. Despite these challenges the service is maintained to a high level. This is a testament to our dedicated team of hardworking midwife sonographers, administrative support staff, fetal medicine midwives and specialists. Specifically, I would like to acknowledge Louise Rafferty, CNM3, Ultrasound Department. Louise has continued to successfully lead her team of midwife sonographers in the maintenance of a high-quality service, despite significant staffing challenges. I am indebted to Bridget Boyd, for her calm wisdom and support throughout my tenure as ultrasound lead and welcome Elaine McGeady in her new role as ADoM with responsibility for the Ultrasound Department. I would also like to acknowledge the significant work and contribution of Felicity Doddy CMM2, our Prenatal Diagnosis Coordinator to the effective operation of the Fetal Medicine Service.

Jane Durkan, one of our most experienced and dedicated CMS departed from our service in August 2023 to move to a new role as Clinical Applications Specialist with MDI Medical. Jane was the longest serving CMS in the department and I wish her every success in the future; she will bring a wealth of experience and energy to her new role. Mathilde Ralli, CMM1 also left the department in September 2023. Mathilde will continue with ultrasound

practice in Paris. I wish to thank Mathilde for her work in the Department and to wish her the best in her new endeavour.

Finally, I would like to thank my predecessor Dr Caoimhe Lynch, my colleagues Professor Mairéad Kennelly, Professor Aisling Martin, Dr Neil O’Gorman and Professor Amy O’Higgins for their dedication to and support for the work of the department in 2023.

1.11 Haemolytic Disease of Fetus and Newborn

Dr Carmen Regan

The management of patients with red cell antibodies (RCA) that may result in haemolytic disease in the fetus and newborn (HDFN) involves paternal genotyping and fetal DNA typing, as indicated. The presence of RCA is established at the time of the booking visit when a blood group and antibody screen is performed. In addition, Rhesus negative women have a repeat blood group and antibody screen prior to routine anti-D prophylaxis at 28 weeks’ gestation. Women who already have or develop RCA in pregnancy are referred to the Rhesus Clinic. A clinical algorithm, based on prior history, antibody type and level, is used to risk assess prior to referral to the Rhesus Clinic. At-risk pregnancies are followed with antibody levels and middle cerebral artery (MCA) Doppler ultrasound when appropriate.

In 2023, using the isoimmunisation guideline, many women with low-risk antibodies were monitored using serial antibody levels in their team clinics and reviewed at the Rhesus Clinic if levels reached the threshold for risk of developing significant fetal anaemia. Previously all affected and at-risk mothers were managed in the Rhesus Clinic.

Forty-two women were referred to the Rhesus Clinic in 2023. The referral numbers ranged between 38 in 2022 and 49 in 2021 (Table 1.11.1). Of these, 38 were diagnosed with RCA for the first time. Two women were diagnosed with multiple red cell antibodies, in both cases the babies were direct Coombs test (DCT) positive (Table 1.11.2). In total, 14 neonates were DCT positive at birth, 12 of whom required admission to the special care baby unit (SCBU) for treatment. No cases required intrauterine transfusion or exchange transfusion postnatally. Seven infants received intravenous immunoglobulin (IVIG) and three infants received red cell transfusions. Four mothers were delivered between 32 and 37 weeks’ gestation due to abnormal MCA Doppler measurements suggestive of significant fetal anaemia. All four neonates were confirmed to be DCT positive, had moderate to severe anaemia (range 7.9 - 10.5 g/dl) and required treatment with phototherapy and IVIG. (Table 1.11.3).

Table 1.11.1 Red cell antibodies, 2020 to 2023

Table 1.11.2 Red cell antibodies and direct Coombs test (DCT), (n = 42), 2023

1.12 Infant Feeding

Kathy Cleere

The Coombe Hospital promotes and supports evidencebased practice in infant feeding in line with HSE/National Infant Feeding Policy, HSE Policy on the Marketing of Breast Milk Substitutes and Breastfeeding Policy for Staff working in the public health service.

Table 1.11.3 Neonatal outcomes, 2020 to 2023

Breastfeeding support and care are provided throughout the antenatal, intrapartum, postnatal and post-discharge periods. The team run weekly breastfeeding classes online, followed up with individual consultations for mothers who are at high-risk of lactation challenges. The demand for antenatal colostrum harvesting packs has increased significantly, partly due to a growing awareness of the benefits of early colostrum to the newborn and an increasing commercial industry selling harvesting colostrum packs, where there is maternal separation, or the newborn is unable to breastfeed. Harvesting colostrum prior to birth helps to reduce early formula supplementation, particularly among mothers with diabetes mellitus, and to prevent admission to NICU. We have worked closely with the Diabetic Service team to ensure timely smooth referral to our team.

The team conducted the first Baby Friendly National Audit of all maternity hospitals in Ireland. This involved the assessment of national infant feeding standards via interviews with service users and staff in The Coombe Hospital and an audit of all infant feeding services provided. Upon completion of the audit, we developed an action plan to improve our existing services. Our thanks to Sheena Bolger, who conducted most of the staff interviews and the breastfeeding support team who completed the service user interviews. This audit will be carried out annually.

2023 was a year of significant staff changes. In February, Mary Toole retired after over 30 years working in The Coombe Hospital, 19 years of which were in infant feeding support. Her knowledge and skills were invaluable to the mothers she assisted, and the staff she taught. In September, Meena Purusharatham left to take up the role of Assistant National Breastfeeding

Coordinator for the HSE after 10 years in The Coombe Hospital. I would like to take this opportunity to thank them both for their service in supporting breastfeeding in The Coombe Hospital.

National Breastfeeding week in October started with an invite from Sabina Higgins to Áras an Uachtaráin to celebrate with other breastfeeding champions and support workers. It was an honour to be invited and to see Mrs Higgins’ passion for breastfeeding. She took great delight in introducing her latest grandchild to us.

During this week we had high visibility throughout the hospital with a stand in the front hall to provide parents with breastfeeding information, balloons, cakes for staff and new mothers, a staff quiz and a coffee morning in the Wisdom Centre with some of our community colleagues and new mothers and their babies.

The team continued to provide weekly breastfeeding classes online due to the large numbers involved. Individual consultations for inpatients and outpatients, were provided both antenatally and in the postnatal clinic.

In collaboration with the CME and the Dublin Midlands Hospital Group (Midland Regional Hospital Portlaoise and Midland Regional Hospital Mullingar) two staff

Table 1.12.1 Infant feeding statistics*, 2017 to 2023

breastfeeding education programmes were delivered in 2023 using a hybrid approach. These programmes included a breastfeeding refresher programme and a breastfeeding programme for staff working in NICU, theatre and gynaecology. These programmes were followed by a practical skills session to enhance learning. It is anticipated that a new HSE breastfeeding education programme for midwives and public health nurses will be launched in 2024.

The team continue to review, assess and support babies with ankyloglossia within The Coombe Hospital, in collaboration with Department of Paediatrics and Newborn Medicine. The team continued to offer follow-up consultations after frenotomy.

The number of mothers wishing to combine feed increased in 2023 as many parents see this as a way for the partner to bond with their baby. However, the figure for exclusive breastfeeding on discharge, where breastfeeding was initiated, decreased from 29.1% in 2022 to 28.0% in 2023. In 2023, 62% of mothers were breastfeeding either exclusively or non-exclusively at the time of discharge compared with 61.0% in 2022 (Table 1.12.1).

* Based on data available on K2

1.13 Medical Clinic

Dr Carmen Regan

The need for a multidisciplinary team-based approach to the care of women with medical disorders in pregnancy was recognised by the management of The Coombe Hospital over two decades ago. The Medical Clinic at The Coombe Hospital has a multidisciplinary team approach and is dedicated to the management of women with medical disorders in pregnancy. As the identification of women with pre-existing medical disorders is key to improving pregnancy outcomes, the clinic has developed a set of referral criteria at booking. The clinic also facilitates and encourages referral of high-risk pregnant women from other hospitals through communication with the Medical Clinic Advanced Midwife Practitioner (AMP). The clinic is the national referral centre for patients with coagulation or bleeding disorders (through the NCC, National Centre for Coagulation, St James’s Hospital) and for patients with sickle cell disease (through the Adult Haemoglobinopathy Service at St James’s Hospital). The cardiology service at St James’s Hospital provides direct echocardiography referrals, when indicated.

Multidisciplinary team involvement is at the heart of management of women with complex medical conditions. This multidisciplinary team care is delivered in conjunction with designated and dedicated specialists in thrombosis and bleeding disorders (Dr Kevin Ryan), renal medicine (Dr Catherine Wall), sickle cell disease (Dr Emma Tuohy), cardiology (Dr John Cosgrove) and the departments of perioperative medicine, pharmacology and neonatology.

Dr Catherine Flynn provides advice and expertise in relation to red cell and platelet disorders, blood dyscrasias and haematological oncology. Streamlined and early access to ultrasound imaging at The Coombe Hospital (Professor Mary Keoghan) and screening echocardiography at St James’s Hospital allow for rapid assessment and management of women with complex medical conditions.

We have close links with our colleagues at St James’s Hospital and Tallaght University Hospital who provide advice and review in the specialty areas of gastroenterology, rheumatology and dermatology. Midwifery input, key to management of labour and delivery planning, is facilitated by our midwifery team members and by the excellent care provided by the Delivery Suite staff of The Coombe Hospital. The medical team adhere to up-to-date guidelines and protocols to ensure best practice.

Multidisciplinary team meetings are hosted by the team on a two monthly basis to review care and management of more complex cases. In these high-risk cases an individualised plan of care is formulated which assists with communication, handover and management, and ultimately a reduction in risk. These care plans streamline delivery of antenatal, intrapartum and postnatal care.

The Medical Clinic is recognised as a valuable resource for teaching and research. In 2023, Dr Cathy Monteith left the service following successful completion of a one year Aspire Fellowship through the auspices of the RCPI and under the supervision of Dr Bridgette Byrne. RCSI and UCD medical students rotate through the Medical Clinic during their attachments and gain valuable exposure to the clinical conditions listed in Table 1.13.1.

1.14 Multiple Birth Clinic

Professor Aisling Martin

One hundred and thirty-nine women with multiple pregnancies (135 twin pregnancy and four triplet pregnancies) booked at The Coombe Hospital in 2023. One woman was lost to follow-up as she delivered elsewhere. Another woman delivered in the second trimester. One hundred and thirty-seven women with multiple pregnancies gave birth to babies weighing ≥ 500 grams at The Coombe Hospital in 2023 (Table 1.14.1). Of these, 133 were twin pregnancies and four were triplet pregnancies. One hundred and three were dichorionic diamniotic (DCDA) twin pregnancies and 30 were monochorionic diamniotic (MCDA) twin pregnancies. Two of the triplet pregnancies were dichorionic triamniotic (DCTA) and two were trichorionic triamniotic (TCTA).

Table 1.14.1 Women with multiple pregnancies who gave birth at The Coombe Hospital, 2017 to 2023

who gave birth to babies ≥ 500 grams (n)

The births of three babies (one baby of three sets of twin pregnancies) were not registered because these babies weighed less than 500 grams at delivery. Two of these were MCDA twin pregnancies and one was a DCDA twin pregnancy. Therefore, a total of 275 babies were born weighing ≥ 500 grams (263 twin and 12 triplets). Details of the gestational age at delivery and mode of delivery of twins and triplets are presented in Tables 1.14.2 and 1.14.3, respectively.

Table 1.14.2 Gestational age at delivery of twin and triplet pregnancies (women) Gestational

Table

1.14.3

Mode of delivery of twin and triplet pregnancies (women)

*Spontaneous vaginal birth † Assisted vaginal breech ‡Lower segment Caesarean section

Monochorionic diamniotic twin pregnancies

Six monochorionic diamniotic twin pregnancies were documented to have been complicated by twin-totwin transfusion syndrome (TTTS). Laser ablation of placental anastomosis was indicated in three of these six pregnancies. These procedures were performed in The Rotunda Hospital. One of these procedures, performed at 22+4 weeks’ gestation, was unsuccessful. An emergency Caesarean section was performed at 23+6 weeks’ gestation following the administration of corticosteroids and magnesium sulphate. The donor twin weighed 360 grams. The recipient twin was hydropic and weighed 910 grams. Both babies died soon after birth.

Laser ablation was conducted at 16 weeks’ gestation in the second case. Preterm premature rupture of membranes (PPROM) occurred at 25+2 weeks’ gestation. Labour ensued at 28 weeks’ gestation. Two liveborn infants weighing 1,125 grams and 1,150 grams were born by emergency Caesarean section. Unfortunately, the first twin (donor) developed cystic periventricular leukomalacia (PVL), and the second twin (recipient) had pulmonary stenosis and tricuspid atresia.

The third case had laser ablation at 19 weeks’ gestation. The pregnancy progressed well until spontaneous labour occurred at 33 weeks‘ gestation. An emergency Caesarean section was performed because the first twin was a breech presentation. The babies weighed 1,780 grams and 1,755 grams, respectively and both babies did very well.

Two other MCDA twin pregnancies diagnosed with TTTS were delivered at 24+5 weeks’ and 29 weeks’ gestation. A third MCDA twin pregnancy with stage 1 TTTS at time of diagnosis did not progress. Labour was induced at 35+2 weeks’ gestation and resulted in the spontaneous birth of healthy babies who did very well postnatally.

Monochorionic monoamniotic twin pregnancies

A monochorionc monoamniotic twin pregnancy was complicated by twin reversed arterial perfusion (TRAP) sequence. The woman was referred to a Fetal Medicine Specialist colleague in London. Radiofrequency ablation was performed to the cord of the acardiac twin at 16 weeks’ gestation. Eight days following this procedure, fetal death in utero was diagnosed.

Triplet pregnancies

Four sets of triplets were born in The Coombe Hospital in 2023. Three women booked in The Coombe Hospital. One woman with an IVF TCTA triplet pregnancy was transferred from another hospital at 24+3 weeks’ gestation following the diagnosis of in-utero demise of the first triplet. Labour occurred the day after transfer. As triplet 2 was a transverse lie a Caesarean section was performed. Triplet one was stillborn and weighed 510 grams. Triplets 2 and 3 were liveborn and weighed 730 grams and 775 grams, respectively.

The other three sets of triplet pregnancies had uncomplicated antenatal courses. Two were DCTA

(one spontaneous conception and one IVF) and the third was TCTA (IVF donor egg pregnancy). They were delivered by elective Caesarean section at 33+5, 34+1 and 34+3 weeks’ gestation. All nine babies were well grown and required minimal neonatal support and went home well.

A woman with a TCTA triplet pregnancy underwent a peripartum hysterectomy because a major obstetric haemorrhage due to atony occurred at the time of Caesarean section. She required a massive transfusion of blood and blood products and was transferred to the ICU in St James’s Hospital. She returned to The Coombe Hospital a few days later and made a full recovery.

1.15 Obstetric Endocrine Clinic

Professor Brendan Kinsley and Associate Professor Amy O’Higgins

The obstetric endocrine service is a multidisciplinary specialist service. The service runs a formal outpatient clinic once a week where antenatal and postnatal women are reviewed in person by endocrinologists, obstetricians, specialist midwives and dieticians. The service also runs a virtual diabetes mellitus clinic twice a week and a virtual thyroid clinic once a week. In addition to these clinics the service also provides a remote and in person dietetics

services, in person diabetes education sessions, insulin education sessions, inpatient care and education and specialist management of continuous glucose monitoring devices, continuous subcutaneous insulin infusions and hybrid closed loop insulin pumps. A direct phoneline for patient and staff support is available 42 hours per week.

The number of women attending the combined obstetric endocrine clinic rose significantly in 2023 compared to 2022 despite a decline in numbers booking for obstetric care at The Coombe Hospital (Table 1.1.1). In 2023, 41 women with type 1 diabetes booked in The Coombe Hospital, 32 of whom gave birth in 2023 and 35 women with type 2 diabetes booked in The Coombe Hospital, 22 of whom gave birth in 2023 (Table 1.15.1). In 2023, the service provided care to 835 women with gestational diabetes mellitus (GDM) who gave birth in 2023, compared with 739 women in 2022 (Table 1.15.1).

Table 1.15.1 Type of diabetes mellitus, as a percentage of all women who gave birth, 2017 to 2023

201720182019

In 2023, the service also provided care to 26 women with thyroid disease (Grave’s disease or hyperthyroidism) and two women with other endocrine disorders, one with Addison’s disease and one with primary hyperparathyroidism. In 2023, there were 7,752 attendances (in-person and virtual) at the Obstetric Endocrine Clinic (Table 1.15.2).

Table 1.15.2 Obstetric Endocrine Clinic attendances, 2023 Type of attendance

Inpatient admission for commencement of insulin therapy, the norm five years ago, is now required for less than 4% of those starting insulin. In 2023, 65% of clinic appointments and 35% of dietetic consultations took place virtually. This change, from inpatient and in-person care to remote care provision, represents a real move forward towards placing the woman at the heart of all we do thereby improving the experience for women while providing a more efficient service. In February 2023, a specialist service for management of continuous glucose monitoring devices, continuous subcutaneous insulin infusions and hybrid closed loop insulin pumps was formalised. This was an important and welcome development allowing the use of advanced technologies for diabetes management to be incorporated into the routine activity of the service.

The national diabetic retinopathy in pregnancy screening programme was launched in 2023 to provide retinal screening for all women with type 1 and type 2 diabetes. All women who qualified for this service were screened following referral from the clinic. Retinopathy was present in 22% (9/41) of women with type 1 diabetes and in 3% (1/35) of women with type 2 diabetes. This high prevalence of

retinopathy shows the important of access to screening during pregnancy. There was a significant improvement in both HbA1c and fructosamine levels in women with pre-pregnancy diabetes between assessment at booking and at delivery. This is testament to high levels of engagement with treatment in women who attended our multidisciplinary service. This effective engagement with our service is also seen in the early gestation at which women with pre-pregnancy diabetes are first seen in our clinic, with the first visit usually taking place before seven completed weeks of gestation in those with pre-pregnancy diabetes.

Maternal and neonatal outcomes for those with prepregnancy diabetes mellitus are presented in Table 1.15.3. In 2023, 50.0% of women with type 1 diabetes and 18.2% of women with type 2 diabetes were delivered before 37 weeks’ gestation. Babies of five mothers with type 1 diabetes and babies of three mothers with type 2 diabetes were macrosomic (>95th centile for gestation) at birth. Babies of 16 mothers with type 1 diabetes and babies of four mothers with type 2 diabetes were admitted to NICU or SCBU.

Table 1.15.3 Pre-pregnancy diabetes mellitus - demographic and obstetric data, 2023

Type of diabetes mellitus

Women booked n = 41 n = 35

Spontaneous miscarriages

(14.6%)

Women delivered in The Coombe Hospital32 (78.0%)

Babies born in The Coombe Hospital

Maternal data n = 41 n = 35 Age (years) (mean, SD)

of DM (years) (mean, SD)

± 5.1

± 5.7

± 3.6

Table 1.15.3 Pre-pregnancy diabetes mellitus - demographic and obstetric data, 2023 continued

Complications of diabetes mellitus n = 41

at booking

at booking

(11.4%)

(2.9%) Nephropathy at booking

Gestation at first visit to clinic (weeks) (mean, SD)

Changes in assessment of glycaemia n = 32

= 22 Booking HbA1c (mmol/mol) (mean, SD)

± 23

± 17 Delivery HbA1c (mmol/mol) (mean, SD)

Booking fructosamine (μmol) (mean, SD)

± 11

± 10

weight (grams) (mean, SD)

± 748

Continuous subcutaneous insulin infusion † Defined as >95th centile for

For women with GDM, the types of treatment used between 2020 and 2023 are shown in Table 1.15.4. The percentage of women treated with insulin alone increased from 13.6% in 2020 to 18.8% in 2023. There were no intrauterine fetal deaths.

Table 1.15.4 GDM - treatment type, 2020 to 2023

- treatment type (n)

Maternal and neonatal outcomes are presented in Table 1.15.5. Twenty-four women with GDM had a multiple pregnancy (including one triplet pregnancy). The births of five babies were complicated by shoulder dystocia (four women treated with diet alone and one woman treated with metformin alone). The total CS rate decreased from 44.1% (326/739) in 2022 to 39.6% (331/835) in 2023.

Table 1.15.5 GDM - demographic and obstetric data, 2020 to 2023

Defined as >95th centile for gestation. Only

A specialist diabetes in pregnancy dietetics service was fully reinstated in 2023 with the addition of Jennifer O’Neill, specialist dietician, to our team. This is a hugely important part of the care provided to optimise health for mothers and babies in pregnancy. There were high levels of engagement with this service with 97% (34/35) women with type 2 diabetes and 83% (34/41) women with type 1 diabetes receiving dietetics support. The dietetics team also review inpatients, in person outpatients, perform remote consultations and run a weekly online education session.

In 2023, Ailbhe McCarthy was appointed as the team’s first candidate advanced nurse/midwifery practitioner, another important development for our service as it evolves to provide care for women with increasingly complex needs in an area of rapid development, particularly in terms of advances in technology and medical devices in diabetes care. The multidisciplinary team, particularly led by the midwives, provide teaching and education to support the development and understanding of diabetes in pregnancy to a wide range of clinical providers including midwifery undergraduate students, midwifery postgraduate students, newly qualified midwives and current midwifery staff. The Coombe Hospital also hosted two sessions of a Dublin-wide Diabetes in Pregnancy study day.

1.16 Options in Pregnancy Clinic

Dr Aoife Mullally

The Options in Pregnancy Clinic was established in February 2019 to provide abortion care in accordance with the Health (Regulation of Termination of Pregnancy) Act 2018. Women are referred electively to the Options in Pregnancy Clinic by their general practitioner or community women’s health provider. The majority of women are referred as they are between nine and twelve weeks’ gestation or because they have a comorbidity which makes them unsuitable for early medical abortion (EMA) in the community. We are fortunate in being able to offer access to inpatient medical termination seven days a week and surgical termination Monday to Friday. Women with suspected complications of EMA are also seen in the Options in Pregnancy Clinic. Women are offered follow-up appointments for insertion of low acting reversible contraceptives (LARCs).

The increase in referrals each year since 2019 was seen again in 2023 (Table 1.16.1). Much of this reflected the increase in EMA provided in the community and an increase in women needing hospital follow-up. In 2023, 335 appointments were made for the Options in Pregnancy Clinic, 17 (5.1%) of which were not attended (Table 1.16.1). This compares with non-attendance rates of 3.3% in 2019 and 9.8% in 2022.

There was an increase in the number of women referred because of complications post-community EMA from 109 in 2022 to 134 in 2023 (Table 1.16.2).

1.16.1 Attendances and non-attendances, 2019 to 2023

2019 2020 202120222023

Appointments made (n) 150 204 249 318 335 Nonattendances (n) 517183117 Attendances (n) 145 187231287318

Table 1.16.2 Clinical outcomes, 2019 to 2023

Other (miscarriage, continued with pregnancy, left clinic without decision) (n)

We were pleased to commence our manual vacuum aspiration (MVA) service in 2023. This provides women with the option of same-day surgical management of women with retained products of conception or early surgical abortion. This greatly lessens the burden on the woman, in addition to reducing the number of cases being added to theatre lists at short notice. Thirty-seven MVA procedures were carried out in 2023 with a high reported patient satisfaction rate.

I would like to acknowledge the support that we have received from the Executive Management Team and colleagues in perioperative medicine, theatre, the ultrasound department and St Gerard’s Ward. I would particularly like to acknowledge the professionalism and expertise of Miriam Strong and Emma O’Neill who facilitate women being seen in a timely manner and collaborate with our colleagues in primary care. I would also like to thank Dr Niamh Murphy, Dr Cliona Murphy and Dr Zahrah Elsafty for facilitating the Options in Pregnancy Clinics to continue during annual leave periods.

Provision of post-abortion contraception has been greatly facilitated by the Department of Health’s free contraception scheme and the National Women and Infants Health Programme contraception scheme for maternity and gynaecology services. I would like to acknowledge the support and collaboration of the Pharmacy Department and local community pharmacies who have helped us provide timely contraception for eligible women.

We welcomed an increasing number of student midwives and medical students to observe our work in the clinic. Clinic staff also participated in a number of local and national educational events.

1.17 Parent Education

Megan Sheppard

In 2023 the Department of Parent Education introduced a new hybrid model of antenatal education. Live interactive classes continued to be facilitated on the virtual platform while parents were invited to attend new face to face modules to complement their preparation for birth and parenting programme.

To ensure choice and accessibility for all parents, classes for first time parents were facilitated on weekday mornings, evenings and at weekends with unrestricted access to all. Class attendances in 2023 reached in excess of 7,000. Parents attended for a comprehensive package of antenatal education inclusive of preparation for birth and parenting, ‘Birth Dynamics’, maternal wellbeing and breastfeeding programmes. The Department also continued to work closely with the Department of Perioperative Medicine to facilitate a module on the use of epidural in labour and with Nora Vallejo, Advanced Nurse Practitioner, to facilitate the birth choices programme designed for women preparing for birth after a previous Caesarean section.

Courses for second time parents, including preparation for birth, ‘Birth Dynamics’ and refresher breastfeeding were also facilitated on weekdays on the virtual platform. The option to attend an in-person ‘Birth Dynamics’ - active birth was also available.

All classes were complemented by a suite of antenatal education videos housed on The Coombe Hospital website.

One on one sessions, both face to face and online, for women in need of additional support were facilitated weekly. Women either self-referred or were referred by the multidisciplinary team which included medical social work and the specialist perinatal mental health services.

In 2023, phases 4 and 5 of the of the ‘Birth Dynamics’ project were launched. ‘Birth Dynamics’ is a programme of evidence-based preparation for birth developed by the Parent Education team. It is a toolkit for labour and birth designed to support women in labour, optimise

physiology and assist parents in navigating the intensity and challenges of birth, irrespective of their care pathway. Phase 4 of the project is comprised of an in-person ‘Birth Dynamics’ - active birth workshop. This phase of the project complements phases 1, 2 and 3, namely the online interactive ‘Birth Dynamics’ class, the ‘Birth Dynamics’ video housed on The Coombe Hospital website and the ‘Birth Dynamics’ 80-page workbook, all of which are available to all parents attending The Coombe Hospital.

In March 2023, phase 5 of the project was launched in collaboration with the Centre for Midwifery Education (CME) and the Departments of Physiotherapy and Perioperative Medicine. This phase of the project consists of a one-day staff and student ‘Birth Dynamics’ training workshop designed to enhance staff education and knowledge around the birthing strategies of the ‘Birth Dynamics’ programme in an endeavour to integrate the programme at an organisational level.

In the autumn of 2023, the department launched a new programme of mindful hypnobirthing, which was developed by Ciara Whelan, CMM2. This programme is available to parents either online or in-person, making the option for hypnobirthing available to all parents attending The Coombe Hospital.

The department is highly involved in the early childhood intervention agenda and works collaboratively with multiple agencies (state, voluntary and community) to support the best possible outcomes for children from conception to three years of age. To support their work in this agenda and in infant and early childhood mental health, midwives from the Parent Education team undertook training and continuous professional development in the Solihull Approach. The Solihull Approach originates in the UK and is an evidence-based relational model of antenatal and postnatal education which aims to help parents understand their baby’s/child’s behaviour in the context of their development and the parent-child relationship. It aims to educate parents in response and communication with their babies, encouraging healthy brain development and thus laying the foundations for positive infant mental health and wellbeing. Staff trained in Antenatal and Postnatal Group facilitation and Circle of Security Parenting facilitation. Staff also undertook online training in Newborn Behavioural Observations (NBO) with two members of the faculty of the Brazelton Institute, one based at the Brazelton Institute, Boston and other at the Brazelton

Centre, UK. This training in NBO is an internationally renowned evidence-based programme which focuses on understanding newborn behaviour and parentinfant relationship-building. In addition, staff underwent Infant Massage Instructor training which is accredited by the International Association of Infant Massage (IAIM). This programme is an evidence-based programme which aims to promote nurturing touch and communication between parents and their babies, supporting bonding and secure attachment and positive parent-infant relationships. All this training enabled the launch of the first Solihull Postnatal Group Parenting programmes and Infant Massage programmes for mothers and babies in the community of Balgaddy. This training was co-facilitated with community care and project teams from Blue Skies Initiative, an area based project. The suite of postnatal parenting programmes was subsequently launched in the Dublin 8 area. Work is underway to develop programmes in Clondalkin Village, Cherry Orchard and Ballyfermot.

At national level, Megan Sheppard, CMM2, continued to be involved in the development of the first national training programme for Antenatal Education Facilitators in Ireland. Rollout of this programme is anticipated in 2024.

1.18 Preterm Birth Prevention Clinic

Dr Neil O’Gorman and Dr Lyndsay Creswell

In 2023, 232 women attended the Preterm Birth Prevention Clinic. Six of these women had twin pregnancies. There were 556 clinic attendances. One hundred and fifty-nine women who attended this clinic gave birth in The Coombe Hospital in 2023 (Table 1.18.1). The remaining women delivered elsewhere or were undelivered by the end of 2023. Referral criteria for the clinic included previous spontaneous preterm birth, previous premature rupture of membranes, previous second trimester miscarriage, previous cervical surgery (not including one large loop excision of the transformation zone), previous cervical cerclage, congenital uterine anomaly, short cervix in the current pregnancy and previous Caesarean delivery at full dilatation.

In 2023, 166 babies were born to women who attended the clinic. One second trimester termination of pregnancy occurred at 22 weeks’ gestation because of a fatal fetal anomaly. The remaining 159 women gave birth in The Coombe Hospital on or after 24 weeks’ gestation (Table 1.18.1) There was one neonatal death of a baby born at term in a pregnancy complicated by severe intrauterine growth restriction. The mother had had preterm birth surveillance but had not required treatment, having a normal cervical length throughout pregnancy.

Fourteen women had cervical cerclage (8.8%) (Table 1.18.1). One woman had undergone placement of a transabdominal cerclage pre-pregnancy following treatment for cervical cancer and one woman had a cerclage placed in another country in early pregnancy. The remaining 12 cerclages were placed vaginally during pregnancy through the service. The mean gestation at placement was 18.7 weeks’ gestation (range 16 - 25; mode 17). Thirteen women were treated with vaginal progesterone alone (8.2%) (Table 1.18.1).

Table 1.18.1. Clinical summary of women who gave birth in 2023

* Excludes second trimester termination of pregnancy

1.19 Severe Maternal Morbidity and High Dependency Unit

Julie Sloan, Dr Bridgette Byrne and Dr Cathy Monteith

Thirty-six of the 6,836 women (4.9 per 1,000) who gave birth to a baby weighing ≥ 500 grams in The Coombe Hospital in 2023, fulfilled the criteria for the diagnosis of severe maternal morbidity (SMM). The number of cases, according to categories, is presented below in Table 1.19.1. Five (22.8%) women required an ICU admission following major obstetric haemorrhage (MOH).

Table 1.19.1 Number of cases and causes of severe maternal morbidity, 2023

* A number followed by a number in brackets indicate that the woman is already included in an organ dysfunction category

High Dependency Unit (HDU)

One-hundred and twenty-seven of women (1.9%) who gave birth to a baby weighing ≥ 500 grams in The Coombe Hospital in 2023 required higher level care (Table 1.19.2). They were cared for in the Delivery Suite but not always in the HDU area because of reorganisation of clinical space due to staffing shortages.

Table 1.19.2 Obstetric related HDU admissions, 2023 Indication for HDU admission

In 2023, seven women required transfer to St James’s Hospital and one woman required transfer to Tallaght University Hospital for ICU care. We are grateful for the collaboration with the ICU staff in St James’s Hospital. This enables us to follow-up on the outcomes of our mothers transferred and the care they receive.

High level care continued to be provided despite staff shortages and infrastructural challenges with a reduction in the number of women requiring HDU level care.

The National Perinatal Epidemiology Centre (NPEC) Study Day provided an informative day with discussions on the MOH Audit and its outcomes

1.20 Specialist Perinatal Mental Health Clinic

Dr Sabrina Coyle and Dr Joanne Fenton

In 2023, the Specialist Perinatal Mental Health (SPMH) team continued a model of hybrid working while also welcoming a full return to in-person outpatient appointments. A total of 921 new patient assessments were provided to mothers with perinatal mental health difficulties and their infants in 2023. This was an increase of 5.4% compared to the previous year (Table 1.120.1). There were 781 more attendances at the service in 2023 compared with 2022 (Table 1.20.1). A new referral triage protocol was developed and implemented in 2023 which resulted in a reduction in the number of non-attendances at appointments and consequently shorter waiting times for women who wanted to access the service.

Table 1.20.1 New patient assessments and reviews, 2022 and 2023

(CBT), psychosocial interventions and a range of supportive interventions including individualised preparation for birth and postnatal support. Group interventions were offered both in an online format and in person. Group interventions included CBT for anxiety and obsessive compulsive disorder, Me to Mum (supporting psychological transition to new motherhood), baby massage, OT led walking group and Parents Time Out (a group for parents of babies in neonatal care). Helen McBride (CNS) also facilitated an online education session for partners of patients attending the SPMH service. These group interventions were well attended and helped to ensure access to high quality interventions for all patients attending the service. The multidisciplinary team continued to provide assessment and triage, as needed, to women who were inpatients in The Coombe Hospital.

