Neonatal Encephalopathy associated with an acute peripartum event

A Neonatal Encephalopathy Case Review

NE following an acute peripartum event Case review 2013-2015 (47 cases)

Event Totaln= 47

Abruption APH 12Shoulder Dystocia 11Cord Prolapse 6Maternal collapse 5Uterine Rupture 4Breech complications 4Other 5

Contributory factors (n=47)

n %

Any Contributory Factor 42 89

Potentially avoidable 31 66

Contributory factors (n=47)n %

ANY CONTRIBUTORY FACTOR 42 89

Personnel

Knowledge and skills of staff 18 38Emergency response by staff 9 19Communication between staff 9 19Seeking help or supervision 6 13Offer or follow recommended best practice 30 64Recognition of complexity or seriousness of condition by care giver 21 45

Contributory factors (n=47)n %

ANY CONTRIBUTORY FACTOR 42 89

Organisation/management

Education and training 7 15Policies, protocols or guidelines 13 28Access to senior clinical staff 7 15

Personnel

Knowledge and skills of staff 18 38Emergency response by staff 9 19Communication between staff 9 19Seeking help or supervision 6 13Offer or follow recommended best practice 30 64Recognition of complexity or seriousness of condition by care giver 21 45

BarriersDeclined treatment or advice 5 11Obesity impacted on delivery of optimal care (e.g. USS) 5 11Environment (e.g. isolated, long transfer, weather prevented transport) 5 11

What was done well?

• Shoulder dystocia management• Antenatal care• Emergency response

maternal collapse, APH

• Care of baby• Good recognition and resuscitation

Summary of themes by event type

Acute peripartum event

Theme

Ute

rine

ru

ptur

e(4)

Mat

erna

l co

llaps

e(5)

Shou

lder

dy

stoc

ia(1

1)

Abr

upti

on(1

2)Co

rd

prol

apse

(6)

Bree

ch(4

)O

ther

(5)

Tota

l

Antenatal risk assessment 2 9 1 12Barriers to access care/ difficult discussions 4 6 1 1 12Documentation 1 7 2 3 1 14Labour management (includes recognition of signs) 5 6 2 1 2 1 17Fetal surveillance in labour 2 4 2 2 1 11Neonatal resuscitation 1 4 3 1 1 2 12

Summary of themes by event type

Acute peripartum event

Theme

Ute

rine

ru

ptur

e(4)

Mat

erna

l co

llaps

e(5)

Shou

lder

dy

stoc

ia(1

1)A

brup

tion

(12)

Cord

pr

olap

se(6

)Br

eech

(4)

Oth

er(5

)

Tota

l

Antenatal risk assessment 2 9 1 12Barriers to access care/ difficult discussions 4 6 1 1 12Documentation 1 7 2 3 1 14Labour management (includes recognition of signs) 5 6 2 1 2 1 17Fetal surveillance in labour 2 4 2 2 1 11Neonatal resuscitation 1 4 3 1 1 2 12

Summary of themes by event type

Acute peripartum event

Theme

Ute

rine

ru

ptur

e(4)

Mat

erna

l co

llaps

e(5)

Shou

lder

dy

stoc

ia(1

1)A

brup

tion

(12)

Cord

pr

olap

se(6

)Br

eech

(4)

Oth

er(5

)

Tota

l

Antenatal risk assessment 2 9 1 12Barriers to access care/ difficult discussions 4 6 1 1 12Documentation 1 7 2 3 1 14Labour management (includes recognition of signs) 5 6 2 1 2 1 17Fetal surveillance in labour 2 4 2 2 1 11Neonatal resuscitation 1 4 3 1 1 2 12

Modifiable systems issues:

Dynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

Preparedness for obstetric and neonatal emergencies

Best practice for maternal and fetal surveillance in labour

Documentation

Best practice for multidisciplinary NE review

Modifiable systems issue: Antenatal risk assessment

Dynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

LGA not recognized -

no serial measure of

fundal height

Antenatal risk assessmentDynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

LGA not recognized -

no serial measure of

fundal height

LGA and/or polyhydramniosrecognised but

not referred

Antenatal risk assessmentDynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

LGA not recognized -

no serial measure of

fundal height LGA but no change

to more appropriate place

of birth

LGA and/or polyhydramniosrecognised but

not referred

Antenatal risk assessmentDynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

Screening for GDM was not according to

current guidelines

LGA and/or Polyhydramnios recognized but

not referred

Antenatal risk assessmentDynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

Serial scans for high BMI recommended

but not done

Communication of risk of

polyhydramniosto woman

Recognition of neonatal risk of NE and neonatal

observation

LGA and/or Polyhydramnios recognized but

not referred

Modifiable systems issue: Antenatal risk assessment

Dynamic risk assessment and mitigation of risk throughout pregnancy and at the start of labour

Areas for improvement1. Support for recommended best practice around

maternal weight measurement, assessment of fetal growth, screening for diabetes in pregnancy

2. Reinforcement of observation of the newborn with risk factors for NE

Modifiable systems issue: Emergency preparedness

Preparedness for obstetric and neonatal emergencies by teaching, practicing and maintaining skills appropriate for acute infrequent events.

