Annual clinical report 2009 - Coombe Women & Infants University Hospital
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Authors Coombe Women & Infants University Hospital
Publisher Coombe Women & Infants University Hospital
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Link to Item http://hdl.handle.net/10147/295992
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Annual Clinical Report 2009 Coombe Women & Infants University Hospital Annual Clinical Report 2009
ANNUAL CLINICAL REPORT 2009
Dr Chris Fitzpatrick Master
Ms Patricia Hughes Director of Midwifery & Nursing
Dr Martin White Director of Paediatrics & Newborn Medicine
Dr Tom D’Arcy Director of Gynaecology
Dr Michael Carey Director of Peri-operative Medicine
Professor John O’Leary Director of Pathology & Molecular Medicine Research
Mr John Ryan Secretary & General Manager
Acknowledgements
Ms Anita Comerford Ms Emma McNamee Ms Fiona FitzGerald Ms Lindsay Cribben Ms Laura Forde
Mr Jim Travers Mr Seamus Travers
Mr Padraic O’Regan Mr Harry Stammers (HSE Print & Design)
1 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Contents
Acknowledgements ...... 1 Contents ...... 2 Introduction (The Master) ...... 4 Executive Summary (The Master) ...... 7 Board of Guardians and Directors ...... 11 Organisational Chart ...... 12 Members of Staff ...... 13 Staff Retirements in 2009 ...... 25 Dublin Maternity Hospitals Combined Clinical Data (The Master) ...... 26 Statistical Summaries (The Master) ...... 32 General Obstetric Report (The Master) ...... 38 Early Pregnancy Assessment Unit (Dr N Farah, Dr S Sheehan, Dr M Anglim) ...... 47 Severe Maternal Morbidity & High Dependency Unit (Dr S Johnson, Dr S Ahmed, Dr B Byrne) ...... 48 Maternal Mortality (The Master) ...... 53 Perinatal Mortality & Morbidity (The Master) ...... 54 Diabetic Endocrine Pregnancy Service (Prof S Daly & Dr B Kinsley) ...... 76 Multiple Pregnancy Clinic (Prof S Daly) ...... 81 Medical Clinic (Dr C Regan) ...... 82 Addiction & Communicable/Infectious Diseases (Dr M O’Connell, Ms O Cunningham, Ms T Gayne, M D Carmody) ...... 86 Fetal Medicine and Perinatal Ultrasound Department (Prof S Daly) ...... 89 Liaison Perinatal Mental Health Service (Dr J Fenton) ...... 94 Department of Paediatrics and Newborn Medicine (Dr M White) ...... 95 General Gynaecological Report (Dr T D’Arcy) ...... 104 Coombe Continence Promotion Unit (Ms F McCarthy, Dr M Higgins, The Master) ...... 109 Oncology Report (Dr N Gleeson) ...... 111 Colposcopy Clinic (Prof W Prendiville) ...... 113 Department of Peri-operative Medicine (Dr M Carey) ...... 116 Midwifery & Nursing Report ...... 119 Director of Midwifery & Nursing Corporate Report (Ms P Hughes) ...... 119 Midwifery & Nursing Practice Development (Ms P Barry) ...... 122 Parent Education/Breastfeeding Support Service (Ms T Dooge, Ms M Toole) ...... 125 Community Midwife Service (Ms B Flannagan) ...... 127 Delivery Suite (Ms S Kelly, Ms A Fergus) ...... 130 Perinatal Day Centre (Ms Helen Castilino) ...... 132 Clinical Midwife Specialist – Diabetes Mellitus in Pregnancy (Ms E Coleman) ...... 134 Perinatal Ultrasound – Midwifery Report (Ms B Boyd, Ms E Mc Geady) ...... 136 Family Planning Advisory Centre (Ms E O’Beirne) ...... 137 Adult Outpatients Clinic (Ms M Nolan, Ms F Richardson) ...... 138 Role of Gynaecology Oncology CNM Co-ordinator (Ms Aideen Roberts) ...... 140 Operating Theatre Department (Ms A Rothwell) ...... 142 Department of Paediatrics & Newborn Medicine (Ms B Boyd, Ms A McIntyre) ...... 143 Neonatal Transition Home Service (Ms B Whelan) ...... 145 Advanced Nurse Practitioner Report – Neonatology (Ms A Sullivan) ...... 147
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Academic Midwifery Report (Ms P Hughes) ...... 149 Centre for Midwifery Education (Ms A Mulhall) ...... 152 Department of Adult Radiology (Dr M Keogan) ...... 154 Department of Paediatric Radiology (Dr D Rea) ...... 155 Department of Pathology/Division of Laboratory Medicine (Prof J O’Leary, Dr C Adida, Dr A Radomska, Dr N O’Sullivan, Dr C Flynn, Dr J O’Donnell, Dr B White, Ms M Ring, Dr C Martin, Dr J Stuart) ...... 156 Laboratory Medicine Administration (Prof J O Leary) ...... 156 Department of Histopathology & Morbid Anatomy (Prof J O Leary) ...... 158 Department of Cytopathology (Prof J O Leary, Mr N Bolger) ...... 161 Department of Haematology/Transfusion Medicine Laboratory (Dr C Flynn, S McMorrow) ...... 163 Haemovigilance (S Varadkar, S McMorrow, C Flynn) ...... 165 Department of Microbiology Infection Prevention & Control (Dr N O Sullivan, Ms C Byrne, Ms R Hanniffy) ...... 166 Department of Biochemistry (Ms R O Kelly) ...... 168 Phlebotomy Service (Ms M Ring) ...... 170 Department of Molecular Pathology (Prof J O Leary, Dr N O Sullivan, Dr C Martin) ...... 171 Hygiene (Ms V Gillen) ...... 176 Clinician Nutrition and Dietetics (Ms F Dunleavy) ...... 178 Pharmacy Department (Ms M McGuire) ...... 180 Physiotherapy Department (Ms M Mason) ...... 183 Clinical Risk Management (Ms S Kelly) ...... 185 Information Technology Department (Mr T O’Sullivan) ...... 187 Medical Social Work Department (Ms R Grant) ...... 188 Psychosexual Clinic (Mr D Gaynor) ...... 191 Chaplaincy (Sr M Nolan) ...... 192 Academic Report: ...... 193 TCD (Prof D Murphy) ...... 193 UCD (Prof M Turner) ...... 197 RCSI (Prof W Prendiville) ...... 202 Postgraduate Medical Training (Dr M O’Connell, Dr MJ White, Dr M Carey, Prof J O’Leary) ...... 206 National Clinical Skills Centre (Prof W Prendiville) ...... 208 Appendices: ...... 209 One History ...... 209 Two Masters ...... 210 Three Matrons and Directors of Midwifery & Nursing ...... 211 Four Guinness Lectures ...... 212 Five George Bernard Shaw Gold Medal Essays 2009 ...... 215 Six Glossary of Terms ...... 223 Seven Friends of the Coombe ...... 226 Eight Irish National Healthcare Award for Best Educational Meeting (2009) ‘Cerebal Palsy: from Conception to Birth and Beyond’...... 227 Index ...... 233
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Introduction
2009 was an exceptionally busy year in the Coombe Women and Infants University Hospital (CWIUH) across the maternity, gynaecology, paediatric, anaesthetic, allied clinical, laboratory, academic and support services. During 2009, a total of 9421 mothers attended the Hospital, 8652 mothers delivering 8812 infants ≥ 500g. The corrected perinatal mortality rate for infants ≥ 500g was 4.4/1000; 1135 infants were admitted to the Neonatal Centre and 8354 surgical operations were performed. I would, first and foremost like to take the opportunity to acknowledge and to sincerely thank each and every member of staff for their very significant contribution to patient care and for their support during the year. I would particularly like to thank the Directors of the Medical Departments: Dr Tom D’Arcy (Gynaecology), Dr Martin White (Paediatrics and Newborn Medicine), Dr Michael Carey (Peri-operative Medicine) and Professor John O’Leary (Pathology/Laboratory Medicine) and also the other members of the Management Executive: Mr John Robinson (Financial Controller), Ms Annette Carey (Human Resources Manager), Mr Tadhg O’Sullivan (IT Manager), Mr Patrick Donohue (General Services/Accreditation Manager), Ms Margaret Mason (Chief Physiotherapist) and, for their overall contribution to the Hospital and for their personal support and collegiality, Ms Patricia Hughes (Director of Midwifery and Nursing) and Mr John Ryan (Secretary and General Manager). I would like also to thank Mr Clive Brownlee, Chairman of the Board for his very considerable support and wise counsel during 2009 and also the individual members of the Board of Guardians and Directors of the Hospital for their hard work, generosity, loyalty, expertise and commitment to the highest standards of corporate governance. I would like to specially thank the medical consultants for their clinical leadership and support and all the non- consultant doctors in-training and the midwives and nurses for their exceptional hard work and support during 2009. In addition I would like to acknowledge the very significant contributions of Professor Bernard Stuart (Director of Ultrasound), Professor Sean Daly (Director of Fetal Medicine and Perinatal Utrasound), Professor Walter Prendiville (Director of Colposcopy), Professor Deirdre Murphy (Labour Ward Lead Clinician), Dr Mary Anglim (Lead Clinician, Early Pregnancy Assessment Unit), Dr Michael Carey (Chairman of Research Ethics Committee) and Dr Michael O’Connell (Director of Postgraduate Training in Obstetrics and Gynaecology). I would like to congratulate the 2009 award winning midwives: Ms Judith Fleming (R M Corbet Award), Ms Karen Hill (Mary Drumm Scholarship), Ms Alison O’Drioscoll (Gold Medal in Midwifery and the Dr T Healy Award), Ms Gillian Walsh (Silver Medal in Midwifery) and Ms Ann Leonard (Best Clinical Teacher Award); congratulation also to final medical students: Ms Lucia Hartigan (UCD) and Ms Karina Sullivan (TCD), for jointly winning the annual George Bernard Shaw Gold Medal in Medical Essay Writing. In 2009, Professor Bernard Stuart, Dr Paul Bowman, Dr Fiona O’Higgins, Ms Mary Clune, Ms Mary O’Donoghue, Ms Mary Burns, Ms Catherine (Triona) McDonald and Ms Mary Tempany retired from clinical practice; I would like to thank these highly respected members of staff for their very significant contributions to patient care in this Hospital over a lifetime of dedicated, professional service. I would also like to warmly welcome the consultants who were appointed to the Hospital in 2009: Dr Mairead Kennelly, (Obstetrics and Gynaecology/Senior Lecturer UCD), Dr Aisling Martin (Obstetrics and Gynaecology), Dr Cliona Murphy, (Obstetrics and Gynaecology), Dr Jan Miletin (Paediatrics and Newborn Medicine) and Dr Nicolay Nikolov (Anaesthesia/Peril-operative Medicine). I would like to both acknowledge and to highlight the very considerable contribution to patient care made by the Visiting Consultants who provide adult and paediatric subspecialist services, often after hours, at week-ends and under emergency circumstances. On behalf of our patients and your colleagues, thank you. I would also like to acknowledge the very considerable support provided by Dr Miriam Headman O’Brien, Chairperson of the Joint Standing Committee of the Dublin Maternity Hospitals and also the collegiality of Dr Sam Coulter-Smith, Master of the Rotunda Hospital and Dr. Michael Robson, Master of the National Maternity Hospital.
4 Coombe Women & Infants University Hospital Annual Clinical Report 2009
The CWIUH community was greatly saddened during 2009 by the death of Dr Elizabeth Griffin; Elizabeth was a pioneering force in the development of Neonatology in this Hospital, Our Lady’s Hospital Crumlin and nationally; thousands of very fragile and vulnerable infants survived and grew up to achieve their full potential as a direct consequence of Elizabeth’s intervention. Elizabeth is very fondly remembered by parents and staff alike. A Memorial Mass was held in the Hospital during the year to acknowledge and celebrate Elizabeth’s career. The Hospital was also deeply affected by the deaths of Dr Aisling Butler, Dr Jane Deasy and Dr Esther Walls who lost their lives in the tragic Air France crash in 2009. Aisling, Jane and Esther had attended the CWIUH as TCD medical students in 2006; a one minute’s silence was observed in the Hospital on 12th June 2009 in their memory. May they rest in peace. As part of the Hospital’s response to the KPMG Review of the Maternity and Gynaecology Services in the Greater Dublin Ireland, the CWIUH convened a public lecture in April 2009 entitled ‘Safety, Satisfaction and Models of Care in 21st Century Ireland’; Ms Patricia Hughes and Professor Deirdre Murphy presented a integrated model of midwifery-led and consultant-led care; the public lecture attracted a broad spectrum audience from the general public patient/client advocacy and healthcare professional groups and representatives of the HSE. In September 2009 the CWIUH and BabyLifeline co-hosted a, a 2-day multidisciplinary conference ‘Cerebral Palsy - from Conception to Birth and Beyond’; the faculty of speakers included obstetricians, paediatricians, neurologists, orthopaedic surgeons, healthcare professionals involved in rehabilitation, clinical risk managers, legal experts, educationalists and bio-technologists. Ms Mary Harney TD, Minister for Health and Children addressed the meeting. In addition Mr Fintan O’Toole (Irish Times journalist, biographer and critic) and Ms Francesca Martinez (award winning actress) presented literary and personal insights respectively into living with Cerebral Palsy. This was the first conference of its kind held in this country and it attracted a large attendance of delegates from a wide spectrum of backgrounds from both the Ireland and the UK. The CWIUH and BabyLifeline were awarded the Irish Health Care Award for the Best Educational Meeting of 2009 for this conference. This conference will be re-staged in the Royal College of Obstetricians and Gynaecologists, London on the 3rd and 4th May 2011. The Guinness Academic Meeting and Lecture was held on October 16th 2009. The Guinness Lecturer was Professor Harry Reich; the title of the Lecture was ‘Advance Laparoscopic Surgery: the Simple Truth’. Professor Reich has the distinction of performing the first ever laparoscopic hysterectomy; he is the Immediate Past President of the International Society of Gynaecological Endoscopy and Former Director of Advanced Laparoscopic Surgery, Columbia Presbyterian Medical Centre, NY. Also speaking on the academic programme were Dr Mairead Kennelly, Professor John O’Leary and Professor Deirdre Murphy. During 2009, the Hospital implemented an organisation-wide cost-containment programme; I would like to thank the management and staff of the hospital for their support, flexibility and ingenuity during these very challenging times. I would like to acknowledge the leadership of Mr John Robinson (Financial Controller) in this programme. I would like to express my gratitude to Ms Emer McKittrick and Friends of the Coombe for the very important fund-raising initiatives undertaken in 2009; I would also like to thank Coombe Care for the support that they provide for some our most vulnerable mothers, babies and families. During 2009, a significant number of infrastructural works were undertaken in the Hospital including the upgrade of sanitary and catering facilities, the opening of the Maurice Reidy Multidisciplinary Teaching/Training Facility, the relocation of the Perinatal Ultrasound Department and the development of the UCD Centre for Human Reproduction. In addition Phase I of CSSD and NICU upgrades were also completed in addition to the extension of the midwifery/nurse call system and fire prevention/protection works. In 2009 the Board of Guardians and Directors of the Hospital also approved the development of a new Colposcopy Centre on the Coombe campus in order to provide a dedicated facility to accommodate the increased number of women being referred for colposcopy as part National Cervical Screening Programme. The dedication and enthusiasm of Mr John Kavanagh,the CWIUH Project Co-ordinator and the support of Mr Michael Quierey (HSE Estates), is acknowledged and greatly appreciated.
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In 2009, H1N1 vaccination was commenced in the Hospital as part of the National Mass Vaccination Programme; the leadership role adopted by Ms Judith Fleming (Clinical Skills Facilitator) in the roll-out of vaccination in addition to the support provided by the nurses of the Gynaecology Department and the medical staff of the Department of Peri-operative Medicine were key factors in this highly effective programme. In 2009, the CWIUH sponsored three Medical Student Research Fellowships in Obstetrics and Gynaecology (for TCD, UCD and RCSI students) to stimulate undergraduate interest in research and to provide both training in research methodology and supervised research experience. The ‘Open Recruitment Evening’ (organised by Dr Michael O’Connell) provided an excellent opportunity for medical students and interns interested in a career in Obstetrics and Gynaecology to learn more about the specialty and this hospital from consultant clinicians and academics as well as from those in the training programmes. In 2009, the Laboratory Department of Cytopathology was accredited by the Irish National Accreditation Board (INAB) with full ISO 15189 compliance; in addition the Department of Transfusion Medicine maintained its INAB status. INAB accreditation represents a significant achievement by the multidisciplinary teams of both laboratory departments. The academic leadership provided by Professor Deirdre Murphy (TCD), Professor Michael Turner (UCD), Professor Walter Prendiville (RCSI/National Clinical Skills Centre), Professor Sean Daly (TCD/Perinatal Ireland), Professor John O’Leary (TCD), Dr Michael Carey (Peri-operative Medicine), Dr Jan Miletin and Dr Margaret Sheridan- Periera (Paediatrics and Newborn Medicine) and Ms Anne Mullhall (Centre of Midwifery Education) is acknowledged and greatly appreciated. The Research Laboratory in the Hospital, under the leadership of Professor John O’Leary, has generated in excess of €15m in grant income over the past 5 years; in 2009 the Laboratory hosted 20 PhD and 3 MD students. The Laboratory has an international reputation for cancer stem cell biology and pregnancy proteomics and transcriptiomics. It also hosts two EU research consortia as well as being the co-ordinator for the Irish Cervical Cancer Screening Research Consortium (Cerviva). I would like to acknowledge the considerable support of the Board and Management of AMNCH/Tallaght Hospital, particularly Professor Kevin Conlon (CEO Designate). Mr John O’ Connell (Deputy CEO) and Mr Tim Lyne (Director of Environmental Services) in relation to accelerating the CWIUH/AMNCH co-location project.and also the support of Mr Ian Carter (CEO, St James’s Hospital) and Professor Dermot Kelleher (Head of School and Vice-Provost of Medical Affairs, TCD) in relation to developing a strategic association with ‘Trinity Health’. In addition I would like to thank Mr Paul de Freine (Chief Architectural Advisor, HSE Estates) and Mr Brian Gilroy (National Director, HSE Estates) for their on-going support. At the time of writing this introduction, the hospital community is greatly saddened by the recent death of Dr John Drumm. As a clinician, researcher, Master and Board member, John made a phenomenal contribution to the health and wellbeing of thousands of mothers, women and infants. To his family, we offer our deepest sympathies and on-going support. The hospital also sends its best wishes to Ms Fiona Fitzgerald (Master’s Office) in her recovery from serious illness and acknowledges her pivotal role in the publication of 19 consecutive Annual Clinical Reports. Finally, I would like also to acknowledge the support given to the Hospital during 2009 by Mr John Bulfin (Network Manager), Mr Gerry O’Dwyer (Regional Director of Operations) and the HSE Mid-Leinster Management Team.
Dr Chris Fitzpatrick Master Coombe Women and Infants University Hospital
6 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Executive Summary 2009 Annual Clinical Report
Obstetrical activity
A total of 9421 mothers attended the Hospital in 2009, 8652 mothers delivering 8812 infants weighing ≥ 500g, including 152 sets of twins and 4 sets of triplets; 2009 was the busiest year in the Hospital’s 183 years of existence.
Obstetrical demographics
31.6% of mothers booking in 2009 were born outside the Republic of Ireland; this is the highest percentage to-date (30.6% in 2008; 27.5% in 2007). Communication difficulties were reported in 6.2% of mothers at booking; this is also the highest recorded percentage (4 3% in 2006). 3.6% of mothers delivered in 2009 were < 20 years; this was similar to 2008 and the lowest percentage in 7 years. Nulliparae accounted for 41.5% of mothers; there was no significant change in this over the last 7 years. 32.6% of pregnancies were unplanned; 55.6% were not taking pre-conceptual folic acid (56.8% in 2008) and 16.1% were smoking, the lowest percentage since 2006 (18.2%); 15.4% of mothers had a BMI > 30, 3.4% of mothers had pregestational/gestational diabetes mellitus and 1.2% had one abnormal OGTT value; 13.8% of mothers had a history of psychological/psychiatric disorders, including 3.9% with a history of post-natal depression, the highest percentage since 2006; there was a significant increase in the number of mothers attending the Liaison Perinatal Mental Health Clinic (386 in 2008, 72 in 2009), 1.2% of mothers gave a history of domestic violence.
Obstetrical Outcomes
The induction rate in 2008 was 30.4%; this was the highest rate over the past 7 years. The rate of LSCS in 2009 (25.1%) was the highest rate over the past 7 years also. The rate of LSCS in nulliparae in spontaneous labour remains high at 11.6% (10.2% in 2008); induction rates in nulliparae significantly increased the risk of LSCS (29.4% for induction with prostaglandin and 22.5% for induction by amniotomy and syntocinon in 2009; 30.4% and 26.1% respectively in 2008). The overall VBAC rate for mothers with one previous LSCS was 35.6% in 2009 (42.5% in 2008); 50.4% of mothers with one previous LSCS (and no previous vaginal delivery) had an elective repeat LSCS (43.6% in 2008); the VBAC rate for mothers with one previous LSCS and at least one vaginal delivery was 58.8% (64% in 2008). There has been a steady decline in overall VBAC rates over the past 7 years (49.2% in 2003). Breast-feeding initiation rates (51%) and breast feeding at discharge (exclusive: 38%, combined 44%) remain low, by international standards.
Obstetrical Complications
There has been a steady increase in the reported incidence of primary post-partum haemorrhage over the past 7 years (1.4% in 2003, 5.1% in 2009); induction of labour in nulliparae (7.1%), instrumental vaginal delivery in nulliparae (ventouse 8%, forceps 7.1%), twin delivery (11.8%) and manual removal of the placenta (44.2%) were associated with higher reported incidences of haemorrhage; the incidence of maternal transfusion (2.3% in 2005, 2.2% in 2009) and transfusion > 5 units (0.3% in 2005, 0.2% in 2009) has, however, remained relatively unchanged over the past 5 years; the percentage of mothers being admitted to HDU with PPH has not changed significantly since 2006 (0.7% in 2006, 0.5% in 2009). In 2009 there were 6 peripartum hysterectomies performed for haemorrhage due to morbidly adherent placentae; in 5 cases, the patient had undergone at least one previous Caesarean section.
There were no maternal deaths in 2009. Forty one mothers were classified as having a serious maternal morbidity in 2009; the definition of massive obstetric haemorrhage was changed in 2009 to include estimated
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blood loss ≥ 2.5L and/or treatment of coagulopathy. In addition there were 137 obstetrical admissions to the High Dependency Unit; 43% were related to PET and 30% to postpartum haemorrhage; there were 5 cases of eclampsia and one case of uterine rupture; one patient required transfer to the ITU (St. James’s Hospital). The incidence of third degree tears (0.6%) was the lowest in seven years; in 2009 there were 8 fourth degree tears (0.1%), It is of note that there has been a year on year increase in the number of high-risk patients attending the multidisciplinary Medical Clinic (142 new referrals in 2006, 184 in 2009); the most common indications for referral relate to thrombosis and haemorrhagic disorders.
Fetal Medicine
The new Perinatal Ultrasound Department opened in 2009 and provides a significantly improved environment for both patients and staff; the co-located UCD Department of Human Reproduction provides additional synergies in relation to teaching, training and research. In 2009 the fetal medicine team was significantly expanded by the appointment of two consultant fetal medicine specialists in addition to midwife and radiographer sonographers. A total of 19270 ultrasound examinations were performed in the Department in 2009 (9477 in 2003, 16223 in 2008); 12 of the 15 infants who died in the early of late neonatal period as a result of congenital malformation had a prior antenatal diagnosis. Further expansion of the Fetal Echocardiography service was undertaken in 2009 with the establishment of the Coombe/Rotunda Fetal Echo Clinic, led by by Dr Orla Franklin (OLHC), Professor Sean Daly (CWIUH) and Dr Fionnuala Breathnach (Rotunda); 144 targeted fetal examinations were performed in 2009. A second specialist screening fetal echocardiographic service is provided for high-risk cases related to maternal and family history of congenital heart disease, diabetes mellitus and specific drug exposure; 131 examinations were performed as part of this service.
Perinatal / Neonatal Outcomes
The overall Perinatal Mortality Rate for infants born weighing ≥ 500g was 5.8/1000; the corrected rate was 4.4 /1000. The Perinatal Mortality Rate for infants weighing ≥ 500g and/or ≥ 24 weeks was 6.4/1000; 12 of the 33 normally formed stillbirths weighed ≤1500g. Hypoxia (8), IUGR (8) Cord accident (7) and Placental Abruption (5) were the most frequent cause of death among the normally formed stillbirths. There were 3 intra-partum deaths in normally formed infants; all weighed < 600g and 2 were < 24 weeks gestation; intervention in the interest of the fetus was not deemed appropriate in any of these cases.
Congenital Malformation (7) and Prematurity (3) were the main causes of early perinatal deaths (13). There were 7 cases of Grade II and III HIE among infants born in the CWIUIH (6 in 2006, 12 in 2007, 9 in 2008); one infant died on day 2 due to hypoxia and 2 infants have abnormal neurological examination on follow-up. A further 7 infants were transferred from other units for the management of Grade II/III HIE.
The survival outcome for infants ≤ 1500 g was 88.3% in 2009. Over 95% of inborn infants delivered ≤1500g had completed ante-natal corticosteroids before delivery, as compared to the average rate of 74% cited in the Vermont Oxford Database Network (VON) for 2009; there was a decrease in the percentage of infants with coagulase negative staphylococcal sepsis (7%) compared to 2008 (11.5%); there was also an improvement in the percentage of infants presenting with late bacterial infection (10%) compared to 2008 (17.3%). There was a lower percentage of infants surviving with chronic lung disease at 36 weeks (8 infants, 12%) compared to the VON average (32%). The availability of in-house echocardiography has facilitated the earlier diagnosis and medical management of PDA; fewer infants required surgical ligation in 2009.
Gynaecological / Surgical Activity
Despite the temporary closure of gynaecology beds due to infrastructural developments in CSSD and NICU and the redeployment of gynaecology nurses into the Hospital’s H1N1 vaccination programme, the
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Gynaecology Department maintained a very busy service; the introduction of new care pathways resulted in an increase in same day admission for major surgery and a reduction in overall length of stay. In 2009 there were 5313 gynaecological operations performed (in addition to 3041 obstetrical operations). There has been a steady decline in the number of women requiring ERPC for early pregnancy loss because of medical treatment. There has been a decline in the number of abdominal hysterectomies and a steady increase in the number of vaginal and laparoscopic hysterectomies performed over the past 7 years: 97 abdominal hysterectomies, 125 vaginal hysterectomies and 55 laparoscopic hysterectomies were performed in 2009. It is of note that 87% of all ovarian cystectomies and 58% of all myomectomies were performed endoscopically in 2009. There has been a steady increase in the number of operations performed for urinary incontinence over the past 7 years (66 in 2003, 99 in 2009). In 2009, as a consequence of the roll-out of the National Cervical Screening Programme, there was a significant increase in the number of first visit attendances to the Colposcopy Clinic (847 in 2008, 1764 in 2009) and also in the number of cervical excisional procedures for CIN/GIN (409 in 2008, 999 in 2009). 272 new gynaecology cancers were diagnosed and treated in 2009 in the Gynaecology Oncology Department at the CWIUH and St. James’s Hospital. Surgical complications during 2009 included blood transfusion (23), blood transfusion > 5 units (4), bladder injury (3), bowel injury (2), return to theatre (6) uterine perforation (7); in addition 12 patients were transferred to HDU after surgery.
Peri-operative Medicine
During 2009, 3925 epidurals were sited; the epidural rate was 45.4% without any significant change over the past 7 years; 98.2% of elective and 94.4% of emergency caesarean sections were performed under regional anaesthesia. The multidisciplinary acute pain service led by the Department of Peri-operative Medicine, established in 2008, continued to operate effectively in 2009. A Pre-operative Anaesthetic Assessment Clinic was established in 2009 to enable all women scheduled for major gynaecology surgery and day case surgery with co-morbid disease to undergo an appropriate anaesthetic review; this greatly facilitated same day admission for all routine major gynaecology patients. The appointment of a CNM2 in anaesthetics has had appositive impact on the provision of anaesthetic services within the hospital, most notably within pain management service.
Academic
In addition to providing tertiary maternal, fetal, neonatal, gynaecology and anaesthetic services both at a network and national level, the Hospital has a very significant academic portfolio in terms of academic appointments, research grant income and publications. Uniquely, medical students from the three Dublin Medical Schools attend the Hospital; the campus also hosts the Hub Centre for Midwifery Education for the Greater Dublin Area and the National Skills Centre, both centres running effective training programmes in 2009.
The Research Laboratory in the Hospital, under the direction of Professor John O Leary, has generated in excess of €15m in grant income over the past 5 years. In 2009 addition the Laboratory hosted 20 PhD and 3 MD students. The Laboratory has an international reputation for cancer stem cell biology and pregnancy proteomics and transcriptiomics. It also hosts two EU research consortia as well as being the co-ordinator for the Irish Cervical Cancer Screening Research Consortium (Cerviva).
A new multidisciplinary training facility was opened in the Hospital in 2009 from funding secured through the HSE/HEA 2007MET-R Audit. The Hospital supports research fellowships in Obstetrics, Peri-operative Medicine and Pharmacy; in addition three Medical Student Fellowships were established by the Hospital in 2009 in order to provide both training and experience in research and audit.
As evidenced in this Report, the three Medical School academic teams under the leadership of Professor Deirdre Murphy (TCD), Professor Michael Turner (UCD), Professor Walter Prendiville (RCSI), Professor Sean Daly (TCD/Perinatal Irealnd) together with departmental researchers, Dr Michael Carey (Peri-operative Medicine), Dr
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Jan Miletin and Dr Margaret Sheridan-Pereira (Paediatrics and Newborn Medicine) have significantly expanded the research portfolio of the Hospital; in addition participation in the multi-centre, randomised controlled ADCAR trial has been of significant importance in terms of midwifery-led research. The leadership role of Ms Ann Mulhall as the (Acting) Director of the Centre of Midwifery Education is also acknowledged. The appointment of Dr Mairead Kennelly as Senior Lecturer In Obstetrics and Gynaecology (UCD) will further strengthen the Hospital’s multi-institutional academic team.
The CWIUH/BabyLifeline 2-day, multidisciplinary, conference ‘Cerebral Palsy from Birth to Conception and Beyond’ was awarded an Irish Healthcare Award for the Best Educational Meeting in 2009; this conference will be re-convened in the Royal College of Obstetricians and Gynaecologists, London on the 3rd and 4th of May 2011. I would like to acknowledge the contributions of both the faculty and the organisers of this unique multidisciplinary initiative.
Dr. Chris Fitzpatrick Master
10 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Members of the Board of Guardians and Directors 2009
Board Members Date of Election Eileen Gleeson 2007
Sean Kelly 2007 (retired June 2009)
Aidan O’Hogan 2007
James Clinch 1978
Frances Stephenson 1997
John E Drumm 2000
Emer Gilvarry 2002
Paul Donnelly 2002
Liz Early 2002
Clive Brownlee 2004 (Chair from January 2007 )
Margaret Fine-Davis 2005
Cormac McCarthy 2005
Cliona Mullen 2005 (2005-2006; 2007-)
Margaret Sheridan-Pereira 2006
Ex - Officio Members
The Lord Mayor of Dublin
Councillor Eibhlin Byrne July 2008-July 2009
Councillor Emer Costello July 2009-
The Master
Dr Chris Fitzpatrick Jan 2006-
11 Coombe Women & Infants University Hospital Annual Clinical Report 2009
AMP S t u d e n t M i d w i v e s S u p e r i n t e n d e n t s C o m m u n i t y M a t e r n i t i e s S t a f f M i d w i v e s / M i d w i f e r y E d u c a t i o n C e n t r e o f C M M / N M 3 s N e t w o r k C M N / N M 1 s C M N / N M 2 s P a r t n e r s H o s p i t a l H e a l t h C a r e ( C M E ) A u x i l i a r i e s D o H C A s s i s t a n t s J o i n t H S E N u r s e s C S S D N i g h t Coombe Women & Infants University Hospital D i v i s i o n a l D i r e c t o r s o f M i d w i f e r y / N u r s i n g G y n a e c o l o g y / O b s t e t r i c s / P a e d i a t r i c s
Organisational Chart 2009 M i d w i f e r y T u t o r s A l l o c a t i o n O f f i c e r P a r e n t E d u c a t i o n D e v e l o p m e n t C o -
A d v a n c e d N u r s e C l i n i c a l P r a c t i c e L i a i s o n S e r v i c e s M i d w i f e r y / N u r s i n g C o - o r d i n a t o r s C l i n i c a l S k i l l s C M S s / C N S s P r a c t i t i o n e r F a c i l i t i o r ( s ) U l t r a s o n o - P l a c e m e n t o r d i n a t o r g r a p h e r s U l t r a s o u n d S t u d e n t C l i n i c a l D i r e c t o r o f M a n a g e m e n t E x e c u t i v e R e s e a r c h F e l l o w s G y n a e c o l o g i s t s O b s t e t r i c i a n s / G y n a e c o l o g y G y n a e c o l o g y G y n a e c o l o g y O b s t e t r i c s / C o n s u l t a n t O b s t e t r i c s / O b s t e t r i c s / R e g i s t r a r s L e c t u r e r s H e a d o f D i v i s i o n D e p a r t m e n t S H O s M e d i c i P n e e r i n a t a l S P R s O b s t e t r i c s A d m i n S t a f f A c a d e m i c - A c a d e m i c S t u d e n t s M e d i c a l M e d i c a l S c h o o l s H e a d o f D i v i s i o n S t a f f G y n a e c o l o g y C o m m i t t e e E t h i c s A n a e s t h e t i s t s A n a e s t h e t i c s A n a e s t h e t i c s A n a e s t h e t i c s C o n s u l t a n t R e g i s t r a r s S H O s S P R s C o m m i t t e e Q u a l i t y & F a i r n e s s H e a d o f D i v i s i o n P e r i o p e r a t i v e M e d i c i n e P a e d i a t r i c i a n s W o m e n Babies & P a e d i a t r i c s P a e d i a t r i c s P a e d i a t r i c s C o n s u l t a n t R e g i s t r a r s S H O s S P R s B o a r d o f G u a r d i a n s N e w b o r n M e d i c i n e & D i r e c t o r s H e a d o f D i v i s i o n P a e d i a t r i c s & M a s t e r L a b I . T . / Q u a l i t y M o r b i d A n a t o m y H i s t o p a t h o l o g y C y t o p a t h o l o g y M i c r o b i o l o g y H a e m a t o l o g y B i o c h e m i s t r y M a n a g e m e n t T r a n s f u s i o n L a b o r a t o r y M o l e c u l a r P a t h o l o g y R e s e a r c h M e d i c i n e H e a d o f D i v i s i o n L a b M e d i c i n e H i s t o p a t h o l o g y E n d o c r i n o l o g y O r t h o p a e d i c s M i c r o b i o l o g y C a r d i o l o g i s t s H a e m a t o l o g y R a d i o l o g i s t s C o n s u l t a n t s V i s i t i n g H o u s e & F i n a n c e C o m m i t t e e A l l i e d C r i t i c a l M e d i c a l S o c i a l P h y s i o t h e r a p y S e r v i c e s C h a p l a i n c y P h a r m a c y D i e t e t i c s W o r k D S A t t e n d a n t s M e d i c a l R e c o r d s R e c e p t i o n H u m a n R e s o u r c e s P o r t e r i n g ) H o s p i t a l ( Hygiene A c c r e d i t a t i o n M a n a g e m e n t C l i n i c a l R i s k D i v i s i o n a l M a n a g e r M o n i t o r X - R a y A t t e n d a n t s
T h e a t r e Services HIQA G e n e r a l M a n a g e r S e c r e t a r y / H u m a n R e s o u r c e s C o m m u n i c a t i o n s G e n e r a l S e r v i c e s T e c h n o l o g y ( I T ) C a p i t a l P r o j e c t s H e a l t h & S a f e t y P a t i e n t S e r v i c e s L i n e n / L a u n d r y E n g i n e e r i n g & M a i n t e n a n c e I n f o r m a t i o n / I n f o r m a t i o n I T M a n a g e r H o u s e h o l d C o n t r o l l e r F i n a n c i a l C a t e r i n g S u p p l i e s F i n a n c e
12 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Members of Staff
MASTER Dr Chris Fitzpatrick
CONSULTANT OBSTETRICIANS/GYNAECOLOGISTS Dr Mary Anglim Dr Katherine Astbury* Dr Paul Bowman Dr Bridgette Byrne Dr Gunther von Bunau Professor Patricia Crowley Professor Sean Daly Dr Thomas J D’Arcy Dr Noreen Gleeson Dr Jansi Jerling* Dr Mairead Kennelly Dr Aisling Martin Professor Deirdre Murphy Dr Cliona Murphy Dr Hugh O’Connor Dr Michael O’Connell Professor Walter Prendiville Dr Carmen Regan Professor Bernard Stuart Dr Soha Said* Professor Michael Turner
CONSULTANT ANAESTHETISTS Dr Michael Carey Director of Perioperative Medicine
Dr Liam Briggs Dr Rebecca Fanning* Dr Steven Froese Dr Niall Hughes Dr Nickolay Nikolov Dr Fiona O’Higgins Dr Tubagere K Raveendranath* Dr Terry Tan*
CONSULTANT NEONATOLOGISTS Dr Martin J White Director of Paediatrics & Newborn Medicine
Dr Jan Janota* Dr Jan Miletin Dr Pamela O’Connor Dr Saulius Satas* Dr Margaret Sheridan-Pereira
13 Coombe Women & Infants University Hospital Annual Clinical Report 2009
CONSULTANT RADIOLOGIST (ADULT) Dr Mary T Keogan
CONSULTANT RADIOLOGIST (PEADIATRIC) Dr David Rea
DIRECTOR OF PATHOLOGY Professor John James O’Leary
CONSULTANT PATHOLOGISTS Dr Colette Adida Dr Anna Radomska*
CONSULTANT MICROBIOLOGIST Dr Niamh O’Sullivan
CONSULTANT HAEMATOLOGIST Dr Catherine Flynn Dr James O’Donnell Dr Barry White
CONSULTANT DIABETOLOGISTS Dr Marie Byrne Dr Richard Firth Dr Brendan Kinsley
CONSULTANT ENDOCRINOLOGIST Dr Frances Hayes
CONSULTANT NEPHROLOGIST Dr Catherine Wall
CONSULTANT CARDIOLOGIST Dr Niall Mulvihill
CONSULTANT PSYCHIATRIST Dr Joanne Fenton
CONSULTANT ORTHOPAEDIC SURGEONS Ms Paula Kelly Mr Jacques Noel
PATHOLOGIST Dr Joe Stuart
*Locum/Temporary Positions
14 Coombe Women & Infants University Hospital Annual Clinical Report 2009
VISITING CONSULTANT PAEDIATRIC CARDIOLOGISTS Dr David Coleman Dr Desmond Duff Dr Colin McMahon Dr Paul Oslizlok Dr Kevin Walsh
VISITING CONSULTANT OPHTHALMOLOGISTS Mr Donal Brosnahan Ms Katherine McCreery
VISITING CONSULTANT PAEDIATRIC RADIOLOGISTS Dr Clare Brenner Dr Roisin Hayes Dr Jerry Kelleher Dr Eithne Phelan
VISITING CONSULTANT PAEDIATRIC NEUROLOGISTS Professor Joe McMenamin Dr David Webb
VISITING CONSULTANT DERMATOLOGISTS Dr Louise Barnes Professor Alan Irvine (Paediatric) Dr Rosemary Watson
VISITING CONSULTANT RESPIRATORY PHYSICIAN Dr Finbarr O’Connell
VISITING CONSULTANT GENITO-URINARY PHYSICIANS Dr Fiona Lyons Dr Fiona Mulcahy
VISITING CONSULTANT IN INFECTIOUS DISEASES Dr Colm Bergin
VISITING CONSULTANT GASTROENTEOLOGIST/HEPATOLOGIST Professor Dermot Kelleher
VISITING CONSULTANT GENETICIST Professor Andrew Greene
VISITING CONSULTANT HAEMATOLOGISTS Professor Owen Smith Dr Aengus O’Marcaigh
VISITING CONSULTANT PAEDIATRICIAN IN INFECTIOUS DISEASE Dr Karina Butler
15 Coombe Women & Infants University Hospital Annual Clinical Report 2009
VISITING CONSULTANT MEDICAL ONCOLOGIST Dr John Kennedy
VISITING CONSULTANT RADIATION ONCOLOGISTS Dr John Armstrong Professor Donal Hollywood
VISITING CONSULTANT PALLIATIVE CARE PHYSICIAN Dr Liam O’Siorain
VISITING CONSULTANT PAEDIATRIC SURGEONS Professor Mr Martin Corbally Professor Prem Puri Mr Feargal Quinn
VISITING CONSULTANT GENERAL SURGEONS Mr Enda McDermott Mr Richard B Stephens
VISITING CONSULTANT UROLOGICAL SURGEONS Mr Thomas Lynch Mr Ronald Grainger
VISITING CONSULTANT COLORECTAL SURGEON Professor Frank B V Keane
VISITING CONSULTANT PLASTIC SURGEON Mr David Orr
VISITING DENTAL CONSULTANT Dr Paddy Fleming
VISITING CONSULTANT E.N.T. SURGEON Mr Donald P McShane
NON-CONSULTANT HOSPITAL DOCTORS
SENIOR HOUSE OFFICERS IN OBSTETRICS/GYNAECOLOGY Dr Eimhin Ansbro Dr Jennifer Hogan Dr. Aoife Frayne Dr. Mairead Butler Dr Alexandros Laios Dr Sucheta Johnson Dr Caroline Walsh Dr Anne de Haan Dr Fiona Magee Dr Roisin Hambly Dr Workineh Tadesse Dr Mark Dempsey
16 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Dr Pooja Sibartie Dr Maria Kennelly Dr Meenakshi Ramphul Dr Charlene Getty
JUNIOR REGISTRARS IN OBSTETRICS/GYNAECOLOGY Dr Adeeb Khalifeh Dr Sinead Barry Dr Jennifer Hogan Dr Caroline Walsh
REGISTRARS IN OBSTETRICS/GYNAECOLOGY Dr Shobha Singh Dr Kayode Muritala Fadare Dr Niamh Barrett Dr Tayyaba Hassan Dr Adeeb Khalifeh
SPECIALIST REGISTRARS IN OBSTETRICS & GYNAECOLOGY Dr Soha Said Dr Yahya Kamal Dr Eve Gaughan Dr Hilary Ikele Dr Donal O’Brien Dr Richard Deane Dr Minna Gesiler Dr Mary Higgins Dr Nita Adnan
CLINICAL FELLOW (OBSTETRICS & GYNAECOLOGY) Dr Shobha Singh
RESEARCH FELLOWS (OBSTETRICS & GYNAECOLOGY) Dr Andrea Nugent, CWIUH/TCD Dr Sharon Sheehan, CWIUH/TCD Dr Jennifer Hogan, CWIUH/UCD Dr Nadine Farah, CWIUH/UCD
RCSI/CWIUH LECTURER (OBSTETRICS & GYNAECOLOGY) Dr Dimityriou Evangelos Dr Srwa Khalid Dr David Morgan Dr Sucheta Johnson
TCD/CWIUH LECTURER (OBSTETRICS & GYNAECOLOGY) Dr Hajeera Ali Butt Dr Nirmala Kondavetti Dr Aoife Mullally
17 Coombe Women & Infants University Hospital Annual Clinical Report 2009
UCD/CWIUH LECTURER (OBSTETRICS & GYNAECOLOGY) Dr Nadine Farah Dr Chro Fattah
SUBSPECIALIST TRAINING POSTS Dr Tom O’Gorman (GynaeOncology - SJH/CWIUH) Dr Fionnuala Breathnach (Fetal Medicine-Rotunda/Coombe/Columbia)
SENIOR HOUSE OFFICERS IN PAEDIATRICS Dr Fiona Treacy Dr Daniela Diacona Dr Oyebolande Diya Dr Azanne Ahmad Kamar Dr Marietta Pal-Magdics Dr Olusegun Oyedeji Dr Rincy Koshy Dr Emma Beatty Dr Rachael Duignan Dr Adam James Dr Mareika Price Dr Amany Maher Tadrous Dr Jan Sirc Dr Lay Ong Tan Dr Christianah Owoeye*
REGISTRARS IN PAEDIATRICS Dr Asma Awadalla Dr Syed Qadri Dr Sudha Moka Dr Sanja Sharma Dr Johnannes Buca Letshwiti Dr Jan Franta Dr Anne Doolan Dr Jan Sirc*
SPECIALIST REGISTRARS IN PAEDIATRICS Dr Yarden Yanishevsky Dr Louisa Glackin Dr Jean Donnelly Dr Ranjana Dhar Dr Eirin Carolan Dr Sinead O’ Donnell
NEONATAL TUTOR Dr Judit Villoslada
SENIOR HOUSE OFFICERS IN ANAESTHETICS Dr Noelle Murphy Dr Aisling Buckley Dr Asma Khan Dr Rizwan Ali Dr Shang Ming Cheng
18 Coombe Women & Infants University Hospital Annual Clinical Report 2009
REGISTRARS IN ANAESTHETICS Dr Ashley Fernandes Dr Sarmad Masud Dr Sohail Khan Dr Sheema Solanki
SPECIALIST REGISTRARS IN ANAESTHETICS Dr Alan Broderick Dr Ajith Vigayan Dr Rory Naughton Dr Nadeem Abbas Zaidi
RESEARCH FELLOW IN OBSTETRIC PAIN Dr Rajesh Bhinder
CLINICAL FELLOW IN OBSTETRIC ANAESTHESIA Dr Rafiu Ojo Dr Rajinish Jesudoss Dr Umara Farooq
SPECIALIST REGISTRARS IN PATHOLOGY Dr Niamh Conlon Dr Linda Mulligan
MIDWIFERY & NURSING
DIRECTOR OF MIDWIFERY & NURSING Patricia Hughes
DIRECTOR OF CENTRE OF MIDWIFERY EDUCATION Ann Louise Mulhall (Acting)
ASSISTANT DIRECTORS OF MIDWIFERY & NURSING Bridget Boyd, Assistant Director of Midwifery & Nursing with responsibility for Neonatal Centre and Ultrasound Department Angela Dunne, Assistant Director of Midwifery & Nursing with responsibility for Maternity Services including Community Midwifery Mary O’Donoghue, Assistant Director of Midwifery & Nursing with responsibility for Midwifery & Nursing Workforce Planning & Recruitment (until her retirement in June 2009) Frances Richardson, Assistant Director of Midwifery & Nursing with responsibility for Gynaecology, Theatre, OPD and Colposcopy Services Vaun Currin, Night Superintendent Lucy More O’Ferrall, Night Superintendent Ann Noonan, Night Superintendent
ADVANCED NURSE PRACTITIONER – NEONATAL NURSING Anne O’Sullivan
INFECTION PREVENTION & CONTROL NURSE Rosena Hanniffy
19 Coombe Women & Infants University Hospital Annual Clinical Report 2009
PRACTICE DEVELOPMENT CO-ORDINATOR Paula Barry (Acting)
CLINICAL MIDWIFE/NURSE MANAGERS 3 Trea Dooge, Parent Education Bernadette Flannagan, Community Midwifery Fidelma McSweeney, Maternity Wards (Acting from January 2009) Ann MacIntyre, Neonatal Centre Mary Nolan OPD (Acting) Susan Kelly, Delivery Suite (until July 2009) Ann Fergus, Delivery Suite (from August 2009) Alison Rothwell, Operating Theatre
MIDWIFERY EDUCATION Patricia O’Hara, Co-ordinator Post Graduate Diploma in Intensive Neonatal Nursing Programme Anne Jesudason, CPC (until September 2009) Meena Purushotoaman CPC Mary Rodgerson, CPC Mary Kenny, Post Registration Programme Facilitator Denise Kiernan, Allocations Liaison Officer
CLINICAL MIDWIFE/NURSE MANAGERS 2 Eileen Boyle, Community Vivienne Browning, Community Niamh Buggy, Neonatal Centre Ita Burke, Delivery Suite Mary Burns, Delivery Suite (until her retirement in February 2009) Carmel Byrne, Neonatal Centre Joanna Colleran, Theatre Raji Dominic (Acting) Ann Fergus, Delivery Suite (until August 2010) Sinead Finn, Delivery Suite Eva Fitzsimons, OPD Kathleen Lynch, Gynaecology Day Ward Mary Holohan, Community Sinead Gavin, St Patrick’s Ward (Acting) Fiona Gilsenan, Theatre Shyla Jacob, Comunity Breege Joyce, Community Anne Little, Neonatal Centre Maureen Lydon, Delivery Suite Catherine Manning, St Monica’s Ward Suzi McCarthy, Delivery Suite & St Joseph’s Ward Olivia McCarthy, Gynaecology Ward & Colposcopy Elaine McGeady, Ultrasound Christina McLoughlin, Delivery Suite & Ultrasound Department Mary McMorrow, Perinatal Centre & St Patricks Ward Grainne McRory, Delivery Suite Nicole Mention, Community Anne Moyne, Delivery Suite
20 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Margaret Moynihan, Neonatal Centre Jean Murray , Our Lady’s Ward (from June 2009) Elizabeth O’Beirne, Well Woman Clinic Margaret O’Brien, Community Mary O’Connor, Neonatal Centre Monica O’Shea, Delivery Suite Orla Phelan, Communicable & Infectious Diseases Services Patricia Ryan, Theatre Fiona Walsh, Community
HAEMOVIGILANCE OFFICER Sonia Varadkar
NURSE CO-ORDINATOR FOR GYNAECOLOGICAL ONCOLOGY Aideen Roberts (from June 2009)
MIDWIFE MANAGER FOR PPGs, AUDIT, STATISTICS & PERSONNEL Anne Jesudason (from September 2009)
CLINICAL MIDWIFE OR NURSE SPECIALISTS (CMS/CNS) Anne Marie Brady, Ultrasound Sinead Cleary, Colposcopy Ethna Coleman, Diabetes Jane Durkan Leavy, Ultrasound Claire McSharry, Ultrasound Siobhan Ni Scannaill, Ultrasound Mary Toole, Lactation Barbara Whelan, Neonatal Transition Home Service
CLINICAL SKILLS FACILITATORS Judith Fleming, Midwifery Anna O’Connor, Midwifery Mary Ryan, Neonatal Nursing (Acting) Pauline O’Connell, Neonatal Nursing Ann Kelly, Neonatal Nursing
CLINICAL MIDWIFE/NURSE MANAGERS 1 Fiona Barrett Sheena Bolger Mary Ann Carroll Mereen Chandy Geraldine Creamer Quinn Grace Cuthbert Cinol Cyriac Maureen Doherty Deborah Duffy Marie Foudy Sinead Gavin Minimol George Nonie Griffin
21 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Reeta Jebakuman Susan Jagen Anne Kelly, Bridget Kirby Ann Leonard Catriona McDonald (until retirement in November 2009) Althea Noble Deirdre O’Connell Alice O’Connor Marion O’Donovan Deborah O’ Dwyer Grainne O’Mahony Sunita Panda Monikutty Rajan Loretta Robinson Elizabeth Sandles Anitha Sevanayagam
ON SECONDMENT to DEPARTMENT of HEALTH & CHILDREN Sheila Sugrue, Nurse & Midwife Advisor to CNO, DoHC
ON SECONDMENT TO HEALTH SERVICE EXECUTIVE Joan Malone, National Maternity Chart Project (Jan-Apr 09) & Code of Practice re Post Mortem (Sept-Dec 2009)
HONORARY MIDWIFERY RESEARCH FELLOWS Declan Devane, Senior Lecturer in Midwifery, NUIG Valerie Smith Doctoral Student - Midwifery, TCD (Both are associated with the multicentred randomized controlled trial, ADCAR, running at CWIUH)
SECRETARIAL SUPPORT Moira Murphy Sarah Bux
MEDICAL SOCIAL WORKERS Rosemary Grant, Principal MSW Mary Treacy Denise Shelley Carmel Cronin Sorcha O’Reilly Nerilee Ceatha Margaret Ebo* (to January 2009) Tanya Francisco (from November 2009)
PHYSIOTHERAPISTS Margaret Mason (Physiotherapy Manager) Ogechi Nseodo (to April 2009) Fiona McCabe (to January 2009) Sinead Larkin (to February 2009) Mary Duffy
22 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Eibhlin Mulhall (from January 2009) Anne McCloskey (from June 2009)
DIETICIAN/CLINICAL NUTRITIONIST Fiona Dunlevy
PHARMACY Mairead McGuire (Chief Pharmacist) Peter Duddy (Senior Pharmacist) Eimear Curran (Basic Grade Pharmacist) Fiona Butler (Pharmacy Intern: Jan.-Sept. 09), Una Rice (Pharmacy Intern: Oct.-Dec. 09) Brian Cleary (Research Pharmacist)
CHIEF MEDICAL SCIENTISTS Martina Ring – Laboratory Noel Bolger – Cytology Stephen Dempsey – Pathology Quality/IT Manager Sheila McMorrow – Haematology/Blood Transfusion Catherine Byrne – Microbiology
PRINCIPAL BIOCHEMIST Ruth O’Kelly
SECRETARY & GENERAL MANAGER John Ryan
FINANCIAL CONTROLLER John Robinson
HUMAN RESOURCES MANAGER Annette Carey
MEDICAL RECRUITMENT MANAGER Joan Priestley
ACCREDITATION PROJECT/GENERAL SERVICES MANAGER Patrick Donohue
PATIENT SERVICES MANAGER Siobhan Lyons/Ann Shannon
HYGIENE SERVICES CO-ORDINATOR Ms. Vivienne Gillen
HOUSEHOLD SUPERVISOR Olive Lynch Patrick Bailey* (to May 2009)
23 Coombe Women & Infants University Hospital Annual Clinical Report 2009
ASSISTANT HOUSEHOLD SUPERVISOR Arlene Kelly Jonathan Roughneed* (from April to October 2009)
ENGINEERING OFFICER Ian Lapsley
PROJECT CO-ORDINATOR John Kavanagh
QUALITY INITIATIVE/RISK MANAGER Mary Clune (to April 2009) Susan Kelly
SUPPLIES MANAGER Leo Flynn
CATERING MANAGER Thomas Dowling
COMMUNICATIONS OFFICER Mary Holden
MEDICAL RECORDS OFFICER Noelle Forrester
INFORMATION TECHNOLOGY MANAGER Tadhg O’Sullivan
HEALTH & SAFETY OFFICER Tom Madden
MASTER’S SECRETARIES Fiona Fitzgerald Lindsay Cribben
* Locum/temporary position
24 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Staff Retirements in 2009*
Emer Martin Staff Nurse/Midwife
Mary Clune Clinical Risk Manager
Mary O’Donoghue Assistant Director of Midwifery & Nursing
Joan Russell Medical Laboratory Scientist
Josephine Quinn Clerical/Administration
Mary Burns Clinical Nurse Manager II
Dr Bernard Stuart Consultant Obstetrician/Gynaecologist
Dr Paul Bowman Consultant Obstetrician/Gynaecologist
Ms Catherine McDonald Clinical Nurse Manager I
Ms Anne McGuinness Domestic
Ms Mary Cross Domestic
Ms Mairead Devlin Domestic
Dr Fiona O’Higgins Consultant Anaesthetist
Ms Maureen Daly Clerical/Administration
Ms Catherine Kavanagh Clerical/Administration
Ms Mary Tempany Staff Midwife
On behalf of both the Board of Guardians and Directors and the Management Executive of the Hospital, I would like to sincerely thank the members of staff who retired from Hospital in 2009 for their enormous contribution during their years of dedicated professional service.