Over the course of 2023, the SPMH team provided a range of specialist education, training and support to staff in The Coombe Hospital and beyond. Conal Harpur (CNS, CBT Therapist) provided training on perinatal mental health to midwives and GPs nationally.

Dr Sabrina Coyle provided a number of masterclasses on Mother and Infant Mental Health through the Centre for Midwifery Education. Specialist training was also provided to a number of departments within The Coombe Hospital (including the Physiotherapy Department and Delivery Suite) on provision of trauma sensitive care. In November 2023, Giulia Milia (CMM2) provided a masterclass for midwives on perinatal mental health interventions. Psychological support for staff was facilitated through the provision of monthly Schwartz rounds (Dr Joanne Fenton, Dr Sabrina Coyle) and also through the provision of reflective space for staff following traumatic incidents within the hospital (Dr Sabrina Coyle).

In 2023, the SPMH multidisciplinary team that included consultant psychiatrists, senior psychiatric registrar, junior psychiatric registrar, senior clinical psychologist, mental health midwives, clinical nurse specialists, senior occupational therapist (OT), senior perinatal social worker and administrative officers. The team offered a wide range of evidence-based interventions at both individual and group level to women (and their infants) both as outpatients and within the hospital setting. Individual interventions provided included medical management, psychological therapy, cognitive behavioural therapy

The SPMH team were actively involved in research and audit. A number of in-service audits were completed including an audit of non-attendances at the service (Dr Yvonne Hartnett) and an audit of correspondence between the SPHM team and Community Psychiatry teams. This was in an effort to understand difficulties patients may have experienced in accessing the service, to improve attendance rates and to improve communication with other services involved in patients’ care. Two clinical psychology trainees from Trinity College Dublin completed doctoral research in The Coombe Hospital. Their research projects explored the ‘Transition to Motherhood in Motherless

Mothers’ and ‘Fathers Experiences of having a baby in neonatal care.’ These projects demonstrated our successful and ongoing collaboration with third level institutions to produce high quality research.

The SPMH team continued to engage in regular continuing professional development (CPD) to enhance learning and improve practise. This included the dissemination of information from training/conferences and regular reflective practise sessions. Dr Sabrina Coyle and Elaine Cowley continued their involvement and collaboration with the local infant mental health network and an inter-

agency perinatal mental health working group in Dublin South/Kildare/West Wicklow. A number of team members also engaged in advanced training courses in 2023. Helen McBride (CNS) successfully completed training in nurse prescribing. Giulia Milia continued in her Masters in Psychotherapy. Conal Harpur undertook a Doctorate in Psychotherapy. Dr Sabrina Coyle successfully completed her Video Interaction Guidance (VIG) training and became one of the only accredited VIG practitioners in Ireland. Elaine Cowley (Mental Health Midwife) continued work towards her Masters in Perinatal Mental Health.

1.21 The Coombe Hospital/HSE Integrated Home Birth Service

Paula Barry and Maria Dado

The National HSE Home Birth Service has undergone change in that the service has been integrated into the acute setting (maternity hospitals/units). The process of integration began at The Coombe Hospital in October 2022. Women, who meet the criteria for a home birth, can request a home birth by liaising with the Designated Midwifery Officer (DMO) in The Coombe Hospital. The DMO co-ordinates the home birth service and supports women who request a home birth and the self-employed midwives (SECMs) who provide the service.

In 2023, 60 women registered for The Coombe Hospital/HSE Integrated Home Birth Service. Twenty-six (43.3%) women were nulliparous. Twenty-seven (45.0%) women had a home birth. Nineteen (57.6%) of the 33 women who gave birth in The Coombe Hospital were transferred antenatally, prior to labour. Fourteen women (42.4%) were transferred during labour. The indications for transfer are presented in Figure 1.21.1. Of the 33 women who gave birth in The Coombe Hospital, 21 (63.6%) women had a spontaneous vaginal birth, three (9.1%) women had an assisted vaginal birth, and nine (27.3%) women had Caesarean section births.

All women initiated breastfeeding and 98% were still breastfeeding on discharge from The Coombe/HSE Integrated Home Birth Service on day 14 of life. All women and their babies received follow-up postnatal care by their SECM, irrespective of place of giving birth. All babies returned to The Coombe Baby Clinic for neonatal examination and auditory screening.

The Coombe Hospital/HSE Integrated Home Birth Service continued to provide choice to women seeking a home birth in 2023. Strong relationships between women embarking on the home birth pathway, the SECMs and The Coombe Hospital staff were developed in 2023. Processes were developed to streamline a safe, high-quality service with referral processes, access to medications for birth, equipment and supplies. In 2023, the DMO began to visit women planning a home birth, in their home at 36 weeks’ gestation.

Figure 1.21.1 Indications for transfer to The Coombe Hospital (n = 33)

The Coombe Hospital continues to provide the largest benign gynaecology service in Ireland

Section 2 Gynaecology Services

2.1 Gynaecology Services Report Overview

Professor Michael O’Connell

In 2023, The Coombe Hospital continued to provide the largest benign gynaecology service in Ireland. There was a total of 18,029 attendances at gynaecology outpatient clinics in 2023 (Table 2.1.1), 592 and 1,091 more attendances than in 2021 and 2022, respectively.

There has been a streamlining of services with a decrease in the number of women seen in General Gynaecology Clinics and an increase in the number of women seen in specialised clinics. There were 621 more attendances at Colposcopy Clinic in 2023 compared with 2022.

Attendances at the Enhanced Endometriosis Clinic doubled between 2022 and 2023. Attendances at the Outpatient Hysteroscopy Clinic increased by 409 between 2022 and 2023.

Two new gynaecology clinics were established at The Coombe Hospital in 2023. The Adolescent Gynaecology Clinic was established in January 2023 to manage adolescents with gynaecological concerns (see section 2.2). A total of 305 adolescents attended this clinic in 2023 (Table 2.1.1). The Fibroid Clinic was established in February 2023 to optimise the evaluation and treatment of women with symptomatic uterine fibroids (see section 2.7). A total of 125 women attended this clinic in 2023 (Table 2.1.1).

Table 2.1.1 Gynaecology outpatient clinic attendances, 2017 to 2023

* Including phone consultations and virtual consultations in 2023

† Prior to 2021 the Subfertility Clinic (now called the Fertility Hub) was combined with the endocrine clinic

‡ Service changed to GP Led-Long-Acting Reversible Contraception Clinic in May 2021

§ Correction to attendances at Options in Pregnancy Clinic from 2017 to 2022

In 2023, 6,042 gynaecological surgical procedures were performed (Table 2.1.1). Tables 2.1.2 to 2.1.7 present the numbers of surgical procedures by category of gynaecological surgery from 2017 to 2023. The highest number of cervical surgical procedures between 2017 and 2023 were performed in 2021 (1,001) and 864 were carried out in 2023 (Table 2.1.1). The highest number of uterine surgical procedures between 2017 and 2023 were carried out in 2023 (3,633), gradually increasing from 2,543 in 2017 (Table 2.1.2). Numbers of other types of gynaecological surgery have remained relatively stable apart from urogynaecology which decreased by almost 50% between 2017 and 2023.

Table 2.1.2

Category of gynaecological surgery, 2017 to 2023

Between 2017 and 2023, the highest number of outpatient large loop excisions of the transformation zone (LLETZ) were performed in 2021 (Table 2.1.3). The number decreased to 569 in 2022 but increased by 81 to 650 in 2023 (Table 2.1.3). Numbers of other types of gynaecological surgery have remained relatively stable between 2017 and 2023.

Table 2.1.3 Cervical surgery, 2017 to 2023

* See abbreviations section

There has been a gradual increase in the number of diagnostic outpatient hysteroscopies performed in The Coombe Hospital since the establishment of the service in 2020 (Table 2.1.4). There were 188 more such procedures performed in 2023 compared with 2022. Between 2017 and 2023, the highest number of hysteroscopy procedures was performed in 2023 (1,666), an increase of 101 compared with 2022 (Table 2.1.4).

Between 2017 and 2023, the highest number of uterine surgical procedures were performed in 2023 (3,633) (Table 2.1.4). The number has gradually increased from 2,543 in 2017. The number of MyoSure treatments performed as an outpatient in The Women’s Health Centre, increased from 77 in 2020 to a peak of 230 in 2023 (Table 2.1.4) while the number of Mirena coils inserted increased from 279 in 2017 to a peak of 434 in 2023 (Table 2.1.4). This reflects an evolution of the ambulatory gynaecology service from not only diagnosing but to the treatment of women with menstrual disorders.

Table 2.1.4 Uterine surgery, 2017 to 2023

In 2023, two fewer total abdominal hysterectomies were performed than in 2022 (Table 2.1.5), of which 75.7% (81) were performed laparoscopically (Table 2.1.5). This was less than in 2022 (80.7%) but was higher than in the previous five years when the rate ranged from 50.6% to 60.5% (Table 2.1.5). The increase in laparoscopic procedures is reflective of the appointment in recent years of consultant obstetricians and gynaecologists with advanced laparoscopic skills.

The number of vaginal hysterectomies performed reached a trough of 43 in 2023 from a peak of 104 in 2017 (Table 2.1.5). The number of vaginal hysterectomies performed non-laparoscopically continued to increase and reached a peak of 88.4% in 2023 (Table 2.1.5).

In 2023, 887 tubal and ovarian surgical procedures were performed, which was the lowest number since 2019 (Table 2.1.6). The decrease in 2023 was mainly due to a decrease in the number of diagnostic laparoscopies, 141 which was 131 less than in 2022 (Table 2.1.6). This is most likely due to streamlining of services as women referred to the Enhanced Endometriosis Clinic must have a diagnosis of endometriosis prior to attending this clinic. The number of bilateral salpingectomies performed laparoscopically continued to increase in 2023 compared with 2022 and the number of adhesiolysis procedures performed laparoscopically remained stable (Table 2.1.6).

Table 2.1.5 Type of hysterectomy, 2017 to 2023

Table 2.1.6 Tubal and ovarian surgery, 2017 to 2023

Unilateral

Bilateral

Table 2.1.7 Vulval and vaginal surgery*, 2017 to 2023

In 2023, 371 vulval and vaginal surgical procedures were performed, 13 less than in 2022 (Table 2.1.7). The number of anterior repairs and the number of posterior repairs performed decreased between 2023 and 2022 (Table 2.1.7). The former peaked at 105 in 2017 while the latter peaked at 90 in 2018. The number of miscellaneous surgeries remained stable at 46 in 2023, ranging between a trough of 32 in 2022 and a peak of 57 in 2020 (Table 2.1.8). Type of vulval and vaginal surgery (n)

repair for dyspareunia/vaginoplasty

*Excludes urogynaecology surgery

Table 2.1.8 Miscellaneous surgery*, 2017 to 2023

*Includes appendicectomy, abdominal wound repair and laparotomy for other reasons

2.2 Adolescent Gynaecology Clinic

Dr Niamh Murphy

The Adolescent Gynaecology Clinic was established at The Coombe Hospital in January 2023. It is dedicated to the management of adolescents with gynaecological concerns.

The clinic accepts referrals nationally as The Coombe Hospital is one of only three hospitals with a dedicated Paediatric and Adolescent Gynaecology (PAG) service. The PAG team (Consultant and SpR) at The Coombe Hospital also attend the PAG clinic in Children’s Health Ireland (CHI) at Temple Street, where care is offered to younger patients.

Table 2.2.1 Types of surgical procedure conducted, 2023

In 2023, 165 new referrals were seen in the clinic and there were 140 return visits (Table 2.1.1). Where appropriate, return visits were conducted virtually via phone consultation which can often be more effective in this cohort.

Referrals included adolescents with menstrual concerns, ovarian masses, disorders of sexual development, Mullerian anomalies, precocious or delayed puberty and premature ovarian insufficiency. A significant proportion of our referrals are for adolescents with additional developmental needs who require specialist input in the management of their menstrual issues.

Patients from the age of 12 years and above can attend the clinic and The Coombe Hospital offers admission for theatre where required from the age of 15 years upwards. In 2023, the PAG service admitted 48 patients for a surgical procedure, 45 of which were admitted as day cases (Table 2.2.1).

In addition, 16 intrauterine devices for heavy menstrual bleeding were inserted in the outpatient clinic.

The PAG clinic has been involved in the establishment of a Gynaecology-Haematology multidisciplinary team with our colleagues in Haematology in CHI at Crumlin, CHI at Temple Street and the National Coagulation Centre in St James’s Hospital. This group was established to manage the care of those with bleeding disorders and associated heavy menstrual bleeding to determine the most appropriate care pathway for this complex cohort of patients.

2.3 Colposcopy Service

Professor

Tom D’Arcy and Olivia McCarthy

The Coombe Hospital Colposcopy Clinic is consultant led, supported by four nurse colposcopists. In 2023, one additional clinical session was added, totalling seven clinical sessions per week. Two sessions per week were entirely nurse-led whilst five sessions per week were consultant-led with support from a nurse colposcopist.

Table 2.3.1 Number of new referrals to Colposcopy Clinic, 2017 to 2023

The number of new referrals to Colposcopy Clinic increased from 2,198 in 2022 to 2,567 in 2023 (Table 2.3.1). Table 2.3.2 presents the type of screening abnormalities in referrals to Colposcopy Clinic in 2022 and 2023 (Table 2.3.2). In 2023, there were 6,077 attendances, an increase of 621 compared with 2022 (Table 2.3.3).

Table 2.3.2 Screening abnormalities in referrals to Colposcopy Clinic, 2022 and 2023

Table 2.3.3 Colposcopy Clinic attendances, 2017 to 2023

Table 2.3.4 Non-attendances at Colposcopy Clinic, 2017 to 2023

There was a welcome decrease in the non-attendance rate from 15.9% in 2022 to 12.7% in 2023 (Table 2.3.4). This may be in part be due to the consistent use of the text reminder system in 2023. There were technical issues with this system in 2022 which was thought to have contributed to a non-attendance rate of 15.9%. At the end of each colposcopy session, the clinician reviews the charts of women who did not attend their appointments. Based on the clinical need, the individual woman is either offered another appointment or discharged back to the care of her GP. If a woman did not attend following an urgent referral, we phone her to establish a reason for non-attendance and to re-schedule another appointment.

The number of diagnostic punch biopsies and large loop excisions of the transformation zone (LLETZ) conducted in the Colposcopy Clinic from 2018 to 2023 are presented in Table 2.3.5. There was an increase in numbers of procedures conducted in 2023 which had been preceded by a reduction in 2022. This increase can be directly correlated with the increase in the number of referrals and the number of attendances.

2.3.5 Procedures conducted in Colposcopy Clinic, 2018 to 2023

The histology results of 1,996 diagnostic punch biopsies performed in 2023 are presented in Table 2.3.6

Table 2.3.6 Histology results of diagnostic punch biopsies, 2022 to 2023

Table

In 2023, 722 LLETZ procedures were conducted compared with 646 in 2022 (Table 2.3.7). These were undertaken primarily in the Colposcopy Clinic, but some were undertaken in the operating theatre department, if clinically required. The histology results of the LLETZ performed from 2018 to 2023 in the Colposcopy Clinic and the operating theatre department are presented in Table 2.3.7.

Table 2.3.7 Histology results of LLETZ, 2018 to 2023

In 2023, multidisciplinary team meetings were maintained consistently and held every second month. There is one British Society for Colposcopy and Cervical Pathology (BSCCP) accredited trainer in The Coombe Hospital who supports trainees in colposcopy. In 2023, there was one trainee nurse colposcopist in post.

Category of Quality Standard

Communication

Results and management plan communicated to woman and GP within six weeks of woman’s attendance

Management of waiting times for new referrals

Proportion of women with a clinical suspicion of invasive cancer or a screening test suggestive of invasive cancer seen within two weeks

Proportion of women with screening test suggestive of high-grade disease (HSIL/ASCH) or any glandular abnormality seen within four weeks

Proportion of all other women seen within eight weeks

One CervicalCheck Quality Standard (QS), with a minimum target of 90%, relates to communication (Table 2.3.8). In 2023, the Colposcopy Clinic had a compliance rate of 99.9% with this QS, compared with 94.4% in 2022. Two other QS relate to appointments management (management of waiting times for new referrals). The minimum target for management of waiting times for new referrals to the Colposcopy Clinic is 90%. In 2023, all women with a clinical suspicion of invasive cancer or a screening test suggestive of invasive cancer were seen within two weeks (Table 2.3.8). Many factors affect the ability and capacity of the Colposcopy Clinic to see women within timeframes set out by CervicalCheck QS. Administrative support levels and a Forsa work to rule action had an impact on the management of waiting times for new referrals. An increase in the number of referrals early in 2023, due to redirection of referrals by CervicalCheck from other units to The Coombe Hospital, also impacted on our ability, for a period, to offer appointments within the recommended QS. However, by the end of Quarter 4 a significant improvement was seen in the waiting times for women with a screening test suggestive of high-grade disease (HSIL/ASCH) or any glandular abnormality as 82.0% were seen within four weeks of referral. Owing to an increase in the overall volume of referrals, the proportion of all other women seen within eight weeks of referral was 66.0% which was similar to the proportion in 2022 (Table 2.3.8). Administrative staffing levels improved by the end of quarter three which had a positive impact our waiting times.

2.4 Complex Menopause Clinic

Professor Michael O’Connell

2023 was the first full year of the Complex Menopause Clinic which continued to be run by Professor Michael O’Connell and Dr Amaliya Morgan Brown. They were joined in December by Claire Brown, Clinical Nurse Specialist. The clinic ran on alternate Wednesday evenings commencing at 5.30pm.

In 2023, 188 referrals were received. Referrals were screened based on complexity and catchment area and 58 referrals did not fulfil the criteria for the clinic. Despite texting and phoning women prior to clinics, to remind them of their appointments, 28 women did not attend appointments. In 2023, there were a total of 102 attendances at the Complex Menopause Clinic.

The ratio of new attendances to return attendances was 2.3:1. Women who reattended the clinic, were in the main either on a trial of medication or further information about their medical condition was required following the first attendance.

Table 2.3.8 CervicalCheck Quality Standards in The Coombe Hospital, 2022 and 2023

The commonest indication for referral to the Complex Menopause Clinic was a personal history of cancer or a family history of cancer which accounted for 29% of new referrals. This was followed by gynaecological factors (e.g. surgical menopause, endometriosis or difficulty in management) (16.6%), premature ovarian insufficiency (15.2%) and a history of a cardiac condition (11%).

The clinic was impacted by the HSE moratorium on staff and once administrative support becomes available in 2024, we aim to increase the service offered.

2.5 Enhanced Endometriosis Clinic

The Coombe Hospital Enhanced Endometriosis Clinic commenced in March 2021. The clinical leads for this service are Dr Hugh O’Connor and Dr Hugh D. O’Connor. The service is supported by our pain management specialist Dr Sabrina Hoesni, and specialist physiotherapist, Tara Murtagh. In June 2021, the Minister for Health announced the expansion of the Endometriosis service at Tallaght University Hospital (TUH) to deliver a specialist

endometriosis centre for the management and treatment of women with all stages of endometriosis, with particular focus on women with advanced and complex disease. Consultant gynaecologists with joint appointments in The Coombe Hospital and TUH provide an integrated and streamlined service to women across both hospitals.

Endometriosis affects approximately 10% of women in Ireland. A tailored approach is taken to the care and management of each individual woman. The service provides care for women who have received a definitive diagnosis of endometriosis from stages 1 to 4. Care is provided holistically with an emphasis on a multidisciplinary approach, both medically and surgically.

Since the clinic was established, it has grown rapidly, initially there was one specialist clinic monthly. Two clinics are held weekly, and the service has welcomed a third consultant, Dr Alison DeMaio. The service is also assisted by a specialist dietician Aisling Kenny, providing valuable education to patients.

In 2023, we were delighted to announce the appointment of a Clinical Midwife Specialist for Endometriosis, Alison Bowes. This has enabled the clinic to grow and develop further. Alison provides a vital interface between patients and clinicians. Alison has developed a patient guide for women diagnosed with endometriosis.

In 2023, 345 women were referred to the clinic. The number of attendances from 2021 to 2023 are presented in Table 2.5.1. In 2023, 52.5% of attendances were new attendances compared with 61.0% in 2021 and 37.6% in 2022 (Table 2.5.1).

Table 2.5.1 Attendances at the Enhanced Endometriosis Clinic, 2021 to 2023

Alison Bowes

2.6 Fertility Hub

The Public Fertility Hub was launched in June 2021 and provides advice, blood tests, ultrasound scans, tubal patency tests, semen analysis, fertility-related surgery and treatments such as ovulation induction to couples in the Dublin Midlands Hospital Group (DMHG). Access to publicly funded intrauterine insemination (IUI), in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) treatments was introduced in late October 2023.

In 2023, 975 couples accessed the service, 48.3% of which were first visits (Table 2.6.1). Two hundred and fifty-seven hysterosalpingo-contrast-sonography (HyCoSy) tests were performed (Table 2.6.2). Thirty-six women with suspected tubal occlusion were referred to Tallaght University Hospital for a hysterosalpingogram and consideration of canalisation (Table 2.6.2).

Table 2.6.1 Attendances at the Fertility Hub in 2022 and 2023

Table 2.6.2 Management in 2022 and 2023

Follicle tracking scans

Tubal patency

Between November and December 2023, 30 couples were referred for publicly funded Assisted Human Reproduction Services. In 2023, 58 pregnancies occurred following treatment.

2.7 Fibroid Clinic

The Fibroid Clinic was established in February 2023 to optimise the evaluation and treatment of women with symptomatic uterine fibroids. Initially the clinic was scheduled once per month (on the first Monday of each month). However, the clinic encountered scheduling challenges due to the occurrence of bank holidays coinciding with clinic dates. Consequently, a total of 151 appointments were offered in 2023 which was less than our original target. In 2023, 82.4% (103) appointments were first appointments, 22 were return appointments (Table 2.1.1) and 26 women (17.2%) did not attend scheduled appointments.

Professor Nadine Farah

Dr Workineh Tadesse

2.8 GP Led LongActing Reversible Contraception Clinic

Olivia McCarthy

The GP Led Long-Acting Reversible Contraception Clinic was established in 2021. A weekly clinic is run by a dedicated team of GP’s who provide care to women availing of intrauterine contraceptive device insertion in an outpatient setting. The GP’s also triage referral letters and decide on suitability for the clinic and the urgency associated with the referral.

In 2023, 388 women attended the clinic for the first time and 59 women attended for a return visit (Table 2.8.1). Thirty-three percent (n = 148) of the total number of women who attended the clinic were discharged from the clinic to the care of their GP. An appointment to attend the clinic was made for 653 women. However, 120 women (18.4%) did not attend their appointments. Appointments were rescheduled for 16 of these women. The non-attendance rate was similar in 2022 (98/522 [18.8%]). In 2023, 126 appointments were either cancelled by women or had to be cancelled by The Coombe Hospital. A SIPTU work to rule action by clerical staff resulted in the clinic being suspended from 11th November 2023 until the end of the year.

In 2023, 177 women had insertion of either a Mirena, Kyleena or copper coil. Intrauterine devices were removed for 28 women. Intrauterine devices were either exchanged or reinserted for 67 women (Table 2.8.2). Thirty-one women were referred for assessment to the general gynaecology service because the administration of a general anaesthetic was deemed necessary for the insertion of an intrauterine device.

Table 2.8.1 Attendances, 2022 and 2023

* Temporary suspension of clinic from 11th November 2023 until 31st December 2023

Table 2.8.2 Procedures conducted in 2022 and 2023

(n)

Insertion of Mirena, Kyleena or copper coil

* Temporary suspension of clinic from 11th November 2023

2.9 Leaf Clinic

Dr Mark Hehir

The Leaf Clinic was established in 2019 to replace what was known as the Miscarriage Clinic. The clinic is structured in repeated four-week blocks throughout the year, where two weeks are spent caring for patients with recurrent miscarriage, one where those who have suffered a midtrimester loss are seen and the final week is a purely virtual clinic for the feedback of results generated from in-person appointments. Women are offered investigation of their loss as suggested by the RCPI guideline. They also receive psychological support from our bereavement midwives who attend the clinic. Women are given a plan for future pregnancies and offered support in the early gestational

period of subsequent pregnancies through counselling or early pregnancy ultrasound.

A total of 212 women (165 women with recurrent miscarriage and 47 women who had suffered a midtrimester loss) were seen at the Leaf Clinic in 2023 (Table 2.9.1). This number has gradually increased from 191 women in 2021 to 205 women in 2022. Virtual consultations in order to feedback results were offered to 209 women in 2023 compared with 172 women in 2021 (Table 2.9.1).

Table 2.9.1 Women seen, and virtual consultations offered, 2021 to 2023

Women (n)

Significant numbers of women attended for counselling, reassurance and early pregnancy scanning in subsequent pregnancies and many of these women went on to deliver healthy babies in the months afterward. The Leaf Clinic received multiple instances of positive feedback and gratitude for the care extended to women during 2023.

2.10 Outpatient Hysteroscopy Clinic

Birgit

The Outpatient Hysteroscopy Clinic was established in mid-2017 to improve access and reduce waiting times for the assessment and/or treatment of women over the age of 40 years referred because of postmenopausal bleeding or abnormal uterine bleeding. Patients undergo assessment using a ‘one-stop’ appointment model of care, integrating transvaginal ultrasound, hysteroscopy (if indicated following scan), and endometrial biopsy.

In 2023, additional resources were mobilised. In August 2023, the number of clinic sessions increased from four per week to five per week, reviewing five to twelve new patients and six return patients, both in person and via telephone consultation. Additionally, with one fully trained and certified nurse hysteroscopist and a candidate advanced nurse practitioner, the number of new patient appointments per clinic increased in 2023.

The service included one Colposcopy/Gynaecology clinic per week for women younger than 40 years, referred with postcoital bleeding or other indications for colposcopy who were not eligible to attend through the CervicalCheck referral pathway.

In 2023, 2,295 appointments were made for the Outpatient Hysteroscopy Clinic, including the Colposcopy/ Gynaecology Clinic, and there were 1,951 attendances for assessment and/or treatment (Table 2.10.1). Of these 1,951 attendances 1,735 were for the Outpatient Hysteroscopy Clinic and 216 were for the Colposcopy/Gynaecology Clinic (Table 2.1.1). There has been a continued upward trend in the numbers of women attending the service since 2019. The non-attendance rate (13.9%) in 2023 was comparable to previous years (Table 2.10.1). The number of cases of complex hyperplasia and cancer between 2018 and 2023 are presented in Table 2.10.2.

Wilmes and Dr Workineh Tadesse

Table 2.10.1 Outpatient Hysteroscopy Clinic, 2018 to 2023

* Includes appointments and attendances from mid-July 2017

† Includes attendances at Colposcopy/Gynaecology clinic

A total of 925 hysteroscopic procedures were performed, out of which 230 involved endometrial polypectomies, (compared to 96 in 2022), carried out in the Women’s Health Unit using a MyoSure device. Most of the polypectomies were conducted as a ‘see and treat’ during the first visit. The results of histology examinations from 2018 to 2023 are presented in Table 2.10.2.

Table 2.10.2 Results of histology, 2018 to 2023

* Includes two ovarian cancers diagnosed incidentally

2.11 Urogynaecology Clinic

Dr Breffini Anglim

The Urogynaecology Clinic offers a comprehensive, multidisciplinary team approach to women experiencing urinary incontinence, prolapse and pelvic floor dysfunction in the Dublin Midlands Hospital Group (DMHG). In 2023, there were a total of 2,073 attendances at Urogynaecology Clinics (505 new and 1,568 return attendances) (Table 2.1.1). Fourteen outpatient cystoscopies were carried out in the Women’s Health Unit. A total of 166 patients attended for urodynamics testing, 402 patients attended for pessary fitting and change in the nurse led pessary clinic, 59 patients attended for cystistat instillations, and 13 patients attended for education on intermittent self-catheterisation prior to intravesical botox injections. The type and numbers of urogynaecology surgery performed in 2023 are presented in Table 2.11.1.

Table 2.11.1 Urogynaecology surgery, 2023

In 2023

The Coombe Hospital cared for 136 very low birth weight infants

Section 3 Paediatrics and Newborn Medicine

3.1 Paediatric and Newborn Medicine Medical Report

Associate Professor Anne Doolan and Julie Sloan

Admissions to The Coombe Hospital Neonatal Unit

Table 3.1.1 Admissions to The Coombe Hospital Neonatal Unit, 2018 to 2023

* Not including readmissions

† Neonatal Unit: Special Care Baby Unit (SCBU) and Neonatal Intensive Care Unit (NICU)

Very low birth weight (VLBW) infants (Vermont Oxford Network) outcome data

Table 3.1.2 Number of cases reported to the VON in 2023 (n = 136)*

* n represents total number of VON infants managed by The Coombe Hospital. This reflects both inborn and outborn VON infants. There was a total of 12 newborns with VON defined major congenital anomalies, 8 of whom survived to discharge. 10 newborns were inborn and 2 were outborn. The number 136 includes all newborns with any sign of life following delivery.

† Excluding major congenital anomalies

3.1.1 Number of infants 401 - 1,500 grams admitted to NICU in The Coombe Hospital (inborn and outborn), 2013 to 2023

Figure 3.1.2 Total number of VON eligible infants (inborn and outborn) including congenital anomalies in The Coombe Hospital, 2013 to 2023

Figure

3.1.3 Survival of VLBW infants in The Coombe Hospital who were admitted to NICU (including congenital anomalies), 2013 to 2023

3.1.4 Survival to discharge without major predefined morbidity of VLBW infants in The Coombe Hospital (VON data including congenital anomalies), 2013 to 2023

Figure

Figure

Table 3.1.3 Gestational age breakdown and survival to discharge of all infants reported to the VON (including congenital anomalies) who were resuscitated/stabilised in delivery room (DR) in 2023, (n = 136)*

Gestational age (weeks)Total (n)Died in DR (n)Survival to

* Includes both inborn and outborn newborns and major congenital anomalies. There were thirteen newborns with major congenital anomalies and eight of these survived to discharge.

In 2023, 136 infants born ≥ 22 weeks and/or ≥ 400 grams were reported to VON. One hundred and thirty of these infants were stabilised in the DR, 107 infants survived to discharge from The Coombe Hospital and three infants subsequently died in CHI, Crumlin.

Table 3.1.4 Outcome to discharge of all newborns < 24 weeks gestational age reported to the VON (≥ 22 weeks and/or ≥ 400 grams) including congenital anomalies, 2013 to 2023 (n = 101)*

* Includes both inborn and outborn newborns

Von Definitions

Nosocomial infection is defined as any late bacterial infection or coagulase negative staphylococcus infection.

Any late infection is defined as any late bacterial infection, coagulase negative staphylococcus infection or fungal infection after day three.

Mortality is defined as death at any time prior to discharge home or first birthday. It is applicable to all infants for whom survival status is known. In this table, it only includes infants 501 - 1,500 grams and it includes infants with major congenital anomalies.

Mortality excluding early deaths excludes infants who die within the first 12 hours of birth.

Survival indicates whether the infant survived to discharge home or first birthday.

Survival without specified morbidities indicates whether the infant survived with none of the following key morbidities: severe IVH, CLD, NEC, pneumothorax, any late infection or PVL.

Source: Vermont Oxford Network Annual Report and Nightingale, the Vermont Oxford Network Internet Reporting Tool.

Table 3.1.5 Morbidity and mortality data for all eligible VON infants with birth weight in The Coombe Hospital (congenital anomalies included), (n = 136), compared to the Vermont Oxford Network in 2022 and the Republic of Ireland in 2022

Outcome measure

Coombe Hospital 2023, n, (%), (denominator)

lung disease (at 36 weeks) 17, (18.1%), (94)

* ROI and VON outcome data are expressed as percentage values. The ROI and VON Network data available at the time of publication of this report was for the year 2022.

Hypoxic Ischaemic Encephalopathy and Mortality Tables

Table 3.1.6 Hypoxic ischaemic encephalopathy (HIE) in 2023

HIE Inborn (n = 7)

Outborn (n = 5)

HIE moderate (stage II) 5 5

HIE severe (stage III) 2

Therapeutic hypothermiaInborn* (n = 5)

Outborn (n = 5)

Outcomes Unknown†

* Two infants with HIE were not cooled for clinical reasons

† Outcomes of four infants unknown as local follow-up

Table 3.1.7 Mortality - inborn infants normally formed ≤ 1,500 grams, 2023 (n = 20, includes 3 infant deaths)

Group classification

Extreme prematurity and aetiology of death otherwise specified, n = 20

Anomaly (leading to death)

PPHN, n = 3

Multiorgan failure, n = 4

Ventilator dependency, prolonged hypoxia and respiratory failure, n = 3

Sepsis/meningitis, n = 10

In 2023, two deaths occurred of outborn normally formed infants weighing ≤ 1,500 grams.

