Plenary Orals
PL1 Prototype “Belly Band” wearable monitor for continuous monitoring of fetal ECG
and fetal movement during the third trimester
Ajay Iyer, Ali Carlile, Bruce Olney, Paul Allen, Sean Kerman, Ryan Workman, Zack Bomsta,
Kurt Workman, Kenneth Ward
Owlet Baby Care, Lehi, UT, USA
Correspondence: Ajay Iyer; Kenneth Ward
Intrauterine fetal demise due to utero-placental insufficiency usually occurs between
obstetric evaluations when the gestation is not being actively monitored. Rapid advances
in the development of “wearable” physiologic monitors linked to smart phone apps allow
us to envision novel methods for evaluating the health of a pregnancy, potentially
allowing intervention before fetal death or damage from asphyxia occur. In this report,
we describe efforts to develop a fetal ECG monitor that can be worn throughout the
day to confirm fetal wellbeing.
A wearable fabric band worn around the maternal abdomen was developed with various
novel electrode materials and using various electrode placement patterns. After optimization,
“in-laboratory” and overnight “at-home” fetal ECG recordings were collected. The raw
signal was processed to subtract interference from maternal ECG, movement, and breathing.
Low-cost breathable materials and miniaturized hardware were selected to allow a comfortable
fit. To date over 125 hours of fetal ECG recordings have been obtained on 38 gravidae
at gestational ages from 20 weeks’ to term (mean 27 weeks’). Remarkably, over 86.7%
of the overnight and 47.6% of the “in-laboratory” records tracked the fetal ECG for
more than 50% of the session. Mean fetal heart rate observed was 135 (range 112-186);
mean maternal heart rate was 82 (range 55-111). As with prior efforts to obtain fetal
ECGs, the best fetal ECG readings were obtained between 20-24 and 36-40 weeks’ gestation.
Progress is reported on development of wearable fetal monitoring hardware. The “belly
band” under development can connect wirelessly to a smart-phone app that monitors,
analyzes, and transmits the maternal and fetal heart rates. It is hoped that improved
monitoring can help to reduce preventable fetal damage and stillbirths.
PL2 Supine going-to-sleep position is a major risk factor for term stillbirth: findings
from the New Zealand multicentre stillbirth case-control study
Minglan Li1, Lesley ME McCowan1, John MD Thompson1,2, Robin S Cronin1, Ngaire Anderson1,
Tomasina Stacey3, Peter Stone1, Beverley A Lawton4, Alec J Ekeroma1, Edwin A Mitchell2
1Department Of Obstetrics And Gynaecology, University Of Auckland, Auckland, New Zealand;
2Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland,
New Zealand; 3School of Healthcare, University of Leeds, Leeds, UK; 4Women’s Health
Research Centre, University of Otago, Wellington, New Zealand
Correspondence: Minglan Li
Stillbirth is a major health burden and is twice as common as neonatal death in developed
countries. Identifying potentially modifiable risk factors for stillbirth may reduce
the prevalence of this tragic condition. Previous studies have reported that going-to-sleep
supine may increase late stillbirth (≥28 weeks’) risk by more than two-fold compared
to left side going-to-sleep position. However, it is not clear if this risk differs
between preterm (≥28-36 weeks’) and term (≥37 weeks’) gestations.
A multicentre case-control study was conducted in seven New Zealand health regions,
between February 2012 and December 2015. Cases (n = 164) were women with singleton
pregnancies and late stillbirth, without congenital abnormality. Controls (n = 569)
were women with on-going singleton pregnancies, frequency matched for health region
and gestation. The going-to-sleep position was the position on the night before the
stillbirth was thought to have occurred or the night before interview for controls.
Multivariable logistic regressions were conducted in all pregnancies and by term and
preterm, and adjusted for known confounders.
The overall risk of supine going-to-sleep position is 3.67 (adjusted odds ratio (aOR),
95% confidence interval (CI) 1.74-7.78). In term pregnancies, there was an increase
in stillbirth risk in women who went to sleep supine (aOR 10.26, 95% CI 3.01-35.04)
compared to women who went to sleep on their left. In preterm pregnancies, the aOR
for late stillbirth in women who went to sleep supine was 3.12 (95% CI 0.97-10.05)
compared to those who went to sleep on their left. The prevalence of supine going-to-sleep
position was 2.8% in term controls, and 4.4% in preterm controls.
The magnitude of risk associated with supine going-to-sleep position may be greater
for term pregnancies compared with those between 28 and 36 weeks’. The prevalence
of supine going-to-sleep position is lower in term gestation than in preterm gestation.
Ethical approval for the New Zealand multicentre stillbirth case-control study was
obtained from the Northern “X” Regional Ethics Committee: NTX/06/05/054. Written informed
consent was obtained by all study participants.
PL3 The public awareness of stillbirth: a population study
Daniel Nuzum1, Sarah Meaney2, Keelin O’Donoghue1,3
1Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland;
2National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland; 3Irish
Centre for Fetal and Neonatal Translational Research (INFANT), University College
Cork, Cork, Ireland
Correspondence: Daniel Nuzum
There is renewed global focus to reduce the incidence of stillbirth. Studies have
identified modifiable and non-modifiable risk factors and causes of stillbirth. The
aim of this study was to evaluate the general population’s understanding of stillbirth
incidence, causes and risk factors.
A cross sectional survey of Irish adults was facilitated by a professional telephone
polling company. Participants were contacted using random digit dialling. To ensure
a representative sample of the population, fieldwork was monitored daily in terms
of age, gender, social class and region of respondents.
There were 999 participants in the study, of whom 53% (n = 510) were female. A minority,
17% (n = 174) were aware of the correct incidence of stillbirth in Ireland. Females
and those aged under 45 believed stillbirth to be more common with 23% (n = 230) believing
it occurred in 1/100 pregnancies and 24% (n = 244) in 1/50 pregnancies. The majority
of respondents 70% (n = 693) stated that stillbirth cannot be prevented. Over half
of respondents 53% (n = 528) responded that stillbirth was due to a problem with the
baby, while 31% (n = 309) agreed that stillbirth was due to care provided to the mother.
One in three, 29% (n = 285) stated that the cause of stillbirth is usually unexplained,
however 79% (n = 792) agreed that all stillbirths should be medically investigated.
Women, were more likely than men (82% v 76.4%; p = 0.043) to state that all stillbirths
should be investigated. Over half of respondents, 56% (n = 556) were unable to identify
any risk factors for stillbirth; 28% (n = 275) identified alcohol, 22% (n = 222) smoking,
16% (n = 158) substance abuse and <1% (n = 2) identified reduced fetal movements.
These findings highlight a lack of knowledge about incidence, causes and investigation
of stillbirth. The findings demonstrate the need for improved education and awareness
about stillbirth risk factors as part of antenatal education.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference; ECM 4 (k) 06/12/16).
PL4 Development and initial validation of ‘Perinatal Bereavement Care Confidence Scale
(PBCCS)’
Felicity Agwu Kalu1, Barbara Coughlan2, Philip Larkin3
1Rotunda Hospital, Dublin, Ireland; 2University College Dublin, Dublin, Ireland; 3University
College Dublin, Dublin, Ireland
Correspondence: Felicity Agwu Kalu
Evaluating the levels of confidence and psychosocial factors that impact on midwives’
and nurses’ confidence to provide perinatal bereavement care to parents who have experienced
a perinatal loss is vital for assessing their abilities for providing effective care
to the parents. Due to the shortage of questionnaires specifically developed and designed
to measure the level of midwives’ and nurses’ confidence (bereavement care knowledge
and skills) and the psychosocial factors that impact on their confidence (self-awareness
and organisational support) to provide bereavement care to parents who experienced
a perinatal loss, a valid and reliable questionnaire was needed.
The purpose of the study was to develop a valid and reliable perinatal bereavement
care confidence scale (PBCCS).
The PBCCS was developed in 4 phases. First, 42 questions were formulated from extensive
literature review. This was followed by expert panel review (n = 6). Then pilot study
was conducted and included cognitive pre-testing interviews (n = 10) and test-retest
reliability assessment with midwives (n = 26). Finally, factor analysis was conducted
to examine the factor structure of the PBCCS with midwives and nurses (n = 277). Item
reduction was done by removing those items with poor loading of less than 0.5. Internal
consistency reliability measurement was assessed. Ethical approval of the study was
obtained from four research sites.
The final questionnaire had 41 items. Bereavement care knowledge had 15 items. Bereavement
care skills had 9 items. Self-awareness had 8 items. Organisational support had 11
items. The internal consistency reliabilities ranged from 0.797 to 0.855.
The PBCCS has adequate psychometric properties to identify the levels of confidence
of midwives and nurses as well as the psychosocial factors that impact on their confidence
to provide effective care to parents who have experienced a perinatal loss.
An ethical approval for the study was granted by four research sites namely; The Health
Service Executive Dublin North East, Rotunda Hospital, National Maternity Hospital,
and Coombe Women & Infants University Hospital Research Ethics Committees (REC-2013-009
& REC-2013-018). Written informed consent was obtained by all study participants with
the exception of participants who completed anonymised survey used for the factor
analysis. In that case, it was clearly stated on each of the participant’s information
leaflet that, by voluntarily completing and returning the questionnaire, the participant
was consenting to participate in the research.
PL5 Global reporting of the causes of stillbirth: a systematic review
Hanna Reinebrant1, Michael Coory1, Susannah Hopkins Leisher1, Sarah Henry1, Rohan
Lourie1, Aleena M Wojcieszek1, Hannah Blencowe1, Vicki Flenady1,2
1Centre of Research Excellence in Stillbirth, Mater Research Institute - The University
of Queensland (MRI-UQ), Brisbane. Australia; 2on behalf of the International Stillbirth
Alliance Collaborative for Improving Classification of Perinatal Deaths, Bristol,
UK
Correspondence: Hanna Reinebrant
Stillbirth is a global health problem. Understanding the causes globally is key to
prevention. Numerous disparate classification systems in use makes understanding causes
difficult. The primary objective of this study was to comprehensively summarise the
causes of stillbirth reported globally to identify areas for prevention and improvement
in data quality.
We undertook a systematic literature review for studies reporting causes of stillbirth
over the period 1 January 2009 to 31 December 2016. Study selection, quality assessment
and data extraction on causes and characteristics of systems used, stillbirth investigations
undertaken and data sources was undertaken independently by two authors. Reported
causes were mapped into clinically relevant groupings. A pooled analysis (including
95% Prediction intervals –PI) of major categories for a selection of country representative
studies was performed by country setting: High, Middle, and Low income countries (HIC,
MIC, LIC).
89 studies reporting 489,305 stillbirths were included with a total of 22 different
classification systems. 897 unique causes were identified and mapped to 13 major and
45 minor categories of which 7 major categories were represented in over 60% of studies.
Pooled analysis of 49 studies (461,166 stillbirths) showed wide variation in the major
categories. Unexplained stillbirth was the top category across all country settings
with a pooled estimate of 30-40% of stillbirths. The leading category in LIC of Hypoxic
peripartum death (16.8%), Other unspecified condition in MIC (17.6%) and Placenta
in HIC (15.5%). Suboptimal data sources (retrospective use of death certificate data)
and investigation of stillbirth (low autopsy and placental pathology rates) were evident
for the vast majority of the studies.
Efforts to improve consistency and accuracy in global reporting of stillbirth is a
priority to inform effective prevention.
Break out orals
B1 Improving quality of care in pregnancies after stillbirth- an improvement science
project in two UK maternity hospitals
Louise Stephens1, Christine Navin2, Suzanne Thomas1, Sreebala Sripada2, Elaine Church2,
Clare Tower1,3, Alexander Heazell1,3
1St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust,
Manchester Academic Health Science Centre, Manchester, M13 9WL, Manchester, UK; 2University
Hospitals of South Manchester, Manchester Academic Health Science Centre, M23 9LT,
Manchester, UK; 3Maternal and Fetal Health Research Centre, School of Medical Sciences,
Faculty of Biological, Medical and Human Sciences, University of Manchester, M13 9WL,
Manchester, UK
Correspondence: Louise Stephens
Pregnancies after stillbirth have increased risk of stillbirth and other adverse pregnancy
outcomes which alter mothers’ needs for maternity care. In response to the additional
need for support and screening we developed a specialist clinic for families at St
Mary’s Hospital, a Tertiary Maternity Unit, in 2013. In response to clinic demand,
a second site in University Hospitals South Manchester, a large secondary maternity
unit, was set up in 2016.
We aimed to improve access to specialist care, improve patient experience and improve
pregnancy outcome for parents who have experienced a stillbirth in a previous pregnancy
by May 2017.
We developed a measurement strategy which recorded process measures of care including:
the number of women attending the Rainbow Clinic, the number of women who did not
attend and their reasons for not attending. Patient experience was measured using
a bespoke Patient Experience Questionnaire, collecting both qualitative and quantitative
responses at the final Rainbow Clinic appointment. The outcome of pregnancies including
gestation at birth, mode of delivery and NICU admissions was recorded.
In 2016, 160 women were seen in Rainbow Clinics on both sites, an increase of 12.5%.
Patient experience improved on both sites over the duration of the project (Fig. 1).
All families would recommend our service to friends and family. Qualitative data indicates
positive patient experience with relevant recommendations for improvement.
There were no subsequent stillbirths, a reduced preterm birth rate from 21 to 13%
and admissions to Neonatal Intensive Care Unit reducing from 17.5% to 8.5%.
Attendance at a specialist clinic in subsequent pregnancy has a positive effect on
patient experience and pregnancy outcomes. Provision of the model of care on a second
site has provided a choice of settings for women and their families with no negative
impact on patient experience.
Fig. 1 (abstract B1).
Mean individual response to PEQ (Max Score 25)
B2 The social and economic value of a clinical service for care in pregnancy after
perinatal death
Suzanne Thomas1,3, Louise Stephens1,3, Christine Navin2, Anthony Harrison4, Alexander
Heazell1,3
1Central Manchester Foundation Trust, Manchester, UK; 2University Hospitals of South
Manchester, Manchester, UK; 3Maternal & Fetal Health Research Centre, Manchester,
UK; 4The Alliance Manchester Business School, Manchester, UK
Correspondence: Suzanne Thomas
The Rainbow Clinic at St Mary’s Hospital, Manchester was established in 2013 to provide
individualised care to women and their families in pregnancies following a perinatal
death. Although the clinic is highly valued by the families it has cared for, the
service has not been evaluated in terms of its wider economic and social impact. In
2015 The Rainbow Clinic worked with Alliance Manchester Business School (AMBS) to
determine the social and economic value of the Rainbow Clinic.
A Social Return on Investment (SROI) framework was used to capture a monetised value
of a range of outcomes whether they already have a financial value or not. SROI analysis
produces a narrative of how a service creates and loses value in the course of making
change. The six stage process results in the calculation of a ratio that states how
much social value is created for every £1 of investment. A mixed methods approach
was used to collect data required to calculate SROI. Interviews were conducted with
stakeholders and service users experiences were collected via questionnaires.
For every £1 invested the Rainbow Clinic delivers £1.78 of social value. The quantified
benefits of the Rainbow Clinic across all stakeholder groups were identified as: reduced
anxiety and stress for mothers-to-be, reduced outlays for mothers-to-be through the
avoidance of funeral costs, avoidance of stillbirth, value of a new life, reduced
health and post-mortem expenses, recognition and donations for charitable funders,
education and enhanced skill base amongst Clinic staff and wider non-specialist antenatal
staff and increased job satisfaction.
The findings suggest that the investment in Rainbow Clinic generates social and economic
value. The clinic also decreases costs for wider health services. SROI analysis is
a valuable means to assess the impact of services for parents who have experienced
a perinatal death.
B3 Journey of loss: the lived experiences of couples’ journeys from stillbirth to
subsequent pregnancy
Margaret Murphy1,2,4, Eileen Savage1, Keelin O Donoghue1,2,3, Patricia Leahy-Warren1
1School of Nursing and Midwifery, University College Cork, Cork, Ireland; 2Pregnancy
Loss Research Group, Cork University Maternity Hospital, Cork, Ireland; 3Infant Research
Centre, Cork University Maternity Hospital, Cork, Ireland; 4International Stillbirth
Alliance, Bristol, UK
Correspondence: Margaret Murphy
Stillbirth affects 2.6 million families globally each year and can have significant
adverse consequences for mothers and fathers, individually and also as a couple. A
high percentage of couples proceed to a subsequent pregnancy within a short timeframe
of their index loss and are trying to bond with a new baby while still actively grieving
their lost baby. Little is known about how mothers and fathers, as a couple, experience
pregnancy after loss. Previous research has predominantly focused on mothers and none
has interviewed couples together to explore this experience. The aim of this qualitative
study was to explore the experiences of couples, in pregnancy after stillbirth.
An Interpretive Phenomenological Analysis (IPA) methodology was employed and eight
heterosexual couples (16 participants), in an immediate pregnancy after loss, agreed
to participate. Following ethical approval, in-depth dyadic interviews lasting 90-120
minutes were conducted. Intensive data analysis using strict IPA principles was performed.
A superordinate theme that emerged from the data was ‘Journey of Loss’ in which couples
made sense of their subsequent pregnancy through the lens of their previous pregnancy
journey. Participants shared experiences of coping with unexpected loss as a couple,
the importance of grieving the lost baby and acknowledging that baby’s place in their
family. The challenges couples experienced trying to achieve a pregnancy after loss
were also explored. Similarities and differences both between mother’s and father’s
experiences and within couples emerged.
This study offers a unique insight into couples’ experiences of pregnancy after loss
as it is the first study to explore the dynamics of couples as a dyad. It provides
insights into how mothers and fathers make sense of their experiences of loss and
subsequent pregnancy. It offers recommendations on how couples can be supported through
the journey of loss and a subsequent pregnancy.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference; ECM 4(d) 14/04/15). Written informed consent
was obtained by all study participants.
