NURSING AUDIT IN

OBSTETRIC CARE

Presented by:
Mrs. Sarla Takoo
Associate Professor
Lakshmi Bai Batra College of Nursing
 INTRODUCTION

Excellence of health delivery is determined by the patients degree of

health which is maintained through health activities with existing
resources. Nursing is a service profession, the profession as a whole should
be accountable for the quality care. The nurses must decide what is best
for their patients and meet their expectations . Nursing must control its
practice in order to guarantee the quality of its service to the public.

Obstetric care of high quality continues to be a key requirement for reducing

maternal mortality. However, the provision of effective, appropriate,
accessible and obstetric care is difficult to define, measure, resource,
sustain and evaluate.
NURSING AUDIT

The word “audit” comes from the latin word “ auditus”, a “hearing”. It
originally meant the hearing of facts and arguments about a situation to
determine the truth.
An audit is an objective, systematic and critical analysis of the quality of
medical care. It includes “the procedures used for diagnosis and
treatment, the use of resources, and the resulting outcome and quality of
life for the patient” (Crombie et al. 1997). An audit is not a substitute for
a review of maternal deaths or ‘near misses,’ but complements the review
process.
HISTORY OF NURSING AUDIT

• One of the first ever clinical audit was undertaken by Florence

Nightingale during the Crimean War Of 1853-1855.
• On arrival at the medical barracks hospital in Scutari in 1854,
Florence was pained by the unsanitary conditions and high
mortality rates among injured or ill soldiers. She and her team
of 38 nurses applied strict sanitary routines and standards of
hygiene to the hospital and equipment.
• Another famous figure who advocated clinical audit was Ernest
Codman (1869 - 1940) by monitoring surgical outcomes.
• Before 1955 very little was known about the concept of nursing
audit .
• First report of Nursing Audit of the hospital was published in
1955.
• For the next 15 years , nursing audit is reported from study or
record of the last decade.
 CONCEPT OF NURSING AUDIT

 Concept of nursing audit is based on debit and credit

system.

Hospital
Infection

Complication
of disease Errors in treatment

Death of
patients Debit Items Patient on LAMA
CONCEPT OF NURSING AUDIT

Expansion of
health knowledge Shorter stay in
in patient Hospital
population

Number of Regular follow up

recovered in the community
patients
Credit
Items
 NURSING AUDITS DEPENDS ON
THE PRESENCE OF TWO THINGS

Written
records

Standards
(or protocols,
or treatment
guidelines)
TYPES OF NURSING AUDIT

Structure

Process

Outcome
AUDIT IN OBSTETRIC CARE

 Nursing Audit in Obstetric Care is a detailed review

and evaluation of selected clinical records by
qualified professional personnel in the field of
obstetrics and gynaecology to identify, examine and
verify the performance of certain specified
aspects of nursing care by established criteria.
 Conducting nursing audit in obstetric care is a
process intended to result in change in the
practice.
THREE MAIN REASONS FOR CONDUCTING
NURSING AUDIT IN OBSTETRIC CARE

Improve Staff
Morale and
Enhance Motivation
Rational Use
Improve of Limited
Clinical Resources
Practice
WHY CONDUCT NURSING AUDIT
IN OBSTETRIC CARE?
 REASONS FOR LACUNAE IN
CLINICAL PRACTICE

Deficiency in Skill Inequalities in the

and Care on the Inadequacy of Health Status and
Part of the Resources Social Status of
Service Provider the End-Users
 NURSING AUDIT PROCESS IN
OBSTETRIC CARE

Clinical audit is a quality improvement process that

seeks to improve patient care and outcomes
through systematic review of care against explicit
criteria and the implementation of change. The
process can be divided into two main phases:
a. Preparatory phase
b. The audit cycle.
PREPARATORY PHASE
 PREPARATORY PHASE

1.Forming the Audit team

The support and involvement of everyone who will
participate in the audit procedure is crucial. The nursing
audit team comprises of:
 Independent Nurse Practioner

 Nurse Midwives

 Nurse Researchers

 Nursing Superintendent

The team members should be interested in quality

assurance, should be clinically competent and they should
be able to work together in a group. The team leader must
be motivated to change his or her own contribution to the
quality of care.
 PREPARATORY PHASE