Selected congenital anomalies in infants born in The Coombe Hospital in 2023

Table 3.1.8 Selected major congenital anomalies (all liveborn)

Type of major congenital anomaly

Table 3.1.9 Musculoskeletal anomalies (all liveborn)

The diagnosis of fetal and neonatal cardiac anomalies is detailed in the Obstetrics and Midwifery Report entitled ‘Fetal Cardiology National (All-Ireland) Service’ (Subsection 1.8). In 2023, 46 liveborn infants in The Coombe Hospital had major congenital cardiac disease. These newborns were jointly managed antenatally with other maternity units in the Republic of Ireland as well as Northern Ireland Obstetrics Services, delivered at The Coombe Hospital and transferred postnatally to CHI Crumlin, Paediatric Cardiology Service.

Comparison with Previous Reports

In 2023 there were a total of 961 admissions to the Neonatal Unit (Table 3.1.1). This number has been stable over the past number of years. The presence of the Neonatal Unit Liaison nurse facilitates short term admissions to the unit and provides care of babies on the postnatal ward with their mothers. This reduces the number of full admissions to the unit and minimises separation of the newborn from their family.

In 2023, The Coombe Hospital Neonatal Unit cared for 136 premature infants whose birth weights were between 401 and 1,500 grams and/or whose gestational ages were between 22+0 weeks and 29+6 weeks. This is inclusive of inborn and outborn infants who were transferred to The Coombe Hospital before 28 days of life and 12 infants with major congenital anomalies. These infants and aspects of their care were all prospectively reported into an international collaborative network known as the Vermont Oxford Network (VON). This number was a substantial increase from 2022.

Survival and morbidity data at the point of discharge or death is known for all infants born in 2023. Of these infants, 89% were inborn and 11% were outborn and includes infants with major congenital anomalies. Total survival was 78.7%. Survival of infants admitted to NICU was 80.8%. This was similar to the rate in 2022. Survival to discharge of infants without specified major morbidities was 58.5%.

In 2023 we cared for a higher number of extremely preterm infants born less than 24 weeks gestation than in previous years. A high proportion of these infants received support and resuscitation at birth. The mortality of these infants remained high. The Coombe Hospital has developed Project 23 in order to provide excellence in care for these smallest infants. We work closely with our obstetric colleagues. Specialised equipment, guidelines and staff are available 24/7 to ensure that a high standard of care is provided.

There was a continued high usage of any breast and/or a diet of exclusive breast milk for Vermont Oxford Extreme Preterm babies at discharge from the NICU. For the year 2023 the use of ‘any human milk on discharge’ was high at 56.8% and ‘human milk only’ was 41.5%. The percentage for the entire VON Network was 55.4% and 11.8% respectively. The unit benefits from the full-time presence of Lactation CNS and weekly nutrition rounds.

Three major clinical and research hubs at University College Cork, Trinity College Dublin and the Royal College of Surgeons in Ireland University of Medicine and Health Sciences have been developed in partnership with the Cerebral Palsy Foundation (CPF) to establish Ireland as an international leader in CP care and research. The CPF have funded these clinical and research hubs. Children’s Health Ireland is the implementation partner in the academic healthcare programme. The aim of the STRIVE programme,

a quality initiative (QI), which was established in The Coombe Hospital in April 2023 is to improve health outcomes for children with or at high-risk of CP. The hypothesis of STRIVE is that the use of standardised clinical assessments in infants who are at high risk for CP will reduce the age of diagnosis of CP to under 12 months of age. The STRIVE programme at The Coombe Hospital is led by Dr John Kelleher (Consultant Neonatologist) and Dr Roisin Phipps (Clinical Specialist Physiotherapist).

To date, at The Coombe Hospital, this QI has achieved the following:

• Clinical Specialist Physiotherapist employed for 21 hours a week

• data collection internal (infants born in The Coombe Hospital): n = 132 infants

• data collection external (infants born external to The Coombe Hospital): n = 50 infants

• STRIVE QI to date (Early Detection and Intervention for Cerebral Palsy in Ireland): n = 132 infants

• general movements assessment completed in NICU from beginning of study: n = 101 assessments

• outpatient appointments offered: n = 124 (a mixture of three, six and nine month assessments)

• CP diagnosis (n = 4) and high-risk for CP diagnosis (n = 4).

Neonatology is a team effort. Thank you to every single person who contributes to provide care for the smallest, sickest and most vulnerable babies in our hospital. We are supported by colleagues in Children’s Health Ireland, who continue to consult. In particular, we are grateful to Professor Orla Franklin, Consultant Paediatric Cardiologist who continues to provide an excellent onsite Fetal Cardiology and Postnatal Cardiology Consultation Service. A further note of gratitude to paediatric consultant radiologists Drs Eoghan Laffan, Clare Brenner and their CHI colleagues and to the excellent team of radiographers. We are extremely grateful to our two consultant paediatric ophthalmologists, Mr Donal Brosnahan and Dr Kathryn McCreery who provide retinal screening and follow-up. Thank you to Mr Brian Sweeney (Paediatric Surgery), who with Professor Mairead Kennelly (Fetal Medicine Specialist) and Dr John Kelleher (Neonatology) set up the Fetal Surgical Clinic in 2023.

This provides families with an opportunity to meet all the relevant specialities in advance of giving birth to a baby that will likely require surgery in the neonatal period. A thank you to all staff members and my colleagues in the Neonatal Unit for their hard work throughout 2023.

I wish to acknowledge the efforts of my consultant neonatology colleagues Professor Jan Miletin, Professor Martin White, Dr John Kelleher, Dr Pamela O’Connor, Dr Jana Semberova, Dr Hana Fucikova, Dr Jan Franta, Professor Eleanor Molloy and Dr Mary O’Dea. I congratulate Dr Matthew McGovern and Dr Madeleine Murphy on their appointments to the Consultant staff.

Our nursing colleagues, led by Ann Kelly, CNM3 are second to none. They provide high quality care to the babies and families they encounter. Anne O’Sullivan, RANP is tireless with her teaching and encouragement of us all. We expanded our RANP team this year and we were delighted to welcome Siobhan Hackett back to the Coombe! Peter Duddy, Neonatal Pharmacist is such a fantastic source of support and wealth of knowledge, we are grateful for his involvement in a clinical and research capacity. Thank you to the healthcare assistants and ward attendants who care for our babies and families. We were sad to see our clinical Specialist Dietitian Dr Rosyln Tarrant move on to another role this year and delighted to welcome Fiona Dunlevy to a role in the neonatal unit. We expanded our team this year to include a Neonatal Occupational Therapist, Dr Sara Kift who provides a comprehensive inpatient and outpatient service.

I wish to thank Julie Sloan (Data Analyst) for keeping me on track again this year. I am also grateful to Catherine Barnes, Ciara Carroll and Emma McNamee for their respective roles with this report. The administrative staff in the Baby Clinic and the Neonatal Unit are always so quick to help and kind to the families that they meet.

We aim to continue to expand our team in 2024 with a Neonatal Speech and Language Therapist, Neonatal Psychologist and Physiotherapist.

Finally, we see such joy and sadness in the Neonatal Unit. Our thoughts are with the families that suffered bereavements during this year. To all the families that we meet, it is an absolute honour to be part of your journey. We feel privileged to play a small part in your lives. Keep sending the photographs, cards and updates.

Research in the Department of Paediatrics and Newborn Medicine

The Neonatology Department continues to be very active in research. We conduct numerous research projects ourselves and participate in other multicentre and international studies. Five research fellows in neonatology worked with us in 2023; Drs Meredith Kinoshita, Aoife Branagan, Dearbhla Byrne, Jsun Wong and Robert McGrath.

See sections 11.7, 11.8 and Appendix Two for details on research grants held in 2023 and research outputs in 2023.

3.2 Advanced Nurse Practitioner in

Neonatology

The role of the registered advanced neonatal nurse practitioner (RANP) is to enable consistency in the standard of health care in the Neonatal Unit. This is achieved by having a presence in the clinical area ensuring care is evidenced based and supported by Policies, Procedures, Protocols and Guidelines (PPGs), as well as offering support and guidance to medical and nursing staff at the bedside. The RANP is involved in all key performance indicators, working closely with other members of the multidisciplinary team to minimise healthcare associated infections and antibiotic use as well as strategies for the prevention and control of multidrug resistant organisms. The RANP works to reduce ventilation days and minimise the incidence of chronic lung disease as well as ensuring optimal nutritional management, while addressing the very specific needs of the extremely low birth weight infants born less than 27 weeks’ gestation. Other priorities include the promotion of breastfeeding and family centred care.

The RANP promotes and facilitates research and audit activities by participating in research studies as a primary researcher, investigator and data collector. The RANP participates in undergraduate and postgraduate education programmes for neonatal nurses, midwives, public health nurses and non-consultant hospital doctors (NCHDs) as well as participating in the National Neonatal Transport and Neonatal Resuscitation Programs. Having established a simulation room and equipment over the last few years, a simulated program is now established using lifelike models to provide optimal training of nurses and NCHDs. This empowers clinical staff with the knowledge and skills to address the multiple competing needs of neonatal infants at delivery and in the Neonatal Unit in a timely fashion.

A second RANP, Siobhan Hackett, joined the Neonatal team in July 2023. It is our ambition to facilitate the presence of an RANP 24 hours per day in the Neonatal Unit, by the recruitment of more RANPs.

Publications

See Appendix Two for a list of peer-reviewed publications from the Department of Paediatric Medicine and Newborn Medicine in 2023.

3.3 Midwifery and Nursing Neonatal Report

2023 was another demanding year for the Neonatal Unit (NNU) which saw the Neonatal Intensive Care Unit (NICU) and Special Care Baby unit (SCBU) relocate to the 3rd floor while works were carried out on the 2nd floor. True to form the neonatal nursing team and allied healthcare professionals carried out the move meticulously. I wish to acknowledge our excellent nursing team that consistently display great teamwork and during periods of high activity in the unit or when short staffed make themselves available to cover shifts, thank you.

Anne O’Sullivan

Ann Kelly

Although Neonatal Nursing recruitment and retention remains a challenge; seven neonatal nurses joined our team (six from overseas and one from Ireland) however we lost three senior staff to retirement. We pride ourselves with nurse education in the NNU and it continues to flourish in the NNU with three neonatal nurses graduating with a Post Graduate Higher Diploma in Neonatal Intensive Care Nursing and five neonatal nurses commenced the programme affiliated with the RCSI. Meanwhile six neonatal nurses completed Principles in Neonatal Nursing Level 2 and seven neonatal nurses commenced Principles in Neonatal Nursing Level 1. On recommendation from NWHIP, a second Clinical Skills Facilitator commenced employment in the NNU and an additional Advanced Nurse Practitioner joined our team.

In conjunction with the Reading to your Baby initiative, the NNU for the first time participated in The Babies with Books Read-A-Thon. This is a friendly reading competition between NICUs across the globe to encourage shared family reading and to improve the NICU experience. Reading with babies supports brain development by creating and strengthening brain connections that according to the American Academy of Paediatrics 'build language, literacy and social and emotional skills at a critical time in a child’s development.' Reading with babies in the NICU also provides an opportunity for parents to bond with their babies. It was an enjoyable experience for both parents and staff.

The postnatal ward liaison team continued to strive to keep mother and baby together. The team cared for 1,913 babies in 2023. Indications for referral to the team included transient tachypnoea of the newborn (TTN), oxygen for TTN, hypoglycaemia, cannulation, septic workup, and antibiotic therapy. The work of this team has reduced the need for admission to the NNU and acts as support to postnatal ward staff.

The work of the dedicated NNU Clinical Midwife/Nurse Specialists in lactation support continue to produce significant improvements within the NNU. They continue to provide mothers and staff with access to lactation education and support to ensure the provision of mother’s own milk to premature and sick babies. In 2023, the expressed breastmilk (EBM) initiation rate for all mothers whose babies were born less than 35 weeks’ gestation was 91%. At the time of discharge from the NICU, 80% of babies born at less than 32 weeks’ gestation and 77% born at less than 35 weeks’ gestation received any maternal EBM, while 70%

of babies less than 32 weeks’ gestation and 59% of babies less than 35 weeks’ gestation were receiving maternal EBM exclusively.

In 2023, the lactation support service maintained its post-discharge follow-up via phone calls, facilitating the transition to exclusive breastfeeding for premature babies. Furthermore, the team expanded their services by setting up a new NICU lactation clinic, with designated capacity, in August 2023. The Blood Bikers service continued to ensure a consistent supply of maternal milk was transported from homes to the NICU. Additionally, the face-to-face preterm lactation workshop was reinstated, taking place every Thursday with the aim of providing prematurity specific lactation education to all antenatal inpatients.

The provision of 20 free breast pump loans to mothers with preterm or sick babies continued to be successful in 2023.

A NICU specific breastfeeding education programme for staff was held twice in 2023 in collaboration with the CME, the National Maternity Hospital, the Rotunda Hospital, the Midland Regional Hospital Mullingar, and the Midland Regional Hospital Portlaoise. These sessions were attended by 50 NNU staff members. Significantly, there has been a notable improvement in NNU staff participation in breastfeeding education, rising from 30% in 2022 to 60% in 2023. The aim is to achieve 100% participation by 2024.

The NICU lactation CM/NS team published an article in the journal MIDRIS Midwifery Digest (edition 33:1, 2023), entitled ‘Impact of NICU Dedicated Lactation Specialist on Breastfeeding Outcomes of Preterm Infants - An Audit Review.’ In November 2023, the Scientex Conference extended an invitation to the team to serve as speakers at the 2nd International Midwifery and Neonatal Care conference in Dubai. Representing The Coombe Hospital on an international platform, the team presented their work and shared valuable knowledge with the broader NICU community.

One of the most exciting service developments to take place in 2023 was the establishment of the Newborn Individualised Development Care and Assessment Programme (IDCAP) clinical nurse specialist (CNS) post in the Neonatal Unit, which was taken up by Mary O’Connor. This post is dedicated to infant and family centred developmental care, striving to help provide an individualised approach to support and care, based on reading each preterm baby’s behavioural cues. From this a care plan is formulated, that enhances and builds on each baby’s strengths, and supports babies in areas of sensitivity and vulnerability.

The NIDCAP CNS is a resource and support for staff, and provides education sessions inhouse for the interdisciplinary team, CHI neonatal staff, and the CME. Additionally, the NIDCAP CNS facilitates Family Infant Neurodevelopmental Education (FINE) as a member of the FINE Faculty (UK). The NIDCAP CNS facilitated FINE Level 1 training in Romania, in collaboration with colleagues from University College Hospital and London. The NIDCAPS CNS represented The Coombe Hospital at the 34th NIDCAP Trainers’ Meeting in Chicago, and subsequently provided feedback to the interdisciplinary team.

The CNS provides support for parents in caring for their baby and collaborates with the Specialist Perinatal Mental Health Service (SPMHS) in facilitating a weekly parents’ group entitled Parents’ Time Out (PTO). Here parents have an opportunity to meet in a safe place and talk about the unique experience of having a preterm baby in the NICU, thus providing psychoeducation. Feedback has been very positive and included the following; “The Parent’s group is a lovely opportunity to meet with and chat to other mammies and daddies about experiences since the arrival of our amazing babies. I would rightly recommend attending.” “I liked the chance to listen to others and tell my story.” A number of parents reported finding the skill building component of the groups beneficial. Since the establishment of the PTO group, neonatal staff report a significant reduction in the need for onward referrals to SPMHS. Parents who are experiencing distress are now identified early and referred to the PTO as a first line, targeted intervention.

The National Neonatal Transport Programme (NTTP) continued to be very busy completing 610 transports in 2023, compared to 577 in 2022. The Coombe Hospital received 43 (32.8%) of all the national referrals (n = 131) for neonatal management in a tertiary NICU. In 2023, 43 (45.3%) of the 95 neonates referred to the three Dublin Maternity Hospitals were transported to The Coombe Hospital by the NNTP.

The NNU received 24 retro transfers of infants born in The Coombe Hospital. These infants were all transferred from Children’s Health Ireland (CHI) following either surgery or cardiology care, 16 from CHI at Crumlin and eight from CHI at Temple Street. Additionally, the NNTP transported four infants born in The Coombe Hospital to St James’s Hospital because their mothers had been transferred there. The NNTP facilitated the transport of 96 infants (96/610 = 15.7% of NNTP transports) from The Coombe

Hospital in 2023. Of these, 80 (83%, 80/96) were transferred to CHI (69 to CHI at Crumlin and 11 to CHI at Temple Street). The remaining 16 infants were returns to hospitals where their mothers had originally booked.

Finally, it is with pride that I wish to thank all staff in the NNU for their continued commitment, and all other staff across The Coombe Hospital for your support in helping us deliver excellent care to the babies and families in the NNU.

Presentation

See Appendix Two for the details of a published conference abstract from the NNU Clinical Midwife/Nurse Specialists in lactation support in 2023.

3.4 Neonatal Transition Home Service

Orla Smyth

The Neonatal Transition Home Service (NTHS) provides education and support to parents of high-risk babies throughout their stay and for several weeks after discharge. The role of the Clinical Nurse Specialist (CNS) is to facilitate and empower families to develop the required knowledge and skills to help them to successfully transition to home. Baby readiness is also assessed in conjunction with the wider multidisciplinary team. Discharge plans are individualised for each family and follow-up appointments are arranged accordingly. Anticipation and planning around additional needs prior to discharge, are vital components of the role of the CNS. Communication with community healthcare providers is essential to ensure optimal ongoing care.

In 2023, 57 families of 61 babies who were born at less than 32 weeks’ gestation and/or weighing less than 1,500 grams at birth and/or babies born with additional medical needs were directly supported by the NTHS. This number was less than that in 2022 (74 families of 85 babies) as the CNS post was vacant from February 2023 until June 2023.

In 2023, twice weekly pre-discharge classes were attended by 131 parents of 65 babies. Parents of preterm babies born at less than 34 weeks’ gestation are strongly encouraged to attend, but all families of babies in the Neonatal Unit (NNU) are welcomed. In addition to Basic Life Support demonstrations, topics discussed include the following: car seat safety, safe sleep and reducing risk of sudden infant death syndrome (SIDS), tummy time, sterilisation and preparation/storage of feeds, nutritional supplementation, moving on with feeding, medication/ supplement administration, managing infection risk in the home, immunisation, recognising signs of illness and seeking medical help and follow-on care. Parents’ feedback from these classes has been very positive and many return for repeat classes. Parents can also be facilitated on a one-to-one basis, if required.

The NTHS provides a point of contact for all parents after discharge from the NNU. In 2023, 577 phone call contacts were recorded, in addition to emails. Scheduled follow-up calls were made weekly or fortnightly to monitor progress and provide advice and reassurance to parents. Individual concerns were addressed in collaboration with the medical team and allied health professionals. Unscheduled calls related to a wide range of topics including feeding and weight, unsettled babies, supplementation, stooling patterns, follow-up and referral queries. Advice was provided and referrals were made, where appropriate, to baby clinic, consultants, lactation team, pharmacist, social worker, dietitian and other health professionals. Calls were also received from public health nurses, GPs, other hospitals and pharmacies, for example, seeking information and advice.

Home oxygen was organised for one baby and arrangements were made for the provision of stoma supplies for another baby.

The NTHS coordinated referral of 52 very high-risk babies to the respiratory syncytial virus (RSV) prophylaxis programme (palivizumab) for the 2022/2023 season. All babies who were born at less than 29 weeks’ gestation or weighed less than 1,000 grams at birth in the previous year were identified and with parental consent, were referred to SynaSupport (home administration team) for monthly injections during the winter months. Prescriptions were dispatched and nine doses were administered in the NNU prior to discharge. The CNS dealt with daily queries from parents, pharmacists and SynaSupport.

In September 2023, referral to community children’s disability network (CDNT) teams, which are early intervention teams, commenced. All babies born at less than 29 weeks’ gestation and/or weighing less than 1,500 grams at birth and babies who were treated with therapeutic hypothermia are referred to community CDNT teams. In 2023, 18 babies were referred to this service.

Pre-recorded online lectures were updated and delivered to students undertaking the Principles of Neonatal Nursing Course. Staff were updated on changes to discharge and nutrition guidelines on an ongoing basis. The NTHS is actively involved in the orientation of new staff members to the neonatal discharge process.

The introduction of ‘Sip til Send’ reduced the fasting times for women scheduled for elective Caesarean section

Section 4 Perioperative Medicine

4.1 Department of Perioperative Medicine

Dr Petar Popivanov

Overview

In 2023, the Department of Perioperative Medicine and Anaesthesiology provided outpatient preoperative assessment for 3,644 elective patients, labour epidural analgesia for 2,729 women and surgical anaesthesia/monitored anaesthesia care for 5,149 patients. Comprehensive inpatient care continued through daily postoperative pain rounds and postnatal epidural rounds. The pain service provided consultations for inpatients and 74 outpatients. The introduction of ‘Sip til Send’ reduced the fasting times for women scheduled for elective Caesarean section. Consistent with the international best practice, the Regional Anaesthesia Alert Bracelet (RAAB) was introduced to assure early recognition of neurological complications following neuraxial anaesthesia/analgesia, while supporting active patient engagement.

Preoperative Anaesthetic Assessment Clinic (PAAC)

In 2023, the Preoperative Anaesthetic Assessment Clinic (PAAC) continued to provide anaesthetic assessment to obstetric and gynaecological patients scheduled for elective surgical procedures, and to obstetric patients with known medical or surgical conditions. The virtual assessment pathway accounted for 39% of attendances in 2023 (Table 4.1.1) compared with 45% of attendances in 2022. The in-person pathway (walk-in and scheduled appointments combined) accounted for 61% of attendances in 2023 (Table 4.1.1) compared with 55% of attendances in 2022. The overall non-attendance rate remained relatively unchanged at 6.4% (248/3,892) in 2023 compared with 6.7% (238/3,552) in 2022 (Table 4.1.2). The appointment of a Clinical Nurse Specialist in Perioperative Medicine expanded the scope of practice of the PAAC by further improving and coordinating the preoperative optimisation of patients with identified risk factors, such as those requiring referrals to single-organ specialists, investigations such as ECHO, MRI, CT scan and follow-up appointments.

Table 4.1.1 Attendances at virtual and in-person appointments, 2023

Table 4.1.2 Non-attendances at virtual and in-person appointments, 2023

Labour and Delivery

Epidural rates have remained relatively stable since 2017 (Table 4.1.3).

Table 4.1.3 Epidural rates in labour*, 2017 to 2023

* Denominators – all nulliparous women and all parous women

Table 4.1.4 Mode of anaesthesia for Caesarean section, 2023

anaesthesia

Table 4.1.5 Spinal anaesthesia and Caesarean section, 2017 to 2023

Operating Theatre

Details about the mode of anaesthesia administered to each patient in the operating theatre (obstetrics and gynaecology are presented in Table 4.1.6. Gynaecological procedures performed as outpatients in the Colposcopy Clinic and The Women’s Health Unit are not included.

Table 4.1.6 Mode of anaesthesia administered per patient in operating theatre, 2023 Mode

The Coombe Hospital

National Cervical Screening Laboratory (NCSL) recommenced screening programme samples in October 2023

Section 5 Pathology and Laboratory Medicine

5.1 Pathology and Laboratory Medicine Overview

Professor John O'Leary and Martina Ring

The Pathology and Laboratory Medicine workload by test result is presented in Table 5.1.1.

There was an increase in the workload of the biochemistry, haematology, transfusion medicine and pathology services in The Coombe Hospital 2023 compared with 2022 (Table 5.1.1). The department underwent the first of its building phases with services being maintained.

The recruitment and retention of staff remained a focus of service provision.

Table 5.1.1 Pathology and Laboratory Medicine workload by test result, 2017 to 2023

5.2 Clinical Biochemistry, Endocrinology and Point of Care Testing

Carl Talbot, Ann O’Donnell and Dr Vivion Crowley

The Biochemistry Department provides test results for diagnostic, screening, therapeutic and disease monitoring purposes. The test repertoire includes 38 biochemistry tests and eight endocrinology tests. Point of care testing (POCT) throughout The Coombe Hospital includes blood gas analysers, glucose meters, meters for testing for threatened preterm labour and rupture of membranes and Clinitek devices for measuring urinary human chorionic gonadotrophin. The Biochemistry Department is accredited to ISO 15189 and 22870 standards by the Irish National Accreditation Board (INAB). The department also participates in research projects with our clinical colleagues in The Coombe Hospital.

The total number of tests performed increased from a trough of 228,598 in 2020 to a peak of 262,133 in 2023 (Table 5.2.1).

Table 5.2.1 Tests performed, 2017 to 2023

* Includes referred tests

The Biochemistry Department moved to its newly refurbished location on 11th October 2023. A new Roche Cobas Pure Immunoassay analyser was received in December 2023 which allows for repatriation and expansion of the hormone assay service provided by the Biochemistry Department. The Biochemistry Department successfully passed its ISO 15189 inspection by INAB on 11th December 2023. The Biochemistry Department verified for use and implemented 10 new assay reagent formulations. These new ‘Sigma Strong’ reagents were released by the manufacturer to improve reagent stability and performance.

Continuous professional development and ongoing education continued to be promoted, with two members of staff completing their Masters in Biomedical Science. Members of the Biochemistry Department also participate at a national level in committees and advisory boards, including Academy of Clinical Science and Laboratory Medicine (ACLSM) advisory body for point of care testing, Green Lab Initiative, Irish Society of Inherited Metabolic Disorders (ISIMD) and European Federation of Laboratory Medicine (EFLM) task force for young scientists.

5.3 Haematology and Transfusion Medicine

Fergus Guilfoyle and Professor Catherine Flynn

There were increases in haematology and transfusion medicine requests in 2023 compared with 2022 (Table 5.3.1). Requests in haematology increased by 2,104 and requests in transfusion increased by 892 (Table 5.3.1). The turnaround times (TATs) for haematology and transfusion medicine are shown in Table 5.3.2 and Table 5.3.3, respectively. There were slight improvements in average TAT in 2023 in comparison to 2022, but the long-term trend continued to show increases in average TATs over the last seven years. This reflects the growing workload within the Haematology and Transfusion Medicine Department due to theincreased complexity of our patient population and ever-growing demands on staff resources to fulfil regulatory and quality requirements.

Table 5.3.1 Haematology and Transfusion Medicine requests, 2017 to 2023

Table 5.3.2 Haematology, Turnaround Times (TATs), 2017 to 2023

Full blood count

Table 5.3.3 Transfusion Medicine, Turnaround Times (TATs), 2017 to 2023

Crossmatch

Inpatient group and screen

There were significant additional challenges to maintaining the service in 2023 as the department moved to a temporary location for six months of the year, before returning to a newly refurbished location. While there are great benefits to the department from the renovated facilities, maintaining a quality service for patients in a greatly reduced work area in 2023 and reinstating ISO 15189 accreditation from INAB twice throughout the year posed a significant demand on staff resources.

The department also completed installation and full validation of new equipment for the provision of most of the testing within transfusion. This was successfully reviewed by INAB in November 2023. Following completion of installation and testing of ICT links, the new equipment is due to go into service in early 2024.

There was a significant level of staff turnover in the department in 2023 which led to a greater demand for staff training. The complexity of conditions that obstetric and neonatal patients attending The Coombe Hospital have, as well as the numbers of such patients with conditions such as simple and complex cytopoenias, bleeding and thrombotic comorbidities and sickle cell disease, have increased in recent years.

Despite workload challenges, continuous professional development and ongoing education continued to be promoted, with a Senior Medical Scientist presenting two posters at the Haematology Association of Ireland conference.

5.4

Haemovigilance

Professor Catherine Flynn and Sonia Varadkar

Haemovigilance is a surveillance system which covers the entire transfusion chain. The surveillance covers all aspects of transfusion from ‘vein-to-vein’ that is from the donation of blood and its components to their safe transfusion and patient follow-up. The haemovigilance function records and analyses expected outcomes and unexpected adverse events.

The Coombe Hospital has a Blood Transfusion Committee that meets four times a year. This committee discusses transfusion issues and helps identify issues as they arise so as to improve care for both women and babies attending The Coombe Hospital. The team is made up of laboratory and clinical staff with an interest in safe blood transfusion. The team is clinically focused on good practice and the provision of new services for our patients. In 2023, the ‘Guideline of anti-D administration’ was updated to include targeted routine antenatal administration of anti-D immunoglobulin. Following a maternal blood test, the baby’s Rhesus factor can be determined antenatally, and anti-D immunoglobulin can be administered to Rhesus negative woman with a known Rhesus D positive baby. This means Rhesus D negative women with a known

Rhesus D negative baby do not need to be given anti-D immunoglobulin antenatally.

In 2023, there was a marked increase in the number of women requiring a blood transfusion (Table 5.4.1). There are two main reasons for this which has been recognised nationally; anaemia prior to delivery and blood loss at the time of delivery. In 2023 the ‘Clinical guideline for the diagnosis and treatment of anaemia in pregnancy and post-delivery’ was reviewed. This guideline not only advises on the use of oral iron in pregnancy but includes the treatment of other nutritional deficiencies such as vitamin B12 and folate deficiency. Prompt management of anaemia antenatally could further reduce postnatal transfusion rates. In 2023, the ‘Adult Blood Transfusion’ patient information leaflet was updated and is based on the national information leaflet. With all new guideline updates, education of staff was provided by the team.

Table 5.4.1 presents the categories and numbers of women who received a blood transfusion between 2021 and 2023. Even though the postnatal transfusion rate increased from 2.3% in 2021 to 3.3% in 2023, 59.4% required a single unit transfusion (Table 5.4.2) compared to 24% in 2021.

Traceability is achieved on 100% of all products leaving our laboratory due to appropriate ICT systems and the due diligence of all our laboratory and clinical team.

There were ten reports to the National Haemovigilance Office in 2023, the same number as 2022 (Table 5.4.3). Six of the reports where wrong blood in tube (WBIT), where blood is taken from patient A and labelled with patient B’s details. All were found by laboratory staff performing routine checks correctly and no patient was transfused incorrectly. There were three anti-D immunoglobulin issues and one preventable blood transfusion due to untreated anaemia identified antenatally.

* Red cell concentrate, plasma, fibrinogen or platelets

5.4.2 Postnatal women who received red cell concentrate (RCC), 2023

Table 5.4.1 Women who received a blood transfusion* by category, 2021 to 2023

Table

Table 5.4.3 Haemovigilance summary data, 2017 to 2023

Women who received a transfusion

Women who received ≥ 5 RCC within 24 hours of delivery

Reports to National Haemovigilance Office

5.5 Histopathology and Morbid Anatomy

Kate Thompson and Professor John O'Leary

In 2023, the department had its busiest year to date. The number of specimens received in 2023 increased by 17,861 compared with 2022 (Table 5.5.1). This was preceded by a decrease of 1,582 specimens between 2021 and 2022. The number of post mortems increased from 38 in 2022 to 58 in 2023. There was also a significant increase in the number of blocks processed from 20,544 in 2022 to 24,935 in 2023. The application of immunohistochemistry (IHC) increased by 1,199 between 2022 and 2023 highlighting the increasing complexity of the cases received. Special stains requests gradually increased from 45 in 2018 to 240 in 2022 with a steep rise to 594 in 2023, confirming its continued importance in a modern histopathology laboratory.

Table 5.5.1 Histopathology workload, 2017 to 2023

*Haematoxylin and eosin stain

Turnaround times (TATs) remained challenging in 2023 (Tables 5.5.2 and 5.5.3). However, they improved in the second half of the year. The addition of a 0.2 whole time equivalent reporting Consultant Histopathologist, helped significantly to improve the TATs.

Table 5.5.2 Total TATs, 2017 to 2023

* Not possible to complete overall 2021 or 2022 TAT report as December 2021 to March 2022 data are not available on the Health Atlas Ireland website due to the December 2021 cyberattack

Table 5.5.3 Histopathology specimen TATs, 2023

In 2023, Florence Cunningham left the Histopathology Department and moved to the Pathology Quality Department. Rosana Alves took up the role of Senior Medical Scientist. Eibhlin Gallagher completed her MSc in Biomedical Science and Ellen O’Reilly completed the second year of her MSc. Mary Ellen Ryan, Rosana Alves, and Helen Lambkin began a histodissection course with Technological University Dublin (TUD). All staff attended multidisciplinary meetings, as well as profession specific courses, and conferences throughout the year.

2023 was the department’s busiest year to date, and we were at our lowest staffing numbers since 2019. Despite the challenges of the increased workload and the decreased staff numbers, the staff of the Department of Histopathology staff maintained professional standards ensuring that the quality of the service provided did not diminish.

INAB ISO 15189 accreditation for histopathology was suspended in the first half of 2023 due to consistent issues with TATs. Remedial actions were put in place that resulted in an improvement in TATs in the second half of 2023. Further actions have been approved that will allow us to meet our TATs going forward.