B4 Care practices after stillbirth: an international perspective
Fran Boyle1,2,3, Dell Horey1,3,4, David Ellwood1,3,5, Aleena Wojcieszek1,2,3, Katy
Gold3,6, Dimitrios Siassakos3,7, Jan Jaap Erwich3,8, Jessica Ruidiaz3,9, Jillian Cassidy3,10,
Paul Cassidy3,10, Susannah Leisher2,3, Lynn Farrales3,11, Claire Storey3, Margaret
Murphy3,12, Mairie Cregan3,13, Claudia Ravaldi3,14, Alfredo Vannacci3,14, Victoria
Bowring3,15, Jose Belizan3,16, Ingela Radestad3,17, Mechthild Gross3,18, Alex Heazell3,19,
Vicki Flenady1,2,3
1Centre of Research Excellence in Stillbirth, Brisbane, Australia; 2Mater Research
Institute - University Of Queensland, Brisbane, Australia; 3International Stillbirth
Alliance, Bristol, UK; 4College of Science, Health & Engineering, La Trobe University,
Melbourne, Australia; 5Griffith University and Gold Coast University Hospital, Gold
Coast, Australia; 6Department of Family Medicine and Department of Obstetrics & Gynecology
University of Michigan, Ann Arbor, MI, USA; 7Academic Centre for Women’s Health, University
of Bristol, Bristol & Southmead Hospital, Bristol, UK; 8Department of Obstetrics,
University of Groningen, University Medical Centre, Groningen, The Netherlands; 9Era
en Abril, Buenos Aires, Argentina; 10Umamanita, Girona, Spain; 11University of British
Columbia and Still Life Canada, Vancouver, BC, Canada; 12School of Nursing and Midwifery,
University College Cork, Cork, Ireland; 13Feileacain, Cork, Ireland; 14CiaoLapo Onlus,
Prato, Italy; 15Stillbirth Foundation Australia, Annandale, Australia; 16Institute
for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina; 17Sophiahemmet
Hogskola, Stockholm, Sweden; 18Hannover Medical School, Hannover, Germany; 19Institute
of Human Development, Faculty of Medical and Human Sciences, The University of Manchester
and St Mary’s Hospital, Central Manchester University Hospitals, NHS Foundation Trust,
Manchester Academic Health Science Centre, Manchester, UK
Correspondence: Fran Boyle
Care after stillbirth has important implications for women and families. Care practices
valued by parents and contributing to better outcomes have been identified, but implementation
appears inconsistent. This international perspective highlights variations in care
practices after stillbirth across selected high- (HIC) and middle-income countries
(MIC).
Data were from a large multi-country survey of parents of stillborn infants conducted
between December 2014 and February 2015. An online questionnaire, distributed primarily
through ISA member organisations, covered a range of topics, including whether seven
care practices were offered. Mothers’ responses (yes/no) to these seven items were
compared for regions and countries.
More than 3000 mothers from 22 HICs and over 600 mothers from 10 MICs responded. Italy,
(720); UK, (576); Australia & New Zealand, (460); US, (402) and Argentina, (423) and
Mexico, (168) were most strongly represented.
Stillbirth was more likely within the last five years for those responding from MIC.
Women from MIC were less likely to be offered recommended care than women from HIC,
including opportunity to: spend time with baby (45 vs 81%); see and hold baby (51
vs 85%); have family and friends meet baby (56 vs 74%); create memories (37 vs 70%);
name baby (62 vs 88%); take baby home (15 vs 19%); and have funeral or other service
(58 vs 84%). Differences were also observed across HICs: e.g., in Ireland and New
Zealand more than half had the opportunity to take their baby home but this was rare
in other countries.
Striking differences were apparent. Despite the complexities of cross-country data
comparisons, considerable variation between HIC and MIC and between some HIC was evident.
Providing respectful and supportive care after stillbirth is challenging but building
health system capacity to respond to families’ needs is an urgent priority, particularly
in lower-resource settings.
Ethics approval was granted by the Mater Health Services Human Research Ethics Committee
on 29th November 2013 (Ref #HREC/13/MHS/121) and by the University of British Columbia
Office of Research Services, Behavioural Research Ethics Board on 22nd December 2014
(Ref #H14-02784). Completion of the anonymous online survey indicated consent to participate
in the study.
B5 Learning from deaths: healthcare professionals’ views on parental involvement in
the perinatal mortality review process (The PARENTS 2 Study)
Danya Bakhbakhi1,2, Christy Burden2, Claire Storey1, Alexander Heazell3, Mary Lynch1,
Laura Timlin1, Dimitrios Siassakos2
1North Bristol Nhs Trust, Bristol, UK; 2University of Bristol, Bristol, UK; 3University
of Manchester, Manchester, UK
Correspondence: Danya Bakhbakhi
There is a national priority to learn from perinatal deaths when they occur. The United
Kingdom (UK) government has recommended that these incidents should be subject to
a standardised process, which incorporates feedback from parents and families within
a multidisciplinary review. The PARENTS1 project investigated parental opinion on
the perinatal mortality review (PNMR) process and concluded that parents were in favour
of a system where they could give and receive feedback as part of the review. Following
on, we assessed healthcare professionals’ views on parental involvement in the PNMR
as part of a larger project (PARENTS2) which aims to integrate of perceptions of parents,
staff, and stakeholders into the design and pilot of a parental involvement in the
PNMR.
We purposively sampled a range of healthcare professionals including obstetricians,
midwives, neonatologists, nursing staff, and hospital chaplains, to participate in
a focus group in Bristol, UK. We conducted a semi-structured group discussion using
a pre-designed topic guide. The data were analysed with an inductive thematic analysis
technique.
All healthcare professionals saw the benefit of receiving feedback from parents. Emerging
themes included: parallels to parent focus group – consideration of emotional and
clinical care, with flexibility and an optional process – and the importance of training
and supporting staff, as well as the importance of multi-disciplinary follow-up consultation.
Other themes were the structural/system adaptations required to the current PNMR process
including ground rules, role of facilitators, and a standardised format, and coping
strategies for emotional impact, conflict, complaints and litigation.
Parental involvement in perinatal mortality reviews is considered desirable by staff.
They have made recommendations as to how it might be undertaken, so that it is feasible.
The next step is to obtain key stakeholders’ views and reach a consensus as to how
parental involvement in the process should be implemented in hospitals across the
UK, and worldwide.
Approval for the study was granted by the Health Research Authority (Reference 220468).
Written informed consent was obtained by all study participants.
B6 Specialist photographic training increases midwives’ confidence in initiating and
undertaking memento photography following perinatal loss
Elizabeth Bailey1, Rachel Hayden2, Sam Collinge3
1University Hospitals Coventry & Warwickshire NHS Trust, & Coventry University, Coventry,
UK; 2Gifts of Remembrance, Hinckley, UK; 3University Hospitals Coventry & Warwickshire
NHS Trust, & Coventry University, Coventry, UK
Correspondence: Elizabeth Bailey; Rachel Hayden
This evaluation was developed to measure midwives’ confidence before and after specialist
training which aimed to support midwives in providing meaningful photographic mementoes
for families experiencing perinatal loss. (Creating memories can be of vital psychological
importance in helping families come to terms with the death of a baby. Parents often
cherish these photographs for the rest of their lives. As we only have ‘one chance
to get it right’ (Downe et al 2103), it is desirable that midwives receive adequate
training in introducing memento photography and memory-making activities).
Two training days took place in 2015. Before attending, those registered had been
invited via email to complete an anonymous, online pre-training questionnaire. The
post-training survey with similar questions to allow before and after comparison was
sent out approx. 14 weeks after the training session. The training session focused
on methods of empowerment along with how to approach families on the sensitive subject
of memory making and skills in documentary photography in this setting.
The pre-training survey was completed by 31 training attenders and the post training
by 22 respondents. There was a notable increase in confidence regarding memento photography
among midwives post-training compared to pre-training. Midwives’ confidence increased
in suggesting poses/positions to families (0% post-training vs 48% pre-training having
‘no confidence at all’). This increase in confidence was echoed in using props in
photographs (such as teddies, blankets, toys); in arranging subjects and items in
shot for photographic effect; and in initiating a discussion with parents on the value
of mementoes (73% post-training vs 36% pre-training being ‘quite confident’).
Providing care to bereaved parents is a challenging component of midwifery practice
with midwives reporting low confidence prior to specialist training on discussing
and conducting memento photography with parents. This training was effective in increasing
midwives’ confidence.
The photography training provided to healthcare staff formed part of their ongoing
professional development and therefore ethics approval for this aspect was not required.
The evaluation of the study however was approved by Coventry University Ethics Committee
(reference P33015).
B7 Failure of placental morphological adaptation may be implicated in stillbirth in
older mothers: a case-control study
Michael Cocker1,2, Samantha C. Lean1,2, Rebecca L. Jones1,2, Gauri Batra1,3, John
M. D. Thompson4, Alexander Heazell1,2
1Divison of Developmental Biology and Medicine, School of Medical Sciences Faculty
of Biology, Medicine & Health, University of Manchester, Manchester, UK; 2St. Mary’s
Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester,
UK; 3Department of Histopathology, Royal Manchester Children’s Hospital, Central Manchester
University Hospitals NHS Foundation Trust, Manchester, UK; 4Department of Paediatrics,
University of Auckland, Auckland, New Zealand
Correspondence: Elizabeth Bailey; Rachel Hayden
Advanced maternal age (AMA) ≥35 years is a recognized risk factor for stillbirth,
although the underlying aetiology is incompletely understood and appears particularly
heightened in later gestations. This study aimed to examine placental factors in the
aetiology of stillbirth in AMA mothers, and if these differ from stillbirths in younger
women. We also aimed to investigate whether placental differences exist in stillbirth
compared to live births in AMA mothers.
A retrospective case-control study was conducted examining differences in placenta
weight, fetal:placental weight ratio and histopathological lesions between non-anomalous,
singleton stillbirths in AMA mothers (n = 35) and stillbirths in women <35 years (n = 70)
identified from the stillbirth database of a tertiary obstetric unit (2009-2015).
AMA live births (n = 70) and live births to women <35 years (n = 27) were included
from the Manchester Advanced Maternal Age Study (MAMAS). Subjects were matched for
gestational age, ethnicity, pre-existing medical conditions, smoking status and fetal
gender (Table 1).
Median placental weight centile corrected for gestation was higher (Mann-Whitney z = 2.90,
p = 0.004), and median corrected F:PWR centile was lower (Mann-Whitney z = -2.52,
p = 0.012) in AMA live birth compared to live births to younger women. No similar
changes were observed between stillbirth groups. No significant differences were seen
in ReCoDe classifications or placental histopathological findings between AMA stillbirths
and stillbirths to women <35 years.
AMA live birth is associated with less efficient but larger placentas. The failure
to develop the adaptive morphological mechanism seen in AMA live births may by implicated
in the aetiology of stillbirth in older mothers. The potential impact of antenatal
surveillance in this population is poorly understood and warrants further investigation
Ethical approval for the study was granted by NRES Committee North West (Reference;
12/NW/0015). Written informed consent was obtained by all study participants
Table 1 (abstract B7).
Study group demographics, placental characteristics & placental histology results
AMA stillbirth
n
= 35
Stillbirth control group
n
= 70
AMA livebirth
n
= 70
Livebirth control group
n
= 27
Matching criteria
Gestational age (days)
Median (IQ range)
237 (199-266)
237.5 (192.5-263.8)
275 (273-278)
279 (272-285)
Pre-existing medical conditions n = (%)
VTE/thrombophilia
4 (11.4)
1 (1.4)
0 (0)
0 (0)
Hypothyroidism
2 (5.7)
0 (0)
1 (1.4)
0 (0)
Hypertensive disease
3 (8.6)
2 (2.9)
0 (0)
0 (0)
Diabetes mellitus
1 (2.9)
3 (4.3)
0 (0)
0 (0)
Asthma
1 (2.9)
5 (7.1)
0 (0)
0 (0)
Epilepsy
0 (0)
2 (2.9)
1 (1.4)
0 (0)
Ethnicity n = (%)
White
17 (48.6)
39 (55.7)
57 (81.4)
20 (74)
African & Caribbean
9 (25.7)
12 (17.1)
3 (4.3)
2 (7)
Mixed race
1 (2.9)
3 (4.3)
2 (2.9)
1 (4)
Asian
6 (17.1)
14 (20.0)
6 (8.6)
3 (11)
Other
2 (5.7)
2 (2.9)
2 (2.9)
1 (4)
Fetal gender n = (%)
Male
21 (60.0)
36 (51.4)
34 (48.6)
15 (56)
Female
14 (40.0)
34 (48.6)
36 (51.4)
12 (44)
Smoker during pregnancy n = (%)
Yes
7 (18)
16 (22.9)
1(1.4)
3(11)
Placental characteristics
Median placental weight (g) (IQ range)
297 (187.8-387.5)
298.5 (196.5-388)
538 (463.5-602.5)
478 (406.5-530.5)
Median F:PWR (IQ range)
5.5 (4.1-7.2)
5.6 (4.1-7.3)
6.5 (5.7-7.2)
7.2 (6.4-7.8)
Turowski placental histological classification n = (%)
Normal morphology
3 (8.6)
6 (8.6)
No data
Chorioamnionitis
5 (14.3)
10 (12.8)
Villitis/intervillositis
10 (28.6)
13 (14.3)
Villitis
4 (11.4)
4 (5.7)
Intervillositis
6 (17.1)
6 (8.6)
Maternal circulatory disorders
18 (51.4)
41 (57.1)
Cotyledon infarct
9 (25.7)
11 (15.7)
Intervillous thrombus
0 (0)
2 (2.9)
Abruption
1 (2.9)
5 (7.1)
Maternal malperfusion
12 (34.3)
25 (35.7)
Fetal circulatory disorders
2 (5.7)
7 (10.0)
Delayed villous maturation
10 (28.6)
13 (18.6)
ReCoDe classification n = (%)
A2.2
4 (11.4)
4 (5.7)
No data
A3
0 (0)
1 (1.4)
A7
12 (34.3)
40 (57.1)
A8
1 (2.9)
0 (0)
B2
2 (5.7)
0 (0)
C1
2 (5.7)
4 (5.7)
C4
4 (11.4)
7 (10)
F1
2 (5.7)
2 (2.9)
F4
3 (8.6)
0 (0)
F8
0 (0)
1 (1.4)
G1
0 (0)
1 (1.4)
I1
5 (14.3)
10 (14.3)
.
B8 Targeted for identification of cardiac variants in unexplained intrauterine fetal
death – a retrospective pilot study
Dana Muin1, Martina Kollmann2, Gregor Hörmann1, Herbert Kiss1, Thomas Schwarzbraun2
1Medical University Of Vienna, Vienna, Austria; 2Medical University of Graz, Graz,
Austria
Correspondence: Dana Muin
Congenital heart disease associated with genetic anomalies contributes to intrauterine
fetal death (IUFD) in up to 27%, of which approximately 75% of the cases had been
prenatally diagnosed. However, structural cardiac disorders (e.g. hypertrophic and
dilative cardiomyopathy) may also affect areas critical for electrical transmission,
well before structural changes appear in the individual. Yet, without those morphological
anomalies detected by ultrasound or post-mortem autopsy, those potential pathomechanisms
get easily missed and many cases of fetal demise falsely concluded as “unexplained”.
Clinical exome sequencing and filtering for 122 genes with a known cardiac phenotype
on post-mortem samples of 16 singleton fetuses after unexplained IUFD between gestational
weeks 23 + 2 and 40 + 5 to analyse the spectrum and frequency of putative pathogenic
variants.
In total, twelve (75%) male and four (25%) female fetuses were analysed. In 14 (87.5%)
samples, 33 variants were detected in 22 genes by sequencing. Two (12.5%) male Caucasian
fetuses elicited no relevant variants in any of the targeted cardiac genes. Potential
cardio-pathogenic variants were found in 13 (81.3%) cases, four (30.7%) of which harboured
two or more putative variants. Ten (30.3%) variants were detected in seven arrhythmogenic-susceptibility
genes and 21 (63,6%) variants were found in 17 genes coding proteins primarily associated
with cardiac morphology; two (6.1%) variants were found in a single gene coding for
both heart rate and morphology. No correlation was observed with fetal gender, gestational
age, medical and family history.
Cardio-genetic pathologies might be a potentially underexplored etiological factor
in unexplained IUFD and should be considered further in fetal post-mortem examinations.
Ethical approval for the study was granted by Medical Research Ethics Committee of
the Medical University of Vienna, Austria (Reference Number 1852/2016). Written informed
consent was obtained by all study participants.
B9 Recruitment barriers and participant feedback in a New Zealand stillbirth study
Robin Cronin1, Minglan Li1, Billie Bradford1, Vicki Culling2, John Michael David Thompson3,
Edwin Mitchell3, Lesley Margaret Elizabeth McCowan1
1University Of Auckland, Auckland, New Zealand; 2Vicki Culling Associates, Wellington,
New Zealand; 3Department of Paediatrics: Child Health and Youth Health, University
of Auckland, Auckland, New Zealand
Correspondence: Robin Cronin
Concern is often raised by maternity providers and families when pregnant and recently
bereaved women are approached to participate in stillbirth research. Our aim was to
assess factors influencing recruitment in the New Zealand Multicentre Case-Control
Stillbirth Study and to gain insight into how women felt about their participation.
Eligible women were contacted through their maternity providers from seven New Zealand
health regions between 2011 and 2015. Cases had a recent singleton non-anomalous late
stillbirth (≥28 weeks’ gestation). Pregnant controls were randomly selected and matched
for region and gestation. Participants were interviewed by a research midwife and
given a free-post feedback form asking their views about participation. Feedback was
evaluated using thematic analysis.
A total of 169 (254 eligible) cases and 569 (913 eligible) controls were recruited.
Non-participants consisted of: 263 (22.5%) women who declined, 106 (9.0%) unable to
be contacted, and 60 (5.1%) declined by the maternity provider. Reasons for women
declining: no reason provided (166, 63.1%), interview missed/cancelled (42, 15.9%),
‘too busy’ (26, 9.9%), maternal/family anxiety concerns (21, 8.0%), and other factors
(8, 3.0%). Of the 60 eligible participants where maternity providers declined on the
woman’s behalf: no reason provided (26, 43.3%), concern regarding maternal anxiety
(22, 36.7%), social/medical concerns (9, 15.0%) and other factors (3, 5.0%). Written
feedback was provided by 111 participants (15.3% of cases and 14.9% of controls) and
all described their involvement positively. Two main feedback themes were identified
by both the cases and controls: ‘motivation to participate’ (with subthemes of ‘helping
others’, ‘finding answers’ and ‘attributing meaning’) and ‘feeling about the experience’
(with subthemes of ‘ease of participation’, ‘talking and sharing’ and ‘personal benefit’).
Identification of recruitment barriers and our reassuring participant feedback may
assist researchers and participants in future stillbirth research.
Ethical approval for the study was granted by the Northern “X” Regional Ethics Committee
(Reference; NTX/06/05/054). Written informed consent was obtained by all study participants.
B10 Anatomy of the collateral venous drainage in late pregnancy in different positions
Aimee Humphries1,2, Peter Stone1, Seyed Ali Mirjalili2
1Department of Obstetrics and Gynaecology, University Of Auckland, Auckland, New Zealand;
2Department of Anatomy and Medical Imaging, University Of Auckland, Auckland, New
Zealand
Correspondence: Aimee Humphries
Recent studies have demonstrated an increased risk of late pregnancy stillbirth while
sleeping in the supine position. In this position the gravid uterus completely obstructs
the inferior vena cava. While this occurs in the majority of women, only a small number
experience supine hypotension syndrome. The aim of this study is to investigate the
role of collateral venous drainage in late pregnancy in various positions.
After obtaining ethics approval, 10 healthy pregnant women at 35–38 weeks gestation,
without supine hypotension syndrome, underwent Magnetic Resonance (MR) scanning in
supine and left lateral decubitus positions. MR images (T2 Weighted) were evaluated
to measure the calibre and blood flow of the major vessels (inferior vena cava, azygos
vein and abdominal aorta) and cardiac output.