2. Selecting a topic for Audit

The second step is to develop a clear idea of the problem
that the team wants to assess and improve through the
audit process. Examples of issues that can be audited are:
Clinical Issues: Auditing adherence to Clinical issues:
auditing adherence to protocols for clinical management.
For example, the audit treatment of obstetric complications
are just one. For example, for eclampsia, treatment is
Injection Magnesium Sulphate.
Other clinical examples are: indications for caesarean section,
blood grouping crossing matching before caesareans, use of
prophylactic antibiotics before caesarean, augmentation of
labor, partograph, vacuum/forceps delivery and so on.
 Written guideline on administration of magnesium sulphate for
eclampsia

S.No Steps
1. Wash hands thoroughly with soap and water and dry before and after the procedure

2. Keep ready 10 ampoules of 50% Mg SO4 ( I ampoule=2ml=1g), Dose = 14 gms

3. Prepares 3 syringes(10ml syringe and 22 gauze needle) with 5 g (10 ml) of 50%
magnesium sulphate solution in 2 syringes for IM injection and one syringe for IV (4gm IV
bolus)
4. Carefully cleans the injection site with an alcohol wipe.

5. Give 5 g (10 ml) by DEEP IM injection in one buttock (upper outer quadrant)

6. Cut the needle with hub cutter and Disposes of used syringe in a proper disposal box
7. Cut the needle with hub cutter and Disposes of used syringe in a proper disposal box

8. Carefully clean the injection site in the other buttock with an alcohol wipe.

9. Give 5 g (10 ml)by DEEP IM injection in other buttock(upper outer quadrant)

10. Cut the needle with hub cutter and Dispose of used syringe in a proper disposal box

11. Record drug administration and finding on the woman’s record.

 PREPARATORY PHASE

 Management issues: the organization of the medical facility looking at

staffing patterns, facility functions or equipment (e.g. blood bank,
infection prevention, completeness of medical records). Examples of
Management issues include the blood bank (availability of blood and
organization)
 laboratory delays

 infection prevention

 sharps disposal

 drug availability

 operation theatre preparation and availability of O.T

 completeness of patient records

 staff scheduling

 If the audit team discovered during a maternal death review that

usually there was a long delay before treatment for women admitted
after-hours (during the evening or at night), the audit team might want
 PREPARATORY PHASE

 Human rights in various areas: clinical setting, health system, legislation

regarding procedures or medications, payment systems, interpersonal
interactions between staff and patients or among staff. Examples of
Human Rights Aspects in the Clinical Setting
 Are patients attended by clinical staff who speak their language?

 Do patients and their families have treatment clearly explained to

them?
 Are fees for various services clearly posted and in the necessary
languages?
 Are patients greeted warmly and sympathetically when they
arrive, or are they ignored or treated coldly?
 Do different levels of staff treat each other with respect?
 PREPARATORY PHASE

3. Define Cases: The team should agree on all case definitions for
audit of clinical, management or human rights issues. The written
definition should be available. Examples of Case Definitions
 Postpartum haemorrhage:

 Bleeding that requires treatment (provision of intravenous fluids

and/or blood transfusion)

 Retained placenta

 Severe bleeding from lacerations (vaginal or cervical)

 Referrals: All cases initially treated at a health centre and

referred to the hospital by the health centre staff.

 Caesarean sections: All caesarean sections (emergency and

elective) conducted at the district hospital. Caesarean

hysterectomies excluded.
 After-hours admissions All obstetric cases admitted between 7pm
 PREPARATORY PHASE

4. Set Criteria
Criterion-based audit involves a comparison of current
practice with agreed evidence-based standards.
Criteria need to be:
 Based on sound scientific evidence

 Measurable, preferably using patient records

 Realistic, given the capacity of the facility in terms of

staff and resources

 Selecting criteria does not mean including all desirable

actions related to your topic. The criteria can be

derived from:

 PREPARATORY PHASE

Examples of criteria Clinical:

