Obstetrical team of the Mother-Child College

Obstetrical team of the

« Mother-Child » College

Rationale for a proposal:

«The way that perinatal services are organised and delivered have a substantial impact on

important clinical outcomes such as mortality or disability rates.

Preterm infants who are cared for in the largest intensive care units, where staff can develop and maintain their skills have better outcomes than infants cared for in smaller, less busy units.»

BMJ (2004); 329 : 730-732

Rationale for a proposal:

«The way that perinatal services are organised and delivered have a substantial impact on

important clinical outcomes such as mortality or disability rates.

Preterm infants who are cared for in the largest intensive care units, where staff can develop and maintain their skills have better outcomes than infants cared for in smaller, less busy units.»

Rationale for a proposal (2):

«Infants who are admitted when neonatal

intensive care units are getting busier have a significantly greater risk of dying.»

BMJ (2004); 329 : 730-732

Rationale for a proposal (2):

«Infants who are admitted when neonatal

intensive care units are getting busier have a significantly greater risk of dying.»

Risk of death for infants in neonatal units according to occupancy of unit on admission

In Belgium, the criteria used for intra-uterine transfer to MICs and for maternal retransfer to peripheral maternity are not standardised.

The delineation of national guidelines aims at optimizing the antenatal care and the foeto-maternal prognosis at a justifiable cost.

The cost/benefit ratios

(about clinical and financial efficacy) of the MICs were not assessed.

In Belgium, the criteria used for intra-uterine transfer to MICs and for maternal retransfer to peripheral maternity are not standardised.

The delineation of national guidelines aims at optimizing the antenatal care and the foeto-maternal prognosis at a justifiable cost.

The cost/benefit ratios

(about clinical and financial efficacy) of the MICs were not assessed.

1. Registration and evaluation of maternal

morbidity and pregnancy outcome in women with a high risk pregnancy and/or intra-uterine transfer in a Maternal Intensive Care (MIC) Unit 2. Accurate global perinatal epidemiology

1. Registration and evaluation of maternal

morbidity and pregnancy outcome in women with a high risk pregnancy and/or intra-uterine transfer in a Maternal Intensive Care (MIC) Unit

2. Accurate global perinatal epidemiology

1. Pregnancy maternal and perinatal outcomes 2. Criteria for intra-uterine transfer

3. Criteria for retransfer to peripheral maternities

1. Pregnancy maternal and perinatal outcomes

2. Criteria for intra-uterine transfer

3. Criteria for retransfer to peripheral maternities

Reasons (1):

Since the creation of the MICs and NICs in

August 1996, no evaluation has been achieved in Belgium of their impact on:

Reasons (1):

Since the creation of the MICs and NICs in

August 1996, no evaluation has been achieved in Belgium of their impact on:

4. Maternal morbidity and mortality associated with high risk pregnancies cared for in Belgian MICs 5. The costs involved in such strategies

4. Maternal morbidity and mortality associated with high risk pregnancies cared for in Belgian MICs

5. The costs involved in such strategies

Reasons (2):

Since the creation of the MICs and NICs in

August 1996, no evaluation has been achieved in Belgium on their impact on:

Reasons (2):

Since the creation of the MICs and NICs in

August 1996, no evaluation has been achieved in Belgium on their impact on:

Therefore, the obstetrical branch of the « mother-child » college suggests to evaluate:

Therefore, the obstetrical branch of the « mother-child » college suggests to evaluate:

1. The clinical activity of the MICs

2. The impact on maternal pregnancy outcome

(morbidity and mortality), of intra-uterine transfer in a MIC

1. The clinical activity of the MICs

2. The impact on maternal pregnancy outcome

(morbidity and mortality), of intra-uterine transfer in a MIC

Therefore,

the obstetrical branch

of the « mother-child » College suggests:

Therefore,

the obstetrical branch

of the « mother-child » College suggests:

3. To evaluate, in collaboration with the team of neonatology of this College, the impact of

maternal treatment in a MIC upon perinatal morbidity and mortality

4. To correlate the perinatal outcomes with the type of maternal pathology and treatment

3. To evaluate, in collaboration with the team of neonatology of this College, the impact of

maternal treatment in a MIC upon perinatal morbidity and mortality

4. To correlate the perinatal outcomes with the type of maternal pathology and treatment

Therefore, the obstetrical branch of the « mother-child » College suggests to evaluate:

Therefore, the obstetrical branch of the « mother-child » College suggests to evaluate:

5. The cost/benefit ratio of maternal intra-uterine transfer. We will document the cost of

therapeutic intervention versus beneficial impact on maternal and perinatal outcome

5. The cost/benefit ratio of maternal intra-uterine transfer. We will document the cost of

therapeutic intervention versus beneficial impact on maternal and perinatal outcome

Criteria for Evaluation (1)

Maternal indications for maternal transfer Criteria for Evaluation (1)

Maternal indications for maternal transfer

- Uncomplicated preterm labour - Coexisting diseases

- Perinatal emergency transfer

- Spontaneous rupture of membranes - Antepartal haemorrhage

- Infection risk (chorioamnionitis, pyelonephritis,…)

- Uncomplicated preterm labour - Coexisting diseases

- Perinatal emergency transfer

- Spontaneous rupture of membranes - Antepartal haemorrhage

Criteria for Evaluation (2)

Maternal indications for maternal transfer Criteria for Evaluation (2)

Maternal indications for maternal transfer

- Diabetes

- Hypertensive diseases of pregnancy

(Preeclampsia, HELLP syndrome, eclampsia…) - Cholestasis

- Diabetes

- Hypertensive diseases of pregnancy

(Preeclampsia, HELLP syndrome, eclampsia…) - Cholestasis

- Drug usage

- Other medical (hyperthyroidism, epilepsy, pulmonary dysfunction, deep venous

thrombophlebitis or pulmonary embolism, other cardiovascular complications,...)