Preliminary results have shown that cardiac output remained relatively unchanged in
both positions. The blood flow and diameter of the IVC dramatically decreased in the
supine position, however, the diameter of the azygos vein was doubled in size.
This MRI study demonstrates for the first time that healthy pregnant women without
symptomatic supine hypotension maintain cardiac output when lying flat by collateral
venous drainage including the azygos venous system. Variations in the collateral system
may affect venous return to the heart, reducing cardiac output and uteroplacental
perfusion. This may, in part, explain the effects of maternal position on risk of
stillbirth in late pregnancy.
B11 Maternal sleep physiology in healthy late pregnancy: effect of position on inspiratory
air flow
Jordan P. R. McIntyre1,2, Kevin M. Ellyett3, Peter R. Stone1, Edwin A. Mitchell2,
John M. D. Thompson1,2, on behalf of the Maternal Sleep in Pregnancy Research Group
1Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand;
2Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland,
New Zealand; 3Respiratory Measurement Laboratory, Auckland District Health Board,
Auckland, New Zealand
Correspondence: Jordan P. R. McIntyre
The Auckland Stillbirth Study (TASS) identified the importance of sleep position in
late stillbirth, but relied on mothers’ self-reports, lacking objective physiological
explanations for the increased risk. Non-clinically conventional measures of sleep
physiology may be required to detect subtle changes associated with maternal position
change. Descriptions of maternal sleep behaviour in late pregnancy, such as duration
of each sleep position and frequency of position change, are also important in the
context of TASS.
30 healthy women with a singleton pregnancy (35-38 weeks) underwent an overnight respiratory
sleep study with infrared video. Sleep position was synchronised with the flattening
index, an estimate of inspiratory flow limitation. The physiological effects of position
were assessed by repeated measures in continuous five minute epochs. Conventional
measures of obstructive sleep apnoea (OSA) severity, the apnoea-hypopnoea index (AHI)
and oxygen desaturation index (ODI), were also assessed by sleep position. Data are
presented as median (IQR).
The AHI and ODI were clinically insignificant in all positions. The supine position
demonstrated a substantially greater proportion of flow-limited breaths (24%, 5-55%)
than left-lateral (6%, 0-29%) and right-lateral (5%, 0-27%). 20/30 women initiated
sleep in the left-lateral position, compared with 8/30 in right-lateral and 2/30 in
supine. The women spent a significantly greater overall proportion of the night left-lateral
(49%, 37-60%) than supine (19%, 1-29%), and the average duration of each left-lateral
before changing position, 35 (26-48) minutes, was significantly longer than supine,
15 (4–32) minutes.
These healthy women in late pregnancy had no clinically-defined OSA in any position,
but instead demonstrated marked inspiratory flow limitation when sleeping supine.
This flow limitation may contribute to the observed reduction in the time spent supine
by increasing arousals from sleep, and thus may have a protective function.
The Regional Human Ethics Committee approved the study protocol (NTX/12/06/048), and
all participants provided written informed consent.
B12 Going to sleep supine and reduced sleep duration are risk factors for late stillbirth:
findings from the MiNESS Case-Control Study
Alexander E. P. Heazell1,2, Minglan Li3, John M. D. Thompson3,4, Jayne Budd1,2, Robin
Cronin3, Edwin Mitchell4, Tomasina Stacey5, Devender Roberts6, Bill Martin7, Lesley
M. E. McCowan3
1Faculty of Biology, Medicine and Health, University Of Manchester, Manchester, UK;
2St. Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust,
Manchester Academic Health Science Centre, Manchester, UK; 3Department of Obstetrics
and Gynaecology, University of Auckland, Auckland, New Zealand; 4Department of Paediatrics:
Child Health and Youth Health, University of Auckland, Auckland, New Zealand; 5School
of Healthcare, University of Leeds, Leeds, UK; 6Birmingham Women’s Hospital NHS Foundation
Trust, Birmingham, UK; 7Liverpool Women’s Hospital NHS Foundation Trust, Liverpool,
UK
Correspondence: Alexander E. P. Heazell
The significant variation in stillbirth rates between and within High Income Countries
suggests that more could be done to reduce stillbirth rates. One approach is to identify
modifiable risk factors. Two case-control studies from New Zealand and Australia have
described an association between going to sleep position and the risk of late stillbirth.
In the Midlands and North of England Stillbirth Study (MiNESS) we investigated maternal
sleep practices and their association with late (> = 28 weeks’ gestation) stillbirth.
MiNESS was a multi-centre case control study conducted in 40 maternity units in England.
In total 291 cases (women with a non-anomalous singleton late stillbirth) and 733
controls (women with ongoing pregnancies) participated. Extensive data were collected
using a researcher-administered questionnaire which included questions on sleep practices
before pregnancy, and in the four weeks prior to and on the night before the interview/stillbirth.
In multivariable analysis supine going to sleep position the night before stillbirth
was thought to have occurred had a greater than 2-fold increased risk of late stillbirth
(adjusted Odds Ratio (aOR) 2.31, 95%CI 1.04-5.11) compared to the left side. In addition,
sleep duration less than 5.5 hours (aOR 1.83, 95%CI 1.24-2.68), getting up to the
toilet once or less (aOR 2.81, 95%CI 1.85-4.26) and a daytime nap every day (aOR 2.22,
95%CI 1.26-3.94) were also associated with late stillbirth. No interaction was detected
between the effect of supine going to sleep position and a small for gestational age
infant, maternal body mass index or gestation. The population attributable risk for
supine going to sleep position was 3.7% (95% CI 0.5-9.2).
This UK study confirms findings from New Zealand and Australian studies that going
to sleep position is associated with late stillbirth. We should now consider the best
way to change practice via a public health campaign.
Ethical approval for the study was granted by Greater Manchester Central Research
Ethics Committee (Reference 13/NW/0874). Written informed consent was obtained by
all study participants.
B13 Intrapartum death and doctors; a qualitative exploration
Karen McNamara1, Sarah Meaney1,2, Keelin O’Donoghue1,3
1Pregnancy Loss Research Group, Department Of Obstetrics and Gynaecology, University
College Cork, Cork, Ireland; 2National Perinatal Epidemiology Centre, Department Of
Obstetrics and Gynaecology, University College Cork, Cork, Ireland; 3The Irish Centre
for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork,
Ireland
Correspondence: Karen McNamara
The death of an infant at any stage in a pregnancy is profoundly traumatic both for
the parents and the healthcare professionals involved. Most of the research pertaining
to healthcare professionals in this area has focused on the effects of antenatal stillbirth
or perinatal death, without investigating the specific impact of unexpected IPD. Our
study aims to provide an in-depth qualitative exploration of the attitudes and responses
that Irish Obstetricians have following direct involvement with an intrapartum fetal
death.
Following ethical approval this qualitative study was conducted in a tertiary university
maternity teaching hospital in the Republic of Ireland. Ten obstetricians composed
of five consultants and five obstetricians in training were purposively recruited.
Semi-structured interviews were conducted in a time and location that suited the participant.
The data were analysed using interpretative phenomenology as it explores and understand
how individuals make sense of major life experiences.
Direct involvement with an intrapartum death had a profound and negative impact on
obstetricians. Devastation, shock, sadness, fear and guilt were some of the emotions
experienced by doctors in the aftermath of an IPD. Analysis of the data revealed two
superordinate themes; the doctor as a person, and supporting each other. The doctor
as person was characterised by two subordinate themes; emotional impact and frustration.
Supporting each other was also characterised by two subordinate themes; the good and
the bad and what might work.
The impact of intrapartum death on Obstetric doctors is profound and long lasting
and doctors are the second victims of these events. This needs greater acknowledgement
and acceptance. The development of timely and effective emotional support interventions
for all obstetricians is of crucial importance.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference No: ECM 4(III) 07/07/15 and ECM (III) 08/12/2015).
Written informed consent was obtained by all study participants.
B14 Confidence and training needs of health professionals providing support to parents
who have experienced a loss from a multiple pregnancy
Judith Rankin1, Louise Hayes1, Nicholas Embleton2
1Newcastle University, Newcastle upon Tyne, UK; 2Newcastle upon Tyne Hospitals NHS
Foundation Trust, Newcastle upon Tyne, UK
Correspondence: Judith Rankin
It is well documented that sensitive emotional care from health professionals has
a significant impact upon life-long memories formed by parents at the time of the
loss of their baby. Less is known about how confident health professionals feel providing
this emotional care and if sufficient training is available to support them. This
study aimed to ascertain self-rated confidence and training needs of health professionals
providing support to parents who have experienced a loss from a multiple pregnancy.
An online survey, consisting of open and closed questions, was sent by email via professional
organisations and clinical networks to fetal medicine and neonatal health professionals
between March and June 2016. Responses were anonymous.
293 health professionals responded including 130 (44.4%) midwives/obstetricians/fetal
medicine specialists and 156 (53.2%) neonatal nurses/doctors. 232 (79.2%) respondents
were female and 171 (66.3%) had worked in their current role for more than 15 years.
Although confidence in providing practical support to parents who had experienced
a loss from a multiple pregnancy was high (156, 58.9%), almost a third of respondents
(80, 30.2%) reported having no or some confidence to provide emotional support. Respondents
with less time in their current role reported lower confidence in providing emotional
support. 131 respondents (47.3%) reported receiving training around loss from a multiple
pregnancy, 91 (32.9%) had used national guidelines to inform their practice and 103
(37.2%) knew of local guidelines. 91 respondents (33%) felt that the current training/guidelines
were inadequate and 263 (95.3%) felt that more training/guidelines would be helpful.
Self-rated confidence in providing emotional support to parents following a loss from
a multiple pregnancy was low. Less than half of respondents had received training
on this important aspect of clinical care and the majority of respondents felt more
training and further guidelines were needed.
B15 Caring for the caregiver: using retreats to care for perinatal loss health professionals
Lindsey Wimmer, Sarah Rodriguez
Star Legacy Foundation, Eden Prairie, MN, USA
Correspondence: Lindsey Wimmer
Health professionals routinely report the impact of work-related stress on job satisfaction,
personal health, and relationships. Health care leaders experience high levels of
burn-out and turn-over as a result. Obstetrics is expected to be a positive place
to work where poor outcomes are rare, which increases the burden on health professionals
in this area when tragedies occur. Perinatal loss has been cited as a primary cause
of obstetrics professionals leaving the specialty. Health professionals have also
reported feeling inadequately trained to care for families experiencing perinatal
death. This lack of knowledge and confidence can magnify the stress on these individuals.
Health professional retreats were designed to support the self-care, educational,
and team-building needs of these caregivers. Each retreat is conducted off-site and
unique to the attendees. Examples of education sessions include Bereavement Photography,
Emerging Evidence in Perinatal Loss, and Understanding Perinatal Autopsy and Evaluation.
Self-care modules may include yoga, Reiki, massage, aromatherapy, and more. Parent
panels are included in every retreat as is time for brainstorming and team-building
activities.
The health professional retreats have been extremely well-received. Event evaluations
indicate high levels of rejuvenation, team-building, gratitude, and knowledge. The
parent panels are consistently the most popular modules offered. In follow-up surveys,
attendees report increased comfort with their role during perinatal loss, decreased
personal and work-related stress, increased confidence in their knowledge, and a desire
to attend additional offerings.
Health professional retreats can be an effective strategy to decrease work-related
stress, burn-out, and turn-over in obstetrics. In addition, they serve to improve
care provided to families experiencing perinatal death.
B16 International variation in the classification of stillbirths and neonatal deaths
at 22 to 26 weeks gestational age
Lucy K. Smith1, Naho Morisaki2, Nils-Halvdan Morken3, Mika Gissler4, Paromita Deb-Rinker5,
Jocelyn Rouleau5, Stellan Håkansson6, Michael R. Kramer7, Michael S. Kramer8
1University of Leicester, Leicester, UK; 2National Center for Child Health and Development,
Tokyo, Japan; 3University of Bergen, Bergen, Norway; 4National Institute for Health
and Welfare, Helsinki, Finland; 5Public Health Agency of Canada, Ottawa, Canada; 6Umeå
University, Umeå, Sweden; 7Emory University, Atlanta, GA, USA; 8McGill University,
Montreal, Canada
Correspondence: Lucy K. Smith
High-income countries differ substantially in reported survival rates of infants born
near the limit of viability. We hypothesized that adherence to “official” criteria
of signs of life at birth to classify deaths as stillbirth vs neonatal death, as well
as classification of stillbirths as ante- vs intra-partum, may explain much of this
variation.
We calculated the number of births by time of death for each completed gestational
week using national data on births at 22-26 weeks from the UK (2014 n = 3,264), Japan
(2014, n = 3,110), US (2012, n = 24,929), Canada (2009-2014, n = 7,491), Finland (2010-2015,
n = 854), and Norway (2010-2014, n = 933) and at 22-25 weeks for Sweden (2011-2014,
n = 1,034). We compared the proportion of births classified as antepartum stillbirths,
intrapartum stillbirths and live births.
At 22 weeks, large differences were observed among countries in the percent of births
classified as ante-partum stillbirth (20%-30%), intra-partum stillbirth (3%-10%) or
live birth (48%-65%). For live births, wide variation was observed in the percentage
infants dying before 1 hour (11%-42%), suggesting differences in perceptions of viability
and in resuscitation practices. All of these differences narrowed with increasing
gestational age and nearly disappeared by 26 weeks.
Our findings show wide international differences in the classification of births and
deaths for fetuses and infants born near the limit of viability. This makes international
comparisons of stillbirth rates and neonatal death rates problematic at very early
gestations.
This study is based on publicly available, de-identified, aggregated datasets exempt
from ethics review.
B17 Perinatal 0utcomes using the Robson Ten Group Classification System (RTGCS)
Fionan Donohoe, Meenakshi Ramphul, Mark O’Connor, Martina Murphy, Michael Robson
National Maternity Hospital, Holles Street, Dublin, Ireland
Correspondence: Fionan Donohoe
The Robson Ten Group Classification System (RTGCS) is increasingly being used worldwide
to compare induction and rates of mode of delivery. It has been less used to simultaneously
examine perinatal outcome of childbirth, which is one of the lesser known advantages
of the classification. The aim of this study is to suggest a method of using the RTGCS
to assess perinatal mortality and morbidity. In particular, the rates of: stillbirths
(infant born without any signs of life after 24 weeks gestation and/or weighing more
than 500g at birth); intrapartum deaths (death of an infant during labour); early
neonatal deaths (death of a liveborn infant within the first seven days of life) and
rates of hypoxic-ischemic encephalopathy (infants > 37weeks who have neonatal encephalopathy
in the first week of life with evidence of metabolic acidosis in intrapartum fetal
umbilical arterial cord or very early neonatal blood samples (pH <7.0, base deficit ≥ 12).
Data were retrospectively collected from contemporaneously written annual reports
of a tertiary teaching maternity hospital in Dublin, Ireland.
From the 1st of January 2005 to the 31st of December 2014, there were 88,005 deliveries
of infants after 24 weeks gestation and/or who weighed >500g. The perinatal mortality
and morbidity rates are described in the table below (Table 2). The rates reported
include congenital anomalies. The overall perinatal mortality rate during that time
period ranged from 5.6 to 9.8 per 1,000.
As recommended by the World Health Organisation and as increasing numbers of countries
worldwide implement the RTGCS to compare induction and rates of mode of delivery,
it is important to remember that other perinatal outcomes can, and should, be analysed
using the same system. This will allow focussed interventions on prospective groups
of women to take place depending on local results.
Table 2 (abstract B17).
See text for description
Stillbirth*
Intrapartum deaths*
Early neonatal death*
Hypoxic-ischaemic encephalopathy
(per 1,000)
(per 1,000)
(per 1,000)
(per 1,000)
Nulliparous singleton cephalic, >37weeks(Robson groups 1,2)
83/35406(2.3)
0/35406(0)
19/35406(0.5)
50/35406(1.4)
Multiparous singleton cephalic, > 37weeks, excluding previous caesarean section(Robson
groups 3,4)
46/35317(1.3)
0/35317(0)
17/35317(0.5)
25/35317(0.7)
Previous caesarean section, singleton cephalic, >37weeks(Robson group 5)
13/8682(1.5)
0/8682(0)
6/8682(0.7)
5/8682(0.6)
Multiple pregnancies(Robson group 8)
27/1647(16.3)
0/1647(0)
53/1647(32.2)
5/1647(1.2)
Malpresentation, deliveries <37 weeks(Robson groups 6,7,9,10)
192/6953(27.6)
2/6953(0.3)
126/6953(18.1)
0/6953(0)
B18 Small for gestational age and perinatal mortality at term: an audit in a Dutch
national cohort study
Martine Eskes1, Adja Waelput2, Sicco Scherjon3, Klasien Bergman3, Ameen Abu-Hanna1,
Anita Ravelli1
1Academic Medical Center, Amsterdam, The Netherlands; 2Erasmus MC, Rotterdam, The
Netherlands; 3University Medical Center Groningen, Groningen, The Netherlands
Correspondence: Martine Eskes; Anita Ravelli
An important goal of prenatal care is a timely detection of fetal growth restriction,
and prevention of fetal asphyxia or perinatal mortality and morbidity by fetal monitoring
and timely birth. Many studies showed the low detection rate of SGA during pregnancy,
which varied between 15-32%. We assessed the underlying risk factors for perinatal
mortality in term born SGA infants.
We performed a population based nationwide cohort study in the Netherlands of 465,532
term born infants from January 2010 to January 2013. Logistic regression analyses
were performed. Also audit results were investigated for detailed care information.
We studied 162 SGA infants who died in the perinatal period. Risk factors were: gestational
age between 37.0-37.6 weeks (adjusted Odds Ratio (aOR) 2.60, 95% Confidence Interval
(CI) 1.58, 4.28), male gender (aOR 1.39, 95% CI 1.01, 1.90), South Asian ethnicity
(aOR 3.63, 95% CI 1.58, 8.35), African (aOR 3.54, 95% CI 1.93, 6.49), and other non-Western
ethnicity (aOR 1.92, CI 1.18, 3.10). At 37.0-37.6 weeks gestation audit results showed
that 26% of the women smoked, 91% were boys and in all but one case death occurred
before birth. In 61% of all deceased SGA infants born at 37.0-37.6 weeks gestation,
referral from primary care by independent midwives to the obstetrician took place
because of antepartum death before labour.
Gestational age between 37.0-37.6 weeks, male gender, South Asian, African or other
non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants.
These risk factors concern the complete term population starting at 37.0 weeks or
even earlier. Therefore, it is of utmost importance to develop accurate diagnostic
tests to screen for SGA before 36 weeks gestation to prevent perinatal.
Poster presentation
P1 Bereavement care services within the Maternity unit at Our Lady of Lourdes Hospital,
Drogheda
Fiona Mulligan, Colette McCann, AnnMarie Connor
Our Lady of Lourdes Hospital, Drogheda, Ireland
Correspondence: Fiona Mulligan
This poster outlines the advancements in Bereavement Services within the Maternity
Unit of Our Lady of Lourdes Hospital, Drogheda.
