The 2010 PMMRC Report - PowerPoint PPT Presentation


Title: The 2010 PMMRC Report


1
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.
2
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.

3
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

4
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.

5
Methodology
  • Contributory factors
  • Organisation/management factors
  • Personnel factors
  • Barriers to access and/or engagement with care

6
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.

7
Themes identified
  • Failure to offer or follow best practice
  • Antenatal
  • gt assessment for place of birth decisions
  • gt assessment of appropriate fetal surveillance
    method for clinical situation
  • gt assessment of fetal growth
  • Labour
  • gt fetal maternal observations
  • gt CTG interpretation

8
Themes
  • Postnatal
  • gt Recognition of potential for NE and transfer
    of a baby from home/primary unit to level
    2/3 unit
  • gt Lack of recognition of need for paediatric
    attendance at birth or after birth
  • gt Resuscitation training equipment
  • gtRecognition of need for induced cooling

9
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.
  • gt Learnings come from reviews

10
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

11
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

12
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))
  •  

13
  • Decisions about ongoing care/transfer of an
    unwell baby are made in consultation with
    paediatric team
  • Passive cooling for transfer at paediatricians
    discretion and as instructed by them

14
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

15
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/multidi
    sciplinary-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/multidi
    sciplinary-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-c
    onsensus-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

16
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.
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The 2010 PMMRC Report

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Title: The 2010 PMMRC Report


1
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.
2
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.

3
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

4
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.

5
Methodology
  • Contributory factors
  • Organisation/management factors
  • Personnel factors
  • Barriers to access and/or engagement with care

6
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.

7
Themes identified
  • Failure to offer or follow best practice
  • Antenatal
  • gt assessment for place of birth decisions
  • gt assessment of appropriate fetal surveillance
    method for clinical situation
  • gt assessment of fetal growth
  • Labour
  • gt fetal maternal observations
  • gt CTG interpretation

8
Themes
  • Postnatal
  • gt Recognition of potential for NE and transfer
    of a baby from home/primary unit to level
    2/3 unit
  • gt Lack of recognition of need for paediatric
    attendance at birth or after birth
  • gt Resuscitation training equipment
  • gtRecognition of need for induced cooling

9
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.
  • gt Learnings come from reviews

10
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

11
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

12
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))
  •  

13
  • Decisions about ongoing care/transfer of an
    unwell baby are made in consultation with
    paediatric team
  • Passive cooling for transfer at paediatricians
    discretion and as instructed by them

14
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

15
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/multidi
    sciplinary-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/multidi
    sciplinary-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-c
    onsensus-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

16
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.
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