Logical Priority

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The aim of the EEPD “Logical Priority” initiative is to facilitate
a) the best possible selection of priority maternity and neonatal questions
b) the exact wording of each question and all associated text - including all allowable answer options
c) what guidance can be given about definitions when the associated Help Keys are pressed
d) the most efficient flow-pattern of questions to avoid duplication of data entry

Contents

EEPD “Logical Priority” Proposals

The current paper-based definitions do not make sense when using a flow-patterned computerised system. This is a suggested solution by Rupert Fawdry.

First, a list of

Previous and Current Paper and Electronic Definitions

National Maternity Services Dataset Initiative

Method of Delivery

Spontaneous Vertex
Spontaneous Other Cephalic
Vacuum Extraction
Vacuum Extraction after Failed Forceps
Forceps after Failed Vacuum
Forceps (low cavity)
Forceps (mid cavity or with rotation)
Spontaneous Breech
Assisted Breech
Breech Extraction
Elective caesarean
Emergency caesarean
Emergency caesarean after failed instrumental delivery
Other (including destructive)

Korner Maternity

Method of Delivery

0. Spontaneous Vertex
1. Spontaneous, Other cephalic
2. Low Forceps, not Breech
3. Other Forceps, not Breech
4. Ventouse
5. Breech
6. Breech Extraction
7. Elective Caesarean Section
8. Other (non-elective) Caesarean Section

Royal College of Obstetricians and Gynaecologists (RCOG)

Annual Return

i. SVD
ii. Vaginal Breech Deliveries
iii. Breech by Caesarean Section
of which
a) Emergency
b) Elective
iv. Forceps Deliveries
v. Ventouse Deliveries
vi. Total Instrumental Deliveries (iv and v)
vii Total Caesarean Sections (NB Singleton pregnancies)
of which
a) Emergency
b) Elective

English National Board for Nursing, Midwifery and Health Visiting (ENB)

Now abolished, but ideas for data potentially required by any similar organisation are still just as relevant:

Total Women Delivered

Total delivered in the hospital

Deliveries in Midwifery-Led Centres


HOME BIRTHS

Total Deliveries (Confinements) in the Home


MIDWIFERY LED CARE

Total Bookings for Midwife-Led care

Total Number of deliveries undertaken by midwives (of all the above)

Women delivered by a midwife known to them

Delivered by midwives in private practice


OBSTETRIC INTERVENTIONS

Number of planned inductions

Number of accelerated labours

Number of episiotomies

Number of epidurals with vaginal births

Number of epidurals/spinals with caesarean section

Number of planned caesarean sections

Number of emergency caesarean sections

Number of forceps deliveries

Total ventouse deliveries

Ventouse deliveries by Midwives

Number of Vaginal Breech Deliveries


Unfortunately, neither the RCOG nor the ENB requirements can be answered from any of the current paper definitions, so all current computer systems often have to ask the same question twice using different answer options!



“Logical Priority” using "Method of Birth" as an example

Default Answers underlined

A draft standard of Flow patterned Questions and all allowable answer options is proposed as follows:

A. Route of Birth?
  1. Vaginal
  2. Caesarean
  3. Abdominal
  4. Unknown (Free Text)

IF VAGINAL

If answer to question A = 1. Vaginal
A1. Time and Date of Start of Labour?
A2. Time and Date of Start of Second Stage? (allows computer to calculate Duration of First & Second Stages)
A3. Presentaion at Birth?
1. Cephalic
2. Breech
9. Other (Free text)

IF VAGINAL AND CEPHALIC

If answer to question A3 = 1. Cephalic
A3/1/1
1. No operative assistance
2. Ventouse
3. Mid Cavity or Outlet Forceps
4. Kjellands Rotation
5. Other Forceps (Free text)
6. Unknown (Free text)
7.Other (Free text)
A3/1/2
1. No shoulder problems
2. Problems with Shoulders (inc Shoulder Dystocia) (Free text)
A3/1/3
Probably needs to be diagnosed as “Shoulder Dystocia”
1.No
2.Yes

It may be argued that the question should be “Shoulder Dystocia?” “Yes” or “No” but it would seem better to encourage front line staff to record their immediate impression that there was a problem with the shoulders and only afterwards try to calculate if what actually happened falls within the strict diagnostic definition of “Shoulder Dystocia”