5.6 HPV and Cytology Screening

Aisling O Connor, Padma Naik and Dr Louise Hogan

The National Cervical Screening Laboratory (NCSL) processed 9,817 cervical screening samples in 2023 compared with 5,398 in 2022. Table 5.6.1 presents the results of specimen throughput from 2021 to 2023. Testing ceased in the NCSL from March 2023 until October 2023. The NCSL regained INAB accreditation status in October 2023 and resumed CervicalCheck testing. A number of key managerial posts were added to the NCSL staff between October and December 2023.

Prior to recommencement of the service, all equipment (Cobas 6800, 8800 and Hologic T5) was validated and accredited, increasing the capacity, automation and streamlining of the service. Staff attended and presented at various conferences and meetings throughout 2023 on behalf of the service and their continuous professional development bodies.

We look forward to service ramp up in 2024.

Table 5.6.1 Specimen throughput, 2021 to 2023

5.7 Microbiology and Infection Prevention and Control

Dr Niamh O’Sullivan, Geraldine Chawke, Alma Clancy and Cian Foley

Microbiology

The Microbiology Department is accredited by the Irish National Accreditation Board to ISO 15189: 2012 Standard. Workload figures in 2023 were similar to those in 2022, apart from environmental screening which decreased by 422 (Figure 5.7.1) and SARS-CoV-2 testing which decreased by 4,133 (Table 5.7.1). Figure 5.7.2 presents the send out workload from 2017 to 2023.

Turnaround times (TATs) were audited on 22 occasions in 2023. Blood cultures, urinalysis, microbiology specimens (both simple and complex), pregnancy tests, referral tests, SARS-CoV-2, cerebrospinal fluid microscopy and positive blood culture microscopy were included in these audits. Nineteen (86.4%) audits were within target which was an improvement compared with 2022, when 15 (71.1%) of 21 audits were within target.

A significant challenge faced by the Microbiology Department in 2023 was the relocation to a temporary laboratory on the first floor of the pathology building. The microbiology service was situated in the temporary laboratory for 11 months. A quality service was maintained for patients in a reduced space in 2023, with ISO 15189 accreditation from INAB re-instated twice, once following relocation and again following the annual INAB assessment in November 2023. This additional workload posed a significant demand on staff resources.

The Microbiology Department also completed the installation and verification of two new microbiological safety cabinets in the temporary laboratory and one new microbiological safety cabinet in the andrology laboratory. In addition, three new Fiocchetti double fridges and one new Don Whitley anaerobic cabinet were installed and verified in the temporary laboratory.

Throughout 2023 the Microbiology Department was shortstaffed by 3.5 whole time equivalent medical scientists, 2.5 of which were at senior grade level. Laboratory aide staff were recruited during 2023, leading to increased training demands within the Microbiology Department. While having laboratory aide staff was a support, the remaining workload of the vacant medical scientist posts was distributed amongst existing medical scientific staff, thereby increasing the workload burden within the department.

Senior staff regularly attended multidisciplinary meetings within The Coombe Hospital including Drugs and

Therapeutic Committee, Infection Prevention and Control Committee, Point of Care Committee and Obstetric and Paediatric meetings. The Infection Prevention and Control dashboard was maintained, alert organism and environmental screening continued and antibiogram data were produced to inform antimicrobial guidelines.

Despite the detailed challenges, continuous professional development and ongoing education continued. Departmental and on-call staff completed microbiology competencies and trained on the new film array analyser for positive blood cultures. Two students from Technological University Dublin completed placement training and two microbiology staff completed on-call competencies in biochemistry, haematology and blood transfusion. Staff completed mandatory health and safety training. Events attended by microbiology staff throughout 2023 included sepsis meetings, Academy of Clinical Science and Laboratory Medicine (ACSLM) Biomedica event, European Committee of Antimicrobial Susceptibility Testing (EUCAST) workshop, quality improvement initiatives and pathology non-conformance training, advanced Rees scientific training and instrument manager training.

Urine

Blood Culture

High Vaginal Swab

Other

Sensitivities

Pregnancy Tests

Cerebrospinal Fluid

Environmental

Semen Analysis

Ureaplasma/Mycoplasma

Figure 5.7.1 Microbiology workload, 2017 to 2023

Table 5.7.1 SARS-CoV-2 testing by laboratory, 2020 to 2023

Figure 5.7.2 Send out Microbiology workload, 2017 to 2023 2,000 12,000

Total Referral Test 2020 2019 2018 2017 2016

NVRL Tests

Infection Prevention and Control

Infection Prevention and Control (IPC) remain paramount priorities in The Coombe Hospital ensuring the safety and wellbeing of our patients, staff and visitors. Good IPC is essential to good clinical care. IPC services exist to support everyone in delivering clean and safe care. Through rigorous adherence to international and national guidelines, comprehensive staff straining and ongoing monitoring, we strive to maintain the highest standards of IPC practices throughout The Coombe Hospital.

IPC encompasses several key elements such as:

• hand hygiene

• environmental hygiene

• equipment hygiene and management

• safe linen and waste management

• safe patient placement

• appropriate use of personal protective equipment (PPE)

• antimicrobial stewardship

• safe use and management of sharps

• safety engineered devices and medication vial

• reprocessing of reusable medical devices

• respiratory hygiene and cough etiquette

• aseptic technique

• surveillance and monitoring

• education and training

• implementation of transmission-based precautions as required.

Effective hand hygiene remains the foundation for providing safe care for everyone. It is the single most effective strategy in preventing healthcare associated infection (WHO, 2009). The overall hand hygiene compliance for 2023, in accordance with the ‘5 moments for Hand Hygiene’, was 97% in The Coombe Hospital compared with 90% in 2022.

The Coombe Hospital achieved 98% in the national audit for period 26, higher than the set target of 90%.

The IPC team and the IPC Committee (IPCC) actively participated in working toward improving standards to reduce the risk of healthcare associated infection to patients, visitors and staff. This was done through daily

communication (face to face, phone or email) or by input into multidisciplinary team meetings or by membership of Sepsis Committee, Drugs and Therapeutics Committee and other meetings as required by the service. A small projects group was developed in response to an increase in environmental upgrades and the IPCC increased meetings from quarterly to six meetings per year.

In response to an external audit conducted by the HSE in 2022 of compliance with the HSE Procedure for the Prevention of Peripheral and Central Venous Catheter Related Infection (September 2021) a quality improvement project (QIP) commenced. This resulted in the development of the ‘Maternity Booklet.’ The implementation of this booklet is expected in 2024, following a pilot trial. A CMM2 started working in the IPC team in October 2023.

An announced HIQA inspection took place in October 2023 to monitor compliance with the National Standards for Safer Better Healthcare.

Surveillance

Both the adult blood stream infection (BSI) rate and the S. aureus hospital acquired infection (HAI) rate decreased in 2023, a marked improvement compared with 2022 (Table 5.7.4). The rates of paediatric early onset sepsis (EOS) and late onset sepsis (LOS) increased significantly in 2023, with LOS increasing by greater than three-fold compared with the rate in 2022 (Table 5.7.4). The goal in 2024 is to return to a decreasing trend for both EOS and LOS. The C. difficile HAI rate decreased in 2023 compared with 2022 (Table 5.7.4).

Table 5.7.4 Infection rates, 2019 to 2023

5.8 Phlebotomy

Art Arganio and Martina Ring

The workload of the Phlebotomy team in the Adult Outpatient Department in 2023 reflected the number of patient attendances at The Coombe Hospital. The numbers presented in Table 5.8.1 are patient attendances, not the numbers of blood samples taken from each patient. While the number of first visit attendances decreased by 1,656 between 2022 and 2023, the number of patient attendances for other indications increased by 679 (Table 5.8.1).

Table 5.8.1 Phlebotomy service in the adult OPD and Perinatal Centre, 2017 to 2023

Despite a decrease in the number of first visit attendances, the number of patients referred for confirmation of diabetes mellitus or with a suspicion of gestational diabetes mellitus increased in 2023. In 2023, there were over 1,000 attendances per month for perinatal glucose tolerance tests (GTT) and/or fasting and post prandial (FPP) tests. There was a 1.5% increase in the number of GTTs and FPPs performed in 2023 compared with 2022.

In 2023, compliments and the overall feedback received from women and families was 90% positive

6.1 Bereavement Support Services

Anita Bouderbala and Fiona Mulligan

The team provides a holistic approach to bereavement care aligned to the National Standards for Bereavement Care (HSE 2016/2022).

Support is available for all parents who experience early pregnancy loss and perinatal death, at the time of loss, in the weeks and months that follow, and includes care in relation to anxiety in a subsequent pregnancy. The Bereavement Midwives also provide bereavement support and ongoing care for families who receive a diagnosis of a life limiting condition and who choose to end their pregnancy early in line with Irish legislation and care services. The Bereavement Midwives work closely with all departments, specifically the Pathology Department, the Fetal Medicine Department, the Early Pregnancy Assessment Unit, the Medical Social Work Department and Chaplaincy, using a multidisciplinary approach to Bereavement Care.

The Bereavement Midwives coordinate the formal structured follow-up care of bereaved parents following multidisciplinary team discussion at the monthly perinatal mortality meeting. The team advocates for the needs of bereaved parents, and the development of service provision in response to these needs.

The CMSs in bereavement and loss provide bereavement support to couples attending the Leaf Clinic who have experienced recurrent miscarriage and/or unexpected mid-trimester miscarriage.

The team provide ongoing training and education in bereavement support to staff in The Coombe Hospital. The team contribute to midwifery programmes for staff midwives in the Centre for Midwifery Education (CME),

on undergraduate programmes in TCD, on postgraduate neonatal nurse programmes and on staff induction sessions, in addition to providing informal education in the clinical setting.

A training programme entitled ‘Dealing with Loss in Maternity Settings’ is facilitated by Anita Bouderbala and Fiona Mulligan in collaboration with the CME. The training programme has been facilitated by The Coombe Hospital and is highly valued.

The team is a resource for all staff and provides informal support to staff impacted by providing care to bereaved families. The bereavement team has worked to forge links with the voluntary support agencies that provide care to bereaved families in the community, with recognition of their invaluable support to families.

The Annual Service of remembrance is held on the first Sunday after Easter in Our Lady of Dolours Church, Dolphin’s Barn. In 2023 the number of attendees increased compared to 2022. Both family members and staff were active participants in the service which enriched the significance of this yearly event, along with the beautiful performance from The Coombe Hospital choir and refreshments provided by the Catering Department.

6.2 Clinical Nutrition and Dietetics

Fiona Dunlevy

In 2023, 82% of women with type 1 diabetes mellitus and 97% of women with type 2 diabetes mellitus were seen by the Clinical Nutrition and Dietetic Service. Fifty-four percent (284) of neonatal patient contacts occurred as inpatients (Table 6.2.1).

The team had an additional 1,020 neonatal patient contacts during neonatal multidisciplinary team ward rounds (Figure 6.2.1). Most outpatient patient contacts were delivered virtually, offering a service at a time and place that is both convenient for parents and delivers efficiencies in terms of the department, in keeping with the Strategic Guidance Framework for Health and Social Care Professions 2021 - 2026.

The department provided ongoing nutrition related education, to colleagues in The Coombe Hospital and affiliated universities. This included dietetic student placements. Our dietitians are actively involved in The Coombe Hospital’s committees, local and national guideline development, quality improvement initiatives and working groups including the Neonatal Dietitians Ireland, Maternity Dietitians Ireland and Expert Advisory Group.

Table 6.2.1 Patient contacts with Clinical Nutrition and Dietetics, 2017 to 2023

* Excludes patient seen on ward rounds

Due to staffing issues, there was a gap in the provision of Clinical Nutrition and Dietetic Service to diabetes, obstetrics and gynaecology services in 2023. In addition, there was a disruption in clinical nutrition service to both neonatal inpatients and outpatient service at different periods of 2023. This lack of available staff in 2023 significantly impacted the provision of clinical nutrition and dietetic service. However, by the end of 2023 staffing levels had increased and had returned to near normal levels.

6.3 Medical Social Work Department

Kate Burke

In 2023, the Medical Social Work (MSW) Department received 1,152 new referrals, 81 more referrals than in 2022. There was also a small cohort of patients who delivered prior to 2023 who continued to receive service from their allocated Medical Social Worker during 2023. Over 66% of referrals were allocated to a Specialist Medical Social Worker with advanced knowledge and skills in the specific area of need. Approximately 45% of new referrals required an immediate medical MSW intervention for reasons which included child protection and patient safeguarding. Unfortunately, a waiting list remained necessary in 2023 for non-urgent referrals. However, efforts were made to ensure efficient prioritisation, led by patient need and complexity. The waiting list averaged 42 patients in 2023 compared with 31 patients in 2022. This is reflective of a number of factors including increased referral numbers, patients presenting with increased complexities and periods of staff shortages.

The MSW Department provided professional support to the Midlands Regional Hospital, Portlaoise (MRHP). A MSW Service was provided to patients of the maternity and neonatal units in MRHP. This service received 164 new referrals in 2023. There was a total of 211 patient contacts which included a small number of women who gave birth prior to 2023. The Senior MSW Service attached to the Specialist Perinatal Mental Health Service in The Coombe Hospital resumed in 2023 and provided a one-toone service to 83 patients as well as facilitating a number of patient support groups.

The MSW Department continued to provide psychosocial, emotional and practical assessment and support to women, their partners and families. Support is provided for a wide range of issues, but most of our referrals are covered under eight specialist areas; addiction, bereavement and fetal medicine, domestic violence, inclusion health, mental health, options in pregnancy, neonatal unit, and those who become pregnant under 18 years of age. Each of these eight specialist areas has a dedicated Medical Social Worker who participates in

ongoing training ensuring the provision of a high quality of care. Continuity of care is considered important by women and staff so the attachment of the Medical Social Workers to the obstetric teams continued, where possible, for all other referrals. To always provide a responsive service, the department also operated a duty system for all other clinics that do not have a dedicated Medical Social Worker.

During 2023, child protection and patient safeguarding referrals, including domestic violence and abuse continued to take priority. These cases represented a high percentage of the referrals that required an immediate MSW intervention and early identification by multidisciplinary colleagues was essential. Medical Social Workers continued to promote the importance of the Children First Act, 2015, supporting other mandated reporters within The Coombe Hospital. The department also continued in its role as the lead representative for The Coombe Hospital in the collaborative Maternity Project with Women’s Aid. The department supported the launch of the ‘Women’s Aid Pilot Training Project’ in November 2023 to support clinical colleagues in engaging in domestic violence training.

In 2023, the department saw a 26% increase in referrals of homeless women and families, compared to 2022. We continued to see an increase nationally in homelessness including a record high number of homeless families and children in emergency accommodation in 2023. The department continues to see significant numbers of pregnant women seeking International Protection. In June 2023, the Inclusion Health Senior Medical Social Worker was involved in the roll-out of the Daisy Clinic (a clinic developed for social inclusion). This is a midwifery-led and MSW supported antenatal clinic for women who are experiencing homelessness or are at risk of homelessness or are seeking International Protection or are in emergency accommodation. The Daisy Clinic provides a holistic approach to the care of women, by addressing the individual medical and psychosocial needs of each woman.

Throughout 2023, the staff in the MSW Department demonstrated an ongoing commitment to their own CPD to the direct benefit of our patients. The department also continued to maintain strong working relationships with third level education providers. Gretchen McGuirk and Kerri O’Brien were guest lecturers in the Department of Midwifery in Dundalk Institute of Technology on

the topics of ‘Fundamentals of Understanding and Responding to Domestic Violence’ and ‘Substance Misuse in a Maternity Setting.’ Kerri O’Brien achieved a First Class Honour in a Postgraduate Certificate ‘Trauma informed care: Theory to practice.’

The cost-of-living crisis continued to have a significant impact on many of the patients who engaged with the MSW Department in 2023. A significant number of patients/ women required practical financial support. We continue to be indebted to the members of Coombe Care who provide support to patients by way of necessary practical help during pregnancy, at the time of a baby’s birth, or in the immediate postnatal period. Furthermore, access to accommodation for parents who live outside of Dublin and whose babies are admitted to the Neonatal Unit remained an ongoing challenge for families and staff. Medical Social Workers along with staff in the Neonatal Unit work tirelessly to facilitate support plans for families. The support from Friends of the Coombe and from Hugh’s House is invaluable in this regard and the MSW Department remains grateful for the support provided to parents by these charity organisations.

My thanks to all the staff in the department, including Medical Social Workers and administrations staff, for all their hard work and dedication throughout the year. Despite the challenges associated with periods of reduced staffing and increased activity within the department; the level of commitment to best practice and to supporting colleagues is both greatly appreciated and deserving of special mention. The support of our colleagues in other departments within The Coombe Hospital was greatly appreciated, as was the support of our colleagues, both social work and non-social work, within the community.

Publications

See Appendix Two for a list of peer reviewed publications and details of a published conference abstract from the MSW team in 2023.

6.4 Pastoral Care

Ann Marie Desmond and Susan Jones

The Chaplaincy Department is staffed by two full time Chaplains; Ann Marie Desmond and Susan Jones. Both provide pastoral and spiritual care to all interested patients and families, as well as to staff and students of The Coombe Hospital.

In their pastoral ministry the chaplains are open to engaging with everyone through deep listening and non-judgement. The Chaplains understand that everyone they meet in their ministry is spiritual in some form or another since the spirituality of an individual is expressed through their psychosocial-cultural experiences within their life’s context.

The Chaplains work within a multidisciplinary hospital team; daily on the wards and through attendance at the weekly perinatal and monthly neonatal meetings. They are also members of the Bereavement and the End of Life teams. There is a very positive rapport with the pathologists and undertakers which is essential to supporting families around the planning of their baby’s funeral with them. The Chaplains network with staff across The Coombe Hospital who make it possible to fulfil their role. These include in particular; security regarding bereaved families parking while inpatient or for funerals, reception, in allowing visiting clergy/religious representatives through to us; catering department for family room events. ICT for computer or printer problems, the purchasing department for stationary supplies, medical social work for financial assistance with funeral or cremation costs, household staff in distributing donated knitting and blankets, laboratory for fetal tissue remains, and Human Resources for everything else.

They also liaise regularly with local clergy such as Fr Fergal of Dolphin’s Barn Parish, Fr John Kelly, Tallaght Hospital, Rev Laurence, Chief Rabbi Yoni Wieder and Imam Abdullah, among others.

Some of the Chaplains’ hours are spent with calligraphists, Céire and Sr. Margaret who inscribe the names of the deceased babies into the Book of Remembrance,

ensuring that the family’s memory written on the Book of Remembrance Form is recorded accurately into the manuscript pages. Each page is removed, inscribed and re-entered into the Manuscript in the Oratory.

The Chaplains also liaise with outside support agencies e.g. Féileacáin, Every Life Counts, Laura Lynn, The Hospice Foundation, among others.

Pastoral care takes place on all wards daily. NICU and SCBU patients and parents are given priority, especially when there is only one chaplain on duty. Blessings or naming services or the Sacrament of Baptism are provided for babies. Personalised funeral services are organised according to the wishes of parent(s) on the death of their baby, as a step in their letting go journey. Prayers are said at the request of parents, usually when baby is unwell or as they take their new baby home. Chaplains are discerning in their ministry, especially when recommending a visit to the Oratory or offering Holy Communion or holy water. Chaplaincy provision is constantly changing and broadening in Ireland, a multifaith, multicultural country.

A Lá le Bríde workshop was provided for staff and patients to make St Brigid’s Cross in the Oratory for 1st February, St. Patrick’s Day and Easter awareness reflections and services were held to support staff. Staff members of the Muslim faith use the Oratory for prayer time and after Ramadan, Happy Eid is said to show respect for their faith system.

The Annual Service of Remembrance was held on 7th April 2024 with approximately 270 people in attendance. The parents were very appreciative of the efforts made in supporting them through this format. Afterwards, The Coombe Hospital catering staff provided beautiful refreshments for the guests.

The team conducted the following in 2023:

• visited 643 women at their bedside before or after the birth of their baby

• had 241 appointments and meetings with staff members of The Coombe Hospital

• bereavement support provided to 221 families

• 152 funeral services held either in the Mortuary Chapel or at the graveside

• naming/blessing services for 32 babies

• celebration of the Sacrament of Baptism for 23 babies

• met and said prayers with eight past patients whose babies had passed away at The Coombe Hospital

• supported 12 families with babies that had fetal anomalies

• provided 15 copies of Baptismal Certificates for babies that were born at The Coombe Hospital who required these because they were either making their First Holy Communion, their Confirmation or getting married

• organised Religious Services for patients and staff members

• organised seven Masses that were celebrated in the Oratory with over 30 people present

• distributed Holy Communion at the bedside or in the Oratory to 33 individuals, outside of Mass times.

The Chaplains conducted:

• 55 hospital burials at the graveside

• cremations at Mount Jerome Crematorium

• 35 private burials

• 30 services at The Coombe Hospital mortuary.

The greatest achievement this year for the chaplains was the updating of Chaplaincy/Bereavement policies, the development of The Coombe Family Garden and the sourcing of a Staff Remembrance Manuscript. The intranet website page on Chaplaincy was developed and continues to be updated. New banners were sourced for the Oratory to broaden the space, e.g. Earth Day and Love Is banners.

6.5

Pharmacy

Mairéad McGuire

The Pharmacy Department continued to provide a comprehensive pharmacy service in 2023, despite staff shortages and increased stock availability issues. There was a significant increase in workload of the department around the management of drug shortages and supply issues and risk mitigation associated with this.

The team provided continued to provide clinical obstetric, neonatal and gynaecological services. The department provided a daily review of prioritised patient drug charts on adult wards, medicines reconciliation at admission and review of medication charts for potential interactions and safety in pregnancy.

A daily clinical service in the Neonatal Intensive Care Unit (NICU) was provided. This included attendance at ward rounds when permissible, review of all neonatal drug charts and continued facilitation and support around prescribing of individualised and standard concentration parenteral nutrition.

The team conducted multidisciplinary acute pain rounds, team-patient education regarding appropriate analgesia and review of medication charts.

The team provided medicines information and advice regarding safety of medicine pre-conception, during pregnancy and breastfeeding and safe prescribing for patients with complex medical conditions in the high-risk pregnancy Medical Clinic. The team also participated and engaged in multidisciplinary team meetings.

The department had previously expanded its role in the facilitation of clinical trials in The Coombe Hospital.

The Early Targeted Treatment of Patent Ductus Arteriosus with Paracetamol in Extremely Low Birth Weight (ETAPA) continued in 2023. The Gel for Early Hypoglycaemia Prevention in Preterm Infants (GEHPPI) and Investigating the Role of Early Low-dose Aspirin iN pre-existing Diabetes (IRELAND) trials were successfully completed in 2023. The PROTECT trial examining the effect of pentoxifylline on late onset neonatal sepsis continued in 2023.

Daily antimicrobial stewardship rounds were conducted. Medication reconciliation for preoperative anaesthetic clinics was expanded and improved as part of an ongoing quality improvement initiative.

The Coombe Hospital’s prescribing app continued to be updated and expanded by the Pharmacy Department as per the requirements of The Coombe Hospital.

The provision of individualised parenteral nutrition remained a significant medication safety challenge for the Pharmacy Department and hospital in general. The department worked collaboratively throughout 2023, with colleagues from the Department of Paediatrics and Newborn Medicine, clinical risk and the executive management team as well as colleagues in other hospitals, the HSE and Dublin Midlands Hospital Group (DMHG) to protect vulnerable patients from new challenges in this arena.

The department continued to support and promote the use of new standard concentration parenteral nutrition solutions for NICU. These new solutions will provide a better source of nutrition for our most vulnerable patients compared to previous products.

The department continued to expand its collaboration with the Quality and Patient Safety team through the medication safety committee and in the provision of data on medication safety to the DMHG. The department provided input into the International Medication Safety Networks Oxytocin Special Interest Group.

The antimicrobial pharmacist continued to be an active member of the Infection Prevention and Control Team (IPCT) and various hospital committees as well as conducting regular clinical ward rounds alongside the IPCT and consultant microbiologist.

The rate of antibiotic use in The Coombe Hospital decreased by 2.8% in 2023 compared to 2022. This was mainly driven by antimicrobial stewardship initiatives,

which lead to lower consumption of oral broad-spectrum penicillins and 2nd and 3rd generation intravenous cephalosporins. However, the cost of antimicrobials increased by 7.1% in 2023 compared to 2022. This was due to significant drug shortages and price increases.

Monitoring of compliance with The Coombe Hospital’s Prescribing and Microbiology Guidelines for Obstetrics and Gynaecology continued in 2023, with documentation of interventions relating to antimicrobial prescribing and clinical ward rounds.

The pharmacy technician-led medication top-up service continued to all clinical areas. The service was expanded to some outpatient areas and to include unloading stock orders on the wards to save valuable time for ward staff.

The department issued stock to wards, outpatients, staff and babies discharged from SCBU on 32,000 occasions, equating to approximately 124 dispensing transactions per day.

Peter Duddy continued his teaching collaboration as Adjunct Clinical Lecturer with the School of Pharmacy in University College Cork and his work as an executive member of the Irish Medication Safety Network. He also represented Ireland at the annual clinical meeting of the International Medication Safety Network.

The strong further education ethos within the department, continued with one staff member completing a Masters in Clinical Pharmacy.

The department continued to provide educational support to training programmes held by the Centre for Midwifery Education.

6.6 Physiotherapy

Tara Murtagh

The service provided by the Physiotherapy Department continued to expand in 2023, with the outpatient department providing 4,032 adult, 1325 paediatric and 636 indirect consultations. This was an increase of almost 14% activity compared to 2022.

In 2023, 990 inpatient referrals were received for women and newborns. Women booked for major gynaecological surgery continue to receive a letter of invitation to attend an online pre-recorded education and exercise class in advance of surgery. This ‘Fit for Surgery’ programme continued to achieve efficiency of the service, both at ward and at Physiotherapy Department level, as 250 women availed of the service in 2023.

Classes remain an integral part of the Physiotherapy Service. The end of 2023 saw the re-introduction of a monthly in person class. However, online classes remained a very popular option. In 2023, 600 women attended antenatal physiotherapy classes, 869 attended pelvic girdle pain classes, and 346 women attended postnatal classes. An early pregnancy class, ‘Fit for Pregnancy’, was also started which was attended by 193 women.

Projects and Achievements

The STRIVE programme, which is supported by the Cerebral Palsy Foundation (CPF) and led by Dr John Kelleher (Consultant Neonatologist) and Dr Roisin Phipps (Clinical Specialist Physiotherapist) commenced at The Coombe Hospital in April 2023. The aim of this programme is to reduce the age of diagnosis of cerebral palsy to less than 12 months of age using evidence based standardised motor and neurological assessments at set time points.

Mary Wrixon was awarded joint second place at the Master’s Medal Research Evening for her quality improvement project (QIP) titled ‘Optimising the care pathway for urogynaecology patients with noncomplex pelvic floor dysfunction through development,

introduction and evaluation of a physiotherapy care pathway.’ The main objective of this QIP was to reduce the waiting time to appointment for urogynaecology patients with non-complex pelvic floor dysfunction by increasing the percentage of patients on the physiotherapy care pathway. In 2023, 159 patients were suitable and removed from the urogynaecology waitlist.

Anna Marie Gleeson undertook a QIP on the Antenatal Bladder Service entitled ‘Optimising the care for antenatal women with incontinence, through the development, introduction and evaluation of a physiotherapy pathway.’ The aim of the project was to increase the number of referrals to the physiotherapy antenatal bladder service while simultaneously reducing the number of women who did not attend their appointments. From January to December 2023, a total of 379 referrals to the service were received. There was a 10% increase in the of number of referrals during the QIP. Between April and October, each month, 23% (median) of women did not attend their appointments with the antenatal bladder service.

Aly Walker and Roisin Phipps completed and were successful in securing a place on the HSE Spark Ignite Programme in May 2023 with an innovative idea to prevent plagiocephaly. Their idea was selected from hundreds of entries and was included in the final 16 presentations. This secured them an invitation to attend the Spark Summit in June 2023.

Committee Involvement

Amanda Drummond Martins and Anna Marie Gleeson were representatives on the Chartered Physiotherapists in Pelvic Health and Continence (CPPHC) committee of the Irish Society of Chartered Physiotherapists (ISCP) which involved organising study evenings and courses on a voluntary basis.

Multidisciplinary team learnings events were held quarterly in 2023, at the ‘lunch and learn sessions’ with a great attendance by all grades of clinical staff

Section 7 Department of Quality, Risk and Patient Safety

7.1 Department of Quality Risk and Patient Safety

Anna Deasy

The Coombe Hospital’s Strategic Plan 2022-2026 outlined plans to build and expand the Department of Quality, Risk and Patient Safety in line with the agreed organisation wide requirements. The plan set out improvements, establishment, expansion and further embedding of all areas and this has certainly taken place throughout 2023. The department now consists of a team of seven whole time equivalent staff.

Each team member has constantly strived and has been successful throughout 2023 in implementing the hospital strategy, improving quality and patient safety, reducing risks, ensuring thorough incident management and review and all the while maintaining and enhancing all of these efforts in line with The Coombe Hospital values of empathy for all, teamwork, dignity and respect, people at the heart of everything we do and always striving to be at our best.

Clinical Risk and Incident Management

The clinical risk managers continued to work in collaboration with staff across all departments within the hospital to assess risks, enhance risk and incident prevention and identification, incident management and review within The Coombe Hospital. Timely reporting of investigations and clinical reviews to extrapolate any findings and any subsequent recommendations is a primary activity within the department and guided by the HSE Incident Management Framework (2020) and The Coombe Hospital Incident Management Policy. There were almost 2,000 incidents reported in 2023. Each

incident underwent a preliminary review, was triaged and reviewed in accordance with the level of severity of the incident (Figure 7.1.1).

All incidents were uploaded onto the National Incident Management System (NIMS), the reporting system of the Clinical Indemnity Scheme within the State Claims Agency.

Figure 7.1.1 Clinical incidents by category, 2023

The levels of severity are categorised as:

• dangerous occurrence: incidents related to failure of equipment, security and resources

• negligible: incident where no intervention was required e.g. medication error

• minor: delay in treatment with no impact on care

• moderate: intervention was required e.g. medication for postpartum haemorrhage

• major/extreme: intrauterine death/stillbirth with birth weight ≥ 500 grams (including those with congenital or chromosomal anomaly).

The Concise Review Team chaired by Dr Mark Hehir met fortnightly and included members of the multidisciplinary team (MDT) including obstetrics, gynaecology, paediatrics, anaesthetics, midwifery and nursing and haemovigilance. Other specialities attended as required depending on the cases under review. A total of 98 incidents were prepared with clearly documented chronology of events and presented by the clinical risk managers at these meetings. The MDT representatives of CRT then discussed the cases in detail and identified any immediate learning points or recommendations that could be implemented. The moderate/serious incidents (62 in total) were then presented at Senior Incident Management Team (SIMT) whereby the level of review and any findings and recommendations were agreed. Finally, 34 of those reviews were prepared in the official HSE documents and presented to the Dublin Midlands Hospital Group Women and Infants Senior Incident Management Forum (SIMF) whereby the local SIMT decisions were ratified. Both the SIMT and DMHG SIMF meetings were held monthly throughout 2023. Due to the timely identification, preparation, presentation and review of these incidents at the various levels of MDT committee, 100% of all incident reviews were closed within the 125 days, well above the key performance indicator of 70% set by the HSE.

Multidisciplinary Team Patient Safety ‘Learnings’ Events

MDT learnings events were held quarterly in 2023, at the ‘lunch and learn sessions’ and there was a great attendance of all grades of clinical staff. There were numerous presentations with information on incident management and review process within the hospital,

as well as specific learnings from recent incidents in obstetrics, anaesthesia, midwifery and neonatology.

Patient Liaison Management

Patient feedback, compliments, complaints and advocacy

In 2023, compliments and the overall feedback received from women and families was 90% positive. Of the 253 new complaints received in 2023, 74 were verbal complaints and 179 were written complaints. Communication and information and access were the most frequent themes of our complaints. In 2023, 80% of all written complaints were acknowledged within five working days and 55% were resolved within 30 working days of acknowledgement of the complaint. While there is no national target, most hospitals and hospital groups have a target of 70 - 75%. The reduction from 83% in 2022 to 55% in 2023 is primarily due to an increase in the complexity of the complaints received. This has also been seen nationally. Different people held the position of patient liaison manager in 2023. Delays in acknowledgement and closure of complaints occurred when this position was vacant in 2023. The patient liaison manager also holds the post of patient advocate. In 2023, 111 advocacy and or support interventions occurred in The Coombe Hospital.

Medico-legal and Claims Management

The number of claims against The Coombe Hospital continued to gradually increase, in line with the 270% increase in the cost of claims nationally since 2013. In 2023, 20 new claims were received, and 16 claims were closed. All claims closed were done so by mediation or settlement. One coroner’s inquest was held in 2023 and resulted in a narrative verdict. However, the number of cases being investigated by the coroner has increased in recent years since the Coroners (Amendment) Act 2019 which increased the scope of maternity and perinatal cases required to be reported to the coroner.

