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

2. 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

3. 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

4. ‘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

5. 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

6. Developed by Gardosi et al
Developed by Gardosi et al. Looking at relevant condition at death (ReCoDe)
Large proportion of stillbirths attributable to fetal growth restriction = 42.9%
Unclassified is reduced to only 16% of all the stillbirths

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

8. 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

9. Booking Risk Assessment
Risk assessment flow chart taken from RCOG guidelines

10. 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

11. 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.

12. 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.

13. 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

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

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

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

17. Semi recumbent-empty bladder

18. Fundal height
Identify the fundus

19. Identify top of the symphysis pubis

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

21. 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

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

23. 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

24. Static growth
Static growth requires referral for USS to assess EFW

25. 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

26. 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

27. 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?

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

29. 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)
address required for every user
Key leads will have a training log of all users who have completed on line training

30. 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

31. 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.

32. Obtaining a birthweight centile
Complete birth details

33. 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

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

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

36. Alterations
can be made to:-
Outcome
Gender
Birth weight

37. 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

38. Reports
This Trust started inputting centiles in Dec.

39. 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

40. Care Bundle- Fetal growth restriction element