Dr Chris Fitzpatrick Master/CEO
* listed in chronological order
25 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Dublin Maternity Hospitals Combined Clinical Data
The following tables have been agreed to form the common elements of the Three Dublin Maternity Hospitals Report.
1. Total Mothers Attending
Mothers delivered ≥ 500 grams. 8652 Mothers delivered < 500 grams and miscarriages 676 Gestational trophoblastic disease 12 Ectopic pregnancies 81 Total mothers 9421
2. Maternal Deaths 0
3. Births ≥ 500g
Singletons 8496 Twins 304 Triplets 12 Quadruplets 0 Total 8812
4. Obstetric Outcome (%)
Spontaneous vaginal delivery 57.5 Forceps 7.2 Ventouse 10.4 Caesarean section 25.1 Induction 30.3
5. Perinatal Deaths ≥ 500g
Antepartum deaths 34 Intrapartum deaths 4 Stillbirths 38 Early neonatal deaths 13 Late neonatal deaths 6 Congenital malformation 15
26 Coombe Women & Infants University Hospital Annual Clinical Report 2009
6. Perinatal Mortality Rates ≥ 500g *
Overall perinatal mortality rate per 1000 births. 5.8 Perinatal mortality rate corrected for lethal congenital anomalies 4.4 Perinatal mortality rate including late neonatal deaths 6.5 Perinatal mortality rate excluding unbooked cases 5.5 Corrected perinatal mortality rate excluding unbooked 4.1
* PNMR for infants ≥ 500g and/or ≥ 24 weeks = 6.4/1000
7. Age
Nulliparous Parous Totals NNN% < 20 yrs 284 30 314 3.6 20-24 yrs 707 439 1146 13.2 25-29 yrs 1096 1063 2159 25.0 30-34 yrs 1056 1725 2781 32.1 35-39 yrs 373 1513 1886 21.8 40+ yrs 79 287 366 4.2
*nulliparous and parous refer to the maternal status at booking or at first presentation to the hospital; nulliparous = never having delivered an infant ≥500g; parous = having delivered at least one infant ≥500g.
8. Parity
Nulliparous Parous Totals NNN% Para 0 3595 359 41.6 Para 1 2783 2783 32.2 Para 2-4 2149 2149 24.8 Para 5+ 125 125 1.4
9. Country of Birth & Nationality
Country N% Ireland 6180 71.4 Britain 209 2.4 EU 852 9.8 EU Accession Countries 2007 130 1.5 Rest of Europe (including Russia) 91 1.1 Middle East 32 0.4 Rest of Asia 571 6.6 Americas 66 0.8 Africa 454 5.2 Australasia 17 0.2 Uncoded 50 0.6 Total 8652 100
27 Coombe Women & Infants University Hospital Annual Clinical Report 2009
10. Socio-Economic Groups
Socio-economic Group N% Higher Profession 494 5.7 Lower Profession 1795 20.8 Clerical 1160 13.4 Skilled 443 5.1 Semi-Skilled 358 4.1 Unskilled 265 3.1 Unemployed 2289 26.4 Not classified 1842 21.3 Not answered 6 0.1 Total 8652 100
11. Birth Weight
Nulliparous Parous Totals NNN% 500 – 999 gms 25 30 55 0.6 1000 – 1499 41 29 70 0.8 1500 – 1999 59 68 127 1.4 2000 – 2499 150 185 335 3.8 2500 – 2999 567 595 1162 13.2 3000 – 3499 1280 1669 2949 33.5 3500 – 3999 1138 1709 2847 32.3 4000 – 4499 343 724 1067 12.1 ≥ 4500 56 143 199 2.3 Not Answered 1010.0 Total 3660 5152 8812 100
12. Gestational Age
Nulliparous Parous Totals NNN% < 26 weeks 12 13 25 0.3 26 – 29 weeks + 6 days 26 25 51 0.6 30 – 33 weeks + 6 days 57 66 123 1.4 34 – 36 weeks + 6 days 144 226 370 4.3 37 – 41 weeks + 6 days 3309 4676 7985 92.3 42+ weeks 46 46 92 1.1 Not answered 1560.1 Total 3595 5057 8652 100
28 Coombe Women & Infants University Hospital Annual Clinical Report 2009
13. Perineal Trauma after Spontaneous Vaginal Delivery
Nulliparous Parous Total N%N%N%* Episiotomy 214 14.6 94 2.6 308 6.2 First degree tear 302 20.6 992 28.3 1294 26.0 Second degree tear 601 40.9 822 23.4 1423 28.6 Third degree tear 12 0.8 13 0.4 25 0.5 Fourth tear 3 0.2 2 0.1 5 0.1 Other 130 8.8 110 3.1 170 3.4 Intact 283 19.3 1476 42.1 1759 35.3 Total Spontaneous vaginal deliveries 1469 3509 4978
14. Third Degree Tears (n = 51)
Nulliparous Parous Totals NNN%* Occurring spontaneously 12 13 25 49.0 Associated with episiotomy 62815.7 Associated with forceps 11 5 16 31.4 Associated with ventouse 72917.6 Associated with ventouse + forceps 1012.0 Associated with OP position 42611.8
* % of all third degree tears; tears may be recorded in > one category
15. Perinatal Mortality in Normally-Formed Stillborn Infants (n = 33)
Nulliparous Parous Totals NN N Hypoxia 62 8 IUGR 35 8 Cord accident 34 7 Infection 01 1 Placental abruption 14 5 Twin to twin transfusion 00 0 Other 13 4
29 Coombe Women & Infants University Hospital Annual Clinical Report 2009
16. Perinatal Mortality in Congenitally Malformed Infants (n = 15)*
Nulliparous Parous Totals NN N Neural tube defects 01 1 Other CNS lesions 00 0 Cardiac 13 4 Renal** 00 0 G.I. 00 0 Chromosomal 24 6 Multiple 12 3 Other 10 1
* includes 3 late neonatal deaths ** 2 deaths with renal agenesis associated with multiple anomalies
17. Early Neonatal Deaths (n = 13)
Nulliparous Parous Totals NN N Congenital malformation 16 7 Prematurity 21 3 Infection 10 1 Hypoxia 02 2 Other 00 0
18. Overall Autopsy Rate 49%
19. Hypoxic Ischaemic Encephalopathy (Grade II and III) 7
20. Severe Maternal Morbidity (n = 41)
Nulliparous Parous Totals NN N Massive obstretric haemorrage* 12 13 25 Emergency hysterectomy 16 7 Transfer to other institution 01 1 Other 44 8
* MOH = EBL ≥ 2.5 L and/or coagulopathy requiring Tx
30 Coombe Women & Infants University Hospital Annual Clinical Report 2009
21. Financial Summary at 31st December 2009
Table 21
Financial Information: Summary Financial Position – 31 December 2008
€€
Income:
Department of Health allocation 2009 53,156,799 Patient Income 11, 962,218 Other 4,976,338 70,095,355
Pay:
Medical 10,874,088 Nursing 22,036,524 Other 22,858,190 55,768,802
Non Pay:
Drugs & Medicines 2,331,364 Medical & surgical appliances 3,840,453 Insurances 174,370 Laboratory 1,997,077 Other 5,889,248 14,232,512
Net Surplus 2009 94,041
Taxes paid to Revenue Commissioners Year ended 31 December 2009
PAYE 7,319,438 PRSI EE 2,389,211 PRSI ER 3,709,856
Withholding Tax 43,464
Does not include any deficit balances carried forward from previous years
31 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Statistical Summaries
1. Mothers Attending Hospital
2003 2004 2005 2006 2007 2008 2009 Mothers delivered ≥ 500 grams 7722 7877 7787 7936 8369 8287 8652 Mothers delivered < 500 grams and Miscarriages 514 619 749 680 627 734 676 Gestational Trophoblastic Disease -----10 12 Ectopic pregnancies 43 33 10 17 90 79 81 Total 8288 8566 8603 8706 8996 9110 9421
2. Maternal Mortality
2003 2004 2005 2006 2007 2008 2009 Maternal deaths: 0000110
3. Births ≥ 500g
2003 2004 2005 2006 2007 2008 2009 Singleton 7598 7740 7651 7790 8242 8095 8496 Twins 242 268 265 281 243 366 304 Triplets 999912 21 12 Quadruplets 0004000 Total 7849 8017 7925 8084 8497 8482 8812
4. Obstetric Outcomes
2003 2004 2005 2006 2007 2008 2009 Induction of labour 25.0% 25.7% 26.5% 24.7% 25.9% 28.1% 30.3% Episiotomy 15.9% 16.8% 17.9% 18.3% 19.8% 16.6% 15.7% Forceps delivery 4.3% 4.2% 5.3% 6.2% 9.5% 8.5% 7.2% Ventouse delivery 10.3% 12.4% 12.0% 10.3% 9.2% 9.4% 10.4% Caesarean section 20.2% 22.3% 23.6% 22.0% 22.1% 24.1% 25.1%
32 Coombe Women & Infants University Hospital Annual Clinical Report 2009
5. Perinatal Deaths ≥ 500g
2003 2004 2005 2006 2007 2008 2009 Stillbirths 37 35 34 36 44 40 38 Early neonatal deaths 27 30 28 29 11 26 13 Late neonatal deaths 4567956 Total 68 70 68 72 64 71 57
6. Perinatal Mortality Rates (PNMR) ≥ 500 g per 1000*
2003 2004 2005 2006 2007 2008 2009 Overall PNMR 8.2 8.1 7.8 8.0 6.5 7.8 5.8 PNMR corrected for lethal malformation 5.1 5.1 5.0 5.7 4.6 4.6 4.4 PNMR including late neonatal deaths 8.7 8.7 8.6 8.9 7.5 8.4 6.5 PNMR excluding unbooked cases 7.8 7.4 6.8 7.5 5.8 7.1 5.5 Corrected PNMR excluding unbooked 5.0 4.6 4.4 5.3 4.2 4.2 4.1
* PNMR for infants ≥500g and/or ≥24 weeks = 6.4/1000
7. Statistical Analysis of Obstetric Population
7.1 Age
Age (years) Nulliparous* Parous* Total NNN% <20 284 30 314 3.6 20 – 39 3232 4740 7972 92.2 40+ 79 287 366 4.2 Total 3595 5057 8652 100
*nulliparous and parous refer to the maternal status at booking or at first presentation to the hospital; nulliparous = never having delivered an infant ≥500g; parous = having delivered at least one infant ≥500g.
7.2 Category
Patient Category Nulliparous Parous Total NNN% Public 2535 3231 5766 66.6 Semi-Private 510 760 1270 14.7 Private 550 1066 1616 18.7 Total 3595 5057 8652 100
33 Coombe Women & Infants University Hospital Annual Clinical Report 2009
7.3 Birthplace
Mother’s Country of Birth N% Republic of Ireland 6180 71.4 EU 1191 13.8 Non EU 1231 14.2 Uncoded 50 0.6 Total 8652 100
7.4 Parity
Nulliparous Parous Totals NNN% Para 0 3595 3595 41.6 Para 1 2783 2783 32.2 Para 2-4 2149 2149 24.8 Para 5+ 125 125 1.4
7.5 Birth Weight
Nulliparous Parous Totals NNN% 500 – 999 gms 25 30 55 0.6 1000 – 1499 41 29 70 0.8 1500 – 1999 59 68 127 1.4 2000 – 2499 150 185 335 3.8 2500 – 2999 567 595 1162 13.2 3000 – 3499 1280 1669 2949 33.5 3500 – 3999 1138 1709 2847 32.3 4000 – 4499 343 724 1067 12.1 4500 - 4999 53 128 181 2.1 > 5000 3 15 18 0.2 Not answered 1010.0 Total 3660 5152 8812 100
7.6 Gestational Age
Nulliparous Parous Totals N% < 26 weeks 12 13 25 0.3 26 – 29 weeks + 6 days 26 25 51 0.6 30 – 33 weeks + 6 days 57 66 123 1.4 34 – 36 weeks + 6 days 144 226 370 4.3 37 – 41 weeks + 6 days 3309 4676 7985 92.3 42+ weeks 46 46 92 1.1 Not answered 1560.1 Total 3595 5057 8652 100
34 Coombe Women & Infants University Hospital Annual Clinical Report 2009
8. Statistical Analysis of Hospital Population 2003-2009
8.1 Age 2003-2009
Age at Delivery 2003 2004 2005 2006 2007 2008 2009 (Years) (n=7722) (n=7877) (n=7787) (n=7936) (n=8369) (n=8287) (n=8652) <20 5.2% 4.4% 4.5% 4.2% 3.9% 3.6% 3.6% 20 – 24 14.7% 14.3% 13.6% 13.8% 13.5% 13.8% 13.2% 25 – 29 24.3% 23.4% 21.7% 23.6% 23.2% 24.4% 25.0% 30 – 34 34.1% 34.4% 34.7% 33.4% 33.9% 32.8% 32.1% 35 – 39 18.3% 19.7% 21.4% 20.7% 21.5% 21.2% 21.8% > 40 3.4% 3.8% 4.1% 4.3% 4.0% 4.2% 4.2%
8.2 Parity 2003-2009
Parity 2003 2004 2005 2006 2007 2008 2009 (n=7722) (n=7877) (n=7787) (n=7936) (n=8369) (n=8287) (n=8652) 0 41.6% 41.0% 40.9% 39.8% 40.5% 40.8% 41.5% 1,2,3 54.6% 55.4% 55.5% 56.2% 55.7% 55.4% 54.9% 4+ 3.8% 3.7% 3.6% 4.0% 3.8% 3.8% 3.6%
8.3 Birth weight 2003-2009
Birth Weight 2003 2004 2005 2006 2007 2008 2009 (grams) (n=7849) (n=8017) (n=7925) (n=8084) (n=8497) (n=8482) (n=8812) 500 - 999 0.5% 0.6% 0.7% 0.6% 0.6% 0.7% 0.6% 1000 – 1499 0.5% 0.8% 0.6% 0.7% 0.6% 0.7% 0.8% 1500 – 1999 1.5% 1.2% 1.4% 1.3% 1.1% 1.6% 1.4% 2000– 2499 3.0% 3.5% 3.7% 3.6% 3.6% 3.9% 3.8% 2500– 2999 13.1% 12.7% 13.4% 13.0% 12.3% 13.0% 13.2% 3000– 3499 33.6% 32.5% 32.2% 33.3% 33.9% 33.0% 33.5% 3500– 3999 32.1% 33.6% 33.1% 33.4% 32.4% 33.1% 32.3% 4000– 4499 13.4% 12.5% 12.1% 11.7% 13.1% 11.3% 12.1% >4500 2.4% 2.5% 2.6 2.3% 2.4% 2.7% 2.3% Unknown 0.2% 0.2% 0.1% 0.1% 0.05% 0% 0%
8.4 Gestation 2003-2009
Gestation 2003 2004 2005 2006 2007 2008 2009 (weeks) (n=7849) (n=8017) (n=7925) (n=8084) (n=8497) (n=8482) (n=8652) <28 weeks 0.6% 0.5% 0.5% 0.5% 0.4% 0.6% 0.5% 28 – 36 5.8% 6.3% 6.2% 6.5% 6.1% 6.8% 6.1% 37 – 41 89.3% 89.7% 90.5% 90.8% 91.4% 91% 92.3% 42+ 3.9% 3.4% 2.5% 2.1% 1.9% 1.5% 1.1% Unknown 0.4% 0.1% 0.2% 0.1% 0.2% 0.1% 0.1%
35 Coombe Women & Infants University Hospital Annual Clinical Report 2009
9. In-patient Surgery 2003-2009
2003 2004 2005 2006 2007 2008 2009 Obstetrical 2225 2639 2749 2716 2820 2918 3041 Cervical 412 325 387 395 410 687 1261 Uterine 1721 1840 1816 1922 2304 3015 2416 Tubal & Ovarian 839 1117 1104 1140 1083 999 950 Vulval & Vaginal 213 198 241 245 322 500 445 Other (incl. urogynae) 596 550 392 505 369 240 241 Total 6006 6669 6689 6923 7308 8359 8354
10. Out-patient Attendances 2003-2009
2003 2004 2005 2006 2007 2008 2009 Paediatric 7908 7673 7550 8093 8212 8511 9558 Obstetrical/ Gynaecological 50418 56301 59071 65334 69139 74025 89261
11. In-patient Admissions 2003-2009
2003 2004 2005 2006 2007 2008 2009 Obstetrics 12762 14114 14328 15434 15643 15971 16467 Gynaecology 1218 1061 994 1023 993 1003 975 Paediatrics 1550 1533 1409 1201 1004 1207 1188
12. Bed Days (overnight admissions) 2003-2009
2003 2004 2005 2006 2007 2008 2009 Infants 10350 12243 12759 11579 10203 11182 11497 Adults 46068 47977 49057 47535 48183 44835 45980
13. Day Case Admissions 2003-2009
2003 2004 2005 2006 2007 2008 2009 Obstetrics 7610 7942 8664 8908 8872 9552 10154 Gynaecology 1436 1894 1800 1904 1593 1670 1432 Total 9046 9836 10464 10812 10465 11222 11586
36 Coombe Women & Infants University Hospital Annual Clinical Report 2009
14. Adult Emergency Room (ER) & Early Pregnancy Assessment Unit (EPAU) 2003-2009
2003 2004 2005 2006 2007 2008 2009 ER 4531 5018 5047 6063 6950 8010 8159 EPAU NR NR 3263 3828 3478 3137 3599
15. Perinatal Day Centre (PNDC) and Perinatal Ultrasound (PNU)* 2003-2009
2003 2004 2005 2006 2007 2008 2009 PNDC 10232 9777 11252 12646 15025 13803 14486 PNU 9477 8617 11464 13889 16492 16223 19270
* refers only to scans performed in the Ultrasound Dept.
16. Laboratory tests 2003-2009
2006 2007 2008 2009 Biochemistry 109238 109701 167484 113709 Haematology 52579 50856 44949 47523 Transfusion 21780 23158 24548 24544 Cytopathology 14090 16969 17401 14934 Histopathology 5564 4918 4999 5601
37 Coombe Women & Infants University Hospital Annual Clinical Report 2009
General Obstetric Report
1. Maternal Statistics
2003 2004 2005 2006 2007 2008 2009 Mothers booking 8253 8246 8451 8729 9225 9206 9484 Mothers delivered ≥ 500g 7722 7877 7787 7936 8369 8287 8652
2.1 Maternal Profile at Booking – general demographic factors (%)
2006 2007 2008 2009 (N=9484) Born in RoI 74.8 72.5 69.4 68.4 6485 Born in rest of EU 9.6 12.1 14.8 15.3 1451 Born outside EU 15.2 15.2 15.4 16.1 1524 Country not known 0.4 0.2 0.5 0.2 24 Resident in Dublin 65.3 65.6 65.9 66.5 6305 Rest of Leinster 33.9 33.8 33.3 32.5 3083 Munster 0.2 0.2 0.1 0.2 24 Connaught 0.3 0.2 0.2 0.3 33 Ulster / RoI 0.3 0.1 0.3 0.2 21 < 20 years 4.1 3.7 3.6 3.6 343 ≥ 40 years 4.3 4.2 4.3 4.3 406 Unemployed 11.7 24.4 26.0 21.6 2501 Communication difficulties reported at booking 4.3 5.2 5.9 6.2 590
2.2 Maternal Profile at booking – general history (%)
2006 2007 2008 2009 (N=9484) Para 0 37.4 40.5 42.4 38.9 3694 Para 1-4 53.9 58.1 55.8 52.5 4976 Para 5 + 1.6 1.4 1.7 1.1 104 Unplanned pregnancy 32.6 30.3 32.2 32.6 3091 No pre-conceptual folic acid 46.6 58.7 56.8 55.6 674 Current Smoker 18.2 17.3 16.7 16.1 1527 Taking illicit drugs/methadone 0.7 0.7 1.15 0.7 66 Illicit drugs/Methadone ever 5.4 5.4 6.4 7.0 666 Giving history of domestic violence 1.3 0.9 0.9 1.2 116 Cervical smear never performed 26.4 24.7 26.0 24.4 2316 History of psychiatric/psychological illness /disorder 16.4 10.0 11.6 13.8 1306 History of postnatal depression 3.4 2.7 2.5 3.9 373 Previous perinatal death 2.0 2.0 1.7 1.6 155 Previous infant < 2500g 5.3 2.5 5.0 5.0 470 Previous infant < 34 weeks 2.3 2.5 2.4 2.7 260 One previous Caesarean section 11.1 11.4 11.2 11.0 1044 Two or more previous Caesarean sections 2.6 2.6 2.6 3.1 295
38 Coombe Women & Infants University Hospital Annual Clinical Report 2009
2.3 Maternal Profile in index pregnancy (mothers delivered ≥ 500g) (%)
2006 2007 2008 2009 (N=8652) Pregnancy Induced Hypertension 9.1 10.5 12.2 8.3 722 Pre-eclampsia 7.8 7.1 6.2 5.9 515 Eclampsia 0.03 0.02 0.02 0.06 5 BMI >30 ---15.4 1462 Pregestational Type 1 DM 0.3 0.3 0.5 0.3 30 Pregestational Type 2 DM 0.1 0.1 0.2 0.2 15 Gestational DM 2.1 2.6 2.8 2.9 233 One abnormal OGTT value 1.4 1.5 1.7 1.2 105 Placenta praevia 0.6 0.4 0.5 0.6 55 Abruptio placentae 0.3 0.3 0.2 0.2 18 Antepartum haemorrhage (other) 0.7 0.7 1.0 1.2 104 Haemolytic antibodies 0.3 0.3 0.4 0.9 79 Hep C + 0.9 0.6 0.7 0.8 71 Hep B + 0.8 0.7 0.6 0.8 66 HIV + 0.3 0.3 0.2 0.4 31 Sickle cell trait 0.8 0.6 0.5 0.5 45 Sickle cell anaemia 0.01 0.05 0.02 0.01 1 Thalassaemia trait 0.6 0.8 1.1 1.3 115 Delivery < 28 weeks 0.5 0.4 0.5 0.5 41 Delivery < 34 weeks 1.7 2.0 2.2 2.3 199 Delivery < 38 weeks 11.5 10.9 12.3 13.1 1132 Delivery < 1500g 1.5 1.2 1.4 1.3 116 Delivery < 2500g 6.5 5.8 6.3 6.0 517 Unbooked mothers 1.2 1.2 1.0 1.4 121 LSCS 22.0 22.1 24.1 25.1 2171 Admissions to HDU 2.4 1.9 1.9 1.6 137 Severe Maternal Morbidity 0.35 0.2 0.3 0.5* 41 Maternal Deaths (N) 0 1** 1*** 00 * Definition of Massive Obstetrical Haemorrhage changed in 2009 ** Road Traffic Accident *** Carcinoma of the colon
3.1 Induction of Labour 2009
% of all % proceeding inductions to LSCS Nulliparae induced 1327 50.5% 29.8% % of nulliparae induced 36.9% Parous induced 1301 49.5% 6.8% % of parous induced 25.7% Total number induced 2628 100% 18.4% Total % of inductions 30.4%
3.2 Induction of Labour 2003-2009
Inductions 2003 2004 2005 2006 2007 2008 2009 N 1927 2021 2067 1959 2166 2328 2628 % 25.0 25.7 26.5 24.7 25.9 28.1 30.4
39 Coombe Women & Infants University Hospital Annual Clinical Report 2009
4.1 Epidural analgesia in Labour 2009
Number % of all epidurals Nulliparae with epidurals 2354 60.0% % of nulliparae with epidural analgesia 65.5% Parous with epidurals 1571 40.0% % of parous with epidural analgesia 31.1% Total number of epidurals 3925 100.0% Overall % of epidurals 45.4%
4.2 Epidural analgesia in Labour 2003-2009
Epidurals 2003 2004 2005 2006 2007 2008 2009 N 3663 3661 3619 3525 3785 3915 3925 % 47.4 46.5 46.5 44.4 45.2 47.2 45.4
5.1. Fetal Blood Sampling in Labour 2009
N < 7.20 54 > 7.20 660 Total 714
5.2. Fetal Blood Sampling in Labour 2003-2009
FBS 2003 2004 2005 2006 2007 2008 2009 N 543 551 666 669 627 621 714 % 7.0 7.0 8.6 8.4 7.5 7.5 8.3
6. Prolonged Labour (PL) 2009
Number % of all Prolonged labour Nulliparae with PL 236 88.7% % of nulliparae with PL 6.6% Parous with PL 30 11.3% % of parous with PL 0.6% Total with PL 266 100% Total % with PL 3.1%
40 Coombe Women & Infants University Hospital Annual Clinical Report 2009
7.1 Mode of delivery (%) - Nulliparae 2003-2009
2003 2004 2005 2006 2007 2008 2009 SVD 50.8 44.1 42.8 44.7 41.6 41.1 40.9 Vacuum 18.1 21.2 20.8 19.0 15.6 16.2 18.4 Forceps 8.2 8.6 10.6 12.1 18.7 17.0 14.8 LSCS 23.6 26.3 26.2 24.6 24.4 26.3 26.2
7.2 Mode of delivery (%) - Parous 2003-2009
2003 2004 2005 2006 2007 2008 2009 SVD 76.0 73.1 70.7 73.1 71.6 70.4 69.4 Vacuum 4.9 6.3 5.9 4.5 4.8 4.7 4.8 Forceps 1.5 1.2 1.7 2.3 3.2 2.6 1.8 LSCS 17.8 19.6 21.9 20.6 20.6 22.6 24.3
7.3 Mode of delivery (%) - all mothers 2003-2009
2003 2004 2005 2006 2007 2008 2009 SVD 65.5 61.4 59.5 61.8 59.5 58.4 57.5 Vacuum 10.3 12.4 12.0 10.3 9.2 9.4 10.4 Forceps 4.3 4.2 5.3 6.2 9.5 8.5 7.2 LSCS 20.2 22.3 23.6 22.0 22.1 24.1 25.1
8. Episiotomy (%) 2003-2009
2003 2004 2005 2006 2007 2008 2009 Nulliparae 28.8 30.6 33.0 34.4 37.3 31.4 31.4 Parous 6.7 7.3 7.4 7.7 7.9 6.3 4.5 Overall 15.9 16.8 17.9 18.3 19.8 16.6 15.7
9.1 Shoulder Dystocia (SD) 2009
Nulliparae with SD 34 % of nulliparae with SD 0.9% Parous with SD 32 % of parous with SD 0.6% Total number of patients with SD 66 Total % of patients with SD 0.8%
41 Coombe Women & Infants University Hospital Annual Clinical Report 2009
9.2 Shoulder Dystocia (SD) & Birth Weight
Number of mothers with babies < 4 Kg with SD 27 % of mothers with babies < 4 Kg with SD 0.4% Number of mothers with babies ≥ 4 Kg with SD 39 % of mothers with babies ≥ 4kg with SD 3.1%
9.3 Shoulder dystocia 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 36 42 36 45 68 59 66 % 0.5 0.5 0.5 0.6 0.8 0.7 0.8
10.1 Third Degree Tearss
Number of nulliparae with 3rd degree tears 31 % of nulliparae with 3rd degree tears 0.9% Number of parous with 3rd degree tears 20 % of parous with 3rd degree tears 0.4% Total number of mothers with 3rd degree tear 51 Total % of mothers with 3rd degree tears 0.6%
10.2 Third Degree Tears 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 69 93 75 108 100 77 51 % 0.9 1.2 1.0 1.4 1.2 0.9 0.6
11.1 Fourth Degree Tears 2009
Number of nulliparae with 4th degree tears 5 % of nulliparae with 4th degree tears 0.1% Number of parous with 4th degree tears 3 % of parous mothers with 4th degree tears 0.06% Total number of mothers with 4th degree tears 8 Total % of mothers with 4th degree tears 0.1%
11.2 Fourth Degree Tears 2003-2009
2003 2004 2005 2006 2007 2008 2009 N NR 129648 % 0.01 0.03 0.11 0.07 0.05 0.1
42 Coombe Women & Infants University Hospital Annual Clinical Report 2009
12. 0 Primary Post Partum Haemorrhage (10 PPH) 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 109 119 112 158 208 270 439 % 1.4 1.5 1.4 2.0 2.5 3.3 5.1
12.1 10 PPH spontaneous labour
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Nulliparae 1.7 1.6 1.9 1.9 2.6 3.6 5.0 1974 Parous 1.3 1.3 1.4 2.0 2.2 2.7 4.2 2850 Overall 1.5 1.4 1.6 2.0 2.3 3.1 4.5 4824
12.2 10 PPH - induced Labour
2003 2004 2005 2006 2007 2008 2009 % %%%%%% N Nulliparae 1.6 2.1 1.4 2.8 4.5 5.5 7.1 1327 Parous 2.2 2.4 1.6 2.0 2.8 3.6 5.0 1301 Overall 1.9 2.3 1.5 2.4 3.7 4.5 6.0 2628
12.3 10 PPH - SVD
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Nulliparae 1.6 1.6 1.6 1.8 3.1 4.0 4.4 1469 Parous 1.5 1.6 1.4 2.1 2.5 2.9 4.4 3509 Overall 1.5 1.6 1.4 2.0 2.7 3.2 4.4 4978
12.4 10 PPH - Ventouse
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Nulliparae 1.9 1.8 2.6 2.7 2.8 3.8 8.0 660 Parous 1.8 2.7 1.1 0.9 0.4 3.4 6.6 241 Overall 1.9 2.0 2.1 2.2 2.1 3.7 7.7 901
12.5 10 PPH - Forceps
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Nulliparae 1.9 4.3 1.5 3.9 5.5 7.3 7.1 533 Parous 1.5 1.9 1.3 0.9 4.3 4.6 1.1 90 Overall 1.8 3.9 1.4 3.2 5.3 6.8 6.3 623
12.6 10 PPH - Caesarean Section (by parity)
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Nulliparae 0.7 0.6 0.7 1.4 1.6 2.6 5.4 941 Parous 0.6 0.5 1.2 1.4 0.9 1.4 5.4 1230 Overall 0.6 0.6 1.0 1.4 1.2 1.9 5.4 2171 43 Coombe Women & Infants University Hospital Annual Clinical Report 2009
12. 7 10 PPH - Caesarean Sections (by priority status)
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Elective 0 0.1 0.3 0.4 0.5 0.6 3.9 942 Emergency 1.0 0.8 1.4 2.2 1.7 3.0 6.5 1229 Overall 0.6 0.6 1.0 1.4 1.2 1.9 5.4 2171
12.8 10 PPH - Twin Pregnancy
2003 2004 2005 2006 2007 2008 2009 % %%%%%% N Nulliparae 4.0 0 4.9 4.5 11.5 7.0 11.5 61 Parous 1.4 2.4 001.6 2.9 12.1 91 Overall 2.5 1.5 2.3 2.1 6.5 4.8 11.8 152
13. 0 Manual Removal of Placenta (%) 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 97 90 143 120 134 112 95 % 1.3 1.1 1.8 1.5 1.6 1.4 1.1
13.1 10 PPH in Manual Removal of Placenta 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 10 16 14 24 32 24 42 % 10.3 17.8 9.8 20.0 23.9 21.4 44.2
14.0 Mothers Transfused 2005-2009
2005 2006 2007 2008 2009 N 181 193 137 139 193 % 2.3 2.4 1.6 1.7 2.2
14.1 Mothers who received Massive Transfusions (> 5units RCC) 2005-2009
2005 2006 2007 2008 2009 N 20 31 12 10 17 % 0.3 0.4 0.1 0.1 0.2
14.2 Mothers admitted to HDU with PPH
2005 2006 2007 2008 2009 N NR 55 43 40 46 % NR 0.7 0.5 0.5 0.5
44 Coombe Women & Infants University Hospital Annual Clinical Report 2009
15. Singleton Breech Presentation 2003-2009
2003 2004 2005 2006 2007 2008 2009 Number of breech in nulliparae 152 155 123 115 152 160 142 % LSCS for breech in nulliparae 94.7 97.4 95.1 93.0 95.4 91.9 94.4 Number of breech in parous 93 117 126 125 134 159 152 % LSCS for breech in parous 95.7 86.3 89.7 86.4 93.3 93.7 92.1 Total number of breech 245 272 249 240 286 319 294 Total % LSCS 95.1 92.6 92.4 89.6 94.4 92.8 93.2
16. Twin Pregnancy 2003-2009
2003 2004 2005 2006 2007 2008 2009 Number of Twin pregnancies in Nulliparae 48 50 61 66 61 84 61 % LSCS in Nulliparae 54.2 58.0 62.3 59.1 55.7 58.3 67.2 Number of Twin pregnancies in Parous 73 84 72 76 62 101 91 % LSCS in Parous 47.9 46.4 45.8 39.5 37.1 39.6 54.9 Total number of Twin pregnancies 121 134 133 142 123 185 152 Total % LSCS in Twin pregnancy 50.4 50.7 54.1 48.6 46.3 48.1 59.9
2 Mothers underwent LSCS for a 2nd twin after vaginal delivery of a 1st twin.
17. Classical Caesarean Section, Ruptured Uterus, Hysterectomy in Pregnancy 2003-2009
2003 2004 2005 2006 2007 2008 2009 Classical Caesarean Section 2252376 Ruptured Uterus 5124461 Hysterectomy in pregnancy 1117137
18.1 Lower Segment Caesarean Sections (LSCS) 2009
Nulliparae - LSCS (%) Parous - LSCS (%) SOL at term • 11.6 3.0* IOL at term – Pg • 29.4 5.8* IOL at term – no Pg • 22.5 3.8* All singleton breech 94.0 93.0 All twins 67.2 54.9
• refers to cephalic presentations only * refers only to parous patients who have not had a caesarean section in the past
18.2 Vaginal Birth (%) after a single Previous Lower Segment Caesarean Section (VBAC) 2009
Para 1 Para 1 + Total Elective LSCS 50.4 26.5 42.3 Emergency LSCS 25.9 14.7 22.1 Total LSCS 76.3 41.2 64.4 VBAC 23.7 58.8 35.6
45 Coombe Women & Infants University Hospital Annual Clinical Report 2009
18.3 Vaginal Birth after a single Previous Lower Segment Caesarean Section (VBAC) 2003-2009
2003 2004 2005 2006 2007 2008 2009 %%%%%%% N Para 1 39.8 34.8 33.1 39.3 37.7 31.7 23.7 615 Para 1+ 68.4 67.8 66.8 69.1 66.8 64.0 58.8 313 Overall 49.2 45.7 44.6 49.4 47.4 42.5 35.6 928
18.4 Caesarean Sections (%) 2003-2009
2003 2004 2005 2006 2007 2008 2009 Nulliparae 23.6 26.3 26.2 24.6 24.5 26.2 26.2 Parous 17.8 19.6 21.9 20.6 20.5 22.6 24.3 Total 20.2 22.3 23.6 22.0 22.1 24.1 25.1
19. Apgar score < 7 at 5 mins 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 42 44 66 92 70 86 70 % 0.5 0.5 0.8 1.1 0.8 1.0 0.8
20. Arterial Cord pH <7 2007-2009
2007 2008 2009 N 32 36 35 % 0.4 0.4 0.4
21. Admission to SCBU/NICU at 38 weeks+ 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 900 899 807 631 482 617 554 % 13.0 12.8 11.6 8.9 6.4 7.3 6.4
22. Born Before Arrival 2003-2009
2003 2004 2005 2006 2007 2008 2009 N 26 24 25 37 31 24 29 % 0.3 0.3 0.3 0.5 0.4 0.3 0.3%
46 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Early Pregnancy Assessment Unit
Head of Department
Dr Mary Anglim
Staff Complement
Dr Soha Said Dr Andrea Nugent Dr Nadine Farah Ms Carol Devlin (secretary)
Key Performance Indicators
Patient attendance 3619 New 2815 Follow-up 804
Management of Ectopic Pregnancy
Methotrexate 9 Laparoscopic 62 Laparotomy 10
Miscarriages managed by ERPC 532
Achievements in 2009
• Experienced clinicians involved in provision of service.