Patient Safety Management

The Coombe Hospital is highly focused on a proactive approach to patient safety. In line with this approach and the hospital strategy, a patient safety manager was appointed

within the QRPS Department in 2023, and Sheena Bolger has been a very welcome addition to the team.

Audit and Compliance

An area of QRPS that has become increasingly prevalent in recent years has been that of audit and compliance with national guidelines and national internal audit findings and recommendations. The QRPS Team are involved in many hospital committees and oversight groups which undertake the completion of internal local hospital audits, analysing audit results, reviewing implementation plans on the recommendations from national clinical guidelines, and the provision of reports on the progress of these findings and implementation plans to the various associated national offices such as HSE Internal Audit Department, HSE National Sepsis Programme, HSE Acute Services, HSE Hospital Group QPS Teams on topics such as:

• the overview report of HIQA’s monitoring programme against the National Standards for Safer Better Maternity Services, with a focus on obstetric emergencies

• compliance with National Clinical Guideline No. 4 Irish Maternity Early Warning System

• compliance with National Clinical Guideline No. 1 Irish National Early Warning System

• audit of compliance with the HSE’s procedure for the prevention of peripheral and central venous catheter related infection

• compliance with National Clinical Guideline No. 26 Sepsis Management for Adults (including maternity).

Learning from Excellence and Safety

Learning from excellence is an initiative which originated in recent years in the UK and promotes the idea of learning from when things go well. It has two interdependent aims: to learn from what works, and to provide positive feedback to staff. Its purpose is to enable learning and improvement, to foster a culture of appreciation and improve morale (RCOG 2021). A team to implement this initiative was established here between QRPS and the Department of Anaesthesia. The project was introduced to staff in late 2023 but following some delays in the layout and design of the

printed documents and posters, the project will be further rolled out and expanded in 2024 to ensure that we learn from and recognise staff that go above and beyond in their daily work within The Coombe Hospital.

Open Disclosure and National Health Care Communication

Open Disclosure training is mandatory for all hospital staff, and they are required to complete the HSeLanD Module 1 programme ‘Communicating Effectively Through Open Disclosure’, or to attend a staff briefing session held within the hospital. Two new members of the QRPS team completed the training in 2023 and have been appointed as the Open Disclosure and National Healthcare Communication leads for the hospital. This involves co-ordinating the in-house promotion and training, collating the training data and updating all staff on any additional updates or education available in relation to open disclosure. There were a number of promotional events held throughout the year in the hospital in line with national promotions on these topics, which enabled a more driven focus, and thus interest, on the principles of excellent communication and open disclosure.

Patient Safety Week 2023

International Patient Safety Day was 13th September 2023. The Coombe Hospital celebrated with a number of events during the week of September 25th in line with the theme of engaging patients in patient safety. Communication was the focus on Day 1 of the events, with rolling training sessions provided on the National Healthcare Communication Programme and some impromptu group discussions on people’s experiences as both staff and patients. Psychological safety and ‘speaking up’ was the focus of Day 2, again aimed at both the patients and the staff within The Coombe Hospital. There was a stand in reception with colourful helium balloons, based on the movie ‘Up’ to embody the theme of speaking up. The stand was hosted by the QPS team, with information leaflets given to patients encouraging them to ask questions and speak up at each interaction with their healthcare providers using the ‘ask 3’ questions of healthcare literacy (what is my main concern? what do I need to do? why is this important for me?). Later that afternoon there was a facilitated discussion on the topic of psychological safety in the workplace, chaired by Dr

Sabrina Coyle, Senior Clinical Psychologist with various nominated members of The Coombe Hospital staff from EMT to junior level, as well as a previous patient of the hospital and parent of an NICU graduate. All of those nominated were invited to discuss psychological safety and what it means to them within their role and share their past experiences of speaking up in various circumstances within healthcare. The discussion was well attended and provoked a very honest and open conversation amongst all in attendance. On Day 3 the focus was on medication safety, with rolling education sessions provided by Peter Duddy, Medication Safety Pharmacist. The sessions throughout the three days were well attended and we are welcoming all feedback to assist us in planning again for next year.

Audit and Inspection by HIQA

The Coombe Hospital underwent an announced inspection by the Health Information and Quality Authority (HIQA) against their National Standards for Safer Better Healthcare on 11th and 12th October 2023. This was their first on-site inspection since 2018 and was coordinated by the QRPS team and the EMT. The inspection involved the collation of a significant volume of hospital information, data and report collection, guidelines and governance documents to be prepared and forwarded to the inspectors in advance of the inspection, to have available at the time of inspection and some additional follow up requests in the weeks following the in person onsite inspection. Their area of focus was primarily on the four areas of known harm; infection prevention and control, medication safety, the deteriorating patient and transitions of care. During the onsite inspection, the three inspectors met with various members of the hospital staff, patients and visitors and held interviews with EMT and line managers. Some verbal feedback was received on the day from the inspectors, and we await the final report publication date.

The inspectors informed EMT during the verbal feedback session that they felt the care, kindness, empathy and dignity provided to the patients in The Coombe Hospital was "second to none." They advised us this aspect and component of care is by far the most important, the level of which they rarely encounter. They acknowledged that whilst this finding would be difficult to portray in their final report, we should all be very proud of our hospital,

our colleagues, our values and we should all strive to always protect this.

There are many positive findings within the written report and The Coombe Hospital was deemed ‘compliant’ or ‘substantially compliant’ in the findings against the national standards. Unfortunately, The Coombe Hospital was deemed ‘non-compliant’ in one standard, which is in relation to the physical environment. It must be outlined that the EMT and all staff are constantly striving and involved in trying to maintain, improve, refurbish and upgrade the hospital campus on an ongoing basis. However, this comes with many challenges including the age and structure of the hospital, trying to obtain sufficient funding for the works, adhering to relevant restrictions and all the while continuing to provide care in a very busy hospital particularly during periods of high activity. We will, as always, continue to work on and improve the areas that they have identified and strive to maintain or excellent standards of care and patient safety within the hospital.

Clinical Audit and Quality Advisory (AQuA) Committee

The Coombe Hospital’s Clinical Audit and Quality Advisory (AQuA) Committee continued their work throughout 2023 to provide structure, governance and support to those pursuing audit and quality improvement projects. However, this committee is comprised of clinical staff with an interest in the area, and some with sessional commitments but no dedicated staff/department with overall responsibility. Over 50 projects were approved throughout the year. Additional support, guidance and coaching on undertaking these projects was provided by some members of the AQuA Committee. There were 22 presentations at the Annual Audit and QI presentations on 19th October 2023 and the competition was very high for the much sought after award of the Masters Medal. The projects presented were from all disciplines within the MDT and allied health professions, and of an exceptionally high standard. Dr Frances Fallon took first place with her presentation entitled ‘Empowering patients in safer anaesthesia care using a Regional Anaesthesia Alert Bracelet.’ The competition was nail biting for further awards and in joint second place was Dr Katie Flynn, Specialist Registrar in Obstetrics and Gynaecology and Mary Wrixon, Senior Physiotherapist in the Physiotherapy Department.

Some examples of other successful QIPs in The Coombe Hospital in 2023 included:

• Mobile epidural QIP. A mobile epidural pilot study was undertaken on the Delivery Suite. This was the first such project in Ireland. It proved to be very safe and successful. Women remained mobile particularly in the early stage of labour while receiving significant levels of analgesia. Both the qualitative and quantitative data from the first arm of the study were very positive, showing that whilst the initial pilot was small and the inclusion criteria were narrow, the overall satisfaction reported by both patients and staff was high, with reports of adequate pain relief, appropriate conversion to full epidural within the expected timeframe and no falls or injuries sustained. The next phase of the project involves a broader scope of patients with the use of infusion pumps to administer the anaesthesia whilst ensuring adequate analgesia and maintaining patient mobility.

• Obstetric anal sphincter injury (OASI) QIP. This QIP on obstetric anal sphincter injury, established in 2018, continued in 2023. The success of this QIP was sustained and the rate of OASI was maintained under the target of 1.8% (Table 1.1.11).

We all bring unique skills and knowledge to The Coombe, and when they are combined, we are at our best

Section 8 Administration

8.1 Human Resources Department

AnneMarie Waldron

The Human Resources (HR) Department aims to provide a professional and supportive service to all staff within The Coombe Hospital. In doing so the HR department has responsibility for all essential people management functions at The Coombe Hospital. An overview of the staff in the HR Department is presented in Figure 8.1.1. The HR team strives on a daily basis to provide the best possible service to all staff.

An operational business requirement of the HR team includes the recruitment and selection of all staff groups within The Coombe Hospital. The HR team ensures compliance with employment legislations, national policies and HSE HR circulars and The Coombe Hospital policies and procedures. In 2023, the Rezoomo Applicant Tracking system was introduced to streamline and automate our recruitment process, in tandem with our presence on Irishjobs.ie website. Rezoomo has facilitated our visibility on more recruitment platforms such as Indeed, LinkedIn and Coombe.ie.

Figure 8.1.1 Overview of the Human Resources Department

Employee Engagement

The People and Culture Committee (a sub-committee of the Board), formed in 2022, which is comprised of staff members, managers and members of the Executive Management Team (EMT) continued to meet on a regular basis. The purpose of this committee is to work cohesively on ways to positively improve the culture of The Coombe Hospital by improving communication and staff retention.

One of the five pillars of The Coombe Hospital’s Strategic Plan is the People and Culture pillar. In 2023, a subgroup of the EMT supported by our Project Management Officer, met regularly to work on the implement of goals outlined in the Strategy, primarily on a hospital wide induction programme and a HR information system.

In 2023, The Coombe Hospital’s Health and Wellbeing Committee and Social Committee with a budget provided by the HSE via the Healthy Ireland Project arranged ice cream events and bike clinics in addition to the purchase of garden furniture for the staff garden named The Jonathan Swift Garden.

The HR team continued to submit statistics to the HSE each month and on request. These statistics included the staff census (number and whole time equivalent of staff paid each month), starters and leavers, absence returns, details of staff appointed to newly funded positions so that the appropriate funding could be drawn down.

Staff

The total headcount of staff as per The Coombe Hospital Census in December 2023 was 1,092. The breakdown was as follows:

• midwifery and nursing staff, n = 424

• management administrative staff, n = 196

• general support staff, n = 163

• medical staff, n = 125

• health and social care professionals, n = 99

• other patient and client care, n = 85.

Staff turnover in 2023 was 12.01% compared with 19.30% in 2022, a reduction of 38%. Compliance with the European Working Time Directive of a 48-hour working week for non-consultant hospital doctors was 92% compared with 73% in 2022, an improvement of 26%.

In 2023, the HSE initially implemented a recruitment embargo on all administrative posts. This was extended, later in 2023, to other staff grades other than those approved in consultant posts, GP training posts, nursing and midwifery posts, and health and social care professional (HSCP) posts later. Subsequently HSCs were removed. To ensure critically important roles were filled, managers completed and submitted risk assessments for unfilled and or new posts for review by the EMT. The EMT decided whether to recruit or not, based on these risk assessments of risk to patients, The Coombe Hospital and the staff. The recruitment embargo is ongoing.

Staff Recruitment

The HR Department ran 172 competitions on Irishjobs.ie and on Rezoomo.ie for all staff groups and recruited 281 staff in the following categories:

• NCHDs (on rotation (n = 120).

• Midwifery and Nursing (n = 76).

• Administration and Management (n = 28).

• Health and Social Care Professionals (n = 26).

• Support staff (n = 23).

• Consultants (n = 8).

NCHD Induction Sessions in July 2023

Changes to the recruitment process have been made as result of the recruitment embargo. Prior to the implementation of the recruitment embargo, a line manager would submit an application form for approval to The Coombe Hospital’s Manpower Committee for approval to recruit to a post. However, now because of the recruitment embargo, a risk assessment must be completed by the line manager indicating the risk to patients and or The Coombe Hospital if the post remains unfilled. This risk assessment is submitted to the Manpower Committee for review. If approval to recruit is given, derogations are also submitted to the HSE. The manager contacts the HR lead for this area. Applications for replacement and new consultant posts are made via the HSE Doctors Integrated Management E-System (DIME). Such applications along with considerable details

related to the post and job description are viewed monthly by the HSE Consultant Applications Advisory Committee (CAAC). Confirmation of funding for all posts is required in advance. Once this is obtained, the HR lead works with the line manager in the recruitment process as follows:

• The job description is reviewed or developed if a new post. Some consultant posts in The Coombe Hospital are joint posts with other hospitals, in such situations the hospitals work closely together.

• The post is advertised via Rezoomo and Irishjobs.ie or on other relevant websites.

• Following the closing date, the line manager and panel shortlist candidates against the criteria in the job description.

• Candidates are invited to attend for interview, and regrets are sent to candidates who have not been shortlisted.

• Interview documentation is prepared.

• The HR lead participates on the interview panel, in most cases.

• Following the interview the successful candidate is contacted and advised of the next stage of the process, i.e. reference checking, application for work permit along with evidence of the relevant employment stamp to work in Ireland, registration with the relevant professional body such as the Nursing and Midwifery Board of Ireland, CORU – Regulation Health and Social Care Professionals or the Irish Medical Council, Garda vetting and pre-employment medical examination. References are reviewed by the line manager.

• Following satisfactory receipt of the above information, the HR lead contacts the successful candidate to formally offer them the post, and to agree a start date in discussion with the line manager.

• The contract and other relevant documentation are prepared and sent to the successful candidate.

• Payroll are informed of the new starter and their details, including their point on the pay scale.

Recruitment Fairs

In 2023, The Coombe Hospital was represented at three recruitment fairs London, Glasgow and Dublin.

A number of midwifery and nursing staff and managers travelled with the HR team to London and Glasgow. A number of staff and managers from many disciplines attended the recruitment fair in Dublin.

The HR team focused on the recruitment of midwives and nurses in 2023. We were delighted to welcomed 76 new midwives and nurses to The Coombe Hospital.

The HSE introduced the Consultant Public Only Contract, known as POC23, in line with Sláintecare in 2023. A number of consultants have transferred to the POC23, and all new consultant appointments are under the POC23 contract. In 2023, the HSE and the Irish Medical Organisation (IMO) reached a new agreement on rest days and length of shifts for NCHDs. Working shifts for NCHDs will reduce from 24 hours to 13 hours by 31st December 2024, with milestones to be achieved meantime.

Gender Pay Gap

The Coombe Hospital published its second annual report in line with the Gender Pay Gap Information Act 2021. This report was published on The Coombe Hospital Website. The results for 2022 and 2023 are presented in Table 8.1.1.

Table 8.1.1 Gender pay gap, 2022 and 2023 20222023

Occupational Health

The Coombe Hospital Occupational Health Department is provided onsite by an external company, Cognate Health Ltd. Ciara Hussey provided an onsite Occupational Health Nurse service from March 2021 until March 2023.

We were pleased to welcome Natasha Joyce as Occupational Nurse from July 2023.

Training

Training events held in 2023 included the following:

• team leadership QQI Level 6 (facilitated by Tallaght Training Centre)

• dignity and quality in the workplace/Quality conversations

• interviewee skills

• dealing with challenging situations

• staff retention and motivation for line managers

• two-day retirement planning course.

In 2023, four staff members secured places on courses via the Technical University Shannon (TUS) which were funded by the Dublin Midlands Hospital Group.

Health and Wellbeing

Staff health and wellbeing events held in 2023 included the following:

• health promotion for staff run by the Occupational Health Department in February

• two ice cream events in the summer

• staff BBQ in July.

Garden furniture was purchased for the Jonathan Swift Garden, funded from the Healthy Ireland budget received by The Coombe Hospital in 2023.

The garden was officially opened by the winner of the competition to name the garden, Glen Cusack, and Professor Martin J White.

8.2 Patient Services Department

Esmé Denvir

The purpose of the Patient Services Department in The Coombe Hospital is ‘To provide a customer orientated service which provides efficient and effective services to our patients and clinical teams.’

The Patient Services Department is responsible for all patient interfaces with The Coombe Hospital and is also responsible for the delivery of frontline support services. The department also supports patient care systems and structures by providing a high quality, professional clerical and administrative service to all areas of The Coombe Hospital, including the following: medical records, central appointments, outpatients both obstetrics and gynaecology, health and social care professional clinics, Baby Clinic, Women’s Health Unit, admissions, all wards, Delivery Suite, Operating Theatre, Perioperative Department, Laboratory Services and the Hospital In-Patient Enquiry (HIPE). The department coordinates over 160,000 outpatient appointments annually across all specialities. The recent expansion of the Gynaecology service led to an increase in outpatient clinic activity which resulted in a need for additional manpower resources.

It was challenging at times in 2023 to deliver adequate patient services with reduced staffing levels. To remedy this the department embarked on a cross-training programme for staff to allow for more flexibility and to maintain a sufficient level of service for patients and the wider hospital community.

However, the introduction of the HSE recruitment embargo in the summer of 2023, had a negative impact on staffing levels. It was not possible to replace outgoing experienced staff members, in response to natural attrition. In response to the HSE recruitment embargo, a work to rule mandate was put in place for all management and administrative grades. This impacted negatively on both recruitment drives and service delivery.

The existing staff body was unable to continue to operate the cross-training programme to help build resilience in the service.

Since 2021 there has been a steady decline in staffing levels in the Patient Services Department from 117 in 2021 to 104 in 2023. This can be attributed to factors such as the COVID-19 pandemic, the two cyberattacks (one on the HSE and one on The Coombe Hospital), an evolving labour market and more recently the HSE recruitment embargo. Despite this, services have continued to be introduced and expanded. It is anticipated the introduction of digital initiatives such as the introduction of MN-CMS will alleviate the pressure on the Patient Services Department.

An electronic maternity registration form was introduced, as part of a quality improvement initiative in 2023, to enhance service delivery to women booking for antenatal care. In 2022, all maternity referrals to The Coombe Hospital were received by post. From there, a booking was made for the woman’s first antenatal appointment and ultrasound scan. From 2023, women were offered a choice to either complete the form electronically or by traditional paper and post. A woman can access an electronic maternity registration form on The Coombe Hospital’s website (www.coombe.ie). This electronic form, which is compatible with iOS and Android software, is submitted through a secure platform and is GDPR compliant. Women receive an immediate response acknowledging their registration and are instructed to bring the necessary supporting documentation with them to their first antenatal appointment. Women are also directed to The Coombe Hospital’s website for information about and links to the wide range of available antenatal services.

In 2023, 98.8% of women who registered for public antenatal care at The Coombe Hospital used the electronic maternity registration form.

In January 2023, 1,279 patients were on the gynaecology outpatient waiting list. Following the validation programme, 398 patients were removed from the list leaving 881 patients on the list, a 31.1% reduction in the number of patients on the gynaecology outpatient waiting list. This validation programme increases appointment availability for patients remaining on the list. This programme allows more accurate reporting of the gynaecology outpatient waiting list which

will bring The Coombe Hospital in line with HSE Wait List Plans and provide further scope to deliver on Sláintecare protocols. The Patient Services department has worked closely with the EMT to develop the Scheduled Care team.

The level of engagement from women using the electronic maternity registration form indicated their clear preference for the use of digital methods of communication over paperbased methods. Following on from this, the provision of a postpartum care leaflet to mothers at the time of discharge from The Coombe Hospital was introduced in 2023. This was developed in response to feedback received from women, many of whom found the old discharge packs "cumbersome and heavy." The postpartum care leaflet was created following multidisciplinary team input. A QR code, printed on this leaflet, provides women with access to a number of relevant services. This initiative contributed to a reduction in printing costs, and an increase in storage space on the wards.

We work as a collective in the best interest of the women, the newborns, the families, staff and all who use our services

Section 9 Support Services

9.1 Central Services Sterilisation Department

John D. K’Eogh

I would first like to acknowledge the hard work and dedication of all the staff in Central Services Sterilisation Department (CSSD) during 2023. With workloads rising year on year, they keep one of the ‘quiet engines’ of The Coombe Hospital running.

In 2023, Katie McGrath and Susan Devine obtained certificates in ‘Decontamination of Reusable Invasive Medical Devices.’ Ninety percent of staff in CSSD have obtained at least a Level VI award in medical device decontamination.

In 2023, a new ultrasonic irrigator was installed into the decontamination room along with new height adjustable

sinks in keeping with best practice and better safer workflow.

With the introduction of environmental testing in the clean room in CSSD, it continued to operate well within limits required to be a Class 8 clean room, allowing the monitoring environmental controls and quantifying colony-forming units (CFUs) of bacteria, mould and aspergillus in the room alerting us to any adverse trends and deviations from a known baseline.

In 2023, there were a total of 30,976 processes in CSSD with the throughout remaining reasonably level throughout the year (Figure 9.1.1). There was an increase of 4,696 processes compared to 2022 (n = 26,280).

Figure 9.1.1 Types and number of processes in CSSD in 2023

9.2

Household Services Department

Michael Cummins

2023 was a very busy year for the Household Services Department with regard to deep cleaning (in preparation for air testing), due to the development of new areas and the up grading of existing areas such as:

• New Emergency Assessment Centre.

• Refurbishment of kitchens in St Monica’s and St Gerard’s Wards.

• Refurbishment of patient and staff toilets on Our Lady’s and St Gerard’s Wards.

The impact of the construction work put pressure on the normal day to day cleaning service delivered, however the Household Services team rose to the challenge and continued to provide a consistent service in the effected departments. The refurbishment of these areas will enhance the patient and visitor experience of The Coombe Hospital and benefit staff as a result on an improved working environment.

The department expanded its head count in 2023 thanks to this investment with the Emergency Assessment Centre requiring 24-hour cover seven days a week and the National Cervical Screening Laboratory (NCSL) requiring a daily cleaning service. Combined, this additional work will lead to the creation of a 0.5 whole time equivalent post which is very positive for job creation in the surrounding area.

I would like to take this opportunity to thank all members of the Household Services team for their effort and diligence throughout the year.

9.3 Information Communications Technology Department

Bryan Smyth

2023 was a progressive year for The Coombe Hospital Information Communications Technology Department (ICT) department. While our goal is always to reduce clinical risk and enhance patient care, our primary focus was on security and protecting our organisational and patient data.

To that end we completed our formal disaster recovery plan in Quarter 2 of 2023, an extensive piece of work documenting our ICT systems and how they should be recovered in the event of a disaster. As part of this we introduced scheduled quarterly testing of recovery procedures and systems and completed two tests in the last two quarters of 2023.

Through various funding requests we have been able to implement new security measures including a new patching tool which helps mitigate vulnerabilities in our applications, a new network penetration testing tool which we have scheduled to run fortnightly, and this produces detailed reports regarding any issues or security risks linked to our perimeter devices like our firewalls and VPN service. Our phishing simulator and education tool allow us to send regular test emails to remind users of security issues as well as educate them and gauge security concerns around user education. We have also introduced a product called Bullwall RC which detects and blocks application and endpoints which demonstrate any behaviour linked with ransom ware attacks.

To enhance the security of our data we added additional cloud backup service for our Office365 tenancy, enabling to recover data instantly for cloud-based services such as email, Sharepoint and MS Teams. The ICT department have completed the challenge of removing all Windows 7 devices from the estate, which was a key target for 2023, as well as

documenting and formalising the management of printers through two key servers, a model required for the implementation of key national application such as the Maternal and Newborn Clinical Management System (MN-CMS).

We added a new support partner in Onnec with whom we have a 24/7/365 network break/fix contract, to enhance our recovery options in the event of an outage or security event.

The National Cervical Screening Laboratory (NCSL) infrastructure work was completed, including the implementation of its permanent network equipment, the rollout of its Wi-Fi solution, the configuration of its resilient fibre network connectivity and the integration of its support into The Coombe Hospital ICT department. We continue to work well with both laboratories as well as CervicalCheck to improve processes and to build strong relationships as we work together to improve services. The addition of a senior staff member within the department has helped with this development as well as being able to support all the ICT requirements of this new facility.

The additions to the site meant we needed to scope and expand our own storage and server environment, and this was achieved with the help of procurement and implemented in Quarter 3 of 2023 enabling to run and expand the services of the NCSL.

2023 saw the addition of three new staff members to the ICT department, to bolster the helpdesk, infrastructure and network teams. This welcome increase has seen us come closer to the staff complement required.

Section 10 Postgraduate Education and Training

10.1 Centre for Midwifery Education

Triona Cowan

The Centre for Midwifery Education (CME) works to support midwives and nurses to deliver safe, high-quality, person-centred care. The CME does this by supporting education through the rollout of national clinical programmes. It also provides continuing professional development (CPD) for midwives and nurses. The CME ensures that CPD activities provided for midwives and nurses are in line with services need.

The CME also records, monitors and audits the provision of midwife and nurse CPD.

There was an overall increase in CME activity in 2023 compared to the previous six years. The number of education and training events provided increased by 966 and the number of attendances increased by 78 compared with 2022 (Figure 10.1.1).

With the accreditation of the Consortium of Centres of Nursing and Midwifery Education (CCNME) in 2022, to deliver Quality and Qualifications Ireland (QQI) Level 5-8 programmes, the CME started working in collaboration with other Centres of Nursing and Midwifery Education and Centres for Midwifery Education to develop a Level 8 (10 credit) Certificate in Neonatal High Dependency and Special Care. Other collaborations included the development and

delivery of the Uterine Involution Programme for Public Health Nurses, supporting the implementation of education and training in perineal management and delivery of the National Return to Midwifery Practice Programme.

In response to service needs the following new education and training events were developed or coordinated or delivered in 2023:

• adaptation programme for midwives

• introduction to infant mental health day 2

• aromatherapy for labour and birth

• optimal fetal positioning for labour and birth

• study day for midwives and nurses in specialist roles

• clinical audit workshop

• wound management

• neonatal bereavement programme

• management of central lines

• national infant feeding programme (pilot)

• coordinator and allocations officer study day

• care of the critically ill pregnant/postnatal woman in the HDU

• IMEWS for acute general services - elearning

• national facilitators education programme.

Publications

See Appendix Two for details of a peer reviewed publication from the Centre for Midwifery Education in 2023.

Figure 10.1.1 CME activity, 2017 to 2023

Education and Training Events

10.2 Department of Pathology

Professor John O'Leary

Training in Histopathology, Morbid Anatomy and Molecular Pathology is provided within the Division of Laboratory Medicine. Training is provided to two specialist registrars (SpRs) per year, each on a six-month rotation.

Training is provided for the Part 1 and Part 2 FRCPath examinations.

SpRs are encouraged to undertake research, publications and audit during their time at The Coombe Hospital.

A rigorous programme of one-on-one training is provided by consultants and scientists to trainees.

Many SpRs, when their rotation is completed, go on to pursue MD and/or PhD degrees by research.

The laboratory also operated the Molecular Cytology Training School (MCTS) up to 2023. This training school educated over 240 scientists, colposcopists and medical doctors, working in the area of cervical pre-cancer and cervical cancer. The training school offered advanced diplomas in Molecular Cytology with the Technological University Dublin. This was a highly successful endeavour, educating the next generation of physicians and scientists working in the cervical cancer space.

10.3 Department of Perioperative Medicine

Dr Stephen Smith

The Department of Perioperative Medicine was successful in advancing and further developing our approaches to teaching and training throughout 2023. Ten specialist anaesthesiology trainees from the College of Anaesthesiologists of Ireland (CAI) rotated through the department fulfilling their training requirements in obstetric anaesthesia. We continued to train a number of supervised ‘beginner’ trainees to anaesthesia and 2023 saw our strong record continue, with a high proportion progressing onto the national structured anaesthetic training scheme.

Our academic programme consisted of both in-person and remote lectures and tutorials, maintaining a vibrant teaching programme for our trainees. A number of workshops in airway management, transthoracic echocardiography, and ultrasound scanning were conducted in 2023. In addition, focused tutorials were organised and attended by those trainees preparing for Membership (MCAI) and final (FCAI) postgraduate examinations.

The anaesthetic-led high fidelity multidisciplinary simulation programme continued, with participation from obstetrics, anaesthesia and theatre nursing staff. This emphasised both the technical and non-technical aspects of managing emergent scenarios and the importance of teamwork in order to achieve positive patient outcomes, further demonstrating our commitment to patient care and safety.

Our departmental bi-monthly Quality and Patient Safety meetings enabled analysis of departmental key performance indicators (KPIs), discussion of challenging cases, and the creation of a highly beneficial case-based learning environment. Our KPIs demonstrated consistent high-quality performance within our unit in 2023, in keeping with best practice worldwide.

Much of our departmental quality improvement, audit and research work was presented at both national and international obstetric anaesthesia meetings.

10.4

Laparoscopic Simulation Training

Dr Hugh D O’Connor

With the adoption of European Working Time Directive compliant rotas and an increase in the number of trainees, it has becoming increasingly more challenging for trainees to become competent performing surgical procedures.

In 2023, The Coombe Hospital continued to deliver a Laparoscopic Simulation Training programme to gynaecology trainees. This programme significantly enhanced the surgical training experience at The Coombe Hospital by allowing trainees to improve their surgical skills outside of the theatre environment. Trainees were able to objectively assess their ability when performing standard laparoscopic tasks in a simulated environment. This improves trainee satisfaction and patient safety.

10.5 Midwifery and Nursing Practice Development Department

Helen Castelino

The Midwifery and Nursing Practice Development Department (PDD) continued to facilitate an optimum clinical learning environment in 2023 for students undertaking clinical placements at The Coombe Hospital as a part of the Bachelor of Science in Midwifery (BScM), Higher Diploma in Midwifery (HDipM), Bachelor of Science in Nursing (BScN) as well as Erasmus international midwifery students. Others on clinical placements at The Coombe Hospital in 2023 included those training in Public Health Nursing or Paramedical Science. The PDD worked in collaboration with affiliated Higher Education Institutions such as Trinity College Dublin (TCD), University College Dublin and the Royal College of Surgeons in Ireland.

With the support of clinical placement coordinators, preceptors and link lecturers, the PDD continued to facilitate structured clinical skills sessions and reflection sessions on a weekly basis in The Coombe Hospital, for midwifery and nursing students to bridge the theory practice gap.

In 2023, 17 BScM interns and 11 HDipM students successfully completed their programmes and qualified as registered midwives. All the HDipM graduates and 88% of BScM graduates chose to continue to work in The Coombe Hospital.

To provide optimum support for midwifery and nursing staff, the PDD liaises with the Centre of Midwifery Education (CME) on an ongoing basis to provide educational programmes based on need analysis to ensure continuing professional development (CPD) of midwifery and nursing staff.

The PDD team is dedicated to:

• work with clinical staff, management and students to ensure that The Coombe Hospital is a quality and enjoyable learning environment for midwifery and nursing students, meeting their clinical learning needs, through effective clinical teaching and preceptorship

• continue to facilitate the midwifery adaptation programme and to seek site approval from the Nursing and Midwifery Board of Ireland (NMBI) to facilitate the general nursing adaptation programme for nursing candidates intending to take up employment in The Coombe Hospital

• continue to support newly qualified and newly employed midwifery and nursing staff, in smooth adaptation to their roles through effective orientation with supernumerary status, and other available staff support systems such as the mentorship programme and the transition to practice programme

• continue to link in with clinical staff and managers to carry out need analysis and facilitate midwifery and nursing educational programmes and updates in collaboration with the CME

• continue to promote and support a positive culture of audit, research, professional development and education among midwifery and nursing staff to enable them to provide safe, effective, evidencebased care to women and babies attending The Coombe Hospital.

The PDD, as a member of The Coombe Hospital’s Clinical Guideline Committee, actively participated in the review and update of clinical guidelines in 2023, in line with national clinical guidelines. The PDD team continued to encourage midwives and nurses to embrace quality initiatives and to provide evidence-based care, supporting the ethos of research throughout The Coombe Hospital.

The PDD team in collaboration with the Director of Midwifery and Nursing, organised combined celebrations on International Day of the Midwife and Nurse (9th May 2023). This was greatly appreciated by the midwifery and nursing staff.

The Coombe Hospital graduation celebrations were held in March and October 2023, once the COVID-19

pandemic restrictions were lifted, to celebrate the successful completion of midwifery and postgraduate neonatal programmes in 2021 and 2022.

The PDD team supported the launch and rollout of the HSE’s Professional Development Plan (PDP) for midwives and nurses during the week of 23rd October 2023 through an awareness and education week along with an information booklet, designed with the help of Deloitte, on the extensive career opportunities within The Coombe Hospital.

The PDD team was involved in promoting a career in midwifery through a Career Planning Open Day in the RDS which was organised for Transition Year students by TCD.

The PDD team was also involved in the successful recruitment, induction and continued support of midwives and nurses from Ireland and abroad. With the support of the team of clinical skills facilitators, the CME and clinical preceptors the structured midwifery adaptation programme was developed in line with NMBI requirements. This effectively facilitated 11 candidates from The Coombe Hospital and three candidates from the Midland Regional Hospital Portlaoise.

Since June 2023, the staff of the PPD have been involved in facilitating the weekly midwives’ clinic held on Mondays.

The PDD team continued to support staff, through regular audits and the development of action plans, to facilitate them to provide safe, evidence-based, quality care to women and babies attending The Coombe Hospital.

