Critical gaps in antenatal care identified in cases of term stillbirths

by Jane Brewin

19 November 2015

It follows an investigation by a team of experts into 133 cases of stillbirth in 2013 - and found that national guidance was not followed by hospitals in the majority of cases and identified ‘missed opportunities’ which could have potentially saved babies lives.

In the UK today, almost one in every 200 babies is stillborn and one third of these occur when the pregnancy has reached full term. A team of academics, clinicians and charity representatives, called MBRRACE-UK*, has looked at how care for these mothers and term babies can be improved.

In its latest report, the group has examined stillbirths born at term who were singletons (sole births) and not affected by a congenital anomaly.  These occur in over 1000 pregnancies a year in the UK. 

A random representative sample of 133 of these babies who were stillborn in 2013 was selected. The pregnancy notes were assessed for all 133 and 85 were reviewed in detail against national care guidelines by a panel of clinicians, including midwives, obstetricians and pathologists who considered every aspect of the care. 

The expert enquiry found:

• Half of all term, singleton, normally formed, antepartum stillbirths had at least one element of care that required improvement.
• Two thirds of women with a risk factor for developing diabetes in pregnancy were not offered testing – a missed opportunity for closer monitoring.
• National guidance for screening and monitoring growth of the baby was not followed for two thirds of the cases reviewed.
• Almost half of the women had contacted their maternity units concerned that their baby’s movements had slowed, changed or stopped. In half of these cases there were missed opportunities to potentially save the baby including a lack of investigation, misinterpretation of the baby’s heart trace or a failure to respond appropriately to other factors.
• Documentation indicating that an internal review had taken place was only present in one quarter of cases and the quality of these reviews was highly variable.
• Only half of the stillbirths selected for confidential enquiry had a post mortem carried out. In the majority of cases post mortems were of satisfactory or good quality.
• A good standard of bereavement care was provided for parents immediately following birth including the offer of an opportunity to create memories of their baby.

The experts have identified key areas for action including:

• Implementation of existing national guidance regarding:
  • Screening and identification of women who should be offered testing to detect those at risk of developing diabetes in pregnancy.
  • Routine measurement of the baby’s growth and detailed plotting of the growth at each antenatal appointment from 24 weeks of pregnancy.
  • Management of reduced fetal movements and identification of additional risk factors.
  • Standardised multidisciplinary review of ALL term stillbirths.
• Obstetric and midwifery care during labour for women following stillbirth should be of the same in quality and content to that of women having a healthy birth
• All parents of a stillborn baby should be offered a post-mortem. This offer should be clearly documented in the mother’s notes.
• All parents should be offered a follow-up appointment with a consultant obstetrician to discuss their care, the actual or potential cause, chances of recurrence and plans for any future pregnancy.
• A summary of the follow-up appointment should be written in plain English and sent to the parents and their GP.

Tommy’s is helping to improve this lamentable situation by:

• Providing pregnancy information and advice to parents so that they can demand high quality pregnancy care. 
• Caring for parents who are at risk of stillbirth and have experienced a previous stillbirth at our Manchester research centre.
• Leading the way in providing the best standard of care. 
• Understanding the causes of stillbirth and developing tests to help identify women at risk and effective treatments.
• Working with the Government, Dept. Health and other organisations to keep reduction of stillbirth as a priority.
• Thank you to everyone who is helping us to reduce stillbirth by taking part in events and fundraising for Tommy’s – with your help we will save more babies’ lives.

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