shared antenatal care update · andrews . et al. survey of australian maternity hospitals to inform...

The University of Sydney

Shared antenatal care update

Presented by Dr Tanya Nippita O&G Staff Specialist Royal North Shore Hospital Senior Lecturer University of Sydney- Northern Clinical School


Outline

1. Case presentation

2. Australian Safer Baby Bundle

3. Every week counts campaign


Mrs AB

– 38yo – G1P0 – PMHx: nil – Meds: nil – SHx: PA local company, lives with husband. Non-smoker – BMI 22

– MWC at RNSH – Serology, NIPT, morphology, 75gGTT NAD – Antenatal care uneventful


35+0/40

– Sunday 7pm: Calls BU regarding decreased fetal movements, otherwise feels well

– Advised to come into hospital – Calls enroute- felt fetal movements- she is going to go home


35+0/40

– Arrives at BU – Feels well – Now fetal movements felt- ?normal

– O/E: BP 160/90 – U/A +++ prot – Abdo soft, SFH 33cm – CTG NAD – Bloods sent off, advised for admission


35+1/40

– Bloods: Hb 110 Plt 100 LFT AST 70 Cr 50 – BP now 140/90 with labetalol 200mg bd – I get a call from MFMU consultant:

– MFMU u/s • EFW <1st centile 1900g • Umbilical artery dopplers: REDF • AFI lower end of normal


35+1/40

– LSCS – Live female infant 1920g – Apgars 8 1 9 5

– Admission to NICU – Uneventful NICU course


Thoughts

– Decreased fetal movements – Could we have detected this growth restricted fetus earlier? – Stillbirth risks

– Clinician – Women – GPs


The Safer Baby Bundle Reducing stillbirths in Australia


What is the Safer Baby Bundle?

The Safer Baby Bundle is a national initiative with five evidence-based elements to address key areas where improved practice can reduce the number of stillborn babies.

• Smoking Cessation

• Fetal Growth Restriction (FGR)

• Decreased Fetal Movement (DFM)

• Side Sleeping

• Timing of Birth

GOAL Reduce stillbirth from 28 weeks’ gestation by 20% by 2023.


Important considerations

In addition to the five Bundle elements, we emphasise the need for maternity services to address the other important aspects of best practice care to reduce stillbirth rates. – Increase the availability of

continuity of care models to all women

– In particular, for women at increased risk of stillbirth.


Why we need the SBB

Globally - 3.5/1000 (8.8-1.3)

1.8% Average Rate Reduction (ARR) (6.8 ± 0.5)

Australia 1.4% reduction: 2.7/1000 ranked 15th

Australia stillbirth rates now 35% higher

than six best performing countries (< 2/1000)

Reduction Rate


Stillbirths in Australia

– 2,200 stillbirths annually - 6 babies every day

– Little progress in reducing stillbirth rates

– <20% are due to congenital abnormality

– 90% of stillbirths are antepartum fetal deaths

– 20-30% due to substandard care/managing risk factors


We know that bundles of care can save lives


The Safer Baby Bundle for Australia

Resources for each element includes:

• Best practice recommendations • Implementation tools including clinical checklists and care pathways • A measurement strategy including Key Performance Indicators (KPIs) and

audit tools • An educational program for health care professionals (both eLearning

and face-to-face training) • Educational resources for women


eLearning and face-to-face workshops


Educational materials accredited for CPD points by

START TODAY - https://learn.stillbirthcre.org.au


Element 1: Reducing smoking in pregnancy

Maternity services survey (n=83)

How often is this practice performed?

All the time

Most Half Not much

Never

Women who smoke offered personalised advice and offered support services on quitting

37

(45%)

26

(31%)

10

(12%)

10

(12%)

0

(0%)

Current practice

Andrews et al. Survey of Australian maternity hospitals to inform development and implementation of a stillbirth prevention ‘bundle of care’. Women and Birth, 2019.


SBB Element 1: Reducing smoking in pregnancy

Description: Stopping smoking in pregnancy by providing support and strategies for women to quit and not resume smoking

Key recommendations for women smoking (pregnancy planned or confirmed) • Explain importance of smoking cessation • Refer to Quitline and consider NRT • Provide brief advice using Ask, Advise, Help model • Follow-up with woman at every subsequent visit


Element 2: Improving detection of FGR



All the time Most Half Not

much

Never

Early in pregnancy, women assessed for risk factors for FGR

31

(37%)

39

(47

%)

7

(8%)

6

(7%)

0

(0%)

Current practice


SBB Element 2: Improving detection of FGR

Description: Risk assessment and surveillance of singleton pregnancies for fetal growth restriction (FGR) Key recommendations • Assess all pregnant women for risk factors

of FGR and document • Use the FGR care pathway (available for

download) to aid decision-making on surveillance for women at low risk (Level 1), intermediate risk (Level 2) and high risk (Level 3)

🎥🎥 Watch the video on Symphyseal Fundal Height (SFH) assessment in the eLearning module


SBB Element 2: Improving detection of FGR


Element 3: Decreased Fetal Movements

• Low frequency of providing information to women



All

the

time

Most Half Not

much

Never

Information about normal fetal movements provided at first antenatal visit

30

(36.1

%)

31

(37.3%

)

11

(13.3%)

8

(9.6%)

