Saving Babies in North England SaBiNE Saving Babies in North England June 2015

Aims of Training Promote best practice Understand risk assessment at booking Increase knowledge of customised growth charts Standardise fundal height measurement Expand awareness of referral criteria

Fetal growth restriction associations Stillbirth Neonatal deaths SIDS Perinatal morbidity Cerebral palsy Effects in later life Associated risks of FGR: 4 - 8 x more likely to die in utero link to NN deaths, probably associate with prematurity, do not cope well in labour and susceptibility to infection Associated with SIDs- ?Linked with premature delivery European studies link FRG with not reaching mile stones compared with appropriately grown baby. Term cerebral palsy- in absence of hypoxia in labour Barker hypothesis- FGR is linked to increased chronic health disease in later life- type 2 diabetes, coronary heart disease, obesity, hypertension

‘Unexplained’ Stillbirths in West Midlands, 2001 n=231; <10th percentile: 140 = 62 % 90 50 10 Chart shows the unexplained still births pre introduction of customised growth charts. Centile lines identify the 10th, 50th and 90th centiles. If there was an even distribution of birth weights (a Bell curve) there should be: 10% above the 90th centile 80% babies between 10th and 90th centiles 10% babies below the 10th centile Graph shows a very different picture – 62% were below the 10th centile = 62% of still born babies were FGR so not unexplained stillbirths 25 28 31 34 37 40 43 weeks

Stillbirths – Wigglesworth classification: consistently about two-thirds are ‘Unexplained’ Classification system that has been used historically but does not take fetal growth restriction into consideration. Large percentage of stillbirths have been classified as unexplained, therefore difficult to establish a plan of care for subsequent pregnancies

Developed by Gardosi et al Developed by Gardosi et al. Looking at relevant condition at death (ReCoDe) http://www.bmj.com/content/331/7525/1113 Large proportion of stillbirths attributable to fetal growth restriction = 42.9% Unclassified is reduced to only 16% of all the stillbirths

Risk assessment at booking Risk assessment to be taken at booking to identify who is 1.suitable for serial fundal height measurements from 26-28 weeks gestation = LOW RISK; and 2. who requires serial scanning from 26-28 weeks gestation until delivery = INCREASED risk. ‘low risk’ ‘increased risk’

RCOG Guidelines Latest evidence = RCOG guidelines support the use of customised growth charts and standardised fundal height measurements and serial scanning for the at risk mother

Booking Risk Assessment Risk assessment flow chart taken from RCOG guidelines

Modified RCOG guidelines from NHS England Saving babies Lives and Early neonatal deaths Care Bundle None- low or increased risk only ( not major or minor risks) All smokers are increased risk

GROW Gestation Related Optimal Weight www.perinatal.org.uk OPTIMAL is the key word. Need to identify the optimal size at term of this baby in the absence of pathology e.g. don’t want to take into consideration does the mother smoke, or have hypertension.

Compare Laura and Manjit’s charts – in clinical practice charts will look the same. Laura is European, taller, heavier compared with Manjit, who is Pakistani, shorter and slimmer.

x Compare the two charts- but note there is less than 600 g difference in term optimal weight Point out that at 28 weeks gestation a 26cm fundal height measurement would be acceptable for Manjit

x Point out 26 cm at 28 weeks is not acceptable for Laura

Standardised Fundal Height Measurement Introduce standardised technique and demonstrate on abdomen if possible

Fundal Height Measurement Primary screening tool Acceptable to women Easy to perform Non-invasive Inexpensive

Semi recumbent-empty bladder

Fundal height Identify the fundus

Identify top of the symphysis pubis

Semi recumbent-empty bladder Measure the longitudinal axis, with an non-elastic tape measure and numbers hidden.

Considerations Descent of the head Transverse Lie Multiple Pregnancies Already having serial scans – how frequent is serial? Obesity Descent of the head- should NOT affect fundal height measurement as an uncompromised baby continues to grow, as is the fundus of the uterus. Hence also, chart has no expected flattening of the curve at term Transverse lie – Consider overall clinical picture. Measurement of fundal height is usual practice, if the plot is outside of the expected parameters then the woman needs ultrasound biometry to monitor growth. Do not excuse a change in the pattern of growth because of the position. Multiple pregnancies- fundal height measurements are not appropriate, serial scanning should be performed as per Trust protocol, individual EFW can be plotted on the customised growth chart. Serial scans =2-3 weeks. Trust guidance on scanning protocols should be discussed. Obesity- High BMI (usually defined as 35+) - serial fundal height measurements not appropriate as not accurate, should be receiving serial scans as per RCOG guidelines

Is this normal growth? Growth is normal. Demonstrate 1st plot is the baseline. Subsequent plots should follow the same curve.

Referral recommendations First plot is below the 10th centile- this does not mean the baby is small, but indicates the need for a scan. If the estimated fetal weight is above the 10th centile this is reassuring and we would expect the following fundal height measurements to follow the trajectory of the first fundal height measurement. If the EFW is below the 10th centile, then this indicates the need for serial scanning

Static growth Static growth requires referral for USS to assess EFW

Slow growth This picture also requires referral for slow growth to assess EFW- the plots are not following the slope of the curve. Discuss plots as per training you have had with PI

Is this normal growth Growth is following a normal pattern trajectory, do not inform the mother she is having a big baby, the plots are following the slow of the curve

Referral recommendations Excessive growth- this is not simply growth above the 90th centile, it is a change in the pattern of growth. To be described as excessive or accelerated growth. Discuss local Trust guidance. Is a OGTT required or a growth scan to assess EFW?

SaBiNE project. Face-to-face training around GAP E learning Monitoring detection rates Audit of non-detected cases of FGR PI support

E-learning Module 1 – Theory Module 2 - Practice Can be accessed from anywhere with an internet connection Will take approximately 1 hour to complete User can update themselves as required (every 12 months recommended) Email address required for every user Key leads will have a training log of all users who have completed on line training

GROW Web App Hospital-based username and password Link to be added to each computer in delivery suite, birth unit, MLU etc to complete birth weight centiles Hospital-based username and password

Confirm mother’s details are correct. If so select “yes” If mothers details are incorrect, re enter chart ID number. If details remain incorrect, generate a new chart, and use the new chart ID number.

Obtaining a birthweight centile Complete birth details

Input unit responsible for antenatal care All maternity units in the United Kingdom are listed with the additional option for ‘no antenatal care’ or ‘other’ for care received outside of UK/ private

Input baby birth details Confirm if SGA / FGR was suspected (from a fundal height) or detected by scan antenatally

New edit function for centile page outcome, gender, birth weight

Alterations can be made to:- Outcome Gender Birth weight

Benefits of Data collection Baseline FGR and antenatal detection rates Quarterly FGR reports Benchmarking against other units (anonymously) National picture Can identify missed cases to audit Can monitor performance and improvement Evidence good practice Commissioning support – Ultrasound resources PI - Evaluation of GAP

Reports This Trust started inputting centiles in Dec.

Aims of GAP-SCORE Review missed cases of SGA in a standardised way across the North of England Determine learning points relevant to clinical practice Action recommendations to enable quality service provision GAP-SCORE is being launched in Trust in September

Care Bundle- Fetal growth restriction element