1. Northern England Strategic Clinical Network Conference
15th May 2015
Stillbirth Care Bundles

2. Saving Babies’ Lives Reducing Stillbirth and early NND
SB rate in UK one of the highest in Europe
In UK, about 33% difference between different regions
Affects 1 in 200 – 300 babies
About 4000 SBs every year in the UK
SB reduction mandate from government to NHS England

3. Saving Babies Lives and early NND Care Bundle Interventions
Smoking cessation
CO Testing at booking and opt out referral pathway
Identification and surveillance of fetal growth restriction
GAP / Grow
Programme
Perinatal Institute
Reduced fetal movement pathway
and Leaflet
Fetal monitoring
Staff training and competency assessment
Fresh Eyes
BME groups Vulnerable women Chronic conditions ↑BMI
WOMEN AND STAFF EXPERIENCE
Communication difficulties for staff over language relating to death – “loss/sleeping baby”
Peer Review
In cases of stillbirth, hypoxia and early neonatal death

4. Saving babies’ lives – Care bundle (element 1) Smoking in pregnancy
Smoking in the UK is known to cause up to:
2,200 premature births
5000 miscarriages perinatal deaths
360 fetal losses in the NE alone
Care bundle interventions
Reduce smoking in pregnancy by carrying out carbon monoxide testing of all pregnant women at booking, and referring to SSS as appropriate, based on an opt out system

5. Saving babies’ lives – Care bundle (element 2) Identify + monitor SGA / FGR
Strong evidence to suggest fetal growth restriction (FGR) is a major risk factor for SB
BWs of SBs are SGA when assessed by a standard based on normal pregnancy
Babies with FGR are usually (but not always) SGA
Antenatal identification of SGA / FGR reduces risk significantly
Most cases are late onset – hence, surveillance required throughout pregnancy
SB weight distribution

6. Saving babies’ lives – Care bundle (element 2) Fetal growth restriction
Interventions
Use of customised antenatal growth charts for all pregnant women by clinicians who have gained competence in their use (GROW charts)
Use of supplied algorithm to aid decision making on classification of risk, and corresponding screening and surveillance of all pregnancies according to their risk
Audit of SGA rates and antenatal detection rates
Case-note audit of selected cases not detected antenatally

7. Yearly stillbirth rates in the 3 regions with high uptake of GROW training and protocols (‘high uptake’) vs the rest (‘low uptake’), 2008–2012 (see table 1).
©2013 by British Medical Journal Publishing Group
Jason Gardosi et al. BMJ Open 2013;3:e003942

8. One or more risk factors
Low Risk
□ No known risk factors
Low Risk Care
Serial assessment (2-3 weekly) of fundal height from weeks until delivery
FH measurements plotted on customised chart
No risk factors
Increased Risk: one or more of the following:
Maternal Risk Factors
□ Maternal age >40 years
□ Smoker (any)
□ Drug misuse
Previous Pregnancy History
□ Previous SGA baby (<10th cust. centile)
□ Previous stillbirth
Maternal Medical History
□ Chronic hypertension
□ Diabetes
□ Renal impairment
□ Antiphospholipid syndrome
Unsuitable for monitoring by fundal height- e.g.
□ Large fibroids
□ BMI >35
Current Pregnancy Complications
Early Pregnancy
□ PAPP-A <0.415 MoM
□ Fetal echogenic bowel
Late Pregnancy
□ Severe pregnancy induced hypertension
or pre-eclampsia (=PIH and proteinuria)
□ Unexplained antepartum haemorrhage
Suspected abnormal growth:
FH <10th centile or not following curve (‘crossing centile lines’)
Direct referral for assessment (<72 hours) for estimated fetal weight (EFW), liquor volume and umbilical artery Doppler
Normal
Abnormal growth: - cust EFW <10th centile and/or
- Serial measurements not following curve and/or
- abnormal umbilical artery pulsatility index
Refer to RCOG guidance on management of the SGA fetus
High Risk Care
Serial assessment (3 weekly) of fetal weight and umbilical Doppler from weeks until delivery; EFWs plotted on customised chart
One or more risk factors

11. Saving babies’ lives – Care bundle (element 3) Reduced fetal movements
Aspiration
Raising awareness amongst pregnant women of the importance of detecting and reporting reduced fetal movement (RFM), and ensuring providers have protocols in place, based on best available evidence, to manage RFM
Interventions
Information and advice leaflet on reduced fetal movement (RFM), based on current evidence, best practice and clinical guidelines, to be provided to all pregnant women by, at the latest, the 24th week of pregnancy and RFM discussed at every subsequent contact
Use provided checklist to manage care of pregnant women who report reduced fetal movement, in line with RCOG Green-top Guideline 57

12. Attendance with reduced Fetal Movements
Please initial when
Ask
Is there maternal perception of reduced fetal movements? □
Assess
Are there risk factors for Fetal Growth Restriction or Stillbirth?
Consider - multiple consultations for RFM, known FGR, maternal hypertension, diabetes, extremes of maternal age, primiparity, smoking, obesity, racial/ethnic factors, past obstetric history of FGR or stillbirth) and issues with access to care
Act
Auscultate fetal heart (hand-held Doppler / Pinnard)
Perform CTG to assess fetal heart rate in accordance with national guidelines
If risk factors for FGR/Stillbirth, perform ultrasound scan for fetal growth, liquor volume and umbilical artery Doppler within 24 hours.
Advise
Convey results of investigations to the mother.
Mother should re-attend if further reductions in fetal movements at any
time
Act upon abnormal results promptly

13. Reduction of late SB with the introduction of FM info + guidelines – a clinical quality improvement
Stillbirths in pregnancies presenting with RFM
Tveit+ BMC Pregnancy and Childbirth

14. Saving babies’ lives – Care bundle (element 4) Effective fetal monitoring in labour
Aim
Effective fetal monitoring during labour
Interventions
All staff who care for women in labour are required to undertake an annual training and competency assessment on CTG interpretation.
No member of staff should care for women in a birth setting without evidence of training and competence within the last year
Buddy system in place for review of CTG interpretation and auscultation, with a
Protocol for escalation if concerns are raised.
All staff to be trained in the review system and escalation protocol

15. Saving Babies’s Lives Conclusions / discussion points
Comprehensive and thorough series of care bundles
Inconsistent evidence base, but plausible
National priority
Ongoing resource / education issues
Innovative solutions – CTG / USS?
Local opportunities for implementation

16. Reduction of late SB with the introduction of FM info + guidelines – a clinical quality improvement
Standard clinical evaluation
NST
Ultrasound scan for size, AFV, activity
Information for women
Primary indicator: maternal perception of major and lasting reduction in the normal activity of her baby
Never to wait to the next day if no kicks in one day
Contact midwife if baby kicks “less and less” in course of a day / days
Contact midwife if < 10 FM in 2 hours at a time of day when baby usually active
Tveit+ BMC Pregnancy and Childbirth