10.6 Obstetrics and Gynaecology

Professor Nadine Farah

I would like to acknowledge Dr McSharry for coordinating rosters from January to July 2023 and Dr Barrett, Dr Worrall and Dr Brennan for coordinating rosters from July to December 2023.

All doctors in training at The Coombe Hospital are assigned to a team and a named trainer.

From January to July 2023, seven full time specialist registrars (SpRs), two flexible training SpRs, five registrars, five junior registrars, three basic specialist training (BST) trainees, three GP trainees and three senior house officers (SHOs) in standalone posts rotated through Obstetrics and Gynaecology at The Coombe Hospital.

From July to December 2023, seven full time specialist registrars (SpRs), two flexible training SpRs, five registrars, four junior registrars, five BST trainees, five GP trainees and two SHOs in standalone posts rotated through Obstetrics and Gynaecology at The Coombe Hospital.

Within the non-consultant hospital doctor (NCHD) staff complement, other posts throughout 2023, included the Bernard Stuart Research Fellow, the Gynaecology Fellow, the Fellow in Early Pregnancy Scanning and Lecturers with RCSI, TCD and UCD. In addition, from January to July 2023, there was a Labour Ward Fellow, a Reproductive Medicine Fellow and an Aspire Fellow in Maternal Medicine. From July to December 2023, there was an additional UCD lecturer and a trainee from Malta in post.

The Coombe Hospital and the Dublin Midlands Hospital Group was approved as a European Board College of Obstetrics and Gynaecology (EBCOG) training hub in January 2023. Training rotations to the Midland Regional Hospital Portlaoise and Tallaght University Hospital commenced in July 2023.

In 2023, 12-hour shifts for NCHDs were implemented, with three registrars and one SHO covering the Delivery Suite and the Emergency Assessment Centre from 8am to 8pm. From 8pm till 8am two registrars and one SHO covered these areas. With the implementation of 12-hour shifts and expanded leave entitlements for NCHDs it became increasingly difficult to preserve the team ethos. It was also difficult to maximise training opportunities for NCHDs in Obstetrics and Gynaecology, in the context of reduced rostering time to comply with the European Working Time Directive.

The Coombe Hospital continued to deliver a

Laparoscopic Simulation

Training programme to gynaecology trainees

Section 11 Academic

11.1 Biological Resource Bank

Ruth Harley and Muireann Ní Mhurchú

The Biological Resource Bank (BRB) stores maternal and fetal blood samples including clinical information with the consent of women who attend The Coombe Hospital. The BRB was established to support scientific knowledge to improve the health of women and babies and is an invaluable resource.

Throughout 2023, we analysed data and met with doctors who were interested in using samples in the BRB to conduct their research studies. We continued to work and extract data for an ongoing study entitled ‘AI PREMie (Artificial Intelligence to Prevent preterm birth due to preeclampsia while protecting Mothers’ lives)’ which was conducted by Dr Neil O’Gorman (Consultant Obstetrician). Samples from women with pre-eclampsia or women who laboured prematurely were matched with control samples using 419 blood samples stored in the BRB.

Audit and ensuring that anonymised data and blood samples are collected and stored correctly are an important key performance indicator of the BRB. General Data Protection Regulation guidelines and procedures that protect, and respect patient confidentiality are strictly adhered to. Therefore, it is essential that the freezers in which samples are stored are kept updated and are monitored 24 hours per day by Rees Scientific to ensure that the blood samples are kept at the optimum level of minus 80 degrees Celsius.

11.2 Master’s Office Research Report

Professor Stephen Lindow

2023 was a successful year with the publication of 12 manuscripts by the Master’s Office.

The formation of the Audit and Quality Advisory (AQuA) Committee to advise and facilitate audit and quality improvement projects has been a substantial development to assist all doctors working at The Coombe Hospital. It works together with the Research Ethics Committee to provide the framework for clinicians and scientists to work collaboratively and ethically.

Research links have been strengthened with Qatar (Hamad Medical Corporation and Sidra Medicine), India (Banaras Hindu University). We look forward to working with Professor van Der Spuy from the University of Cape Town, South Africa, who delivered the Guinness Lecture in 2023.

Collaborative output for 2023 resulted in 12 publications from the Master’s Office. Doctors working in The Coombe Hospital were the first authors of nine of these publications. The published articles covered a wide range of subjects including preterm birth, prenatal testing and domestic violence in addition to managerial aspects of practice such as labour ward staffing and the introduction of the new consultants’ contract.

The philosophy remains the same, in that it is expected that all junior doctors will contribute to or take the lead on a project during the course of their attachment at The Coombe Hospital.

Publications

See Appendix Two for a list of peer reviewed publications from the Master’s Office in 2023.

11.3 Molecular Pathology and Research

(Molecular Pathology Research Group, Trinity College Dublin)

The Coombe Hospital

Professor Cara Martin and Professor John O’Leary

Head of Department/Division/ Clinical area

Professor John O’Leary

Staff Complement Academics

Professor Cara Martin, Assistant Professor in Molecular Pathology (Trinity College Dublin)

Molecular Pathology Manager

Professor Cara Martin (Trinity College Dublin /The Coombe Hospital)

Research Fellows

Dr Prerna Tewari

Dr Mark Ward

Dr Tanya Kelly

Dr Ola Ibrahim

Dr Bashir Mohammed

Dr Sharon O’Toole

Dr Brian Henderson

Research Students (PhD/MD)

Laura Edgerton

Padma Naik

Faye Lewis

Etain O’Rourke

Dr Colm Kerr

Dr Roisin O’Connor

Dr Victoria Malone

Adjunct Professors

Professor Doug Brooks (University of South Australia)

Professor Stavros Selemidis (RMIT University)

Affiliated Researchers

Dr Lucy Norris (Trinity College Dublin)

Dr Robert Brooks (University of South Australia)

Dr Helen Keegan (The Coombe Hospital)

Dr Christine White (The Coombe Hospital)

Dr Mairead O’Connor (University College Cork)

Professor Fiona Lyng (Technological University Dublin)

Professor Colm Bergin (Trinity College Dublin)

Dr Jessica Logan (University of South Australia)

Professor Doug Brooks (University of South Australia)

Dr Ben Ung (University of South Australia)

Dr James O’Mahony (Trinity College Dublin)

Summary

• Research areas: Cervical, ovarian, prostate, head and neck, breast cancer, melanoma, cancer metastasis, the cancer immune-proteasome, cancer stem cell biology, gene transfection, nanotechnology and artificial intelligence (AI).

• Group publications in Nature, Nature Medicine, Nature Immunology, Nature Communications, Nature Protocols, PNAS and Cancer Research.

• Accumulated grant income: > €250 million.

• Total number of publications: > 800 publications, 330 papers, 29 book chapters and three books.

• Post-doctoral scientists (internal and visiting), n = 21.

• PhD students, n = 8 (5 internal and 3 external).

• MD students, n = 2.

• PhD students completed, n = 54.

• MD students completed, n = 11.

• MSc students completed, n = 11.

• Industrial collaborations (biotechnology and biopharma), n = 27.

Core group competencies:

Epidemiology

Research

• Group consortia: CERVIVA, DISCOVARY/INNOVATION and PCRC (Prostate Cancer Research Consortium).

CERVIVA group consortium:

Psychology

Translational Research: Basic Science, Pre-clinical testing, Translation to practice.

Health Psychology: Qualitative & quantitative research Behavioural science.

Health Economics: CEA, Disease modelling Health outcomes, Health policy analysis.

Molecular Epidemiology: Molecular biomarkers, Genetic analysis, Genotyping, Epidemiology.

Innovation: Patents n = 6, Spin-outs n = 1

Industrial collaborations.

Funding: Cumulative funding > €200M

CERVIVA funding € 7.7M.

Supervision: PhD students completed n = 156

MSc/MD students completed n = 82

Current PhD students n = 40

Current MSc/MD students n = 13

MSc Public Health n = 116 NCTS n = 189.

Metrics: Cumulative citations = 51,732

Cumulative h-index = 344.

Publications: Peer reviewed articles n = 1,444

Published abstracts n > 3,000.

Impact: CervicalCheck, Screening practices, Immunisation office, HIQA HTA, Sláintecare, HPV Vaccination Alliance, International HPV Alliance.

Discipline of Histopathology

(Trinity College Dublin) 2021 to 2023

• PhD students, n = 10 (7 internal and 3 external).

• MD students, n = 2.

• MSc students, n = 2.

• Grant income (national and international) > €14,950,00.00.

• Publications: > 150 peer reviewed papers in top ranking journals such as: Nature Protocols, Cell (Helyion), Cancers, Cancer Letters, Methods in Molecular Biology, Clinical Epigenetics, BMC Bioinformatics, Frontiers in Cell and Developmental Biology, Cancer Epidemiology, Biomarkers and Prevention, Translational Oncology, Journal of Nanobiotechnology, Frontiers in Immunology, Frontiers in Pharmacology, PLOS Computational Biology, Cells, British Medical Journal and International Journal of Cancer.

• Industrial philanthropic support: > €21,200,000 (equipment, Clinical Scientist posts, PhD studentships, support for new spinouts, a new Genomics Unit, Trinity Translational Medicine Institute).

Grants held in 2023

All-Ireland Cancer Liquid Biopsies Consortium (CLuB) Awarding Body: HEA North South Research Programme. Duration: 2022-2026. Value: €4 million

Delivering tomorrow's diagnostics today (Coinvestigator) Awarding Body: Enterprise Ireland Innovation Partnership Programme (2021-2024). Value: €476,405.00

CUPID: Cancer - Understanding Cancer Prevention in people with Intellectual Disabilities. Awarding Body: EU COST Action. Duration: 2022-2026

Performance for laboratory evaluation of HPV nucleic acid based qualitative technologies for WHO prequalification (Principal Investigator) Awarding Body: Roche Molecular Diagnostics (2022-2023). Value: €69,097.00

Advancing Ovarian Cancer Diagnostics and Prognostics; ADAPT (Amendment to Cancer Trials Ireland Study) Awarding Body: Royal City of Dublin Hospital Trust (2021-2023). Value: €63,333.00

Precision Molecular Diagnostic Testing in Solid Tumours (Principal investigator) Awarding Body: Industrial support (2020-2023). Value: €133,203.00

Developing Diagnostic, Prognostic and Therapeutic Biomarkers in Prostate Cancer. Awarding Body: University of South Australia and Envision Sciences (2019-2023). Duration: 4 years. Value: €638,689.00

CERVIVA-Vax: Monitoring the impact of HPV vaccination in Ireland. Awarding Body: Merck Investigator Projects. Value: €200,000.00

CERVIVA-Vax: Monitoring the impact of HPV vaccination in Ireland. Awarding Body: Health Research Board. Investigator Led Projects. Value: €370,000.00

What influences cervical screening uptake in older women and how can screening programmes translate this knowledge into behaviour changing strategies? A CERVIVA-CervicalCheck co-production project Awarding Body: Health Research Board. Applied Partnership Award (APA) Awards (2017-2023). Total value: €119,973.00

CERVIVA HPV Primary Screening Study - Molecular triage strategies for HPV positive women Awarding Body: Health Research Board - part of CARG Programme Grant 12/29 (follow-up ongoing). Total value: €1,250,000.00

Publications

In 2023, the Molecular Pathology Group at The Coombe Hospital and St James’s Hospital under the Discipline of Histopathology and Morbid Anatomy, Trinity College Dublin published 20 peer reviewed journal articles and 20 abstracts at international meetings. See Appendix Two for a list of these journal articles and details of published conference abstracts.

11.4 Royal College of Surgeons in Ireland

Department of Neonatology

Associate Professor Martin J. White

Head of Department

Associate RCSI Professor Martin J. White MD

Administrative

Louise Burke

Academic

Professor Martin J. White

Lecturer and Research Fellow

Dr Robert McGrath

Academic Developments

In 2023, we continued to develop RCSI undergraduate teaching in The Coombe Hospital in coordination with Professor Naomi McCallion, Head of Neonatology RCSI, using simulation resources on-site in The Rotunda Hospital, The Coombe Hospital and in RCSI York Street. Students were part of the Paediatrics Senior Cycle which is undergoing change in 2024 as part of a college wide curriculum and teaching programme review.

Postgraduate Research Degree Awarded in 2023

MD: Dr Meredith Kinoshita (RCSI Lecturer 2020 - 2022). Methods of Assessing Breastmilk Intake in Preterm Infants. Supervisors: Dr Anne Doolan and Professor Martin J. White.

Research in Progress

MD: Dr Rob McGrath (RCSI Lecturer and Research Fellow 2022 - 2024). An Observational Study of Regional Cerebral and Splanchnic Oxygen Saturation in Neonates with a Haemodynamically Significant Patent Ductus Arteriosus: A Prospective Study within the ETAPA Trial (Early TArgeted Treatment of Patent Ductus Arteriosus with PAracetamol in Extremely Low Birth Weight Infants). Supervisors: Professor Jan Miletin and Professor Martin J. White.

Publications

See Appendix Two for a list of peer reviewed publications and details of a published conference abstract from the Royal College of Surgeons in Ireland Department of Neonatology in 2023.

11.5 Royal College of Surgeons in Ireland Department of Obstetrics and Gynaecology

Dr Bridgette Byrne and Dr Carmen Regan

Heads of Department

Dr Bridgette Byrne, Senior Lecturer, Consultant in Obstetrics and Gynaecology

Dr Carmen Regan, Senior Lecturer, Consultant in Obstetrics and Gynaecology

Lecturer

Dr Carmel Sheridan (until July 2023)

Dr Eibhlin Healy (from July 2023)

Secretarial Support

Daniel Gillan

Consultants Providing Clinical Teaching

Dr Mark Hehir, Clinical Senior Lecturer, Consultant in Obstetrics and Gynaecology

Dr Chris Morris, Consultant in Obstetrics and Gynaecology

Professor Tom D’Arcy, Consultant in Obstetrics and Gynaecology

Professor Nadine Farah, Consultant in Obstetrics and Gynaecology

Dr Workineh Tadesse, Consultant in Obstetrics and Gynaecology

Dr Hugh O’ Connor, Consultant in Obstetrics and Gynaecology

Dr Hugh D O’Connor, Consultant in Obstetrics and Gynaecology

Dr Neil O’Gorman, Clinical Senior Lecturer, Consultant in Obstetrics and Gynaecology

Teaching

Undergraduate

In 2022/2023 we again welcomed two further rotations of RCSI medical students to The Coombe Hospital. The objective review of student feedback was excellent. The teaching programme continues to provide high quality clinical teaching to students.

Drs Byrne and Regan contributed several chapters to the new RCSI Obstetrics and Gynaecology Handbook.

Dr Bridgette Byrne supervised an RCSI student research project exploring the impact of the COVID-19 pandemic on severe maternal morbidity.

Postgraduate

Dr Cathy Monteith completed the Aspire Fellowship in Severe Maternal Morbidity in January 2024 under the supervision of Dr Bridgette Byrne, Dr Terry Tan (The Coombe Hospital) and Dr Liz Connolly (St James’s Hospital).

Dr Eibhlin Healy commenced her research into the effects of vaping in pregnancy under the supervision of Dr Carmen Regan. This is a Science Foundation Ireland funded longitudinal cohort study of the effects of vaping

in pregnancy with follow-up into the first two years of life (ECHO study).

A simulated transfer from The Coombe Hospital to the intensive care unit in St James’s Hospital, by ambulance of a critically ill woman was conducted in March 2023 to test a handover communication tool.

Dr Carmen Regan is a facilitator on the Obstetric Emergency clinical skills course run by the Royal College of Physicians of Ireland.

Grants held in 2023

The impact of e-cigarettes on childhood health outcomes (ECHO) study. Science Foundation Ireland. Co-principal investigator: Dr Carmen Regan. €478,956.00.

Research

Dr Bridgette Byrne was invited to be part of a multicentre prospective study of Charcot Marie Tooth disease in pregnancy funded by a National Institutes of Health (NIH) inherited neuropathy consortium.

Dr Bridgette Byrne held the following national roles:

• Member of the National Women and Infants Health Programme.

• Member of the Postpartum Haemorrhage, Quality Improvement Programme.

• Member of the Advisory Committee on Severe Maternal Morbidity, National Perinatal Epidemiology Centre.

Publications

See Appendix Two for a list of peer reviewed publications from the Royal College of Surgeons in Ireland Department of Obstetrics and Gynaecology in 2023.

Presentations - invited speakers

Dr Bridgette Byrne was invited to speak about ‘the National PPH guideline’ at the Spring meeting of the Institute of Obstetricians and Gynaecologists in March 2023.

Dr Carmen Regan was invited to speak about ‘Heparin in pregnancy’ at the Maternal Medicine Meeting in Mullingar in 2023. Dr Regan was also invited to speak about ‘Fetal growth restriction - optimisation of care’ at the 3rd Conference of the Red Crescent Society in Jerusalem in September 2023.

11.6 Trinity College Dublin Academic Department of Obstetrics and Gynaecology

Professor Deirdre J Murphy

Notable highlights for 2023 were the promotion of Professor Richard Deane to the role of Director of Undergraduate Teaching and Learning where he now leads the Trinity College Dublin undergraduate programmes in Medicine and Health Professions education. Professor Deirdre Murphy was elected to the Medical Council in April 2023. She is a member of the Board and chairs Fitness to Practice inquiries. We were delighted to appoint Professor Catherine O’Gorman to the post of Associate Professor in Gynaecology Oncology based at Trinity College, St James’s Hospital and The Coombe Hospital. She held the locum position in 2023 and took up the substantive appointment in January 2024.

Head of Department

Professor Richard Deane (to September 2023)

Professor Deirdre Murphy (from September 2023)

Secretarial Support

Ms Aisling Moloney, Executive Officer

Ms Nadia Pryadilova, Executive Officer

Academic Staff

Professor Deirdre Murphy, Professor and Consultant in Obstetrics (Chair and Head of Discipline)

Professor Richard Deane, Associate Professor and Consultant in Gynaecology

Professor Catherine O’Gorman, Associate Professor and Consultant in Gynaecology Oncology

Dr Rosie Dillon, Lecturer in Gynaecology and Module Coordinator

Dr Sahr Yambasu, Lecturer and PhD Fellow in Obstetrics and Gynaecology

Dr Prerna Kamath, Lecturer in Obstetrics and Gynaecology

Ms Clare Dunney, Midwifery Lecturer and Clinical Midwife

Consultant Staff Providing Clinical Teaching

Professor Feras Abu SaadahDr Cliona Murphy

Professor Tom D’Arcy Dr Niamh Murphy

Dr Alison DeMaio Dr Nedaa Obeidi

Dr Joanne Fenton Dr Hugh D O’Connor

Dr Jennifer Hogan Dr Hugh O’Connor

Dr Waseem Kamran Dr Aoife O’Neill

Dr Patrick Maguire Dr Workineh Tadesse

Dr Niamh Maher

Dr Aoife Mullally

Teaching

Dr Terry Tan

Dr Gunther Von Bunau

As part of their eight-week Obstetrics and Gynaecology rotation which runs throughout the academic year (September to May), all TCD medical students attend placements at The Coombe Hospital for five weeks. The teaching programme is blended, combining technology enhanced learning activities with focused, supervised and self-directed patient-based clinical sessions. In 2023, 186 TCD medical students attended for clinical tutorials and workplace-based clinical sessions at The Coombe Hospital. Students indicated a high level of satisfaction, with over 90% rating their experience of in-person clinical activities as good or excellent. The success of the programme is a testament to the enormous support and commitment of staff at The Coombe Hospital in welcoming students into the clinical environment, which is greatly appreciated.

Research

Professor Deirdre Murphy leads a research programme focused on intrapartum care. Current projects are designed to evaluate second-line tests of fetal wellbeing in labour with a Cochrane Systematic Review, a cohort study and a multicentre randomised controlled trial funded by the Health Research Board of Ireland (FIRSST). The research team are also involved in developing the National Guidelines for assisted vaginal birth and fetal monitoring, which will increase the impact of the group’s research.

Professor Richard Deane leads the discipline’s medical education research with a current focus on student assessment methods.

Grants held in 2023

The FIRSST multi-centre randomised controlled trial. HRB Definitive Intervention Award. 2018-2024. Principal Investigator: Professor DJ Murphy: €1.1 million.

HRB funded Summer Research Electives:

Lauren Hayes, June - July 2023.

Crystal Percival, July - August 2023.

Presentation - invited speaker

Professor Deirdre J Murphy was invited to speak, at a plenary session, about the ‘Short and long-term complications of instrumental delivery’ at the 6th European Intrapartum Care Conference in Florence in September 2023.

Publications

See Appendix Two for a list of peer reviewed publications from Trinity College Dublin Academic Department of Obstetrics and Gynaecology in 2023.

11.7 Trinity College Dublin Discipline of Paediatrics and Child Health

Co-located at The Coombe Hospital and Children’s Health Ireland

Head of Department

Professor Eleanor Molloy

Senior Academics

Professor Edna Roche

Dr Judith Meehan

Professor Anne Doolan

Dr Jana Semberova

Lecturer and Registrars

Dr Aoife Branagan (Neonates)

Dr Eman Isweisi (Paediatrics)

Dr John Allen (Paediatrics)

Dr Philip Stewart (Paediatrics)

Dr James Trayer (Paediatrics)

Secretarial Support

Sandra Archbold-Kenny

Anna Lambe

Nuala Bermingham

Teaching

Structured teaching in neonatology is part of the overall course on the Medicine and Surgery of Childhood based in the hospitals in Children’s Health Ireland. This incorporates over 38 specialty areas in Child Health as well as communication modules and an evidence-based project. The latter is presented nationally and internationally and there have been on average five peer-reviewed papers published by the students annually.

Neonatology module

Four specialist teaching days with parents and families discussing neonatal intensive care with students and incorporating neurology, nutrition, respiratory, overview of preterm birth and jaundice.

Postgraduate Research Degrees

Postgraduate Research Degrees awarded in 2023

PhD: Megan Ní Bhroin. BRAIN: BRAIN: Brain Injury in Neonates. Primary supervisor: Professor Arun Bokde.

Co-supervisor: Professor Eleanor Molloy.

PhD: Dr Nawal Taher: PHOENIX: Phenotyping T cells in Neonatal brain Injury and followup in childhood. Co-supervisors: Professor Derek Doherty and Professor Eleanor Molloy.

PhD: Fiona Quirke. COHESION: Develop a Core outcome set for use in clinical trials and other studies in the prevention and treatment of Neonatal Encephalopathy: Primary supervisor: Professor Declan Devane.

Co-supervisors: Dr Patricia Healy and Professor Eleanor Molloy.

PhD: Megan Dibble. NEON: Investigate the functional brain changes in Neonatal Encephalopathy and the associated behavioural and cognitive consequences. Primary supervisor: Professor Arun Bokde. Cosupervisors: Professor Elizabeth Nixon and Professor Declan Devane.

Postgraduate Research Degrees ongoing in 2023

PhD: Dr Eman Isweisi: FIREFLY: Followup of Inflammatory Responses and multiorgan outcomes following neonatal brain injury. Primary supervisor: Professor Eleanor Molloy.

PhD: Dr Aoife Brannigan: PUFFIN: Point of care

Ultrasound For multIorgan evaluation in Neonatal encephalopathy. Primary supervisor: Professor Eleanor Molloy.

PhD: Dr Philip Stewart: STARFISH: Sustained inflammation in preterm infants and multiorgan dysfunction correlates with long term outcomes. 20222025. Primary supervisor: Professor Eleanor Molloy.

Grants held in 2023

Lead applicant: Professor Eleanor Molloy

PLATYPUS project: preterm infant immunomodulation to treat sepsis and brain injury prevention; Proposal ID: 21/FFP-P/10105. SFI Frontiers for the Future Projects funding by the Children’s Health Foundation. 2022: €372,280.00.

HRB STARFISH: Sustained inflammation in preterm infants and multiorgan dysfunction correlates with long term outcomes: Health Research Board; ILPPOR-2022-055; €369,950.00.

PROTECT: Pentoxyfylline to improve long-term outcomes in preterm in preterm infants with late-onset sepsis or necrotising enterocolitis: Ireland, RCSI: Lead in Ireland: Professor Eleanor Molloy. €73,024.00; Overall: Professor Eleanor Molloy €272,621.62 (Aus $ 401,386.36).

HRB Irish Network for Children's Clinical Trials (in4kids) CTN-2021-007. Co-lead: Professor Geraldine Boylan. €995,536.00.

FIREFLY: Followup of Inflammatory Responses and multiorgan outcomes following neonatal brain injury. Health Research Board HRA Grant 2019-22: €369,891.00. Health Research Board Collaborative Doctoral Award. Irish Neonatal Brain Injury Consortium. 2018 - 2024. €1.47 million. National Children’s Research Centre.

GEMINI: Gender and inflammation in neonatal encephalopathy. Paediatric research project grant. 2019 - 2023. €282,553.00.

Co-applicant/collaborator: Professor Eleanor Molloy

HRB Paediatric Clinical Research Centre Children’s Health Ireland. €3.5 million.

FOUNDCOG: Curiosity and the Development of the Hidden Foundation of Cognition. ERC Advanced Grant: Principal Investigator: Professor Rhodri Cusack. 2018 - 2023: €3,030,538.00.

BRAIN Injuries in Neonates: MRI Networks: National Children’s Hospital Foundation Ref: 1716 - Principal Investigator: Professor Arun Bokde. €144,487.00.

Investigating the immune evasion mechanisms of respiratory syncytial virus in paediatric patients

attending NCH: towards the development of novel curative therapeutics. National Children’s Hospital Foundation Ref: 1719; Principal Investigator: Dr Nigel Stephenson. €50,000.00.

National Children’s Hospital Foundation Comprehensive and Effective Laboratory Test Reference Intervals for Irish Children: Celtic Ranges Project (Phase 1 study) Ref: 1713: Principal Investor Professor Gerard Boran. €148,311.00.

Publications

See Appendix Two for a list of peer-reviewed publications from Trinity College Dublin Discipline of Paediatrics and Child Health in 2023, which are included under the Department of Paediatrics and Newborn Medicine.

11.8 UCD Centre for Human Reproduction

Associate Professor Amy O’Higgins

Centre Staff and Affiliated Staff

Daniel Gillan, Administrator

Amy O’Higgins, Centre Director, Associate Professor

Mairead Kennelly, Associate Professor

Syeda Farah Nazir, UCD Tutor in Obstetrics and Gynaecology

Asma Fagear Mohamed, Special Lecturer in Obstetrics and Gynaecology

Michael Turner, Clinical Professor

Jan Miletin, Clinical Professor

Chris Fitzpatrick, Clinical Professor

Martin White, Clinical Professor

Aisling Martin, Associate Professor

Nadine Farah, Associate Professor

Tom D’Arcy, Associate Professor

John Kelleher, Associate Professor

Sharon Sheehan, Associate Professor

Terry Tan, Associate Professor

Anne Doolan, Associate Professor

Doireann O’Flaherty, Assistant Professor

Breffini Anglim, Assistant Professor

Mary Anglim, Assistant Professor

Workineh Tadesse, Assistant Professor

Neil O’Gorman, Assistant Professor

Jana Semberova, Assistant Professor

Madeleine Murphy, Assistant Professor

Antony Dempsey, Lecturer

Natasha Joyce, Lecturer

The UCD Centre for Human Reproduction (Centre) was established by Professor Michael Turner in 2007 and was officially recognised as an academic centre by UCD in 2015. A formal review of the Centre’s work and outputs was carried out by UCD in 2023. The Centre was recognised as successfully contributing to education, research and innovation and approval was renewed for the Centre to continue as one of UCD’s recognised academic centres. The Centre has produced research outputs which have guided national policy, including national clinical guidelines, the development of the Irish Maternity Early Warning Score (IMEWS) and the National Maternity Strategy. These outputs, (MDs, PhDs, MScs, publications, presentations and awards) have covered areas including maternal obesity, unplanned pregnancy, folic acid use, neural tube defect prevention, maternal sepsis, identification of the critically unwell pregnant patient, gestational diabetes mellitus (GDM), intrauterine growth restriction, nutrition in pregnancy, smoking in pregnancy and socioeconomic deprivation and its impact on pregnancy.

In 2023, Dr Asma Fagear Mohamed was appointed as our new Special Lecturer in Obstetrics and Gynaecology. 2023 also saw the retirement of Professor Michael Turner with Professor Amy O’Higgins taking over as UCD professor in March 2023 and as Director of the Centre in December 2023. Professor Turner’s leadership, vision, sense and humanity have grown the Centre from a

fledgling research centre into a productive, multiprofessional, multidisciplinary centre with outputs contributing to the advancement of science and the shaping of healthcare policy nationally. Clinicians and researchers that have trained through the Centre are now in leadership roles in diverse areas of Irish healthcare. Professor Turner’s focus on striving to improve outcomes for parents and their babies had the effect of not only nurturing scholarship but also nurturing people. This environment, based on core values, allowed those of us who had the privilege of working with him to learn lessons that can never be captured in publication outputs or grants received. We look forward to continuing his work into the future.

The Centre had three ongoing MD projects in Obstetrics in 2023. Dr Syeda Farah Nazir studied continuous glucose monitoring (CGM) in the first trimester in women at risk of developing GDM. This work continued the focus of the Centre in exploring novel technologies to improve future health. Dr Somaia Elsayed studied clinical, biochemical and ultrasonographic predictors of successful medical management of first trimester miscarriage and is due to submit the MD thesis in 2024. Dr Asma Fagear Mohamed undertook a novel study focusing on health optimisation in the first year postpartum. This project is supported through the HSE and the Irish Heart Foundation, to provide a post-pregnancy intervention for health optimisation for women at increased risk of type 2 diabetes and early onset cardiovascular disease. This work has a workstream planned in collaboration with Professor Walter Cullen, UCD Professor of Urban General Practice, and is an example of the Centre’s role in leading interdisciplinary collaboration, producing novel nationally strategic research, supporting excellence in scholarship and in enhancing patient-public involvement in research.

In 2023, Ciara Turner undertook an MSc in Pharmacy with a project exploring anti-epileptic drug use in pregnancy and its association with contraceptive use, unplanned pregnancy, folic acid use and neural tube defects. This project again continues the work of the Centre in building research data to inform public policy.

The Centre continued its collaboration with the Departments of Health and Human Performance and Computing at Dublin City University (DCU). In 2023, Mark Germaine worked on a PhD thesis using data collected at the booking visit to develop a novel tool based on machine learning for the prediction of GDM. This work is supported by Science Foundation Ireland. Carl McCarry was awarded a Health Research Board (HRB) summer student scholarship to undertake work on the relationship between maternal and neonatal body composition.

In 2023, the Centre developed a new collaboration with the College of Engineering and Architecture in UCD and is engaged in novel work exploring the relationship between micro and nanoplastics and human health in conjunction with Dr Aoife Gowan and Dr Junli Xu. A collaboration was also begun with Dr Claire Buckley and a team of public health doctors investigating trends in changes in maternal body mass index from historical data from The Coombe Hospital.

Professor Jan Miletin, Dr Jana Semberova and Dr Anne Doolan continued to lead a progressive programme in neonatal research with multiple novel projects including the use of a nipple shield to measure breast milk flow, the use of 3D printing for customised infant face masks, and novel use of cerebral oximetry in premature babies.

Dr Niamh O’Catháin submitted a doctoral thesis entitled ‘Randomised placebo-controlled trial of early target treatment of patent ductus arteriosus with paracetamol in extremely low birth weight patients.’

Dr Jsun Loong Wong, commenced an MD thesis in 2023. The focus of the MD is on ‘Individualised Masks for Infants Requiring Nasal Continuous Positive Airway PressureTailor Mask (tMask) Feasibility Study.’

2023 was also productive with NCHD and undergraduate student research. Second place prize in the Master’s Medal competition was awarded to Dr Katie Flynn for her project entitled ‘The clinical and cost implications in using placental growth factor (PLGF) for the assessment of hypertensive disorders of pregnancy.’ This project was carried out by a team of NCHDs including Dr Lisa

O’Sullivan and Dr Grace Ryan. In addition to our summer clinical elective students, summer student research projects were undertaken by Carl McCarry, Ks Yuet Emily Siu, Aadar Shrestha, Lynne Pomeroy and Krithika Darmaraj.

The Centre’s staff continued to deliver a varied undergraduate teaching programme which encompassed obstetrics, gynaecology, neonatology and anaesthesiology. We are particularly indebted to all the consultant staff who volunteered their time to give lectures on the undergraduate programme; Dr Workineh Tadesse, Dr Breffini Anglim, Dr Terry Tan, Professor Jan Miletin, Dr Anne Doolan, Professor Aisling Martin, Dr Chris Fitzpatrick, Professor Tom D’Arcy, Professor Nadine Farah and Dr Alex Muresan. Professor Mairead Kennelly’s expertise was, as always, invaluable in the planning, coordination and delivery of the undergraduate teaching as was the care and attention given to the students by our tutors Dr Farah Nazir and Dr Asma Mohamed. The smooth running of a diverse teaching programme alongside multiple research strands was possible thanks to the dedication of our administrator, Daniel Gillan.

