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Summary of rapid report forms 1999 - Chapter 2

Stillbirth Rate

(no.of stillbirths/no.of total births) = 5 per 1000 total births

Perinatal mortality rate

(no. of stillbirths + early neonatal deaths/ no.of total births) = 7.9 per 1000 total births

Neonatal death rate

(no. of deaths within the first 28 days of life/no. of live births) =3.9 per 1000 live births

Post-neonatal mortality rate

(infants who die between 28 completed days and 1 year/live births)=1.8 per1000 live births

Regional mortality rates

(combined stillbirth, neonatal and post neonatal mortality rates) range 9.1-13.2per 1000 total births

West Midlands 13.2/1000 total births - Again the region with the highest mortality rate in the country

Intrapartum related mortality rate = 0.62 per 1000 total births

Enquiry comments on stillbirths - Chapter 3

Stillbirths account for a third of all deaths reported to CESDI.

The 1 in 10 enquiry (6^th annual CESDI report 1996-97) examined a random sample of the deaths reported to CESDI excluding babies weighing less than 1000g, major congenital abnormalities and post neonatal deaths. The majority (422/573) of these deaths were stillbirths.

The majority of stillbirths are classed as “unexplained” (8^th annual report figures: 71% unexplained by Wigglesworth classification and of those 70% remained unclassified by Aberdeen classification).

However an extensive panel review of the 1in10 enquiry revealed that 45% of the stillbirths were associated with grade 2 or 3 suboptimal care.

This suggests that unexplained does not equate to unavoidable.

The 8^th annual report included a review of the comments made in the 1 in 10 enquiry to aim to identify potentially preventable factors.

Most frequently cited areas of suboptimal care:

Risk assessment- including lack of communication between GPs and hospital at booking and inappropriate booking by junior hospital staff

Growth- failure to suspect growth restriction in a mother with a previous history, failure to detect it, to act on it and to monitor it.

Fetal movement- failure of mother to report decrease fetal movements, failure of professionals to convey importance to mother, failure to act on history of diminished fetal movements.

Management- delay in instigating management plan, lack of senior care, failure to investigate infection and cholestasis, suboptimal management of anaemia, rhesus disease, hypertension, diabetic control.

Communication - poor documentation, poor oral and written communication between mother and healthcare professionals and between health care professionals.

Lifestyle- failure to attend antenatal visits, failure to stop smoking, failure of healthcare professionals to advise re smoke cessation.

Post-delivery- Although this did not affect pregnancy outcome there were several areas of suboptimal care post delivery that could have added to maternal distress and suboptimal preparation for future pregnancy. The majority of comments involved post mortems; failure to offer them, to counsel correctly and poor quality of postmortem reports including failure of identification of IUGR or its cause. Failure to send the placenta for histology was also criticised.

The 8^th annual report includes an “update on issues surrounding the postmortem” which provides an overview of the recently published guidelines from several organisations in view of the recent postmortem controversies. This is not included in this review- for more information see www.cemach.org.uk chapter 5.

Other areas that were mentioned were failure to investigate fully following stillbirth and lack of bereavement services.

The Euronatal study - Chapter 4

This international audit consisted of a panel of 12 experts reviewing 1619 cases of perinatal death from 10 European countries. The aim was to identify areas of suboptimal care and to identify differences in care between different countries and health systems.

Three groups of babies were considered: antenatal stillbirths>28 weeks, intrapartum stillbirths >28 weeks and neonatal deaths >34 weeks.

Overall 46.3% of cases had either grade 2 or 3 substandard care, (a similar number to the 45% substandard care of the 1 in 10 enquiry). The range of substandard care between countries was 32-54%.

The most commonly cited reason for substandard care was failure to detect IUGR, the next most common were; failure of fetal monitoring, suboptimal management of IUGR and suboptimal management of hypertension.

The results showed a similarity between the comments made by the CESDI panels and those across Europe.

Electronic Fetal Monitoring - Chapter 6

The Clinical Effectiveness Support Unit of the Royal College of Obstetricians and Gynaecologists carried out an audit on electronic fetal monitoring in response to CESDIs work on the subject over the past 5 years. It was also part of the background to the national evidence based guideline development by the Department of Health and later the National Institute of Clinical Evidence (NICE).

Aim :

Assessment of current practice

The availability of guidelines was poor and did not correspond to the size of unit.

Despite high overall use of EFM for high-risk labours, the definition of high risk varied considerably between units.

There has been a doubling of the availability of FBS facilities over the past 20 years.

Most units sampled cord pH in situations of suspected fetal compromise but the definition if compromise again varied between units, for example only 68% of units routinely samples cord pH after emergency Caesarean sections.

This aimed to provide national and regional survival rates for babies born between 27+0 and 28+6 weeks during 1998-2000. This data is not routinely collected centrally despite being recorded on all births.

The overall survival rate was 88% - much better than expected and double the rate of the mid-1980s.

The type of hospital in which they were born did not affect survival rate.

Full enquiry findings will be published in the next annual report.