In 2012, in spite of the financial and operational challenges the ‘Butterfly Room’
was developed to provide a quiet comfortable space for bereaved parents and their
baby. It allows for the parents to spend time with their baby and close family and
friends before their final goodbye. The use of a Cuddle cot donated by Feileacain
(again as a result of fundraising from bereaved parents) allows for the baby to remain
with the parents for as long as they wish.
The Flower room was later established in order to provide a cool environment for baby
prior to Postmortem or burial in accordance to the wishes of the parents. This was
followed by the appointment of The Bereavement support midwife in 2013. Practical
and emotional advice and support is facilitated by the bereavement team-Bereavement
midwife, Pastoral care and Medical social work and staff at ward level, at this very
difficult time.
Subsequently in 2015 the ‘Dragon Fly Room’ was opened to provide a quiet private space
for parents who receive bad news during pregnancy and also for women and their families
who receive poor diagnosis from the Gynaecological ward. This came about as a result
of fundraising by two families who had been affected by the loss of a baby through
stillbirth.
We continue to develop our bereavement services with the support of our Bereavement
Midwife, the Multi-disciplinary Bereavement Team, The Breaking Bad News Training Programme
and most recently, The National standards for Bereavement care following Peri-natal
death and Pregnancy loss.
Ethical approval was not required as this work was a service evaluation.
P2 Breaking the conspiracy of silence - narratives about disenfranchised grief and
actions to enfranchise it
Juha Itkonen
University Of Helsinki, Orivesi, Finland
Stillborn children were surrounded by silence for a long time. The issue of having
a stillborn has been something awkward; not a proper topic to speak about, not to
mention to mourn. Even today the parents tend to be met with silence, intended as
a form of kindness, by care givers in hospital and church, friends stopping by at
home and coworkers on the job.
The data of the first phase was collected by narrative interviews (N = 24). Interviews
were analyzed with computer assisted NCT –method (notice, collect, think). The second
phase was an action research. With KÄPY - The Child Death Families and The Federation
of Finnish Midwives we started a citizens’ initiative to change the law so that stillborn
children could be written in the Finnish Population Information System by their own
names. Response to the initiative in internet conversations were also analyzed with
NCT –method.
Parents did not feel encounters with professionals supportive, rather formal and distant.
When support was received, the helper did not approach the bereaved parent as a professional
but as a human being who had courage to come close and be there. The Finnish media
were first reluctant to publish articles about our citizens’ initiative and when we
get our message trough, a lot of comments were dismissive to the subject. These can
be seen in framework of disenfranchised grief. However, our action research process
broke the silence in some degree.
The results shows that “a conspiracy of silence” is still an issue in Finnish context,
although there were a lot of narratives about supportive encounters too. Seems that
the first step to help a parents of a stillborn is recognizing that the they have
sustained a real loss, a death of a human being.
The research was carefully made by the guidelines of the Finnish Advisory Board on
Research Integrity. Written informed consent was obtained by all 24 study participants.
P3 Stillbirth Stories: audio oral history archive of personal testimonies - a tool
for peer support, professional learning and public engagement
Emma Beck1, Nicola Gibson1, Alexander Heazell1,2
1Stillbirth Stories, London, UK; 2University of Manchester, Manchester, UK
Correspondence: Emma Beck
‘Stillbirth Stories’ is a Wellcome Trust funded oral history archive documenting the
experience of stillbirth from the perspective of parents and professionals. The testimonies
gathered on the open-access website will provide a unique peer support resource for
those directly affected by the experience of stillbirth and for those who care for
them.
The value of access to the material gathered is anticipated to be both immediate and
lasting for bereaved parents, families and friends especially parents from “hard to
reach” groups or those who may have not accessed formal support before. It is hoped
that for interested clinicians and other professionals it will provide the basis of
a tool for informal and formal learning.
Inspired by personal experiences, two former documentary producers worked with the
perinatal bereavement team at St Mary’s Hospital, Manchester to record parents’ and
professionals experiences in 60-90 minute interviews covering the clinical and bereavement
care received/provided. The first phase of www.stillbirthstories.org will feature
20+ audio interviews and transcriptions. The audio interviews can also be searched
by ‘Theme’: headings include: ‘The birth’; ‘Spending time with your baby/making memories,
‘Deciding about a post-mortem’, ‘Getting pregnant again’.
The stillbirthstories.org site will launch in Autumn 2017. A functioning section can
be viewed at: http://nominomi.com/stillbirthstories/. Evaluation has included a survey
of maternity staff to address whether the opportunity to listen to clinical and personal
experiences of bereaved parents and other clinicians improves clinicians’ confidence
in caring for families who have had a stillbirth. The results of this evaluation will
be presented.
This project has established a methodology that could be applied in other countries/units
to extend the archive. Personal testimony can be used as a peer support resource for
bereaved parents, a tool for professional learning and to engage the public and raise
awareness
The archive itself did not require ethical approval, but all interviewees gave written
consent for their interviews to be used.
P4 Women’s attitudes, experiences and compliance concerning the use of Mindfetalness-a
method for systematic observation of fetal movements in late pregnancy
Anna Akselsson1,2, Susanne Georgsson1,2, Helena Lindgren1, Karin Pettersson1, Ingela
Rådestad2
1Karolinska Institutet, Stockholm, Sweden; 2Sophiahemmet University, Stockholm, Sweden
Correspondence: Anna Akselsson
Maternal perception of decreased fetal movements and low awareness of fetal movements
are associated with a negative birth outcome. Mindfetalness is a method developed
for women to facilitate systematic observations of the intensity, character and frequency
of fetal movements in late pregnancy. We sought to explore women’s attitudes, experiences
and compliance in using Mindfetalness.
We enrolled 104 pregnant women treated at three maternity clinics in Stockholm, Sweden,
from February to July of 2016. We educated 104 women in gestational week 28-32 by
providing information about fetal movements and how to practice Mindfetalness. Each
was instructed to perform the assessment daily for 15 minutes. At each subsequent
follow-up, the midwife collected information regarding their perceptions of Mindfetalness,
and their compliance. Content analyses, descriptive and analytic statistics were used
in the analysis of data.
Of the women, 93 (89%) were positive towards Mindfetalness and compliance was high
78 (75%). Subjective responses could be binned into one of five categories: Decreased
worry, relaxing, creating a relationship, more knowledge about the unborn baby and
awareness of the unborn baby. Eleven (11%) women had negative perceptions of Mindfetalness,
citing time, and the lack of need for a method to observe fetal movements as the most
common reasons.
Women in late pregnancy are generally positive about Mindfetalness and their compliance
with daily use is high. The technique helped them to be more aware of, and create
a relationship with, their unborn baby. Mindfetalness can be a useful tool in antenatal
care. However, further study is necessary in order to determine whether the technique
is able to reduce the incidence of negative birth outcome.
The women gave consent to receiving the study material. The study was approved by
the Regional Ethical Review Board in Stockholm: DNR: 2015/2105-31/1.
P5 Renegotiating father’s identity following stillbirth: what and who am I?
Kerry Jones1,2
1The Open University/The Talking Shed, Milton Keynes, UK; 2The Talking Shed [Counselling
services], Credtion, UK
This study examines the experiences of men following stillbirth in particular the
challenges they face in claiming their identity as a father of an absent child. Fathers
felt diminished when concerns about how they were coping were directed only to the
women. Contrary to the notion that father’s experience suggests men suffer less distress,
this research shows that men also deal with loss at an emotional level.
This investigation into men’s accounts of loss forms part of a larger study in which
28 men and women participated in interviews and focus groups about their experiences
of perinatal death.
By listening to narrative accounts of loss, the passage to parenthood for bereaved
men represents a disruption and re-evaluation of who they are, what they knew about
the world as they negotiate the incomprehensibility of the death itself. Narratives
by bereaved men also reveal how their sense of self and identity is mediated by the
social and cultural milieu to which they belong and are largely disenfranchising experiences
when friends, family and others, at times, fail to acknowledge the enormity of their
loss.
The findings suggest that recognition of the death of baby who is stillborn as well
as the impact of the death for father’s is intertwined with personal identity. Men
in this study needed to receive recognition as fathers, both at the time of their
loss and after. In examining the reproductive and bereavement journey of men, several
domains occurred to illuminate the experience of men including; men as support partners;
the impact of the death; parenting an absent child [advocate, protector]. The findings
from this study will offer insight into the experiences of men that will resonate
for others including practitioners who support individuals going through similar experiences.
Ethical approval for the study was granted by the University of Bristol Ethics Committee
as part of doctoral research. Written informed consent was obtained by all study participants.
No formal recruitment was obtained through the National Health Service or Government
Institution and was entirely voluntary.
P6 The four-leg model of recovery - clues to identify parents of stillborn at high-risk
Juha Itkonen
University Of Helsinki, Helsinki, Finland
Grief is fundamental part of human life and people grieve in various manners. However,
all ways to grieve are not equally beneficial. It is difficult to recognize those
mourners at higher risk, because of the multidimensional nature of grief. Recent studies
have shown that many factors can complicate the grief of having a stillborn child.
This paper aims to discover the significant risk-factors in stillbirth-grief and presents
a model to identify them.
The data of this paper was collected by narrative interviews (14 mothers and 10 fathers
of stillborn child). Interviews were analyzed with computer assisted NCT –method (notice,
collect, think) with help of Atlas.ti –software. The Four-Leg-Model of recovery was
created from the data and based contemporary grief theories. The data was analyzed
again in the light of this Model.
The first result was the analysis-tool itself. According to The Four-Leg-Model the
recovery is like a stool with four legs. These legs are nature of loss, personal resources,
social support and other concurrent stressors. If one of these legs are broken, a
mourner will most likely recover. If two, a mourner is at a high-risk of falling.
If three, a mourner will almost certainly fall. If all four, immediately actions are
needed. Results also revealed that grief after having a stillborn can test the firmness
of all three of the loss-related legs. After loss, social support is only leg that
can be affected directly and only through social support can help be offered in dealing
with the concurrent stressor and personal resource legs.
All forms of social support – emotional, tangible, informational and spiritual – play
an essential role in helping mourners. The Four-Leg-Model gives professionals a useful
tool to identify mourners at high-risk – not only after a stillbirth, but in any loss
situation.
The research was carefully made by the guidelines of the Finnish Advisory Board on
Research Integrity. Written informed consent was obtained by all 24 study participants.
P7 Perinatal palliative care after a stillbirth - midwives experiences of using Cubitus
baby
Ingela Rådestad, Karin Henley Listermar
Sophiahemmet University, Stockholm, Sweden
Correspondence: Ingela Rådestad
In Sweden, around 450 babies are stillborn every year. Usually, the parents stay at
the hospital a couple of days after the birth and they can have the baby in their
room. Due to the importance to keep a dead body cold it has, until recently, been
a routine to separate the baby from the parents and place the baby in a refrigerator
during the night. With the goal to improve the dignity for the baby and the family
a tool was developed. Cubitus baby, a special cot with cooling blocks, was implemented
at all 48 delivery wards in Sweden during 2013-2014.
The aim of the study was to investigate the midwives experiences of using Cubitus
baby. In total 155 midwives answered a questionnaire. One open question was analyzed
with content analyses.
Five categories were formed concerning the midwives experiences; a gracious feeling,
a sense of relief in their work, caring with coldness, time to say goodbye and a good
feeling for the parents.
Cubitus Baby is an essential tool for the midwife when they provide perinatal palliative
care. The midwife can give time to say farewell without feeling stressed that they
must separate the baby from the parents.
P8 A review of the stillbirth registration process in the UK: support and care offered
to parents
Bethany Jakubowski, Laura Oakley, Diane Duclos
London School Of Hygiene And Tropical Medicine, London, England
Correspondence: Bethany Jakubowski
To review the stillbirth registration process in the UK and identify gaps in the care
and support offered to parents.
This mixed-method study included a document analysis (see Fig. 2) and five face-to-face,
semi structured interviews. The documents gathered were samples of the written information
provided to parents about the stillbirth registration process, taken from a purposive
sample of four hospitals in the London area. The first round of interviews conducted
with five stillbirth charity workers were identified through purposive and snowball
sampling. One follow-up phone interview was also conducted.
The primary themes identified using a thematic analysis were; the lack of consistent
care, the importance of bereavement midwives, a desire for change to the registration
process, and the need to normalise stillbirth through support networks. Most charity
workers identified that registering a stillbirth was a traumatic and difficult experience,
and made suggestions to improve the process, such as changing the locality of the
registration and lowering the gestational age specified in the registration law. All
charity workers interviewed viewed two samples from the document analysis to be unsympathetic
to bereaved parents. The analysis of the documents demonstrated there are inconsistencies
in written information provided to bereaved parents.
This study demonstrates a strong desire among stillbirth charity workers to change
the registration process, and for a consistent level of care to be provided to bereaved
parents. Findings from both the interviews and the document analysis demonstrate parents
currently receive an inconsistent level of care. Participants suggested the level
of care and support provided by bereavement midwives can vary, indicating the need
for standardisation at a national level. Efforts should be made to include perspectives
of bereaved parents to pinpoint gaps and weaknesses in current practices of care and
support provided during the stillbirth registration process.
Fig. 2 (abstract P8).
Table comparing the documents included in the document analysis
P9 Placental findings and perinatal deaths - a national review using consensus terminology
Yvonne McCartney1, Edel Manning2, Irene O’Farrell2, Eoghan Mooney1,2
1National Maternity Hospital, Holles Street, Dublin, Ireland; 2National Perinatal
Epidemiology Centre, Cork, Ireland
Correspondence: Yvonne McCartney
The National Perinatal Epidemiology Centre (NPEC) collects anonymised perinatal mortality
data from all 19 Irish maternity units. Consensus terminology has been published to
assist in reporting of placental pathology, and is now used in Ireland on a national
basis.
Placental pathology contributes to or causes stillbirth in 11 to 65% of cases in various
classifications. Maternal vascular malperfusion (MVM) and fetal vascular malperfusion
(FVM) play a major role. We assessed perinatal deaths where placental disease is the
main cause of death, focusing on MVM and FVM.
For the years 2014 and 2015, all cases of early and late neonatal deaths (regardless
of gestation and birthweight at delivery) and stillbirths (≥24 weeks gestation or
birthweight ≥500g) were included when placental disease was the main cause of death
or an associated factor (n = 571).
MVM and FVM were reported in 73.7% and 77.9% of stillbirths and in 26.3% and 22% of
neonatal deaths, respectively. There were 28 (5%) cases with both MVM and FVM. Both
MVM and FVM were more common in males (57.5% and 55.2%). Co-existing pathologies included
intra-uterine growth restriction (3.9% of MVM) and cord pathology (9.5% of FVM).
This is the first application of placental consensus terminology to national data
of which we are aware. The frequency of placental pathology is consistent with previous
studies. Our results highlight the major contribution to perinatal loss of MVM and
FVM. The co-existence of MVM and FVM is an under-recognised phenomenon and is seen
in 5% of cases.
Ethical approval for the NPEC national clinical audits of obstetric outcomes was provided
by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (Reference:
ECM 4(g) 05/08/08
P10 Mixed maturation patterns - when acceleration meets delay
Yvonne McCartney, Marie Culliton, Paul Downey, Eoghan Mooney
National Maternity Hospital, Holles Street, Dublin, Ireland
Correspondence: Yvonne McCartney
Placental maturation that is appropriate for gestation is important in ensuring optimal
fetal development. An accelerated maturation pattern reflects maternal vascular malperfusion
(MVM), the leading cause of perinatal loss, seen in approximately one third of cases.
Delayed villous maturation (DVM) has also been associated with perinatal loss and
is reported in 5 – 7% of placentas. A combination of both accelerated and delayed
maturation patterns could be expected in a number of cases.
The aim of this study was to compare a cohort of placentas diagnosed as DVM or as
a mixed pattern (features of both accelerated and delayed maturation).
Cases with a diagnosis of DVM (n = 116) and those with a diagnosis of a mixed pattern
(n = 116) were selected from the pathology database between 2013 and 2016. Cases were
reported by a single experienced placental pathologist. Gross details were recorded,
including cord insertion, cord coiling and the presence or absence of placental disruption.
Clinical details obtained included maternal age and parity, mode of delivery, gestation
at delivery, birth weight and infant gender.
Groups were comparable in terms of gestational age, gender and mode of delivery. Disruption
of the maternal surface was similar in both groups. Cases with a mixed maturation
pattern showed a statistically significantly smaller placenta size (fetoplacental
weight ratio p value 0.0113) and lower birth weight (p value 0.0263).
A mixed pattern of placental maturation correlates with features that suggest MVM.
This study uses anonymised laboratory data, ethical approval was neither sought nor
required.
P11 Women’s mental health following a miscarriage: the influence of personal and contextual
variables
Francine deMontigny1,2, Chantal Verdon2,3, Sophie Meunier4, Isabel Coté1,2, Christine
Gervais2,3
1Université Du Québec En Outaouais, Gatineau, Canada; 2Center of Research and Studies
on Family Intervention, Gatineau, Canada; 3Université du Québec en Outaouais, St-Jérôme,
Canada; 4Université du Québec à Montréal, Montréal, Canada
Correspondence: Francine deMontigny
In Western societies, it has been estimated that between 20% and 25% of pregnancies
end in spontaneous abortion (miscarriage). Despite this high prevalence, bereavement
associated with miscarriage has received much less attention from the scientific and
professional communities than that associated with stillbirth.
This cross-sectional study aimed to examine personal and contextual variables associated
with women’s mental health following a miscarriage. A total of 231 women who had miscarried
in the past 4 years answered a self-report questionnaire assessing their mental health
(depression, anxiety, perinatal grief) and collecting personal as well as contextual
characteristics.
One-way analyses of variance indicated that women who had miscarried within the past
6 months had higher scores for depressive symptoms than did women who had miscarried
between 7 and 12 months ago, while anxiety level and perinatal grief did not vary
according to time since miscarriage. Moreover, low socioeconomic status, immigrant
status, and childlessness were associated with worse mental health following a miscarriage.
In contrast, regression analysis indicated that quality of the conjugal relationship
and satisfaction with health care were positively associated with women’s mental health.
Results suggest that researchers and health professionals working with women experiencing
miscarriages should pay particular attention to women living in vulnerable situations
(e.g. low socioeconomic status, immigrant status, childlessness). Quality of the conjugal
relationship and satisfaction with health care appear to be important protective factors
and could be the target of interventions aimed at reducing the deleterious effect
of miscarriage on women’s mental health.
P12 Rates, causes and risk factors of stillbirth in a large cohort of pregnant women
from peri-urban areas of Karachi, Pakistan
Muhammad Imran Nisar, Muhammad Ilyas Ilyas, Urooj Fatima, Komal Naeem, Yasir Shafiq,
Fyezah Jehan, Anita Zaidi
Aga Khan University, Karachi, Pakistan
Correspondence: Muhammad Imran Nisar
An estimated 2.6 million babies are stillborn every year with the highest Still Birth
Rate (RBR) in Pakistan of 43.1 stillbirths/1000 births. We describe here burden, risk
factors and causes of stillbirths in a cohort of pregnant women from low income community
setting in Karachi.
