Neonatal Encephalopathy associated with an acute peripartum event A Neonatal Encephalopathy Case Review
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