Lessons from a critical review of stillbirths?

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Lessons from a critical review of stillbirths?

• Malcolm Griffiths

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Avoiding avoidable stillbirths
Defining the unavoidable (lessons from an audit
of stillbirths at LD)

• Malcolm Griffiths

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Background
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CEMACH Data 2004 (EWNI)
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CEMACH Data 2004 (EWNI)
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CEMACH Data 2004 (EWNI)
SB rates 2000 2001 2002 2003 2004
EW NI 5.4 5.4 5.7 5.8 5.7
LD 8.9
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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

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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

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Contributors

• Kathy Waller
• Helen Lucas
• Katie Chilton
• Eleanor Mirzaians
• Tracey Scivier
• Martina McIntyre

Sandra White Hilary Hemming Sue Jalali HV Stephen
Ramsden Malcolm Griffiths
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Topics

• Retrospective Audit (Sandra White)
• Critical analysis of cases
• Risk factors
• Avoidability
• Issues
• Birthweight study
• Areas for improvement/action
• As we go along!
• Reprise!

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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Unavoidable

• Missed IUGR
• Missed IUGR in twins
• Missed diagnosis of diabetes

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Unavoidable

• Missed IUGR

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

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Unavoidable

• Missed IUGR in twins

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

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Unavoidable

• Missed diagnosis of diabetes

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

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Birthweights

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

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Reprise!

• 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

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And also!

• 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!

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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

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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

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Gestation 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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