From Jan 2012 – Dec 2013, Community Health Workers (CHWs) identified newly pregnant
women through 3 monthly household visits. They were followed up till end of their
pregnancy. In case of a stillbirth, a detailed verbal autopsy (VA) form was filled.
Forms were reviewed by 2 independent Physicians and 3 physicians in case of disagreement
to assign a cause of stillbirth. Consensus between at least two physicians was required
for a definitive cause.
There were 17,321 births in total, including 16,786 live births and 535 stillbirths
giving SBR of 30.8/1000 births. Previous history of stillbirth, mother’s age >30 years,
nulliparity, deliveries conducted by skilled birth attendant or in hospitals, squatting
position during delivery and antibiotic use at time of delivery were found to be associated
with high risk of stillbirth. During pregnancy, iron supplementation, tetanus toxoid
injection and physical work were found to decrease risk of stillbirth. Complications
during pregnancy (vaginal bleeding, foul smelling discharge or convulsions) and at
time of delivery (water breaking before pain began, premature rupture of membrane,
excessive vaginal bleeding, foul smelling discharge, convulsions, abnormal fetal presentation,
prolonged labor or fever within a week of delivery) were associated with high risk
of stillbirths. VA coding identified pregnancy induced hypertension, antepartum hemorrhage
and obstructed labor as most important causes of stillbirths.
We report a lower than reported SBR for Pakistan and identify a spectrum of risk factors
and protective factors for still births. This reemphasizes need for good quality antenatal
and perinatal care to decrease burden of stillbirths.
P13 Structured daily observation of fetal movements is associated with fewer children
referred to neonatal care
Anna Akselsson1,2, Anders Linde1,2, Susanne Georgsson1,2, Helena Lindgren1, Karin
Pettersson1, Ingela Rådestad2
1Karolinska Institutet, Stockholm, Sweden; 2Sophiahemmet University, Stockholm, Sweden
Correspondence: Anna Akselsson
Low awareness of fetal movements is associated with negative pregnancy outcome and
the knowledge about pregnant women’s use of methods when they observe fetal movements
is limited. We aimed to investigate how women, seeking care due to decreased fetal
movements, pay attention to fetal movements in the third trimester. A specific aim
was to identify if the degree of awareness had any effects on pregnancy outcome.
In this prospective study a questionnaire was distributed to 2683 pregnant women who
contacted health care due to decreased fetal movements between January 1st and December
31st 2014, at all seven maternity clinics in Stockholm. The questionnaire was presented
to the women after a physical examination where no signs of a compromised fetus were
identified. The women were followed until birth and outcome data were collected from
an obstetric record registry.
Women who counted the fetal movements daily had a lower risk of their child being
referred to neonatal care (RR 0.25, 95% CI 0.03-0.94) and had a caesarian section
before onset of labor more often (RR 1.6, 95% CI 1.2-2.2) compared with women that
observed fetal movements in an unstructured way daily. Compared with women born in
Sweden, a counting method was used more commonly by women born in Asia (RR 4.0, 95%
CI 3.1-5.2), Africa (RR 4.0, 95% CI 2.7-5.8), Europe (RR 2.3, 95% CI 1.6-3.3), South
America (RR 3.1, 95% CI 1.7-5.5) and North America (RR 4.2, 95% CI 1.8-10.0). A counting
method was also used more often by women with lower education (RR 2.7, 95% CI 1.7-4.2).
Women who observed fetal movements daily by counting the movements had a lower risk
of having their child referred to a neonatal clinic than those using an unstructured
method.
The women gave consent to participate and permission to access supporting data when
receiving information about the study. The data will not be made available in order
to protect the participant’s identity. The study was approved by the Regional Ethical
Review Board in Stockholm: DNR: 2013/1077-31/3.
P14 Assisting health professionals in supporting fathers after stillbirth
Francine deMontigny1,2, Chantal Verdon2,3, Christine Gervais2,3
1Université Du Québec En Outaouais, Gatineau, Canada; 2Center of Research and Study
in Family Intervention, Gatineau, Canada; 3Université du Québec en Outaouais, St-Jérôme,
Canada
Correspondence: Francine deMontigny
In spite of health professionals’ good will, fathers’ grief after a stillbirth remains
invisible and is barely taken care of by the health services in Canada. Different
bereavement and socialisation theories have attempted to explain men’s bereavement
and their associated reactions, in order to help bridge the gap between bereaved fathers’
needs and the help and support offered. Meanwhile, research with health professionals
have underlined their lack of education in regards to the triple challenges of composing
with masculinity, fatherhood and bereavement. Our research team has been conducting,
over the past 15 years, a program of research, which, combined with our extensive
clinical experience, has enabled us to develop, implement, and evaluate a set of tools
(online video, books and workshops) to assist health professionals in supporting fathers
after stillbirth. The Father Bereavement Project (Movember grant 2014-2017) was implemented
in two regions of Quebec, Canada in 2015.
This presentation will describe the one day workshop, its implementation and the effects
on health professionals’ sense of efficacy towards fathers.
The implementation phase 1 reached 75 health professionals. The evaluation phase was
carried out through a pre-post self-report questionnaire, which was analyzed with
SPSS 20.
The workshop’s objectives, themes and strategies will be shared. Analysis revealed
that participating health professionals reported higher self-efficacy after the workshop.
Health professionals sense of self-efficacy working with bereaved fathers can be strengthened
through innovative workshops that integrate reflexive approaches and grief theories.
The discussion will explore implications for bereavement education, research and clinical
practices to enhance support for fathers after stillbirth.
P15 Parents’ experiences of medical care during second trimester miscarriage
Sarah Cullen1, Barbara Coughlan2, Brenda Casey1, Sheila Power3, Anne McMahon2, Mary
Brosnan1
1National Maternity Hospital, Dublin, Ireland; 2University College Dublin, Dublin,
Ireland; 3Psychoanalytic psychotherapist in Private Practice, Dublin, Ireland
Correspondence: Sarah Cullen
Second trimester miscarriage is defined as pregnancy loss between 12 and 24 weeks
gestation A recent study conducted in a large Dublin maternity hospital reported a
rate of second trimester miscarriage as 0.8%. The hospital admission has been identified
as a critical part of mothers’ experiences of miscarriage and can greatly influence
the mother’s recovery. The overall aim of the study was to explore parents’ experiences
of hospital care during a second trimester miscarriage. This presentation will report
on mothers’ and fathers’ views on the medical care received in the hospital from the
time of diagnosis of the second trimester miscarriage through to follow-up care.
A focused ethnographic design was used and a series of semi-structured interviews
were completed with 14 bereaved parents [9 mothers and 5 fathers]. Thematic network
data analysis was used to analyse the data. Ethical approval was granted by both the
Hospital and University Ethics Committees.
Under the first Global Theme of Clinical Care Needs both mothers and fathers highlighted
the need for effective medical care in relation to medical treatment, pain relief
and length of hospital stay. Parents highlighted the importance of adequate pain relief
throughout the labour and birth. Of particular importance to some parents was the
going home to prepare following the diagnosis of intra uterine death and the follow
up care which they received.
Second trimester miscarriage is a significant life event for parents. The parents’
encounter of medical care received has the potential to impact positively on their
experience. Recommendations for clinical practice centre on individualised pain assessment,
phlebotomy procedures, follow-up investigations and appointments.
P16 Perinatal hospice care; a different journey
Sarah Cullen, Heather Hughes, Barbara Cathcart, Brenda Casey
National Maternity Hospital, Holles street, Dublin, Ireland
Correspondence: Sarah Cullen
Pregnancy and child birth is generally a joyful experience for parents. However, when
a diagnosis of life limiting condition is made during pregnancy, parents embark on
a different journey. Parents need supportive, compassionate, individualised care from
experienced health professionals. With this in mind a care pathway for families whose
baby has been diagnosed with a life limiting condition has been developed. This care
pathway adopts a multi-disciplinary specialist approach to provide individualised
care to families.
The aims of care for families with diagnosis a life limiting condition is to provide
compassionate supportive care from a team of experienced health professionals. At
diagnosis parents are linked with a Prenatal diagnosis midwife, a Fetal medicine consultant
and the Bereavement midwives. Care is provided using a multi-disciplinary team approach.
The team consist of two Prenatal Diagnosis midwives, two Bereavement midwives and
Consultant Obstetricians specialising in Fetal Medicine. The team is supported by
other disciplines including Paediatricians, Social workers and Chaplains.
Parents are provided with individualised information regarding their baby’s condition
and prognosis. Families are supported in memory making both during the pregnancy and
the neonatal period. The Bereavement midwives are available to families for practical
and emotional support. Parents are offered a follow up appointment with their Consultant
and the Bereavement midwives following the delivery to allow for further discussions
and provide on-going support.
Parents whose baby has been given a diagnosis of a life limiting condition embark
on a very different journey to other parents. Families are empowered through this
pregnancy journey within a supportive sensitive environment. Audit of this service
is undertaken regularly using feedback from the parents and the team members. Parents
are provided with individualised multi-disciplinary care from a team of experienced
professionals and are guided through the journey from diagnosis to delivery and beyond.
P17 Association of maternal sleep patterns with risk of late stillbirth in high income
countries: a literature review
Ayesha Mir1,3,4, Matthew Hewitt1,2,4
1Bon Secours Hospital, College road Cork, Cork, Ireland; 2Cork University Hospital,
Cork, Ireland; 3Royal College of Physicians of Ireland, Dublin, Ireland; 4Royal College
of Obstetrician and Gynaecologists, London, UK
Correspondence: Ayesha Mir
Still birth is associated with profound adverse psychosocial outcome for families
and care providers. Global burden of stillbirth is very high with an estimated 2.6
million still births at 28 weeks or more occurring every year with the rate of >1/200
births in high income areas. Studies have examined risk factors for still birth but
they have been unable to explore a broad range of potential risk factors in particular
those relating to maternal life style and personal habits e.g obesity is highly linked
to sleep related disorders.Around 1/3 of a person’s life is spent asleep but there
has been little research on potential impact of sleep practices on developing foetus.
We searched the English literature from January 2006 till February 2017 for all articles
related to the title of review. Data sources were Embase, Medline, Cochrane Library,
PubMed, BMJ and WHO and UNICEF publications.
Studies have concluded that foetal heart rate variability is affected by maternal
position.These effects are most likely foetal adaptations to positions which may produce
a mild hypoxic foetal stress. Literature shows no association between risk of still
birth with snoring either before or during pregnancy. A high twofold rise in still
birth risk has been shown with non-left sided sleeping position on the last night
of pregnancy with sleeping on back shown the greatest risk.Moreover a significant
relationship has been found between sleeping regularly in daytime and late still birth
risk. Getting up for toilet infrequently (once or less) has also been found significantly
associated with late still birth risk.
Given the results observed in these studies, it may be required from all health care
providers to emphasize optimal sleeping practices especially in late pregnancy. Further
Studies with prospectively collected data are required to confirm or refute these
findings.
P18 Genetic disease in patients with fetal death
Monica Aguinaga1, Samuel Carmona1, Maria Cervantes1, Irma Monroy1, Rosalba Sevilla1,
Yolotzin Valdespino2, Elsa Moreno3, Rodrigo Zamora3, Arturo Cardona4
1Genetics and Genomics Department. Instituto Nacional De Perinatología, Mexico City,
Mexico; 2Pathology Department. Instituto Nacional de Perinatologia, Mexico City, Mexico;
3Medical Direction. Instituto Nacional de Perinatologia,, Mexico; 4General Direction.
Instituto Nacional de Perinatologia,, Mexico
Correspondence: Monica Aguinaga
Fetal death defined as the death occurring after 22 weeks of pregnancy can be caused
by maternal, fetal and placenta factors. Congenital defects are a common cause of
fetal deaths. They can be isolated or part of a genetic disease which can be chromosomal,
monogenic or polygenic. In 2012 it was reported that 7.3% of stillbirths in Mexico
were attributed to congenital disorders. The aim of this study was to evaluate all
patients with fetal death during two years in the National Institute of Perinatology,
Mexico City. We describe the congenital defects found in the patients.
Patients with fetal death born during 2015 and 2016 were evaluated by a medical geneticist
at birth. A complete prenatal and postnatal clinical evaluation, radiography and chromosomal
analysis were performed. Consent of parents was taken to perform karyotype and/or
MLPA (multiplex ligation probe amplification) and necropsy. Chromosomal and DNA analysis
was performed in a sample of umbilical cord.
During the study period a total of 473 stillbirths were born. Congenital defects were
observed in 142 (30%) patients which are shown in Table 3. The most common cause was
chromosomal anomalies (33%), followed by hydrops fetalis (10.5%) and renal anomalies
(9.8%). Karyotype was obtained in 60% of samples, we validated the MLPA technique
in umbilical cord and were able to obtain a result in 97% of cases.
Congenital defects cause 30% of fetal deaths in our Institute. The most common cause
is a chromosomal anomaly which has been successfully diagnosed by the MLPA technique.
A microarray will help to define if babies with multiple congenital defects present
pathogenic copy number variants. We need to perform more studies in patients with
hydrops fetalis and renal diseases in order to provide a better reproductive risk
for parents.
Ethical approval for the study was granted by the National Institute of Perinatology,
Mexico City Research Ethics Committee. Written informed consent was obtained by all
study participants
Table 3 (abstract P18).
Causes of congenital defects in stillbirth
GENETIC DISEASE
Number of patients
GENETIC DISEASE
Number of patients
Chromosomal
47
Cardiac
4
Caudal anomalies
11
Monogenic
10
Multiple anomalies
8
Diaphragmatic hernia
5
IUGR
4
Hydrops fetalis
15
Bone dysplasia
5
Amniotic bands
3
Hydrocephalus
1
Trombocitopenia
1
Renal
14
Disorder of Sexual Differentiation
1
Abdominal Wall defects
10
Holoprosencephaly
3
P19 The Ten Group Classification System used to assess maternal and perinatal morbidity
and mortality; a 10-year study in the Netherlands
Loes Monen1, Ida Smailbegovic1, Michael Robson3, Victor Pop2, Tom Hasaart1, Simone
Kuppens1
1Department of Obstetrics and Gynaecology Catharina Hospital, Eindhoven, the Netherlands;
2Department of Medical Health Psychology, Tilburg University, Tilburg, the Netherlands;
3National Maternity Hospital, Dublin, Ireland
Correspondence: Loes Monen
During recent years there has been an increase in inductions and Caesarean sections
(CS). It is important to analyze if this has led to improved maternal and/or neonatal
outcomes. In order to compare obstetric care, a valid and uniform classification system,
such as the ‘Ten Group Classification System’ (TGCS) should be used. The TGCS has
been implemented to analyze CS rates, but so far it has not been used to assess neonatal
and maternal outcomes. In the current study, we have analyzed inductions, CS and maternal
and neonatal outcomes.
In this retrospective cohort study, all pregnancies ≥24 weeks from 2000 to 2009, were
extracted from the Netherlands Perinatal Registry (PRN), a database consisting of
>95% all births in the Netherlands. For all births, neonatal and maternal outcomes
were collected. All pregnancies were classified according to the TGCS. Differences
were calculated using chi-square tests. For trend analyses the Cochran-Armitage test
was used.
Maternal mortality did not show significant changes. In groups 1 and 2 (nulliparous
women), maternal obstetric hemorrhage (>1000mL) has steadily increased over the years,
from 4.4% in 2000 to 6.8% in 2009 (p < 0.001), with a similar pattern as the rise
in CS rates. In all groups stillbirth rates decreased tremendously. In groups 3 and
4, postpartum hemorrhage increased from 3.1% to 4.8% (p < 0.001).
Maternal morbidity has increased over the years, while stillbirth rates have decreased.
As a CS might also influence maternal morbidity in a possible subsequent pregnancy
individualized care is very important. To analyze the effects of changes in obstetric
care, it is important to collect the best quality of data. To achieve this, a system
like the TGCS should be used. The TGCS can thus not only be used to analyze CS, but
also for analyzing perinatal and maternal outcomes.
P20 Unheard cries: the impact of infant loss on African American communities
Stacy Scott1,2
1Global Infant Safe Sleep Center, Columbus, OH, USA; 2Baby 1st Network, Cuyahoga Falls,
OH, USA
The racial disparities that exist in the United States, specifically, as it relates
to prenatal, perinatal and postnatal loss cannot be ignored. Historically, African
American babies die more than two to three times the rate of white babies in all categories.
It also known one in 160 pregnancies ends in stillbirth for which African-American
women are twice as likely to experience this type of loss. Although there is major
research addressing why these type of deaths occur. This presentation will address
the aftermath and impact these losses have on a segment of population who experience
inequites in birth outcomes across the board.
The researcher employed a qualitative research method utilizing a phenomenological
approach. Phenomenology is grounded in philosophy studying consciousness as experienced
by the participant.
Analysis of the data revealed four themes common to all parents.
Recognizing problems and responding to the loss,
Dealing with stressful life events,
Creating and cherishing memories of their infant, and
Living with the loss.
Factors that influence the impact on African American parents that experience infant
loss is only compounded by the lack of resources for families of color related to
grief and trauma support. The goal of this research is to frame a model for addressing
the gap in support services for communities who experience increased rates of infertility,
miscarriages, stillbirth and infant death.
P21 Spontaneous abortion, miscarriage and early pregnancy loss: a bibliometric analysis
Amanda Ross-White
Queen’s University, Kingston, Canada
Language is a powerful way of conveying meaning and use of specific terms can include
unintended consequences. This is particularly true in medicine, where the terminology
used by laypersons and professionals can differ widely, and can lead to confusion
and even patient safety errors. This paper analyzes terminology used for miscarriage,
early pregnancy loss and/or spontaneous abortion, revealing how its use has changed
over time, resulting in a change to the Medical Subject Headings for Spontaneous Abortion
beginning in January of 2018.
Using Web of Science, the author tracked publications that used the terms miscarriage,
spontaneous abortion or early pregnancy loss in the keywords, titles or abstracts
of scientific literature over time to determine if there has been a change in the
use of these terms and whether that change is geographically based.
By the late 1990s, the term miscarriage came to be the dominant term used in the scientific
literature, showing a marked increase compared to the other two terms. In separating
terms by subject heading and abstract/title use, the decline in the use of the term
spontaneous abortion to describe pregnancy loss in the first trimester was even more
precipitous.
Based on analysis of these terms in the literature, the National Library of Medicine
(US) which controls Medical Subject Headings, will be changing the entry term for
Spontaneous Abortion to Miscarriage for 2018.