- Other obstetric (twin-to-twin transfusion syndrome, intra-uterine growth retardation, cholestasis of

pregnancy,…)

- Drug usage

- Other medical (hyperthyroidism, epilepsy, pulmonary dysfunction, deep venous

thrombophlebitis or pulmonary embolism, other cardiovascular complications,...)

- Other obstetric (twin-to-twin transfusion syndrome, intra-uterine growth retardation, cholestasis of

pregnancy,…)

Criteria for Evaluation (3)

Maternal indications for maternal transfer Criteria for Evaluation (3)

- Antenatal steroids

- Tocolytics (beta-mimetics, calcium channel blockers, Atosiban, others)

- Antibiotics - Others

- Antenatal steroids

- Tocolytics (beta-mimetics, calcium channel blockers, Atosiban, others)

- Antibiotics - Others

Treatment before, during and after intra-uterine transfer

Treatment before, during and after intra-uterine transfer

- Type of stay (duration)

- Retransfer to a peripheral hospital

- Duration of stay in the MIC before retransfer to a peripheral hospital

- Delivery during stay

- Medical assistance during stay

- Type of stay (duration)

- Retransfer to a peripheral hospital

- Duration of stay in the MIC before retransfer to a peripheral hospital

- Delivery during stay

- Medical assistance during stay

Stay Stay

- Cervical length (cervical echography ?) - Cervical dilatation

- Cervical consistency

- Type of presentation (cephalic, breech,others)

- Cervical length (cervical echography ?) - Cervical dilatation

- Cervical consistency

- Type of presentation (cephalic, breech,others)

Pelvic inspection

before intra-uterine transfer Pelvic inspection

- Gestational age at transfer - Gestational age at delivery

- Gestational age at transfer

- Gestational age at delivery

Gestational age Gestational age

- Single - Twins - Triplets - Quadruplets - Parity - Gestation - Maternal age - Single - Twins - Triplets - Quadruplets - Parity - Gestation - Maternal age Pregnancy Pregnancy

- Vaginal – spontaneous

- Vaginal – instrumental (forceps or vacuum) - Caesarean section planned

- Caesarean section after onset of labour - Indications: maternal, fetal

- Vaginal – spontaneous

- Vaginal – instrumental (forceps or vacuum) - Caesarean section planned

- Caesarean section after onset of labour - Indications: maternal, fetal

Mode of delivery

- Less than one hour or one hour - One hour to less than 2 days

(time necessary for steroids efficacy) - 2 days up to one week

- Over one week

- Less than one hour or one hour - One hour to less than 2 days

(time necessary for steroids efficacy) - 2 days up to one week

- Over one week

Time to delivery interval Time to delivery interval

- Intensive care unit admission

(requiring ventilation, CPAP or over 60% oxygen, CVP lines, intra-arterial line, invasive blood

pressure monitoring, anti-hypertensive infusion, renal replacement therapy,…)

- Others

- Intensive care unit admission

(requiring ventilation, CPAP or over 60% oxygen, CVP lines, intra-arterial line, invasive blood

pressure monitoring, anti-hypertensive infusion, renal replacement therapy,…)

- Others

Postpartum complications Postpartum complications

- Postpartum haemorrhage requiring transfusion - Hypertension requiring treatment

- High dependency care (frequent BP monitoring, pulse oximetry, oxygen, special midwife input)

- Postpartum haemorrhage requiring transfusion - Hypertension requiring treatment

- High dependency care (frequent BP monitoring, pulse oximetry, oxygen, special midwife input)

Postpartum complications Postpartum complications

- Stillborn

- Neonatal death

- Admission to neonatal intensive care unit - Apgar score

- Neonatologist criteria (to be implemented in

collaboration with the neonatologist team of this College)

- Stillborn

- Neonatal death

- Admission to neonatal intensive care unit - Apgar score

- Neonatologist criteria (to be implemented in

collaboration with the neonatologist team of this College)

Perinatal outcome Perinatal outcome

Epidemiology

- Establishment of accurate perinatal and

obstetrical epidemilogy with on line registration of classical obstetrical and perinatal criteria allowing adequate evaluation

- Contacts taken with and approval by the VVOG, GGOLFB and SPE

Conclusions

• _{The obstetrical team of the Mother-Child}

College is just starting its activities in close coordination with the Neonatologist team

• It has a strong commitment

• The delineation of an optimal therapeutic strategy must be based on scientific hard epidemiological data to be collected,…at a certain price.