Active management o the 3rd stage of labor:
 10 units IM of oxytocin were given within 1 minute of delivery of (last) baby
 Controlled cord traction was done to deliver placenta
 Immediate uterine massage was done after placental delivery. Uterine massage
was done every 15 minutes for first 2 hours
 Observations of blood loss were recorded
Management:Referral process
 Patients and family were told why referral was necessary
 Prophylactic antibiotics given
 Written notice of what has already been given (e.g. diazepam) and what
procedures have already been(e.g. catheterization, MVA) sent with patient
 Written notice of reason for referral sent with patient
 Written notice of patient’s history (e.g. previous caesarean section, previous
postpartum haemorrhage) sent with patient
 PREPARATORY PHASE

 Human rights:
Discrimination and access to EmOC
Family or woman paid unofficial fees for admission or treatment
Family had to purchase drugs outside the hospital

Identify Information Sources

Depending on the subject of the audit – whether it applies to clinical
treatment, management issues of the facility or organizational facets related
to the health system, or human rights issues – the data will be derived from
one or more of the following sources:
 hospital registers

 patients’ case records

 staff or family interviews

 patient interviews

 pharmacy stock lists

 blood bank inventories

 PREPARATORY PHASE

5. Design Data Extraction/Collection Sheet

Data collection forms need to be drafted, pre-tested,
revised, finalized. Preparing the forms may take some time.
Review 10 cases, one at a time. If the criterion is met, write
in the column Y(yes). If it is not met, write N (no).
 PREPARATORY PHASE

1 2 3 4 5 6 7 8 9 10 Total
No.
Criteria for Referral Procedures
Yes/10
Patients and family were told why referral was necessary

Admission time and referral time at the health centre were

recorded
Prophylactic antibiotics were given

IV (normal saline or Ringer’s Lactate ) with disposable bag

set up was sent along with the patient

Written notice of what drugs have been given is sent with

the patient
Written notice of what procedures have been done (e.g.
catheterization) is sent with patient
Written notice of reason for referral sent with patient

Written notice of patient’s history (e.g. previous caesarean

section, previous postpartum haemorrhage) sent with patient
 PREPARATORY PHASE

1 2 3 4 5 6 7 8 9 10 Total
No.
Criteria for Active Management of Third Stage of Labour
Yes/10
Palpated the mother’s abdomen to rule out the presence of
additional baby (ies)
Administered Inj.Oxytocin, 10IU, IM OR Tab. Misoprostol
600 micrograms
Delivered the placenta by applying Control cord traction with
counter pressure in upward direction to be applied on the
uterus at the suprapubic region
Massaged the uterine fundus in a circular motion and ensures
that the uterus is well contracted
Examine the placenta-maternal and fetal surface for
completeness
Written notice of what procedures have been done (e.g.
catheterization) is sent with patient
Written notice of reason for referral sent with patient
Written notice of patient’s history (e.g. previous caesarean
 PREPARATORY PHASE

7. Data Collection
There are at least three possible methods of data collection:
 Extraction from written records

 Observation

 Interviews

8. Analysis
 The analysis is based on the comparison between the existing

situation and the facility’s established criteria.

9. Recommendations or action plan
 During the analysis, the audit team should discuss the findings and

consider the options for improving the situation is usually enough

to generate several ideas for improvement. Recommendations could
include training of staff, developing new systems or protocols,
eliminating unnecessary steps in various procedures and so on.
 PREPARATORY PHASE

Example of an action plan to reduce the delay of caesarean delivery:

Problems Causes Recommendations Who will Time

implement
LSCS Shortage of Appointment of Medical Officer As soon as
instruments not nursing staff in new staff in charge/ possible
prepared on OT Nursing
time/ Labour Superintendent
OT not
prepared
Lack of Improper store Training in Medical Officer Within one
emergency management inventory Incharge month
drugs management
Lack of blood No one attends Have 24/7 blood Pathologist Within one
blood bank at bank attendance month
night
 PREPARATORY PHASE

Example of an action plan to reduce the perineal tear:

Problems Causes Recommendations Who will implement Time

Perineal tears Lack of skill Inservice Nursing As

in and practice Education/contin Superintendent soon
multigravidas Lack of uing nursing as
seen perineal education with possibl
frequently support demonstration e
during labour
METHODS USED IN AUDIT