P22 The Hummingbird Project: primary health care support for families pregnant after
stillbirth, an intersectoral collaboration
Lynn Farrales1,2,3,4, Lee Saxell5,6, Jaime Ascher3, Zoë Hodgson5,6, Lora Boshoff3,
Petra Selke6, Jessica Liauw6
1University of British Columbia, Vancouver, Canada; 2Fraser Health, Burnaby, Canada;
3Still Life Canada: Stillbirth and Neonatal Death Education, Research and Support,
Vancouver, Canada; 4International Stillbirth Alliance, Bristol, UK; 5South Community
Birth Program, Vancouver, Canada; 6BC Women’s Hospital, Vancouver, Canada
Correspondence: Lynn Farrales
For bereaved families, pregnancy after stillbirth is often wrought with intense fear
and anxiety with limited effective support and evidence to guide antenatal care. The
long-term psychological outcomes after stillbirth include depression, anxiety and
post-traumatic stress disorder. This study aims to: (1) describe the care and support
which bereaved parents identify as important in subsequent pregnancies, (2) implement
group care support for bereaved parents in their subsequent pregnancies within a primary
health care context, and (3) set the groundwork for expansion of this model of care
to satellite clinics.
Using principles of community-based participatory research, a research team composed
of bereaved parents, midwives, nurses, family doctors and obstetricians will conduct
a 3-year study. Year 1: Focus groups with bereaved families who have had subsequent
pregnancies to identify important components of care and support, and construction
of a curriculum for group psychosocial care. Year 2: Pilot test a curriculum for group
care and support in a primary health care setting. Assess group curriculum using mixed
qualitative and quantitative analyses. Year 3: Overall assessment and planning for
expansion to satellite clinics.
Through focus group discussions (Year 1) and pilot testing of group sessions (Year
2), we will identify key components of effective care and support.
Our goal is to identify and develop community and psychological interventions to be
integrated into clinical protocols, which enhance relevant care and support for families
who are pregnant after stillbirth. It is our hope that an intersectoral team with
a high index of patient involvement will help to frame a holistic approach to pregnancy
after stillbirth and create the groundwork for more research in this area.
Ethical approval for the study was granted by the Behavioural Ethics Research Board
of the University of British Columbia and Fraser Health Authority (Reference: H16-02671).
Written informed consent will obtained for all study participants.
P23 Cause of stillbirth in low- and middle-income countries: a multi-country study
Mamuda Aminu, Sarah Bar-Zeev, Sarah White, Nynke van den Broek
Liverpool School of Tropical Medicine, Liverpool, UK
Correspondence: Mamuda Aminu
OBJECTIVES: To assess cause of stillbirth in low- and middle-income countries (LMIC),
and test the performance of computer algorithms in identifying cause of death, and
to highlight vital priority areas for overall improvement in quality of care in LMIC.
DESIGN: Retrospective, observational study.
SETTINGS: 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe.
POPULATION: Cases of stillbirth in the selected health facilities.
METHODS: Healthcare providers (HCPs) were trained to conduct stillbirth reviews; they
assigned cause of death through consensus, and collected data on cases reviewed. An
expert panel reviewed the data and independently assigned cause of death. A set of
computer algorithms were then used to assign cause of death for each case. Results
of the three methods of cause of death assessment were analysed and compared.
MAIN OUTCOME MEASURE: Cause of stillbirth.
RESULTS: A total of 1,563 stillbirths were recorded; 1,329 (85.0%) were reviewed and
1,267 (95.3%) met the inclusion criteria. The hospital stillbirth rates for Malawi,
Zimbabwe, Kenya and Sierra Leone were: 20.3, 34.7, 38.8 and 118.1 per 1,000 births,
respectively. The major causes of stillbirth were: asphyxia (18.5% – 37.4%), placental
disorders (8.4% – 15.1%), hypertensive disorders (5.1% – 13.6%), infections (4.3%
– 9.0%), cord problems (3.3% – 6.5%), ruptured uterus (2.6% – 6.1%) and unknown (17.9%
– 26.0%). The algorithms generally agreed with the expert panel (k-value = 0.34; p < 0.0005).
CONCLUSIONS: Majority of stillbirths in LMIC could be prevented with better care for
all mothers and babies. HCPs should be encouraged to conduct reviews and act upon
the findings to improve quality of care. Computer algorithms could complement human
reviews and provide acceptable results in a research context. More research is needed
to refine algorithms for facility- and community-based audits.
Our study was approved by the following ethics committees. Ethics Committee, Liverpool
School of Tropical Medicine: Reference number 14.026; dated 22nd October 2014, 6th
January 2015, 15th January 2015 and 19th March 2015. Kenyatta National Hospital/University
of Nairobi Ethics & Research Committee; Reference number KNH-ERC/A/398; dated 23rd
December, 2014. College of Medicine Research & Ethics Committee (COMREC) Malawi: Reference
number P.07/14/1601; dated 15th December, 2014. Sierra Leone Ethics and Scientific
Review Committee: Dated 9th October 2014 and 31st August 2015. Medical Research Council
of Zimbabwe: Reference number MRCZ/A/1895; dated 9th March, 2015.
P24 Postmortem after late stillbirth: influences on maternal decision-making in a
New Zealand study
Robin Cronin1, Jane Zuccollo2, Minglan Li1, Vicki Culling3, John Michael David Thompson4,
Edwin Mitchell4, Lesley Margaret Elizabeth McCowan1
1Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand;
2Department of Obstetrics and Gynaecology, University of Otago, Wellington, New Zealand;
3Vicki Culling Associates, Wellington, New Zealand; 4Department of Paediatrics: Child
Health and Youth Health, University of Auckland, Auckland, New Zealand
Correspondence: Robin Cronin
Postmortem examination after late stillbirth is the gold standard investigation and
knowing the cause of a stillbirth is important to parents. We aimed to identify factors
influencing maternal decision-making about postmortem examination after late stillbirth
through analysis of the New Zealand Multicentre Stillbirth Study data.
A total of 169 women with singleton pregnancy and non-anomalous late stillbirth (≥28
weeks’ gestation) from seven New Zealand health regions were interviewed within six
weeks of stillbirth. We investigated decision-making about postmortem by asking participants
if they would make the same decision to accept or decline a postmortem again.
All women were offered a postmortem examination. The majority (99, 58.6%) chose a
full postmortem examination, 47 (27.8%) had a placental examination only, 16 (9.5%)
had no investigations and 7 women (4.1%) chose a limited examination, babygram or
MRI. Declining a full postmortem was associated with Maori or Pacific ethnicity (p = <0.001),
parity ≥2 (p = <0.001), being unmarried (p = 0.029) and not having tertiary education
(p = 0.048). The most common (47/70, 67.1%) reason for declining was that they ‘did
not want the baby to be cut’. No women who consented to a full postmortem (0/99) regretted
their decision but (2/99) were unsure about their choice. Ten percent (7/70) who declined
a full postmortem said they would not make this decision again.
The finding that no participants in the New Zealand Multicentre Stillbirth Study regretted
consenting to a full postmortem examination when interviewed in the postpartum period,
but 10% regretted their decision to decline, may assist parents facing this difficult
choice in the future.
Ethical approval for the study was granted by the Northern “X” Regional Ethics Committee
(Reference; NTX/06/05/054). Written informed consent was obtained by all study participants.
P25 “I’m afraid of upsetting them further”: student midwives educational needs in
relation to bereavement in the maternity setting
Jean Doherty1, Sarah Cullen1, Brenda Casey1, Anne McMahon2, Mary Brosnan1, Lucille
Sheehy1, Barbara Lloyd2, Theresa Barry1, Barbara Coughlan2
1National Maternity Hospital, Dublin, Ireland; 2University College Dublin, Dublin,
Ireland
Correspondence: Jean Doherty
Caring for bereaved parents, in the maternity setting, can be challenging for all
healthcare professionals. Midwifery students are often vulnerable in their transition
to becoming qualified. Being ‘sheltered’ from these situations by staff midwives and
managers is quite common, exacerbating the problem. The beginning of the undergraduate
midwifery program concentrates on physiological birth, with little benefit given to
bereavement care in the maternity setting. It is not until the students reach their
final year, that theoretical classes on grief and bereavement are given to the students.
It has been questioned if this is too late, as some students end up in situations
where they are left to look after bereaved parents with little or no training.
A mixed methods approach was used to evaluate the impact on students, participating
on a newly developed, inter-active, bereavement care workshop. Preliminary data from
a group of BSc Midwifery interns (n = 18), commencing the workshop, is presented.
89% of the students stated that lack of, or limited, exposure to bereaved parents
was the main inhibitor to their confidence in supporting them. Of the respondents
who answered about exposure, 6% had been in more than three situations involving bereavement,
whereas 25% had not yet had any exposure. When asked what they find most difficult
about caring for bereaved parents, being unsure of what to say was dominant in their
responses. Other issues mentioned were the practicalities of bereavement; being afraid
of upsetting parents further and how to deal with the silence in the room.
Although bereavement education is life long process, some initial findings from this
study affirm the need for a more interactive approach in education and training for
student midwives.
Ethical approval for this study was granted by the ethical committee of the National
Maternity Hospital and University College Dublin. Written informed consent was obtained
from all participants.
P26 Bereavement care education and training in clinical practice: a workshop supporting
the development of confidence and competence in midwifery students
Jean Doherty1, Brenda Casey1, Sarah Cullen 1, Anne McMahon2, Mary Brosnan1, Lucille
Sheehy1, Barbara Lloyd2, Theresa Barry1, Barbara Coughlan2
1National Maternity Hospital, Dublin, Ireland; 2University College Dublin, Dublin,
Ireland
Correspondence: Jean Doherty
Shock, isolation, sadness, self blame and anxiety are the emotions which feature predominantly
with midwives who look after families suffering bereavement through stillbirth, neonatal
death and miscarriage. With 82% of healthcare professionals reporting having received
no bereavement training, midwives often feel ill-equipped to cope with this aspect
of their jobs. These feelings are even more prominent with student midwives, who lack
the confidence needed to communicate properly with grieving parents. With this in
mind, an interactive workshop was compiled to fill the competence and confidence gap
in the area of bereavement education.
A review of the literature outlined the gap in bereavement education, and guided the
specific topics to be covered, and the most effective educational tools to be included.
Key staff members, with extensive clinical and academic experience, devised an interactive
workshop. An expert panel, which included midwives, senior midwifery management, and
a member of the chaplaincy team, participated in a focus group to gain their insight
into the proposed content of the workshop.
The full day workshop included practical advice for students about communication –
good and bad; making memories; where students can find information requested by parents;
and parents’ perspectives on the impact of bereavement and how staff can help or hinder
their grieving process. The workshop also included interactive role-play, which has
been proven to be advantageous over didactic approaches. The final part of the workshop
concentrated on the importance of self-care and included a mindfulness hour. Self-care
has been advocated to increase personal coping.
The workshop is being evaluated, with the intention that it can be integrated into
the curriculum going forward.
Ethical approval for this study was granted by the ethical committee of the National
Maternity Hospital and University College Dublin. Written informed consent was obtained
from all participants.
P27 Improving birth outcomes: a prospective audit of the detection and management
of small for gestational age (SGA) fetuses
Claire Dougan1, Alyson Hunter1, Stan Craig1, Dale Spence2, Emma Mc Call2, Emily Bailie1,
Sunneva Gilmore1, Naomi Harvey1, Nazish Kanwal1
1Royal Jubilee Maternity Hospital, Belfast Health and Social Care Trust (BH&SCT),
Belfast, N. Ireland; 2Queen’s University, Belfast, N. Ireland
Correspondence: Claire Dougan
Stillbirth rates in the UK are one of the highest in the developed world. Using ReCoDe
classification, 43% of stillbirths can be attributed to intrauterine growth restriction(IUGR).
Small for gestational age(SGA); <10th centile on a customized growth chart, is synonymous
with IUGR. Risk of stillbirth is reduced when IUGR is detected antenatally compared
to undetected. Royal College of Obstetricians and Gynaecologists(RCOG) 2013 guidance
stratifies antenatal care in those at risk of SGA.
Objectives:
Determine whether women identified ‘at risk of SGA’ receive appropriate antenatal
care according to RCOG guidance
Compare detection rates of SGA in women who received appropriate vs. inappropriate
antenatal care according to RCOG guidance;
Compare intrapartum management and perinatal outcomes where SGA was detected vs. undetected
antenatally.
We prospectively collected anonymised data for 494 consecutive singleton deliveries
in BH&SCT (8.6% of annual singleton births). Clinical risk for SGA, birth weight,
antenatal and intrapartum management and birth outcome data were analyzed using “IBM
- Statistical analysis software package - SPSS Statistics.”
In total, 33% (165/494) of women were categorized at risk of SGA in accordance with
RCOG guidance (minor 42, major 123). Overall, 56% (91/163, 2NA) were managed appropriately
antenatally, with 65% (79 of 121, 2 NA) and 29% (12/42) in major and minor risk groups
respectively (see Table 4). Across all categories (including ‘low risk) 11% (56/493,
1 missing) of babies were SGA at birth with a 55% (30/55, 1 missing) antenatal detection
rate. SGA babies detected antenatally were on average delivered 13 days earlier than
their undiagnosed counterparts. A higher proportion were delivered by caesarean section
(50% vs 32%),
Our data suggests detection of SGA results in earlier delivery and changes the mode
of delivery. Further research is required to ascertain whether antenatal detection
of SGA impacts intrapartum management and perinatal outcomes.
Table 4 (abstract P27).
See text for description
Care received
<10th centile at birth
SGA detected antenatally
stillbirth
Apgar <7 @5mins
Neonatal unit admission
Low riskN = 329
25/328(8%)
Yes 10 (42%)
0
0
2
No: 14 (58%)
0
1
2
x1 missing data
X1 missing data
Minor riskN = 42
Inappropriate30/42 (71%)
2/30(7%)
Yes: 2/2 (100%)
0
0
0
No: 0
N/A
N/A
N/A
Appropriate 12/42 (29%)
2/12(16%)
Yes: 0
N/A
N/A
N/A
No: 2/2 (100%)
0
1
0
Major riskN = 123
Inappropriate42/121 (35%)
6/42 (14%)
Yes: 4 (67%)
0
0
1
No: 2 (33%)
1
0
0
2-late bookers
x1 missing data
Appropriate 79/121 (65%)2- late bookers
21/79 (27%)
Yes: 14/21 (67%)
0
0
1
No 7/21 (33%)
0
0
1
P28 Translating lessons learnt from perinatal deaths into policies, programs and practice:
perinatal death audits in Sri Lanka
Kapila Jayaratne
Family Health Bureau, Colombo 10, Sri Lanka
With the reduction of infant mortality rate to a single digit (8.2 per 1000 live births)
and a larger proportion (60%) of such deaths being early neonatal deaths (END), perinatal
deaths (PND) emerge as a priority area in Sri Lanka -a low and middle income country
in South Asia. We aimed to analyze national PND data for action.
National Perinatal Mortality Surveillance system was implemented in 2006. All specialized
hospitals (with an obstetrician/paediatrician) are required to document all PNDs,
review them monthly at a hospital stakeholder meeting and send a report to Ministry
of Health. Structured data collection formats, monthly reporting formats and guidelines
are available.
In 2014, data were received from all hospitals (government and private sector) with
labour rooms from a total of 452 hospitals (74 Specialized government hospitals, 357
Non-specialized peripheral hospitals and 21 Private hospitals). Considering total
live births reported by Civil Registration System (349715), coverage of live births
in this study was 99.6% (n = 348362).
The analysis included 1386 (46%) stillbirths and 1623 (54%) ENDs (Total 3009 PNDs).
Stillbirth and early neonatal mortality rates were 4.0 per 1000 total births and 4.7
per 1000 live births respectively. The perinatal mortality rate was 8.6 per 1000 total
births. Majority of PNDs (52.1%) were male. One third (35.7%) of PNDs occurred in
primies. Birth weight < 1000g was reported in 20% of all PNDs. Nearly 10% of ENDs
had a period of gestation.
Outcomes were translated into action at hospital, district and national levels; prevention
strategies on premature deliveries, expansion of premature baby units, strategies
on birth defects prevention, early neuro-developmental care, neonatal retrieval systems
and introducing therapeutic body cooling.
Sri Lanka being a low and middle income country implements an organized PND audit
system to translate the outcome for meaningful interventions.
P29 The importance of clear inter-professional communication following stillbirth
in the hospital environment
Vivienne Manley
Belfast Health & Social Care Trust, Belfast, N. Ireland
Clear visual, verbal and written communication are vital to assist the various professionals
working in the care of parents following stillbirth so that the most appropriate and
sensitive care is given.
This is a verbatim case-review of a chaplaincy encounter following stillbirth where
a chaplain did not receive adequate information. This verbatim highlights three aspects
of communication and how it can be enhanced.
Verbal communication
Professionals who are not permanent ward staff may not receive adequate information
and thereby patient care may be affected. Extra care must be taken to communicate
verbally.
Visual communication
A visual sign was not used in this instance to alert the professional to a death having
occurred on the ward. This would have been very beneficial to all.
Written communication
Written information could have been offered to the parents at the time of still birth
and so enhance the spiritual and pastoral value of the pastoral visit.
A newly written booklet for parents following stillbirth, and other distressing times,
entitled “When hopes seem dashed” has been produced, and is available in the Royal
Jubilee Maternity hospital of the Belfast Trust. This will enable the availability
of spiritual care via a hospital chaplain to be offered and the pastoral encounter
enhanced.
This study highlights the importance of clear, verbal, visual and written communication
between healthcare professionals around the time of stillbirth in the hospital environment.
Appropriate communication could have enabled the chaplain to be better prepared and
additional written information could have enhanced the spiritual and pastoral care
of the parents. The study also emphasises that reflection on a verbatim case review
is a valuable tool in the learning process.
P30 Placental changes in diabetic stillbirths
Daniel Shingleton1, Alexander Heazell1,2, Gauri Batra1
1Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK; 2Manchester
University, Manchester, UK
Correspondence: Daniel Shingleton
Stillbirth has numerous associated risk factors and placental pathologies. However,
the predictive value of these factors is low as they are also seen in live births.
One such factor is maternal diabetes which is associated with a 4-fold increased risk
of stillbirth. This study aimed to elucidate the spectrum of placental pathology associated
with diabetes, and whether this is more profound in diabetic pregnancies which end
in stillbirth.
Histological techniques were carried out on slides cut from representative blocks
of placental parenchyma from different clinical conditions; normal live births, diabetic
live births, unexplained stillbirths and diabetic stillbirths. Photomicrographs were
taken and examined to assess placental vascularity (CD31), proliferative index (Ki67),
syncytial nuclear aggregates (H&E). cytokeratin area/nuclear area (CK7) and avascular
villi (CD31). Histopathological data were extracted from clinical reports.
Stillbirths had an increased CK7 area compared to normal live born cases with unexplained
stillbirths being significantly raised compared to live births (p = 0.005) and diabetic
stillbirths significantly raised compared to diabetic live births (p = 0.0008). Proliferative
index was significantly lowered in cases of unexplained stillbirth compared to normal
live born cases (p = 0.04). There was no difference in placental vascularisation in
diabetes. Additionally, 80% of unexplained stillbirth placenta were classified as
normal and 90% of diabetic stillbirth placenta presented with maturation disturbance
based on histopathological examination.