• Increase in number of patients opting for medical management of miscarriage.
• Dedicated theatre spaces for ERPC.
Challenges
• Provision of midwifery/radiography sonography sessions.
47 Coombe Women & Infants University Hospital Annual Clinical Report 2009
High Dependency Unit (HDU)
There were 152 admissions to HDU in 2009. 137 were obstetric patients. Five of these women were admitted to the unit on two occasions.
Hypertensive disorders of pregnancy together with Obstetric haemorrhage comprised around three quarters of the reasons for admission to HDU (73%).
Reason for admission N %
Severe PET 65 43 PPH 46 30 Post-operative haemorrhage (gynaecology) 12 8 Maternal medical/surgical illness 96 APH 53 Cardiac diseases in pregnancy 4 2.6 Suspected/Confirmed Pulmonary Embolism 4 2.6 Maternal collapse 2 1.4 Miscellaneous 5 3.4
Suchetta Johnson Samar Ahmed Bridgette Byrne
52 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Maternal Mortality 2000-2009
Year No of Maternal Deaths Total Number of Mothers
2000 0 7958 2001 0 8132 2002 1 7982 2003 0 8409 2004 0 8529 2005 0 8546 2006 0 8633 2007 1 9088 2008 1 9110 2009 0 9421 Total 3 85808 Maternal Mortality Rate 3.5/100000
2002 Stevens Johnson Syndrome and Liver Failure secondary to Nevirapine (HIV +) 2007 RTA 2008 Metastatic Carcinoma of the Colon
53 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Perinatal Mortality and Morbidity
A. Overall Statistics
1. Perinatal Deaths ≥ 500g
Antepartum deaths 34 Intrapartum deaths 4 Stillbirths 38 Early neonatal deaths 13 Late nonatal deaths 6 Congenital malformations 15*
* includes 3 late neonatal deaths
2. Perinatal Mortality Rates ≥ 500g*
Overall perinatal mortality rate per 1000 births. 5.8 Perinatal mortality rate corrected for lethal congenital malformations 4.4 Perinatal mortality rate including late neonatal deaths 6.5 Perinatal mortality rate excluding unbooked cases 5.5 Corrected perinatal mortality rate excluding unbooked 4.1
* Perinatal mortality rate for infants ≥ 500g and/or ≥ 24 weeks = 6.4/1000
3. Perinatal Mortality in Normally-Formed Stillborn Infants ≥ 500g (n = 33)
Nulliparous Parous Totals NNN Hypoxia 628 IUGR 358 Cord accident 347 Infection 011 Abruption 145 Twin to twin transfusion 000 Other 134
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4. Intrapartum Deaths ≥ 500g (n = 4)
Parity Gestation Birth Weight Conclusion 11+2 23 544g Cord Prolapse 20 27 546g Infection 30 27 565g IUGR 40 36 3640g Chromosomal
5. Malformed Infants ≥500g (n = 15)*
Nulliparous Parous Totals NNN Neural tube defects 011 Other CNS lesions 000 Cardiac 134 Renal** 000 G.I. 000 Chromosomal 246 Multiple 123 Other 101
* includes 3 late neonatal deaths ** 2 deaths with renal agenesis associated with multiple anomalies
6. Early Neonatal Deaths ≥ 500g (n = 13)
Nulliparous Parous Totals NNN Congenital 167 Prematurity 213 Infection 101 Hypoxia 022 Other 000
7. Overall Autopsy Rate 49%
8. Hypoxic Ischaemic Encephalopathy (Grade II and III) 7
55 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Diabetic Endocrine Pregnancy Service
Professor Sean Daly & Dr Brendan Kinsley
Type 1
n = 36 Pregnancies 36 Spontaneous abortions 6 Preterm deliveries 4 *footnote 1 Term deliveries 23 Live Infants 31 IUD 0 NND 0
Maternal Data (Type 1)
n = 36 *footnote 2 Age 30.1 ± 6.3 DM duration 14.2 ± 7.8 DM complications Hypertension 3 Retinopathy 3 Nephropathy 1 Neuropathy 1 PET 1 Gestation at OPD booking 6.9 ± 2.96 *footnote 3 Booking HbA1c 7.2 ± 1.1 Delivery HbA1c 6.4 ± 0.7 Booking Fructosamine 319 ± 54 Delivery Fructosamine 233 ± 19 Caesarean section 12 ie 46%
Infant data (Type 1)
n= 31 live births Gestation at delivery 38.4 ± 2.3 Birth Weight 3.51 ± 0.82 Macrosomia (4.0-4.449kg) 5 Macrosomia (4.5-4.99kg) 1 Macrosomia (>5kg) 1 Shoulder dystocia 2 Congenital abnormalities 0
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Maternal Data (Type 2)
n = 19 Age 32.6 ± 5.5 DM duration 1.2 ± 0.6 DM complications Hypertension 2 PET 1 Gestation at OPD booking 8.9 ± 3.3 *footnote 4 Booking HbA1c 6.0 ± 0.7 Delivery HbA1c 5.8 ± 0.6 Booking Fructosamine 236 ± 15 Delivery Fructosamine 214 ± 23 Caesarean section 1 ie 8%
Infant data (Type 2)
n = 14 live births Spontaneous abortions 4 Delivered elsewhere 1 Gestation at delivery 37.7 ± 3.4 Birth weight 3.28 ± 0.87 Macrosomia (4.0-4.5kg) 3 Macrosomia (>4.5kg) 0 Macrosomia (>5kg) 0 Congenital abnormalities 0 IUD/PND 1 Case Study *1
Gestational Diabetes Mellitus
Pregnancies n= 249 Rx with Insulin 136 Rx with Diet 113
GDM Total Group
n = 233 Coombe births 225 *footnote 5 Delivered elsewhere 8 Age 32.8 ± 4.8 Gestation at delivery 38.7 ± 1.6 Birth weight 3.44 ± 0.62 Caesarean section 82 ie 35% IOL 97 Perinatal death 0 Congenital abnormalities 1 *footnote 6
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Rx with insulin
n = 136 Coombe live births 131 *footnote 7 Delivered elsewhere 5 Age 32.8 ± 4.8 Seen at DM OPD 10.2 ± 4.4 *footnote 8 To insulin 27.1 ± 8.6 Gestation at delivery 38.6 ± 1.4 Birth weight 3.43 ± 0.57 Caesarean section 49 ie 38% PET 4 Hypertension 9 IUD/PND 0 Congenital abnormalities 1 Shoulder dystocia 1
Rx with Diet
n = 97 Coombe live births 94 *footnote 9 Delivered elsewhere 3 Age 32.9 ± 4.7 Booking gestation 12.8 ± 5.6 Gestation at delivery 39.0 ± 1.80 Caesarean section 33 ie 34% Neonatal death 0
There were 16 early pregnancy losses among women with previous GDM who had booked at the clinic.
Based on Total GDM No.
<4kg 191 4-4.499kg 31 4.5-4.999kg 4 >5kg 2
One abnormal value on OGTT
n = 105 pregnancies Delivered elsewhere 2 Coombe live births 103 Age 31.37 ± 5.58 Gestation at delivery 39.11 ± 1.90 Birth weight 3.50 ± 0.61 Caesarean section 35 ie 35%
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Birth weights
<4kg 82 4-4.499kg 19 4.5-4.999kg 2 >5kg 0
*1: pre-term deliveries: Type 1
1 @ 36+2 – PET 1 @ 36+0 – MCDA Twins. 1 @ 36+5 1 @ 28+0 – transfer in with Stage 4 CKD.
*2: Type 1
Includes 1 set of twins.
*3: Late bookers: Type 1
1 @ 15+1 1 @ 19+6 1 @ 18+4 1 @ 27+2 – transfer in. 1 @ 28+0 1 @ 33+0 Inclusion of these figures results in booking gestation of 9.7 +/- 5.2.
*4: Late bookers: Type 2
1 @ 15+0 1 @ 19+2 – transfer in 1 @ 23+0 – transfer in. 1 @ 27+3 Inclusion of these figures results in booking gestation of 11.6 +/- 6.4.
*5: Multiple Births: GDM Total Group
Includes 2 sets of twins.
*6: Congenital Abnormalities: GDM Total Group
Trisomy 21
*7: Multiple Births: GDM Total Group
1 set twins
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*8: Late bookers: GDM Insulin
1 @ 36+5 1 @ 25+1 1 @ 22+5 1 @ 20+1 inclusion of these figures results in booking gestation of 11.2 +/- 6.5. transfers in: 1 @ 35+6 1 @ 35+6 1 @ 33+1 1 @ 31+2 1 @ 30+5 1 @ 29+6 inclusion of these figures results in booking gestation of 11.7 +/- 7.0.
*9: Multiple Births:
1 set twins
80 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Multiple Births Service
In 2009 there were 152 twins and 4 triplet pregnancies with infants delivered weighing ≥ 500g.
In 35 (3%) twin pregnancies conception was achieved through assisted reproduction. In 27 (23%) delivery occurred < 34 weeks; in 11(7.2%) delivery occurred > 38 weeks; all were delivered < 40 weeks. The Caesarean rate for twin pregnancies was 59.9%; 2 mothers underwent Caesarean section for the second twin after vaginal delivery of the first twin.
There were 3 perinatal deaths among the 152 twin pregnancies. Two deaths were associated with significant abnormalities: anencephaly and renal agenesis/VATER-like sequence. The latter mother was unbooked but had care in Poland and arrived in the hospital in labour. There was also one intra-partum death in an infant born at 23+5 weeks who weighed 546g. The PNM rate among twins attending the clinic of 9.8/1000 (corrected PNM 3.3).
There were 3 patients whose pregnancies were complicated by TTTS. One of these pregnancies was a triplet pregnancy. These three pregnancies were all referred to the Rotunda Hospital. In the case of the triplet pregnancy, the woman returned to her country of origin and was lost to follow up. There was one case of laser ablation and one case which resolved. The outcome of the laser ablation case resulted in the live delivery of both twins.
The four triplet pregnancies were all delivered by caesarean section; there was no perinatal deaths.
I would like to thank all the staff for the care and support provided to mothers and partners attending the Hospital with a multiple pregnancy.
Professor Sean Daly
81 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Medical Clinic Report 2009
Heads of Department
Dr Bridgette Byrne and Dr Carmen Regan
Staff Complement (indicate position & WTE status)
Dr Carmen Regan Consultant Obstetrician and Gynaecologist Dr Bridgette Byrne Consultant Obstetrician and Gynaecologist Dr Suchetta Johnson RCSI Lecturer in Obstetrics and Gynaecology Dr Barry White Consultant Haematologist Dr James O' Donnell Consultant Haematologist Ms Elizabeth O Berne, CNM
Medical clinic referrals continue to increase; 870 new patients have been referred over a 6 year period. The table below reflects the diversity of conditions seen.
Key Performance Indicators
In 2009 there were 184 new referrals to the medical clinic.
Achievements
• Provision of consultant led multidisciplinary clinical service to high risk mothers. • Monthly multidisciplinary team meetings to discuss patient management plan involving obstetric, anaesthetic, midwifery and maternal medicine. • Ongoing database of all patients is maintained for the purpose of research and education. • Continued increase in non haematological referrals. • We welcome the recent appointment of a clinical nurse manager with an interest in high-risk pregnancy. This post will coordinate inpatient and outpatient management of our high risk pregnancies and facilitate liaison with other specialties.
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Challenges
• In the past few decades our ability to predict and avert adverse obstetric outcome has increased greatly. Women with high risk pregnancies benefit from increased care and should be identified early in pregnancy. Providing care to high risk patients presents certain challenges.
• The identification of the patient at increased risk is fundamental and ideally should occur preconceptually. High risk patients often have more than one underlying medical condition and are often on disease modifying therapies. Initial consultation in pregnancy should be early in pregnancy when risks can be assessed and a management plan outlined.
• A multidisciplinary team approach and communication with other disciplines is the cornerstone of care in these complex cases. A small number of patients are deemed to be best delivered on a general hospital site for the purpose of access to general or vascular surgery and interventional radiology and we are indebted to our Gynaecological and Anaesthetic colleagues at St James’s Hospital for their involvement in the care of these women.
Diagnoses of New Patients Referred to the Medical Clinic 2009
Haematological Disorders:
Thrombosis/Thromboprophylaxis: 22
History of pulmonary embolism: 9 History of DVT 10 Thrombosis/Thromboprophylaxis 26 History of pulmonary embolism 14 History of DVT 8 Saggital sinus thrombosis 1 Venous sinus thrombosis 1 Polyctyhaemia, pulmonary embolism 1 Inferior Vena Cava thrombosis 1
Clotting Factor Deficiencies 17
Haemophilia carrier 3 Factor V deficiency 1 Von Willebrand's disease 5 Von Willebrands/Factor V deficiency 1 Haemophilia B/Factor IX deficiency 1 Factor VII/XI deficiency 1 Factor XI deficiency (partner) 1 Factor IX/XI deficiency 1 Hx of bleeding tendency 3
Thrombophilias 14
Protein S deficiency 2 Protein C deficiency 1
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APLS 1 FVLeiden heterozygous 4 FVLeiden homozygous 1 ATIII deficiency 1 Prothrombin gene mutation 1 MTHFR mutation 2 Paroxysmal Nocturnal Haemoglobinuria 1
Platelet Disorders 10
Thrombocytopaenia 5 Gestational thrombocytopaenia 2 ITP 3
Red Cell Disorders 3
Anaemia/beta thalassaemia trait 1 Hereditary spherocytosis 2
Oncological 3
CML in remission 2 Non-Hodgkins Lymphoma 1
Hypertensive Disease 5
Essential Hypertension in Pregnancy 3 Secondary Hypertension Midthoracic Syndrome 1 Hx of severe early onset PET 1
Renal Disorders 5
Renal Transplant 1 Adult polycystic kidney disease 2 Lupus nephritis 1 Nephrotic syndrome 1
Connective Tissue Disease 10
Systemic Lupus Erythematosis 5 Juvenile Rheumatoid Arthritis 1 Mixed Connective Tissue Disease 1 CREST Syndrome 1 Ehlers Danlos syndrome 1 Marfan’s syndrome 1
Cerebrovascular Disease 41
Epilepsy 28 Hemiplegic migraine 1
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History of CVA 3 History of TIA 2 Multiple sclerosis 1 Hx of Berry aneurysm/subarachnoid haemorrhage 3 Benign intracranial hypertension 1 Cerebral tumour: 1 Neurofibromatosis 1
Cardiac Disease 16
Arrhythmia/Palpitations 3 Mitral Valve Prolapse 4 ASD (post repair) 2 Hx of Cardiac Surgery 1 HOCUM 1 Heart Murmur 4 Hx of SADS 1
Recurrent Fetal Loss 10
Liver/GI disease 9
Ulcerative Colitis 2 Crohn’s disease 4 Primary biliary cirrhosis 2 Liver transplant 1
Respiratory Disease 7
Asthma 4 Alpha 1 antitrypsin deficiency 1 Bronchiectasis/IgG deficiency 1 Recurrent pneumothorax 1
Infectious Diseases 4
Primary CMV 1 Primary Toxoplasmosis 1 Primary Tuberculosis 1 Cysticercosis 1
Endocrine/Metabolic 3
Pituitary Adenoma 2 Phenylketonuria 1
Other 1 Hx of IUGR 1
85 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Addiction/Infectious Diseases
Head of Department
Dr Michael O’Connell, Consultant Obstetrician & Gynaecologist
Staff Complement
Orla Cunningham, CMM 2 Infectious Diseases (1 WTE) Tracey Gray, Acting CMM 2 Infectious Diseases (Aug-Dec 2009, 0.64 WTE) Deirdre Carmody, CMS, Drug Liaison Midwife (DLM), Addiction Service, HSE Dublin Mid-Leinster Dr Eve Gaughan, Specialist Registrar (Jan-June 2009) Dr Minna Geisler, Specialist Registrar (June-Dec 2009) Carmel Cronin, MSW (Jan-Aug 2009) Nerilee Ceatha, MSW (Sep-Dec 2009)
Genitourinary Medicine Consultants (St James’s Hospital)
Dr Fiona Mulcahy Dr Fiona Lyons
Key Performance Indicators
Infectious Diseases (Hepatitis B/C, HIV and Treponema pallidum)
• 53 women who booked for antenatal care in 2009 were positive for Hepatitis B; 11 were newly diagnosed on antenatal screening. • 65 women who booked for antenatal care were positive for Hepatitis C; 14 were newly diagnosed on antenatal screening; 33 were PCR positive, 29 were PCR negative and 3 were unavailable for follow up testing. • 35 women booked for antenatal care were HIV positive; 6 were newly diagnosed. 3 women were co- infected with Hepatitis C (1 was PCR positive); 2 women co-infected with Hepatitis B. • 18 women booked for antenatal care had positive serology for Treponema pallidum; 8 women required treatment in pregnancy, 10 women were confirmed to have had appropriate treatment before. • 84 antenatal women required follow up and repeat testing for indeterminate serological tests for Treponema pallidum attributed to cross-reactivity in pregnancy.
Addiction
• 118 women with problems relating to substance addiction booked for care in 2009 (85 delivered; 33 women still pregnant end of 2009). • In 2009, within this cohort. 5 women had a new diagnosis of hepatitis C antibodies on booking visit. 57 women were hepatitis C antibody positive (41 delivered + 16 women still pregnant). 7 women were HIV positive (6 delivered + 1 woman still pregnant). • 85 women delivered 86 infants (one set of twins) • Out of the 86 deliveries, there were 2 intrauterine deaths at 32 and 36 weeks gestation; in addition there was one early neonatal death. • Mean gestation: 37 weeks; range: 28-41 weeks. • Mean birth weight: 2766g; range: 700-4241g.
86 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• 58% babies were admitted to SCBU, mean length of stay: 20 days; range: 1-157 days. • 33% babies were treated for neonatal abstinence syndrome (NAS); the mean length of stay in SCBU for infants who received pharmacological treatment for NAS was 21 days; range from 2- 34 days.
Additional
• 29 women with high-risk pregnancies unrelated to infectious disease/addiction attended this service for specialist care.
The role of the Medical Social Work Department
This specialist clinic was established to promote the safe delivery of women booked for antenatal care in CWIUH with high risk pregnancies complicated with infectious disease/addiction.
The multi-disciplinary team (MDT) works collaboratively with hospital staff and community services to enable the safe discharge of women and infants following delivery.
The MDT approach has been streamlined to deliver a model of care, which promotes bio-psychosocial assessment, and response to identified antenatal need. This re-orientation of antenatal services provides a patient-centred model of care.
Mothers with a history of addiction are routinely referred to the Medical Social Work Department (MSWD) for follow- up; the role of the MSWD is of pivotal importance in relation to facilitating early access to hospital services, the support of individual mothers, infants and families and linkage with community based services.
The MDT has continues to develop this model of delivery of care through:
• Provision of continuity of care through medical social work involvement antenatally. This model of patient- centred practice was introduced by Ms Carmel Cronin and has been continued by Ms Nerilee Ceatha. This enables the medical social worker to provide an ongoing link between antenatal, postnatal and paediatric care. • Implementing the weekly MDT meetings piloted by Ms Carmel Cronin and continued by Ms Nerilee Ceatha following antenatal clinics. These meetings provide an opportunity to discuss attendance, identify social issues impacting on antenatal care, share information about medical and midwifery needs where increased support may be required. • Ms Nerilee Ceatha initiated the piloting of a project where the medical social worker is present at the antenatal clinic. This has been successful in promoting the role of the medical social worker within the MDT, profiling the role of medical social worker and increasing accessibility of the service. • Enabling increased liaison within the MDT by highlighting the role of the medical social worker within the team. This has facilitated Ms Nerilee Ceatha to link in antenatally with patients with a history of substance use booked for antenatal care in the CWIUH.
Opportunities
• To develop and implement the pilot project to ensure the provision of a medical social work service at antenatal clinics for women with a history of substance misuse. • To highlight the identified gap in provision of patient centred care in relation to patients with infectious diseases. There is a need for a dedicated medical social worker (MSW) to be appointed to work with patients with infectious diseases.
87 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Achievements in 2009
• A combined consultant provided Obstetric and Adult HIV service was established in February 20009 in association with Dr Fiona Mulcahy and Dr Fiona Lyons (St James’s Hospital). • A streamlined Treponema pallidum Indeterminate Serology review service was established. • Weekly MDT meetings. • Ongoing education of staff of the CWIUH and outside agencies. • Ongoing close co-operation with external agencies including Adult GUIDE services, Adult Hepatology services, Paediatric Infectious Disease services, Community Addiction Services, NVRL, HPSC, and HSE Department. of Public Health. • Poster Presentation: ‘Drug use in pregnancy: challenges for health care workers’ a collaboration between CWIUH and the Addiction Service, HSE Dublin Mid-Leinster; Deirdre Carmody, Noreen Geoghegan, Rose Sheppard, Dr Mike Scully, Dr Eamonn Keenan and Dr Michael O’Connell. This Poster was presented at two conferences: 1. Ireland’s Annual Joint Midwifery Conference 2009, Slieve Russell Hotel, Ballyconnell, Co Cavan. 2. The National Council for the Professional Development of Nursing and Midwifery, 9th Annual Conference 2009, Clinical Excellence: Safety, Quality and Evidence, Croke Park. Out of a total of 107 presentations it was awarded a prize. • Collaborative study with the Rotunda Hospital led by Brian Cleary, Research Pharmacist CWIUH. Commenced in August 2009 recruiting women who are pregnant and on a methadone programme attending our specialised clinic. • CWIUH assisted in the funding of an education booklet ‘Drug Use in Pregnancy’. This was a collaborative project with the two other Dublin maternity hospitals and the HSE Addiction Services. • Guidelines for dispensing methadone to inpatients was successfully implemented and distributed to the wards in the CWIUH. • Facilitated direct midwifery students (BSc Midwifery programme) on community placement with the Drug Liaison Midwife and medical students to attend the CWIUH outpatient specialised clinic.
Opportunities for 2010
• Preparation for the provision of a combined Obstetric & Hepatology (SJH) service to take place in the CWIUH, for the cohesive management of women with a history/diagnosis of Hepatitis in pregnancy. • Streamlining of MSW involvement in the management of mothers with Hepatitis B/C, Treponema pallidum, and HIV. • To determine the impact of the dedicated antenatal addiction/infectious diseases clinic on clinical outcomes and patient satisfaction. • Provision of a methadone dispensing guideline for the three Dublin Maternity Hospitals. • Formal acknowledgement of the Infectious Disease midwifery role as a Clinical Midwife Specialist.
88 Coombe Women & Infants University Hospital Annual Clinical Report 2009
The Fetal Medicine and Perinatal Ultrasound Department
Professor Sean Daly
Retirement of Professor Bernard Stuart
In October 2009 Dr Bernard Stuart retired from the Perinatal Ultrasound Department and was replaced as departmental head by Professor Sean Daly; Bernard had been departmental head since the mid 1980s and during his tenure made an enormous contribution to the well-being of the highest-risk mothers and infants in the hospital; Bernard’s practice was characterised by his total dedication to patient care, his constant availability and for the highest levels of support and mentorship he provided to generations of medical, midwifery and radiography sonographers who came to this department for training. During his distinguished career Bernard had achieved international recognition for research in ultrasound. Bernard will be sadly missed as a clinician, an expert sonographer and as a colleague; we are, however, delighted that Bernard has retained a research and teaching commitment in the Perinatal Ultrasound Department and the UCD Centre for Human Reproduction; we would also like to congratulate Bernard on his appointment as Clinical Professor in Obstetrics and Gynaecology (UCD) in recognition of both his commitment to research and undergraduate education over many years.
New Developments
The new Perinatal Ultrasound Department opened in 2009; this new facility, funded by the Board of Guardians and Directors of the Hospital, provides a significantly improved environment for both patients and staff; the co- located UCD Department of Human Reproduction provides additional synergies in relation to teaching, training and research. The planned upgrade of equipment and the introduction of new work practices will also enhance the quality of service to patients and to referring obstetricians.
New Appointments
In 2009 both Dr Mairead Kennelly and Dr Aisling Martin joined the department as a fetal medicine consultants; Dr Kennelly was also appointed as Senior Lecturer in the UCD Department of Obstetrics and Gynaecology. Both Mairead and Aisling join an expanding multidisciplinary team of fetal medicine obstetricians, midwives and radiographers. Ms. Christina Mc Loughlin and Ms Feena Sheeran also commenced practice as midwifery sonographers; the department also employed its first radiographer sonographer, Ms Patricia McGinty.
Ultrasound Examinations
Every mother booking in the CWIUH is offered a dating scan which is performed at the first antenatal visit; this has resulted in fewer difficulties in late pregnancy in relation to dates and also in the earlier diagnosis of multiple pregnancies and earlier referral for specialist care. Preparations are also being advanced to offer a comprehensive anatomy survey performed at 20-22 weeks to all mothers attending the CWIUH in addition to a dating ultrasound scan; it is also planned to introduce after-hours ultrasound clinics in order to increase capacity.
The Viewpoint software package was installed during 2009 and by the end of year all ultrasound examinations were being reported using this system. The Viewpoint format is very structured and will ensure that reporting is standarised. It will also facilitate efficient data collection in the department in the years ahead.
The total number of ultrasound examinations performed during 2009 was 19,270; the breakdown is indicated in Table 1.
89 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 1 Ultrasound Examinations
First trimester (outside of EPAU) 103 Dating 8649 Booked anomaly scan 6133 Ultrasound ordered from OPD/External referral 1062 Follow-up 1771 In Patient ultrasound exams 876 Ultrasound scans in Naas 676 Total 19270
Structural Anomalies
There were 127 structural abnormalities identified on ultrasound examination in 2009. These are categorised according to the RCOG classification.
Cardiovascular abnormalities are also reported within the fetal echocardiography section of this report.
Table 2 Structural Anomalies Diagnosed
Central Nervous System (excluding CPCs) 28 Head & Neck (including Cystic Hygroma) 21 Cardiovascular 29 Renal (excludes pyelectasis <10mm) 27 Abdominal (excludes echogenic bowel ) 11 Skeletal 05 Thoraic 05 Others 01
First Trimester Screening
There were 109 first trimester screens performed which included nuchal translucency measurement and serum PAPP-A and free beta HCG. Second trimester serum screening is still offered but the demand has fallen considerably.
Invasive Diagnostic Procedures
• There were 124 invasive prenatal diagnostic procedures. • 89 amniocentesis and 35 CVS procedures performed.
90 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 3 Results of Invasive Procedures
Normal 89 Trisomy 21 10 Trisomy 18 07 Trisomy 13 02 Trisomy 16 01 45XO 06 Triploidy 01 Mosac Trisomy 21 01 Chromsome duplication 01 Chromosome deletion 03 Balanced translocation 01
Fetal ECHO Service
Further expansion of the Fetal Echocardiography service was undertaken in 2009 with the establishment of the Coombe/Rotunda Combined Fetal Echo Clinic in the Coombe Women and Infants University Hospital (CWIUH). This clinic provides a weekly consultant delivered Fetal Echo service and is led by Dr Orla Franklin, Consultant Cardiologist, Our Lady’s Hospital Crumlin, Prof Sean Daly, Consultant Obstetrician and Fetal Medicine Specialist and Dr Fionnuala Breathnach, Fellow in Fetal Medicine in the Rotunda Hospital and CWIUH. An email address was established to allow easy access to the service: [email protected].
144 targeted fetal echo examinations were undertaken in 110 pregnancies in 2009. This represented a 200% increase in activity when compared to 2008 figures; 29 cases (26%) of major structural congenital heart disease (defined as structural defects requiring surgery in the first 6 weeks of life) were detected. In 13 of these cases the fetus had a single ventricle lesion. All cases had their diagnoses confirmed post-natally. A further 5 cases of fetal arrhythmia were treated in-utero. It is anticipated that this service will continue to expand.
In addition to this service there is also a specialist fetal echocardiography service provided by Professor Sean Daly. This service offers fetal echocardiography for standard indications such as diabetic pregnancy, mothers exposed to drug therapy associated with congenital heart abnormality and patients with affected first degree relatives; 131 examinations were performed in this clinic and referral to the combined service was undertaken whenever an abnormality was detected.
Multidisciplinary Fetal Cardiology Course
A very successful multidisciplinary Fetal Cardiology Course was organised in November 2009 in conjunction with many units throughout Ireland. Dr Pran Pandya was the guest lecturer and he outlined the strategy being implemented in the UK for the antenatal diagnosis of congenital heart disease. A website is currently being established to provide additional information for parents on congenital heart disease.
Weekly Multidisciplinary Team (MDT) Meetings
The Director of Fetal Medicine and Perinatal Ultrasound co-chairs the weekly MDT meeting in association with the on-service Consultant Neonatologist; this important meeting facilitates optimal planning of interventions together with regular updated feedback on delivered high-risk infants. Fetal medicine specialists also attend the Friday hand-over MDT meeting in relation to planning week-end service.
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Strategic Associations
The Fetal Medicine Department continued it’s association with the National Maternity Hospital and the Rotunda Hospital. There were four intrauterine transfusions and one case of twin to twin transfusion syndrome which required laser ablation.
Research
The ESPRIT trial, a longtitudinal investigation of growth and outcomes in twin pregnancy concluded enrollment in 2009; this research was conducted under the auspices of the Perinatal Ireland national research consortium.
Dr Nadine Farah and Dr Jennifer Hogan also conducted MD research programmes within the department under the supervision of Professor Michael Turner and Professor Bernard Stuart; several abstracts from this research were presented at national and international meetings. Dr Farah’s research involves the investigation of body composition in mothers and fetuses using innovative bioelectrical impedance technology; Dr Hogan’s research is focused on the assessment of maternal cardiovascular haemodynamics using peripheral arterial pulse pressure wave analysis; both research programmes form part of a pioneering research strategy within the UCD Human Centre for Human Reproduction.
Combined Subspecialty Training Programme
Dr Fionnuala Breathnach completed her fellowship and was appointed a consultant in the Rotunda Hospital. She was the first person to complete the combined Rotunda/Coombe/Columbia Fellowship Programme. She is now part of the fetal ECHO team and ensures a seemless transition for patients coming from the Rotunda Hospital.
Haemolytic Disease Service
Dr Carmen Regan is the consultant in charge of this service. The management of patients with red cell antibodies which may cause haemolysis in pregnancy involves paternal genotyping and fetal DNA typing when indicated. At risk pregnancies are followed with antibody levels and where appropriate, middle cerebral artery dopplers for assessment of moderate or severe fetal anaemia. Intrauterine transfusions are conducted at the Rotunda Hospital or the National Maternity Hospital in consultation with maternal fetal medicine specialists; 79 patients with red cell antibodies were identified in 2009; 17 patients had > 1 antibody; 15 different antibody specificities detected (Table 4); the outcome of mothers with red cell antibodies is highlighted in Table 5.
92 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 4 Antibody Specificities
No Antibody Solo Multiple Total Specificity Specificity Antibodies Number 1 Anti-Cw 62 8 2 Anti-D 14 7 21 3 Anti-E 13 9 22 4 Anti-Jka 23 5 5 Anti-K 23 5 6 Anti-Lea 50 5 7 Anti-Lea + Anti-Leb 30 3 8 Anti-Leb 10 1 9 Anti-M 13 0 13 10 Anti-P1 10 1 11 Anti-S 21 3 12 Anti-C 05 5 13 Anti-G 02 2 14 Anti-c 05 5 15 Anti-e 01 1 Total 62 38 100
Table 5 Outcome of Patients with Red Cell Antibodies
Number of patients delivering with antibodies 79 Number of patients affected 11 Number of patients affected not transfused 11 Number of patients affected and transfused (neonatal) 0 Intrauterine transfusions for HDFN 0
The Future
Continuous expansion in the services offered by the Fetal Medicine and Perinatal Ultrasound Department is anticipated in the coming years. The planned upgrade of equipment and the introduction of new work practices will also enhance the quality of service to patients and to referring obstetricians ; the planned expansion of the NICU capacity in 2009 will also increase access for in-utero transfers requiring tertiary level care.
The historic and on-going strategic association of the Department with the UCD Centre for Human Reproduction, Perinatal Ireland, the academic Departments of Obstetrics and Gynaecology of the RCSI and TCD in addition to Professor John O’Leary’s Research Laboratory (TCD) will facilitate the further advancement of important inter-institutional research.
I would like to thank the multidisciplinary team of obstetricians, midwives, radiographers and support staff for their professionalism, hard work, support and dedication to patient care during 2009. I would also like to acknowledge the excellent clinical support and collegiality of the Paediatric Department of this Hospital and the subspecialist expertise provided by the medical and surgical teams in Our Lady’s Hospital Crumlin and The Children’s University Hospital, Temple Street.
93 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Liaison Perinatal Mental Health Clinic
Head of Department
Joanne Fenton
Staff Complement
Dr Joanne Fenton, Consultant Psychiatrist 0.4 WTE 1 Psychiatric Registrar (rotating) 0 .4 WTE
Key Performance Indicators
• Patients seen in Perinatal Clinic 722
• Patients seen for inpatient consultations 85
• Diagnosed with antenatal depression 24%
• Diagnosed with postpartum depression 26%
• Diagnosed with anxiety disorder 15%
• Severe & enduring mental illness 5%
• 1 patient with puerperal psychosis requiring admission.
Achievements in 2009
• Presentation and introduction of new Perinatal Mental Health referral form.
• An increased level of referrals – two fold (2008).
Challenges for 2010
• With increased clinical activity continuing to provide high quality care.
• Recruitment of liaison midwife in mental health.
94 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Report of the Department of Paediatrics and Newborn Medicine 2009
Table 1
Admissions: Coombe Women & Infants University Hospital Neonatal Centre Total No of Admissions to Neonatal Centre 1135* No of Infants > 1.5kg 1013 *No infants born <500g were admitted to the NICU in 2009
Table 2
Birth Weight and Mortality for Babies 401-1500g (N=111 VON) Birth Weight (g) N = 111 Death N = 13* 401-500 00 501-600 42 601-700 81 701-800 10 2 801-900 74 901-1000 16 0 1001-1100 80 1101-1200 12 1 1201-1300 91 1301-1400 18 2 1401-1500 19 0
*Includes 4 neonatal deaths with a congenital anomaly
Table 3
Survival to 28 Days of Infants 401-1500g (N = 111) Birth Weight N Survivors %Survival 401- 500g 000 501- 600g 4375 601- 700g 8788 701- 800g 10 8 80 801- 900g 7457 >900g 88 85 97
Table 4
Survival to 28 days of Infants <1500g Excluding Lethal Malformation (N=107) No of liveborn without malformation 107 (4 with major congenital abnormalities) No of survivors 101
95 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 5
Morbidity of Infants Weighing 501-1500g (N = 111) N (%) VOD Network (%) Inborn 105 95 48891 85 Male 65 59 29191 51 Caesarean Section 64 58 40053 70 Antenatal Steroids 105 95 42314 74 RDS 63 60 40621 74 Pneumothorax 22 2546 5 Surfactant (any time) 67 60 36535 64 Nasal CPAP 89 85 36599 67 Conventional Ventilation 64 61 35348 64 High Frequency Ventilation 99 12191 22 Chronic Lung Disease (at 36 weeks) 8 12 11383 32 Steroids for CLD 22 4574 8 Home Oxygen 57 5562 13 PDA 39 37 21129 38 Ibuprofen 21 20 6967 13 Indomethacin (any reason) 00 11444 21 PDA Ligation 22 4640 8 Coagulase neg Staphylococcal Sepsis 77 5812 11 NEC 11 10 3796 7 GI Perforation 44 1367 2 Any Grade IVH 22 22 13117 26 Severe IVH (Grade 3-4) 11 11 4612 9 Cystic PVL 33 1656 3 Retinopathy of Prematurity 16 17 13647 33 Severe ROP (Stage 3 or more) 00 3010 7 Early Bacterial Infection 11 1368 2 Late Bacterial Infection 10 10 5702 11 Fungal Infection 00 1046 2
Observed Mortality 13 12 8642 15 Standardised mortality rate 2009* 1.05 (0.65-1.45) Standardised mortality rate 2007-2009* 1.16 (0.87-1.45) Standardised mortality rate for severe IVH 2009* 1.28 (0.79-1.76) Standardised mortality rate for severe IVH 2007-2009* 1.33 (0.98-1.68) *95% confidence interval
Table 6
Timing of Surfactant for Inborn Infants <1500g (N = 67) N (%) VON Network (%) < 15 mins 59 88 15497 42 16 – 30 mins 34 5737 16 31 – 60 mins 34 5010 14 61 – 120 mins 1 1 3834 10 >120 mins 1 1 5999 16
96 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 7
Hypoxic Ischemic Encephalopathy in Term Infants (N = 45) Stage 1 Encephalopathy 32* Stage 2 Encephalopathy 8 Stage 3 Encephalopathy 5
*Includes 4 with abnormal CFAM but no clinical seizures Number of cooled babies = 5 (external = 2) Table 8
Main Indications for Admission to the Neonatal Centre Prematurity 310 Respiratory Symptomatology 285 Low Birth Weight 180 Hypoglycaemia 113 Jaundice 124 Suspected Sepsis 49 Perinatal asphyxia 64 Gastro-Intestinal Symptoms 42 Congenital Abnormalities 30 Neonatal Abstinence Syndrome 28 Cardiology 33 Infant of Diabetic Mother 4 Social 8 Dehydration 12 Seizures 6 Some infants are assigned more than one reason for admission.
Table 9
Causes of Respiratory Morbidity in Term Infants (> 37 weeks) Transient Tachypnoea of the Newborn 92 Respiratory Distress Syndrome 10 Air Leak Syndrome 17 Meconium Aspiration Syndrome 18 Pneumonia 8 Persistent Pulmonary Hypertension of the Newborn 0 Congenital Diaphragmatic Hernia 2 Apnoea 9 Choanal Atresia 1 Laryngomalacia 5 CCAM 1 Bronchiolitis 0 Upper Respiratory Infection 0 Tracheo-Oesophageal Fistula 0
Comment: The commonest respiratory morbidity predicating admission continues to be Transient Tachypnoea of the Newborn.
