lessons from a critical review of stillbirths? malcolm griffiths

Lessons from a critical review of stillbirths?

Malcolm Griffiths

Avoiding avoidable stillbirths

Malcolm Griffiths

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

Background

CEMACH Data 2004 (E&W&NI)

CEMACH Data 2004 (E&W&NI)

CEMACH Data 2004 (E&W&NI)

SB rates

2000 2001 2002 2003 2004

E&W

NI

5.4 5.4 5.7 5.8 5.7

L&D 8.9

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

Retrospective auditCritical incident review of each case by a

multidisciplinary panelOpen non-punitive discussionClassification of avoidable/non-avoidableFurther review of common issues

Contributors

Kathy WallerHelen LucasKatie ChiltonEleanor MirzaiansTracey ScivierMartina McIntyre

Sandra WhiteHilary HemmingSue JalaliHVStephen RamsdenMalcolm Griffiths

Topics

Retrospective Audit (Sandra White)Critical analysis of cases

Risk factorsAvoidabilityIssues

Birthweight studyAreas for improvement/action

As we go along!Reprise!

Retrospective dataMassive 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

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

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

Avoidable & Unavoidable Stillbirths

Unavoidable

Avoidable - staff

Avoidable-patient/family

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 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 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 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 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 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 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

• 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

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

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”

Missed IUGR

Missed IUGR in twins

Missed diagnosis of “diabetes”

“Unavoidable”

Missed IUGR

•Customised Growth Charts pilot•Customised Growth Charts RCT•Possible need for work with ultrasonographers

“Unavoidable”

Missed IUGR in twins

•Review evidence for more frequent scans•Review policies in other units•Consider greater use of SFH charts

“Unavoidable”

Missed diagnosis of “diabetes”

•Ask NICE to consider merits of screening for gestational diabetes•Local review – possible selective screening

Birthweights

Are “unexplained” stillbirths missed intra-uterine growth

retardation (IUGR)?

0 to25

25 to50

50 to75

75 to100

Observed0

5

10

15

20

25 Observed

Expected

•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

Reprise!

•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!

And also!

Lessons for others•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 project

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

• Gestation specific birth weight centilesFrom 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 growthrestriction and stillbirth and neonatal death at a national level.