We are very grateful to the Master and the Executive Management Team for their support of UCD students and of our Centre. We are also very grateful to Professor Michael Keane and to UCD. The teaching programme would not be possible without the generous and sustained commitment of the wider consultant body and midwifery staff in The Coombe Hospital who provide hands-on teaching and access to clinics, theatres and other clinical areas for the education of the students. We thank all those who gave their time and expertise in examining our students throughout 2023 including all our affiliated consultant staff listed above and Professor Bernard Stuart, Dr Francois Gardeil, Professor Patricia Crowley, Dr Andrew Curtain, Professor Richard Deane, Dr Zahrah Elsafty, Dr Chris Morris, Dr Mary Anglim, Dr Maria Farren, Dr Davor Zibar and Dr Alex Muresan. We also appreciate the ongoing support from our colleagues in TCD and RCSI.

Grants held in 2023

SFI/Frontiers for Future Project 2021 (21/FFP-P/10103).

Individualised mask for infants requiring nasal Continuous Positive Airway Pressure - tailored Mask (tMASK) feasibility study. PrincipaI Investigator: Professor Jan Miletin. Co-investigator: Dr Jana Semberova. Ongoing (2022 - 2024). €374,911.00.

Randomised Placebo-Controlled Trial of Early Targeted Treatment of Patent Ductus Arteriosus with Paracetamol in Extremely Low Birth Weight Infants (ETAPA). HRB/Definitive Intervention and Feasibility Awards 2020 (DIFA-2020-016). PrincipaI Investigator: Professor Jan Miletin. Co-investigator: Dr Jana Semberova. On-going (2021 - 30.9.2024). €718,576.47.

Safeguarding the Brain of Our Smallest Childrenan open-label phase-III randomised trial of cerebral oximetry combined with a treatment guideline versus treatment as usual in premature infants. HRB/Definitive Intervention and Feasibility Awards 2020 (DIFA-2020013). Co-applicant: Professor Jan Miletin. Ongoing (2021 - 2025). €982,646.88.

Publications

See Appendix Two for a list of peer reviewed publications from University College Dublin Centre for Human Reproduction in 2023. Neonatal peer reviewed publications are listed under the Department of Paediatrics and Newborn Medicine.

We strive to give people the very best possible care, and that’s what makes The Coombe Hospital a truly human place

Section 12 Friends of The Coombe

12.1 Friends of the Coombe

Liz Burke

We are indebted to the many families and individuals who organised events, baked cakes, ran marathons, took part in challenges, held quizzes, and shook collection buckets during 2023 to help raise funds in support of Friends of the Coombe. Many of these fundraisers took place as a thank you for the incredible care received at The Coombe Hospital, while some were held as a way of honouring the precious memory of a son or daughter.

2023 marked the second year of The Master’s Coombe Camino Challenge which saw the team, led by Professor Michael O’Connell, Master of The Coombe Hospital, embark on second of five trips to walk the 780 km Camino Frances. They are due to complete the challenge in Santiago de Compostella in 2026, coinciding with The Coombe Hospital’s bicentenary.

The local Coombe Camino 5 km walk which was created to honour the history of The Coombe Hospital and the local area was, this year, extended to a week-long virtual Camino challenge which saw staff, family and friends challenged to walk, jog or run their own Camino wherever they happened to be.

The Coombe Hospital Camino Team has chosen to raise much needed funds for the Neonatal Intensive Care Unit at The Coombe Hospital which will be used to provide overnight accommodation for parents from outside Dublin whose extremely sick babies have been transferred to The Coombe Hospital for specialised lifesaving care.

Our 2023 Friends of the Coombe Golf Classic was held at Powerscourt Golf Club. As always, we are extremely grateful to the individuals and organisations who entered teams, provided sponsorship and donated prizes.

Section 13 Appendices

*Does not include all spontaneous miscarriages † Deaths of women while pregnant or within 42 days of the end of the pregnancy ‡ Excludes three babies weighing < 500g

Robson Ten Group Classification System - Caesarean section rates, 2018 to 2023

2

3 29/1618 (1.8%)31/1449 (2.1%)10/1376 (0.7%)30/1327 (2.3%)25/1105 (2.3%)12/1101 (1.2%)

4 211/1443 (14.6%)198/1476 (13.4%)167/1427 (19.3%)221/1576 (20.8%)163/1355 (12.0%)194/1235 (15.7%)

4a 76/1308 (5.8%)65/1343 (4.8%)41/1301 (3.2%)64/1419

4 211/2754 (7.7%)198/2618 (7.6%)167/2432 (6.9%)221/2697 (8.2%)163/2450 (6.7%)194/2591 (7.5%)

4a 76/2754 (2.8%)65/2618 (2.5%)41/2432 (1.7%)64/2697 (2.4%)55/2450 (2.3%)63/2591 (2.4%)

* Categories less than 26 weeks’ gestation reported for the first time in 2023 † PMR by gestational age not calculated as gestation was uncoded

Infant characteristics, 2017 to 2023

* Underestimation of obstetric attendances in 2023 likely due to misclassification errors

† Excludes attendances at Perinatal Day Centre

‡ Emergency Assessment Centre opened on 20th September 2023

§ Refers only to scans performed in the Perinatal Ultrasound Department

Appendix Two

Publications and Presentations

Publications: Centre for Midwifery Education

Fletcher A, Cowman T, Cazzini H, Fleming J, Healy N. Evaluation of a termination of pregnancy programme in the Republic of Ireland: Part 1. British Journal of Midwifery. 2023;31(6). Available at: https://doi.org/10.12968/ bjom.2023.31.6.308.

Publications: Department of Paediatrics and Newborn Medicine, The Coombe Hospital

Ashoori M, O'Toole JM, O'Halloran KD, Naulaers G, Thewissen L, Miletin J, Cheung PY, El-Khuffash A, Van Laere D, Straňák Z, Dempsey EM, McDonald FB. Machine Learning Detects Intraventricular Haemorrhage in Extremely Preterm Infants. Children (Basel). 2023 May 23;10(6):917. doi: 10.3390/children10060917.PMID: 37371150; PMCID: PMC10297241.

Aslam S, O'Dea M, Kelly LA, O'Neill A, McKenna E, Hurley T, Branagan A, O'Driscoll D, Normile C, Saleemi S, Sweetman D, Vavasseur C, Murphy J, Donoghue V, Watson W, Molloy EJ. Melatonin Alters Innate Immune Function in Infants with Neonatal Encephalopathy. Neonatology. 2023;120(3):325-333. doi: 10.1159/000527714. Epub 2023 Jun 15. PMID: 37321183.

Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2023 Jul;108(4):333-341. doi: 10.1136/archdischild-2022-324184. Epub 2022 Dec 9. PMID: 36600484; PMCID: PMC10313962.

Duignan SM, Lakshminrusimha S, Armstrong K, de Boode WP, El-Khuffash A, Franklin O, Molloy EJ; Infection, Inflammation, Immunology and Immunisation (I4) section of the European Society for Paediatric Research (ESPR). Neonatal sepsis and cardiovascular dysfunction I: mechanisms and pathophysiology. Pediatr Res. 2024 Apr;95(5):1207-1216. doi: 10.1038/s41390-023-02926-2. Epub 2023 Dec 4. PMID: 38044334.

Eliwan HO, Watson WRG, Melo AM, Kelly LA, Omer M, Jafar A, O'Hare FM, Downey P, Mooney EE, O'Neill A, Blanco A, Regan I, Philbin B, O'Rourke M, Nolan B, Smith O, Molloy EJ. Selective modulation of monocyte and neutrophil responses with activated protein C in preterm infants. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2183467. doi: 10.1080/14767058.2023.2183467. PMID: 36935364.

Fucikova H, Blatny J, Stingl J, Miletin J. Capnometry during neonatal transport-Mini review. Acta Paediatr. 2023 May;112(5):919-923. doi: 10.1111/apa.16729. Epub 2023 Mar 8. PMID: 36843232.

Gadancheva V, Molloy E, McNicholas F. Transition from paediatric to adult services for patients with 22q11.2 Deletion Syndrome. Ir Med J. 2023 Jan 25;116(No.1):5. PMID: 36916975.

Grane FM, Lynn F, Balfe J, Molloy E, Marsh L. Down syndrome: Parental experiences of a postnatal diagnosis. J Intellect Disabil. 2023 Dec;27(4):1032-1044. doi: 10.1177/17446295221106151. Epub 2022 Jun 14. PMID: 35698902; PMCID: PMC10647884.

Hansen ML, Pellicer A, Hyttel-Sørensen S, Ergenekon E, Szczapa T, Hagmann C, Naulaers G, Mintzer J, Fumagalli M, Dimitriou G, Dempsey E, Tkaczyk J, Cheng G, Fredly S, Heuchan AM, Pichler G, Fuchs H, Nesargi S, Hahn GH, Piris-Borregas S, Širc J, Alsina-Casanova M, Stocker M, Ozkan H, Sarafidis K, Hopper AO, Karen T, RzepeckaWeglarz B, Oguz SS, Arruza L, Memisoglu AC, Del Rio Florentino R, Baserga M, Maton P, Truttmann AC, de Las Cuevas I, Agergaard P, Zafra P, Bender L, Lauterbach R, Lecart C, de Buyst J, El-Khuffash A, Curley A, Vaccarello OO, Miletin J, Papathoma E, Vesoulis Z, Vento G, Cornette L, Lopez LS, Yasa B, Klamer A, Agosti M, Baud O, Mastretta E, Cetinkaya M, McCall K, Zeng S, Hatzidaki E, Bargiel A, Marciniak S, Gao X, Huijia L, Chalak L, Yang L, Rao SA, Xu X, Gonzalez BL, Wilinska M, Yin Z, Sadowska-Krawczenko I, Serrano-Viñuales I, Krolak-Olejnik B, Ybarra MM, Morales-Betancourt C, Korček P, Teresa-Palacio M, Mosca F, Hergenhan A, Koksal N, Tsoni K, Kadri MM, Knöpfli C, Rafinska-Wazny E, Akin MS, Nordvik T, Peng Z, Kersin SG, Thewissen L, Alarcon A, Healy D, Urlesberger B, Baş M, Baumgartner J, Skylogianni E, Karadyova V, Valverde E, Bergon-Sendin E, Kucera J, Pisoni S, Wang L, Smits A, Sanchez-Salmador R, Rasmussen MI, Olsen MH, Jensen AK, Gluud C, Jakobsen JC, Greisen G. Cerebral

Oximetry Monitoring in Extremely Preterm Infants.

N Engl J Med. 2023 Apr 20;388(16):1501-1511. doi: 10.1056/ NEJMoa2207554. PMID: 37075142.

Hayes R, Hartnett J, Semova G, Murray C, Murphy K, Carroll L, Plapp H, Hession L, O'Toole J, McCollum D, Roche E, Jenkins E, Mockler D, Hurley T, McGovern M, Allen J, Meehan J, Plötz FB, Strunk T, de Boode WP, Polin R, Wynn JL, Degtyareva M, Küster H, Janota J, Giannoni E, Schlapbach LJ, Keij FM, Reiss IKM, Bliss J, Koenig JM, Turner MA, Gale C, Molloy EJ; Infection, Inflammation, Immunology and Immunisation (I4) section of the European Society for Paediatric Research (ESPR). Neonatal sepsis definitions from randomised clinical trials. Pediatr Res. 2023 Apr;93(5):1141-1148. doi: 10.1038/s41390-021-017493. Epub 2021 Nov 6. PMID: 34743180; PMCID: PMC10132965.

Isaza-Correa J, Ryan L, Kelly L, Allen J, Melo A, Jones J, Huggard D, Ryan E, Ó Maoldomhnaigh C, Geoghegan S, Gavin P, Leahy TR, Butler K, Freyne B, Molloy EJ. Innate immune dysregulation in multisystem inflammatory syndrome in children (MIS-C). Sci Rep. 2023 Sep 30;13(1):16463. doi: 10.1038/s41598-023-43390-6. PMID: 37777557; PMCID: PMC10542373.

Kelly LA, Branagan A, Semova G, Molloy EJ. Sex differences in neonatal brain injury and inflammation. Front Immunol. 2023 Oct 25;14:1243364. doi: 10.3389/fimmu.2023.1243364. PMID: 37954620; PMCID: PMC10634351.

Leonard A, Bolger T, Molloy E, Boran G. The CELTIC ranges project (comprehensive and effective laboratory test reference intervals for Irish children) methodology and results for renal profile tests in plasma on the Roche modularTM system. Ann Clin Biochem. 2024 May;61(3):163172. doi: 10.1177/00045632231202330. Epub 2023 Sep 27. PMID: 37669625.

Malhotra A, Molloy EJ, Bearer CF, Mulkey SB. Emerging role of artificial intelligence, big data analysis and precision medicine in pediatrics. Pediatr Res. 2023 Jan;93(2):281283. doi: 10.1038/s41390-022-02422-z. Epub 2023 Feb 17. PMID: 36807652.

Maunder K, Molloy E, Jenkins E, Hayden J, Adamis D, McNicholas F. Anorexia Nervosa in vivo cytokine production: a systematic review. Psychoneuroendocrinology. 2023 Dec;158:106390. doi: 10.1016/j.psyneuen.2023.106390. Epub 2023 Sep 15. PMID: 37769539.

Molloy EJ. What's next for clinical trials for Neonatal Encephalopathy? Ir Med J. 2023 Jan 9;116(No.1):5. PMID: 36917071.

Molloy EJ, Bearer CF. Doing a PhD: ten golden rules. Pediatr Res. 2023 Feb;93(3):448-450. doi: 10.1038/s41390022-01950-y. Epub 2022 Mar 21. PMID: 35314793.

Molloy EJ, El-Dib M, Soul J, Juul S, Gunn AJ, Bender M, Gonzalez F, Bearer C, Wu Y, Robertson NJ, Cotton M, Branagan A, Hurley T, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Wintermark P, Bonifacio SL; Newborn Brain Society Guidelines and Publications Committee. Neuroprotective therapies in the NICU in preterm infants: present and future (Neonatal Neurocritical Care Series). Pediatr Res. 2024 Apr;95(5):1224-1236. doi: 10.1038/s41390-023-02895-6. Epub 2023 Dec 19. PMID: 38114609; PMCID: PMC11035150.

Molloy EJ, Nakra N, Gale C, Dimitriades VR, Lakshminrusimha S. Multisystem inflammatory syndrome in children (MIS-C) and neonates (MIS-N) associated with COVID-19: optimizing definition and management. Pediatr Res. 2023 May;93(6):1499-1508. doi: 10.1038/s41390-022-02263-w. Epub 2022 Sep 1. PMID: 36050390; PMCID: PMC9436161.

Molloy EJ, El-Dib M, Juul SE, Benders M, Gonzalez F, Bearer C, Wu YW, Robertson NJ, Hurley T, Branagan A, Michael Cotten C, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Bonifacio S, Soul JS, Gunn AJ; Newborn Brain Society Guidelines and Publications Committee. Neuroprotective therapies in the NICU in term infants: present and future. Pediatr Res. 2023 Jun;93(7):1819-1827. doi: 10.1038/s41390-022-02295-2. Epub 2022 Oct 4. PMID: 36195634; PMCID: PMC10070589.

Molloy EJ, Branagan A, Hurley T, Quirke F, Devane D, Taneri PE, El-Dib M, Bloomfield FH, Maeso B, Pilon B, Bonifacio SL, Wusthoff CJ, Chalak L, Bearer C, Murray DM, Badawi N, Campbell S, Mulkey S, Gressens P, Ferriero DM, de Vries LS, Walker K, Kay S, Boylan G, Gale C, Robertson NJ, D'Alton M, Gunn A, Nelson KB; Steering Group for DEFiNE (Definition of Neonatal Encephalopathy). Neonatal encephalopathy and hypoxic-ischemic encephalopathy: moving from controversy to consensus definitions and subclassification. Pediatr Res. 2023 Dec;94(6):1860-1863. doi: 10.1038/s41390-023-02775-z. Epub 2023 Aug 12. PMID: 37573378.

Mulkey SB, Bearer CF, Molloy EJ. Indirect effects of the COVID-19 pandemic on children relate to the child's age and experience. Pediatr Res. 2023 Nov;94(5):1586-1587. doi: 10.1038/s41390-023-02681-4. Epub 2023 Jun 6. PMID: 37280324; PMCID: PMC10242215.

Murphy DJ, Devane D, Molloy E, Shahabuddin Y. Fetal scalp stimulation for assessing fetal well-being during labour. Cochrane Database Syst Rev. 2023 Jan 10;1(1):CD013808. doi: 10.1002/14651858.CD013808.pub2. PMID: 36625680; PMCID: PMC9831024.

Olsen MH, Hansen ML, Lange T, Gluud C, Thabane L, Greisen G, Jakobsen JC; SafeBoosC-III Trial Group. Detailed statistical analysis plan for a secondary Bayesian analysis of the SafeBoosC-III trial: a multinational, randomised clinical trial assessing treatment guided by cerebral oximetry monitoring versus usual care in extremely preterm infants. Trials. 2023 Nov 16;24(1):737. doi: 10.1186/s13063-023-07720-3. PMID: 37974280; PMCID: PMC10655478.

Quirke FA, Battin MR, Bernard C, Biesty L, Bloomfield FH, Daly M, Finucane E, Haas DM, Healy P, Hurley T, Koskei S, Meher S, Molloy EJ, Niaz M, Bhraonáin EN, Okaronon CO, Tabassum F, Walker K, Webbe JRH, Parkes MJ, Kirkham JJ, Devane D. Multi-Round versus Real-Time Delphi survey approach for achieving consensus in the COHESION core outcome set: a randomised trial. Trials. 2023 Jul 19;24(1):461. doi: 10.1186/s13063-023-07388-9. PMID: 37468987; PMCID: PMC10354951.

Sankaran D, Molloy EJ, Lakshminrusimha S. Is epinephrine effective during neonatal resuscitation? Pediatr Res. 2023 Feb;93(3):466-468. doi: 10.1038/s41390-022-02411-2. Epub 2022 Dec 12. PMID: 36509848; PMCID: PMC9998334.

Taneri PE, Kirkham JJ, Molloy EJ, Biesty L, Polin RA, Wynn JL, Stoll BJ, Kissoon N, Kawaza K, Daly M, Branagan A, Bonnard LN, Giannoni E, Strunk T, Ohaja M, Mugabe K, Suguitani D, Quirke F, Devane D. Protocol for the development of a core outcome set for neonatal sepsis (NESCOS). PLoS One. 2023 Dec 5;18(12):e0295325. doi: 10.1371/journal.pone.0295325. PMID: 38051733; PMCID: PMC10697588.

Publications: Early Pregnancy Assessment Unit

Elsayed S, Farah N, Anglim M. Heterotopic Pregnancy: Case Series and Review of Diagnosis and Management. Case Rep Obstet Gynecol. 2023 May 5;2023:2124191. doi: 10.1155/2023/2124191. PMID: 37187915; PMCID: PMC10181901.

Kumari J, Hogan J, Farah N, Anglim M. Medical management of miscarriage - Old versus new regimens. Ir Med J. 2023 Sep 21;116(8):829. PMID: 37791648.

Publications: Medical Social Work Department

Jenkins E, Corbett M, Breen A, O’Brien K, Cooney C, McGrath R, Flynn E, White M. Child protection pathways for newborn infants: A multi-disciplinary retrospective chart review of an Irish maternity hospital’s records. Child Abus Rev. 2023;32:e2807. https://doi.org/10.1002/car.2807

Lee SA, Compton A, McGuirk G, Franciosa T, Foley MP, Kennelly MM, Turner MJ. Medical and social needs of pregnant asylum-seekers in Direct Provision. Ir Med J. 2023 Aug 17;116(7):808. PMID: 37606235.

Published Conference Abstract: Medical Social Work Department

Jenkins E, Corbett M, Breen A, O’Brien K, Cooney C, McGrath R, Flynn E, White M. Child protection pathways for newborn infants: A multi-disciplinary retrospective chart review of an Irish maternity hospital’s records. The 9th National Child Protection and Welfare Social Work Conference. 27th October 2023, University College Cork.

Published Conference Abstract: NNU Clinical Midwife/Nurse Specialists in lactation support

Conboy L, Chacko I. Impact of NICU dedicated lactation specialist on breastfeeding outcomes of extreme preterm infants - an audit review. 2nd International Conference on Midwifery and Neonatal Care, 13 - 14th November 2023, Dubai, United Arab Emirates.

Publications: Molecular Pathology and Research (Molecular Pathology

Research Group, Trinity College Dublin)

Alharbi B, Qanash H, Binsaleh NK, Alharthi S, Elasbali AM, Gharekhan CH, Mahmoud M, Lioudakis E, O'Leary JJ, Doherty DG, Mohamed BM, Gray SG. Proof of concept nanotechnological approach to in vitro targeting of malignant melanoma for enhanced immune

checkpoint inhibition. Sci Rep. 2023 May 8;13(1):7462. doi: 10.1038/s41598-023-34638-2. PMID: 37156818; PMCID: PMC10167246.

Bates M, Mullen D, Lee E, Costigan D, Heron EA, Kernan N, Barry-O'Crowley J, Martin C, Keegan H, Malone V, Brooks RD, Brooks DA, Logan JM, Martini C, Selemidis S, McFadden J, O'Riain C, Spillane CD, Gallagher MF, McCann A, O'Toole S, O'Leary JJ. P53 and TLR4 expression are prognostic markers informing progression free survival of advanced stage high grade serous ovarian cancer. Pathol Res Pract. 2024 Jan; 253:155020. doi: 10.1016/j.prp.2023.155020. Epub 2023 Dec 7. PMID: 38103365.

Connor AE, Hughes C, Schäfer L, McNally L, Raw DO, Bahramian K, Carr B, Dunne IH, Lysaght J, Toole SAO, Simpson JC, Perry AS. Involving patients in healthcare research is well documented but can it work in lab-based research? Res Involv Engagem. 2023 Oct 12;9(1):90. doi: 10.1186/s40900-023-00500-y. PMID: 37821914; PMCID: PMC10568930.

Ffrench B, Kashdan E, Huang Y, Spillane CD, Cocchiglia S, Charmsaz S, Varešlija D, O'Brien C, Scholz D, Martin C, Gallagher M, Brooks DA, Brooks RD, Selemidis S, Gleeson N, Abu Saadeh F, O'Riain C, Kamran W, Flavin R, Young L, O'Toole SA, O'Leary JJ. CTC-5: A novel digital pathology approach to characterise circulating tumour cell biodiversity. Heliyon. 2023 Jan 18;9(1):e13044. doi: 10.1016/j.heliyon.2023.e13044. PMID: 36747925; PMCID: PMC9898658.

Kelly TE, Spillane CL, Ward MP, Hokamp K, Huang Y, Tewari P, Martin CM, Norris LA, Mohamed BM, Bates M, Brooks R, Selemidis S, Brooks DA, Kamran W, Abu Saadeh F, O'Toole SA, O'Leary JJ. Plasminogen activator inhibitor 1 is associated with high-grade serous ovarian cancer metastasis and is reduced in patients who have received neoadjuvant chemotherapy. Front Cell Dev Biol. 2023 Dec 7;11:1150991. doi: 10.3389/fcell.2023.1150991. PMID: 38143926; PMCID: PMC10740207.

Lam GT, Prabhakaran S, Sorvina A, Martini C, Ung BS, Karageorgos L, Hickey SM, Lazniewska J, Johnson IRD, Williams DB, Klebe S, Malone V, O'Leary JJ, Jackett L, Brooks DA, Logan JM. Pitfalls in Cutaneous Melanoma Diagnosis and the Need for New Reliable Markers. Mol Diagn Ther. 2023 Jan;27(1):49-60. doi: 10.1007/ s40291-022-00628-9. Epub 2022 Dec 7. PMID: 36477449.

Lam GT, Sorvina A, Martini C, Prabhakaran S, Ung BS, Lazniewska J, Moore CR, Beck AR, Hopkins AM, Johnson IRD, Caruso MC, Hickey SM, Brooks RD, Jackett L Karageorgos L, Foster-Smith EJ, Malone V, Klebe S, O'Leary JJ, Brooks DA, Logan JM. Altered endosomal-lysosomal biogenesis in melanoma. Neoplasia. 2023 Sep;43:100924. doi: 10.1016/j.neo.2023.100924. Epub 2023 Aug 9. PMID: 37562257; PMCID: PMC10423698.

Lam GT, Martini C, Brooks T, Prabhakaran S, Hopkins AM, Ung BS, Tang J, Caruso MC, Brooks RD, Johnson IRD, Sorvina A, Hickey SM, Karageorgos L, Klebe S, O'Leary JJ, Brooks DA, Logan JM. Insights into Melanoma Clinical Practice: A Perspective for Future Research. Cancers (Basel). 2023 Sep 19;15(18):4631. doi: 10.3390/ cancers15184631. PMID: 37760601; PMCID: PMC10526186.

Lazniewska J, Li KL, Johnson IRD, Sorvina A, Logan JM, Martini C, Moore C, Ung BS, Karageorgos L, Hickey SM, Prabhakaran S, Heatlie JK, Brooks RD, Huzzell C, Warnock NI, Ward MP, Mohammed B, Tewari P, Martin C, O'Toole S, Edgerton LB, Bates M, Moretti P, Pitson SM, Selemidis S, Butler LM, O'Leary JJ, Brooks DA. Dynamic interplay between sortilin and syndecan-1 contributes to prostate cancer progression. Sci Rep. 2023 Aug 18;13(1):13489. doi: 10.1038/s41598-023-40347-7. PMID: 37596305; PMCID: PMC10439187.

Logan JM, Hopkins AM, Martini C, Sorvina A, Tewari P, Prabhakaran S, Huzzell C, Johnson IRD, Hickey SM, Ung BS, Lazniewska J, Brooks RD, Moore CR, Caruso MC, Karageorgos L, Martin CM, O'Toole S, Bogue Edgerton L, Ward MP, Bates M, Selemidis S, Esterman A, Heffernan S, Keegan H, Ní Mhaolcatha S, O'Connor R, Malone V, Carter M, Ryan K, Clarke A, Brady N, Klebe S, Samaratunga H, Delahunt B, Sorich MJ, Moretti K, Butler LM, O'Leary JJ, Brooks DA. Prediction of Prostate Cancer Biochemical and Clinical Recurrence Is Improved by IHC-Assisted Grading Using Appl1, Sortilin and Syndecan-1. Cancers (Basel). 2023 Jun 16;15(12):3215. doi: 10.3390/cancers15123215. PMID: 37370825; PMCID: PMC10296524.

Martini C, Logan JM, Sorvina A, Gordon C, Beck AR, S-Y Ung B, Caruso MC, Moore C, Hocking A, Johnson IRD, Li KL, Karageorgos L, Hopkins AM, Esterman AJ, Huzzell C, Brooks RD, Lazniewska J, Hickey SM, Bader C, ParkinsonLawrence E, Weigert R, Sorich MJ, Tewari P, Martin C, O'Toole S, Bates M, Ward M, Mohammed B, Keegan H, Watson W, Prendergast S, Heffernan S, Ní Mhaolcatha S, O'Connor R, Malone V, Carter M, Ryan K, Brady N, Clarke

A, Sokol F, Prabhakaran S, Stahl J Klebe S, Samaratunga H, Delahunt B, Selemidis S, Moretti KL, Butler LM, O'Leary JJ, Brooks DA. Aberrant protein expression of Appl1, Sortilin and Syndecan-1 during the biological progression of prostate cancer. Pathology. 2023 Feb;55(1):40-51. doi: 10.1016/j.pathol.2022.08.001. Epub 2022 Aug 20. PMID:36089417.

Martini C, Logan JM, Sorvina A, Prabhakaran S, Ung BS, Johnson IRD, Hickey SM, Brooks RD; kConFab Consortium; Caruso MC, Klebe S, Karageorgos L, O'Leary JJ, Delahunt B, Samaratunga H, Brooks DA. Publisher Correction to: Distinct patterns of biomarker expression for atypical intraductal proliferations in prostate cancer. Virchows Arch. 2023 Sep 29. doi: 10.1007/s00428-023-03666-8. Epub ahead of print. Erratum for: Virchows Arch. 2023 Sep 14. doi: 10.1007/s00428-023-03643-1. PMID: 37773453.

Miles MA, Liong S, Liong F, Coward-Smith M, Trollope GS, Oseghale O, Erlich JR, Brooks RD, Logan JM, Hickey S, Wang H, Bozinovski S, O'Leary JJ, Brooks DA, Selemidis S. TLR7 promotes chronic airway disease in RSV-infected mice. Front Immunol. 2023 Sep 14;14:1240552. doi: 10.3389/fimmu.2023.1240552. PMID: 37795093; PMCID: PMC10545951.

Mohamed BM, Ward MP, Bates M, Spillane CD, Kelly T, Martin C, Gallagher M, Heffernan S, Norris L, Kennedy J, Saadeh FA, Gleeson N, Brooks DA, Brooks RD, Selemidis S, O'Toole S, O'Leary JJ. Ex vivo expansion of circulating tumour cells (CTCs). Sci Rep. 2023 Mar 6;13(1):3704. doi: 10.1038/s41598-023-30733-6. PMID: 36879003; PMCID: PMC9988863.

Nuttall DS, Anderson WJ, Savage AJ, Denton K, Martin CM, O'Leary JJ. Calibration of the Becton Dickinson FocalPoint GS slide profiler is essential for optimal performance: Avoiding the algorithm supersaturation cascade effect pitfall. Cancer Cytopathol. 2023 Jun;131(6):383-391. doi: 10.1002/cncy.22693.Epub 2023 Mar 27. PMID: 36973942.

Rourke M, Fitzpatrick P, Popoola O, Boms R, Mooney T, Heavey L, Mohan CM, Martin CM, Jessop L, Russell NE. The effect of HPV vaccination on the rate of highgrade cytology in 25-year-old women attending cervical screening in Ireland. Ir J Med Sci. 2024 Apr;193(2):665-668. doi: 10.1007/s11845-023-03551-y. Epub 2023 Oct 19. PMID: 37853306; PMCID: PMC10961267.

Sorvina A, Martini C, Prabhakaran S, Logan JM, S-Y Ung B, Moore C, Johnson IRD, Lazniewska J, Tewari P, Malone V,

Brooks RD, Hickey SM, Caruso MC, Klebe S, Karageorgos L, O'Leary JJ, Delahunt B, Samaratunga H, Brooks DA. Appl1, Sortilin and Syndecan-1 immunohistochemistry on intraductal carcinoma of the prostate provides evidence of retrograde spread. Pathology. 2023 Oct;55(6):792-799. doi: 10.1016/j.pathol.2023.05.004. Epub 2023 Jun 20. PMID: 37422404.

White C, Reynolds S, Murphy K, Keegan H, Naik P, O'Brien R, Pilkington L, Sharkey Ochoa I, Gleeson G, Russell N, Nuttall D, Tewari P, Wright F, O'Toole S, Sharp L, Flannelly G, O'Leary JJ, Martin CM; CERVIVA the Irish Cervical Screening Research Consortium. Performance of the HPV E6/E7 mRNA Aptima HPV assay combined with partial genotyping compared with the HPV DNA Cobas 4800 HPV test for use in primary screening: Results from the CERVIVA HPV primary screening study in Ireland. Int J Cancer. Epub 2023 Aug 26. PMID: 37632406.

Published Abstracts, including conference abstracts and proceedings: Molecular Pathology and Research (Molecular Pathology Research Group, Trinity College Dublin)

Eakins J, O’Conner L, Bates M, Ibrahim O, Martin C, Gray SG, Abu Saadeh F, Rajab H, Brooks DA, Brooks RD, Selemidis S, David J, O’Toole S, Doherty DG, O’Leary JJ, Mohamed BM. Ex vivo upregulation of CD1d expression to enhance the therapeutic benefit of iNKT cells of ovarian cancer. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Kelly TE, Ward MP, Lewis FB, Henderson BD, Hurley S, Norris LA, Martin CM, Kamran W, Abu Saadeh F, O’Gorman C, Maguire P, D’Arcy T, O’Leary JJ, O’Toole SA. Circulating Free DNA and Circulating Tumour DNA: Can Longitudinal Monitoring Aid Treatment Management in High-grade Serous Ovarian Cancer? Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Lewis F. Enumerating circulating tumour cells in serous and non-serous epithelial ovarian cancers. 2023. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Malone V, Tewari P, Mohamed BM, O’Toole S, Martin C, O’Leary JJ. HPV’s influence on proteasomal function in cervical cancer. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Martin CM, White C, Reynolds S, Naik P, Keegan H, Rivellini, E, Ibrahim O, Gleeson, G, Russell N, Tewari P, Flannelly G, O’Toole S, O’Leary JJ, on behalf of CERVIVA the Irish Cervical Screening Research Consortium. P4 Cancer Screening: a multi-modal approach to screening for cervical cancer. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Martin C, White C, Reynolds S, Naik P, Keegan H, Rivellini E, Ibrahim O, Gleeson G, Russell N, Tewari P, O'Brien R, O'Toole S, Normand C, Sharp L, O'Leary JJ. P4 Cancer Screening: a multi-modal approach to screening for cervical cancer. In Laboratory Investigations: Volume 103 Issue 3 page 335.