97 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 10
Congenital Heart Disease N = 154 Patent Ductus Arteriosus 72 Murmur 20 Ventricular Septal Defect 11 Atrial Septal Defect 5 Peripheral Pulmonary Branch Stenosis 9 Arrhythmia 5 Persistent Fetal Circulation 15 Atrioventricular Septal Defect 3 Transposition of the Great Arteries 1 Coarctation of Aorta 2 Hypoplastic Left Heart Syndrome 4 Pulmonary Atresia 0 Aortic Stenosis 0 Dextrocardia 1 Right Ventricular Hypertrophy 0 Biventricular Hypertrophy 1 Fallot’s Tetralogy 1 Truncus Arteriosus 0 Double Outlet Right Ventricle 1 Hypoplastic Right Ventricle 3 Tricuspid Atresia 0
Table 11
Gastro-Intestinal Anomalies N = 33 Inguinal Hernia 3 Congenital Diaphragmatic Hernia 3 Imperforate Anus 4 Cleft Lip and Palate 4 Cleft Palate 5 Umbilical Hernia 3 Exomphalos 0 Duodenal Atresia 2 Colonic Atresia 5 Oesophageal Atresia 0 Gastroschisis 2 Tracheo-Oesophageal Fistula 2 Volvulus/Malrotation 0 Meconium Ileus 0 Cleft Lip only 0
98 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 12
Genito-Urinary Anomalies N = 35 Undescended Testes 7 Hypospadias 7 Hydronephrosis 4 Hydrocoele 5 Ambiguous Genitalia 3 Polycystic Kidney 0 Posterior Urethral Valve 0 Duplex Ureter 1 Absent Kidney 0 Torsion of Testes (in utero) 0 Pyelectasis 8
Table 13
Central Nervous System Abnormalities N = 23 Erb’s Palsy 5 Microcephaly 4 Myelomeningocoele 4 Anencephaly 1 Hydrocephalus 3 Facial Palsy 6 Subdural Haemorrhage 0 Subarachnoid Haemorrhage 0
Table 14
Orthopaedic Anomalies N = 52 Developmental Dysplasia of Hip 27 Talipes 13 Fracture of Clavicle 2 Fracture of Humerus 2 Accessory Digit 2 Syndactyly 2 Radial Hypoplasia 0 Fused Ribs 0 Amniotic Band 0 Calcaneovalgus 3 Fracture of Skull 0 Thanatophoric Dysplasia 1
99 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 15
Ophthalmological Abnormalities N = 24 Retinopathy of Prematurity 23 (Laser therapy in 1) Microphthalmia 0 Retinal Haemorrhage 1
Table 16
Cutaneous N = 4 Capillary Haemangioma 4 Vascular Naevi 0 Cystic Hygroma 0 Port Wine Stain 0
Table 17
Metabolic / Endocrine / Haematological Abnormalities N = 356 Hypoglycaemia 160 Anaemia of Prematurity 70 Thrombocytopenia 32 Hyperglycaemia 13 Polycythaemia 31 Transient Metabolic Acidosis 13 Anaemia (not including Anaemia of Prematurity) 16 Feto-Maternal Transfusion 3 Haemolytic Disease of Newborn 0 Hypothyroidism 5 Rickets of Prematurity 2 Disseminated Intravascular Coagulopathy 8 Hyperinsulinism 2 Galactosaemia 1
Table 18
Dysmorphic Syndromes N = 15 Trisomy 21 (Down) 9 Dysmorphic Features (no final diagnosis) 0 Trisomy 13 (Patau) 0 Trisomy 18 (Edwards) 1 Fetal Alcohol Syndrome 1 Turner Syndrome 0 Klinefelter Syndrome 1 Beckwith Wiedeman Syndrome 0 VATER/VACTERL 2 Smith Lemli Opitz 1
100 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 19
Causes of Jaundice in Term Infants >37 weeks Non-Haemolytic 163 Haemolytic ABO 7 RH 11 Other 3
I would like to thank all the nursing, physiotherapy, medical, chaplaincy, dietetic, medical social work, laboratory, pharmacy, information technology, radiology, infection control and bioengineering personnel as well as the human resources staff and our obstetric/midwifery colleagues for their continued support and dedication in providing care for infants born at the Coombe Women and Infants University Hospital. I would also like to thank a number of our colleagues from Our Lady’s Hospital for Sick Children, Crumlin and the Children’s University Hospital, Temple Street, who continue to consult both pre and postnatally and visit the unit – often in the late hours – Consultant Cardiologists (Dr Orla Franklin, Dr Oslizlok, Dr Kevin Walsh, Dr Coleman, Dr Colin McMahon), Consultant Neurologists, (Professor McMenamin and Dr David Webb), Consultant Paediatric Surgeons, (Professor Corbally, Mr Feargal Quinn and Professor Puri), Consultant Neurosurgeons Mr David Alcutt and Mr T Sattar, Consultant Dentist Dr Paddy Fleming, Consultant Respirologists (Dr Gerry Canny, Dr Paul McNally and Dr Barry Linnane), Consultant Geneticists (Prof Andrew Green, Dr Marie Greally, Dr Sally-Ann Lynch and Dr William Reardon), Consultant Nephrologists (Dr Mary Waldron, Dr Atif Awan and Dr Michael Reardon), Consultant Dermatologists (Dr Rosemarie Watson and Prof Alan Irvine), Consultant Plastic Surgeons (Mr David Orr and Ms Patricia Eadie) and Metabolic Physicians (Dr A Monavari, Dr E Crushell and Prof E Treacy) who provide advice and support on our patients with suspected metabolic disorders, Prof Karina Butler and Dr Patrick Gavin (Consultants in Paediatric Infectious Diseases), Ms Paula Kelly and Mr Jacques Noel (Orthopaedic Surgeons) and Mr Donal Brosnahan and Ms Kathryn McCreery (Consultant Ophthalmologists) provide a comprehensive inpatient and outpatient service. Ms Laura Duggan, the Cleft Palate Co-Ordinator, has visited with all families whose babies were born with a cleft lip/palate during the year.
The Neonatal Resuscitation Programme has been led by Ms Margaret Moynihan and I, with large numbers of candidates completing the NRP programme. The hospital was also closely involved in the STABLE Neonatal Transport training programme.
Comparison with Previous Reports
The Paediatric Report 2009 continues to show good outcomes in infants born less than 1.5kg. Again, over 95% of mothers of inborn infants having completed antenatal steroids before delivery for this group. There was a decrease in the percentage of infants with coagulase negative staphylococcal sepsis (CONS) compared to 2008 (11.5%). This would be in keeping with international trends, which have noted a decrease in CONS infections, but with an expected increase in other organisms such as MSSA (methicillin sensitive staphylococcus aureus). In relation to patent ductus arteriosus (PDA), 39% of very low birth weight infants had PDA. There was a slight decrease in the numbers receiving PDA ligation to 2 (2%) compared with 2008 when 5 (4.6%) had PDA ligation. The facility to perform in-house echocardiography has greatly facilitated earlier diagnosis and medication (Ibuprofen) for symptomatic infants. Overall numbers of infants ventilated and treated with surfactant was 67 (60%), similar to 2008. The Neonatal Intensive Care Unit at the Coombe Women & Infants University Hospital continues to have a lower percentage of infants surviving with chronic lung disease at 36 weeks (8 infants, 12%) compared to a Vermont Oxford Network (VON) average of 32%. There were improvements in the numbers of infants presenting with late bacterial infection (10, 10%) compared to 2008
101 Coombe Women & Infants University Hospital Annual Clinical Report 2009
(17.3%). Our late bacterial infection rate compares favourably with the VON percentage of 11%. Severe ROP (stage 3 or more) was not documented in any infants in 2009, continuing previous trends.
In relation to hypoxic ischaemic encephalopathy (HIE), there were 32 infants who were classified as HIE grade 1 (no clinical seizures) but who had had normal CFAM. The Neonatal Intensive Care Unit began total body cooling therapy for infants with defined criteria including abnormal CFAM where this therapy would be commenced within 6 hours of birth. In keeping with other neonatal units within maternity hospitals in Dublin, we are receiving infants from other hospitals for assessment with regard to body cooling therapy. 2 of the infants treated with total body cooling in 2009 were transferred from other hospitals. Total body cooling offers potential benefits in infants of more mature gestation, who will obviously require follow-up. All infants who received body cooling are being entered on the international register of cooled infants.
In relation to main indications for admission, prematurity, respiratory disorders and low birth weight continue to be the commonest reason for admission. 28 infants were admitted with neonatal abstinence syndrome.
There was an increase in the number of infants treated for developmental dysplasia of the hip (27 infants were treated in 2009).
Neonatal echocardiography was developed on-site and we are grateful to our visiting cardiologists. This has been an invaluable resource, particularly for infants born less than 1.5kg. The Neonatal Centre continues to receive significant numbers of infants diagnosed with congenital abnormalities prenatally including congenital cardiac disease. The Coombe Women & Infants University Hospital has a close relationship with cardiology, cardiothoracic surgery and paediatric intensive care at Our Lady’s Children’s Hospital Crumlin in the care and transfer of these infants. Babies born with significant paediatric surgical problems receive care through the paediatric surgical teams based at the Children’s University Hospital Temple Street and Our Lady’s Children’s Hospital Crumlin. I would also like to acknowledge the active research programmes being led by Dr Jan Miletin in relation to the haemodynamics of prematurity and Dr. Margaret Sheridan-Pereira in relation to neonatal body composition*.
Ms Ann MacIntyre took up her official position as Neonatal Centre Manager in February 2009 and we wish her well in her new post. The first stage in refurbishment and expansion of our Neonatal Intensive Care Unit occurred in 2009 and we expect to complete phase 2, with an increased NICU / HDU capacity, in 2010. We are grateful to the Master, Mr John Ryan, Secretary & General Manager, the hospital administration and the Board of Guardians & Directors for their support in this.
I would like to thank my Paediatric Registrar colleague, Dr Johannes Letshwiti, Baby Clinic staff, Ms Maureen Higgins and Ms Ciara Carroll, for their invaluable help and assistance in preparing this Annual Report. In relation to development of guidelines, Ms Anne O’Sullivan ANNP and Mr Peter Duddy, Neonatal Pharmacist, with the help of the Paediatric Drugs & Therapeutics Committee, reviewed our in-house drug policies and protocols. Finally, I would like to thank all staff members at the Neonatal Centre for their hard work during 2009.
Dr Martin J White MD, MBA (HSM), FRCPI, FRCPCH, FAAP Director of Paediatrics & Newborn Medicine Senior Lecturer in Neonatology RCSI
102 Coombe Women & Infants University Hospital Annual Clinical Report 2009
*Selected Paediatric Publications & Presentations
Awadalla A., Baunok A., Sheehan, K., Miletin J., Sheridan-Pereira M: Late Preterm Infants at the CWIUH in the 21st Century. Irish Journal of Medical Science 2009; 24: 532-537
Moran M, Miletin J, Pichova K, Dempsey EM: Cerebral tissue oxygenation index and superior vena cava blood flow in the very low birth weight infant. Acta Paediatr. 2009; 98 (1): 43-46
Miletin J, Pichova K, Dempsey EM: Bedside detection of low systemic flow in the very low birth weight infant on day 1 of life. Eur J Pediatr. 2009; 168 (7): 809-13
O'Connell S, O;'Mullane E, Murphy J, Roche E, Sheridan M, Hoey H: Maternal smoking in pregnancy as a risk factor for Small for Gestation Age. (SGA) births British Medical Journal, 2009: 38
O'Regan GM, Irvine AD, Yao N, O'Marcaigh A, Sheridan-Pereira M, Phelan E, McDermott MB, Twomey A, Russell J, Watson R: Mediastinal and neck kaposiform hemangioendothelioma: report of three cases. Pediatric Dermatology May-June 2009; 26: 331-337
Paul K, Melichar J, Miletin J, Dittrichova J: Differential diagnosis of apneas in preterm infants. Eur J Pediatr. 2009; 168 (2): 195-201.
Villoslada J., Meenan, A.M., Sheridan-Pereira, M: Neonatal Bloodstream Infection with Gram-Negative Bacilli (GNB BSI): 20 Years at the Coombe Women & Infants University Hospital. Irish Journal of Medical Science 2009; 9: 532-537
Abstracts
Awadalla A., Baunok A., Sheehan, K., Miletin J., Sheridan-Pereira M: Late Preterm Infants at the CWIUH in the 21st Century. Presented at the IPS Spring 2009
Hopewell J, Miletin J: Total Parenteral Nutrition in Very Low Birth Weight Infants in the United Kingdom and Ireland - Are We Aggressive Enough? Pediatric Academic Societies Annual Meeting 2009, Baltimore, USA. 5503.53 (poster presentation)
Miletin J, Pichova K, Doyle S Dempsey EM: Relationship between Cortisol Values, Blood Pressure and Superior Vena Cava Flow in the VLBW Infant. Pediatric Academic Societies Annual Meeting 2009, Baltimore, USA. 2740.3 (oral presentation)
Villoslada J., Meenan, A.M., Sheridan-Pereira, M: Neonatal Blood Stream Infection with Gram-Negative Bacilli (GNB BSI): 20 Years at the Coombe Women & Infants University Hospital. Presented at the IPS Spring 20009 and abstract at the European Pediatric Research Meeting in Hamburg, October 2009
Villoslada J, Meenan AM, Miletin J, Sheridan-Pereira M: Neonatal Blood Stream Infection with Gram-negative Bacteria in the Last 20 Years: Single Centre Retrospective Study. 50th Annual Meeting of the European Society for Paediatric Research 2009, Hamburg, Germany. Acta Paediatr. 2009; 98 (Suppl.460): (poster presentation)
103 Coombe Women & Infants University Hospital Annual Clinical Report 2009
General Gynaecology Report*
Introduction
2009 was once again an exceptionally busy year. The total number of patients treated was greater than 2008, with almost an equivalent number of operations being performed. The upgrade of CSSD, the decanting of neonatal cots due to the upgrade of NICU and the H1N1 mass vaccination programme (supported by the nurses of the Gynaecology Department) all contributed to an increase in the number of surgical postponements in 2009. In order to maintain activity, specific care pathways for patient management were introduced in 2009 which improved access and reduced length of stay.
I would like to acknowledge the continued support and leadership provided by Dr Michael Carey, Director of Peri-operative Medicine, Ms Alison Rothwell, CNMIII (Theatre), Ms Bridget Kirby, CNMII (St. Gerard’s Ward), Ms Katherine Lynch CNMII (Day Ward) and Professor John O’Leary, Director of Pathology.
The Coombe Women & Infant University Hospital (CWIUH) continues to remain the busiest surgical gynaecology service in this country; the gynaecology service provided by Coombe consultants in the CWIUH, St. James’s Hospital and AMNCH/Tallaght Hospital is the largest regional/supra-regional surgical gynaecology service. I would like to thank all members of staff once again for their continued support, dedication and clinical professionalism. Despite the continued pressure of limited resources, increased expectations and case complexity, the enthusiasm and dedication of all staff involved in the delivery of care to patients attending the Gynaecology Department is very much appreciated.
Dr Tom D’Arcy Director of Gynaecology
Table 1: Inpatient Surgery
2003 2004 2005 2006 2007 2008 2009 Patients 5054 5558 5559 5645 5299 5359 6150 Operations 6006 6669 6689 6923 7308 8359 8354
Table 2: Operation Categories
2003 2004 2005 2006 2007 2008 2009 Obstetrical 2236 2639 2749 2716 2820 2918 3041 Cervical 383 325 387 395 410 687 1261 Uterine 1790 1840 1816 1922 2304 3015 2416 Tubal & Ovarian 855 1117 1104 1140 1083 999 950 Vulval & Vaginal 189 198 241 245 322 500 445 Other (including urogynae) 553 550 392 505 369 240 241 Total 6006 6669 6689 6923 7308 8359 8354
* New system of regarding operations introduced in 2008. – = operation(s) not recorded in this category ( ) = operation(s) not counted in this category (as counted in other category) 0 = operation not performed
104 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 3: Obstetrical Operations
2003 2004 2005 2006 2007 2008 2009 Lower Segment Caesarean Section 1411 1691 1756 1675 1778 1928 2070 Caesarean Section & Tubal Ligation 81 72 81 64 61 61 95 Classical Caesarean Section 3252276 Hysterectomy in Pregnancy 0114137 ERPC 520 619 644 678 627 573 533 ERPC Postpartum -----12 26 Gestational Trophoblastic Disease 1011010 12 Laparotomy for Ectopic 33200810 Laparoscopy Sx for Ectopic 52 70 67 79 75 54 62 Cervical Suture/cerclage/shirodkar 24 16 28 35 29 21 23 Perineal Repair Postpartum in theatre 58 54 63 105 108 85 66 Manual Removal of Placenta 79 89 90 95 91 84 79 Operative Vaginal Delivery in theatre -----55 52 Other 50 83 74 43 82 17 0 Total 2282 2680 2812 2781 2840 2918 3041
Table 4: Cervical Operations
2003 2004 2005 2006 2007 2008 2009 LLETZ/NETZ/SWETZ/LEEP (in theatre) 95 138 139 153 152 95 159 LLETZ/NETZ/SWETZ/LEEP (in clinic) -----314 841 Cone Biopsy 9 10 20 19 10 10 13 Punch & Wedge Biopsy of Cervix 33 15 25 22 19 11 11 Cervical Polypectomy 53 62 71 71 65 68 61 Suture of Cervix 9822500 Diathermy of Cervix 15 26 32 21 2 15 6 Other 169 64 98 107 157 174 170 Total 383 325 387 395 410 687 1261
* previously only recorded in Colposcopy Clinic Statistics
105 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 5: Uterine Operations
2003 2004 2005 2006 2007 2008 2009 Hysteroscopy and D&C 1092 1153 1101 1195 1460 1905 1228 TCRE 65 59 60 40 37 64 53 Total Abdominal Hysterectomy (TAH) 179 166 142 142 142 117 97 Subtotal Abdominal Hysterectomy (SAH) 9744731 SAH & Oophorectomy 7635000 Radical Hysterectomy 5125523 Vaginal Hysterectomy (VH) 58 58 59 48 99 150 125 Laparoscopic Hysterectomy 3827 20 30 40 55 Gilliam’s Suspension 1300000 Myomectomy (Hysteroscopy) -----18 17 Myomectomy (Laparoscopy) -----25 13 Myomectomy (Laparatomy) -----13 22 Myomectomy (All) 63 51 57 64 46 (56) (52) Other Operative Hysteroscopy 37 27 33 23 16 49 32 Mirena Coils inserted 201 228 238 284 330 453 337 Other 000094 176 417 Total 1790 1840 1816 1922 2304 3015 2416
Table 6: Tubal and Ovarian Operations
2003 2004 2005 2006 2007 2008 2009 Laparoscopic Sterilisation 161 139 138 105 39 92 67 Tubal Ligation at Laparotomy 3001541 Diagnostic Laparoscopy 288 451 463 418 447 385 323 Laparoscopy & Dye 116 145 133 187 130 120 90 Tubal Reconstructive Surgery (Laparotomy) -----62 Tubal Reconstructive Surgery (Laparoscopy) -----54 Tubal Reconstructive Surgery (All) 16 16 9 16 5 (11) (6) UO/USO (Laparotomy) -----22 45 UO/USO (Laparoscopy) -----23 24 UO/USO (All) 39 54 18 14 47 (45) (69) BSO (All) 12 17 5668 120 96 Removal of Ovarian Cyst (Laparotomy) -----15 14 Removal of Ovarian Cyst (Laparoscopy)- - - - - 72 87 Removal of Ovarian Cyst (All) 62 58 91 79 93 (87) (101) Other Operative Laparoscopy 74 134 106 119 181 134 191 Other 37 42 77 130 21 16 Total 808 1056 1104 1140 1036 999 950
106 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 7: Vulval and Vaginal Operations
2003 2004 2005 2006 2007 2008 2009 Simple Vulvectomy 2064401 Vaginal Repair for Dyspareunia/ Vaginoplasty 2014 7396 Anterior & Posterior Repair* 19 23 16 26 12 -- Posterior Repair (only)* 22 2046 57 - Posterior Repair (all) -----111 110 Anterior Repair (only)* 13 0012 69 - Anterior Repair (all)) -----136 103 Vault Prolapse/Enterocele Repair -----45 45 Hymenectomy/Hymenotomy 2256142 Excision of Vulval/Vaginal Cysts 22 24 26 44 44 14 11 Bartholin’s Cyst/Abcess 24 28 31 37 29 30 22 Diathermy to Warts 6371666 Vulval Biopsy 16 24 25 24 10 24 27 Other 61 89 109 37 87 121 112 Total 189 198 241 245 322 500 445
* repair operations are coded individually.
Table 8: Urogynaecology**
2003 2004 2005 2006 2007 2008 2009 Colposuspension 0235430 Pubovaginal Sling 0002222 TVT 64 59 59 51 62 74 88 TOT/TVTO 0000028 Bulking Injection 2002211 Cystoscopy 188 143 122 137 95 99 88 Other 0000010 Total 255 204 184 197 165 182 187
** excludes operations for prolapse (included in Tables 6 and 7)
Table 9: Other Operations
2003 2004 2005 2006 2007 2008 2009 Abdominal Wound Dehiscence 1004111 Appendicectomy 10 13 16 11 23 20 21 Laparotomy for Other Reason 83 71 57 68 28 54 Other 243 262 135 227 156 32 28 Total 337 346 208 310 208 58 54
107 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 10: Total Gynaecological Outpatient Attendances
2003 2004 2005 2006 2007 2008 2009 Adolescent 280 212 296 266 174 269 262 Colposcopy 3070 3213 3305 3662 3784 3588 4740 Endocrine/Infertility 584 557 630 597 410 377 473 General 4230 4022 4498 4718 4246 4035 3917 Urogynaecology 1040 1055 846 857 817 1029 919 Anaesthetic 91 69 52 89 116 129 194 Oncology 551 298 268 345 341 658 589 Cervical Screening 391 313 390 429 365 355 63 Total 10184 10029 10215 10505 9401 10440 11157
Table 11. Gynaecology Complications & Transfer to HDU
Complication N Blood transfusion (all) 23 Blood transfusion > 5 units 4 Bladder Injury 3 Bowel Injury 2 Uterine perforation 7 Return to theatre 6 Transfer to HDU 12
108 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Coombe Continence Promotion Unit
Head of Unit
Dr Chris Fitzpatrick
Staff Complement
Ms Frances McCarthy Staff Midwife Dr Hilary Ikele SpR Dr Mary Higgins SpR
Description of Unit
• Urogynaecology Clinic • Specialist Nursing Services • Physiotherapy
The Coombe Continence Promotion Unit was established in 1998 to provide a comprehensive multidisciplinary service to women with continence–related problems. The unit has three specialist subdivisions: Urogynaecology (established in 1993), Specialist Nursing Services and Physiotherapy.
Key Performance Indicators
• 284 urodynamic evaluations and 635 consultations. • Diagnostic rate of 93% in patients undergoing urodynamic evaluation
Diagnosis % GSI 40 GSI + DI 24 GSI + HRVD 2 DI 21 DI + HRVD 3 HRVD 3 No diagnosis 7 Total 100
GSI = genuine stress incontinence DI = detrusor instability HRVD = high residual voiding dysfunction
109 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• Number of procedures performed in 2009 (Excluding operations for prolapse)
Procedures N TVT/TVTO/TOT 96 Pubovaginal sling 2 Colposuspension 0 Bulking injection 1 Cystoscopy 88 Total 187
Achievements in 2009
• 98% of major procedures performed under regional anaesthesia.
• Continuation of clinical service with reduced sessional commitments.
Challenges
• Appointment of an additional subspecialist trained Urogynaecologist.
• Appointment of an additional physiotherapist with special interest in continence promotion.
Ms Frances McCarthy Dr Mary Higgins Dr Chris Fitzpatrick
110 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Gynaecological Oncology Division Dept of Gynaecology Coombe Women & Infants University Hospital & St. James’s Hospital
Head of Department
Dr Noreen Cleeson, Director of Gynaecology CWIUH/SJH
Consultant Gynaecological Oncologists
Dr Noreen Gleeson Dr Tom D’Arcy Dr Katharine Astbury
Staff Complement
Professor John O’Leary Director of Pathology CWIUH Dr Dearbhaile O’Donnell Consultant Medical Oncologist Dr Charles Gilham Consultant Radiation Oncologist Dr Tom O’Gorman Subspecialist Gynaecological Oncology Registrar Ms Debra McKnight Gynaecological Oncology Nurse Co-ordinator Ms Aidín Roberts Gynaecological Oncology Nurse Co-ordinator Ms Cristin Leavy Data Manager Ms Fiona McCourtney Administrator/Secretary
Description of the Unit
The Division of Gynaecological Oncology operates as a single unit between SJH and CWIUH. The St. James’s outpatient clinics are run in parallel with medical and radiation oncology. Five outpatient clinics are provided per week. Primary treatment, if surgical, is offered at the site considered to be most appropriate for the individual patient’s needs. Chemotherapy is administered at St. James’s Hospital or at the regional referring hospitals. Radiation is administered at St. Luke’s Hospital.
All new cases are discussed at a weekly multidisciplinary meeting.
Key Performance Indicators
272 new gynaecological cancers were diagnosed in 2009; 61 patients were diagnosed and/or treated at CWIUH.
Cervix Uteri (N = 26)
• Age – 27-84 years; median 39 • Histology – Squamous (16), Adenocarcinoma (10) • Stages – IA1(4), IA2 (3), IB (2), IB1 (9), IB2 (3), IIB (5)
111 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Corpus Uteri (N = 23)
• Age – 40-76years; median 57 • Histology – Endometrial Adenocarcinoma (20), Papillary Serous (3) • Stages – I (14), II (3), III (3), IV (2), Unstaged (1)
Cancer of the Ovary/Peritoneum (N = 7)
• Age – 15-71 years; median age 57 • Histology – Papillary Serous (3), Clear Cell (2), Adenocarcinoma (2) • Stages – IIIA (2), IIIC (4), IV (1)
Carcinoma of Vulva (N = 5)
• Age – 41-72 years; median 52 • Histology – Squamous (4), Malignant Melanoma (1) • Stages – I (4), II (1)
Bladder (N = 1)
• Age – 78 • Histology – Papillary
Molar Pregnancy (N = 12)
• Age – 17-39 years; median 30 • Histology – Partial (9), Complete (3) No persistent gestational trophoblastic disease.
Achievements
• Provision of subspecialist consultant care to women with gynaecological cancers in a multidisciplinary setting. • Weekly multidisciplinary meetings. • Progression of gynaecological oncology subspecialty training programme (RCOG approved). • Expansion of database. • Participation in EORTC and ICORG clinical trials. • Addition of one gynaecological oncology nurse co-ordinator thanks to the support of the Irish Cancer Society. • Addition of part-time administrator/secretary.
Challenges
• Appointment of additional gynaecological oncologists, clinical nurse specialist and support staff to support the continued centralisation of the gynaecological service in the greater Dublin area.
112 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Colposcopy Service
Staff Complement
Consultant Colposcopists Professor Walter Prendiville Professor Michael Turner Dr Tom D’Arcy Dr Gunther Von Bunau Dr Cliona Murphy Dr Mary Anglim Nurse Colposcopist Ms Sinead Cleary Clinical Nurse Manager 2 Ms Olivia McCarthy Nurse Colposcopy Trainee Ms Aoife Kelly Registered General Nurses Ms Rani Hilarose Ms Feba Paul Health Care Assistant Ms Amanda Kennedy Auxiliary Ms Ann Marie Smith Failsafe Officer/Office Manager Ms Bernie Cummins Secretaries Ms Frances Cunningham Ms Helen Browne Ms Helen Conlon Assistant Masters As per 6 month rotation RCSI Lecturers
In 2009 the Colposcopy service at the CWIUH increased the number of clinics from 3 to 6 per week. The service is consultant led and provided by BSCCP accredited colposcopists as consultants, registrars and one nurse practitioner, Sinead Cleary who is now fully integrated in the direct management of patients. The clinics are also supported by specialist registrars and research fellows. As well as trained (BSCCP) colposcopists, several trainees attended the clinics as part of their BSCCP training programme.
In 2009 the hospital appointed a second colposcopy trainee Ms Aoife Kelly and a Clinic Nurse Manager, Ms Olivia McCarthy.
Clinic attendances
New patient attendances in 2009 rose dramatically. There were 1764 first visits during 2009 compared to 847 in 2008. This, of course, reflects the roll-out of a National Cervical Screening programme in 2008. This long roll- out is likely to have precipitated a particularly high number of referrals during the first year or two but it is expected that this referral rate will settle over time. Also the fact that screening smears in Ireland are being referred to the US for processing and reading adds a new dimension to smear reporting.
In 2009 there were 2837 follow-up visits, which was a slight increase on 2008 (2741 patients). This brings the total number of patient visits to 4601 patients for 2009, which reflects a 38% increase.
These figures are summarized in Table 1 and illustrated in figure 1.
750 patients did not attend (DNA) their appointments and 1491 patients deferred or changed their appointments. This DNA rate has improved in 2009, there were 1046 in 2007 (27.7%), reducing to 865 in 2008 (24%) with a further reduction to 750 in 2009 (16.3 %) so progress has been made.
113 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Table 1 Colposcopy attendance figures 1999-2009
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 First Visits 568 749 712 910 936 895 864 795 935 847 1764 Follow-up Visits 1824 2044 1684 2158 2158 1692 1959 2034 2841 2741 2837 Total 2392 2793 2396 3068 3094 2587 2823 2829 3776 3588 4601
Figure 1 Attendance at the colposcopy clinic at the CWIUH 1999-2009
5000
4000
3000 First Visits 2000 Return Visits
1000 Total
0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Table 2 Histological breakdown of the transformation zones which were removed by LLETZ in the clinics during 1999-2009
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
No CIN 29 27 32 70 42 27 34829 CIN1 68 159 139 139 77 91 89 68 72 95 187 CIN2 93 173 159 153 125 177 130 112 99 88 226 CIN3 224 187 192 215 240 231 161 202 169 204 406 CGIN 61495788511 7 Micro Invasion 34242619976 Invasive Neoplasia 43434153229 Total 427 554 532 593 495 539 397 406 357 409 841
Figure 2: Histological breakdown of excised transformation zones 1999-2009
1000
800
600 CIN I
400 CIN II & III TOTAL ` 200
0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
114 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Treatment and Histology
The great majority of patients in whom treatment was advised because of cytological and/or colposcopic evidence of disease were treated in the colposcopy clinic by LLETZ (Large Loop Excision of the Transformation Zone).
A small number of women (159) in 2009 had this or a similar electrosurgical excision procedure carried out in theatre. The procedures reported from theatre included:
• 115 LLETZ • 38 NETZ • 6 SWETZ
Table 3 Selected NHSCSP/BSCCP Clinical Standards
BSCCP CLINICAL STANDARDS Target CWIUH Proportion of LLETZ performed as outpatients > 80% 84.1% Proportion of Women with CIN+ on Histology > 85% 98.9% Proportion of LLETZ as inpatients < 20% 15.9%
Quality Assurance and CPCs
The service continues to hold regular joint Quality Assurance and Management Initiative meetings with the Colposcopy Service providers at AMNCH/Tallaght Hospital.
The Colposcopy Department holds a monthly CPC meeting which is supported by all the cytopathology staff and Dr Collette Adida, Consultant pathologist and our own clinicians. Olivia McCarthy CNM 2 and Noel Bolger, Chief Medical scientist prepares the cases.
The fortnightly videoconference link set up in 2008 between Coimbatore and Ambilikai Hospitals in Tamil Nadu, Southern India and the CWIUH continue.
Infrastructure
As predicted in last years report, an increase in referrals has been generated from the roll-out of the National Cervical Screening Programme. The hospital recognizes that the accommodation for the expanding colposcopy service is inadequate. A proposal to build a purpose built facility to accommodate the colposcopy service has been approved by the board of the hospital.
Walter Prendiville Olivia McCarthy Director of Colposcopy Services Clinic Nurse Manager
115 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Department of Peri-operative Medicine
Head of Department
Michael Carey
Staff Complement
Liam Briggs Consultant 37 hours Michael Carey Consultant 23.5 hours Steven Froese Consultant 23.5 hours Niall Hughes Consultant 10 hours Fiona O’Higgins Consultant 30 hours (Dr Fiona Higgins retired in April 2009 after more than 30 years service in the CWIUH) Rebecca Fanning Senior Research Fellow 10 hours
Jan - June 2009
A. Buckley SHO, N. Murphy SHO, Muhammed Shahid Registrar, A.Fernandes Registrar, S Khan Registrar, A. Broderick SpR, A. Vijayan SpR, R. Ojo Research Fellow, R. Jesudoss Research Fellow, R. Bhinder Acute Pain Fellow.
July – Dec 2009
A. Khan SHO, R. Ali SHO, S. Cheng SHO, S. Solanki Registrar, A. Fernandes Registrar, R. Naughton SpR, N. Zaidi SpR, U. Farooq Research Fellow, R. Ojo Research Fellow, R. Bhinder Acute Pain Fellow.
Key Performance Indicators
THEATRE: Total number of Anaesthetics 5230 General -2591 (49.5%) Regional - 2502 (47.8%) Local - 137 (2.6%) Elective - 3668 (70.1%) Emergency - 1562 (29.9%)
116 Coombe Women & Infants University Hospital Annual Clinical Report 2009
CAESAREAN SECTIONS
Number of caesarean sections – 2171 (25% of all mothers delivered) Elective – 942 (43.4%) Emergency – 1229 (56.6%)
Mode of anaesthesia for caesarean section:
ELECTIVE EMERGENCY General 19 * (2.0%) 56† (4.6%) Spinal 923 (98.0%) 574 (46.7%) Epidural 0 587 (47.7%) CSE 0 12 (1%) Total 942 1229
* includes 5 converted from regional †includes 5 converted from regional
ANALGESIA IN LABOUR
Total numbers of mothers delivered 8652
Mode of analgesia
None 860 (9.9%)
Entonox 5336 (61.6%)
Pethidine 473 (5.5%)
TENS 387 (4.4%)
Epidural 3925 (45.3%)
Number of epidurals in nulliparae 2354 (65.5%) Number of epidurals in parous 1571 (31%)
Achievements in 2009
• Dr Nikolay Nikolov commenced as consultant in May 2009. • Dr Terry Tan appointed as locum consultant in August 2009. • Ms Sarah Ann Walsh commenced as clinical nurse manager in anaesthetics. • Drs Raj Bhinder and Noelle Murphy both won 1st prize for their presentation and poster respectively at the South of Ireland Association Scientific meeting. • The Department acquired a Thromboelastograph which has been of great benefit in the management of major haemorrhage.
117 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Challenges for 2010
• Challenges for 2010. • Development of a daily nurse led Pre-op Assessment Clinic and the establishment of a weekly Anaesthetic Clinic. • Increased research output.
Publications and Presentations
Tan T, Bhinder R, Carey M, Briggs L. Day surgery patients anaesthetised with propofol have less postoperative pain than those anaesthetised with sevoflurane. Delaney Medal Presentation – College of Anaesthetists 2009.
Tan T, Bhinder R, Fanning R, Carey M. Oxycodone versus morphine for postoperative pain in day case patients. Annual Congress - College of Anaesthetists 2009.
Jesudoss R, Bhinder R, Tan T, Carey M. Audit of pain after caesarean section in the Coombe Women and Infants University Hospital Annual Congress - College of Anaesthetists 2009.
Bhinder R, Tan T, Fanning R, Carey M. Evaluation of point of care thromboelastography in a maternity setting. South of Ireland Association of Anaesthetists Scientific Meeting 2009.
Murphy N, Fanning R. A survey of midwives knowledge of and attitudes to obstetric anaesthesia. South of Ireland Association of Anaesthetists Scientific Meeting 2009.
Tan T, Bhinder R, Carey M, Briggs L. Day-Surgery Patients Anesthetized with Propofol Have Less Postoperative Pain than Those Anesthetized with Sevoflurane. Anesth Analg. 2009 Nov 12. [Epub ahead of print]PMID: 19910624.
Murphy DJ, Carey M, Montgomery AA, Sheehan SR. Study protocol. ECSSIT - Elective Caesarean Section Syntocinon Infusion Trial. A multi-centre randomised controlled trial of oxytocin (Syntocinon) 5 IU bolus and placebo infusion versus oxytocin 5 IU bolus and 40 IU infusion for the control of blood loss at elective caesarean section. BMC Pregnancy Childbirth 2009 (9): 36.
118 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Midwifery & Nursing Corporate Report
Head of Department
Patricia Hughes, Director of Midwifery & Nursing
Staff Complement
Total Complement for Midwives & Nurses as of 31st December 2009 355 WTE Total Complement for Auxiliary Staff as of 31st December 2008 37 WTE
Table 1. Breakdown of Midwifery & Nursing Complement as of 31st December 2009
Title of Post Complement In Post Variance (WTE) (WTE) (WTE) Director of Midwifery & Nursing 110 Assistant Director of Midwifery & Nursing 6.5 6.56 0.6 Advanced Nurse/Midwife Practitioner 110 Midwifery Practice Development Co-ordinator 110 Postgraduate Neonatal Programme Co-ordinator 110 Clinical Midwife/Nurse Manager 3 6 6.93 0.93 Clinical Midwife Manager 2 40 35.74 4.26 Clinical Midwife/Nurse Specialists 7 8.72 1.72 Clinical Skills Facilitators 3.5 3.82 0.32 Clinical Placement Coordinators 321 Post Registration Programme Facilitator 110 Allocation Liaison Officer 0.5 0.5 0 Clinical Midwife Manager 1 28 26.67 1.33 Staff Midwives & Nurses 230.5 220.06 9.9 Midwifery Students 25 19 6 HVO 110
2009 was the busiest year on record for the Coombe Women & Infants University Hospital and was the second year of a current recession in the Irish economy. The HSE announced a moratorium on recruitment in the Spring of 2009. There was a one day strike across the entire Public Sector on 24th November 2009. It was the year of the worldwide alert on Influenza H1N1 2009 Pandemic whereby the entire Health Service both nationally and internationally prepared for the worst. CWIUH set up special vaccination clinics and staff and patients were provided with a drop-in vaccination service 5 days a week for a period of two months. 2009 also saw the roll- out of the National Cervical Screening Programme. This concurred with extensive media coverage of Jade Goody, a UK TV celebrity who was terminally ill from Cervical Cancer. Uptake of the service in Ireland was beyond expectation as a result of what would later become known as the Jade Goody effect. 2009 was also the year of publication of the KPMG Review of Maternity Services in the Greater Dublin Area and the MidU study in HSE DNE. Despite the difficulties that can arise when such major events occur, our staff continued to deliver high quality patient and demonstrated commitment to continually improving service provision whilst taking pride in their ability to do so. Three of our longstanding members of staff retired in 2009, Mary O’ Donoghue, ADoN&M, Mary Burns, CMM2 and Catriona McDonald, CMM1. We thank them for their commitment to the service and wish them the very best in their retirement.
119 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Key Performance Indicators
• To lead, develop and manage a midwifery & nursing workforce that is suitably qualified to undertake the work involved in delivering a safe, effective, evidence based, women/family centred service which delivers on our Mission Statement, Excellence in the Care of Women & Babies. • Recruitment and retention of staff to ensure safe staffing levels by utilising close collaboration with the HEIs and FETAC to ensure high quality training for midwives, nurses and healthcare assistants. • Development and promotion of a research culture and a partnership approach to service delivery including all stakeholders especially women and their families who choose to use the services provided at the CWIUH.
Achievements in 2009
• Following months of preparation at national level, a H1N1 vaccination clinic was set up and lead by J. Fleming, CSF in conjunction with a group of nurses predominantly from the Gynaecology services to provide a 7 day Mass Vaccination Clinic (MVC) initially but then reduced to a 5 day ‘drop-in’ MVC for patients and staff. Over 1700 people were vaccinated including 650 staff members. A separate postnatal rubella vaccination service also commenced in November for women prior to discharge home. • Commencement of capital development works in a number of areas within the hospital e.g. Kitchen, Ultrasound, Neonatal Centre and CSSD required increased flexibility from staff in relation to work locations and schedules. The results were worth the inconvenience as the hospital was better placed at the year end to provide enhanced services in each of those areas. • Publication of the much awaited KPMG Review of Maternity Services in the Greater Dublin Area (2009). This report advocated co-location with adult general hospitals and the provision of a greater range of choices in the models of maternity care provided, going so far as to advocate midwifery led units with capacity for 2000 births pa. within the new maternity hospitals. Discussions and working initiatives began in earnest with AMNCH and significantly a weekly midwives clinic (for new bookings as well as follow ups) was established in AMNCH in the Summer of 2009. • CWIUH continued to participate in the Multicentred randomised controlled trial, ADCAR, which is being carried out to assess the value of the Admission CTG on low risk women at term. • The Midwifery & Nursing department continued to implement a hospital wide system of internal rotation lasting up to two years for all newly qualified and newly appointed staff midwives/nurses. The rotation was already proving beneficial in terms of overall service provision, greater job satisfaction leading to reduction in turnover of staff and enhanced interdepartmental communication. It was also adopted by more senior members of staff up to and including a number of CMM2’s. • The 2nd Essence of Midwifery Care Conference was held in May 2009. It was attended by over 80 delegates and it was very positively evaluated. Professor Debra Bick delivered the 2009 Maureen McCabe Lecture entitled; ‘The Use of Evidence in the Organisation and Development of Midwifery Practice?’ • Joan Malone was seconded to the HSE from CWIUH to work on the finalisation of the National Maternity Chart. On completion of that, she was later seconded again to the HSE to lead up on the development of a Code of Practice on Post Mortem at National level. • Work began on the development of a role for a bereavement Midwife and a Perinatal Mental Health Midwife in order to seek to provide a high quality service to woman and their families. • Work continued at the MNCMS Board for the procurement of the national IT project, the Maternal and Newborn Clinical Management System (MNCMS). I was the representative for Midwifery on the Board. • We had a site visit from the National Council for Nursing & Midwifery (NCNM) for accreditation of the site and of a post for an Advanced Midwife Practitioner. We were later informed that the visit was successful but we would have to await further guidance from the NCNM before we proceeded to make any appointments. This decision applied nationally to all applications in respect of Advanced Practitioner Posts. At the time of writing, a decision is awaited following the dissolution of the NCNM and the expansion of An Bord Altranais to oversee this function with the advent of the New Nurses & Midwives Bill expected in 2010.
120 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• A second midwife was recruited to train up as a CMS Colposcopy and Aoife Kelly commenced in late 2009.
Challenges in 2010
The biggest challenge to the organisation in 2009 will be the impact of the declining economic status of the country. It is critically important to use resources wisely. We will have to continue to examine every opportunity to reduce our costs whilst at the same time increase our safety and quality levels. This will also provide us with an opportunity to examine our current ways of working and if we are open to such challenges, we may see that we can affect very positive changes which will be for the greater good.
121 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Midwifery & Nursing Practice Development Department
Head of Department
Paula Barry, Acting Midwifery & Nursing Practice Development Co-ordinator (Author of Report)
Staff Complement
1 WTE Midwifery & Nursing Practice Development Co-ordinator 2 WTE Clinical Placement Co-ordinators 3.5 WTE Clinical Skills Facilitators 1 WTE Post-Registration Programme Co-ordinator 0.5 WTE Allocations Liaison Officer 0.5 Secretarial Support
Key Performance Indicators
• The development and maintenance of the clinical learning environment for Bachelor of Science (BScM) and Higher Diploma (HDip) in Midwifery Students and Bachelor of Science (BScN) in Nursing Students undertaking clinical placements at the CWIUH. • Practice Development issues in midwifery and nursing. • Quality assurance in midwifery and nursing practice. • Promote and support research and evidence based practice. • Promote pregnancy and childbirth as a normal healthy life event where possible and protect the autonomous role of the midwife in providing care for both ‘high’ and ‘low’ risk women. • Link with the Centre of Midwifery and Nurse Education (CME) in the provision of continuing educational needs of existing Midwifery and Nursing staff. • Promotion and facilitation of Midwives Clinics.
Achievement in 2009
1) Students
• Continued facilitation of the 4 year BSc in Midwifery as well as the 18 month Higher Diploma in Midwifery Programmes. • Maintaining close communications and working relationships with Trinity College Dublin regarding midwifery and nurse education programmes. • Continued facilitation and support of BSc Student Nurses on maternity placement from St James’s and Tallaght (AMNCH) Hospitals.
2) Staff
• Preceptorship Courses facilitated in conjunction with the CME. • Further development of the Competency Assessment Tool for Midwives and Clinical Midwife Managers. • Continued to support and guide clinical staff in order to provide an optimal learning environment for midwifery and nursing students. • Continued to encourage staff embrace evidence based care to continuously improve standards which are reflected in our Mission Statement ‘Excellence in the Care of Women and Babies’. • Departmental staff were involved in the recruitment process of Midwifery Students as well as Midwifery and Nursing staff throughout the hospital.
122 Coombe Women & Infants University Hospital Annual Clinical Report 2009
3) Practice Development
• Facilitation of a Midwives Clinic by the Practice Development Team (440 consultations were conducted in the Friday Midwives Clinic in 2009). • Provision of Midwives clinics was expanded to five mornings per week in the OPD from May 2009. • Co-wrote Information Leaflets for women attending the CWIUH regarding: • Induction of Labour • Labour and Birth • Perineal Massage • What to Bring in for the Birth of your Baby? • Continued development of midwifery and nursing policies, procedures and guidelines. • Members of the Practice Development Team participated on a number of Committees within the hospital and Trinity College Dublin including; Midwifery Management Meetings, Weekly Perinatal Review, Monthly Perinatal Mortality Meetings, Weekly Delivery Suite Meetings, Drugs and Therapeutics Committee, Breastfeeding Committee, Health and Safety, Student Council, Course Co-ordinating Group and Joint Working Group meetings. • Development of VE and CTG Stickers in an attempt to raise the quality and standardise the documentation hospital wide.