If answer to question A3/1/1 = 2. Ventouse or 3. Forceps
A3/1/1/1 Previous failed Ventouse?
1. No
2. Yes (Free text)

IF VAGINAL AND BREECH

If answer to question A3 = 2. Breech
A3/2/1
1. Simple Assisted Breech
2. Breech with Forceps to the Aftercoming head
3. Breech Extraction
8. Unknown (Free text)
9. Other (Free text)


A3/2/2 Timing of Diagnosis of Breech
1. Before Labour
2. In First Stage
3. Second Stage
8. Unknown (Free text)
9. Other (Free text)


IF CAESAREAN

If answer to question A = 2. Caesarean

A2/1 Presentation just before birth

1. Cephalic
2. Breech
3. Transverse or Oblique
8. Unknown
9. Other (Free text)

Essential question to avoid confusion if a Cephalic Presentation Caesarean is delivered as a Breech Extraction.

Urgency of Caesarean

The distinction between the different levels of urgency of a Caesarean (“Emergency”, “Plannedʼ etc. is not just yet another “Paralysis by Analysis” essential since the computer default list for the Indications for a “Planned Caesarean” is the same as for a “Planned Caesarean needed doing early”, and not the same as for an “Emergency Caesarean”

A2/2
1. Immediate (Crash Section): (Within 20 mins?)
2. Urgent: (Within 30 mins?)
3. Scheduled: (Within 2 hrs?)
4. Planned (= Elective)
5. Planned done as an emergency
6. Peri-mortem (Caesarean at the time of a Maternal Death)
8. Unknown
9. Other (Free text)

Although the term “Crash Section” is currently ʻout of fashionʼ it is, in real life, far more likely to galvanise everyone involved into the urgency required. Too often in my experience as a labour ward consultant locum in 30 different hospitals over the past 8 years I have, for example, waited while a senior midwife carefully checks that every labouring mother has ʻone to oneʼ care, while a fetal brain is, by the second, getting more and more damaged from for example an abruptio placentae emergency. ʻImmediate Caesarʼ does not in practice ring such powerful alarm bells as ʻCrashʼ and, although more worrying to the expectant mother if, by chance, she overhears, that risk seems worth taking for the sake of the baby. (Rupert Fawdry, 27 July 2010).


A2/3 1. In Labour? Yes/ No
If Yes.
1. Time and Date of Start of Labour
2. In Second Stage Yes / No
If Yes, Start of 2nd Stage?
1.Time and Date
Failed Forceps or Ventouse?
1.No
2.Yes

Allows computer to calculate Duration of First & Second Stages whenever relevant

The 15 different “Methods of Birth”

Using the above, a maximum of three questions are all that is needed for the “Method of Delivery of each Fetus" to be classified under one of the following 15 options:

VAGINAL CEPHALIC (All with or without Shoulder problems/Shoulder Dystocia)

1. Vaginal - Cephalic - Unassisted (Also known as Spontaneous Vertex Delivery)
2. Vaginal - Cephalic - Ventouse
3. Vaginal - Cephalic - Midcavity or Outlet Forceps
4. Vaginal - Cephalic - Kjellands Rotation Forceps (Free text)
5. Vaginal - Cephalic - Other Forceps (Free text)
6. Vaginal - Other (Free text)

VAGINAL BREECH

7. Simple Assisted Vaginal Breech
8. Vaginal Breech with Forceps to the Aftercoming head
9. Vaginal Breech Extraction
10. Vaginal Breech- Assistance Unknown
11. Vaginal Breech Other (Free text)

CAESAREAN

12. Caesarean - Cephalic
13. Caesarean - Breech
14. Caesarean - Transverse or Oblique
15.Caesarean - Presentation Unknown (Free text)


This may seem excessive but it is the only way in which to allow a computer to answer in a simple way the data requests of the RCOG and others. Other options (especially Korner) require many more questions or a great deal of complex and unneccesary computer programming.

The above questions will also allow a calculation of the Duration of the First and Second Stages whenever appropriate, and will also identify all vaginal deliveries with shoulder delivery problems.

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