Diabetic stillbirths have similar phenotype to that of live born controls, however,
the increased CK7 area of diabetic stillbirths when compared to diabetic live births
points towards the role of increased distance between fetal capillary walls and the
trophoblast basement membrane playing a crucial role in outcome when pregnancy approaches
term. Data gathered from unexplained stillbirths indicates an unknown mechanism for
stillbirth or a non-placental cause in these cases that cannot be determined by routine
histopathological examination alone.
Ethical approval for the research was sought for and granted by the proportional review
sub-committee of the West Midlands – South Birmingham Research ethics committee (16/WM/0372)
on the 16th August 2016. The patients whose tissue samples were used in this study
had previously given consent for their use in research during either the consent for
a post mortem examination of a stillborn child or during the biobank consent process
for liveborn cases.
P31 Analysis of missing data for stillbirths in a retrospective register review in
six facilities across in Tanzania, Bangladesh and Nepal
Kyohei Takano, Hannah Blencowe
London School of Hygiene and Tropical Medicine, London, UK
Correspondence: Kyohei Takano
An estimated 2.6 million stillbirths occur annually and half of all stillbirths are
estimated to occur during the intrapartum period. Although effective prevention needs
a global strategy based on knowledge of risk factors for intrapartum stillbirths,
the quality of data on intrapartum stillbirths, which have not been routinely collated
in many low-income countries, tends to be poor with some data missing. The ability
of study to accurately conduct analysis is dependent upon the degree of missingness
of data and how the missingness of data is addressed. An overall aim of this project
is to explore missingness of data in routine labour ward registers regarding stillbirths.
A retrospective register review of data collected on birth outcomes over a 1-year
period was undertaken for women delivering in six health facilities across 3 countries.
Descriptive analysis of the available data will be undertaken, including the prevalence
of adverse birth outcomes and the levels and types of missingness of data. The impact
of missing data on estimates of prevalence of stillbirth and the proportion intrapartum
and antepartum will be assessed, using multiple imputations where appropriate. Data
analysis is currently underway.
Labour ward registers are an important source of routinely collected data for facility
births, missingness of data, and lack of collation of relevant stillbirths currently
impede their use for tracking stillbirth outcomes. Improved end-user input in design
and ownership of labour ward registers may improve the quality and use of data locally.
Ethical approval for the study was granted by the MSc Research Ethics Committee of
London School of Hygiene and Tropical Medicine (Reference; 13581).
P32 Getting a better picture: a prospective audit on the accuracy in ultrasound-detection
in patients managed as small for gestational age
Sunneva Gilmore, Claire Dougan
Belfast Health and Social Care Trust, Belfast, Northern Ireland
Correspondence: Sunneva Gilmore
Placental insufficiency and intrauterine growth restriction are leading causes of
stillbirth. To identify the pathologically small fetus for gestational age (SGA),
an ultrasound estimated fetal weight (EFW) is referenced against a customised individual
growth chart. This audit examined the accuracy of ultrasound-detected SGA compared
with actual birth-weight (ABW) and birth-centile, in fetuses managed by delivery in
a maternity unit.
A prospective audit was conducted for patients with singleton intrauterine pregnancies,
who were induced or scheduled an elective caesarean section (ELCS) for the primary
indication of SGA, in a maternity tertiary unit from 1st-30th September 2016. Data
was collected within a teaching-hospital employing regular trainee competency assessments
in ultrasonography.
In total, 6% (30/494) of deliveries underwent induction/ELCS for suspected SGA, defined
as EFW below the tenth-centile on the customary growth chart. Despite this, three
fetuses were on the tenth-centile. The gestational age was equal or greater than 37weeks
in 90.3% (range 26weeks + 4day—40weeks + 3 days). The scan to delivery interval averaged
at 5.3 days.
The birth-centile derived from the ABW detected 56.6% (17/30) with SGA appropriately.
43.4% were managed for SGA, but were not SGA based on birth-centile. Among these (13/30),
46% had an ultrasound difference of >10%, compared with 11.7% in those with birth-centile
SGA. Emergency caesarean-section was similar in both groups (38% v 41%). In this audit,
those with a higher ultrasound margin of error, were more likely to be above the tenth-birth-centile
(Table 5).
This study reveals a discrepancy between estimated and birth-centile in a significant
proportion of patients. However, in most cases the ABW is within a 10% ultrasound-margin
of error. This is similar to other studies. A larger study would better inform on
the accuracy of ultrasound-detection rates, establish an acceptable margin of error
to improve standards, and inform rates of inappropriate medicalization in misdiagnosed
SGA.
Ethical approval for the project was not required for audit purposes, however data
was collected within an ethical framework.
Table 5 (abstract P32).
Accuracy of ultrasound estimation in patients managed as small for gestational age
Proportion of error within (%)
+/- 10%
+/- 15%
+/- 20%
All Patients (30)
73.3 (22)
86.7 (26)
93.3 (28)
Gestational Age <37weeks
66.6 (2)
100 (3)
100 (3)
Gestational age >37weeks
74.1 (20)
92.5 (25)
92.5 (25)
Mean percentage difference when Birth Weight <10th
5.5%
Birth weight >10th
11.1%
P33 Giving sleep position advice in pregnancy: will we make women anxious?
Jane Warland, Georgie Beaufoy, Jill Dorrian
Unisa, Adelaide, Australia
Correspondence: Jane Warland
Over the past decade there has been emerging evidence that suggests that maternal
sleep position may be associated with stillbiirth. It has been postulated that approximately
one quarter, to one third of stillbirths might be prevented by simply asking women
to change their sleep position. However, there are concerns that giving women information
about sleep position and stillbirth risk may make them anxious. This study aimed to
determine underlying messages being conveyed to pregnant women especially with respect
to sleeping position during pregnancy in order to understand any anxiety associated
with giving this message.
An online survey of 537 Australian women (107 of whom were “currently pregnant”).
The survey examined participant’s views regarding sleep position messages, type of
information source, and pre-existing knowledge. Participant characteristics such as
general anxiety and the ‘Fetal Health Locus of Control’ Scale were also collected.
The results showed that of the participants who were currently pregnant 65% (n = 66)
settled to sleep on their left side, whereas only 23% (n = 23) said they settled in
this position when not pregnant. When asked on a 5 point Likert scale how anxious
they may have been about sleep position in their current pregnancy 85% held a “neutral”
to “not at all anxious” view. Data analysis is still underway examining the correlation
between state trait anxiety, fetal locus of control and any anxiety about the sleep
position message in the pregnant group and these results will be presented at the
conference.
This study indicates that many pregnant women were already changing their sleeping
position in pregnancy. A small subset of pregnant women may feel anxiety associated
with the sleep position in pregnancy message and therefore some care needs to be taken
to inform women about the importance of sleep position without unduly provoking anxiety.
Ethical approval for the study was granted by The Human Research Ethics Committee
of the University of South Australia (Reference; 0033096). Written informed consent
was obtained by all study participants.
P34 Withdrawn
P35 Perinatal mortality MDT meetings: attendance in a tertiary university maternity
hospital
Rama Akachuku, Keelin O’donoghue
Cork University Maternity Hospital, Wilton Cork, Ireland
Correspondence: Rama Akachuku
Perinatal deaths should be reviewed at perinatal mortality meetings. The perinatal
mortality multidisciplinary team (PM-MDT) meeting is a vital forum for communication
between clinicians as it ensures understanding of individual cases and facilitates
appropriate follow-up. These meetings are also a valuable forum for learning for the
wider disciplinary team. The aim of this project was to review the attendance of healthcare
staff from a single maternity unit at PM-MDT meetings.
Our perinatal pathology service was established with the appointment of a perinatal
pathologist in 2012. All hospital staff are notified about clinical/academic meetings,
including PM-MDT meetings. We examined attendance records for the PM-MDT meetings
from 2013 to 2016, and compared this with numbers of staff employed in the various
disciplines.
There were 31 PM-MDT meetings held from 2013 to 2016 (median,8; range 6-9 per year).
Those who attended included consultant obstetricians and neonatologists, doctors-in-training,
midwife-specialists in bereavement/loss, clinical-midwife-managers in pregnancy loss
and quality/patient safety, medical students and healthcare chaplains. Numbers of
staff at the MDT meetings ranged from an average of 14 per meeting in 2013 to 13 in
2016 (range;7-17). Only 7 consultant obstetricians (7/16;44%) ever attended the meeting,
although 3 consultants only attended on one occasion. Among neonatology consultants,
one attended each meeting, although only for discussion of neonatal deaths. No representatives
from senior midwifery management (including the Director of Midwifery) or administration
(including the Hospital Manager) ever attended the meetings, and there were no staff
attendees from the labour ward, ultrasound or out-patients department.
Perinatal deaths should be reviewed formally at PM- MDT meetings in maternity units.
All healthcare staff have a responsibility to attend. We need to examine the reasons
why attendance at PM-MDT meetings in our unit is poor, particularly among senior clinicians,
labour-ward midwives, midwifery educators, and management.
P36 Factors associated with stillbirth autopsy rates in Georgia and Utah, 2010-2014:
the importance of delivery location
Katie Forsberg, Lauren Christiansen-Lindquist
Emory University Rollins School of Public Health, Atlanta, USA
Correspondence: Katie Forsberg; Lauren Christiansen-Lindquist
As the gold standard for determining the cause(s) of stillbirth, autopsies can help
the grieving process, inform the management of current and future maternal care, and
foster new interventions. However, stillbirth autopsies are underused in the United
States, and little is known about what factors are associated with their receipt.
This study aimed to determine whether demographic, operational, and medical factors
are associated with the performance of stillbirth autopsies in Georgia and Utah.
Using Georgia and Utah fetal death certificates from 2010-2014, we evaluated the relationship
between demographic, operational, and medical factors and stillbirth autopsy performance.
Analysis was conducted using logistic regression with a predicted margins approach.
Each state was analyzed separately.
The stillbirth autopsy rate was low (11.9% in Georgia (N = 5,610) and 23.9% in Utah
(N = 1,425)). In Utah, the autopsy rate significantly decreased during the study period
(p = 0.01). Stillbirths delivered outside of large metropolitan areas were less likely
to receive an autopsy (medium/small metropolitans: prevalence ratio_GA [PR] = 0.57,
95% confidence interval [CI]: 0.48, 0.68 and PR_UT = 0.48, CI: 0.38, 0.59; nonmetropolitans:
PR_GA = 0.57, CI: 0.43, 0.75 and PR_UT = 0.37, CI: 0.21, 0.63). In Georgia, autopsies
were less common among stillbirths of Hispanic (vs. white) women women (PR = 0.57,
CI: 0.41, 0.79), of earlier than later gestational ages (PR = 0.59, CI: 0.51, 0.69)
and of multiple birth pregnancies (PR = 0.71, CI: 0.53, 0.96).
Despite strong evidence supporting the value of stillbirth autopsies, autopsy rates
were low in Georgia and Utah. Approximately half of the stillbirths were delivered
outside of large metropolitan areas, and this population may be particularly underserved.
Additional research is needed to determine whether autopsies were not performed because
they were not offered or because parental consent was not given.
This research was approved by the Institutional Review Boards of Emory University
and Georgia Department of Public Health. Utah Department of Health did not require
formal Institutional Review Board approval, but reviewed our study and executed a
data sharing agreement, which was submitted to the Emory University Institutional
Review Board
P37 Developing and characterising animal models of stillbirth
Samantha Lean1, Rebecca Jones1, Mark Dilworth1, Esther Aiyelaagbe1,2, Kathryn Hentges2,
Alexander Heazell1
1Division of Developmental Biology and Medicine, University Of Mancheter, Manchester,
UK; 2Division of Evolution & Genomic Sciences, University of Manchester, Manchester,
UK
Correspondence: Samantha Lean
Investigating stillbirth in human pregnancies using laboratory approaches is challenging.
Tissues are usually obtained several days after fetal death and analyses are largely
limited to retrospective histopathological studies. Alternatively, pregnancies at
high risk of stillbirth are studied it is difficult to know which infants would have
been stillborn without intervention. There is a critical need for alternative approaches
to study stillbirth. Animal models have been valuable to study and develop therapeutic
strategies in other pregnancy complications. We have aimed to develop murine models
of in utero fetal death to advance the understanding and prevention of stillbirth.
We have developed and characterised two mouse models of stillbirth. The first is a
model of placental-related, late gestation stillbirth that involved ageing virgin
female mice to 38 weeks (equivalent to ~40 years in humans) before pregnancy (controls
are 8-12 weeks old). 56% of the resulting pups are growth restricted and 14% die in
late pregnancy; the pups that die are significantly smaller than those that survive.
Growth restriction and stillbirth in this model is associated with placental dysfunction.
The second model involves a mutation in the gene ErbB2 which causes sudden mid-gestation
stillbirth in the absence of placental causes. We identified cardiac dysfunction in
these fetuses, which parallels with sudden infant death syndrome, and altered expression
of key target cardiac ion channel genes that may be responsible for in fetal demise
secondary to cardiac pathology. These studies offer target genes to investigate in
currently unexplained stillbirths.
These models provide new platforms in which to investigate stillbirths due to: a)
placental dysfunction, thereby representing >40% of stillbirths in human pregnancies,
or b) genetic cardiac pathologies. Furthermore, with these models we will be able
to test risk stratification and therapeutic interventions. Ultimately, these studies
will form the foundation for future human studies.
Table 6 (abstract P37).
See text for description
2014
2015
2016
FETAL MORTALITY RATE(x 1000)
5.9
6.1
22.1
BIRTHS (N)
663
648
619
INTRA UTERINE FETAL DEATHS (N)
4
4
14
MATERNAL AGE (YEARS)
29
23
25.8
GESTACIONAL AGE (WEEKS)
34.2
35
31.3
WEIGHT (GRAMS)
1980
2536.2
1686.4
PREVIOUS ABORTIONS (N)
1
0
2
PREVIOUS PREGNANCIES (N)
1.5
1.5
2.5
VAGINAL DELIVERY (N)
1
1
6
CESAREAN SECTION (N)
3
3
8
CONGENITAL ANOMALIES (N)
1
0
3
MATERNAL PATHOLOGIES (N)
1
1
7
All animal husbandry and experimental practices were carried out in accordance with
the UK Animals (Scientific Procedures) Act 1986 under Home Office Licence 40/3385
and 70/8504. The Local Ethical Review Process of the University of Manchester approved
all protocols
P38 Frequency of intra-uterine fetal deaths in Zonal hospital of Puerto Madryn (Argentina)
during the period 2014-2016
Maria Soledad Silva, Damián Leonardo Taire
Zonal Hospital “Dr. Andrés R. Isola”, Puerto Madryn, Argentina
Correspondence: Maria Soledad Silva
The Zonal Hospital “Dr. Andrés R. Isola”, serves an estimated population of 100.000
habitants. About 700 births occur in the hospital each year. The objective of this
presentation is to determine the frequency of Intra Uterine Fetal Deaths (IUFD) in
hospital births during the years 2014, 2015 and 2016.
Retrospective, longitudinal, observational and descriptive design. The documentation
consulted is compiled in the Births-Book, and in the Monthly Obstetric Summary. The
data analyzed in both documents are: gestational age, birth weight in grams, condition
at birth, end of pregnancy, previous pregnancies, sex, congenital anomalies and maternal
pathologies. In this series, the IUFD refers to all losses of 22 or more weeks of
gestation.
The occurrence of 22 IUFD was observed from January 2014 to December 2016, out of
a total of 1930 live births. The Fetal Mortality Rate was 5.9 (2014), 6.1 (2015) and
22.1 (2016) (see Table 7).The mean gestational age was 32.5 weeks. The average weight
was 1894 grams. The mean maternal age was 25.9 years, multigravidae (2.1 previous
pregnancies), way of ending pregnancy was cesarean section 63.6% and vaginal delivery
36.3%.
With respect to the sex of IUFD: female sex 40.9%, male sex 50% and undetermined 9%.
Congenital anomalies (CA) were observed in 4 dead fetuses (18.1%). They correspond
to Potter sequence, trisomy 18 phenotype, unclassified CA.
The maternal pathologies associated were: cholestasis 4.5%, placental detachment normoincerta
13.6%, pregnancy-induced hypertension 13.6%, chorioamnionitis 4.5%, gestational diabetes
4.5% and syphilis 9%.
The frequency of IUFD in our series demonstrates an increase in cases during the year
2016 with the same number of births. It is inferred the need for early detection of
maternal risk factors, to avoid IUFD. The collection of data is essential to facilitate
the monitoring of the content and quality of care during pregnancy and childbirth.
Ethical approval for the study was granted by the Bioethics Committee Hospital Zonal
de Trelew
Table 7 (abstract P38).
See text for description
2014
2015
2016
FETAL MORTALITY RATE(x 1000)
5.9
6.1
22.1
BIRTHS (N)
663
648
619
INTRA UTERINE FETAL DEATHS (N)
4
4
14
MATERNAL AGE (YEARS)
29
23
25.8
GESTACIONAL AGE (WEEKS)
34.2
35
31.3
WEIGHT (GRAMS)
1980
2536.2
1686.4
PREVIOUS ABORTIONS (N)
1
0
2
PREVIOUS PREGNANCIES (N)
1.5
1.5
2.5
VAGINAL DELIVERY (N)
1
1
6
CESAREAN SECTION (N)
3
3
8
CONGENITAL ANOMALIES (N)
1
0
3
MATERNAL PATHOLOGIES (N)
1
1
7
P39 Registry of post-neonatal home deaths in Chubut (Argentina) during the period
2011-2015
Damian Leonardo Taire, María Soledad Silva
Zonal Hospital “Dr.. Andrés R. Isola”, Puerto Madryn, Argentina
Correspondence: Damian Leonardo Taire
In post-neonatal mortality, occurring from 28 days to the year of life, environmental
and socioeconomic conditions have a greater impact. The estimated population (2017)
of the province of Chubut is 587.956 habitants. Chubut (6.9) is the second district
of the country with the lowest infant mortality per 1000 live births (2015). About
9.887 newborns are born in the province every year. The objective of this presentation
is to describe the incidence of Post-Neonatal Deaths (PD) in Chubut and the percentage
of these deaths produced at home during the years 2011, 2012, 2013, 2014 and 2015.
Retrospective, longitudinal, observational and descriptive design. The documentation
consulted is compiled by the National Direction of Statistics and Information in Health
of the Ministry of Health of the Nation. This publication called Vital Statistics
contains basic statistical information on deaths for the country as a whole and by
jurisdiction.
In Chubut, in 2011, 2012, 2013, 2014 and 2015 there were 26, 27, 32, 24 and 18 PD,
respectively. The 23.0% (2011), 25.9% (2012), 25% (2013), 33.3% (2014) and 22.2% (2015)
deaths occurred at home (Fig. 3).
In the last 5 years, there has been a stable number of PD with an average of 25.4
deaths per year, with a decrease from 2015. It has been observed in the study period
that the only year where there is no data from the PD on the place of occurrence is
in 2011 (1 death without data). Based on these data, it could be inferred that a better
preparation of the Statistical Reports of Death has resulted in an improvement in
the registry of household mortality in Chubut.
