PREGNANCY LOSS

Karen StoylesApril 2013

Immediate Care & Support

How many babies die & why?

Stillbirth rates (1:200) in the UK among the highest in high income countries (33/35)

Despite availability of PM 50-70% of SB categorised as unexplained ( unavoidable).

10% SBs associated with congenital abnormality 30%SBs associated with IUGR (Inclusion of IUGR

in SB classification = drop to 15% in unexplained SB)

Most SBs occur in “low risk” pregnancies Smoking (inc. passive) risk by 30% 500 die every year due to an event during birth NND rates 20% in 10 years (1:300)

Risks of Stillbirth IUGR (x 4 if detected, x 8 if not detected) Reduced fetal movement Pre-eclampsia Smoking (10 a day = double risk ) Obesity (BMI 30 twice risk of BMI 25) Infection Multiple pregnancy Diabetes Mother <20 or >35 years (>40 =double risk ) Previous stillbirth (x 2 risk) Obstetric cholestasis Socially deprived

Preventing Babies` Deaths, Sands. 2012

Role of the Health Professional Validate the woman`s feelings of loss Recognise the baby as an individual Encourage acknowledgement of birth & death Educate about grief Give information about available choices Take time to listen Provide good physical care Make the birth as positive an experience as

possible

Effective Care Treat parents & baby with respect & dignity Continuity of carers where possible Make no assumptions Support parents to make their own decisions Prepare parents for labour and delivery Clear, sensitive & honest communication Avoid making reassurances which may turn out to be

false Empower parents to make choices Use the baby's name Resist the temptation to give advice unless specifically asked for

Communication Give information in small amounts Choose words sensitively – no medical jargon Check for understanding Look at the person Actively listen Use names Smile – if appropriate Ask open questions Admit it when you don't know the answer Be non-judgemental Be genuine – visual & verbal behaviour should tell the same story Closing the consultation – agree the next steps

Not only Midwives work with pregnancy loss

Why there is so much paperwork

Pregnancy Loss

Cornwall Crematoriu

m Committee Child Health

Dept

Child Death Review

Cornwall Registration

Office

MBRRACE-UK

Department of Health

Bereavement Office

Mortuary

GP

Pathologist (Bristol)

Cytogenetics Lab.

Midwife

Obstetric Team

Chaplaincy

Pastoral Care Chaplain will perform a Blessing

Service at anytime The same Chaplain will conduct

funeral if parents wish Chaplains will provide ongoing

pastoral care if required Annual Remembrance Service Also provides support for staff Stepping Stones support group

Bereavement Care Co-ordinator

Not a counselling service Organises PM arrangements & transfer of baby

to Bristol Liaises with funeral directors if hospital funeral Gives information about legal requirements

following a death Rarely sees parents during hospital stay Service operates Monday – Friday 9-4

MBRRACE-UK Replaced MNPN / CEMACE - commenced January 2013 Aim is to provide robust information to support safe,

equitable, high quality, patient centred health care Now includes late fetal losses & TOP (>22/40) More detailed information gathered inc. maternal

carbon monoxide level (all women) Data reported by nominated MWs registered with

MBRRACE-UK (Ward managers @ RCHT) Projects for 2013:- - Maternal Sepsis- - Congenital Diaphragmatic hernia- -

Required Paperwork

Good record keeping is an integral part midwifery practice. It is not an optional extra to be fitted in if circumstances allow.NMC

STORK SB & NND require full input of delivery

details

SB requires registration for CR & NHS numbers

< 24 weeks cancel pregnancy (STORK Options )

Generate GP discharge letter (as for A/N discharge) prior to cancelling pregnancy

Stillbirth & NND Certificates

Stillbirths (>24 weeks) - midwife Neonatal deaths of any gestation (inc TOP) -

Dr Parents need stillbirth / death certificate to

register their baby Funeral not possible without registration Forms must be complete with no omissions Completed by same person Name printed clearly with NMC/ GNC number

Cornwall Crematorium CommitteeMISCARRIAGE & TOP STILLBIRTH

Forms required for burial or cremation.

NND requires same cremation forms as an adult.

Certificate A

Certificate A must be completed by two doctors before TOP can be legally commenced.

File in notes

Abortion Notification to DoH

Dept. of Health must be notified of all TOPs

Form has to be signed by the doctor taking responsibility for the TOP and who signed Certificate A

Clinical details completed by midwife when TOP complete

Reason for TOP as on Certificate A

Needs to be posted to the Chief Medical Officer within 14 days – do not leave in the medical notes.

Consent for Funeral < 24 weeks Required only for miscarriage &

TOP <24 weeks who do NOT show signs of life. Law does not allow NND & SB to have collective cremation

Not required if parents / funeral director take the baby from the ward

Form must accompany the baby to the mortuary (or histology). The baby may be returned if no form.

Requirement of the Human Tissue Authority

Notification of Stillbirth & NND Required for all pregnancy

losses after 24 weeks.

