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Lessons from a critical review of stillbirths?. Malcolm Griffiths. Avoiding avoidable stillbirths. Defining the unavoidable (lessons from an audit of stillbirths at L&D). Malcolm Griffiths. Background. CEMACH Data 2004 (E&W&NI). CEMACH Data 2004 (E&W&NI). CEMACH Data 2004 (E&W&NI).

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Avoiding avoidable stillbirths

Avoiding avoidable stillbirths

Defining the unavoidable

(lessons from an audit of stillbirths at L&D)

Malcolm Griffiths






Aims of the project
Aims of the project

  • Reduce the number of stillbirths to women resident in Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital

  • By reducing avoidable stillbirths


Methodology
Methodology

  • Retrospective audit

  • Critical incident review of each case by a multidisciplinary panel

  • Open non-punitive discussion

  • Classification of avoidable/non-avoidable

  • Further review of common issues


Contributors
Contributors

Sandra White

Hilary Hemming

Sue Jalali

HV

Stephen Ramsden

Malcolm Griffiths

Kathy Waller

Helen Lucas

Katie Chilton

Eleanor Mirzaians

Tracey Scivier

Martina McIntyre


Topics
Topics

Retrospective Audit (Sandra White)

Critical analysis of cases

Risk factors

Avoidability

Issues

Birthweight study

Areas for improvement/action

As we go along!

Reprise!


Retrospective data
Retrospective data

  • Massive amounts of data

  • Each stillbirth told its own story

  • More common in primips

  • Many of the women had had multiple attendances

  • Much higher rates by

    • Ethnic origin

    • Practice

    • Electoral wards


Avoidable stillbirths
Avoidable Stillbirths

  • More appropriate actions by clinical staff likely to have altered outcome

  • More appropriate actions by mother or family likely to have altered outcome


More appropriate actions by clinical staff likely to have altered outcome
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to consider induction of labour in high risk case (raised BP)

  • Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour

  • Failure to recognise non-reassuring CTG


More appropriate actions by clinical staff likely to have altered outcome1
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring)

  • Failure of GP to mention recent treatment for diabetes in referral letter


More appropriate actions by clinical staff likely to have altered outcome2
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to consider induction of labour in high risk case (raised BP)

  • Feedback to clinician


More appropriate actions by clinical staff likely to have altered outcome3
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour

  • Feedback to clinician

  • Emphasising policy

  • Empowering other staff to intervene


More appropriate actions by clinical staff likely to have altered outcome4
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to recognise non-reassuring CTG

  • Feedback to clinician

  • Increased training

  • Emphasising policy

  • Empowering other staff to intervene


More appropriate actions by clinical staff likely to have altered outcome5
More appropriate actions by clinical staff likely to have altered outcome

  • Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring)

  • Feedback to clinician


More appropriate actions by clinical staff likely to have altered outcome6
More appropriate actions by clinical staff likely to have altered outcome

  • Failure of GP to mention recent treatment for diabetes in referral letter

  • Feedback to clinician


More appropriate actions by patient or family likely to have altered outcome
More appropriate actions by patient or family likely to have altered outcome

  • Late booking – failure to receive anti-HIV therapy

  • Delay in seeking help (decreased movements & APH)

  • Refused appropriate induction of labour

  • Delay in seeking help (APH)


More appropriate actions by patient and staff likely to have altered outcome
More appropriate actions by patient and staff likely to have altered outcome

  • Patient being followed up in DAU due to be reviewed in ANC - DNA


More appropriate actions by patient and staff likely to have altered outcome1
More appropriate actions by patient and staff likely to have altered outcome

  • Meeting with members of the community

  • Access to minority language link-workers by mobile phone

  • Specialist HIV midwife

  • Policy for chasing DNAs


Unavoidable
“Unavoidable” altered outcome

Missed IUGR

Missed IUGR in twins

Missed diagnosis of “diabetes”


Unavoidable1
“Unavoidable” altered outcome

Missed IUGR

  • Customised Growth Charts pilot

  • Customised Growth Charts RCT

  • Possible need for work with ultrasonographers


Unavoidable2
“Unavoidable” altered outcome

Missed IUGR in twins

  • Review evidence for more frequent scans

  • Review policies in other units

  • Consider greater use of SFH charts


Unavoidable3
“Unavoidable” altered outcome

Missed diagnosis of “diabetes”

  • Ask NICE to consider merits of screening for gestational diabetes

  • Local review – possible selective screening


Birthweights
Birthweights altered outcome

Are “unexplained” stillbirths missed intra-uterine growth retardation (IUGR)?


Reprise! altered outcome

  • Feedback to clinician

  • Increased training

  • Emphasising policies

  • Empowering other staff to intervene

  • Meeting with members of the community

  • Access to minority language link-workers by mobile phone

  • Specialist HIV midwife

  • Policy for chasing DNAs


And also! altered outcome

  • Integration of community midwifery and health visiting

  • Improve access of ethnic minority women to service

  • Expected HV involvement would be welcome by bereaved families and would allow late feedback –

    • not so!


Lessons for others
Lessons for others altered outcome

  • The critical incident review approach is useful and could be used in other areas (operative deaths, ITU deaths, readmissions)

  • But needs

    • Manageable numbers

    • Multidisciplinary input

    • Openness & Strict approach

    • Enthusiasm & Ownership

    • “Nagging voice”


Aims of the project1
Aims of the project altered outcome

No proof yet that we have achieved our aim

  • Reduce the number of stillbirths to women resident in Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital

  • By reducing avoidable stillbirths

  • But we are hopeful


altered outcomeGestation specific birth weight centiles

From January 2005 onwards, CEMACH has collected adequate information to allow the application of appropriate gestation-specific birth weight centiles to stillbirths and neonatal deaths. This will enable us to estimate the number of deaths that are of babies who are small for gestational age. This, coupled with a further question on evidence of fetal growth restriction, will allow some exploration of the association between growth

restriction and stillbirth and neonatal death at a national level.


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