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Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures).

Below are some recommended measures to use, as appropriate, to track your progress. In selecting your measures, consider the following:

  • Whenever possible, use measures you are already collecting for other programs.
  • Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.
  • Try to include both process and outcome measures in your measurement scheme.
  • You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.
  • Posting your measure results within your hospital is a great way to keep your teams motivated and aware of progress. Try to include measures that your team will find meaningful and exciting (IHI, 2012).

    For more information on measuring for improvement contact the Canadian Patient Safety Institute Central Measurement Team at

Outcome Measures

  1. Per cent of patients with vaginal delivery (with and/or without instrumentation) with an obstetric anal sphincter injury (third and fourth degree perineal tears).
  2. Per cent of deliveries resulting in uterine rupture:
  • Single parity
  • Previous vaginal delivery with no history of uterine scar
  • VBAC or previous uterine incision
  • Those with more than one caesarean section

Process Improvement Measures

Obstetric anal sphincter injuries (third and fourth degree perineal tears)

  1. Percentage of vaginal deliveries in which the obstetrical care provider slows the fetal head at crowning.
  2. Percentage of vaginal deliveries in which an episiotomy was performed? (low is better)
  3. Percentage of episiotomies performed using a mediolateral incision with a cutting angle between 45 degrees-60 degrees.
  4. Percentage of vaginal deliveries in which warm compresses were applied and antenatal perineal massage was performed. 
Uterine rupture
  1. Per cent of women with no contraindications to a TOL and one or more previous transverse low-segment Caesarean section that are offered a trial of labour (TOL).
  2. Per cent of women who are undergoing a TOL after Caesarean who have all of the following completed:
    1. Informed consent
    2. Counselled on risks / benefits associated with ERCS vs TOL (i.e. increased risk of uterine rupture for those delivering within months of Caesarean section)
    3. Documentation of the location of previous uterine scar is recorded.
    4. In hospital delivery with obstetric, anesthetic, pediatric, and operating-room staff available and notified.
    5. Urgent laparotomy set-up is completed to facilitate rapid delivery if necessary.
    6. Continuous electronic fetal monitoring