Post form to Child Health Department

Do NOT file in medical notes

Child Death Review Complete for all deaths < 18

yrs Referrer = midwife Agency = RCHT Follow up forms may be sent

to midwife later for further detail

Fax to Child Death Review Co-ordinator

Deceased Baby Care Record Provides system of tracking babies

bodies whereabouts (DoH 2006)

The name of the Porter taking the baby to the mortuary must be recorded

Provides record of patient's property

Post MortemCONSENT REQUEST

Parents must be given a copy Must be fully completed with copies of scans attached

Investigations

When a baby dies almost every parent will want to know why.Sands 2012

Post Mortem Most Dr / MWs underestimate the benefits of PM Some make assumptions that parents will not want

PM Some avoid seeking consent for fear of adding to

parent's distress 2 x parents regret declining PM than consent Essential that staff offer to all parents (>16 weeks) 2013 - National consent form No longer delays in PM Parents can see baby following PM Baby returned before results available Results may take 6-12 weeks

Cytogentetic tests Parents to be given verbal & written

information Separate consent form May only be taken by midwife or doctor

certified to do so Samples must be taken in Daisy Nursery (HTA

licensed satellite mortuary) Log book must be completed for audit trail Use skin biopsy medium – do not use CVS

medium (unless in an emergency) Inform ward clerk when stock low

Maternal Investigations Need to be done ASAP after diagnosis of IUD for

best results (7% SB caused by infection)

A/N Kleihauer on all women

Anticardiolipins & Lupus tests to be sent to lab within 60 minutes

Not required for TOP (G & S / FBC only)

PracticalitiesGood care cannot remove the pain of loss, but care that is inadequate or poor makes things worse and affects a family's wellbeing both in the short and long term.Sands 2012

On Diagnosis Ensure that the woman is not on her own Do not leave her to wait with pregnant women Scan only by appropriately trained staff Facilitate a second scan if woman requests Ensure she is seen by a senior doctor ASAP Record maternal observations Gain consent & take blood tests Cancel appointments Inform Fetal Medicine, Diabetes/Drug & Alcohol

Specialist Midwife Ensure woman understands what happens next

Admission Plan admissions later than IOL admissions Prepare the Daisy Suite / delivery room Avoid delays (unless parent's wish) Determine the wishes of bereaved parents Ensure analgesia is prescribed before it is needed Warn that the labour / delivery can be

unpredictable Aim for one to one care in labour Complete checklists as you go

Post delivery Give P/N care as standard normal delivery Document care in notes File paperwork that should be in the medical

notes – do not leave in folder or green notes (If woman readmitted to Tolgus / EGU notes get separated )

Label baby (initially with handwritten label) On Mortuary id label - Use labels at the loose

end first so that the label can be trimmed Do not use up all red sticky id labels & do not

cut off Send discharge letter to GP before cancelling

STORK Contact CMW & arrange follow up care

Cold Mattress Cooling the baby slows the deterioration process Give parents more time with their baby if they wish it Ensure antibacterial solution is added to water and

system drained after use

Babies born alive at threshold of viability

A baby who shows any sign of life at any gestation is regarded as being born alive (WHO 1992)

Legal obligation to provide appropriate care and not cause suffering.

The mother should be told what to expect when the baby is born

If the baby can not survive inform parents that the baby will be given comfort care if born alive

Warn the parents that some babies who are born too early to survive may make movements at birth for sometime

Call doctor (not Paed.) to certify

Funerals< 24 WEEK GESTATION

STILLBIRTH & NND No legal requirement to

bury or cremate fetal remains

RCHT will arrange & pay for basic funeral

Communal burial or cremation is permitted

Ashes can not be guaranteed

Environmental Health Dept. and Environment Agency give advice about burial on private land

Responsibility of parents RCHT will arrange & pay

for basic funeral Parents may be eligible

for a Social Fund Funeral Expenses Payment

Environmental Health Dept. and Environment Agency give advice about burial on private land

Must notify the Registrar of births & deaths of date & place of private burial

Making MemoriesThe greatest gift you can give a bereaved parent is the gift of remembrance

Seeing & Holding the Baby It must be the parents choice (NICE agreement 2010)

If parents are unsure: - Show photographs first - Put the baby in a cot nearby first - Staff offer to hold baby & stay with parents - Ensure parents do not feel pressurised to hold their

baby

Possible factors in parent's choice: - Cultural or religious beliefs - Fear of seeing a dead body - Coping style of not confronting stressful issues

Acknowledgement of <24wk baby

Recommended by SANDS, RCOG, and Dept. of Health as there is no legal recognition of a baby before 24 weeks.

Photographs Aim for photos to be “album worthy” Photos of the baby in natural positions Photos with parents / family Focus on relationships not just baby Photos of toys, clothes, flowers etc Detail shots of every part of the baby (ears, lips etc) Use something to give perspective of size (ring,

finger ) Avoid flash / yellow based colours Give parents the camera memory card Record in camera log book

www. gifts of remembrance. orgwww.toddhochberg.com

Hand & Foot prints Use inkless wipes to create prints. Use

card provided Make clay imprints using kits donated by

Ella's Memory

Remembrance Garden

Memorial fountain with pebbles written by parents

Daisy Suite now has entrance & garden separate from Remembrance Garden

Open 24/7

Support

Stepping Stones

Pregnancy loss & MidwivesIn an area of practice that requires skilled emotion work, self neglect can limit our ability to respond to the needs of our clients and colleagues.Kenworthy & Kirkham 2011

Effect on Staff Shock on diagnosis of death / abnormality Accumulated grief / sharing a loss “Guilt” that unable to give parents a healthy baby Unable to give care that they want to (time constraints) Balancing engagement & detachment Additional stress of paperwork + caring for bereaved

mother Impact on memory & clerical skills Emotional “juggling” in caring for more than one woman Fear of “not doing it right” Coping strategies of avoidance or isolation Conscientious objection to TOP

Support for Staff Practical help in care of bereaved woman / baby Colleagues taking on other work to free up time Acknowledgment of emotional impact on midwife Reflection – “closure conference” Peer support – talk it through with the right colleague MWs need to know their limits of supporting bereaved Good role models Senior MWs need to be mindful of burden placed on juniors Sands, ARC, Child Bereavement Trust support lines RCHT Pastoral Care team Skilled support via Occupational Health Supervision Training – www.e-lfh.org.uk (End of life care ) Bereavement Care Network