Direct
Checklists
Observation

Documentations/
Questionnaire
record audit

Clinical Case
Interviews
Review
 AUDIT CYCLE

The five classic steps of the audit cycle are shown

systematically in figure 1.
The effectiveness of the cycle can be assessed
primarily in terms of change in the proportion of
complications where management has met the
criteria for good care, although structure, e.g.
staffing and facilities, must also be monitored.
STEPS IN THE NURSING AUDIT
PROCESS IN OBSTETRIC CARE
 MATERNAL DEATH AUDIT

It is critical to determine the levels and causes of maternal

mortality. This will tell us the public health importance of
specific maternal health problems. We can then design
appropriate interventions to reduce maternal mortality. For
example, a large number of maternal deaths due to hemorrhage
will point to the need for:
 Early management of bleeding
 Timely referral
 Access to emergency transport

Or, high levels of maternal death due to puerperal sepsis, for

example, may indicate the need for:
 Improved management during delivery

 STEPS OF MATERNAL
DEATH AUDIT

St • Examine case records and interview staff

ep
1
St • Interview the household of the deceased
ep person
2
St
• Use this information to reconstruct the
ep circumstances leading to the death
3
St • Assign a Cause of Death
ep
4
Step 1: Examine case records
and interview staff

• Visit the health premises where

1 she was treated to examine case
records and interview staff.

• Take note of the recorded

2 obstetric history

• Ask staff about any special

3 circumstances regarding the
death
Step 2: Interview the household
of the deceased person

Meet the relatives of the deceased to collect information on:

• The location of the death
1
• The economic, social and educational
2 profile of the family

• The deceased’s obstetric history and

3 record of antenatal, delivery and
postnatal care, referral

4
• The circumstances of death
 Step 3: Reconstruct the
circumstances of the death

• Obstetrician to analyze the direct and

1 indirect obstetrical causes which led to
death

• Other team members to examine non-medical

causes of death: antenatal care, risk factors,
2 complications, delay in referral or in initiation
of treatment, non-availability of specialists,
equipment, blood, etc.

3
• Highlight system failures
Step 4: Assign a Cause of Death

• Use all the information to

1 assign, as a team, the primary
cause of death

• Ask yourselves - Was it

2 preventable?

• Ask yourselves – Was it because

3 of a systems failure?
 After the above steps, the following things needs to be done:

• Provide feedback to relevant

1 institution

• Provide feedback to relevant

2 personnel involved in the case

• Conduct annual analysis of maternal

3 deaths to understand causes of death

and formulate appropriate response
 Analysis – What does the
Maternal Death Audit tell you?

• Poor distribution of first referral units

1 (FRUs)

• Unnecessary referrals
2
• Poor quality of care
3
• Delay in accessing emergency transport
4
5 • Obstetric first aid not provided
before referral
Analysis – Possible Solutions

• Making FRUs functional by contracting in additional staff

1
• Ensuring emergency transport – either by using untied

2 funds to establish a tie-up with local transport facility or

by setting up an ambulance facility

• Establishing blood storage facilities at the PHCs

3
• Providing additional training to PHC staff in emergency

4 obstetric care

• Ensuring that all staff are aware of Emergency Obstetric

5 Care protocols
 NURSING AUDIT OF
OBSTETRIC CASES
 The indicators used are:

Number of
Number of
caesarean
forceps/vacuum
sections with
application
indications

Number of Number of
maternal maternal and
complications neonatal death
PARAMETERS USED IN AUDIT
OF OBSTETRICAL CASES

Investigation done,
History and physical
treatment given and Nursing care chart
examination
progress note

The initial diagnosis is compared Treatment given is judged

with the final diagnosis after against correctness, adequacy
investigation according to norms

The end result of treatment is Any deviation found from the

compared with patient condition norms are intimated for
at discharge improvement
 CONCLUSION

 A profession dedicated for the quality of its

service to patients constitutes the heart of its
public.
 An audit helps to ensure that the quality of
obstetric care rendered to the mothers is
achieved.
 Nursing Audit in Obstetric Care promotes
understanding, makes effective use of the
resources, helps to raise standards of care and
promotes change.
THANK
YOU