McNevin CS, Lewis F, Hurley S, Norris L, Ward M, Donachie V, Finn SP, O’Donnell D, Kamran, W, Abu Saadeh F, O'Gorman C, Maguire P, D'Arcy T, O’Leary JJ, Alken S, Coleman N, O’Toole S, Cadoo K. Clinical and histopathologic analysis of young onset Ovarian Cancer: A single centre experience over 18 years. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Mohamed B, Bates M, Elgenaidi I, Ibrahim O, Martin C, Gray SG, O'Sullivan MP, Abu Saadeh F, Cadoo K, Doherty DG, Rajab H, Brooks DA, Brooks RD, Selemidis S, O’Toole S, O’Leary JJ. Harnessing the power of nanotechnology to optimise a therapeutic strategy for ovarian cancer. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

O’Conner L, Eakins J, Bates B, Ibrahim O, Martin C, Malone V, Gray SG, Abu Saadeh F, Rajab H, Brooks DA, Brooks RD, Selemidis S, David J, O’Toole S, Doherty DG, O’Leary JJ, Mohamed BM. Enhancement of γδ-T–cell capability for metastatic therapy by ex vivo activation and nanomedicine application. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

O’Connor R, Malone V, Ibrahim O, Naik P, Keegan H, Brooks RD, Gallagher E, Thompson K, Selemidis S, O’Toole S, Martin C, Brooks DA, Tewari P, O’Leary JJ. Multilayer Investigation of Toll-Like Receptor Pathways in Cervical Cancer Pathogenesis. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Plunkett L, Ward MP, Ibrahim E, O'Toole S, Haughey N, Gleeson N, Abu Saadeh F, O’Donnell D, O’Gorman C, Norris LA. The role of the aPC pathway as a potential predictor of chemoresponse and survival in ovarian cancer patients

treated with neoadjuvant chemotherapy. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Rourke M, Mooney T, Fitzpatrick P, Heavey L, Mason Mohan C, Jessop L, Martin C, Russell N. The effect of HPV vaccination on the rate of high-grade cytology in 25-yearold women attending for cervical screening in Ireland. BSCCP Annual Meeting, April 2023, Birmingham.

Shaikh R, Loughlin S, Malkin A, O'Leary JJ, Martin CM, Lyng F. The clinical transferability of Raman MicroSpectroscopic Systems for Cervical Cytopathology (2023). Conference papers. 15. https://arrow.tudublin.ie/radcon/15

Shaikh R, Loughlin S, Malkin A, O'Leary JJ, Martin CM, Lyng F. The clinical transferability of Raman Micro-Spectroscopic Systems for Cervical Cytopathology. Advanced Chemical Microscopy for Life Science and Translational Medicine 2023 | (2023) | Publications | SPIE. https://spie.org/ Publications/Proceedings/Volume/12392#_=_

Sharkey Ochoa I, O'Regan E, Toner M, Kay E, Faul P, O'Keane C, O'Connor R, Mullen D, Nur M, O'Murchu E, Barry Crowley J, Kernan N, Tewari P, Keegan H, O'Toole S, Woods R, Kennedy S, Feely K, Sharp L, Gheit T, Tommasino M, O'Leary J, Martin CM. The role of HPV in determining treatment, survival, and prognosis of head and neck squamous cell carcinoma. EUROGIN 2023, February 2023, Bilbao, Spain.

Ward M, Kelly T, Lochrin S, O'Connor R, Felce J, Klgour E, Brooks RD, Brooks DA, Selemidis S, Kamran W, Beirne J, Abu Saadeh F, Kennedy J, Norris L, Martin C, O'Toole S, O'Leary JJ. Circulating tumour cells correlate with markers of inflammatory response in metastatic breast cancer. Laboratory Investigations. 2003:Volume 103, issue 3, Supplement, 100081,2023.

Ward MP, Lewis F, O’Gorman C, Kelly CT, Hurley S, Henderson B, Abu Saadeh F, Cadoo K, O'Leary JJ, O'Toole S. Prognostic Significance of Circulating Tumour Cells and Disseminating Circulating Tumour Cell Clusters in Epithelial Ovarian Cancer. 5th Annual Congress of Liquid Biopsy (International Society of Liquid Biopsy, November 2023, Madrid, Spain). ISLB 2023 | Congress - Abstract Book Supplement. https://2023.islb.info/wp-content/ uploads/2023/11/ISLB-Abstracts.pdf

Ward MP, Kelly TE, Lewis F, O’Gorman C, Henderson B, Hurley S, O’Connor R, Brooks RD, Brooks DA, Selemidis S, Maguire P, Kamran W, Beirne J, Cadoo K, Abu Saadeh F,

Norris LA, Martin CM, O’Toole SA, O’Leary JJ.Prognostic significance of circulating tumour cells (CTCs) and circulating tumour DNA (ctDNA) in high-grade serous ovarian cancer. Irish Society of Gynaecological Oncology Annual Meeting, December 2023, Belfast.

Ward MP, Lewis F, O’Gorman C, Kelly TE, Mohamed BM, Henderson B, Hurley S, O’Connor R, Brooks RD, Brooks DA, Selemidis S, Maguire P, Kamran W, Beirne JP, Abu Saadeh F, Cadoo K, Norris LA, Martin C, O’Toole SA, O’Leary JJ. 2023. #836 Liquid biopsy isolation of circulating tumour cells from epithelial ovarian cancer patients and their prognostic significance. International Journal of Gynecologic Cancer, 33, A70-A371.

White C, Reynolds S, Naik P, O’ Brien R, Keegan H, Gleeson, G, Russell NE, Tewari P, O’Toole S, Normand C, Sharp L, Flannelly G, O’Leary JJ, Martin CM. CERVIVA HPV primary screening study: 3 year follow up of HPV DNA positive and HPV RNA positive women with normal cytology. EUROGIN 2023, February 2023, Bilbao, Spain.

Publications: Royal College of Surgeons in Ireland, Department of Neonatology

Hurley S, Franklin R, McCallion N, Byrne AM, Fitzsimons J, White M, O'Mahony L, Hourihane JO. Atopic outcomes at 2 years in the CORAL cohort, born in COVID-19 lockdown. Pediatr Allergy Immunol. 2023 Sep;34(9):e14013. doi: 10.1111/ pai.14013. PMID: 37747751.

Jenkins E, Corbett M, Breen A, O'Brien, K, Cooney C, McGrath R, Flynn E, White M. Child protection pathways for newborn infants: A multi‐disciplinary retrospective chart review of an Irish maternity hospital’s records. Child Abuse Review. 2023;32(1):e2807. https://doi.org/10.1002/car.2807 Wiley Online Library

Published Conference Abstract: Royal College of Surgeons in Ireland, Department of Neonatology

Hurley S, Franklin R, Fitzsimons J, Byrne A, White M, O'Mahony L, Hourihane J. Allergic Outcomes at 2 years in children born during COVID-19 lockdown: the CORAL study. Journal of Allergy and Clinical Immunology. 2023: 151:2 supplement page AB167. American Academy of Allergy, Asthma and Immunology Annual Meeting. 24th27th February 2023. San Antonio, Texas.

Publications: Royal College of Surgeons in Ireland, Department of Obstetrics and Gynaecology

Al Sayegh K, Dakin A, Clinton S, Sloan J, Byrne BM. Severe Maternal Morbidity and the Impact of the Covid Pandemic. Ir Med J. 2023 Sep 21;116(8):832. PMID: 37791667.

Dakin A, Clinton S, Sloan J, Dicker P, Byrne BM. Severe maternal morbidity trends over 20 years in a tertiary referral stand-alone maternity unit. Eur J Obstet Gynecol Reprod Biol. 2023 Apr;283:136-140. doi: 10.1016/j.ejogrb.2023.02.009. Epub 2023 Feb 14. PMID: 36868005.

Sanchez-Lechuga B, Salvucci M, Ng N, Kinsley B, Hatunic M, Kennelly M, Edwards J, Fleming A, Byrne B, Byrne MM. A retrospective cohort study evaluating pregnancy outcomes in women with MIDD. Acta Diabetol. 2023 Oct 31. doi: 10.1007/s00592-023-02202-z. Online ahead of print. PMID: 37907768.

Publications: The Master’s Office

Cooney C, Kennedy N, Doherty A, Shipsey M, Lindow SW, Hinds C. Evaluation of a new Perinatal Mental Health Service in a University Maternity Hospital. Ir J Psychol Med. 2023 Dec;40(4):588-591. doi: 10.1017/ipm.2023.18. Epub 2023 May 26. PMID: 37231740.

Corbett GA, Carmody D, Rochford M, Cunningham O, Lindow SW, O'Connell MP. Drug use in pregnancy in Ireland's capital city: A decade of trends and outcomes. Eur J Obstet Gynecol Reprod Biol. 2023 Mar;282:24-30. doi: 10.1016/j.ejogrb.2022.12.021. Epub 2022 Dec 22. PMID: 36621262.

Creswell L, Lindow SW, Monteith C, McNamee E, O'Gorman N, O'Connell MP. The duration of labor in spontaneous preterm deliveries: A retrospective observational study in a tertiary Irish maternity hospital. Eur J Obstet Gynecol Reprod Biol. 2023 Jun;285:110-114. doi: 10.1016/j. ejogrb.2023.04.016. Epub 2023 Apr 19. PMID: 37099860.

Creswell L, Lindow BJ, Lindow SW, MacIntyre A, O'Gorman N, Hehir M, O'Connell MP. A retrospective observational study of labour ward work Intensity: The challenge of maternity staffing. Eur J Obstet Gynecol Reprod Biol. 2023 Jul;286:90-94. doi: 10.1016/j.ejogrb.2023.05.021. Epub 2023 May 20. PMID: 37229963.

Creswell L, Doddy F, Manning C, Nazir SF, Lindow SW, Lynch C, O'Gorman N. Cell free DNA screening for fetal aneuploidy in Ireland: An observational study of outcomes following insufficient fetal fraction. Eur J Obstet Gynecol Reprod Biol. 2023 Nov;290:143-149. doi: 10.1016/j. ejogrb.2023.09.023. Epub 2023 Sep 27. PMID: 37797414.

Creswell L, Burke B, O'Sullivan L, Lindow SW, O'Gorman N. A cross-sectional survey of women's views and preferences for preterm birth screening and treatment. Eur J Obstet Gynecol Reprod Biol. 2023 Nov;290:14-21. doi: 10.1016/j.ejogrb.2023.09.005. Epub 2023 Sep 11. PMID: 37713943.

Creswell L, Rolnik DL, Lindow SW, O'Gorman N. Preterm Birth: Screening and Prediction. Int J Womens Health. 2023 Dec 21;15:1981-1997. doi: 10.2147/IJWH.S436624. PMID: 38146587; PMCID: PMC10749552.

Farrell T, Minisha F, Abu Yaqoub S, Rahim AA, Omar M, Ahmed H, Lindow S, Abraham MR, Gassim M, Al-Dewik N, Ahmed S, Al-Rifai H; Q-precious group. Impact of timing and severity of COVID-19 infection in pregnancy on intrauterine fetal growth- a registry-based study from Qatar. PLoS One. 2023 Jun 30;18(6):e0288004. doi: 10.1371/journal.pone.0288004. PMID: 37390057; PMCID: PMC10313033.

McTiernan AM, Ruprai CK, Lindow SW. Assisted vaginal delivery in the obese patient. Best Pract Res Clin Obstet Gynaecol. 2023 Dec;91:102403. doi: 10.1016/j. bpobgyn.2023.102403. Epub 2023 Aug 22. PMID: 37683519.

Mohan M, Appiah-Sakyi K, Oliparambil A, Pullattayil AK, Lindow SW, Ahmed B, Konje JC. A Meta-Analysis of the Global Stillbirth Rates during the COVID-19 Pandemic. J Clin Med. 2023 Nov 21;12(23):7219. doi: 10.3390/jcm12237219. PMID: 38068270; PMCID: PMC10707675.

Pandey U, Narayan A, Lindow S W. Study of institute of medical sciences, BHU and Sir Sunder Lal Hospital staff regarding their attitudes and experiences of domestic violence. Indian J Obstet Gynecol Res 2023;10(3):254-258.

Whelan N, Faraah N, Lindow S, O'Connell MP. Women's views on the impact of the Slaintecare consultant contract on private obstetric care. Ir Med J. 2023 Dec 14;116(10):876. PMID: 38258736.

Publications: Trinity College Dublin Academic Department of Obstetrics and Gynaecology

Oduola O, Kennelly M, Murphy DJ. Admission ultrasonography as a means of identifying unrecognized fetal compromise in term singleton pregnancies at the onset of labor - a feasibility study. J Matern Fetal Neonatal Med. 2023 Dec;36(2):2241104. doi: 10.1080/14767058.2023.2241104. PMID: 37527967.

Murphy DJ, Devane D, Molloy E, Shahabuddin Y. Fetal scalp stimulation for assessing fetal well-being during labour. Cochrane Database Syst Rev. 2023 Jan 10;1(1):CD013808. doi: 10.1002/14651858.CD013808.pub2. PMID: 36625680; PMCID: PMC9831024.

Murphy DJ. The unwelcome consequences of guideline authorship. BJOG. 2023 Nov;130(12):1435-1436. doi: 10.1111/1471-0528.17566. Epub 2023 May 31. PMID: 37259679.

Publications: University College Dublin, Centre for Human Reproduction

Anglim B, Zhao ZY, Parshad S, Matelski J, Lemos N. Pain resolution and functional outcomes of total mesh excision: a case series. Int Urogynecol J. 2023 Sep;34(9):2115-2123. doi: 10.1007/s00192-023-05516-2. Epub 2023 Apr 1. PMID: 37004520.

Ashoori M, O'Toole JM, O'Halloran KD, Naulaers G, Thewissen L, Miletin J, Cheung PY, El-Khuffash A, Van Laere D, Straňák Z, Dempsey EM, McDonald FB. Machine Learning Detects Intraventricular Haemorrhage in Extremely Preterm Infants. Children (Basel). 2023 May 23;10(6):917. doi: 10.3390/children10060917. PMID: 37371150; PMCID: PMC10297241.

Brady S, Tan T, O'Flaherty D. Hereditary haemorrhagic telangiectasia and neuraxial anaesthesia in pregnancy: when should magnetic resonance imaging be performed? Anaesth Rep. 2023 Apr 27;11(1):e12227. doi: 10.1002/anr3.12227. PMID: 37124667; PMCID: PMC10140102.

Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2023 Jul;108(4):333-341. doi: 10.1136/archdischild-2022-324184. Epub 2022 Dec 9. PMID: 36600484; PMCID: PMC10313962.

Cheung MA, Martin AM. Single incision Caesarean section for dicavitary twin pregnancy in uterus didelphys. Eur J Obstet Gynecol Reprod Biol. 2023 Dec;291:259-260. doi: 10.1016/j.ejogrb.2023.10.025. Epub 2023 Oct 18. PMID: 38353089.

Cody F, Unterscheider J, Daly S, Geary M, Kennelly M, McAuliffe F, Morrison J, O'Donoghue K, Hunter A, Dicker P, Tully E, Fhearaigh R, Malone F; Perinatal Ireland Research Consortium. Dynamic growth changes in fetal growth restriction using serial ultrasonographic biometry and umbilical artery doppler: The multicenter PORTO study. Int J Gynaecol Obstet. 2023 Apr;161(1):198-203. doi: 10.1002/ ijgo.14470. Epub 2022 Sep 29. PMID: 36129374.

Corbett GA, Hunter S, Javaid A, McNamee E, O'Connell M, Lindow SW, Martin A. Non-diabetic fetal macrosomia: outcomes of elective delivery versus expectant management. Ir J Med Sci. 2023 Jun;192(3):1249-1257. doi: 10.1007/s11845-022-03076-w. Epub 2022 Jul 4. PMID: 35781860; PMCID: PMC9251024.

Elsayed S, Farah N, Anglim M. Heterotopic Pregnancy: Case Series and Review of Diagnosis and Management. Case Rep Obstet Gynecol. 2023 May 5;2023:2124191. doi: 10.1155/2023/2124191. PMID: 37187915; PMCID: PMC10181901.

Floyd R, Anglim B. Tubo-ovarian abscess after vaginal delivery: A case report and review of current literature. Case Rep Womens Health. 2023 Jul 4;39:e00526. doi: 10.1016/j.crwh.2023.e00526. PMID: 37457818; PMCID: PMC10344697.

Fucikova H, Blatny J, Stingl J, Miletin J. Capnometry during neonatal transport-Mini review. Acta Paediatr. 2023 May;112(5):919-923. doi: 10.1111/apa.16729. Epub 2023 Mar 8. PMID: 36843232.

Hansen ML, Pellicer A, Hyttel-Sørensen S, Ergenekon E, Szczapa T, Hagmann C, Naulaers G, Mintzer J, Fumagalli M, Dimitriou G, Dempsey E, Tkaczyk J, Cheng G, Fredly S, Heuchan AM, Pichler G, Fuchs H, Nesargi S, Hahn GH, Piris-Borregas S, Širc J, Alsina-Casanova M, Stocker M, Ozkan H, Sarafidis K, Hopper AO, Karen T, RzepeckaWeglarz B, Oguz SS, Arruza L, Memisoglu AC, Del Rio Florentino R, Baserga M, Maton P, Truttmann AC, de Las Cuevas I, Agergaard P, Zafra P, Bender L, Lauterbach R, Lecart C, de Buyst J, El-Khuffash A, Curley A, Vaccarello OO, Miletin J, Papathoma E, Vesoulis Z, Vento G, Cornette L, Lopez LS, Yasa B, Klamer A, Agosti M, Baud O, Mastretta E, Cetinkaya M, McCall K, Zeng S, Hatzidaki E, Bargiel A,

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Appendix Three

Members of the Board of Guardians and Directors (Charity Trustees)

Mary Donovan Board Chair

Bernadette Byrne Deputy Board Chair

Anne-Marie Curran

Professor Robbie GilliganRetired from the Board in June 2023

Theresa Daly

Ger Prendergast

Dr Michael F. O’Hare

Rosemary Grant

Richard Woulfe

Catherine Keane

Dr Terry Tan

Professor Nadine Farah

Siobhan O’Leary

Joined the Board in June 2023

Leo Clancy Joined the Board in June 2023

Ex-Officio Members

The Master/CEO Professor Michael P. O’Connell

The Lord Mayor of DublinCouncillor Caroline Conroy June 2022 - June 2023 Councillor Daithí de Róiste June 2023 - June 2024

Appendix Five Organogram 2023

Board of Guardians & Directors

Appendix Six

Masters of The Coombe Lying-In Hospital / Coombe Women's Hospital / CWIUH / The Coombe Hospital

Richard Reed Gregory, 1829 - 1831

Thomas McKeever, 1832 - 1834

Charles Joseph O’Hara, 1835 - 1835

Hugh Richard Carmichael, 1835 - 1841

Robert Francis Power, 1835 - 1840

William Jameson, 1840 - 1841

Michael O’Keeffe, 1841 - 1845

John Ringland, 1841 - 1876

Henry William Cole, 1841 - 1847

James Hewitt Sawyer, 1845 - 1875

George Hugh Kidd, 1876 - 1883

Samuel Robert Mason, 1884 - 1890

John Colclough Hoey, 1891 - 1899

Thomas George Stevens, 1900 - 1907

Michael Joseph Gibson, 1907 - 1914

Robert Ambrose MacLaverty ,1914 - 1921

Louis Laurence Cassidy, 1921 - 1928

Timothy Maurice Healy, 1928 - 1935

Robert Mulhall Corbet, 1935 - 1942

Edward Aloysius Keelan, 1942 - 1949

John Kevin Feeney, 1949 - 1956

James Joseph Stuart, 1956 - 1963

William Gavin, 1964 - 1970

James Clinch, 1971 - 1977

Niall Duignan, 1978 - 1984

John E. Drumm, 1985 - 1991

Michael J. Turner, 1992 - 1998

Sean F. Daly, 1999 - 2005

Chris Fitzpatrick, 2006 - 2012

Sharon R. Sheehan, 2013 - 2019

Michael P. O’Connell, 2020 - present

Appendix Seven

Matrons and Directors of Midwifery and Nursing at The Coombe Lying-in Hospital / Coombe Women’s Hospital / CWIUH / The Coombe Hospital

Over a period of 156 years since the granting of the Royal Charter of Incorporation to the Coombe LyingIn Hospital in 1867, there have been sixteen Matrons or Directors of Midwifery and Nursing (DoMN).

Mrs Watters, Matron 1864 - 1874

Kate Wilson, Matron 1874 - 1886

Mrs Saul, Matron 1886 - 1886

Mrs O’Brien, Matron 1886 - 1887

Mrs Allingham, Matron 1887 - 1889

Annie Hogan, Matron 1889 - 1892

Annie Fearon, Matron 1892 - 1893

Hester Egan, Matron 1893 - 1909

Eileen Joy, Matron 1909 - 1914

Genevieve O’Carroll, Matron 1914 - 1951

Nancy Conroy, Matron 1952 - 1953

Margaret (Rita) Kelly, Matron 1954 - 1982

Ita O’Dwyer, DoMN 1982 - 2005

Mary O’Donoghue, DoMN - Acting 2005 - 2006

Patricia Hughes, DoMN 2007 - 2016

Ann MacIntyre, DoMN 2016 - present

Appendix Eight

Guinness Lectures

1969 The Changing Face of Obstetrics. Professor T.N.A. Jeffcoate, University of Liverpool.

1970 British Perinatal Survey. Professor N. Butler, University of Bristol.

1971 How Many Children? Sir Dougald Baird, University of Aberdeen.

1972 The Immunological Relationship between Mother and Fetus. Professor C.S. Janeway, Boston.

1973 Not One but Two. Professor F. Geldenhuys, University of Pretoria.

1978 The Obstetrician/Gynaecologist and Diseases of the Breast. Professor Keith P. Russell, University of Southern California School of Medicine.

1979 Preterm Birth and the Developing Brain. Dr J. S. Wigglesworth, Institute of Child Health, University of London.

1980 The Obstetrician a Biologist or a Sociologist? Professor James Scott, University of Leeds.

1981 The New Obstetrics or Preventative Paediatrics? Dr J. K. Brown, Royal Hospital for Sick Children, Edinburgh.

1982 Ovarian Cancer. Dr J. A. Jordan, University of Birmingham.

1983 The Uses and Abuses of Perinatal Mortality Statistics. Professor G.V.P. Chamberlain, St. George’s Hospital Medical School, London.

1984 Ethics of Assisted Reproduction. Professor M. C. McNaughton, President, Royal College of Obstetricians and Gynaecologists.

1985 Magnetic Resonance Imaging in Obstetrics and Gynaecology. Professor E. M. Symonds, University of Nottingham.

1986 Why Urodynamics? Mr S. L. Stanton, St. George’s Hospital Medical School, London.

1987 Intrapartum Events and Neurological Outcome. Dr K. B. Nelson, Department of Health and Human Services, National Institute of Health, Maryland.

1988 Anaesthesia and Maternal Mortality. Dr Donald D. Moir, Queen Mothers Hospital, Glasgow.

1989 New approaches to the management of severe intrauterine growth retardation. Professor Stuart Campbell, Kings College School of Medicine and Dentistry, London.

1990 Uterine Haemostasis. Professor Brian Sheppard, Department of Obstetrics and Gynaecology, Trinity College, Dublin.

1991 Aspects of Caesarean Section and Modern Obstetric Care. Professor Ingemar Ingemarsson, University of Lund.

1992 Perinatal Trials and Tribulations. Professor Richard Lilford, University of Leeds.

1993 Diabetes Mellitus in Pregnancy. Professor Richard Beard, St. Mary’s Hospital, London.

1994 Controversies in Multiple Pregnancies. Dr Mary E D’Alton, New England Medical Center, Boston.

1995 The New Woman. Professor James Drife, University of Leeds.

1996 The Coombe Women’s Hospital and the Cochrane Collaboration. Dr Iain Chalmers, the UK Cochrane Centre, Oxford.

1997 The Pathogenesis of Endometriosis. Professor Eric J Thomas, University of Southampton.

1998 A Flux of the Reds - Placenta Prevail Then and Now. Professor Thomas Basket, Nova Scotia.

1999 Lessons Learned from First Trimester Prenatal Diagnosis. Professor Ronald J Wagner, Jefferson Medical College, Philadelphia.

2000 The Timing of Fetal Brain Damage: The Role of Fetal Heart Rate Monitoring. Professor Jeffrey P Phelan, Childbirth Injury Prevention Foundation, Pasadena, California.

2001 The Decline and Fall of Evidence Based Medicine. Dr John M Grant, Editor of the British Journal of Obstetrics and Gynaecology.

2002 Caesarean Section: A Report of the U.K. Audit and its Implications. Professor J.J. Walker, St James’s Hospital, Leeds.

2003 The 20th Century Plague: It’s Effect on Obstetric Practice. Professor Mary-Jo O’Sullivan University of Miami School of Medicine, Florida.

2004 Connolly, Shaw and Skrabanek - Irish Influences on an English Gynaecologist. Professor Patrick Walker, Royal Free Hospital, London.

2005 Careers and Babies: Which Should Come First? Dr. Susan Bewley, Clinical Director for Women’s Health, Guys and St Thomas NHS Trust, London.

2006 Retinopathy of Prematurity from the Intensive Care Nursery to the Laboratory and Back Professor Neil McIntosh, Professor of Child Life and Health, Edinburgh, Vice President Science, Research and Clinical Effectiveness, RCPCH, London.

2007 Schools, Skills and Synapses. Professor James J. Heckman, Nobel Laureate in Economic Sciences. Henry Schultz Distinguished Service Professor of Economics, University of Chicago, Professor of Science and Society, University College Dublin.

2008 Cervical Length Screening For Prevention of Preterm Birth. Professor Vincenzo Berghella, MD, Director of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia.

2009 Advanced Laparoscopic Surgery: The Simple Truth. Professor Harry Reich, Wilkes Barre Hospital, Pennsylvania; Past President of the International Society of Gynaecologic Endoscopy (ISGE).

2010 Magnesium – The Once and Future Ion. Professor Mike James, Professor and Head of Anaesthesia, The Groote Schuur Hospital, University of Capetown.

2011 Pre-eclampsia: Pathogenesis of a Complex Disease. Professor Chris Redman, Emeritus Professor of Obstetric Medicine, Nuffield, Department of Obstetrics and Gynaecology, University of Oxford.

2012 Non-invasive prenatal diagnosis: from Down syndrome detection to fetal whole genome sequencing Professor Dennis Lo, Director of the Li Ka Shing Institute of Health Sciences, Department of Chemical Pathology, Prince of Wales Hospital, Hong Kong.

2013 A procedural approach to perceived inappropriate requests for Medical Treatment. Lessons from the USA. Professor Geoffrey Miller, Professor of Pediatrics and of Neurology; Clinical Director Yale Pediatric Neurology, Co-Director Yale/MDA Pediatric Neuromuscular Clinic Yale Program for Biomedical Ethics.

2014 ‘THE CHANGE’, Highlighting the change in diagnosis and management in the past thirty years. Professor C.N. Purandare. Consultant Obstetrician and Gynecologist. President Elect FIGO.

2015 Why you shouldn’t believe what you read in medical journals. Dr Fiona Godlee, Editor in Chief, British Medical Journal.

2016 ‘We are such stuff as Dreams are made on’: Imagination and Revolution – the Epiphany of a Photograph. Professor Chris Fitzpatrick, Consultant Obstetrician and Gynaecologist CWIUH, Clinical Professor UCD School of Medicine.

2017 ‘Women; the journey is far from over.’ Professor James Dornan. Chair Health and Life Sciences University of Ulster. Emeritus Chair Fetal Medicine Queen’s University Belfast.

2018 ‘Domestic Violence and the Obstetrician.’ Professor Stephen Lindow, Division Chief of Obstetrics at Sidra Medical and Research Centre, Qatar.

2019 ‘From Queen Victoria to the Duchess of Cambridge.’ Professor Rob Dyer, University of Cape Town, New Groote Schuur Hospital.

2020 Deferred due to the COVID-19 pandemic.

2021 Deferred due to the COVID-19 pandemic.

2022 Umbilical cord management at birth: Getting the timing right. Professor Eugene Dempsey, Consultant Neonatologist, Cork University Maternity Hospital.

2023 Fertility and Infertility: An African Perspective. Professor Zephne van Der Spuy, Emeritus Professor/ Senior Scholar, University of Cape Town.

People are at the heart of everything we do

14. Definitions, terms and abbreviations

Booking: A woman who has attended an antenatal clinic or a consultant for antenatal care in consulting rooms has booked.

Corrected perinatal mortality rate: The sum of stillbirths and early neonatal deaths excluding those associated with or due to a major congenital anomaly per 1,000 total births.

DOMINO and early transfer home services: The DOMINO (domiciliary care in and out of hospital) and early transfer home services are available to healthy pregnant women attending the CWIUH who live in specified areas. The team of midwives look after a woman from the booking visit, throughout the pregnancy, during the labour and for the first week after the birth of the baby.

Early neonatal death: Death within seven days of a liveborn infant who weighed 500 grams or more at birth.

Fourth degree tear: An injury to the perineum that involves the anal sphincter complex and the anorectal mucosa.

Infant feeding: Includes breastfeeding and formula feeding.

Late maternal death: The death of a woman from direct or indirect obstetric causes, more than 42 days, but less than one year after the end of the pregnancy.

Late neonatal death: Death between seven and 28 days of a liveborn baby who weighed 500 grams or more at birth.

Nulliparous: A woman who has not previously given birth to an infant, either liveborn or stillborn, weighing greater than or equal to 500 grams.

Obstetric anal sphincter injuries: Include both third degree and fourth degree perineal tears.

Major obstetric haemorrhage: Occurs if one of the following criteria are met: (a) estimated blood loss of at least 2,500 ml, (b) transfusion of five or more units of blood or (c) receiving treatment for coagulopathy.

Maternal death: The death of a of woman while pregnant or within 42 days of the end of the pregnancy irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Parous: A woman who has previously given birth to at least one infant, either liveborn or stillborn, weighing greater than or equal to 500 grams.

Perinatal mortality rate: The sum of stillbirths and early neonatal deaths per 1,000 total births.

Primary postpartum haemorrhage: The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.

QUiPP app: A clinical decision-making tool that can help clinicians determine the risk of preterm birth in women with symptoms of threatened preterm labour as well as in asymptomatic women who are at high-risk of preterm birth.

Severe maternal morbidity: A pregnant or recently pregnant woman (up to 42 days following the end of the pregnancy) who experienced any of the following: major obstetric haemorrhage, uterine rupture, eclampsia, renal or liver dysfunction, pulmonary oedema, acute respiratory dysfunction, pulmonary embolism, cardiac arrest, coma, cerebrovascular event, status epilepticus, septic shock, anaesthetic complications and peripartum hysterectomy.

Stillbirth: A baby weighing 500 grams or more, who shows no sign of life at delivery.

Third degree tear: An injury to the perineum that involves the anal sphincter complex.

The following abbreviations are used but not explained in the Annual Report:

Anti-VEGF Anti-vascular endothelial growth factor

AVSD Atrioventricular septal defect

BMI Body mass index (kg/m2)

CGIN Cervical glandular intra-epithelial neoplasia

CIN Cervical intra-epithelial neoplasia

CoNS Coagulase-negative staphylococci infection

CPAP Continuous positive airway pressure

CT Computed tomography scan

CTG Cardiotocography

ECHO Echocardiogram

ECMO Extracorporeal membrane oxygenation

EMT Executive management team

GP General practitioner

H & E Haematoxylin and eosin stain

HDU High dependency unit

HELLP Syndrome haemolysis, elevated liver enzymes and thrombocytopenia syndrome

IUGR Intrauterine growth restriction

IVH Intraventricular haemorrhage

LEEP Loop electrical excision procedure

MgS04 Magnesium sulphate

MRI Magnetic resonance imaging

NPEC National Perinatal Epidemiology Centre

NEC Necrotising enterocolitis

NETZ Needle excision of the transformation zone

NCHD Non-consultant hospital doctor

NVRL National Viral Reference Laboratory

PDA Patent ductus arteriosus

PPHN Persistent pulmonary hypertension of the newborn

PVL Periventricular leukomalacia

ROP Retinopathy of prematurity

STABLE Sugar, temperature, airway, blood pressure, lab work and emotional support

SWETZ Straight wire excision of the transformation zone

TGA Transposition of the great arteries

TVT Tension free vaginal tape

TVTO Tension free obturator tape

TOT Transobturator tape

TRAADP Targeted routine antenatal anti-D prophylaxis programme

VAIN Vaginal intra-epithelial neoplasia

VSD Ventricular septal defect

WPW Wolff-Parkinson White

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