4) Education
• Involved in both clinical and theoretical teaching: Midwives and Nurses, Midwifery and Nursing Students, Practice Nurses, A&E Nurses (who are midwives) and participants on an MSc in Women’s Studies at the RCSI. • Organised and facilitated a monthly Journal Club for midwifery and nursing staff and students. • One staff member chaired and another presented a paper at the 2008 Essence of Midwifery Care Conference in the CME on International Day of the Midwife. • Judith Fleming and Paula Barry successfully completed their Masters in Midwifery Studies (MSc), in Trinity College Dublin. • Mary Rodgerson commenced year one for her MSc.
5) Annual Events
• Involved in the ‘Essence of Midwifery Care Conference’ which was held in the Rita Kelly Conference Centre in May to mark International Day of the Midwife. • Four staff attended the INO ‘North/South Joint Midwifery Conference’ in Cavan. • Co-presented a poster regarding Community Midwifery Services at the CWIUH at the above conference.
Challenges and Plans for 2010
• Continue to promote the midwifery philosophy that pregnancy and childbirth is a normal, healthy life event for many women. • Become involved in a multidisciplinary co-ordinating group to review clinical practice and develop guidelines in an attempt to improve the normal birth rate. • Continue to meet the clinical learning needs of midwifery and nursing students while on placement in the CWIUH. • Continue to support and assist midwifery and nursing staff involved in clinical teaching and preceptorship of midwifery and nursing students.
123 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• Continue to facilitate preceptorship courses, to improve the standard of clinical supervision, teaching and assessing of midwifery and nursing students. • Continue auditing midwifery and nursing record keeping and medication management to maintain standards as per An Bord Altranais. • Continue to facilitate midwifery and nursing educational programmes and up-dates in collaboration with the Centre of Midwifery Education. • Continue to promote, increase attendance at and facilitation of midwives clinics. • Commence auditing the effectiveness of same. • To promote and support professional development and education among midwifery and nursing staff in order to deliver safe, effective, evidence- based care to women and babies attending the CWIUH.
124 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Parent Education/Breastfeeding Support Service Report
Staff Complement
1 WTE Clinical Midwife Manager 3, Trea Dooge 1 WTE Clinical Midwife Specialist, Mary Toole 0.5 WTE Secretary
Key Performance Indicators
• Provision of a comprehensive antenatal and postnatal education programme for women and their partners. • Provision of a service that encompasses and is mindful of our multicultural patient population. • Provision of individualised education and support where indicated or requested. • Continuity of education, support, care and follow up, facilitating women in active participation in their own birth and parenting process. • Resource and Support to all clinical staff.
Achievements . • Delivery of a comprehensive service with limited human resources. • Participated in the induction programme for newly appointed midwifery staff. • Education and clinical support for Higher Diploma & BScM midwifery students on campus and in Trinity College. • Participated in education for student nurses on obstetric placement and medical students. • Developed and facilitated on 6x20hr (18 days) breastfeeding education study days under the auspices of the Centre of Midwifery Education. • Developed and facilitated new infant feeding education programme (5hrs) for health care assistants. • Organised and participated in activities for national breastfeeding week. • Daily audit of post partum records and provision of individualised appropriate breastfeeding information and support (step 10 of 10 steps to successful breastfeeding). • Responded to telephone self referrals and followed with appropriate action and intervention. • Provided information and support to mothers of pre-term and ill infants in the neonatal centre. • Provided support and assistants to all post natal departments, paediatric out patients and emergency departments. • Developed Baby Friendly Hospital Initiatives within the hospital and reported to BFHI National Co- coordinator.
Antenatal/ Postnatal Parent Education Classes
Class Number Provided Number of women attended Introductory 12 341 Refresher 12 188 Antenatal (1-5) 120 3932 Post natal breastfeeding 225 1448
The data above does not include partners, but the majority of women were accompanied and figures were reliant on individuals registering on the attendance sheets.
125 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Breastfeeding Practices
Breastfeeding initiation 51.00% Skin to skin contact post- delivery 75.00% Breastfeeding on discharge (combined) 44.00% Breastfeeding on discharge (exclusive) 38.00%
Challenges in 2010
• Provision of a comprehensive service with limited human and financial resources.
• Development of a patient and family focus service providing optimum care and evidence based practice.
• Facilitating audit and reflective practice to improve the provision of quality patient care and promote further education and professional development of staff within the department.
126 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Community Midwife Service
Head of Department/Division/Clinical Area:
Ms B Flannagan, CMM3 (Author of Report)
Staff Complement at end of December 2009:
1 WTE CMM3 5.16 WTE CMM2 4 WTE Midwives
Key Performance Indicators:
• Uptake of early transfer home by women in the catchment area of the Early Transfer Home Scheme. • Average length of stay in hospital. • Saving in acute hospital bed days. • Re-admission rates by Day 5 Postnatal. • Breastfeeding rates state at what point measured on Day 5. • Number of women accommodated in their local area with booking appointments. • Number of women with return appointments in midwife clinic. • Number of women with booking and return appointments at Naas clinic.
Achievements in 2009 Trends in Activity
2007 2008 2009 Uptake of postnatal care at home 88.5%1 88.1%2 35.5%3 Uptake of postnatal care where available Number of women seen 1,000 947 1,423 Average length of stay (days) 1.34 1.36 1.74 Total bed days saved 1,017 953 1,628 Readmission rates: Mothers 0.4% 0.74% 0.8%5 Readmission rates: Babies 1.3% 1.3% 0.9% Breastfeeding rate at Day 5 on discharge to PHN 40.5% 37.5% 40% Booking clinic appointments with community Midwives 805 899 1,229 Return clinic appointments with community midwife. 4,038 4,320 4,926 Team Naas first visit appointments – Doctor 389 377 383 Team Naas return appointments – Doctor 1,670 930 1,081
1 This data was collected by a manual tracking system. Community MW attended the ward to identify women from the geographical area and select the women clinically suitable for the service. The calculation is a % of women selected from the total of those geographically and clinically suitable. 2 Same as for number1 3 The number of women who availed of the service from the total no of births in the geographical area – based on figures from IT dept therefore the denominator data in this category was changed and constitutes a larger number and more accurately depicts the situation 4 Same reason as in Number 3 i.e. greater denominator data and updated selection criteria and guidelines e.g. Taking women who delivered by CS or other factors which prevented ETH as a choice before review of selection criteria in May 2009. CS women may go home between 48-96 hours, so overall LOS is longer. 5 Reasons for readmission were raised BP x 4, headache, suspected dural tap, infected perineum, UTI, infected perineum and 1 woman to Tallaght Hospital for haemorrhoidectomy. It is to be expected to see an increase in readmission of women as now taking women now who would previously not have been eligible for ETH, but overall increase in rate of readmission suggest women receive appropriate care since the review the selection criteria for ETH.
127 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• A new booking clinic and a midwife antenatal clinic (x1 per week per location) were established in both Lucan and in the Outpatient Department of AMNCH Hospital. Community midwives had identified the need to develop the maternity service available to women in the Lucan area and to relieve the pressure on hospital antenatal clinics. On average, 55 women from Lucan give birth per month at the CWIUH. The number of community midwives was increased from 8WTE to 10WTE to facilitate the additional clinic and increase in postnatal workload. Approximately 115 women per month from Tallaght book to attend for maternity care in CWIUH, of whom 22 per month were booked locally in Mary Mercer Health Centre, Tallaght. With the increase in midwifery resources and the availability of accommodation in AMNCH Hospital, the community midwives commenced a booking clinic and midwife follow up clinic there in June 2009. As a result, another 16 women per month are booked locally, increasing the number of bookings from 22 to 38. In addition the number of follow up appointments available per month has increased from 120 to 184.
• The catchment area for postnatal care was extended to include Lucan and Dublin 8 to facilitate more women with a choice for the Early Transfer Home scheme. These areas were selected because, after Tallaght and Clondalkin, they are the areas with the highest population of births in CWIUH from our catchment area.
• A midwife antenatal clinic moved from Rowlagh Health Centre to a new venue in Neilstown, Clondalkin providing a better environment for service users. The new venue is a semi-detached house, run by a community development and support group providing services to local people. The house offers a clean and homely environment. The kitchen area is used for the waiting room and reception staff welcomes the women and offer information and advice on other services available in the house. These include Breastfeeding Support, Healthy Eating Programmes, Baby Massage, First Aid for Infants, Pregnancy Yoga and counselling support for anxiety and depression. Midwives using the house find the atmosphere safe, calm and welcoming to women, creating a nurturing atmosphere for women to discuss their hopes and concerns about pregnancy and childbirth.
• Selection criteria for women and babies suitable for the Early Transfer Home scheme were updated to facilitate more women to access the scheme and to include women who delivered by caesarean section. This is reflected in the increase numbers of women using the service and in the average length of stay. Examples of women who can now go home earlier then previously are women who are clinically well but may need BP monitoring, women who have sustained third degree tears, women who may be breastfeeding for the first time and would benefit from additional support and very young mothers, for example 14-16 year olds. Babies whose mothers may not had the choice of going home early before the guidelines were reviewed are babies with borderline birth weights for gestational age who need extra support with monitoring feeding and babies at 36-37 weeks gestation at birth who are otherwise clinically well.
• Parent Education course for teenage parents were established and delivered in partnership with HSE and Youth Services in Tallaght in 2009. The Community Midwife Service was approached by the Community Workers in Tallaght provide a Parent Education programme for teenagers in the area who were not attending classes held locally or in CWIUH. Community midwives worked with the representatives from the public health nursing, physiotherapy and youth services in Tallaght to develop a course of antenatal classes tailored to meet the needs of teenagers. The course consists of 4 classes and 2 courses were held in 2009. The courses are held in the Community Centre in Fettercairn and are facilitated by a local Community Health Worker, who also co-ordinates the bookings. This helps to provide continuity and a familiar face for the young parents. The aim of the course is to be informative and interactive for the participants, using discussion groups, DVD presentation and demonstration as appropriate. The public health nurse advises on all aspects of infant care and child safety. Information pregnancy and birth is
128 Coombe Women & Infants University Hospital Annual Clinical Report 2009
provided by the community midwife. The community physiotherapist encourages active participation with exercises and advice on posture and self help strategies to cope with pain in labour. Advice on access to other support services for teenagers, young parents, benefits and entitlements is offered by staff from Youth Services. The size of the classes varied from 4 to 6 young women and partner of their choice.
• Feedback from the teenagers is positive: they prefer being in a group with their peers and like that the course is held locally. They felt they were better prepared for birth and caring for their baby. Recruitment to the classes is an ongoing challenge for healthcare professionals to motivate teenagers to attend. Information about the service has been provided to midwives, public health nurses, CWIUH social workers and OPD department, GPs, practice nurses and school nurses and publicity leaflets left in venues used by teenagers.
Challenges for 2010
• Improve local access to maternity services and increase number of booking appointments in Clondalkin and Lucan.
• Increase breastfeeding rates by 2% annually in line with the national strategy.
• Promote breastfeeding as a choice of infant feeding in the antenatal period and continue to offer additional support visits to postnatal women.
• Reduce length of stay in hospital for women living in geographical areas where postnatal midwifery support at home is available by promoting the Early Transfer Home scheme to women in the antenatal period with information leaflet in the BiB packs, at antenatal clinics and classes and encouraging midwives to plan for discharge from birth onwards.
• Improve access to maternity services for teenagers living in Tallaght, Dublin 24, by raising awareness of GPs, public health nurses, practice nurses and community youth workers of the antenatal clinics, classes and postnatal care that midwives offer in Tallaght and encouraging them to make referrals to the service.
• Improve access to maternity services for women from Traveller community living in Tallaght and Clondalkin, in collaboration with representative group from Traveller community.
• Review needs identified by the group and how the community midwife service can address these needs.
• Review antenatal booking procedure of women suitable for Midwifery Led Care model by reviewing guidelines for this model of care and to empower and support midwifery staff to offer safe, evidenced based care and choices for maternity care.
• Encourage more women to avail of Early Transfer Home scheme and to use opportunities at antenatal appointments and classes to promote ETH as an option for women to consider for the postnatal period and support midwifery staff on the postnatal ward to offer ETH as women will continue to receive professional midwifery care in their own homes thereby reducing demand on hospital resources.
• Continue to extend the geographical area where the scheme is available to Dublin 10 and 20.
129 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Delivery Suite
Heads of Department
Susan Kelly CMM 3 (until June 09), Ann Fergus A/CMM3 (Sept-Dec 2009] Professor Deirdre Murphy, Lead Obstetrician
Staff Complement:
Total WTE CMM 3 0.96 WTE CMM 2 10 WTE CMM 1 6 WTE Midwives 51 WTE
Student Midwives The BSc student midwives entered their 4th year in training (supernummery student status). The HDip student midwives (18 month programme) were also in the clinical area and are included in the staffing numbers. The number varied throughout the year depending on their college commitment.
Health Care Assistants 4 WTE
Auxiliary Staff 2 WTE (night duty)
Attendant Staff 2 WTE
Clerical Staff 1 WTE on duty Monday – Friday and a number of part-time, evening and weekend staff. Night Duty cover is shared with the Admission Office.
Key Performance Indicators
• The Episiotomy Rate with Spontaneous Vaginal Deliveries was 6.2%. This is well below the accepted standard of less than 10% and below the rate for 2008 which was 7.5%.
• Skin to skin contact between mother and baby following birth, regardless of chosen method of feeding, was achieved following 74.7% of births.
• The 3rd degree tear rate in 2009 was 0.6% which was an improvement on a rate of 0.9% in 2008.
Achievements in 2009
• 8812 infants weighing 500g or more were born in 2009 making it the busiest years on record in the Coombe Women and Infants University Hospital.
• The High Dependency Unit had a total of 152 patients admitted with complex Obstetric, Medical and Gynaecological conditions. 2009 saw a multidisciplinary team start work on the development of a High Dependency Unit Chart specifically for the care of these patients.
130 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• High Risk Deliveries in St. James`s Hospital: several Mothers with very complex medical conditions required delivery by Caesarean Section in St. James’s Hospital. A Multidisciplinary team attended each delivery and co-ordinated with the staff in St. James’s Hospital regarding same.
• The midwifery staff in the delivery suite actively participated in facilitating a midwives clinic in the Out- Patient Department. Karen Hill, A/CMM 1 from the DS produced information booklets for women on Induction of Labour and Information for Women regarding Labour and Birth.
• The ADCAR Trial, a randomised controlled trial comparing the effect of admission cardiotocography versus auscultation of the fetal heart rate with a Pinard stethoscope or a hand held doppler on low risk women on admission to the delivery suite, continued.
• There was a drive to promote and encourage perineal suturing by midwifery staff already proficient in this procedure. There were education workshops to up-skill all midwifery staff working in the delivery suite.
• Judith Fleming, Clinical Skills Facilitator in the DS was redeployed to co-ordinate the vaccination clinics in anticipation of the H1N1 pandemic. Arrangements were prepared in the department to care for women in labour who may be affected.
Challenges for 2010
• Staff Retention: Facilitating continuous professional development within the current climate of budgetary constraints and the HSE embargo on staff recruitment.
• The Assessment Area: The Delivery Suite assessment area was allocated for use by another Department in early 2009 due to space requirements for renovations within the hospital. However, planning began again in late 2009 to facilitate the provision of an assessment area on the second floor, adjacent to the Delivery Suite.
• A commitment to review intervention rates and develop multidisciplinary guidelines in an effort to reduce such interventions.
• The introduction of the customized High Dependency Chart incorporating an ‘Early Warning’ system.
• To promote a shared perception of the importance of patient safety through continuously reviewing clinical incident reports and disseminating the learning points.
• To continue to increase the number of midwives competent in suturing skills in the Delivery Suite.
• In an effort to provide more choice for women there are further infra-structural developments planned to facilitate the introduction of a Domino Scheme.
131 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Perinatal Day Centre
Head of Department/Division/Clinical Area
Ms Mary McMorrow December 2008 – October 2009 Helen Castelino, CMM1 from Oct 2009 (Author of Report)
Staff Complement
3 WTE midwives: Head of Department as above Ms Rachel Cron RM (replaced by Ms Clare Flynn RM while on leave) Ms Donna Christison RM Ms Helen Castelino CMM1 (July 2009 – December 2009)
1 WTE Clerical Officer Ms Jennifer Walsh
Support staff combined with other departments
Key Performance Indicators
Reason For Attendance 2002 2003 2004 2005 2006 2007 2008 2009 Fetal Assessments 1432 942 680 645 1021 779 1271 1170 CTG only 4021 3857 2804 2133 Hypertension 1087 1573 1457 2405 2705 3005 2180 2405 Glucose Tolerance Test 1335 1585 1757 1671 1823 1679 2103 2434 Blood Glucose Series 233 464 501 833 931 1913 1110 825 Diabetic phone ins 104 1612 1445 1166 Other blood tests (PET, bile acids, Anti Xa) 233 464 501 833 931 1913 1100 885 Admissions to ANW from PNDC 296 331 308 449 412 293 261 351 Admissions to DS from PNDC 191 85 129 48 18 19 40 Emergency LSCS from PNDC 11 17 14 10 9 13 7 28 ECV NR NR NR NR NR NR 63 50 Wound dressings NR NR NR NR NR NR 413 152 Miscellaneous 271 871 882 978 836 1084 1042 2940 Total 7988 10231 9777 11252 12646 15025 13803 14486
132 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Achievements in 2009
• Total number of attendances in the Centre was 9646 (up from 9257 in 2008 and 8468 in 2007) facilitating Day Centre management of a high volume caseload and reducing admission rates to hospital.
• Provision of phone in service for women on insulin to give their blood sugar meter readings
Challenges for 2010
• To set up and maintain a computerised appointment system on PAS
• Need for additional medical cover.
• Need for spatial expansion including the waiting area
133 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Clinical Midwife Specialist (CMS) – Diabetes Mellitus in Pregnancy
Heads of Department
Professor S. Daly, Consultant O&G Dr B. Kinsley, Consultant Diabetologist Fiona Dunlevy, Dietician 1 WTE Ethna Coleman, CMS Diabetes (Author of Report)
Diabetes Mellitus is a chronic disease that utilises 10% of the total health budget (DSDG 2002). The incidence is on the increase worldwide which translates to an annual increase in the numbers of pregnant women with diabetes. Diabetes has a huge impact on pregnancy with increased maternal and perinatal morbidity and mortality compared to that of non-diabetic pregnancy. International diabetes organisations all support the model of the diabetes team: a multidisciplinary group of professionals with specialised training in the care of people with diabetes. The team here in the Coombe Women and Infants University includes a CMS Diabetes, dietician, endocrinologists and obstetricians.
As a member of the team the CMS (Diabetes) has responsibilities that include initial and ongoing care, education, advice and support. The CMS (Diabetes) reviews and reinforces education and understanding, provides women with the necessary equipment, education and skills they require to manage their diabetes. The CMS (Diabetes) refers to and liaises with other healthcare professionals as appropriate, and provides an educational resource for professional colleagues. The role of the CMS (Diabetes) includes organisation and coordination of services for both in-patients and out-patients. The CMS (Diabetes) works exclusively in the field of diabetes as an educator, communicator, manager, researcher, innovator and counsellor (DSDG, 2002).
Key Performance Indicators
• Provide multi-disciplinary team care to women with diabetes and other endocrine problems. • Assist them to achieve maternal and fetal outcomes that are equivalent to those of non-diabetic pregnancy. • Patients with diabetes require high quality services which are coordinated, comprehensive and integrated, and care should be appropriate to the patients’ needs (DoHC 2006).
Achievements in 2009
• Organised clients with diabetes mellitus to partake of the H1N1 vaccine programme within the hospital. • Education of carefully selected patients who required insulin therapy as outpatients, thus reducing admission rates. Provided advice and support by phone to patients and to colleagues in other hospitals, and dealt with referrals of patients from other hospitals, GPs and self-referrals. Involvement in multi- disciplinary team ward rounds and meetings. • Development of patient database of all patients in the service. • Participated in development of policies and patient information leaflets I was a member of the policy development committee who developed the national guideline on the management of diabetes in pregnancy (to be launched 2010). Started developing documentation and a policy to allow patients to e-mail in for insulin dose adjustments. Discussed this with IT manager. • Provision of education for new midwifery and nursing staff about diabetes and its management in pregnancy as part of their induction to the hospital and in the provision of ongoing care e.g. organisation of training on use of new glucometers. Facilitation of students and staff who opted to ‘shadow’ the CMS Diabetes in order to learn more about care of the diabetic mother during pregnancy, labour and the puerperium.
134 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• Provision of sessions on management of diabetes in pregnancy to the BScM and HDip midwifery students at TCD and to the Graduate Diploma Students in Diabetes Nursing in UCD. • Met with a representative from the Diabetes Federation of Ireland (DFI) and colleagues from two other maternity hospitals and made a plan to develop a structured education programme for women with gestational diabetes mellitus. • Attendance at study days and updates including a study day for clinical supervisors of nurses doing higher and graduate diplomas. • Member of Irish Diabetes Nurse Association and Diabetes Federation of Ireland. • Staff Midwife Louise Conlan rostered to work in diabetes clinic. She commenced studies in UCD for graduate diploma in diabetes nursing in September 2009.
Challenges in 2010
• Transfer of patients from other hospitals for assessment and care leads to an increase in pressure on resources. • Dedicated space for Diabetes Clinic is inadequate and it is difficult to find space for teaching outpatients. • Increasing challenges of education of non-English speaking patients through interpreters, more time is required in such instances. • Addressing the Did Not Attend (DNA) rates at the clinics and the requirement for the subsequent follow up. • Difficult to get post-natal women to attend for their post-natal GTT and clinic visit. • CMS (Diabetes) does not have clerical support. • The increase in demand for the service increases annually.
Plans for 2010
• To continue work on policies. • To finalise patient information leaflets and begin providing them to patients. • To introduce a system whereby patients can e-mail in their blood sugar readings for review by an endocrinologist instead of the phone-in system currently in use. • Plan to work with DFI and other CMS (Diabetes) to develop a structured education programme for women with gestational diabetes mellitus. • Plan to develop and run a diabetes study day, in conjunction with the CME and involving CMS (Diabetes) from the Rotunda and National Maternity, for midwives from the three maternity hospitals in Dublin. • To commence nurse prescribing course in RCSI.
135 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Perinatal Ultrasound Department
Heads of Department
Professor B. Stuart (Retired in October 2009) Professor S. Daly (Director of Department from Oct 2009) B. Boyd, Assistant Director of Midwifery & Nursing with responsibility for Midwifery & Nursing within Department Elaine McGeady, CMM2 Department Manager (Author of Report)
Staff Complement
1WTE CMM2, Elaine McGeady 4.5 WTE Clinical Midwife Specialists
Key Performance Indicators
• In 2009 the Ultrasound department was relocated to a large newly refurbished area within the hospital on the ground floor. This new facility provided much needed enhancements in service provision by increasing access to patients by the provision of additional scan rooms. It also included an increase in staffing levels and the procurement of new replacement and additional technology and equipment. It provided better facilities for patients particularly in the provision of a waiting area. An office was provided for staff. As some of the staff members are in training for Clinical Midwife Specialist posts in Ultrasonography, there was an inbuilt commitment to further and ongoing education both in the undertaking of the formal MSc in Ultrasonography and in professional updating in areas such as fetal echo, and in Doppler Studies.
Achievements in 2009
• Successful training of two new members of staff.
• Procurement, installation and implementation of new software, VIEWPOINT in order to provide, maintain and develop a high standard of Ultrasound reporting.
Challenges in 2010
• Recruitment & Retention of trained and experienced staff.
136 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Family Planning Advisory Centre
Head of Department/Division/Clinical Area
Elizabeth O’Beirne
Staff Complement
1 WTE = CMM 2 (Elizabeth O’Beirne)
Key Performance Indicators
• Advising In-patients and their partners, on all methods of family planning and contraception.
• Maintaining a phone-in service.
• Counselling women on issues relating to the planning, preventing and spacing of pregnancies.
Achievements in 2009
• Provided information booklets to our non-English speaking patients, ensuring all possible information was given, e.g. French, Romanian, Russian, Polish & Mandarin.
• A total of 2409 patients were seen, 204 of whom were couples.
Challenges for 2010
• Ensure all women/couples have correct information.
137 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Adult Outpatient Clinics, including Public & Semi-Private Antenatal, Postnatal & Gynaecological Clinics, Emergency Room and Early Pregnancy Unit
Heads of Department
Dr Chris Fitzpatrick – Master/CEO Dr Tom D’Arcy – Head of Gynaecology Division Dr Mary Anglim – Lead Consultant EPAU Prof. Walter Prendiville – Director of Colposcopy Dr Michael Carey – Director of Peri-operative Medicine Frances Richardson – Asst Director of Midwifery Mary Nolan – Acting Clinical Midwife Manager 3 (Author of Report)
Staff Complement
• 16.36 WTE Midwifery/Nursing Staff to include: • 1 WTE A/CMM 3 • 0.82 WTE CMM I • 10.54 WTE Staff midwives • 1 WTE RGN • 3 WTE Student Midwives • 10 WTE OPD Clerical Staff • 6 WTE Records Clerical Staff
Key Performance Indicators
• Antenatal women (Public and Semi-Private) Booking Attendance = 6699 ( 6.8%) • Total Consultant New and Return Public appointments = 26776 ( 7%) • Semi-Private appointments (includes antenatal and postnatal consultations) = 7163 ( 12%) • Midwife Clinic Return and New appointments = 3675 • Diabetic clinic appointments = 2785 ( 1.6%) • Total = 47098
The above clinics include antenatal and postnatal consultations.
• Gynaecological clinics excluding Colposcopy.
• New Appointments women seen = 2193 • Return Appointments seen = 4224 • Total = 6417
• ER attendances = 9407 ( 17%)
• EPAU appointments = 3619 ( 11.5%)
• Total Attendances at the OPD irrespective of clinic or insurance status= 66541 ( 6.9%)
138 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Early Pregnancy Unit Attendances
4500 3828 4000 3478 3619 3500 3263 3137 3000 2500 2000 1500 1000 500 0 2005 2006 2007 2008 2009
ER Attendances
10000 9407 9000 8010 8000 6950 7000 6306 6000 5018 5047 5000 4531 4000 3000 2000 1000 0 2003 2004 2005 2006 2007 2008 2009
Achievements in 2009
• Continued ongoing education of staff. • Provision of midwife clinics daily Monday to Friday. • Expansion of Anaesthetic Clinic.
Challenges for 2010
• To cope with increasing numbers of women attending with diminishing resources. • Provision of up to date equipment with diminishing resources. • Expansion of Liaison Perinatal Mental Health Outpatient Clinic service. • To facilitate the establishment of Perinatal Loss Clinic. • Continuing on going staff education. • To establish Pre-Op Assessment Clinics in order to reduce length of hospital stay for women requiring surgery.
139 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Report of Gynaecology Oncology CNM Co-ordinator
Heads of Department
Dr N. Gleeson, Consultant O&G Dr T. D’Arcy, Consultant O&G
Staff Complement
1WTE CNM2 Coordinator, Aideen Roberts, (Author of Report)
Key Performance Indicators
• The Gynaecological Oncology Nurse Co-ordinator works within the gynaecological oncology division that is a single unit between SJH and CWIUH. 272 new gynaecological cancers were diagnosed in 2009, of which sixty-one patients were diagnosed and/or treated at CWIUH. The role of the Gynaecological Oncology Nurse Co-ordinator is to assist in ensuring that an efficient and seamless pathway of care is delivered for the gynaecological oncology patient.
Achievements
• The Gynaecological Oncology Nurse Co-ordinator is a new role within the CWIUH that was established in June 2009, it is a shared role between CWIUH and SJH, providing an additional channel of communication between the two sites. The post was funded in equal parts by both the CWIUH and the Irish Cancer Society.
• The Co-ordinator is a visible presence in both the inpatient and outpatient environment, working closely with the team in Colposcopy, St Gerard’s ward and Day Surgery.
• The Gynaecological Oncology Nurse Co-ordinator attends the weekly multidisciplinary meeting, where all cases that have been diagnosed or have been treated in the CWIUH are discussed and where management of care is planned.
• The Gynaecological Oncology Nurse Co-ordinator attends the gynae-oncology out-patients clinics that are run between SJH and CWIUH, where new and return patients are seen and followed up.
• The Co-ordinator organises the relevant imaging that is required for staging purposes in new cases, the booking of beds for admission for both diagnostic and therapeutic purposes and the submission of patient’s details for MDT discussion.
• The Co-ordinator liaises with all divisions of the gynae oncology team, including the co-ordinating of referrals to both radiation and medical oncology, for patients who require adjuvant treatment.
• The Gynaecological Oncology Nurse Co-ordinator would meet women both pre and post operative, providing both verbal and written information and support regarding their gynae-oncology surgery and their possible need for further treatment.
• The Co-ordinator would also provide support to both patients and relatives via the telephone, where they can contact the co-ordinator if they have any issues or concerns.
140 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Future Plans
• To further develop the role of the Gynaecological Oncology Nurse Co-ordinator at the CWIUH.
• It is planned that a new Colposcopy unit will open in CWIUH in 2010-2011, where the Co-ordinator and Gynae Oncology Administrator will relocate to and look forward to working within the designated team in the new Colposcopy unit.
Challenges
• With the increasing number of gynae oncology patients being diagnosed and treated in the CWIUH, the co-ordinator will continue to provide a seamless pathway of care in order for the highest standard of care to be delivered.
141 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Operating Theatre Department
Heads of Department/Division/Clinical Area
Dr Tom D’Arcy, Director of Gynaecology Division Dr Michael Carey, Director of Perioperative Medicine/Anaesthesia Ms Frances Richardson, Asst. Director of Midwifery & Nursing, Gynaecology Ms Alison Rothwell, CNM 3, Theatre Manager (Author of Report)
Staff Complement
Approved posts 28 WTE 1 WTE CNM 3 1.5 WTE CMM 2 1 WTE CNM 2 (Anaesthetics) 4.24 WTE Staff Midwives 21.5 WTE RGN Total as of Dec 2008: 29.24 WTE
Key Performance Indicators
The necessary closure of gynaecology beds during Phase 1 of the redevelopment of CSSD provided the impetus for the introduction of new care pathways for several categories of patients. The aim was to maintain gynaecology surgical services at close to normal levels. However, the number of cancellations did increase in 2009, due to reduced bed capacity associated with the CSSD Development, but also due to H1N1 and Neonatal contingency planning and unplanned, unavoidable essential maintenance works.
• Pre-operative gynaecology anaesthetic assessment clinic was set up in 2009, to enable all women scheduled for major gynaecology surgery and for day cases with co-morbid disease, to undergo an appropriate anaesthetic review. This enabled and facilitated the introduction of same day admission for all routine major gynaecology patients, as pre operative tests were completed prior to admission.
• The appointment of CNM 2 (anaesthetics) has also had a positive impact on the provision of anaesthetic nursing service within the hospital, notably within pain management services.
• Under normal circumstances, the management of women for EPRC procedures now commences at home. This facilitates early treatment and discharge.
• Under normal circumstances, women requiring management for hyper-emesis are now managed as day- cases and go home following completion of their management regime.
Challenges for 2010
• Elective and Emergency LSCS activity continued to increase. The challenge will be to ensure that this activity is managed whilst also ensuring that gynaecology services are maintained and developed as required.
• To improve the provision of gynaecology services further, through further streamlining of services and developing appropriate care pathways for gynaecological women.
142 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Department Of Paediatrics and Newborn Medicine
Head of Department/Division/Clinical Area
Dr M.J. White, Director of Paediatrics and Newborn Medicine Bridget Boyd, Assistant Director of Midwifery and Nursing Ann Mac Intyre, CMM3 (Author of Report)
The NICU refurbishment (Phase 1) began in February 2009 and was completed in September 2009. We would like to take this opportunity to thank Dr Chris Fitzpatrick, the Master, Patricia Hughes DOM&N, John Ryan Secretary & General Manager, Rosena Hanniffy ADoN&M for Infection Prevention & Control, Dr. Niamh O’Sullivan, Consultant Microbiologist, John Kavanagh, Capital Project Co-ordinator for all their help and assistance. We would also like to thank sincerely the Managers and staff of the Neonatal unit for their dedication and support throughout the year including auxiliary and clerical staff.
Staff Complement
Complement of 77.8 WTE Nurses & Midwives s follows:
1 WTE Advanced Nurse Practitioner – Neonatal Nursing 1 WTE CMM3 7 WTE CMM2 7 WTE CMM1 1 WTE CMS Neonatal Transition Home Service 1.5 WTE Clinical Skills Facilitators 58.3 WTE Midwives / Nurses Clerical Staff Support Staff
Key Performance Indicators
• CWIUH Neonatal Team is committed to improving the quality and safety of medical care for newborn infants and their families.
• Evidence-based practice and clinical audit motivate staff to practice quality improvement and staff development.
• Improvement in medication management.
• Reduction of Nosocomial infection rates.
• Reduction of number of ventilated days.
• Promotion of evidence based practice.
143 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Achievements
• 5 WTE staff nurses were recruited, with a retention rate of 98%.
• 2 staff midwives/ nurses graduated with the post-graduate diploma, 9 staff midwives/nurses were progressing through the programme. 1 staff midwife completed BSc in Nursing Management.
• 2 staff attended the Reason Conference in the UK, 21 staff attended the National Neonatal study day in Croke Park, and a further 17 attended the In-Service Programme in September. 9 staff completed the Stable Programme.
• NIDCAP workshops organised by M. O’Connor CMM2 and facilitated by Inga Warren from Winnicott Unit, Hammersmith, London were attended by 38 members of staff.
• Total of 147 staff attended NRP study days organised by Mgt. Moynihan CMM2 including 19 Doctors, 21 staff nurses from A&E, St James Hospital and 33 NICU staff.
• The NTTP team from the CWIUH conducted 37% (98) of the total number of Transports, 56% (55) of which were outside the greater Dublin area, including 1 international transport. The CWIUH spent a total of 620 hrs on NTTP transports.
• Medication Management competency programme designed specifically for the Neonatal Unit was developed by Bridget Boyd, ADoN&M, A. O’Sullivan, ANP, NNC Ann Mac Intyre, CMM3 and Peter Duddy, Pharmacist and implemented on an ongoing basis.
• A O’Sullivan, ANP NNC and Mary O’Connor, CMM2 presented a poster presentation entitled ‘Sweeten, Soother and Swaddle for ROP Screening’, at the Paediatric Academic Society Conference in Baltimore, Maryland, USA.
• Barbara Whelan, CMS NTHS and A O’Sullivan, ANP, NNC were awarded a Commendation at the Irish Healthcare Awards for their entry in the Nursing Project of the Year Category.
Challenges
• Meeting the needs for high dependency beds within existing NICU remains a challenge. Bed occupancy in the NICU was 90-105% throughout 2009, therefore refurbishment of SCBU to accommodate HDU patients and the relocation of SCBU to the 3rd floor with provision of additional cots/spaces will help alleviate this situation and is required for this level of tertiary unit.
• The provision of neonatal care in the delivery suite and post-natal wards that is appropriate and optimum. It is proposed to develop the role of a Postnatal Ward Liaison Nurse post to meet this need.
• To develop an emergency evacuation plan that is unique to the NICU and meets relevant Health and Safety requirements.
• To reduce infection rates.
144 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Neonatal Transition Home Service (NTHS)
Head of Department/Division/Clinical Area
Dr. Martin J White, Director of Paediatrics and Newborn Medicine Bridget Boyd, Assistant Director of Nursing and Midwifery Ann Mc Intyre, Clinical Midwife Manager 3 Barbara Whelan, Clinical Midwife Specialist – Neonatal Transition Home Service (Author of Report)
Staff Complement
1 WTE CMS – NTHS, Barbara Whelan 0.85 WTE CMM1 Jean Cousins
Key Performance Indicators
• Provision of comprehensive discharge planning and parent education to ensure smooth and timely discharge of infants to home. Increasing parental confidence and competence.
• Education sessions delivered to Unit staff, students on Post Graduate Neonatal Intensive Care Programme, 2nd year direct entry midwifery students.
• Provide support and education to mother’s expressing breast milk for their babies’ liaising with Parent Education Department.
• Mobile telephone support, a valuable resource for parents, Public Health Nurses (PHN) and GP Practice nurses.
• Synagis Administration ( RSV prophylaxis) Co-ordinating administration for both in-patient and out- patients, 80 babies were included in the programme in 2009.
• 63 post discharge home visits were provided to families.
Achievements in 2009
• In partnership with Ann O’Sullivan ANP, NNC and Patricia O’Hara Coordinator for the PG Dip Neonatal Intensive Care Nursing, we provided education session for PHNs and GP practice nurses on the care of ex-premature and sick neonatal infants following hospital discharge. This session was provided in response to a growing number of calls from members of the primary health care team looking for information and support on how best to look after the ex premature baby and the family on return home from hospital. 91 nurses attended a 2.5 hour sessions in one of 4 venues and all sessions were very positively evaluated. These teaching sessions won a Commendation in The Irish Healthcare Awards in the category of Nursing Project of the Year.
• The role of the CMS NTHS was expanded in 2009 to take on managerial responsibility for the Neonatal Out-patient Services. The annual attendance for 2009 was 9558 babies.
145 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• The Neonatal Support Group continues to achieve a high monthly attendance rate. Great thanks must go to the dedicated multidisciplinary team who give of their time to facilitate the group.
Challenges for 2010
• Enhance Neonatal Outpatients Services.
• Continue to lead and further develop the service.
146 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Advanced Nurse Practitioner Report (Neonatology)
1WTE Advanced Nurse Practitioner, Anne O Sullivan (Author of Report) Department of Paediatrics and Newborn Medicine
Key Performance Indicators
• To ensure and enable consistency in standards of health care delivery. This is achieved by having a clinical presence whereby I offer support and guidance to other members of the multidisciplinary team while also managing a caseload.
• To deliver evidence-based neonatal nursing; this is achieved by ensuring nursing and medical care is based on current best evidence. Clinical guidelines are reviewed and staff are updated using formal and informal educations programmes. I participate in education secessions for midwifery staff, BScM & Higher Diploma midwifery students, public health nurses, practice nurses. I am also involved in the induction/orientation and in-service education for medical and nursing staff. I am available as a resource and in a consultative capacity to midwifery and obstetric staff and to staff from other Hospitals within the area network and nationally. I am a provider of the Neonatal Resuscitation Programme and participate in several programmes annually to ensure there are consistency and high standards in the management of infants requiring resuscitation and stabilization following delivery.
• To promote family centred care and minimize separation of mothers and infants we endeavour to reduce the admission rate to the Neonatal Department, staff education required to support this initiative is ongoing.
• To improve outcomes, this is achieved by participating in quality improvement initiatives and incorporation of potentially better practices into our clinical practice. Outcomes are measured by regular audits.
• To promote and facilitate research activities. This is achieved by participating in the journal club and as a member of the research committee. I am involved in the development of evidence based clinical guidelines and as a member of the Drugs and Therapeutics committee we have an ongoing commitment to ensure drugs used in neonatal care are evidenced based.
Achievements in 2009
• With two of my colleagues, Barbara Whelan, CMS, NTHS and Patricia O Hara, Coordinator for the PGDip in Neonatal Intensive care Nursing we were nominated for an Irish Health Care Award for Nursing Project of the Year 2009 and received a commendation for an education programme developed to support Public Health Nurses and Practice Nurses in caring for high risk neonatal infants post discharge.
• Audits carried out in 2009 include:
• Regular hand hygiene audits. • Infection rates associated with the use of Percutaneously Inserted Central Catheters. • Nutritional Practice in Infants weighing less than 1500g. • Temperature Regulation in Infants weighing less than 1500g from delivery to stabilization.
147 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Professional Development
• I became a Registered Nurse Prescriber.
• Presented an update on ‘Gentle Ventilation Strategies’ at the Annual Neonatal Study Day.
• Presented a paper entitled ‘Sweeten, Soother and Swaddle for Retinopathy of Prematurity Screening’, at the Irish College of Ophthalmologists Annual Conference.
• Presented a poster entitled ‘Sweeten, Soother and Swaddle for Retinopathy of Prematurity Screening’ at the Pediatric Academic Societies Annual Meeting, the National Council for the Professional Development of Nursing and Midwifery Conference and at Ireland’s Annual Joint Midwives Conference.
Conferences Attended
• Annual Neonatal Study Day, Croke Park, January 28th 2009.
• Hypothermia Study Day, Rotunda Hospital, March 27th 2009.
• Pediatric Academic Societies Annual Meeting, Baltimore, May 2-5th, 2009.
• Irish College of Ophthalmologists Annual Conference May 8th 2009.
• Cerebral Palsy from Conception to Birth and Beyond, Dublin, September 2009.
• RSV Awareness and Prevention, Dublin, September 23rd 2009.
• Irelands Annual Joint Midwives Conference, October 2009.
• National Council for the Professional Development of Nursing and Midwifery Advanced Nurse Practitioner, Role Evaluation Workshop, November 10th 2009.
• National Council for the Professional Development of Nursing and Midwifery Annual Conference, November 11th 2009.
Plans for 2010
• To publish results of our RCT, entitled ‘Sweeten, Soother and Swaddle for Retinopathy of Prematurity Screening’.
• As a member of the research committee, to initiate a nursing research project and increase participation at the journal club.
• To further promote family centred care, I hope to contribute to the development of a guideline to enable the administration of IV antibiotics on the postnatal wards and to facilitate and support staff in the implementation of this guideline.
148 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Midwifery Academic Report
Ms Patricia Hughes
Director of Midwifery and Nursing
Midwifery Education between Coombe Women & Infants University Hospital and Trinity College Dublin continued for both the BScM 4 year Midwifery programme (pre-registration) and the 18 month Higher Diploma Midwifery Programme (post registration). By December 2009 we had a total of 69 midwifery students undertaking one of the two programmes. The breakdown was as follows: 18 month Higher Diploma post- registration programme with TCD (n = 19); BScM pre-registration programme Third Years (n = 13), Second years (n = 17) and First years (n = 20). Our thanks to Margaret Carroll, Director of Midwifery programmes and all the staff at the Department of Nursing & Midwifery in Trinity College Dublin without whose direction and assistance, the programmes would not be possible.
The Postgraduate Diploma in Neonatal Intensive Care Nursing continued as a joint venture between the three Dublin Maternity Hospitals and the Royal College of Surgeons Ireland and we are indebted to both Professor Seamus Cowman and the coordinator of the programme, Patricia O’Hara for the continued success of this programme which prepares and enables nurses and midwives to provide the highest quality of neonatal nursing care as is required in all three tertiary neonatal units.
The Centre of Midwifery Education was well established and now in its second year of running under the direction of Ms Mulhall who collaborated with a co-coordinating group (COG) of senior staff drawn from all three Dublin Maternity Hospitals. Thanks are due also to Ms Liz Roche, Director of the NMPDU in the Dublin Mid Leinster Area and Chair of the Board of the Board of Management for the Centre for Midwifery Education and from whom much support is gleaned in respect of practice development and continuing education. The CME participated in the HSE Review of CNE and CMEs being carried out by Dr Isobel Butler.
The 2nd Annual Essence of Midwifery Care Conference took place on International Day of the Midwife on the 5th May 2009. Professor Debra Bick presented the 2009 Maureen McCabe Lecture entitled “The Use of Evidence in the Organisation and Development of Midwifery Practice?”. The day was again very positively evaluated.
2009 Essence of Midwifery Care Conference Research in Midwifery
At the Rita Kelly Conference Centre, Coombe Women and Infants University Hospital on International Day of the Midwife, 5th May 2009.