3

(3.6%

)

Current practice


SBB Element 3: Improving awareness and management of DFM

Resources for women (19 languages)

Description: Supporting women to be aware of their baby’s movements from 28 weeks’ gestation onwards and to contact their health care provider if they are concerned Key recommendations • Provide information brochure and advice to all

pregnant women by 28 weeks’ gestation • Discuss importance of being aware of DFM and

report concerns • Use the DFM care pathway to undertake

clinical examinations


Element 4: Maternal safe sleeping position



All the time Most Half Not much Never Advised to sleep on side in 3rd trimester 15

(18.1%)

37

(44.6%)

12

(14.5%)

18

(21.7%)

1

(1.2%)

Current practice


SBB Element 4: Improving awareness of maternal safe sleeping position

Description: Raising awareness amongst pregnant women of the importance of going-to-sleep on their side from 28 weeks of pregnancy

Key recommendations • Information brochure on safe going-to-

sleep position based on current evidence to be provided to all pregnant women by week 28 of pregnancy, and the importance of going to sleep on their side discussed at every subsequent contact.


Element 5: Timing of birth for women with stillbirth risk factors

Maternal Factor aOR PAR% Maternal overweight 1.23 12

Maternal obesity 1.63 -

Maternal age > 35 yrs 1.65 11

Smoking 1.36 6

Preg/Med Factors aOR PAR%

SGA < 10th centile 3.9 23

Primiparity 1.4 14 Pre-existing hypertension 2.6 7

Pre-existing diabetes 2.9 3

IVF/ICSI 2.7 3

Preeclampsia 1.6 2

Previous stillbirth 2.6 <1

Multiple pregnancy 2.9 3


SBB Element 5: Timing of birth for women with risk factors

Key recommendations • Undertake assessment for stillbirth risk

factors at first visit and monitor throughout the pregnancy

• Reassess all women for stillbirth risk at 34-36+6 weeks and implement increased surveillance where indicated

• Provide women with individualised information to support informed, shared decision-making on timing of birth

Description: Improving decision-making about the timing of birth for women with singleton pregnancies with risk factors for stillbirth


Develop (2018-2019)

Implement (2019-2020)

Evaluate (2020-2024)

• Survey • Expert panels • Secure funding • Jurisdictional

health departments • Clinician

awareness campaign

• Public awareness campaign

• Process outcomes

• Health outcomes

• User acceptability

• Women’s experience

Implementation of the Safer Baby Bundle


Safer Baby Bundle endorsed by the Stillbirth CRE and


Gestational age by year for all hospitals in NSW- singletons

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

33 34 35 36 37 38 39 40 41 42

Perc

enta

ge o

f bi

rths

by

year

Gestational age in completed weeks

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015


3

0

10

20

30

40

50

33 34 35 36 37 38 39 40 41 42

1994-1996

1997-1999

2000-2002

2003-2005

2006-2008

2009-2011

2012-2015

Perc

enta

ge o

f birt

hs b

y ye

ar g

roup

Gestational age by year group for Sydney LHDs - singletons

Northern Sydney LHD


Severe neonatal morbidity by mode of delivery

0%

10%

20%

30%

40%

50%

60%

70%

33 34 35 36 37 38 39 40 41 42

Weeks gestation at delivery

Pre-labour caesarean Labour induction Spontaneous VB

+

Morris JM, et al. Am J Obstet Gynecol 2012; 207:186.e1-8 35


Brain Development

March of Dimes

• late preterm infants have less-developed myelination

• more immature gyral folding

• Myelination and gyral folding are both thought to be important processes in early brain development

Walsh et al, 2014


What is driving this increase in late preterm and early term birth?


Perceptions and beliefs

– ‘...there is somewhere in the back of their [obstetricians’] mind, litigation, definitely. I think they're more aware of patients wanting to perhaps sue later on if, "why didn't you do this [IOL] if you knew it was a risk?’’’ (B_P30_MW)

– ‘...if there are any adverse outcomes, well that's - you know it's

all the obstetrician's fault, so - so I tend to do inductions very easily’ (H_P21_O)

– ‘Some consultants and some midwives are a little bit more anxious, so they might induce closer to 38 [weeks gestation] when I might have sat on somewhere to 39 [weeks gestation]. But that’s because last year they sat on someone to 39 [weeks gestation] and it didn’t go as well.’ (I_P41_O)


Women’s perceptions and beliefs

Zhang LY et al. ANZJOG 2015


Is it possible to safely reverse the trend towards earlier birth ?


What is our message?


Every week counts

– Educational support to establish whether pregnancy can be safely extended

– Brochures to help guide conversations around the timing of

planned birth

– Website www.everyweekcounts.com.au and social media

– Evaluation: NSLHD, WSLHD, CCLHD, NBMLHD

– Outcomes to be collected pre and post intervention from routinely collected data


Acknowledgements

– Jonathan Morris – Christine Roberts – Jane Ford – Katherine Owen – Natasha Nassar – Jason Bentley – Tanya Nippita – Deborah Randall – Jenny Bowen – Michael Nicholl – Judy Simpson – Siranda Torvaldson – Angela Todd – Kristen Rickard – Felicity Gallimore

shared antenatal care update · andrews . et al. survey of australian maternity hospitals to inform...

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