Emergency preparednessPreparedness for obstetric and neonatal emergencies by teaching, practicing and maintaining skills appropriate for acute infrequent events.

Delay to perimortem Caesarean

Emergency preparednessPreparedness for obstetric and neonatal emergencies by teaching, practicing and maintaining skills appropriate for acute infrequent events.

Suboptimal neonatal

resuscitation due to delay

to call for help

Delay to perimortem Caesarean

Emergency preparednessPreparedness for obstetric and neonatal emergencies by teaching, practicing and maintaining skills appropriate for acute infrequent events.

Suboptimal neonatal

resuscitation due to skills

Suboptimal neonatal

resuscitation due to delay

to call for help

Delay to perimortem Caesarean

Suboptimal management of

shoulder dystocia

Emergency preparednessPreparedness for obstetric and neonatal emergencies by teaching, practicing and maintaining skills appropriate for acute infrequent events.

1.Multidisciplinary and frequent simulation training/skill enhancement around rare but known obstetric emergencies and for neonatal resuscitation

2.Checklists to assist with learning/action and documentation –eg shoulder dystocia

3.Transfer, especially of neonates from level 1 or 2 facilities

Modifiable systems issue: Maternal and fetal surveillance in labour

Best practice for maternal and fetal surveillance in labour

Maternal and fetal surveillance in labour

Best practice for maternal and fetal surveillance in labour

Suboptimal fetal surveillance of two separate twins in

labour and of second twin after

birth of first

Maternal and fetal surveillance in labour

Best practice for maternal and fetal surveillance in labour

Suboptimal fetal surveillance of two separate twins in

labour and of second twin after

birth of first

Maternal and fetal surveillance in labour

Best practice for maternal and fetal surveillance in labour

Suboptimal fetal surveillance of two separate twins in

labour and of second twin after

birth of first

Fetal surveillance difficult due to

Hepatitis B status and high BMI

suboptimal interpretation

Modifiable systems issues

Best practice for maternal and fetal surveillance in labour

Multidisciplinary maternal and fetal surveillance training

Modifiable systems issue: Documentationa. Of acute peripartum events to facilitate neonatal care,

communication/debriefing with families and the review of acute events.

Documentationa. Of acute peripartum events to facilitate neonatal care, communication with

families and the review of acute events.

b. In the clinical record of difficult discussions during pregnancy and labour along with documentation of decisions made.

Documentationa. Of acute peripartum events to facilitate neonatal care, communication with

families and the review of acute events.

b. In the clinical record of difficult discussions during pregnancy and labour along with documentation of decisions made.

Documentation of management

of shoulder dystocia limited

Scan report not standard

Documentationa. Of acute peripartum events to facilitate neonatal care, communication with

families and the review of acute events.

b. In the clinical record of difficult discussions during pregnancy and labour along with documentation of decisions made.

Documentation of management

of dystocia limited

Scan report not standard

Documentation of neonatal

resuscitation limited

Documentation around declined

screening for GDM

Documentationa. Of acute peripartum events to facilitate neonatal care, communication with

families and the review of acute events.

b. In the clinical record of difficult discussions during pregnancy and labour along with documentation of decisions made.

Documentation of management

of dystocia limited

Scan report not standard

Documentation of neonatal

resuscitation limited

Documentation not clear

Documentation of acute events facilitated by debrief and collegial supportReinforcing learning around difficult discussions, as they apply to assessment and management of risk related to antenatal and intrapartum care; and documentation of these

Modifiable systems issue: Multidisciplinary NE review

Best practice for multidisciplinary NE review

Multidisciplinary NE reviewBest practice for multidisciplinary NE review

1. Refine the process of NE review including where and how this is best done (local and/or independent or a mixture of both)

Multidisciplinary NE reviewBest practice for multidisciplinary NE review

1. Refine the process of NE review including where and how this is best done (local and/or independent or a mixture of both)

2. Incorporation of human factors items into the PMMRC review tool

Multidisciplinary NE reviewBest practice for multidisciplinary NE review

1. Refine the process of NE review including where and how this is best done (local and/or independent or a mixture of both)

2. Incorporation of human factors items into the PMMRC review tool

Decision making due to cognitive biasesNormalisation of variance or drift

Multidisciplinary NE reviewBest practice for multidisciplinary NE review

1. Refine the process of NE review including where and how this is best done (local and/or independent or a mixture of both)

2. Incorporation of human factors items into the PMMRC review tool

Decision making due to cognitive biasesNormalisation of variance or driftSafety cultureAwareness of nature of tasks

Multidisciplinary NE reviewBest practice for multidisciplinary NE review

1. Refine the process of NE review including where and how this is best done (local and/or independent or a mixture of both)

2. Incorporation of human factors items into the PMMRC review tool

3. Role of consumers

What was done well?

• Shoulder dystocia management• Antenatal care• Emergency response

maternal collapse, APH

• Care of baby• Good recognition and resuscitation

ACKNOWLEDGEMENTS• Families• LMCs• Neonatal Nurses, Neonatal Nurse Practitioners• Paediatricians, Neonatologists• DHB local coordinators• PMMRC and the NE working group – past and present• Otago University data group• National coordination service• HQSC• ACC