12 months data January – December 2016 Laura Bassett Risk Manager for Obstetrics & Gynaecology Cardiff & Vale University Health board.
In the UK 1 in every 200 births results in a stillborn baby. The Welsh initiative to reduce stillbirths, resulting from an Assembly one day enquiry on Stillbirths (2013) set a primary driver to learn from the Perinatal review process both locally and nationally. The MBBRACE report 2015 also highlighted the need for a multidisciplinary review of all of these cases to help identify the cause of stillbirth. Locally there was no in-depth analysis and no overall review of care was in place apart from an initial review within the clinical risk forum.
A local review process that would identify themes and causative factors for learning and future quality improvement. Prior to each meeting a full case review of the woman’s care from the time she accesses our service until the time of her discharge is prepared with all investigations undertaken. The forum focuses on assessing the quality of care received, identifying any points for learning and improvement and for feedback to the family and the staff involved. The findings are fed back to the family as part of the postnatal appointment with an Obstetrician and bereavement midwife; this ensures that all information is given at one point in time.
Purp rpose ose of the Meeti ting ng To present a case review of all Fetal losses which occur at ≥ 22 weeks gestation (All intra partum IUD’s will be discussed at Clinical Risk meeting and actions noted at this meeting). To identify appropriate actions if any further investigation is required To monitor progress of all cases under investigation or awaiting further results To present final pathology reports and governance investigations as a feedback and learning mechanism to staff involved To provide sign off process for investigation of cases
MDT Senior midwife Obstetrician Consultant midwife Bereavement midwife Risk manager Pathologist SANDS representative Supervisor of midwives All Wales Perinatal Survey member Open for other staff members to attend. Meetings take place monthly.
Review of all cases with the exception of MTOP’s Ongoing action plan for monitoring Feedback mechanism for staff to enable closure of cases Following discussion at the review forum, learning outcomes and causation are agreed and identified and the decision is made if further governance investigation is necessary along with a plan of care for any subsequent pregnancy. There is a joint focus in reducing Stillbirth through implementation of quality management goals identified though learning and outcomes.
12Months Data January – December 2016 Month of stillbirth Gestation Growth Ethnicity Smoker Investigations BMI Age Parity Placental Histology Post-mortem uptake Reason/ causative factor MBBRACE quality of care criteria
9 8 7 6 5 4 3 2 1 0
12 10 10 8 8 6 6 5 4 4 3 3 2 1 1 1 0 Number
Retrospectively plotted on customised growth charts 1 st 6 months 50 % under 10 th centile
Number ber 40 35 30 25 20 15 10 Number 5 0
Smoker 5 Non-smoker 17
2 cases Root Cause Analysis Cases reviewed by supervisor of Midwives
BMI <20 20-25 25-30 30-35 >35
Age 14 12 10 8 Age 6 4 2 0 <20 20-25 25-30 30-35 35-40 40-45
Number ber Primip Multip
Number ber Placenta No Placenta
Number ber Full External None
0 1 2 3 4 5 6 7 8 A851 - Unknown despite… A830- Unknown no autopsy A854- Unknown - unxplained A800 - Unknown no autopsy A831 - Unknown A099- Infection A714- Maternal Hypertension A791- Maternal trauma A644 - Placental Infarcts and… A680- Placental A651- Placental diabetes A637- Placental infection A681- Small placenta <2.5 A632- Placental abruption A673-Placental TTT syndrome A725- Uterine rupture A111- Extreme prematurity
• Documentation of condition of baby • Customised growth charts - weight centiles • Post mortem rates • Gestation on histology forms • Reduced fetal movements • Interpreters
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