Making Stillbirths Count A Local Approach Katy Evans, Maternity - - PowerPoint PPT Presentation

Making Stillbirths Count

A Local Approach

Katy Evans, Maternity Matron – 11/2/2016

Commitment

• SB within our Maternity Strategy / 3 year QI Plan – Aims:
• 50% reduction by 2018
• Zero avoidable stillbirths by 2018
• High level aim of Maternity Sign Up To Safety work stream
• 12 study days for Midwives ~ Saving Babies Lives
• Review/ RCA of all stillbirths

Didn’t search for perfection, enabled us to drive the possible

Saving Babies Lives Study Day

• Scene setting
• Smoking cessation
• Baby movements
• DVD - The Deafening Silence
• GROW training & assessment
• Sharing learning from missed SGA/SB

cases

Smoking Cessation

• Lead Midwife one day a week
• CO breath test
• Focus, targets and objectives
• Close links with Public Health
• Made a real difference

Baby Movements

• Leaflet given at 16 week appt
• Sign up from Community Midwives
• Scenario based learning
• Consistency of message
• Revolving door
• Weekly monitoring compliance
• Weekly feedback individuals

GAP

• Phased approach
• Introduced Sonographers plotting EFW
• Introduce new guideline
• Monitor compliance with training
• Monitor SGA detection rates

Intrapartum Care

• Purchase K2
• Buddy system in place
• New Latent phase guideline
• Monitoring compliance
• Review through risk

Keep up momentum

• Newsletter each quarter
• Standing item at Governance
• Email every 100 days
• Brief summary each stillbirth to all staff
• Connecting with whole team
• Celebrate success

• 7 babies died  60%
• Less women smoking
• 30 more women a month seen in

DCAU with RFM

• Scan referrals up 20%
• 76% births recorded onto GROW
• Identify 45% SGA babies
• 141 days

Going Forward

• Measure, measure
• Keep learning lessons
• Sharing the learning to

improve

• Annual SB Report
• RCA stillbirths
• Ultrasound capacity
• Upgrade IT system
• Website
• Focus intrapartum care

Thank you