0900hrs Chairperson Angela Dunne Assistant Director of Midwifery & Nursing, CWIUH
0905-0915 Opening Address Patricia Hughes Director of Midwifery & Nursing Coombe Women & Infants University Hospital
149 Coombe Women & Infants University Hospital Annual Clinical Report 2009
0915-0945 Research and the Midwife in Europe Deirdre Daly President European Midwives Association
0945-1015 Promoting Midwifery Research in Ireland Dr. Sarah Condell Research Development Officer National Council for Professional Development of Nursing And Midwifery/Health Research Board
1015-1045 Maternal & Child Health Research in UCD Dr. Michelle Butler School of Nursing, Midwifery & School of Nursing, Health Systems Midwifery & Health Systems, UCD
1045-1100 Coffee
1100 Chairperson Paula Barry A/Practice Development Co-ordinator, CWIUH
1100-1130 Maternity Care and Women’s Health Prof. Cecily Begley Research in TCD School of Nursing School of Nursing & Midwifery, TCD & Midwifery
1130-1200 An Exploration of the Strengths & Denise Lawlor Weaknesses of the Publicly Funded Midwife Lecturer & PhD Student, TCD Health Services for Women with Disabilities during Pregnancy, Childbirth and early Motherhood
1200-1230 The ADCAR Trial – Fetal cardiotocography Valerie Smith versus intermittent auscultation during MW & PhD student, TCD labour ward admission : a randomised trial and qualitative follow up
1230-1300 Designer Breastfeeding Dr. Janine Stockdale TCD School of Nursing & Midwifery
1300-1350 Lunch
1350 Chairperson Ann Mulhall Acting Director, CME
1400-1445 The Maureen McCabe Lecture Prof. Debra Bick The Use of Evidence in the Organisation Prof. of Evidence Based Midwifery Practice and Development of Midwifery Practice? King’s College, London Editor of Midwifery
1445-1515 The Mothers Experience of Midwifery Judith Fleming Care in Labour Clinical Skills Facilitator, CWIUH
150 Coombe Women & Infants University Hospital Annual Clinical Report 2009
1515-1545 Exploring the Maternal Lived Experience Patricia O’Hara following Transition Home of the Medically Co-ordinator PG Diploma, Neonatal Intensive Fragile Infant Care Nursing, Centre for Midwifery Education
1545-1615 Internet Mums 3rd Year BSc (Midwifery) Midwifery Students Trinity College, Dublin
1615-1630 Closing Remarks Patricia Hughes, DoM/N
Awards to Midwives & Nurses in 2009
Dr R. M. Corbet Award 2009 Judith Fleming, Clinical Skills Facilitator
Mary Drumm Scholarship 2009 Karen Hill, Acting CMM2, Delivery Suite
Awards to Midwifery Students
Gold Medal Alison O’Driscoll
Silver Medal Gillian Walsh
Dr T. Healy Award – Best Clinical Student Midwife Alison O’Driscoll
Best Clinical Teacher Award Ann Leonard, CMM1
151 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Centre For Midwifery Education (CME)
Head of Department:
1 WTE Director, Ann Louise Mulhall (Acting) Author of Report
Staff Complement:
1 WTE Co-Ordinator of the Post Graduate Diploma in Neonatal Intensive Care Nursing: Patricia O’Hara 0.5 WTE Secretary: Patricia Griffiths (from May 2009)
Key Performance Indicators
• The CME provides continuing midwifery and nursing education and training programmes for staff in the Coombe Women and Infants University Hospital, the National Maternity Hospital and the Rotunda
Hospital as well as the general requirements for midwifery education in the Greater Dublin Area.
• The Centre also provides national specialist programmes for midwives.
• The education provided includes midwifery, neonatology, gynaecology and other related programmes.
• The Centre has a potential student population in excess of 2,000 midwives, nurses, self employed midwives, public health nurses, A&E nurses, Practice nurses and health care assistants.
Achievements in 2009
• 29 programmes were provided on 136 occasions to 1,373 participants.
• 11 students commenced the Post Graduate Diploma in Neonatal Intensive Care Nursing from the three Dublin Maternity Hospital and 2 students from Our Lady of Lourdes Hospital, Drogheda.
• Programmes provided by the CME included: • CPR BLS HCP • NRP • Preceptorship Programmes • Wound Care in Maternity Services
152 Coombe Women & Infants University Hospital Annual Clinical Report 2009
• Customer Care Course • Management Development Programmes • Neonatal Seminar • Midwifery skills update for practice nurses who are midwives • Midwifery skills update for A&E nurses who are midwives • IV Cannulation and Venepuncture • Care of the Critically Ill Obstetric Patient • Update in Antenatal, Intrapartum and Postnatal Care • Neonatal Preceptorship Course • Neonatal Educational Seminars for Public Health Nurses held in 3 Dublin Health Centres and in the CME • Development of programmes for the 3 maternity hospitals that rotate between each hospital and the CME • 20 hr Breastfeeding course • Fetal Heart Rate Monitoring workshop • Dr Denis Walsh conducted a workshop 'Enhancing Skills for Normal Birth' • Professor Christine Kettle provided a workshop on Perineal Suturing • Review of Centres of Nurse Education located in Voluntary Hospitals including the Centre for Midwifery Education was carried out by Isobel Butler on behalf of the HSE • HINI Vaccination Clinic Training 2009. At the request of the HSE Director of Nursing Services, the CME provided 28 x 2-3 hr Medication Protocol sessions, 12 Anaphylaxis workshops, 3 CPR-BLS study days for HCP and 4 Neonatal Update workshops for midwives and nurses from Dublin Mid Leinster and the Greater Dublin Area
Challenges for 2010
• Further Development of courses for staff from the 3 maternity hospital to include the following:
• Bereavement
• Gynaecology Update Study Day
• Diabetes in Pregnancy Update
• Neonatal IV Cannulation
• Parent Education Facilitator Programme
• Development of a website for the CME to be entitled www.centreformidwiferyeducation.ie
• HETAC Accreditation
153 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Department of Adult Radiology
Head of Department
Dr Mary T Keogan
Staff Complement
3 radiographers (shared with Paediatric and Perinatal service)
Key Performance Indicators
Radiographs 247
Ultrasounds 1990
Total adults examinations 2237
Achievements in 2009
• Expansion of the general adult and gynaecological service despite space constraints (1692 ultrasounds in 2008, 1990 in 2009).
Challenges for 2010
• The Radiology Department was pleased to welcome Ms. Patricia McGinty, sonographer who has joined the Adult Gynaecology Ultrasound Service and we are also pleased to welcome Ms. Zoe Mnguni as a new radiographer.
• The key challenge is to deliver an adult radiology service in the limited physical space required.
154 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Department of Paediatric Radiology
Head of Department
Dr D Rea ( Paediatric Radiology)
Staff Complement
2 radiographers shared between adult and paediatric services 1 Clinical Specialist Radiographer and 1 senior post.
Key Performance Indicators
Outpatient radiographs 1432
Inpatient radiographs 1791
Inpatient ultrasounds 810
Total paediatric examinations 4030
Achievements in 2009
• Appointment of Consultant Paediatric Radiologist in August 2009.
• Teaching registrars on the RCSI Radiology Training Scheme about neonatal imaging, particularly emergency US.
• Improving standards for neonatal MRI in OLHC, with appropriate imaging guidelines.
Challenges for 2010
• The fetal MRI imaging service has been taken over by the paediatric imaging group in Crumlin. We look forwards to collaborating with our obstetric colleagues in this exciting field.
• Continuing to meet the growing requirements of a busy neonatal department.
• To provide the adequate staffing framework to allow development of a hip ultrasound service for the orthopaedic team.
155 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Department of Pathology/Division of Laboratory Medicine
Laboratory Medicine [Administration]
Administration
Head of Department
Director of Pathology
Professor John O’Leary
Staff Complement
Prof John O’Leary Director of Pathology Martina Ring Chief Medical Scientist (Laboratory Manager) Ruth O’Kelly Principal Biochemist
Pathology Consultants
Dr Niamh O’Sullivan Microbiology Dr Catherine Flynn Haematology/Transfusion Dr James O’Donnell Haematology Dr Barry White Haematology Dr Colette Adida Histopathology/Cytology Dr Anna Radomska Histopathology/Cytology (Locum)
Pathologist
Dr Joseph Stuart Morbid Anatomy
Pathology Quality/IT Manager
Stephen Dempsey
Staff Complement
Medical Scientist & Lab Aide Staff 36 WTE Biochemists 3 WTE Phlebotomist 2 WTE (one locum) Administration/Clerical Staff 4.5 WTE Laboratory Porter 1 WTE Specialist Registrar [SPR] Histopathology 1 WTE Consultant Staff 3 WTE Haemovigilence Officer 1 WTE
156 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Key Performance Indicators
Area 2005 2006 2007 2008 2009 Microbiology 155993 173767 163175 49463* 46897 Biochemistry 108622 109238 109701 167484 113709 Haematology 52373 52579 50856 44949 47523 Transfusion 19705 21780 23158 24548 24544 Cytopathology 14064 14090 16969 17401 14934 Histopathology 5261 5564 4918 4999 5601 Post mortems 32 39 46 70 50 Phlebotomy 11772 11896 12321 13877 15662
* = new numbering system adopted in 2008
Achievements in 2009
• Award of INAB accreditation and full compliance with ISO 15189 to the Cytopathology Department.
• The Transfusion Medicine Department maintained its compliance with ISO 15189.
• Excellent external quality assurance [EQA] performance in all pathology disciplines.
• MScs were awarded to four of the Pathology Departments staff-Declan Lyons in Haematology, Brid King in Histopathology, Teresa Sweeney in Biochemistry and Sabrina McCaffrey in Microbiology.
• Graham O’Lone and John Savage successfully completed The Laboratory Assistant SKILLS FETAC Certificate programme.
• The Pathology Dept. provided in service training to two third year DIT Medical Laboratory Science students.
• Continued growth of research student numbers at PhD, MSc and MD levels.
• Continued growth in research funding for Molecular Pathology.
• Continued and expanded funding from EU 7th FP.
Challenges for 2010
• Completion of accreditation in Histopathology and Haematology.
• Appointment of a molecular scientist for molecular diagnostic service provision.
157 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Histopathology and Morbid Anatomy
Head of Department
Professor John O’Leary
Staff Complement
Scientific Head of Department
Jacqui Barry O’Crowley
Consultant Pathologists
Professor John O’Leary Dr Colette Adida Dr Anna Radomska
Pathologist
Dr Joe Stuart
Non Consultant Hospital Doctors
Dr Aoife Canney Dr Linda Mulligan
Scientific Staff
Jacqui Barry O’ Crowley Senior Medical Scientist (1 WTE) Bríd King Acting Senior Medical Scientist from De ’09 Paul Moorehead Medical Scientist (1 WTE) Ciara Murphy Medical Scientist (1 WTE) Elaine Matthews Medical Scientist (1 WTE) Louise Kehoe Medical Scientist (1 WTE) for Colposcopy Johnny Savage Lab Assistant (1 WTE) Niamh Walsh Lab Assistant (1 WTE) for Colposcopy Graham O’Lone Post mortem technician (0.5 WTE)
158 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Key Performance Indicators
Overall specimen throughput
Specimens 5601 Blocks 27,970 Slides 31,900 Special Stains 250 Manual Immunocytochemistry 2,351 Frozen Sections 7 Post Mortems 42
Colposcopy Specimens 2009
Specimen Type Case Numbers Blocks Numbers
LLETZ 975 Generates approximately 15 blocks per sample with x 2 levels on each block
Cervical Bx 760 With x 3 levels on each block
UK External Quality Assessment 2009
UK National External Quality Assessment Results for Routine Haematoxylin/Eosin Stained Tissue Sections
159 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Specimen Turnaround Times
Achievements in 2009
• Submitted our application to INAB for ISO15189 accreditation in July 2009. • INAB Pre-Inspection of the histopathology laboratory took place in October 2009. • Increased the number of Immunohistochemistry panels of antibodies offered to Pathologists. • Continue to be involved in the following Quality Assurance Schemes; 1. UKNEQAS: H/E, Special Stains and Immunohistochemistry Quality Assurance schemes. 2. NordiQC: Immunohistochemistry Quality Assurance scheme. The histopathology department’s QA results continue to be above the National average score. • Researching Silver In-Situ Hybridisation (SISH) with a view to its implementation routinely in molar pregnancy diagnostics. • Brid King completed and was awarded a Masters in Molecular Pathology. • John Savage completed his FETAC Healthcare programme and was awarded L5 Certification. • All medical scientists take part in a CPD programme.
Challenges for 2010
• INAB Accreditation Certification for histopathology. • Proceed with Internal Audits for Histopathology. • To offer Silver In-Situ Hybridisation in molar pregnancy diagnostics. • Develop an Inter Laboratory IHC Assessment Scheme. • Staff attendance at Ventana IHC Training Programme. • Staff attendance at UKNEQAS seminars.
160 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Cytopathology
Head of Department/Division/Clinical Area
Professor John O’Leary
Staff Complement
Scientific Head of Department
Noel Bolger
Consultant Pathologists
Professor John O’Leary Dr Colette Adida Dr Anna Radomska
Scientific Staff
1 Chief Medical Scientist ( 1WTE) Noel Bolger 1 Senior Medical Scientist 1(WTE) Mary Sweeney Medical Scientist (1WTE) Grace Creighton Medical Scientist (0.5WTE) Mary McKeown Medical Scientist (1WTE) Roisin O’Brien Medical Scientist (1WTE) Niamh Cullen Lab Aide (0.5 WTE) Graham O’Lone Clerical Officer (2 x 0.5 WTE) Anne O’Reilly & Mary Nugent
Key Performance Indicators
• External QC/Internal Audit
• Irish Cervical Screening Program (ICSP) Report – Quarterly
Specimen throughput 2009 2008 Specimen throughput 14935 17401 Out patients Department 1500 (10.0%) 1768 (10.2%) Consultants Clinics 4168 (28.0%) 2293 (13.2%) Colposcopy Clinics 4380 (29.3%) 3118 (17.9%) General Practitioners 4885 (32.70%) 10222 (58.7%)
161 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Results of smears from all sources
2009 2008 Unsatisfactory 664 (4.4%) 473 (2.7%) Negative 10815 (72.4%) 14223 (81.7%) Borderline 996 (6.7%) 1039 (6.0%) CIN 1 1714 (11.5%) 1143 (6.6%) CIN 2 444 (3.0%) 328 (1.9%) CIN 3 277 (1.9%) 180 (1.0%) CGIN 25 (0.2%) 15 (0.1%)
Achievements in 2009
• Attainment of ISO 15189 accreditation.
Challenges for 2010
• In 2009, 93.8% of smear reports were reported within the one-month turnaround time (TAT). In 2010, it is hoped that all reports will be issued within this TAT.
162 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Haematology and Transfusion Medicine Laboratory
Head of Department
Dr Catherine Flynn
Scientific Head of Department
Sheila McMorrow
Staff Complement
1 WTE Chief Medical Scientist Sheila McMorrow 3 WTE Senior Medical Scientists Derek Merrin Karen Foley Declan Lyons (Acting) 4 WTE Staff Grade Medical Scientists Lillian Broderick Theresa O’Donovan Therese Coholan Jennifer Kennedy 1 WTE Haemovigilance Officer Sonia Varadkar 0.5 WTE Clerical Officer Maureen Hand
Key Performance Indicators
• External/Internal Quality Control
• Irish Medicines Board hospital blood bank annual report
• Maintaining INAB accreditation for transfusion medicine
Specimen Throughput
Haematology
Internal tests: 42,129 (39,517 in 2007 increase 6.6%) External tests: 2820 (2629 in 2007 increase 7.2%)
Transfusion Medicine Internal tests: 24,544
163 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Achievements in 2009
• Maintained INAB ISO 15189 Accreditation for Transfusion Medicine.
• Achieved INAB ISO 15189 accreditation for fetomaternal haemorrhage (FMH) estimation by flow cytometry.
• New coagulation analyser for haematology laboratory.
Challenges for 2010
• INAB inspection for accreditation for haematology laboratory to be completed in early 2010.
• Cost saving in the department.
• Expansion of FMH estimation service to include other maternity hospitals in Ireland.
• Blood wastage review/audit and improvement within our HSE network.
• Recruitment of 1 permanent senior medical scientist.
164 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Haemovigilance
Head of Service
Dr Catherine Flynn
Staff Complement
1 WTE Haemovigilance Officer Sonia Varadkar
Key Performance Indicators
• Number of women transfused 216
• Number of women who received 5 or more RCC 20
• Number of babies who received pedipacks 95
• Neonatal exchange transfusions 0
• Reports to National Haemovigilance Office 5
• Umbilical Cord Blood Collection 4 (under the direction to the IBTS)
Achievements in 2009
• Accreditation ISO 15189 (INAB Accreditation).
• 100% traceability of blood components and blood products.
Challenges for 2010
• Education of staff.
• Review guidelines/SOPs relating to blood components and blood products.
• Transfusion rate reduction – staff identifying risk factors early and involvement in Massive Obstetric Haemorrhage Drills.
• To maintain ISO 15189 Accreditation.
165 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Microbiology and Infection Prevention and Control
Heads of Department/Division/Clinical Area
Dr. Niamh O’Sullivan Consultant Microbiologist Rosena Hanniffy Assistant Director of Midwifery/Nursing Infection Prevention and Control Dr. Catherine Byrne Chief Medical Scientist
Staff Complement
0.3 Session Consultant Microbiologist Dr Niamh O’Sullivan 1 WTE Infection Prevention and Control ADoM/N Rosena Hanniffy 1 WTE Chief Medical Scientist Dr Catherine Byrne 1 WTE Surveillance Scientist (Senior Grade) Anne Marie Meenan 2 WTE Senior Medical Scientists Sheila Collins Kelly Anne Herr 3 WTE Staff Grade Medical Scientists Ciaran Byrne Sabrina McCaffrey Andrea Hoyne 0.5 x 2 Lab Aides Teresa Hannigan Susan Byrne
Key Performance Indicators
• Infection prevention and hygiene audits.
• Number and type of infection prevention and control education sessions.
• Surveillance of antibiotic resistant isolates and curtailment of spread.
• NICU bacteraemia rates.
• Microbiology turnaround times.
• External Quality Control performance.
• Microbiology specimen throughput: Internal 34197 External 12700 Total 46897
• External/Internal Quality Control Audit.
• EARSS (European Antimicrobial Resistance Surveillance System).
166 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Achievements in 2009
• Infection Prevention and Control Committee quarterly meetings chaired by Professor Michael Turner.
• Infection Prevention and Control Education including induction and targeted specialist sessions e.g. aspergillosis for contractors. Hand hygiene education remains the cornerstone of education.
• Audit and monitoring of hand hygiene continues as required by HSE/HPSC.
• Involvement in capital development projects: CSSD, NICU, Catering Department, Theatre decontamination area, Colposcopy department and Ultrasound.
• Targeted environmental sampling.
• The Surveillance Scientist in the CWIUH developed a form to collect data on Caesarean Section Surgical Site Infections. This form was adopted by the HPSC for national rollout.
• Management of H1N1 outbreak.
• Sabrina McCaffrey was awarded MSc. Sabrina’s work on subtyping CWIUH isolates of Group B streptococcus and their sensitivity patterns will extend our understanding of this pathogen.
• Group B Streptococcus susceptibility testing continued; a large body of data will be analysed and results used to inform prescribing.
Challenges for 2010
• The scope of the infection prevention and control team continues to expand. This includes but is not limited to: • Staff screening • Caesarean Section SSI surveillance • Outbreak management • Development and update of policies • Education and induction training • National audits – Hygiene and Decontamination • Drugs and therapeutics • Antimicrobial guidelines for Paediatrics • Environmental monitoring and Infection Control issues related to refurbishment
• Microbiology contributes to many areas of Infection Control. Challenges in 2010 include: • Microbiology Cost containment • Preparation for INAB Accreditation • Provision of data for Hospital Clinical audits • Development and update of Standard Operating Procedures
• One of the greatest challenges to Microbiology and the Infection Prevention and Control Team is dealing with an ever-increasing volume of documentation from HSE, NHO and HIQA.
167 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Biochemistry Department
Head of Department/Division/Clinical Area
Ms Ruth O’Kelly Principal Biochemist
Staff Complement
1 WTE Principal Biochemist Ruth O’Kelly 0.5 WTE Senior Biochemist Dr Stan Barry 0.9 WTE Specialist Medical Scientist Ann O’Donnell Pentony 1 WTE Senior Biochemist Mary Stapleton 0.5 WTE Senior Biochemist Eileen Byrne 1 WTE Basic Grade Medical Scientist Teresa Sweeney (post vacant from Sept 2009)
Key Performance Indicators
• External and Internal Quality Control.
• Involvement in Multidisciplinary Team Meetings (Diabetes Team, Perinatal Review, POCT committee).
• Total in-house Biochemistry tests for 2009 were 160683. A small decrease (4%) was seen in Electrolyte requests reflecting increased confidence in Point of Care testing (POCT) in the NICU. However increases (10%) were seen in Thyroid function tests (due to the increased awareness of adequate thyroid function in pregnancy) and in Glucose requests (reflecting the increased risk of diabetes in the general population particularly in women of child-bearing age).
• Members of staff attended Irish and UK Scientific conferences during the year (IEQAS, ACBI. WEQAS, FOCUS).
Achievements in 2009
• A study of the use of Procalcitonin in neonatal sepsis was performed in conjunction with the NICU as part of an MSc project.
• The Principal Biochemist, as member of the ACBI scientific committee and the POCT Consultative Group, conducted a national survey on Point of Care Testing in Ireland. The results were presented at the IEQAS annual conference.
• Cost savings were achieved by removing infrequently requested tests from our test menu.
• Ann O’Donnell Pentony was upgraded to Specialist Scientist to reflect her specialisation in training particularly in the area of POCT.
• The department facilitated work experience for Transition year students and third year Biomedical Science degree students.
168 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Challenges for 2009
• Loss of staff
• Increased workload
• Accreditation
• Roll-out of POCT
• Increased incidence of diabetes
169 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Phlebotomy Service (OPD)
Head of Department Martina Ring Chief Medical Scientist ( Laboratory Manager)
Staff Complement
0.5 WTE x 2 Hazel Robins Susanna Hansen 1 WTE (locum) Artemio Arganio
Key Performance Indicators
Continued increase in workload through the department, which is now providing a service to the Private Clinics for their patients.
2003 2004 2005 2006 2007 2008 2009 First Visits 5383 5147 5522 5860 6435 6509 7212 Other Visits 6382 6250 6036 5886 7269 8450 Total 11529 11772 11896 12321 13778 15662
Phlebotomy statistics 2 003-2000
18000
16000
14000
12000
10000 First Visits Other Visits 8000 Total
6000
4000
2000
0 2003 2004 2005200620072008 2009
Y e a r
Achievements in 2009
• Maintenance of INAB Accreditation and full compliance with ISO 15189 for Phlebotomy as relates to the Transfusion Medicine.
Challenges for 2009
• Cost saving in the department while continuing to provide an increased quality driven service.
170 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Molecular Pathology
Heads of Department
Professor John J. O’Leary Dr Niamh O’Sullivan
Staff Complement
Consultants Professor John J. O’Leary Dr Niamh O’Sullivan Dr Colette Adida Dr Anjia Radomska
Academics Dr Cara Martin (TCD) Professor Orla Sheils (TCD)
Laboratory Manager Dr Cara Martin (TCD/CWH)
Research Scientists Ms Loretto Pilkington Dr Michael Gallagher Dr Helen Keegan Dr Sharon O’Toole (TCD) Dr Catriona Logan (OLHC) Dr Adele Habbington (OLHC)
Research Students
MD Dr Cathy Allen, Dr Edgar Mocanu
PhD Jamie McInerney, Cathy Spillane, Louise Kehoe, Yvonne Salley, Salah Elbaruni, Christine White, Itunu Soyingbe, Brendan Ffrench, Lynda McEvoy, Mairead Murphy, Aoife Cooke, Aoife Canney, Sebastian Vencken, Lisa Keogh, Katharine Astbury, Andrea Nugent, Gary Sommerville, Emma Cantwell, Darragh Crowley, Aneta Radwizon.
Research Associates Prof Michael Turner (UCD), Prof Walter Prendiville (RCSI), Dr Tom D’Arcy, Dr Gunther von Bunau, Dr Mary Anglim, Dr Margaret Sheridan, Dr Bridgette Byrne (RCSI), Prof Sean Daly (TCD), Prof Eoin Gaffney (TCD), Prof Colm O’Morain (TCD), Dr Eamonn McGuinness, Dr Sharon O’Toole, Dr Niamh O’Sullivan, Dr Grainne Flannelly (NMH), Dr Susan Clarke (SJH), Dr Fiona Mulcahy (SJH), Professor Dolores Cahill (UCD), Professor Steve Pennington (UCD), Professor Brian MacCraith (DCU), Dr Fiona Lyng (DIT), Dr Linda Sharpe (NCRI), Prof Charles Normand (UCD).
171 Coombe Women & Infants University Hospital Annual Clinical Report 2009
PUBLICATIONS, ABSTRACTS & GRANTS IN 2009
Abstracts K Astbury, L McEvoy, M Ring, CM Martin, JJ O’Leary. Expression Levels of Nuf2 in Cervical Dysplasias and Cancers. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A. doi:10.1038/modpathol.2008.237. RJ Flavin, M Gallagher, S Elbaruni, CC Heffron, S O’Toole, P Smyth, A Laios, S Aherne, C Martin, K Lao, O Sheils, JJ O’Leary. Downregulation of miRNAs in Pluripotent Cancer Stem Cells Is Mirrored in Advanced Ovarian Serous Carcinoma. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A doi:10.1038/modpathol.2008.237. M Gallagher, S Elbaruni, R Flavin, C Martin, A Laios, S O’Toole, O Sheils, JJ O’Leary. Regulation of Toll-Like Receptors in Cancer Stemness: A Pro Inflammatory Switch Model. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A. doi:10.1038/modpathol.2008.237. YM Salley, P Smyth, CM Martin, O Sheils, JJ O’Leary. Holoclone and Non-Holoclone Derived Cell Lineage miRNA Analysis in Prostate Cancer. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A. doi:10.1038/ modpathol.2008.237. C Allen, CM Martin, JJ O’Leary. Gene Expression Profiling of Peripheral Blood during In Vitro Fertilisation Treatment Reveals Predictive Markers of Pregnancy. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A. doi:10.1038/modpathol.2008.237. M Barrett, C Hannigan, J McInerney, R Flavin, L Pilkington, CM Martin, O Sheils, M Griffin, JJ O’Leary. Co- Analysis of HPV DNA, mRNA E6/E7 HR-HPV Expression and mcm2 and TOPIIa (ProEx C) in Cervical Pre-Cancer. Modern Pathology, Jan 2009; Vol.22, Iss.1s 1-377A. doi:10.1038/modpathol.2008.237. K Astbury, L McEvoy, M Ring, CM Martin, JJ O’Leary. Expression Levels of Nuf2 in Cervical Dysplasias and Cancers. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.139. RJ Flavin, M Gallagher, S Elbaruni, CC Heffron, S O’Toole, P Smyth, A Laios, S Aherne, C Martin, K Lao, O Sheils, JJ O’Leary. Downregulation of miRNAs in Pluripotent Cancer Stem Cells Is Mirrored in Advanced Ovarian Serous Carcinoma. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.139. M Gallagher, S Elbaruni, R Flavin, C Martin, A Laios, S O’Toole, O Sheils, JJ O’Leary. Regulation of Toll-Like Receptors in Cancer Stemness: A Pro- Inflammatory Switch Model. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.139. YM Salley, P Smyth, CM Martin, O Sheils, JJ O’Leary. Holoclone and Non-Holoclone Derived Cell Lineage miRNA Analysis in Prostate Cancer. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.139. C Allen, CM Martin, JJ O’Leary. Gene Expression Profiling of Peripheral Blood during In Vitro Fertilisation Treatment Reveals Predictive Markers of Pregnancy. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.154. M Barrett, C Hannigan, J McInerney, R Flavin, L Pilkington, CM Martin, O Sheils, M Griffin, JJ O’Leary. Co- Analysis of HPV DNA, mRNA E6/E7 HR-HPV Expression and mcm2 and TOPIIa (ProEx C) in Cervical Pre-Cancer. Laboratory Investigations, Jan 2009; Vol.89, Iss.1s 4A-416A. doi:10.1038/labinvest.2008.139. Spillane CD, Kehoe L, Sheils O, Martin CM, O’Leary JJ. Growth Inhibition of Cervical Cancer cells by RNA Interference. 25th International Papillomavirus Meeting, May 8-14th, 2009: Malmo, Sweden. L Kehoe, CD Spillane, M Gallagher, O Sheils, C Martin, JJ O'Leary. The p16[INK4A] Pathway in Cervical Cancer. 25th International Papillomavirus Meeting, May 8-14th, 2009: Malmo, Sweden. C. Allen, C. Martin, E. Mocanu, J. O’ Leary. Gene expression profiles during in vitro fertilization treatment describe the functional transcriptome of the peri-conceptual period. Human Reproduction 2009 24: i105-i107; doi:10.1093/humrep/dep765.
172 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Papers Published in Peer-Review Journals (2009) Gallagher MF, Flavin RJ, Elbaruni SA, McInerney JK, Smyth PC, Salley YM, Vencken SF, O'Toole SA, Laios A, Lee MY, Denning K, Li J, Aherne ST, Lao KQ,Martin CM, Sheils OM, O'Leary JJ. Regulation of microRNA biosynthesis and expression in 2102Ep embryonal carcinoma stem cells is mirrored in ovarian serous adenocarcinoma patients. J Ovarian Res. 2009 Dec 16;2:19. PubMed PMID: 20015364; PubMed Central PMCID: PMC2805659. Sheedy FJ, Palsson-McDermott E, Hennessy EJ, Martin C, O'Leary JJ, Ruan Q, Johnson DS, Chen Y, O'Neill LA. Negative regulation of TLR4 via targeting of the proinflammatory tumor suppressor PDCD4 by the microRNA miR-21. Nature Immunol. 2010 Feb;11(2):141-7. Epub 2009 Nov 29. PubMed PMID: 19946272. Baier T, Hansen-Hagge TE, Gransee R, Crombé A, Schmahl S, Paulus C, Drese KS, Keegan H, Martin C, O'Leary JJ, Furuberg L, Solli L, Grønn P, Falang IM, Karlgård A, Gulliksen A, Karlsen F. Hands-free sample preparation platform for nucleic acid analysis. Lab Chip. 2009 Dec 7;9(23):3399-405. Epub 2009 Sep 30. PubMed PMID: 19904407. Flavin R, Smyth P, Barrett C, Russell S, Wen H, Wei J, Laios A, O'Toole S, Ring M, Denning K, Li J, Aherne S, Sammarae D, Aziz NA, Alhadi A, Finn SP, Loda M, B S, Sheils O, O'Leary JJ. miR-29b expression is associated with disease-free survival in patients with ovarian serous carcinoma. Int J Gynecol Cancer. 2009 May;19(4):641- 7. PubMed PMID: 19509563. Martin CM, Astbury K, McEvoy L, O'Toole S, Sheils O, O'Leary JJ. Gene expression profiling in cervical cancer: identification of novel markers for disease diagnosis and therapy. Methods Mol Biol. 2009;511:333-59. PubMed PMID:19347305. Keegan H, Mc Inerney J, Pilkington L, Grønn P, Silva I, Karlsen F, Bolger N, Logan C, Furuberg L, O'Leary J, Martin C. Comparison of HPV detection technologies: Hybrid capture 2, PreTect HPV-Proofer and analysis of HPV DNA viral load in HPV16, HPV18 and HPV33 E6/E7 mRNA positive specimens. J Virol Methods. 2009 Jan;155(1):61-6. Epub 2008 Nov 13. Maher SG, Gillham CM, Duggan SP, Smyth PC, Miller N, Muldoon C, O'Byrne KJ, Sheils OM, Hollywood D, Reynolds JV. Gene expression analysis of diagnostic biopsies predicts pathological response to neoadjuvant chemoradiotherapy of esophageal cancer. Ann Surg. 2009 Nov;250(5):729-37. PubMed PMID: 19801928. Nucera C, Eeckhoute J, Finn S, Carroll JS, Ligon AH, Priolo C, Fadda G, Toner M, Sheils O, Attard M, Pontecorvi A, Nose V, Loda M, Brown M. FOXA1 is a potential oncogene in anaplastic thyroid carcinoma. Clin Cancer Res. 2009 Jun 1;15(11):3680-9. Epub 2009 May 26. PubMed PMID: 19470727. Mocanu E, Shattock R, Barton D, Rogers M, Conroy R, Sheils O, Collins C, Martin C, Harrison R, O'Leary J. All azoospermic males should be screened for cystic fibrosis mutations before intracytoplasmic sperm injection. Fertil Steril – accepted
Book Chapters
Martin CM, Astbury K, McEvoy L, O'Toole S, Sheils O, O'Leary JJ. Gene expression profiling in cervical cancer: identification of novel markers for disease diagnosis and therapy. Methods Mol Biol. 2009;511:333-59. PubMed PMID: 19347305.
173 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Grants
Title: HPV mRNA and p16 INK4a detection for improved diagnosis and management of cervical neoplasia in smokers (2009-2012) Awarding Body: Cancer Research Ireland. Total value: €120,000
Title: Molecular pharmacological targeting of a viral transforming protein in cervical pre- cancer and cancer (Co-applicant) Awarding Body: The Meath Foundation, www.meathfoundation.com Total value: €43,000
Title: A novel tool for cervical cancer screening based on low resolution Raman spectroscopy, CERVASSIST. (Co-applicant) Awarding Body: Enterprise Ireland, www.enterprise-ireland.com Total value: €339,915
Title: EU 7th FP grant (FP7-HEALTH-2007-A) Automatic Cancer Screening Based on real-time PCR (2008-2011) (Principal Investigator) Awarding Body: European Union 7th Framework Programme Total value: €4,188,503 EU contribution €2,999,770
Title: Hsa-miR-141 and hsa-miR-223 are central to Ovarian Serous Carcinoma Pathogenesis through Regulation of JAG1 and SMARCD1 proteins.(Principal Investigator) 2008-2011 Awarding Body: Cancer Research Ireland Total value: €150,000 for 3 years
Title: Regulation and Function of Toll-like Receptors in Ovarian Cancer: A Synergistic Model (2009-2012) (Principal Investigator) Awarding Body: Cancer Research Ireland Total value: €168,000
Title: Improving GPs' knowledge of cervical screening, HPV infection and HPV vaccination: a randomised controlled trial of educational interventions. (Principal Investigator) Awarding Body: Friends of the Coombe Total value: €158,000
Title: Antibody profiling in ovarian cancer (2008-2011) Awarding Body: Emer Casey Foundation http://www.emercaseyfoundation.com Total Value: €150,000
Title: Hypoxia and ovarian cancer Awarding Body: Emer Casey Foundation http://www.emercaseyfoundation.com Total Value: €150,000
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Title: Cancer stem cells in ovarian cancer Awarding Body: Emer Casey Foundation http://www.emercaseyfoundation.com Total Value: €150,000
Title: Specific Targeting of Cancer Stemness: Potential Cancer Therapy? (2008-2011) Awarding Body: Cancer Research Ireland Total value: €150,000 for 3 years
Title: Working towards a world-class cervical screening system for Irish Women. 2006-2011 Awarding body: HRB Health services R&D Award Total Value: €1,250,000
Title: Health Research Board 2004-2008 PhD training site grant Awarding body: Health Research Board Total value: €4,000,000.00
175 Coombe Women & Infants University Hospital Annual Clinical Report 2009
2009 Hygiene Services Report
Hygiene Services remains an integral part of the day-to-day workings of this hospital and following on from the recommendations of the 2007 and 2008 Health Information and Quality Authority (HIQA) reports, the hospital appointed a Hygiene Services Coordinator in May 2009 to lead the Hygiene Team and chair the Hygiene Services Committee to ensure continuous improvements in hygiene services.
The Hygiene Services Committee is a multi-disciplinary committee that includes senior management and continues to meet on a monthly basis. The Hygiene Services Inspection Team carries out weekly ‘walkabouts’ to conduct unannounced audits on wards and in departments. The hygiene services programme is further supported through regular tours of the hospital campus by members of the Board of Guardians & Directors of the hospital.
In 2009, HIQA expected that all hospitals are achieving levels of compliance greater than 85%, with the essential requirements to deliver safe, efficient and effective hygiene services as set out in the National Hygiene Services Quality Standards. They now carry out a series of randomised unannounced monitoring assessments focusing specifically on the day-to-day delivery of hygiene services and in particular cleanliness, hand hygiene and waste and linen management practices. Regardless of the results of the monitoring assessment, the ratings achieved by hospitals in 2008 remain unchanged.
Achievements in 2009
• Appointment of Hygiene Services Coordinator.
• Upgrading of Patient Sanitary Facilities at Ward level.
• Refurbishment of Main Hospital Kitchen completed.
• Refurbishment of Phase I of NICU completed.
• Development of plans for the upgrading and refurbishment of CSSD.
• Refurbishment of Old School of Midwifery to accommodate relocation of Perinatal Ultrasound completed.
• Introduction of Permanent Night Cleaner role.
• Continuation of Hygiene Services, Patient Survey (Hygiene – Your Views).
• Refurbishment of Outpatient Clinic Areas.
• Installation of Secure Compound for Clinical Waste.
• Continuation of training for staff on hygiene, infection control and waste management issues.
• Evaluation of new hygiene services products at Hygiene Services Committee meetings.
• Hand Hygiene Audits undertaken.
• Continuation of programme for ultrasonic cleaning of window blinds and fly screens.
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• Development of business cases for Hygiene Services associated works.
• Replacement of all clinical and non-clinical waste bins in clinical areas.
• Replacement of all seating, which had fabric covering to those with a washable vinyl.
• Increased recycling facilities for wood, metal, bulky items and glass.
• Introduction of absorbent material for liquid healthcare waste resulting in cost savings of over €6k per annum.
The Hygiene Services Committee continue to review new technologies for the improvement of hygiene services and through involvement in the procurement process, ensuring that projects being undertaken or items being purchased are assessed and approved, taking compliance with hygiene services into account.
A number of business cases for funding, specifically relating to hygiene, were submitted to the HSE during 2009, which included:
• Provision for upgrading of patient and public sanitary facilities.
• Upgrade of CSSD.
• Refurbishment works to the Neonatal Unit.
• Upgrade of storage facilities.
Challenges for 2010
• Upgrading hygiene facilities to incorporate implementation of flat mop system.
• Enhanced training for hygiene staff to optimise cleaning standards.
• Improving hygiene standards within current budgetary constraints.
• Improvements in the recycling of various waste streams.
• Plans for upgrade of bathrooms and sinks is progressing as planned and are ongoing.
Summary
The Hygiene Services Committee and Hygiene Team work towards the constant improvement of our services rather than working specifically towards an audit or assessment as we believe that regardless of the assessment process maintaining these standards is good for patient care. The Hospital looks forward to 2010 as an opportunity to continue the innovative developments in the management and delivery of hygiene services and welcomes the chance to not only maintain but improve upon its current position.
Vivienne Gillen Hygiene Services Coordinator On behalf of the Hygiene Services Committee
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Department of Clinical Nutrition and Dietetics
Head of Department/Division/Clinical Area
Senior Dietitian Fiona Dunlevy (under management of Clinical Nutrition Manager Sandra Brady, St. James’s Hospital)
Staff Complement
1 WTE Senior Clinical Nutritionist
Key Performance Indicators
Outpatient attendances
2006 2007 2008 2009 Antenatal 77 105 94 82 Diabetic 366 412 449 382 Gynaecology 63 99 34 26 Paediatric 327 234 301 207 Postnatal 7 Total 833 850 878 704
Inpatient Consultations
2006 2007 2008 2009 Antenatal 194 413 332 228 Diabetic 409 398 373 348 Gynaecology 37 27 10 10 postnatal 59 Total 640 838 715 645
Reduction in activity reflects reduced hospital admissions, reduced overtime, capping of service to paediatrics and increased demand for dietetic representation on committees and working groups.
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Achievements in 2009
• Member of the steering committee for National Guidelines on the Management of Diabetes in Pregnancy and liaison with the CWIUH multidisciplinary team on the development of Hyperemesis Gravidarum care.
• Member of IES and INDI working groups.
• Continued participation in house study and training days.
Challenges
• To continue to provide high quality evidence based service within competing demands for limited dietetic resources. Activity does not reflect true need for dietetic services. Service has been prioritised based on clinical need and dietetic resources available.
• Increase liaison with multidisciplinary teams and integration with community services to improve nutritional advice given to mothers in particular during the complementary feeding stage for the infant.
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Pharmacy Department
Head of Department
Mairead McGuire
Staff Complement
1 WTE Chief Pharmacist Mairead McGuire 1WTE Senior grade Pharmacist Peter Duddy 1 WTE Basic grade Pharmacist Eimear Curran 1WTE Intern Pharmacist Fiona Butler (Jan-Sept 2009) Una Rice (Oct-Dec 2009)
Academic Staff
CWIUH/TCD/RCSI Lecturer/ResearchFellow Brian Cleary
Key Performance Indicators
• Increased clinical service provision: • Weekly Medical clinic • Twice weekly Acute pain round / team • NICU, including Paediatric Drug and Therapeutics Committee and attendance of morning meetings and rounds • Twice monthly Antenatal Guide Clinic
• The department dispensed 32,051 items to wards, outpatients, babies discharged from SCBU and staff.
• Maintained clinical service provision to wards eg regular review of drug kardexes.
• Electronic recording of medicines information queries – MIDatabank software introduced in May 2007. Seventy two new queries were recorded for 2009 and previously recorded queries were updated. Queries are searchable and all documentation is included in electronic format and can be accessed from OPD Medical clinic.
• Ongoing research collaborations with the Schools of Pharmacy in the Royal College of Surgeons in Ireland and University College Cork, the School of Medicine in Trinity College Dublin, the Rotunda Hospital, the HRB Centre for Primary Care Research (RCSI) and HSE Addiction Services.
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Achievements in 2009
• Continued development and revision of comprehensive NICU medication prescribing and administration guidelines.
• Participation in the multidisciplinary Post-operative Analgesia team.
• Continued implementation of Post-natal Analgesia guidelines.
• Continued strong post-graduate education ethos.
• One staff member progressed to the second year of an MSc in Clinical pharmacy (P. Duddy).
• PhD currently being undertaken within the department (B. Cleary).
• Another staff member commenced an MSc in Clinical Pharmacy (E. Curran).
• The only maternity hospital in Dublin with a research pharmacist.
• One member of staff commenced the new MPharm pharmacy Intern training year.
• Twice yearly review of antimicrobial guidelines. External funding was secured to enable professional printing of these guidelines.
• Educational links with the three Irish Schools of Pharmacy and one UK School of Pharmacy.
• Continued and expanded multidisciplinary participation eg antenatal guide clinic, acute pain round, medical clinic, D&T and Paed D&T committees.
• Continued co-working with the other maternity hospitals in Dublin.
• Established system of work placement s for 3 undergraduate Pharmacy students.
• Facilitation of second level students work placements where possible.
• Provision of information sessions on H1N1 2009 vaccination in pregnancy and guidance on use of antivirals for the management of pandemic influenza.
• Completion of an audit of Clarithromycin use for preterm prelabour rupture of membranes.
• Participation in the new intern Training year for the intern Pharmacist. This involves much more in-depth training for the intern and increased workload and input from the Tutor. However, the intern is now awarded an MPharm. at the completion of the training year.
Publications
Cleary BJ, Källén B. Early pregnancy azathioprine use and pregnancy outcomes. Birth defects research. Part A, Clinical and molecular teratology 2009; 85:647-54.
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Poster Presentations
Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Association of University Departments of General Practice in Ireland Research Conference – RCSI, Feb 2009.
Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Hospital Pharmacists Association of Ireland research conference – Dublin, April 2009. Winner of poster prize.
Prevalence and Predictors of Folic acid use during pregnancy in a large Irish obstetric cohort. Hospital Pharmacists Association of Ireland research conference – Dublin, April 2009.
Challenges
• To maintain current service levels without required additional staffing.
• To continue developing pharmacy services to meet the needs of the hospital and improve patient care without the required additional staff and appropriate staff skill mix.
• To achieve the optimum staff skill mix within the pharmacy, ie approval for a pharmaceutical technician, to allow for the most cost-effective use of pharmacy staff skills, with advantages for other areas of the hospital for example saving midwifery and medical time.
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Physiotherapy Department
Head of Department
Margaret Mason BA MA Grad DipPhys MCSP MISCP
Staff Complement
1 WTE Ogechi Nsoedo Physiotherapist (until April 2009) 1 WTE Anne McCloskey Physiotherapist (From July 2009) 1 WTE Eibhlin Mulhall Physiotherapist 1 WTE Mary Duffy Physiotherapy 0.6 WTE – unfilled throughout 2009
Key Performance Indicators
Antenatal Classes (number of attendances) 2760
Postnatal Classes (number of attendances) 920
Continence Information and education Class (number of attendances) 246
Inpatients
Obstetric 2020 Gynaecology 1075 Paediatric 1970
Outpatients
Obstetric 2455 Urogynaecology 1810 Paediatric 1725 Developmental 2674 DDH Talipes Torticollis Positional plagiocephaly
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Achievements in 2009
• Continuance of a high standard of service to women and infants, with limited resources. Unfortunately the waiting times for treatment of musculoskeletal problems increased due to the fact that we were not fully staffed during the whole of 2009. This will be addressed in 2010 by the establishment of class- based sessions for women with Pelvic Girdle Pain and Low Back Pain.
• We continued to provide services to the NICU/SCBU, the baby clinics, and to the specialist neurodevelopmental and orthopaedic clinics. The lack of resources in the community has led to many infants with special needs attending physiotherapy in CWIUH for longer due to long waiting lists for assessment and treatment by Early Intervention Services in the community. This has put huge strain on our services as we are not resourced for this kind of work.
• Continuing provision of a comprehensive range of adult services including pregnancy-related musculoskeletal conditions (pelvic girdle pain, back pain, carpal tunnel syndrome etc); promotion of continence and treatment of incontinence; pre-operative and post-operative physiotherapy; treatment of women who have sustained third/fourth degree tears; we also provided services to women with special needs who were pregnant.
• Continuation of our successful Continence Information and Education sessions for newly referred patients. The majority of patients with continence problems attend one of these sessions prior to individual treatment.
• The antenatal education classes (physiotherapy) continue to be very well attended particularly by women expecting their first baby and feedback from these classes is excellent.
• One member of staff continues to be involved in the multidisciplinary Neonatal Post-Discharge Support Group. This group was set up to provide support to families of babies who have spent time in the NICU and SCBU. It runs once a month on a Saturday morning and is facilitated by a Clinical Midwife Specialist and Clinical Nurse Manager from the neonatal centre, a physiotherapist and a medical social worker. Attendance at this group has continued to grow in the three years that it has been running and it has proven to be very successful with families.
• Participation in the multidisciplinary post-operative analgesia team.
• One member of staff commenced postgraduate work in Women’s Health at Bradford University.
Challenges for 2010
• To continue to provide high quality care with our very limited resources.
• To continue to develop the physiotherapy services within the constraints of the available resources.
• To establish exercise classes for women with pelvic girdle pain and low back pain.
• To develop the postnatal service through multidisciplinary awareness.
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Clinical Risk Management
Head of Department
Susan Kelly
Staff Complement
Ann Byrne, Assistant Clinical Risk Manager
Mission / Key Performance Indicators
• The promotion of patient safety through the delivery of a quality risk management service within the multidisciplinary team.
• The goal of effective risk management is not so much to minimise particular errors and violations as to enhance human performance at all levels of the system.
• Effective risk management is dependant on a reliable and robust reporting culture. The key purpose of a reporting culture is to identify system vulnerabilities that then lead to positive action and not merely to generate statistics.
Achievements in 2009
Mary Clune retired from her role as Clinical Risk Manager after many years of dedicated service in this post and to the hospital in general. Mary was among the pioneers in risk management in this country and raised the profile of risk management among the multidisciplinary team in the hospital. I would like to take this opportunity to wish her health and happiness in her retirement.
• The establishment of Divisional Incident Review Groups, which meet on a monthly basis to discuss incident reports received, track patterns and trends and identify educational/practice issues to be addressed.
• There has been an increase in the number of incident reports both clinical and non-clinical during the year and for that I sincerely thank my midwifery and medical colleagues. The reporting and analysis of incidents and near-miss events increases the likelihood of improved patient care and safety.
• The facilitation of information sessions and workshops on the introduction of a hospital Risk Register. The Risk Management process intertwines with the quality cycle and thus the HSE are driving an integrated Quality, Safety and Risk Framework.
• CMACE Ireland was launched in May 2009. I attended an Interactive Workshop on ‘Saving Mothers Lives’ facilitated by CMACE Ireland in conjunction with CMACH, UK. I am the contact person in the CWIUH for CMACE Ireland.
• I continue to participate in facilitating the regular education workshops on CTG Interpretation, which are collaboratively run by the 3 Dublin Maternity hospitals.
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Challenges for 2010
• To promote a positive safety culture by encouraging shared Perceptions of the importance of safety and confidence in the efficacy of preventative measures.
• To improve the service user experience and introduce service user involvement on committees within the hospital.
• To ally risk management principles with the organisation’s objectives in order to achieve maximum efficiency.
• To participate in the development of National Practice Guidelines in the context of the new Clinical Directorate System.
I would like to take this opportunity to acknowledge the commitment and diligence demonstrated by Ann Byrne, Assistant Clinical Risk Manager in continuing the work of this department during the prolonged absence through illness and then retirement of the previous incumbent. I would also like to personally thank her for her patience and assistance in orientating me to the role. I would like to acknowledge with gratitude the support and encouragement I have received from Dr. Chris. Fitzpatrick, Master, Ms.Patricia Hughes, Director of Midwifery/Nursing, and Mr. John Ryan, Secretary and General Manager. The support and commitment of the Risk Management Committee is very much appreciated. Finally I would like to acknowledge the generosity with which Dr. Karen Robinson, Clinical Risk Advisor, CIS and Ms. Marie Hutton, Solicitor/Claims Manager, SCA have shared their knowledge and expertise.
I would also like to thank Mary and Monica for their administrative support.
Susan P Kelly Clinical Risk Manager
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Information Technology Department
Head of Department/Division/Clinical Area
Tadhg O’Sullivan, IT Manager
Staff Complement
Ms Emma McNamee, Systems Administrator Mr Eamonn Sheridan, Technical Support Officer Ms Carol Cloonan, Technical Support Officer Ms Hilary Minogue, IT Midwife (job-sharing) Ms Anne Clarke, IT Midwife (job-sharing)
Key Performance Indicators
• Providing a high level of service to internal and external users of IT services.
• Providing high availability of equipment and services.
• Ongoing integration of systems and services.
• Ongoing provision of an effective statistical information service.
Achievements in 2009
• Ongoing implementation of the joint ICT strategy prepared under the aegis of the Joint Maternity Hospitals Standing Committee.
• Ongoing upgrade of core operational and technical environment.
• Implementation of a new Ultrasound Clinical Information System.
Challenges for 2010
• Increase in level and complexity of demands for IT services, both internally and externally, without commensurate increase in resources.
• Lack of clarity in national ICT strategy.
187 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Medical Social Work Department
In 2009 the permanent staffing complement in the Medical Social Work Department remained unchanged at five and half WTE posts. The Medical Social Workers employed during 2009 were:
Head of Department
Rosemary Grant
Staff Complement
Ms Nerilee Ceatha Ms Carmel Cronin B.Soc.Sc., MA Social Work, N.Q.S.W. Ms Tanya Franciosa B.S.S., N.Q.S.W. (Locum Post from November 2009) Ms Rosemary Grant B.S.S, C.Q.S.W. Ms Sorcha O’Reilly B.S.S. N.Q.S.W. Ms Denise Shelly B.Soc. Sc. C.Q.S.W. Ms Mary Treacy (part time post) B.Soc. Sc., H. Dip. in Ed., Dip. In Applied Social Studies, C.Q.S.W., MA in Social Work
The Reception/Secretarial services provided to the Medical Social Work Department changed during 2009. Ms Josephine Quinn who had worked in the Medical Social Work Department for many years retired at the end March 2009. In recent years Ms Quinn and Ms Bernie White jointly provided the Reception/Secretarial services to the Dietetics and Nutrition Department, the Medical Social Work Department and the Physiotherapy Department. Following Ms Quinn’s retirement it was decided to separate the three Departments. Ms White continued to provide the Receptionist/Secretarial services to both the Dietetics and Nutrition Department and the Physiotherapy Department. Ms Kerry Ann Durbin joined the Medical Social Work Department as Receptionist/Secretary.
Staff in the Medical Social Work Department adjusted during 2009 to the use of the computers supplied to the Medical Social Work Department late in 2008. This is an on-going process which in 2009 included the introduction of a computerised database for the Department. Work on a revised Referral Form was completed during 2009. This was done with a view to increasing the timely receipt of appropriate referrals, to decreasing the receipt of inappropriate referrals and to enabling referrals be prioritised appropriately. The updated Referral Form is used in conjunction with a newly instituted once weekly Allocations Meeting where issues such as the capacity of the Medical Social Worker to take on new referrals and the priority of the referral are taken into account.
During 2009 the Medical Social Workers continued to provide a social work service to patients, their partners and their families. Continuity of care was considered important by patients and by staff so the attachment of the Medical Social Workers to the Obstetric Teams (Public, Semi-Private and Private) continued where possible. Periodically this proved impossible due to the unpredictability of the caseload generated at any given time by a particular team. The provision of a dedicated service to the Special Care Baby Unit (Denise Shelly), to those with addiction problems (Carmel Cronin/Nerilee Ceatha from August 2009) and to those attending the Naas Clinic (Sorcha O’Reilly/Tanya Franciosa from November 2009) continued.
In 2009 the number of patients, who were referred to the Medical Social Worker by a range of professionals in the hospital and in the community and those who self referred, continued to increase. The unpredictability involved in the maternity setting continues to challenge the provision of a Medical Social Work service to
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patients. This is further challenged by the increasing emphasis on Combined Antenatal Care with the patient’s General Practitioner, attendance by patients at outlying Clinics and Early Transfer Home. The ‘window’ enabling patients to access a Medical Social Work service while they are actually in the hospital either as an in-patient or while attending an out-patient clinic is becoming shorter. At the same time the need for assessment of a patient’s situation is essential particularly if child protection concerns are raised. Referrals are prioritised and Child Protection concerns continue to receive the highest priority.
Appropriate referrals include public, semi-private and private patients who are attending the maternity, neonatal/paediatric and gynaecology departments. Referrals include patients who experience different problematic issues in their lives generally and those where issues arise as a result of the pregnancy. They include bereavement, domestic violence, addiction, relationship issues, mental health issues, underage pregnancy, the birth of a baby with special needs, child protection/child care issues, concealed pregnancy, crisis pregnancy and learning disability.
In all our work with patients, communication and liaison with a wide range of professional groups and voluntary specialist organisations within the hospital and in the community are essential. This liaison occurred during 2009 both at individual patient/family level and at a broader level. The Medical Social Work Staff continued to be involved in a formal way with organisations such as the Crisis Pregnancy Agency, the Teen Parent Support Programme, Women’s Aid the Irish Stillbirth and Neonatal Death Society and the Miscarriage Association of Ireland. The work done with Women’s Aid to develop a training module for the maternity setting will enable a wide range of staff that identify a domestic violence issue arising for women in their care to be able to respond appropriately.
The 31st of December 2009 saw the end of the Crisis Pregnancy Agency which was incorporated into the HSE on the 1st of January 2010 as its Crisis Pregnancy Programme. The Board of the Crisis Pregnancy Agency ceased operation at the time. My membership of the Board ceased marking the end of a nine year involvement on two distinct Boards of the Agency. Membership of the Board presented a wonderful opportunity for me as Principal Medical Social Worker in the Coombe Women and Infants University Hospital to learn from the other Board members and members of the staff of the Crisis Pregnancy Agency and to contribute both a Medical Social Work and a maternity hospital perspective on the issues being discussed. I trust that the new Crisis Pregnancy Programme of the HSE is successful and wish to express my best wishes to all of the staff in the CPA/CPP and to thank them for their enormous contribution to the very complex area of crisis pregnancy over the past 9 years.
Internally the Medical Social Workers continued to be involved in the teaching programme for the undergraduate RCSI medical students, for newly recruited midwives undergoing an inhouse orientation programme and also in the induction programme for new NCHDs in Obstetrics and Gynaecology.
The challenges facing the Social Work Department are many. The emphasis on child protection and crisis situations takes from the potential for preventative interventions with our patients and their families. The lack of access to a budget for training for Medical Social Workers is particularly difficult in a situation where ‘best practice’ is a definite goal. The increased pressure on families due to the broader economic situation is palpable. The staff of the Medical Social Work Department continue to be indebted to the members of Coombe Care who provide assistance to patients by way of necessary practical help at the time of a baby’s birth. This help may include clothing and toiletries for the mother for her admission and clothing and other items for the baby for its hospital stay and discharge home. They also provide vouchers over the Christmas period to enable patients to buy items for which they would not ordinarily have the resources. The work of the Coombe Care Committee is much appreciated by hospital patients, the staff in all areas of the hospital and in particular by staff of the Medical Social Work Department. Committee members are always willing to engage with the Medical Social Work team to discuss potential areas of need. During 2009 assistance was given to individual families who were in particular need where it was impossible to locate an alternative source of support.
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During 2009 as in other years, I have appreciated the support of the Head Medical Social Workers in other hospitals and in particular the support of Ms Loretto Reilly, Head Medical Social Worker, National Maternity Hospital and Ms Eilis McDonnell, Head Medical Social Worker, Rotunda Hospital. There has always been a good liaison between the three Social Work Departments, which contributes to the ideal of best practice. During 2009 the Medical Social Workers in the maternity hospitals continued to meet with the Social Workers in some Adoption Societies and others to discuss issues arising in the area of adoption and our respective roles when we meet a patient considering placing her baby for adoption. 2009 saw the launch of three booklets, Introduction to Adoption for birth parents, Adoption in Ireland Today for birth parents considering adoption and a Workbook for parents in the adoption process. These documents will also be of assistance to professionals in both the maternity hospitals and in the community who are providing care to a woman in this situation. The booklets were funded by the CPA and their production was coordinated by Treoir, an organisation which produces many valuable written resources for parents and professionals alike. The Medical Social Workers assigned to the Paediatric Units in each of the three hospitals continued to meet on a number of occasions during 2009 as did the Medical Social Workers working in the area of addiction. There were benefits to all in sharing knowledge and experiences of these particular areas of social work in the maternity setting.
In conclusion I would like to express my sincere appreciation to those who work in the Medical Social Work Department including the Medical Social Workers, Receptionist/Secretary. The demands on the social work service by patients and by hospital staff on their behalf continues to expand well beyond the level of service which such a small group can provide. The level of professionalism and the seeking to attain a standard of best practice demands a major commitment on the part of the staff in the Department, which is much, appreciated. The support of our colleagues in other departments within the hospital is essential as is the support of our colleagues both social work and non-social work within the community. This year it is particularly appropriate to wish Ms Josephine Quinn every success and happiness in her retirement and to welcome Ms Kerry Ann Durbin to the Medical Social Work Department.
Rosemary Grant Principal Medical Social Worker
190 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Psychosexual Therapy
Head of Department/Division/Clinical Area
Donal Gaynor
Staff Complement
One Counsellor (part-time)
Key Performance Indicators
• Number of Consultations Private 60 Public 146 Total 206 • Number of New visits Private 7 Public 13 Total 20 • Number of Return visits Private 53 Public 133 Total 186
Achievements in 2009
• Delivery of therapy to a couple where both partners presented with the same dysfunction, but resulting from different causes.
• The treatment of dysfunctions where the patients partner used internet pornographic sites to an excessive degree.
Challenges for 2009
• The provision of therapy to couples with either one partner or both is not able to attend the clinic with the optimum frequency due to difficulties arising from unemployment or work commitments as a consequence of the economic recession. This is the main reason for a reduction of appointments in the Private Clinic by 49% and in the Public Clinic by 11.5%.
• There was a notable increase in patients presenting with Vaginismus while their partner presented with Inhibited Sexual Desire.
191 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Chaplaincy
The Chaplaincy Department is staffed by Sr. Margaret Nolan FMDM. and Sr. Gina Chua FMM. The Parish of Our Lady of Dolours, Dolphins Barn continue to provide additional support. The Church of Ireland parishes and clergy of other denominations and religions are also available to patients. The Hospital Oratory is on the fourth floor is open day and night and everyone is welcome to visit and attend services.
Key Performance Indicators
• Bereavement counselling / spiritual support (fetal deaths/miscarriage) 249 • Funeral services 124 • Baptisms 55 • Naming/Blessing ceremonies 80 • Appointments for patients from past 22 • Counselling re fetal anomalies 12
Achievements in 2009
• Daily visits of wards/NICU providing spiritual/emotional support to patients and staff.
• Weekly attendance Perinatal MDT; monthly attendance at Perinatal Mortality/Morbidity MDT Audit.
• Integration of chaplaincy with MTD care teams in relation to bereavement after early pregnancy loss, peri-natal deaths and serious congenital fetal abnormalities.
• Installation of mini Hi-Fi system in Oratory has proved very beneficial; reflective music is played daily; this is greatly appreciated by staff, patients and relatives.
• Annual Service of Remembrance for bereaved parents and relatives.
• Book of Remembrance continues to be displayed in Oratory.
• Responsiveness to multi-ethnic, multi-cultural and multi-religious profile of mothers, women, partners and families attending the hospital.
• Increased access to international interpretation service.
The support and encouragement of all the Staff and Management is deeply valued.
Sr Margaret Nolan FMDM Chaplain
192 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Trinity College Dublin, Academic Department of Obstetrics & Gynaecology
Head of Department
Prof Deirdre J Murphy
Staff Complement
Deirdre J Murphy Professor, Head of Department, Consultant in Obstetrics Patricia Crowley Associate Professor, Consultant in Obstetrics & Gynaecology Sean Daly Clinical Professor, Consultant in Obstetrics & Gynaecology Mary Anglim Hon Senior Lecturer, Consultant in Obstetrics & Gynaecology Aoife Mullally Clinical Lecturer, Obstetrics & Gynaecology Sharon Sheehan HRB/Cochrane PhD Research Fellow Brian Cleary HRB PhD Research Fellow
Key Performance Indicators
Grant income
• Research Fellowship for Brian Cleary PhD, Supervisor D Murphy • PhD programme for Dr Sharon Sheehan, Supervisor D Murphy • HRB Clinical Trial €300,000, Principal Investigator D Murphy • HRB Pilot project €30,000 Co-Investigator D Murphy • HRB PhD programme (RCSI/TCD) €5m, Collaborator D Murphy • HSE Commissioned Research €250,000 Euro, Principal Investigator D Murphy • PhD programme for Andrea Nugent, Supervisor S Daly • HRB 2007-2011 €4,100,000 Perinatal Ireland, ESPRIT Study, Co-PI S Daly
Achievements in 2009
• 16 Peer-review publications in high impact journals including BMJ, Br J Obstet Gynaecol, Am J Obstet Gynecol.
• Invited plenary addresses at National and International meetings.
• Professor S Daly organiser of National Fetal Echocardiography Training Meeting.
Challenges/Opportunities
• Appointment of new Professor of Gynaecology (Consultant Obstetrics & Gynaecology) – joint appointment Trinity College Dublin, St James’s Hospital & Coombe Women and Infants University Hospital.
193 Coombe Women & Infants University Hospital Annual Clinical Report 2009
PUBLICATIONS, PRESENTATIONS & GRANTS
Original Publications in Peer-Review Journals McGuire M, Cleary B, Sahm L, Murphy DJ. Prevalence and predictors of peri-conceptional folic acid uptake – prospective cohort study in an Irish urban obstetric population. Hum Reprod [Epub 2009 Nov 12]. Bahl R, Murphy DJ, Strachan B. Qualitative analysis by interviews and video recordings to establish the components of a skilled low-cavity non-rotational vacuum delivery. Br J Obstet Gynaecol 2009;116(2):319-26. Frost J, Shaw A, Montgomery A, Murphy DJ. Women’s views on the use of decision aids for decision making about the method of delivery following a previous caesarean section: qualitative interview study. Br J Obstet Gynaecol 2009; 116: 896-905. Inkster ME, Fahey TP, Donnan PT, Leese GP, Mires GJ, Murphy DJ. The role of modifiable pre-pregnancy risk factors in preventing adverse fetal outcomes among women with type 1 and type 2 diabetes. Acta Obstet Gynecol Scand 2009 Aug 4:1-5. Murphy DJ, MacGregor H, Munishankar B, McLeod G. A randomised controlled trial of oxytocin 5IU and placebo infusion versus oxytocin 5IU and 30IU infusion for the control of blood loss at elective caesarean section – pilot study. ISCRCTN 40302163. Eur J Obstet Gynecol Reprod Biol 2009;142(1):30-3. Sheehan SR, Wedisinghe L, Macleod M, Murphy DJ. Implementation of guidelines on oxytocin use at caesarean section – A survey of practice in Great Britain and Ireland. Eur J Obstet Gynecol Reprod Biol [Epub 2009 Nov 6]. Murphy DJ, Carey M, Montgomery AA, Sheehan SR and The ECSSIT Study Group. Study protocol. ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial. A multi-centre randomised controlled trial of oxytocn (Syntocinon) 5IU bolus and placebo infusion versus oxytocin 5 IU bolus and 40 IU infusion for the control of blood loss at elective caesarean section. BMC Pregnancy and Childbirth 2009, 9:36. Barrett N, Sheehan SR, Murphy DJ. A complication after a previous caesarean section (uterine rupture). BMJ 2009, 339:b2979. Cleary BJ, Källén B. Early pregnancy azathioprine use and pregnancy outcomes. Birth defects research. Part A, Clinical and molecular teratology 2009;85:647-54. Bolton S, Cleary B, Walsh J, Dempsey E, Turner MJ. Continuation of metformin in the first trimester of women with polycystic ovarian syndrome is not associated with increased perinatal morbidity. European Journal of Pediatrics. 2009 Feb;168(2):203-6. Niedhammer I, O'Mahony D, Daly S, Morrison JJ, Kelleher CC; Lifeways Cross-Generation Cohort Study Steering Group. Occupational predictors of pregnancy outcomes in Irish working women in the Lifeways cohort. BJOG. 2009 Jun;116(7):943-52. Epub 2009 Apr 7. Kabir Z, Clarke V, Conroy R, McNamee E, Daly S, Clancy L. Low birthweight and preterm birth rates 1 year before and after the Irish workplace smoking ban. BJOG. 2009 Dec;116(13):1782-7. Epub 2009 Oct 13. Sweeney MR, Staines A, Daly L, Traynor A, Daly S, Bailey SW, Alverson PB, Ayling JE, Scott JM. Persistent circulating unmetabolised folic acid in a setting of liberal voluntary folic acid fortification. Implications for further mandatory fortification? BMC Public Health. 2009 Aug 18;9:295.
Editorials / Reviews / Book Chapters Campbell R, Murphy DJ. Smoking in pregnancy. BMJ 2009;338:b2188. Sheehan SR, Murphy DJ. Can repeated courses of antenatal corticosteroids for threatened preterm birth be justified? Expert Rev Obstet Gynecol 2009; 4: 223-226.
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Murphy DJ. Operative Delivery. Clinical Obstetrics & Gynaecology. Second Edition. Eds Magowan B, Owen P, Drife J. 2009 Saunders Elsevier. Butt H, Murphy DJ. Second stage of labour. Best Pract Res Clin Obstet Gynaecol 2009 Elsevier.
Published abstracts Sheehan SR, Wedisinghe L, Macleod M, Murphy DJ Implementation of guidelines on oxytocin use at caesarean section – A survey of practice in the British Isles XIX FIGO World Congress, Cape Town, South Africa 2009 Sheehan SR, Carey M, Montgomery AA, Murphy DJ, ECSSIT Study Group A Cohort study of 500 patients recruited to ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial XIX FIGO World Congress, Cape Town, South Africa 2009 S Daly et al. March 2010 USCAP (United States and Canadian Association of Pathologists): A non-infectious mechanism for Preterm Delivery involving Fetal DNA sensed by maternal TLR-9.
National/International presentations Murphy DJ. Forceps delivery in modern obstetric practice. Invited Plenary, XIX FIGO World Congress, Cape Town, South Africa 2009. Murphy DJ. Obstetrics for Lawyers. Royal College of Obstetricians & Gynaecologists, London, 2009. Murphy DJ. Decision-making about delivery after a previous caesarean section - maternal and perinatal perspectives. Invited plenary, Irish Perinatal Society, Kildare 2009. Murphy DJ. Women-centred obstetric care. Public Lecture, Coombe Women & Infants University Hospital, Dublin 2009. Murphy DJ. Operative delivery in the second stage of labour. Baby Lifeline Cerebral Palsy Conference, Dublin 2009. Murphy DJ. Alcohol exposure and perinatal outcomes. Guinness Annual Lecture Meeting, Coombe Women & Infants University Hospital, Dublin 2009. Sheehan SR, Wedisinghe L, Macleod M, Murphy DJ. Implementation of guidelines on oxytocin use at caesarean section – A survey of practice in the British Isles. XIX FIGO World Congress, Cape Town, South Africa 2009. Sheehan SR. Steroids in Obstetrics. Invited plenary, Specialist Registrars in Obstetrics and Gynaecology Society Annual Meeting, Dublin 2009. Sheehan SR, Carey M, Murphy DJ. A cohort study of the first 500 patients recruited to ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial RAMI Registrars Prize Meeting, Dublin 2009. Sheehan SR, Carey M, Montgomery AA, Murphy DJ. ECSSIT Study Group A Cohort study of 500 patients recruited to ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial. XIX FIGO World Congress, Cape Town, South Africa 2009. Sheehan SR, Carey M, Montgomery AA, Murphy DJ. ECSSIT Study Group ECSSIT – Elective Caesarean Section Syntocinon Infusion Trial. A Cohort Study of 500 patients. Specialist Registrars in Obstetrics and Gynaecology Society Annual Meeting, Dublin 2009. Cleary BJ, Butt H, Strawbridge J, Gallagher PJ, Fahey T, Murphy DJ. Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Association of University Departments of General Practice in Ireland, 12th ASM, February 2009, Dublin.
195 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Grants Received
Wellbeing of Women 2005-2009 £124,980 Research Training Fellowship for Dr Rachna Bahl The skill, evaluation and assessment of operative vaginal delivery Strachan BS, Murphy DJ (Co-supervisors).
HRB 2007-2010 €300,000 A randomised controlled trial of oxytocin bolus versus bolus and infusion for the control of blood loss at caesarean section Murphy DJ (PI), Carey M
HRB 2008-2010 €110,000 Treatments for minimising blood loss during caesarean section Cochrane Training Fellowship for S Sheehan Sheehan S, Murphy DJ (Supervisor)
Friends of the Coombe / HRB / RCSI 2008-2011 €300,000 Medication exposure and perinatal outcomes among a cohort of pregnant women Research fellowship for B Cleary Cleary B, Murphy DJ (Supervisor)
Health Service Executive 2007-2010 €250,000 Alcohol exposure in pregnancy and perinatal outcomes Murphy DJ (PI), A Mullally
HRB 2007-2011 €4,100,000 Perinatal Ireland, ESPRIT Study Malone F (PI), Geary M, Mc Auliffe F, Morrison J,Higgins J, Burke G,Dornan J, Higgins S, Daly S (Joint Co PI)
Friends of the Coombe 2006-2009 €190,000 PhD Fellowship for Andrea Nugent (S Daly Supervisor) Role of Toll Like Receptors in Preterm Birth
196 Coombe Women & Infants University Hospital Annual Clinical Report 2009
UCD Academic Centre: Obstetrics and Gynaecology
Staff Members
Professor Michael Turner Dr Mairead Kennelly Senior Lecturer Professor Bernard Stuart Consultant Lecturer Dr Chro Fattah Lecturer (Jan-June) Dr Nadine Farah Lecturer (July-Dec) Research Fellow (Jan-June) Dr Jennifer Hogan Research Fellow (July- ) Ms Marie Greene Student coordinator Ms Laura Bowes Administrator
Honorary Clinical Lecturers
Dr Mary Anglim Dr Tom D’Arcy Dr Hugh O’Connor Dr Martin White Dr Liam Briggs Dr Michael Carey
Achievements
• UCD Centre for Human Reproduction opened April with research office, seminar room and administrative offices.
• Dr Mairead Kennelly commenced as Senior Lecturer in April 2009.
• Dr Bernard Stuart appointed as UCD Clinical Professor in December.
Publications
• Peer-reviewed publications: 10
• Abstracts: 31
197 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Peer-reviewed Publications
Bolton S, Cleary B, Walsh J, Dempsey E, Turner MJ. Continuation of metformin in the first trimester of women with PCOS is not associated with increased perinatal morbidity. Eur J Pediatr 2009; 168: 203-6.
Barry S, Fattah C, Farah N, Broderick V, Stuart B, Turner MJ. The growing challenge of maternal obesity (editorial). IMJ 2009: 102; 5-6.
Fattah C, Farah N, O’Toole F, Barry S, Stuart B, Turner MJ. Body Mass Index (BMI) in women booking for antenatal care: comparison between self reported and digital measurements. Eur J Obstet Gynecol Reprod Biol 2009;144:32-4.
Agnew GA, Turner MJ. Vaginal prostaglandin gel to induce labour in women with one previous caesarean section. J Obstet Gynaecol 2009; 29:209-11.
Farah N, Stuart B, Donnelly V, Rafferty G, Turner MJ. What is the value of ultrasound soft tissue measurements in the prediction of abnormal fetal growth? J Obstet Gynaecol 2009;29:1-7.
Farah N, Barry S, Broderick V, Donnelly V, Stuart B, Turner MJ Is the antenatal prediction of a big baby worthwhile? (editorial). IMJ 2009;102:201-2.
Fattah C, Farah N, O’Connor N, Stuart B, Turner MJ. The measurement of maternal adiposity. J Obstet Gynaecol 2009;29:686-9.
Astbury K, Turner MJ. Human Papillomavirus Vaccination in the prevention of cervical neoplasia. Int J Gynecol Cancer 2009;19:1610-3.
Kennelly MM, Cooley SM, McParland PJ. Natural history of apparently isolated severe fetal ventriculomegaly: perinatal survival and neurodevelopment outcome. Prenat Diagn 2009;29:1135-40.
Farah N, Maher N, Barry S, Kennelly M, Staurt B, Turner MJ. Maternal morbid obesity and obstetric outcomes. Obes Facts 2009;2:352-4.
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Abstracts
Barry S, Fattah C, Farah N, Stuart B, Doran P, Murray D, Turner MJ. Can maternal Bioelectrical Impedance Analysis (BIA) predict birth weight? Registrars Prize, Obstetric section, Royal Academy of Medicine, Dublin, February 2009.
Barry S, Fattah C, Farah N, Stuart B, Turner MJ. Maternal Bioelectrical Impedance Analysis (BIA) is a better predictor of birth weight than Body Mass Index (BMI). British Maternal and Fetal Medicine Society, June 2009.
Barry S, Fattah C, Farah N, Stuart B, Turner MJ. Maternal Bioelectrical Impedance Analysis (BIA) is a better predictor of birth weight than Body Mass Index (BMI). Irish Perinatal Society, Kildare, March 2009.
Barry S, Fattah C, Farah N, Stuart B, Turner MJ. Maternal Bioelectrical Impedance Analysis (BIA) is a better predictor of birth weight than Body Mass Index (BMI). XIX FIGO World Congress of Gynaecology and Obstetrics, Cape Town October, 2009.
Barry S, O’Connor N, Fattah C, Farah N, Murray D, Stuart B, Kennelly M, Turner MJ. Maternal body composition and serum leptin in the first trimester of pregnancy. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Barry S, Farah N, Stuart B, Kennelly M, Turner MJ. What happens to body composition in pregnanacy? Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Barry S, Mitchell C, Farah N, Stuart B, Kennelly M, Turner MJ. Maternal exercise levels and birthweight. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Broderick V, Farah N, Walsh C, Fattah C, Barry S, Stuart B, Turner MJ. Is increasing Body Mass Index (BMI) associated with increased maternal perineal trauma following childbirth? XIX FIGO World Congress of Gynaecology and Obstetrics, Cape Town October, 2009.
Broderick V, Broderick S, Farah N, Stuart B, Turner MJ. Caesarean section rate versus maternal body mass index (BMI). XIX FIGO World Congress of Gynaecology and Obstetrics, Cape Town October, 2009.
Broderick V, Farah N, Walsh C, Fattah C, Barry S, Stuart B Turner MJ. Is increasing Body Mass Index (BMI) associated with increased maternal perineal trauma following childbirth? Irish Perinatal Society, Kildare, March 2009.
Fallon A, Kennelly M, Turner MJ. Sleep patterns reported before and during pregnancy. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
199 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Farah N, Fattah C, Harrold E, Stuart B, Donnelly V, Rafferty G, Turner MJ. The role of Fetal Abdominal Subcutaneous Tissue (FAST) in predicting macrosomia. SpROGs, Dublin, June 2009.
Farah N, Fattah C, Barry S, Stuart B, Rafferty G, Donnelly V, Turner MJ. Maternal body composition as a predictor of fetal adiposity. British Maternal and Fetal Medicine Society, June 2009.
Farah N, Donnelly V, Kennelly M, Stuart B, Turner MJ. Maternal body composition as a predictor of fetal adiposity. International Society of Ultrasound in Obstetrics and Gynaecology, Hamburg, September 2009.
Fattah C, Farah N, O’Toole F, Barry S, Donnelly V, Rafferty G, Stuart B, Turner MJ. Body Mass Index BMI in women booking for antenatal care, comparison between selfreported and digital measurement. British Maternal and Fetal Medicine Society, June 2009.
Fattah C, O’Toole F, Farrah N, Barry S, Stuart B, Turner MJ. Body Mass Index (BMI) in women booking for antenatal care: comparison between selfreported and digital measurements. UCD Young Investigators Symposium, Dublin, May 2009.
Fattah C, Farah N, O’Connor N, Barry S, Kennelly M, Stuart B, Turner MJ. Maternal weight and body composition in the first trimester of pregnancy. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Hogan J, Maguire P, Craven S, O’Connor N, Farah N, Kennelly M, Stuart B, Turner MJ. Does mid-arm circumference measurement correlate with maternal adiposity during pregnancy? Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Hogan J, Barry S, Walsh C, O’Connor N, Khalid A, Turner MJ. Evaluation of body fat using bioelectrical impedance in women with polycystic ovary syndrome. Irish Fertility Society, Galway, May 2009.
Kelly RE, Farah N, O’Connor N, Kennelly M, Stuart B, Turner MJ. Are fathers-to-be too fat? Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Maher N, Farah N, Barry S, Fattah C, Stuart B, Turner MJ. Maternal morbid obesity and pregnancy outcomes. British Maternal and Fetal Medicine Society, June 2009.
Maher N, Farah N, Barry S, Fattah C, Stuart B, Turner MJ. Morbid obesity and caesarean delivery. Irish Perinatal Society, Kildare, March 2009.
Murphy MC, Craven S, Farah N, Barry S, Kennelly M, Stuart B, Turner MJ. Does maternal body composition change in the early postnatal period? Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
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Rowentree R, Hogan J, Stuart B, Kennelly M, Turner MJ. Routine pregnancy dating with ultrasound reduces the rate of induction of labour for postdatism. Submitted to Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Ramphul M, Murphy M, Farah N, Kennelly M, Stuart B, Turner MJ. Ethnicity and maternal body composition. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Singh S, Martin CM, Pilkington L, O’Toole S, Cleary S, Prendiville W, D’Arcy T, Turner MJ, O’Leary JJ. Predicting disease recurrence using HPV testing post colposcopic treatment for cervical intraepithelial neoplasia, Cerviva; an interim report. British Society for Colposcopy & Cervical Pathology, May 2009.
Tadesse W, Farah N, Hogan J, Kennelly M, Stuart B, Turner MJ. Peripartum hysterectomy in the 21st century. Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
Turner MJ. This house believes that an obstetrician cannot be trained in a 48-hour week. SpROGs, Dublin, June 2009.
Turner MJ. Emergency obstetric hysterectomy. XIX FIGO World Congress of Gynaecology and Obstetrics, Cape Town October, 2009.
Walsh C, Farah N, Barry S, Fattah C, Stuart B, Turner MJ. Is low Body Mass Index (BMI) a high risk for pregnancy? Irish Perinatal Society, Kildare, March 2009.
Walsh CE, Farah N, Barry S, Hogan J, Kennelly M, Stuart B, Turner MJ. Is low Body Mass Index (BMI) a predictor of poor obstetric outcome? Junior Obstetrics and Gynaecology Society, Dublin, November 2009.
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RCSI Academic Department of Obstetrics and Gynaecology
Staff Complement
Walter Prendiville Associate Professor Bridgette Byrne Senior Lecturer Carmen Regan Senior Lecturer Andrea Nugent Lecturer in Women’s Health and Community Gynaecology Evangelos Dimitriou Lecturer in Gynaecology (to July 2009) Srwa Khalid Lecturer in Obstetrics (to July 2009) David Morgan Lecturer in Gynaecology (from July 2009) Sucheta Johnson Lecturer in Obstetrics (from July 2009) Marie Greene Academic Secretary Fidelma Kavanagh Departmental Administrator
Key Performance Indicators
Professor Walter Prendiville
Committee Membership
• International Federation for Cervical Pathology and Colposcopy (Secretary General)
• Information Technology Committee. (Member); Nomenclature Committee (Member)
• British Society for Colposcopy and Cervical Pathology (President to July 2009) (Member Executive Committee)
• International College of Out Patient Gynaecology (Secretary)
• Professsional Specialist Societies/RCOG Liaison Group (Member to May 2009)
• NCSS HPV Expert Advisory Group (Member)
• British Society for Colposcopy and Cervical Pathology Annual Scientific Meeting Dublin May 7 & 8 2009 Chair Local Organizing Committee
Publications Active versus expectant management in the third stage of labour... Prendiville WJ, Elbourne D, McDonald SJ. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD000007. Review.PMID: 19588315. The treatment of CIN: what are the risks? Cytopathology Volume 20, Issue 3, pages 145–153, June 2009 PMID: 19489986 European guidelines for clinical management of abnormal cervical cytology, part 2. Jordan J, Martin-Hirsch P, Arbyn M, Schenck U, Baldauf JJ, Da Silva D, Anttila A, Nieminen P, Prendiville W. Cytopathology. 2009 Feb;20(1):5-16.PMID: 19133067 .
202 Coombe Women & Infants University Hospital Annual Clinical Report 2009
Policies for manual removal of placenta at vaginal delivery: variations in timing within Europe. Deneux- Tharaux C, Macfarlane A, Winter C, Zhang WH, Alexander S, Bouvier-Colle MH; (Prendiville W Member EUPHRATES Group.) BJOG. 2009 Jan;116(1):119-24.PMID: 19087083. Predicting disease recurrence using HPV testing post colposcopic treatment for cervical intraepithelial neoplasia. CERVIVA ; An interim report Shobha Singh, Cara M Martin, Loretto Pilkington, Sharon O’Toole, Sinead Cleary, Walter Prendiville, Tom D’Arcy, Michael, J Turner,1, John J O’Leary Poster Presentation BSCP Annual Scientific Meeting Dublin May 2009 (Poster Number 58). Risk of Preterm Labour after LLETZ: Does size matter? A retrospective study and a new classification system of excision type Srwa Khalid, Evangelos Dimitriou, Walter Prendiville. Poster Presentation BSCP Annual Scientific Meeting Dublin May 2009 (Poster Number 69).
Presentations (selected) Predicting LLETZ Related Problems BSCCP. British Society for Colposcopy and Cervical Pathology Annual Scientific Meeting Dublin 7-9 May 2009. What’s New – New Techniques and Where We Are Going: The use of the epitheliometer and spectroscopy: The treatment of CIN: Predicting morbidity and failure; Training, Quality Assurance, Standards and Accreditation: Distance colposcopy training : Dublin/Tamil Nadu, an experiment. ASCCP The XXIst Scientific Meeting of the Australian Society for Colposcopy and Cervical Pathology Darwin August 13-16 August 2009. Excision of the Transformation Zone. Deutsche Arbeitsgemeinschaft fur Zervixpathologie und Kolposkopie/German Society for Colposcopy and Cervical Patyhology Dresden Sept 24-26 2009.
Research Grants HRB Global Research Fund: Evaluation of distance learning/quality assurance for the management of pre- cancer of the cervix after VIA screening in southern rural India.
Courses Organized Intermediate/Advanced Colposcopy Laparoscopic Surgical Skills Basic Surgical Skills
Dr Bridgette Byrne
Publications Pulmonary thromboembolism in pregnancy. Khalid S, Babiker E, Byrne B. Ir Med J 2009; 102(7): 237. Severe maternal morbidity for 2004-2005 in the three Dublin maternity hospitals. Murphy CM, Murad K, Deane R, Byrne B, Geary MP, McAuliffe FM. Eur J Obstet Gynecol Reprod Biol. 2009 Mar;143(1):34-7.Epub 2009 Jan 12. PMID: 19136192 [PubMed – indexed for MEDLINE]
Research projects Collaborator in a multicentred trial of the safety of tinzaparin in pregnancy. Prospective audit of major obstetric haemorrhage. Improving standards of care in severe pre-eclampsia.
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Dr Carmen Regan
Presentations (selected) Fetal growth restriction due to cigarette smoking in pregnancy - the role of thromboxane A2 formation.Lynch CM, Stuart B, Conroy R, Traumann A, Regan CL. 29th Annual Meeting of the Society of Maternal Fetal Medicine. San Diego, California, January 2009. Thromboxane A2 formation in pregnancies complicated by intrauterine growth restriction. Lynch CM, Stuart B, Conroy R, Traumann A, Regan CL. 29th Annual Meeting of the Society of Maternal Fetal Medicine. San Diego, California, January 2009. Maternal prostacyclin formation is not altered in intrauterine growth restriction. Four Provinces JOGS Annual Scientific Meeting RAMI Dublin Maternity Hospitals Reports Meeting November 2009. A case of Massive Obstetric Haemorrhage (MOH) secondary to Amniotic Fluid Embolism (AFE): A case report SN Johnson, C Mid Thoracic Syndrome in Pregnancy: A Rare Cause Of Secondary Hypertension SN Johnson, T Kelleher, S O Neill, J Cosgrave, J Meaney, P Crean, N Mulvihill, K Astbury, C Regan, B Byrne BMFM Society 14th Annual Conference UK 2009.
MD Supervision Supervisor of MD thesis awarded to Dr Caoimhe Lynch 2009 ‘The role of thromboxane formation in intrauterine growth restriction’ Ongoing research projects. The role of platelets in placentation. The investigation of a novel test of platelet function in pregnancy Prospective audit of maternal disease in pregnancy.
Dr David Morgan
Publications Quality of life, fertility and complications following laparoscopic anterior resection for endometriosis; results from 100 consecutive cases. English J, Lo J, Dilley J, Morgan D. Gynaecological Surgery 2009;6(S1):S89. European society for Gynaecological Endoscopy Annual Scientific Meeting, Florence, Italy 2009. Laparoscopic excision of rectovaginal endometriotic nodule: The J English approach. Morgan D, English J. Gynaecological Surgery 2009;6(Supple1):S160 European Society for Gynaecological Endoscopy Annual Scientific Meeting, Florence, Italy 2009.
