Building capacity in the maternity sector

PMMRC Conference 2015

Title: How can health professionals use audit research to reduce morbidity and mortality?

Presenters: Gail McIver and Suzanne Miller on behalf of the Neonatal Encephalopathy Working Group.

Neonatal Encephalopathy (NE)Case Review

NE Working Group Additional reviewers National Co-ordination Centre

•The aim of the study:To determine whether there were contributory factors to death and morbidity from NE, and whether death or the severity of morbidity could have been prevented by the absence of recognised contributory factors.

Neonatal Encephalopathy

• NE is a clinically defined syndrome of disturbed neurological function within the first week of life in the full term infant.

• NZ reported rate 1.27/1000 term births

• 149 cases of NE reported 2010 and 2011

Method of case review

• Multi-disciplinary teams comprising:– Midwives– Obstetricians– Paediatricians– Neonatologists – Neonatal Nurse practitioners

Undertook case review of 83 babies identified as having moderate or severe NE (Sarnat stage 2 or 3) without an identified acute event in labour.

Methodology

• Contributory factors –

1. Organisation/management factors

2. Personnel factors

3. Barriers to access and/or engagement with care

Case reviewResults

• 84% of cases contributory factors were associated with hypoxia at birth

• 76% personnel factors• 37% organisation/management factors• 24% barriers to access and/or engagement

with care• Overall, 52% of cases were assessed as being potentially

avoidable due to personnel issues.

Themes identified

• Failure to offer or follow ‘best practice’• Antenatal

> assessment for place of birth decisions> assessment of appropriate fetal surveillance method for clinical situation> assessment of fetal growth

• Labour> fetal & maternal observations> CTG interpretation

Themes

• Postnatal

> Recognition of potential for NE and transfer of a baby from home/primary unit to level 2/3 unit

> Lack of recognition of need for paediatric attendance at birth or after birth

> Resuscitation – training & equipment

>Recognition of need for induced cooling

Implications of findings

Recommendations 9th report•Recognition of NE, emphasis on babies with intrapartum asphyxia

• Every DHB should review local incidences of NE at a multidisciplinary level.> Learnings come from reviews

Practice Points

• The Neonatal Encephalopathy Working Group (NEWG) believes that early identification of ‘at risk’ babies, and timely collaboration with the paediatric service, has the potential to reduce the rate of morbidity and mortality from NE in New Zealand.

– Recognition– Action and collaboration– Ongoing education

Recognising the neonate who may be at risk of developing NE: background

factors…• Having an abnormal CTG in labour or concerning FHR pattern

in primary setting where transfer has not been possible• Apgar ≤ 7 at 5 minutes of age• Requiring resuscitation at birth• Being slower than usual to initiate feeding• Having a weak or absent cry

• Consider paediatric consultation…

Babies at risk for NE may experience the following:

• Difficulty in initiating and maintaining respirations• Depression of tone and reflexes• Having abnormal level of consciousness (eg,

hyperalert, irritable or lethargic)• Seizures• Referral to paediatric service• (Dawson & Walker (2015); Sabzehei MK, Basiri B, Bazmamoun H. (2014))

• Decisions about ongoing care/transfer of an unwell baby are made in consultation with paediatric team

• Passive cooling for transfer at paediatrician’s discretion and as instructed by them

Practice points:• All practitioners involved in the care of babies• Informed choice and consent• regular fetal surveillance education including appropriate use of IA for low risk

women • education about, and use of, customised growth charts when these are

considered appropriate• annual neonatal resuscitation updates • education that supports recognition of brain injury in the neonate • contemporaneous documentation of intrapartum events by all practitioners

involved in care which reflects information sharing with parents and decision-making processes, and recognising practitioner responsibility to uphold informed consent

• regular breastfeeding education to enable identification of disturbances to normal newborn patterns of breastfeeding initiation

Guidance for Practice• Dawson & Walker (2015). The Compromised neonate. In S. Pairman, J. Pincombe, C. Thorogood & S. Tracy.

Midwifery: Preparation for practice (3rd ed)(pp. 1182-1202). Chatswood, NSW: Churchill Livingstone Elsevier

• Ministry of Health (2012). Observations of the mother and baby in the immediate postnatal period: Consensus statements guiding practice. Wellington, New Zealand: Author. Retrieved from http://www.midwife.org.nz/quality-practice/multidisciplinary-guidelines

• Ministry of Health (2012). Guidelines for consultation with obstetric and related medical services (Referral Guidelines). Wellington, New Zealand: Author. Retrieved from http://www.midwife.org.nz/quality-practice/multidisciplinary-guidelines

• New Zealand College of Midwives (2012). Assessment of fetal well-being during pregnancy: Consensus Statement. Retrieved from http://www.midwife.org.nz/quality-practice/nzcom-consensus-statements

• Royal College of Australian and New Zealand Obstetricians and Gynaecologists (2014). Intrapartum fetal surveillance clinical guidelines (3rd ed.). East Melbourne, Australia: Author. Retrieved from http://www.midwife.org.nz/quality-practice/multidisciplinary-guidelines

References

•Dawson & Walker (2015). The Compromised neonate. In S. Pairman, J. Pincombe, C. Thorogood & S. Tracy. Midwifery: Preparation for practice (3rd ed)(pp. 1182-1202). Chatswood, NSW: Churchill Livingstone Elsevier

•PMMRC 2015. Ninth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2013. Wellington: Health Quality and Safety Commission 2015. http://www.hqsc.govt.nz/our-programmes/mrc/pmmrc

•Sabzehei MK, Basiri B, Bazmamoun H. (2014). The Etiology, Clinical Type, and Short Outcome of Seizures in Newborns Hospitalized in Besat Hospital/ Hamadan/ Iran. Iran J Child Neurol. 8(2):24-28.