Sucheta Navroop Johnson
Presentations (selected) A prospective qualitative analysis of management of massive obstetric haemorrhage (MOH) in a tertiary obstetric Johnson SN, Khalid S, Varadkhar S, Fleming J, Fanning R, Byrne B Oral presentation Four Provinces JOGS Annual Scientific Meeting RAMI Dublin Maternity Hospitals Reports Meeting November 2009.
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Outcome of triplet pregnancies in three tertiary referral hospitals in Dublin: A 10 year retrospective analysis Johnson SN, Basit I, Geary M, Wingfield M, Daly S Four Provinces JOGS Annual Scientific Meeting RAMI Dublin Maternity Hospitals Reports Meeting November 2009. A case of Massive Obstetric Haemorrhage (MOH) secondary to Amniotic Fluid Embolism (AFE): A case report SN Johnson, C Regan BFMM Society 14th Annual Conference UK 2009. Mid Thoracic Syndrome In Pregnancy: A Rare Cause Of Secondary Hypertension S N Johnson, T Kelleher, S O Neill, J Cosgrave , J Meaney, P Crean, N Mulvihill , K Astbury, C Regan, B Byrne BFMM Society 14th Annual Conference UK 2009. A Prospective Audit Of Major Obstetric Haemorrhage.Johnson SN, Khalid S, Varadkar S, Fleming J, Fanning R, Flynn C, Byrne B Regan BFMM Society 14th Annual Conference UK 2009. Triplets Morbidity And Mortality, A Dublin Experience Johnson SN, Basit I, Geary M, Wingfield M, Daly S. Poster presentation BFMM Society14th Annual Conference UK 2009.
Dr Srwa Khalid
Pulmonary thromboembolism in pregnancy. Khalid S, Babiker E, Byrne B. Ir Med J 2009; 102(7): 237. Women’s compliance after cervical intraepithelial neoplasia management Srwa Khalid, Xavier Carcopino Georges Michael1, Ronan Conroy, Walter Prendiville BSCCP 2009 Dublin (Poster Number 87).
Dr Evangelis Dimitriou
Risk of Preterm Labour after LLETZ: Does size matter? A retrospective study and a new classification system of excision type Srwa Khalid, Evangelos Dimitriou, Walter Prendiville BSCCP 2009 Dublin (Poster Number 69).
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POSTGRADUATE MEDICAL TRAINING
OBSTETRICS AND GYNAECOLOGY
Dr Michael O’Connell Director of Postgraduate Training
Key Performance Indictors
• Assigned trainer and training number for all Doctors in Training.
• Advocate role of the Director of Postgraduate Training for Doctors in Training.
• Close Liaison with the Master and Director of Postgraduate Training on training issues.
• Close liaison with the Human Resources department on recruitment issues.
• Preparatory course for MRCPI examination.
• Special Skills Module Urodynamics with the Institute of Obstetrics and Gynaecology.
• Dedicated protected sessions on Delivery suite, Theatre, Colposcopy, MAS, Urogynaecology, Adolescent Gynaecology, Subfertility and High Risk Pregnancy.
• Sub Speciality Opportunities: • Gynaecology Oncology in association with St James Hospital (Drs Gleeson and D’Arcy) • Fetomaternal Medicine with Rotunda Hospital (Prof Daly and Prof, Malone)
Achievements in 2009
• Excellent success rates in MRCOG Part 1, DOWH and MRCPI Part 2.
• Excellent progression rate of senior trainees to Higher Specialist Training.
• Highly successful ‘Open Evening’ for Doctors and Students interested in a career in Obstetrics and Gvnaecology.
Challenges
• Maximisation of training opportunities with less Doctors in Training.
• The creation of an SHO rotation scheme that is recognised for its excellence and recognised by the Medical Council.
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PAEDIATRICS AND NEWBORN MEDICINE
Dr Martin J White Director of Paediatrics & Newborn Medicine
Six Specialist Registrars in Paediatrics rotated through the Department of Paediatrics & Newborn Medicine in 2009. Each Specialist Registrar was completing 6 months of a 12-month rotation, posts are July to June. The Specialist Registrars are encouraged to undertake specific research projects and participate in audit. The Department of Paediatrics & Newborn Medicine is a tertiary level Neonatology Centre offering experience in intensive care as well as neonatal transport. Neonatal training is a core component of the Specialist Registrar Programme in General Paediatrics.
PERI-OPERATIVE MEDICINE
Dr Michael Carey Director of Perioperative Medicine
The Department of Perioperative Medicine in the CWIUH continues to provide a comprehensive training programme for anaesthetic trainees. The controversial decision of HSE-METR to designate NCHD posts as training posts only if they are in recognised rotations will result in a reduction in the number of training posts from 7 to 4 (2 at specialist registrar level and 2 at basic specialist trainee level). The Department of Perioperative Medicine continues to treat all NCHDs as equal in terms of training requirements – providing 2 formal teaching sessions per week in addition to many one to one educational opportunities in theatre and the delivery suite. NCHDs are also encouraged to attend multidisciplinary meetings in the hospital. The Department hosts mock OSCE examinations twice yearly for our NCHDs from the CWIUH, SJH and AMNCH in preparation for the Part I of the Anaesthetic Fellowship examination; in addition to clinical and technical training, the Department provides training in audit and research methodology.
PATHOLOGY
Professor John O Leary Director of Pathology
Medical training in Laboratory Medicine in 2009 is provided in Histopathology, Cytopathology, Morbid Anatomy and Molecular Pathology. The SpR is attached to the Department for a 6 month period. The SpR is encouraged to undertake a dedicated piece of research during his/her rotation in the CWIUH. The Department of Cytopathology is the only centre in the Republic of Ireland that offers training in gynaecological cytopathology.
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National Clinical Skills Centre (Women & Infants Health)
Director
Professor Walter Prendiville
The NCSC was established in 2007 to provide a facility for state-of-the-art, multidisciplinary, skills-acquisition training using simulation technology; the NCSC has also pioneered (intercontinental) distance learning.
Achievements in 2009
• Basic Surgical Skills (an intensive three day course for NCHDs) Course Director: Professor Walter Prendiville.
• Laparoscopic Surgical Skills (A six-Month Course) Course Directors: Professor Walter Prendiville and Mr Ray O’Sullivan.
• Major Obstetric Haemorrhage Drills (A monthly half-day multi-disciplinary Course) Course Director: Dr Bridgette Byrne.
• Masters in Women’s Health (A two year once weekly Post-Graduate Course) Course Director: Dr Andrea Nugent.
• The Centre for Midwifery Education (CWIUH) organised the following courses in the NCSC:
• Perineal Suturing Workshop with Professor Christine Kettle.
• IV Cannulation and Venepuncture workshops.
• Practice Nurses (who are midwives) Update in midwifery skills workshops.
The Facilities of the NCSC are available for use to all disciplines interested in organizing practical training.
For details of and registration for future courses please visit: www.nationalclinicalskillscentre.com For further information please email: [email protected]
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Appendix One
Outline History of the Coombe Women’s Hospital
1770 Foundation stone laid on 10th October by Lord Brabazon for new general hospital in the Coombe. 1771 Hospital opened in the Coombe known as ‘The Meath Hospital and County Dublin Infirmary’. 1822 Meath Hospital transferred to Heytesbury Street to a site known as ‘Dean Swift's Vineyard’. 1823 Old Meath Hospital bought by Dr. John Kirby and opened in October under the name of ‘The Coombe Hospital’. 1826 Maternity service founded in The Coombe Hospital by Mrs. Margaret Boyle. 1829 Hospital bought from Dr. John Kirby and opened on February 3rd as ‘The Coombe Lying-in Hospital’. 1835 Dublin Ophthalmic Infirmary established in outpatient department (until 1849). 1839 Gynaecology ward opened in hospital. 1867 Royal Charter of Incorporation granted to the Coombe Lying-in Hospital on November 15th. 1872 Due to the benevolence of the Guinness family, a new wing, including gynaecology beds, known as ‘The Guinness Dispensary’ opened on April 24th. 1877 Coombe Lying-in Hospital rebuilt and reopened by the Duke and Duchess of Marlborough on May 12th. 1903 Weir Wing in hospital opened. 1911 Pembroke dispensary for outpatient care of children opened July 6th. 1926 Hospital centenary celebrated by first international medical congress to be held in Dublin. 1964 Foundation stone laid for new Hospital in Dolphin's Barn on May 14th by Minister for Health, Mr. McEntee. 1967 New Coombe Lying-in Hospital opened on July 15th. 1976 Celebration of the 150th birthday of Hospital held in October. 1987 Maternity service in St. James's Hospital transferred to Coombe Lying-in Hospital on October 1st. 1993 Hospital renamed the ‘Coombe Women's Hospital’ on December 8th. 1995 UCD Department of General Practice opened in February. 2001 175th Anniversary of the Coombe Women’s Hospital. 2008 Hospital renamed ‘Coombe Women & Infants University Hospital’ on January 1st.
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Appendix Two
Masters of the Coombe Lying-in Hospital/Coombe Women’s Hospital/Coombe Women & Infants University Hospital
Richard Reed Gregory 1829 - 1831 Thomas McKeever 1832 - 1834 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 - 1880 George Hugh Kidd 1887 - 1893 Samuel Robert Mason 1894 - 1900 Thomas George Stevens 1901 - 1907 Michael Joseph Gibson 1908 - 1914 Robert Ambrose MacLaverty 1915 - 1921 Louis Laurence Cassidy 1922 - 1928 Timothy Maurice Healy 1929 - 1935 Robert Mulhall Corbet 1936 - 1942 Edward Aloysius Keelan 1943 - 1949 John Kevin Feeney 1950 - 1956 James Joseph Stuart 1957 - 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 - present
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Appendix Three
Matrons and Directors of Midwifery and Nursing at the Coombe Lying-in Hospital/Coombe Women’s Hospital/Coombe Women & Infants University Hospital
Over a period of 145 years since the granting of the Royal Charter of Incorporation to the Coombe Lying In Hospital in 1867, there have been 15 Matrons or Directors of Midwifery & Nursing (DoM&N) as follows;
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 DoM&N 1982 - 2005 Mary O’Donoghue DoM&N – Acting 2005 - 2006 Patricia Hughes DoM&N 2007 - present
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Appendix Four
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 Dugald 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 & 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 & Human Services, National Institute of Health, Maryland, USA
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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 & 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, Sweden
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 Praevia Then and Now Professor Thomas Baskett, Nova Scotia.
1999 Lessons Learned from First Trimester Prenatal Diagnosis Professor Ronald J Wapner, 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 & Fall of Evidence Based Medicine Dr John M Grant, Editor of the British Journal of Obstetrics & Gynaecology, United Kingdom.
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: its Effect on Obstetric Practice Professor Mary-Jo O’Sullivan University of Miami School of Medicine, Florida, U.S.A.
2004 Connolly, Shaw and Skrabanek – Irish Influences on an English Gynaecologist Professor Patrick Walker, Royal Free Hospital, London, U.K.
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2005 Careers and Babies: Which Should Come First? Dr Susan Bewley, Clinical Director for Women’s Health, Guys & St Thomas NHS Trust, U.K.
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 & Clinical Effectiveness, RCPCH, London
2007 Schools, Skills & Synapses Professor James J. Heckman, Nobel Laureate in Economic Sciences Henry Schultz Distinguished Service Professor of Economics, University of Chicago, Professor of Science & 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, PA
2009 Advanced Laparoscopic Surgery: The Simple Truth Professor Harry Reich, Wilkes Barre Hospital, Pennsylvania Past President of the International Society of Gynaecologic Endoscopy (ISGE) Former Director of Advanced Laparoscopic Surgery, Columbia Presbyterian Medical Centre, NY
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Appendix Five
The George Bernard Shaw Gold Medal in Medical Essay Writing
George Bernard Shaw was born on 26th July 1856 in 3 Upper Synge Street (now 33 Synge Street), which is located just off Harrington Street. His delivery was attended by a previous Master of this Hospital, Dr John Ringland. As well as achieving an international reputation as a playwright, winning the Nobel Prize for Literature in 1924, George Bernard Shaw was an influential essayist and commentator on contemporary socio-political and medical issues. This medal is being awarded to honour his association with this Hospital and to encourage critical commentary by doctors in training.
This award was open to all medical students attending the Coombe Women and Infants Hospital in 2009. The topic for the 2009 essay is was
THE IMPLICATIONS OF SOCIO-ECONOMIC DEPRIVATION ON OBSTETRICS & GYNAECOLOGY
There were two prize-winners in 2009: Ms Lucia Hartigan (UCD) and Ms Lisa Karina Sullivan (TCD).
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THE IMPLICATIONS OF SOCIO-ECONOMIC DEPRIVATION ON OBSTETRICS AND GYNAECOLOGY
Lucia Hartigan (University College Dublin)
Live in contact with facts and you will get something of their brutality. George Bernard Shaw
The brutal fact of the matter is that a person’s health and well-being is greatly influenced by their socio- economic environment. A cursory glance at the literature reveals that the socio-economic status of an individual is of crucial importance in determining their risk of acquiring a medical disorder, their compliance with health care provisions and their eventual prognosis1. The developing world provides the most obvious demonstration of one’s good health being directly proportional to one’s monetary income but for the purposes of this essay I will deal with socio-economic disparities within the western world, with a particular focus on Ireland. The field of Obstetrics and Gynaecology provides a particularly acute example of the relationship between health and social inequalities in this regard. Socially deprived groups from an obstetrical viewpoint are more likely to have a greater number of unplanned pregnancies as mothers are often less educated, and the pregnancies are often of higher risk because baseline health is worse in the first instance. Cigarette and drug abuse are also more prevalent. With regard to gynaecology, low socio-economic class is a risk factor for the acquisition of sexually transmitted infections which in turn may lead to infertility and cervical carcinoma. In this country, access to health services is fundamentally unequal and more affluent groups use significantly more health services than would be expected given their level of need compared with their less well-off counterparts2. These factors contribute to avoidably poor outcomes for the socially deprived obstetric and gynaecology patient and as such demand discussion, debate and analysis.
The socially and economically deprived make up a disproportionate amount of unplanned pregnancies. A nineties London survey demonstrated this when it showed that the incidence of unwelcomed pregnancy was higher in the more socially deprived inner city (20.6%), than a more affluent suburb (12.5%)3. A third of all pregnancies in Ireland are unplanned and a disproportionate numbers of the mothers are from a lower socio- economic class. Unplanned pregnancies have worse outcomes for a number of reasons. Alcohol and teratogenic drugs are more likely to have been consumed unknowingly in the first trimester of an unplanned pregnancy with the grave potential for negative outcome for the unborn. Unplanned pregnancies are more likely to result in bottle feeding, infant morbidity and infant hospital admission4. Moreover according to the Coombe Women and Infants University and Hospital (CWIUH) annual clinical report in 2007, 6 out of every 10 mothers are not taking pre-conceptual folic acid which is recommended in order to reduce the incidence of neural tube defects arising in the foetus5. Many foods are fortified with folic acid so the lack of folic acid supplementation need not necessarily be detrimental. However there are significant associations between lower socio-economic class and poor diet meaning that unplanned pregnancies from a lower socio-economic background are more likely to have less folic acid intake. In short, unplanned pregnancies have negative implications for health and they are more likely to occur in socially deprived groups.
Nutrition and diet is also important for health outcomes in obstetrics beyond folic acid alone. Pregnancy and breast-feeding are metabolically demanding and so a balanced diet before, during and after pregnancy is desirable. There are significant associations between low socio-economic class and inadequate diet. Grocery shoppers with low levels of education, and those residing in low-income households, are less likely to purchase
1 Dalgren and Whitehead, 1991 2 Barry, J. et al. (2001) Inequalities in Health in Ireland – Hard Facts, Dublin: Department of Community Health and General Practice, Trinity College Dublin 3 CHILD: CARE, HEALTH AND DEVELOPMENT, 1990 Jul-Aug;16(4):219-26. 4 Journal of Nutrition. 2001;131:1247-1249Bridget Chinebuah and Rafael Pérez-Escamilla 5 www.coombe.ie/annrp07/report07.pdf
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foods comparatively high in fibre and low in fat, salt and sugar6. In pregnancy, iron-rich foods, oily fish, food fortified with folic acid and food low in refined sugars are required in greater quantity. Financial and educational barriers decree that the socio-economically deprived do not meet the nutritional ideals of pregnancy and lactation.
Diet is also problematic for pregnancy in another sense as 39% of Irish adults are overweight and 18% are obese7. The incidence of obesity in pregnant women continues to rise and there is a link between maternal obesity and lower socio-economic status. Maternal obesity impacts pregnancy outcome primarily through increased rates of hypertensive disease and diabetes (both pre-gestational and gestational). However, the list of risks that obesity incurs in the pregnant woman is extensive. Caesarean section, venous thromboembolic disease and respiratory complication rates are increased. Maternal obesity also increases the risk of delivering a macrosomic baby and all the inherent complications associated with this8.
Psychiatric illness in pregnancy is a major risk factor for maternal death and socio-economic deprivation is a risk factor for the development of post natal depression and puerperal psychosis. The following factors are thought to be the strongest predictors of postpartum depression: depression during pregnancy, anxiety during pregnancy, experiencing stressful life events during pregnancy or the early puerperium, low levels of social support, and a previous history of depression. There are a number of gaps that need to be addressed in future research. These include examining specific risk factors in women of lower socioeconomic status, risk factors pertaining to teenage mothers, and the use of appropriate instruments assessing postpartum depression for use within different cultural groups9.
Cigarette smoking has grave implications for obstetrics and gynaecology and it is a significant issue as one fifth of women smoke during pregnancy making their pregnancies high risk10. Smoking is associated, in a dose- response manner, with an increased risk of IUGR, miscarriage, still births, low birth weight babies, placental abruption and SIDS (Sudden infant death syndrome). Pre-eclampsia is interestingly, less common in smokers but is more severe when it occurs and leads to full-blown eclampsia more commonly in smokers than in non- smokers. Cigarette smoking best demonstrates the relationship between social class and adverse outcomes in pregnancy. Recent research in Ireland shows that the lowest smoking levels have been recorded by socio- economic group I (professional workers) while 49% of unemployed people are smokers11. In short, pregnant women from lower socio-economic groups are more likely to be smokers and are risk for all its associated potential consequences for their pregnancy.
Domestic violence is obviously detrimental to the health of both mother and foetus. is all too common in our society and is more common in socio-economically deprived groups. Domestic abuse is associated with increased rates of miscarriage, premature births, low birth weights, chorioamnionitis and fetal death12. Indirect maternal death increases also, as suicide in sufferers of domestic abuse is more prevalent13. A study published in the
6 Public Health Nutrition (2006), 9:375-383 Cambridge University Press 2006 doi:10.1079/PHN2005850 7 Department of health and children Report of the National Taskforce on Obesity: Obesity - the policy challenges 8 Current Opinion in Obstetrics and Gynecology: December 2002 - Volume 14 - Issue 6 - pp 601-606 General obstetrics:Maternal obesity and pregnancy outcomes, Castro, Lony C.; Avina, Robert L. 9 Antenatal risk factors for postpartum depression: a synthesis of recent literature General Hospital Psychiatry, Volume 26, Issue 4, Pages 289-295 E.Robertson, S.Grace, T.Wallington, D. 10 (BMC Public Health 2007; 16;18) 11 Brugha, R., Tully, N., Dicker, P., Shelley, E., Ward, M. and McGee, H. (2009) SLÁN 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Smoking Patterns in Ireland: Implications for policy and services, Department of Health and Children. Dublin: The Stationery Office 12 Gillian C Mezey, Senior lecturer,a Susan Bewley, Director of obstetrics BMJ 1997;314:1295 (3 May)‘ Domestic violence and pregnancy’ 13 Domestic violence and mental health: Correlates and conundrums within and across cultures Ruth L. Fischbach;Barbara Herbert, 1998
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New England Journal of Medicine concluded that women are at the greatest risk of injury from domestic violence if they have male partners who abuse alcohol or drugs, are unemployed or have less than a second- level education14. In this regard domestic violence, with its potentially detrimental effect on mother and foetus, is more likely to occur in those from a socially deprived background.
Socio-economic deprivation also hinders optimum outcome in the field of gynaecology. Unplanned pregnancies are more common among the socially deprived as discussed above but those couples finding it difficult to achieve a successful pregnancy are affected by their socio-economic status. Rates of in-vitro fertilization (IVF) and other methods of assisted reproduction have increased in recent years. There is a disparity between IVF utilization based on socio-economic status because of the huge financial constraints involved. In Ireland approximately 2,000 couples each year seek IVF treatment and it costs in the region of € 4,500 per cycle. Thus, a couple from a socio-economically deprived group have limited choices when it comes to the management of infertility. Social class inequalities have historically persisted in relation to sexually transmitted infection (STI). The Royal Commission on Venereal Diseases as far back as 1913 reported that 3-7% of working class, adult females had acquired syphilis, an infection that was virtually unheard of in the upper classes15. The highest rates of STIs in Western society are reported in inner cities and low-income suburban communities16. The majority of women in Ireland attending clinics for sexually transmitted diseases are from lower socio-economic groups. A study carried out in the Mater Misericordiae Hospital in the 1990s reviewed 32 teenage girls who attended an STI clinic over a 12 month period. 75% of the girls were from socio-economic group V. The average age at first intercourse was 16.1 years and the range of number of sexual partners was between one and five. Almost half of these girls had never used contraception.
The sexually transmitted virus, HPV (human papilloma virus) is the known aetiological factor for cervical intraepithelial neoplasia (CIN) and cervical squamous cell carcinoma. It would appear 50% of sexually individuals will acquire HPV at some point. The most important risk factor for CIN is the number of sexual contacts and early age of first intercourse, which again points to the socially deprived communities.
Socially deprived groups from an obstetrical and gynaecological viewpoint have worse health outcomes due to socioeconomic deprivation’s association with unplanned pregnancy, inadequate nutrition, obesity, infertility, psychiatric problems, domestic violence and sexually transmitted disease. Rising levels of unemployment, coupled with government budgetary deficits means that shifting of the population into lower socio-economic groups is inevitable. It is likely that these effects will soon be recognized in the outcomes of the obstetric and gynaecologic patient.
Solutions to combat the link between lower socio-economic status and health status must be attempted at both a national and individual level. Patient education is the first port of call. Sexual education has improved dramatically in recent years. The launch of the “Think contraception” campaign in 2004 in Ireland is one example of recent measures to educate and inform the population. Pre-pregnancy counselling is not always possible but would benefit a patient’s antenatal course. The ideal outlet for this would rest with the general practitioner who could informally identify high-risk patients and advise them of ways in which they can optimise their health for future pregnancies. In Ireland, the National Action Plan for Social Inclusion 2007-2016 has developed initiatives to encourage healthy eating, promote access to healthy food and physical activity with a particular focus on adults living in areas of disadvantage. Improved nutrition will greatly benefit both maternal and fetal health.
14 Risk Factors for Injury to Women from Domestic Violence Demetrios N. Kyriacou, M.D., Ph.D., Deirdre Anglin, M.D., M.P.H., Ellen Taliaferro, M.D., Susan Stone, M.D., M.P.H., Toni Tubb, M.D., Judith A. Linden, M.D., Robert Muelleman, M.D., Erik Barton, M.D., and Jess F. Kraus, Ph.D., M.P.H. 15 Weeks, J. (1989). Sex, Politics and Society – The Regulation of Sexuality 16 HIV, Sexually Transmitted Infections and Social Inequalities:When the Transmission is More Social than Sexual by Catherine Heffernan, University of Oxford, UK. Volume 22 Number 4/5/6 2002
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Attacking the root of the problem - the socio-economic deprivation itself - would be the most effective solution. Societies with more equal distribution of income across the population have higher average life expectancies and better health outcomes than less equal societies. In Norway and Denmark, countries which have comparatively equitable wealth distribution, there are smaller differences in health than countries which have a wider gap between the rich and the poor. Health inequalities, whether they are derived from differences in financial state, education, living conditions or other determinants of health must be dealt with. Finally our aim and our dream should be to improve women’s health care equally across the socio-economic spectrum precisely because my discussion above highlights the grave implications of socio-economic deprivation upon the health outcomes for patients within the field of obstetrics and gynaecology.
Live in contact with dreams and you will get something of their charm: Live in contact with facts and you will get something of their brutality17.
17 Shaw GB. John Bull’s Other Island. (Penguin: Harmondsworth, 1907, 1984)
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THE IMPLICATIONS OF SOCIO-ECONOMIC DEPRIVATION ON OBSTETRICS AND GYNAECOLOGY
Lisa Karina Sullivan (Trinity College Dublin)
Socio-economic deprivation is not only an issue faced by people living in the developing world, it spans every continent. In 2001 United Nation (UN) member states adopted targets in order to improve the care received by people in impoverished nations, The Millennium Development Goals. These goals set out to improve the health and well being of people living in developing nations by the year 2015. The goals which dealt specifically with obstetric and gynaecological care were goals four and five. Goal four was to ‘Reduce child mortality’ and goal five was to ‘Improve maternal health’.
With regards Millennium Development Goal (MDG) 4, the UN looked into the implementation of certain policies. These policies were aimed at making treatment for life threatening disorders in newborns more readily available (for example by allowing midwives to administer antibiotics) and also aims to increase the total government expenditure on health and obstetric care. Currently 11 million children under the age of five die every year, one in ten children in low income countries dies, compared to wealthier nations where the figure is one out of 143 children1.
The Lancet published a report in 2008 tracking the progress of some of the interventions. The report focused on the 68 countries which have 97% of the world wide maternal and child mortality. Of the 68 priority countries, only 16 were on track to reach the targets by 2015. The parameters which were most closely observed to be a good marker of neonatal well being were, nutrition, immunisation, malaria prevention and treatment, prevention of mother to child HIV transmission, diarrhoeal disease treatment and pneumonia treatment.
Despite the figures indicating that only 16 countries were on track to reach the MDG target, there has been a two third decrease in the number of global child deaths from measles since 19902. This has surpassed the initial target to half the number. The same report also revealed that measles deaths fell by an astonishing 91% in Sun- Saharan Africa.
The report published in the Lancet also outlined the level of uptake of the interventions in the 68 countries and the balance of the uptake of certain interventions against others. On average the areas of skilled intervention during labour, oral rehydration therapy and pneumonia treatment only saw an increase in uptake of up to 2% whereas there was an increase in tetanus vaccination in pregnancy, antenatal care(of at least one visit) and the use of insecticide treated bed nets of up to 7%3.
The lifetime maternal mortality rate of women living in developing nations is estimated to be as high as 900 per 100,000, this is an unacceptably high level when compared with Ireland and the UK where the figure is as low as 4 per 100,0004.
Antenatal visits are vital both in terms of foetal well being and maternal wellbeing. One of the major issues tackled by the United Nations was the goal to increase the number of women availing of antenatal care. In the year 1990 it was estimated that only 39% of women aged between 15 and 49 in southern Asia availed of one antenatal visit. In 2005 that figure had risen to 68% of women5.
1 End poverty 2015 campaign 2 UN MDG progress report 2008 3 Lancet 2008 report on tracking coverage of interventions 4 WHO mortality country factsheet 2006 5 United Nations Millennium development goals
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Multiparity is risk factor for maternal mortality. Grand multiparity carries greater risk of maternal haemorrhage, amniotic fluid embolism, uterine rupture, uterine atony and placenta praevia - all potentially serious events. The UN estimated that one in four women in Sub-Saharan Africa have an unmet need for contraception and the increased uptake of contraception in this part of the world is not keeping up with the demands of women to limit the number of children they are having6 making grand multiparity an even bigger possibility for these women.
Cervical cancer is the third most common cancer worldwide with 80% of the cases occurring in the third world, where it causes an estimated 190,000 deaths per year7. Cervical cancer is a very preventable disease that has a precancerous state that may last up to ten years before cancer is clinically detected. The prevention and treatment of cervical cancer is, however, dependant on adequate screening programmes and follow up of women who have been found to have a precancerous lesion. It has been estimated that only 5% of women in the developing world have been screened for cervical dysplasia in the last five years compared to 40-50% of women in the developed world8. Even though there have been efforts to introduce screening programmes in the third world there has been a limit to their success due to several reasons including inadequate cytological services, inadequate follow up and treatment options. In some clinics in Mexico it has been proved that the rate of false negative results for Pap smears was around 54%9 compared to a widely accepted rate of approximately 15-25%10.
Socioeconomic deprivation does not only affect people living in developing countries, it affects people all over the world. In Dublin alone Focus Ireland reports that there are approximately 2,015 homeless people and in 2005 the total number of households awaiting local authority housing was 43,684 and with the massive rise in the immigrant population, the recession and the ever increasing strain on the healthcare system it is becoming harder and harder to provide adequate antenatal, postnatal and gynaecological care to those who require it.
The WHO cites the major causes of maternal morbidity and mortality in developed countries to be venous thromboembolism, eclampsia, ectopic pregnancy, haemorrhage and infection. In countries outside Ireland abortion is also a major cause of maternal morbidity and mortality if performed under unsafe or unsanitary conditions.
Non attendance to hospital appointments is a major reason for not receiving adequate care during pregnancy or illness. A study published in the Oxford journal of family practice lists (among young age and psychological problems) low socioeconomic status as being one of the major predictive factors in attendance scores for women attending hospital appointments11. Other factors which may hinder the attendance of a person of a lower socioeconomic background to an appointment may be the inability to avail of childcare for the duration of the appointment, lack of transport options to and from the hospital and work commitments that they feel they can’t afford to break.
As discussed non attendance is a problem particularly in women of a lower socioeconomic class. In 1997 and again in 2002 the Confidential Inquiry into Maternal Deaths revealed that 20% of all maternal deaths occurred in women who were late bookers (after 20wks), had no antenatal care or were poor attendees. Within the study it was also identified that all of these risk factors also had an important link with perinatal mortality12.
6 United Nations Millennium development goals 7 1. Pisani P, Parkin DM, Bray F, Ferlay J. Estimates of the worldwide mortality from 25 cancers in 1990. Int J Cancer 1999;83: 18-29 [published erratum appears in Int J Cancer 1999;83:870-873] 8 2. World Health Organization. Control of cancer of the cervix uteri: review article based on a report of a WHO meeting, November 1985, Geneva. Bull World Health Organ 1986;64: 607-618. 9 10. Alonso de Ruiz P, Lazcano-Ponce E. Quality control in cytopathology laboratories in six Latin American countries. In: Wied GL, Keebler CM, Rosenthal DL, Schenck V, Somrak TM, Vooijs GP, eds. Compendium on Quality Assurance, Proficiency Testing, and Workload Limitations in Clinical Cytology. Chicago: International Academy of Cytology; 1995. 10 World health organisation 11 Waller J, Hodgkin P. Defaulters in general practice: who are they and what can be done about them? Fam Pract 2000 12 CEMD 1997-1999
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Aside from maternal complications of socioeconomic deprivation there are of course foetal and neonatal complications associated also. A study conducted in Amsterdam focused on foetal outcomes based on neighbourhood. The neighbourhoods that were particularly looked at were ones with a high unemployment rate and high social security dependence rates. The result showed that women from a lower income neighbourhood were 1.32 times more likely to have a small for gestational age baby than a woman living in a high income area.
The effects of socioeconomic background on preterm birth also give a useful insight into the class divide of obstetric care. An article in the BMJ in 1995 showed that lower social class carried a risk of preterm birth but contrary to the previous article it claimed that there was apparently no link between psychosocial factors and low birth weight. The author then went on to explain that the timing of birth associated with lower social class could be explained by smoking as this was a common factor13.
The rates of admission to neonatal ICU also show a very strong correlation with lower social class. A study conducted by Queens University Belfast showed that the rate of admission to NICU was 31.4 per 1,000 births; areas of social deprivation had a figure up to 19% higher than the national average which corresponded with the main reasons for admission to NICU, prematurity and IUGR.
The implications of substance abuse to the unborn foetus are very negative. Alcohol can cause spontaneous miscarriage, foetal alcohol syndrome, IUGR and CNS dysfunction among other things. The use of illegal substances is also well documented as causing many ill effects to the unborn foetus as well as neonatal abstinence syndrome in the newborn. A paper published by a team from the Rotunda Hospital, Dublin outlined a study performed in which 1000 urine samples were taken from women on a random basis but looked at the social class and in particular the employment status of the women involved. The results showed that of the unemployed 9 out of 1000 women were taking at least one of the following substances in the antenatal period, alcohol, benzodiazepines, cocaine, cannabis, amphetamine or opiates14.
Socioeconomic class also affects the uptake of preventative healthcare such as the cervical screening programme. The UK has a well established cervical screening programme offering free smear tests to women over the age of 25 every 3 years until the age of fifty and then five yearly until the age of 65. A study performed by the University of London outlined predictive criteria for non attendees to complimentary smears among the predictors of poor attendance were unemployment, education up to secondary level alone, smokers, non- Caucasian ethnicity15.
In conclusion, socioeconomic deprivation spans every country and has the potential to have a very detrimental effect on the health of a woman and her children. Initiatives like the millennium development goals and the cervical screening programme are showing signs of progress but we are a long way from providing the same standard of gynaecological and obstetric care for every patient regardless of what part of Dublin, Europe or the world they are from.
13 Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol and caffeine BMJ 1995;311:531-535 (26 August) 14 The Prevalence of Chemical Substance and Alcohol Abuse in an Obstetric Population in Dublin P Bosio, *E Keenan, R Gleeson, *A Dorman, T Clarke, M Darling, *J O’Connor. Rotunda Hospital, Parnell Square, Dublin 1. *National Drug Advisory & Treatment Centre, Trinity Court, 31/32 Pearse Street, Dublin 2. 15 The role of education in the uptake of preventative healthcatre: The case of cervical screening in Britain. Ricardo Sabates and Leon Feinstein. Social science and medicine June 2006
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Appendix Six
Glossary of Terms
Booked patient: Booked patient: a patient who is seen at the antenatal clinic, other than the occasion on which she is admitted. This includes patients seen by the consultant staff in their consulting rooms.
Miscarriage: expulsion of products of conception or of a fetus weighing less than 500 grams.
Maternal Mortality: death of a patient for whom the hospital has accepted medical responsibility, during pregnancy or within six weeks of delivery (whether in the hospital or not). Maternal mortality is calculated against the total number of mothers attending the hospital including miscarriages, ectopic pregnancies and hydatidiform moles.
Stillbirths (SB): a baby born weighing 500 grams or more who shows no sign of life.
First week neonatal death (NND): death within seven days of a live born infant weighing 500 grams or more.
Late neonatal death (late NND): death between 7 and 28 days of a live born baby weighing 500 grams or more.
Perinatal Mortality: the sum of stillbirths and first week neonatal deaths as defined above. The perinatal mortality rate refers to the number of perinatal deaths per 1,000 total births infants weighing 500 grams or more in the hospital.
The following abbreviations are used throughout the report:
ABG arterial blood gas ACA anticardiolipin antibody AC abdominal circumference on ultrasound AEDF absent end diastolic flow in uterine arteries AMNCH Adelaide, Meath, incorporating the National Children’s Hospital (Tallaght Hospital) Amnio amniocentesis ANA antinuclear antibody ANC antenatal care APH antepartum haemorrhage ALPS anti-phospholipid syndrome ARM artificial rupture of membranes ASD atrial septal defect ATIII Anti-thrombin III BBA born before arrival BPP biophysical profile CANC combined antenatal care CIN cervical intraepithelial neoplasia CBG capillary blood gas CNM clinical nurse manager CNO chief nursing officer CMM clinical midwife manager Cord pH (a) arterial cord pH Cord pH (v) venous cord pH CPD cephalopelvic disproportion
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CPR cardio-pulmonary resuscitation CRP c reactive protein CTPA computerised axial tomography pulmonary arteriography Cryo cryoprecipitate CT Chlamydia trachomatis CTG cardiotocograph CWIUH Coombe Women & Infants University Hospital DCDA dichorionic diamniotic D&C dilatation and curettage DIC disseminated intravascular coagulopathy DoHC Department of Health and Children DVT deep venous thrombosis EBL estimated blood loss ECV external cephalic version ECHO echocardiogram EEG electroencephalogram EFM electronic fetal monitoring EFW estimated fetal weight EPAU early pregnancy assessment unit ERPC evacuation of retained products of conception ETT endotrachial tube EUA examination under anaesthetic FAS fetal assessment scan FBS fetal blood sample in labour FHNH fetal heart not heard FM fetal movement FMNF fetal movement not felt FTA failure to advance FV Leiden factor V Leiden GA general anaesthesia HB haemaglogin HCG human chorionic gonadotrophin Hep B Hepatitis B Hep C Hepatitis C HFOV high frequency oscillatory ventilation HRT hormone replacement therapy HVS high vaginal swab HIV infection with human immuno deficiency virus Hx history of INAB Irish National Accreditation Board IOL induction of labour IPPV intermittent positive pressure ventilation IPS Irish Perinatal Society ITP idiopathic thrombocytopoenia IUCD intrauterine contraceptive device IUD intrauterine death IUGR intrauterine growth retardation IVH intraventricular haemorrhage LFD large for dates LLETZ large loop excision of the transformation zone LMWH low molecular weight heparin LSCS lower segment caesarean section LV liquor volume MSU mid stream urinalysis NAD no abnormality detected NEC necrotising enterocolitis NETZ needle excision of transformation zone
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NG neisseria gororrhoea NICU neonatal intensive care unit NNC neonatal centre NND neonatal death NO nitric oxide NR not relevant NS not sent NTD neural tube defect OGTT oral glucose tolerance test OFC occipitio-frontal circumference OLHC Our Lady’s Hospital Crumlin OP occipito-posterior PCO polycystic ovary PET pre eclamptic toxemia PDA patent ductus arteriosus Pg prostaglandin PIH pregnancy-induced hypertension PMB post menopausal bleeding POP persistent occipito posterior PPH postpartum haemorrhage PPHN persistent pulmonary hypertension of the newborn PTL preterm labour PVB per vaginal bleeding RBS random blood sugar RCSI Royal College of Surgeons in Ireland RDS respiratory distress syndrome RV right ventricle Rx treated with SB stillbirth SCBU special care baby unit SE socio economic group SFD small for dates SIDS sudden infant death syndrome SIMV synchronised intermitent mandatory ventilation SJH St James’s Hospital SOL spontaneous onset of labour SpR specialist registrar SROM spontaneous rupture of membranes SVD spontaneous vaginal delivery TAH total abdominal hysterectomy TCD Trinity College Dublin TPA transposition of the great vessels TTTS twin to twin transfusion syndrome TVT tension free vaginal tape UCD University College Dublin US ultrasound USS ultrasound scan UTI urinary tract infection VBAC vaginal birth after caesarean section VBG venous blood gas VG volume guaranteed VE vaginal examination VSD ventriculo-septal defect
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Appendix Seven
Friends of the Coombe is a charity organisation established in 1982 to help raise funds to assist the development of the Coombe Women & Infants University Hospital and support its vital research programmes.
2009 was a busy year for Friends of the Coombe. Our donors were generous in their support and participation in our annual fundraising events increased significantly.
The 2009 Flora Women’s Mini Marathon raised €13,000, a fantastic achievement for all those involved. Amongst those fundraising were the Mc Bennett family seen below. Mr and Mrs Mc Bennett had welcomed quadruplets in the Coombe Women & Infants University Hospital, so the McBennett ladies were delighted to fundraise on the Hospitals behalf.
The Golf Classic was an equal success, raising €19,000.
2009 saw Friends of the Coombe profile build and expand, and with that came invaluable support from past patients and individual donors who undertook their own fundraising initiatives.
Employees at Symantec raised €460 during a company bake sale, as seen below.
Employees at Kildare based Pfizer established a Friends of the Coombe fundraising point in their staff canteen. They are aiming to purchase an “Infant Flow Sipap Machine” for the Hospital and are well on their way to achieving their target. Other fundraising initiatives included coffee morning, bucket collections at football matches, sponsored walks and pub quizzes to name but a few.
Friends of the Coombe aim to build on their success in 2010. Our website www.friendsofthecoombe.ie is reaching more people on a daily basis, our literature is circulated to a public who are increasingly aware of the vital equipment we seek to acquire for the Hospital and communication with our current donors remains paramount.
We continue to nurture the invaluable relationship we have with our fundraisers and we extend a sincere thank you to all those who contribute to our charity.
E Mckittrick
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Appendix Eight
Conference Programme
Cerebral Palsy: From Conception to Birth and Beyond
Winner of Irish Healthcare Award for Best Educational Meeting 2009
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Index
Academic Reports TCD ...... 193 UCD ...... 197 RCSI ...... 202 Acknowledgements ...... 1 Addiction & Infectious Diseases ...... 86 Adult Outpatients Department ...... 138 Advanced Nurse Practitioner (Neonatology) ...... 147 Anaesthetic Department (see Perioperative Medicine) ...... 116 Appendices ...... 209 Biochemistry ...... 168 Board of Guardians & Directors ...... 11 Centre for Midwifery Education ...... 152 Chaplaincy Department ...... 192 Clinical Nutrition and Dietetics ...... 178 Clinical Risk Management ...... 185 Community Midwife Service ...... 127 Contents ...... 2 Continence Promotion Unit ...... 109 Colposcopy ...... 113 Cytopathology ...... 161 Delivery Suite & High Dependency Unit ...... 130 Combined Clinical Data (Dublin Maternity Hospitals) ...... 26 Diabetic Endocrine Pregnancy Service ...... 76 Diabetes Mellitus (Midwifery Service) ...... 134 Director of Midwifery & Nursing Corporate Report ...... 119 Early Pregnancy Assessment Unit ...... 47 Executive Summary ...... 7 Fetal Medicine & Perinatal Medicine ...... 89 Family Planning Advisory Centre ...... 137 Glossary of Terms ...... 223 Guinness Lectures ...... 212 Gynaecological Oncology ...... 111 Gynaecology Oncology (Role of CNM Co-ordinator) ...... 140 Gynaecological Report (General) ...... 104 Haematology & Transfusion Medicine ...... 163 Haemovigilance ...... 165 History of the Hospital ...... 209 Histopathology & Morbid Anatomy ...... 158 Hygiene ...... 176 Index ...... 233 Information Technology Department ...... 187 Introduction ...... 4 Laboratory Medicine ...... 156 Liaison Perinatal Mental Health Clinic ...... 94 Masters ...... 210 Matrons & Directors of Midwifery & Nursing ...... 211
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Maternal Mortality ...... 53 Medical Clinic ...... 82 Medical Social Work Department ...... 188 Members of Staff ...... 13 Microbiology & Infection Prevention/Control ...... 166 Midwifery & Nursing Practice Development ...... 122 Midwifery & Nursing Report ...... 119 Molecular Pathology ...... 171 Multiple Pregnancy ...... 81 National Clinical Skills Centre ...... 208 Obstetrics Report (General) ...... 38 Operating Theatre Department ...... 142 Organisational Chart ...... 12 Parent Education/Breastfeeding Support Service ...... 125 Paediatric Department (Midwifery/Nursing) ...... 143 Paediatrics & Newborn Medicine ...... 95 Perinatal Day Centre ...... 132 Perinatal Mortality & Morbidity ...... 54 Perinatal Ultrasound Department ...... 136 Perioperative Medicine ...... 116 Pharmacy ...... 180 Physiotherapy Department ...... 183 Postgraduate Medical Training ...... 206 Psychosexual Clinic ...... 191 Radiology Department (Adult) ...... 154 Radiology Department (Paediatric )...... 155 Severe Maternal Morbidity & High Dependency Unit ...... 48 Staff Retirements in 2009 ...... 25 Statistical Summaries ...... 32
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Microarray cluster analysis demonstrating differential gene expression patterns in IVF and non-IVF pregnancies
HPV E7 gene silencing on HPV infected cervical cancer cell lines
Images courtesy of CWIUH Molecular Pathology Research Laboratory
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