Ethical approval for the study was granted by the Bioethics Committee Hospital Zonal
de Trelew
Fig. 3 (abstract P39).
See text for description
P40 Raised fasting plasma glucose and diagnosis of gestational diabetes in relation
to risk of late stillbirth
Tomasina Stacey1, Peter Tennant1, Miglan Li2, Edwin Mitchell3, Lesley McCowan2, John
Thompson3, Jayne Budd4, Bill Martin5, Devender Roberts6, Alexander Heazell4,7
1School of Healthcare, University Of Leeds, Leeds, UK; 2Department of Obstetrics and
Gynaecology, University of Auckland, Auckland, New Zealand; 3Department of Pediatrics,
University of Auckland, Auckland, New Zealand; 4St. Mary’s Hospital, Central Manchester
University Hospitals NHS Foundation Trust, Manchester, UK; 5Birmingham Women’s Hospital
NHS Foundation Trust, Birmingham, UK; 6Liverpool Women’s Hospital NHS Foundation Trust,
Liverpool, UK; 7Maternal and Fetal Health Research Centre, University of Manchester,
Manchester, UK
Correspondence: Tomasina Stacey; Peter Tennant
The UK has one of the highest rates of stillbirth in Europe. To address this, one
recommendation from MBRRACE-UK was increased focus on detection and management of
gestational diabetes (GDM). The 2015 NICE guidelines recommended GDM be diagnosed
by either fasting plasma glucose (FPG) ≥5.6mmol/L or 2-hour oral glucose tolerance
test (OGTT) ≥7.8mmol/L. Use of FPG however remains sporadic. This study examined the
joint effects of FPG levels and formal diagnosis of GDM by OGTT on stillbirth risk.
The Midlands and North of England Stillbirth Study (MiNESS) is a case-control study
of non-anomalous singleton pregnancies between April 2014 and March 2016 within 41
maternity units in England. 291 women who recently experienced a late stillbirth (≥28
weeks’ gestation) and 733 controls (matched on NHS Trust and gestation) were recruited.
Data were collected on various demographic, health, and lifestyle factors. 355 women
were screened for GDM (89 cases and 266 controls) and had information on their FPG
and OGTT results.
35 of the 355 (9.9%) women with complete screening information were diagnosed with
GDM. Women with a raised FPG (≥5.6mmol/L) and a GDM diagnosis experienced similar
odds of late stillbirth (OR = 1.52, 95% CI = 0.49-4.73) to women with a normal FPG
and no GDM diagnosis. Women with raised FPG but no GDM diagnosis (and hence did not
receive specialist care) however experienced 5.32 (95% CI = 1.44-19.72) times greater
odds. This was unaffected by adjusting for ethnicity, BMI, age, and education.
A raised FPG is associated with an increased risk of late stillbirth that is largely
ameliorated by a formal diagnosis with GDM, reflecting the benefits of receiving current
pathways of care for GDM. Women with a raised FPG but who are not diagnosed with GDM
(e.g. due to a normal 2-hour OGTT result) have a substantially increased risk of stillbirth.
Ethical approval for the study was granted by Greater Manchester Central Research
Ethics Committee (Reference 13/NW/0874). Written informed consent was obtained by
all study participants.
P41 Patterns of fetal movement and the association with late stillbirth
Alexander Heazell2,3, Minglan Li1, Jayne Budd3, Robin Cronin1, Billie Bradford1, Lesley
M. E. McCowan1, Edwin A. Mitchell4, Tomasina Stacey5, Bill Martin6, Devander Roberts7,
John M. D. Thompson1,4
1Department of Obstetrics and Gynaecology, University Of Auckland, Auckland, New Zealand;
2Maternal and Fetal Health Research Centre, School of Medical Sciences, Faculty of
Biological, Medical and Human Sciences, University of Manchester, Manchester, UK;
3St. Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust,
Manchester Academic Health Science Centre, Manchester, Manchester, UK; 4Department
of Paediatrics: Child Health and Youth Health, University of Auckland, Auckland, New
Zealand; 5School of Healthcare, University of Leeds, Leeds, UK; 6Birmingham Women’s
Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK; 7Liverpool Women’s Hospital
NHS Foundation Trust, Liverpool, UK
Correspondence: Alexander Heazell; John M. D. Thompson
Reduced frequency and intensity of fetal movements in late gestation has been associated
with stillbirth. In the Midlands and North of England Stillbirth Study (MINESS) we
investigated changes in fetal movements and their association with late (> = 28 weeks)
stillbirth.
The MINESS case-control study was carried out over two years from April 2014 to March
2016. It recruited and interviewed 291 cases (mothers with late stillbirths) and 733
control mothers (pregnant women with ongoing pregnancies), frequency matched for maternity
unit and gestation. Using a structured questionnaire data were collected about fetal
movements, in particular relating to the strength and frequency during the last two
weeks. Information was also collected about hiccups.
Control women most commonly reported an increase in the strength of movements in the
last 2 weeks (62%), few reported a decrease (7%). For frequency staying the same was
the most common response (54%) followed by an increase (25%) with few reporting decreases
(9%). Cases were less likely to report increases in strength or frequency (18% and
13% respectively) and more likely to report decreases (21% and 30% respectively).
In multivariable analyses, compared with those who reported no change in strength
or frequency of movements in the last two weeks, those with increased strength were
at a decreased risk of having a late stillbirth OR = 0.18 95%CI = (0.13,0.26). Those
with decreased frequency (with no increase in strength) of fetal movements were at
an increased risk OR = 3.45 95%CI = (2.20,5.43). Women who felt hiccups on a daily
basis were also at reduced risk OR = 0.31 95%CI = (0.17, 0.56).
An increase in the strength of fetal movements is the norm in late pregnancy and clinical
guidelines should be updated to reflect this. Patterns of fetal movements are important
in predicting stillbirth, and strength is as important as frequency.
Ethical approval for the study was granted by Greater Manchester Central Research
Ethics Committee (Reference 13/NW/0874). Written informed consent was obtained by
all study participants.
P42 Perinatal mortality audit of last 5 years at Bolton NHS Foundation Trust
Priti Wuppalapati, Joanna Smith, Neeraja Singh
Bolton NHS Foundation Trust, Bolton, UK
Correspondence: Priti Wuppalapati
Yearly audit of perinatal mortality since 2008-2009 but easily comparable data since
2011
All stillbirths and early neonatal death (NND) in 2014 identified databases. Information
gathered from casenotes, Euroking, Badger, perinatal meeting minutes and stillbirth
proformas. Compiled on excel spreadsheet and analysed.
Crude stillbirth rate 4.4/1000 in 2015 which has improved from previous year and lower
than UK adjusted average for similar Trust. Main causes of death was Intrauterine
Growth Restriction (IUGR) +/- placental insufficiency (1/3 of cases)
IUGR contributed to cause of death in 2/3 of cases. More than 1/3 of cases were missed
IUGR. However, ongoing reducing trend of missed IUGR cases compared to previous years.
1 case of grade 3 care and 8 cases of grade 2 care – 1/3 of cases of suboptimal care.
About 1 in 4 stillbirths not reported as clinical incident. About 9 in 10 women did
not complete all investigations recommended in Stillbirth Pathway
Almost 8 in 10 women who required thrombophilia screen did not have this fully completed.
Contraception often not discussed at postnatal review.
Recommendations: continue Growth Assessment Protocol (GAP) training and case reviews
of missed Small for Gestational Age(SGA) to improve detection of Fetal Growth Restriction
(FGR).
Medical review when stillbirth diagnosed to outline investigations to be carried out
in management plan + review investigations ordered before discharge.
Thrombophilia results to be reviewed at postnatal review or arranged/repeated if necessary
Increased awareness to follow recommendations in Stillbirth Pathway and ensure Pathway
completed – both doctors and midwifery colleagues (including in postnatal review -
to include discussion of contraception)
P43 How accurate is assessment of foetal weight in obese women?
Natasha Mitchell, Nabila Kalar, Kavita Verma
Scarborough District Hospital, Scarborough, UK
Correspondence: Natasha Mitchell
Obesity is increasingly common in the obstetric population and increases the risk
of adverse pregnancy outcomes. This includes an increased risk of SGA by 50%, and
significantly stillbirth, with estimated odds ratio of 1.43 . Obesity makes palpation
of symphysis fundal height more difficult. Recent studies suggest however is does
not affect the accuracy of ultrasound derived estimated foetal weight (EFW) but this
is not routinely done in many units for all women with a BMI above 30. This study
looked at the accuracy of both symphysis fundal height and ultrasound derived EFW
with actual weight at delivery in a district general hospital.
38 women were prospectively identified with a singleton pregnancy and a BMI of more
than 30. Symphysis fundal height was plotted on customised growth charts in addition
to EFW on ultrasound. These were compared to neonatal weight at delivery. Data was
analysed using ANOVA to compute F and p-values with a Tukey post hoc test to verify
differences.
There was a non-significant difference between estimated foetal weight for serial
ultrasound scan and actual foetal weight at birth. The difference between actual foetal
weight and estimated foetal weight by symphysis fundal height was statistically different
with p = 0.0001. As expected, EFW by fundal height was higher with an average difference
of 788 grams.
This study found that estimated foetal weight on ultrasound in our unit was accurate
at predicting estimated foetal weight in high BMI mothers. However Symphisis fundal
height measurements were inaccurate often over estimating foetal growth. This may
mean if pregnancies are monitored using solely fundal height measurements SGA foetuses
may be missed especially those suffering from early IUGR as there may be no previous
measurements to compare velocity.
P44 Use of an integrated care pathway to improve care for women who present with intrauterine
fetal death and experience stillbirth
John Tomlinson1,3, Alexander Heazell1,2, Karen Bancroft1,3, Elizabeth Martindale1,4
1Greater Manchester and East Cheshire Special Interest Group into Stillbirth, Manchester,
UK; 2Maternal and Fetal Health Research Centre, University of Manchester, UK; 3Bolton
NHS Foundation Trust, Bolton, UK; 4East Lancashire Hospitals NHS Trust, Burnley, UK
Correspondence: John Tomlinson
In 2014 a Multidisciplinary Special Interest Group in Greater Manchester, Lancashire
and South Cumbria was convened with a remit to improve care for women who present
with intra-uterine fetal death and experience stillbirth. A clinical guideline was
synthesised from available evidence and national clinical guidance. To aid implementation
an integrated care pathway was also introduced to facilitate delivering optimal care.
The first version of these documents was released in December 2014 and updated in
February 2016; this was then used in the 13 hospitals in the geographical area.
An audit of care was undertaken prior to implementation with two further audit data
collections, the first was performed 1 year after introduction of the documents. The
second audit was performed a year after the guideline was updated. Data were collected
using a standardised proforma.
A total of 87 cases were included in this audit, which included 29 cases from the
baseline, 27 in the first year 1 and 31 at the second time point (Table 8). This audit
demonstrated that use of the integrated care pathway improved the care of women who
present with intra-uterine fetal death and stillbirth. There was an increase in the
number of women being given a patient information leaflet. A greater proportion of
women had a recommended method of induction of labour (e.g. dose and timing of misoprostol)
and more likely to receive appropriate opiate analgesia when in labour. Staff gave
favourable feedback about using the integrated care pathway, with many suggesting
that it aided care.
Use of this integrated care pathway improves care for women who present with fetal
death in utero and experience stillbirth. Ongoing development is required to ensure
that improvements to care and feedback from staff suing the tools are incorporated.
Table 8 (abstract P44).
See text for description
2014
Post implementationAudit 1
Post implementationAudit 2
Number
29
27
31
Presentation
Antenatal
23
17
23
Termination for fetal abnormality
1
4
2
Intrapartum
3
5
6
Unclassifiable
1
1
Urgent Management Required
4/2914%
11/2741%
7/3124%
Patient Information Leaflet Given - if urgent management not needed
17%
37%
65%
Expectant management offered - if urgent management not needed
24%
27%
32%
If induction of labour performed - National Guidance followed
0%
73%
70%
Analgesia in labour – ratio of use of diamorphine compared to pethidine
67%
75%
84%
P45 Whose fault is it? Maternal guilt and blame 15 months after perinatal death
Katherine Gold1, Ananda Sen3, Irving Leon3
1Department of Family Medicine, Department of Obstetrics & Gynecology, University
of Michigan, Ann Arbor, MI, USA; 2Department of Family Medicine, Department of Biostatistics,
University of Michigan, Ann Arbor, MI, USA; 3Department of Obstetrics & Gynecology,
University of Michigan, Ann Arbor, MI, USA
Correspondence: Katherine Gold
Parents who experience stillbirth or infant death often struggle with postpartum guilt.
This may be an adaptive response or can become chronic and maladaptive.
We conducted a longitudinal, three-wave mail survey over two years of bereaved mothers
in Michigan (United States) who experienced perinatal death. At 15 months after loss,
survey domains included questions on demographics, depression, guilt, and blame. We
also analyzed whether data available at 9 months predicted guilt at 15 months. Self-report
information was linked with data from an earlier survey and with State of Michigan
birth and death certificates.
311 (42%) mothers responded. Most reported persistent guilt or self-blame. In multivariable
analysis, higher education level (OR 2.55), depression (OR: 7.60), and presence of
a maternal medical risk factor (OR 4.17) predicted greater guilt. Nearly half of women
blamed their medical team for the loss, about a fifth reported feeling blamed by others.
Both of these attributions were significantly associated with greater guilt in multivariable
regression. Thirteen percent of women stated someone had told them to their face that
the death was their fault. No other socioeconomic factors besides education were significant
predictors.
The majority of mothers report persistent guilt after perinatal loss. Depression at
either 9 or 15 months, higher education, and maternal medical risk factors were the
strongest predictors of guilt. Attribution of blame served no protective function
for mothers. While many women do not spontaneously reveal their thoughts of guilt,
the high correlation between guilt and depression suggest that early screening for
depression may be one option to identify women who may also be struggling with guilt
or self-blame for their loss.
P46 When there are no words: loss, meaning making and the arts
Louise Foott1,2
1CIT Crawford College of Art & Design, Cork, Ireland; 2University College Cork, Cork,
Ireland
Stillbirth is recognized as a traumatic loss, but there remains considerable silence
around it. Current research into ‘grief work’ challenges the stages model of grieving,
advocating for an approach that supports the grieving to create meaning within their
experience of loss. At a time when words feel inadequate, the arts can enable meaning
making through a range of different approaches.
Drawing on her own experience following the still birth of her youngest child, Laura,
this auto ethnographic presentation will explore the role of a range of arts approaches
within one family’s grieving process. Laura died as the author was conducting research
into the role of the arts within reflective learning. Several years later this author
now aims to look at her family’s own journey with grief through the lens of her research
interests, exploring the important support provided by the arts within the family’s
search for meaning. The author discussed her auto ethnographic research with her now
teenage family and they gave their informed consent to be included.
Key aspects of this family’s experience of grieving the still birth of Laura will
be documented through a multi-media presentation. Creative writing, poetry, image-making
and music will give voice to the silence around particular characteristics of the
trauma of stillbirth – relational connection to a child never met, meaning making
when nothing makes sense and the importance of acknowledging the senses in grieving
and memory making. (Fig. 4) As they journeyed with their loss, the arts supported
this family to incorporate “Laura missing” in their lives.
Much of the current discourse on death and bereavement advocates for an approach that
enables the grieving to ‘craft’ meaningful experiences as they navigate their way
through loss. When the weight of grief exposed the limits of words, the arts offered
this family other languages to connect and make sense of their loss.
Fig. 4 (abstract P46).
See text for description
P47 Understanding the associations and significance of fetal movements in overweight
or obese pregnant women: a systematic review
Billie F. Bradford1, John M. D. Thompson1,2, Alexander E. P. Heazell3,4, Lesley M.
E. McCowan1, Chris J. D. McKinlay2,5
1Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences,
University Of Auckland, Auckland, New Zealand; 2Department of Paediatrics: Child and
Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland,
New Zealand; 3Maternal and Fetal Health Research Centre, School of Medical Siences,
Faculty of Biological, Medical and Human Sciences, University of Manchester, Manchester,
UK; 4St. Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust,
Manchester Academic Health Science Centre, Manchester, UK; 5Liggins Institute, University
of Auckland, Auckland, New Zealand
Correspondence: Billie F. Bradford, Alexander E. P. Heazell
Presentation with decreased fetal movement (DFM) is associated with fetal growth restriction
(FGR) and stillbirth. DFM may be more frequent amongst overweight or obese mothers.
Perception of fetal movements is widely believed to be impaired in heavier mothers
due to increased abdominal fat, but this association has not been systematically assessed.
Objectives
To determine the significance and associations of fetal movements in women of increased
body size.
This systematic review was conducted in accordance with the PRISMA statement and the
protocol was registered (PROSPERO CRD42016046352). Major databases were searched from
inception to November 2016, using a pre-defined search strategy. Studies of any design
that compared fetal movements in women of increased and normal body size were included.
Two authors independently extracted data and assessed quality.
22 publications from 18 observational studies were included and data were extracted
from 10 studies. Increased maternal body size was not associated with altered perception
of fetal movement (4 studies, 95 women, very low quality evidence), but was associated
with increased presentation for DFM (2 cohort studies, 20,588 women, OR 1.56, 95%
CI 1.27-1.92: 3 case-control studies, 3,445 women, OR 1.32, 95% CI 1.12-1.54; low
quality evidence).
Amongst women with DFM, increased maternal body size was associated with increased
risk of stillbirth and FGR (1 study, 2,168 women, very low quality evidence).
This systematic review identified limited evidence that women with increased body
size are more likely to present with DFM but do not have altered perception of fetal
movements. In women with DFM, increased body size is associated with worse pregnancy
outcome, including stillbirth. Concerns about DFM in larger women may have greater
clinical significance and should not be downgraded due to assumptions about impaired
perception of fetal movements, though further confirmatory studies are warranted.
P48 Perinatal mortality: mourning three - four years after the loss and the need for
counseling
Janine Van Veen - Doornenbal, Judith Derks, E. van Leeuwen, I. M. de Graaf
Academic Medical Centre, Amsterdam, The Netherlands
Correspondence: Janine Van Veen - Doornenbal
Grief gradually decreases in time after perinatal death. Not much is known about long
term grieving after perinatal death. We studied the magnitude of grief after 3-4 years.
We randomly selected cases of perinatal death between 2013-2014 in the Academic Medical
Centre (Amsterdam). Women and partners were included if pregnancy was longer than
22 weeks and death occurred within 28 days after birth. We included 44 mothers with
30 partners (all male), 53% filled out the questionnaires. They separately completed
the Perinatal Grief Scale (PGS-33), the Dutch Grief Scale and the Hospital Anxiety
and Depression Scale (HADS). A selection of patients and their partners underwent
a structured interview to evaluate the psychological counselling that was given at
that time.
The results show, first, that part of the population experiences high levels of perinatal
grief after 3-4 years. 11 of 39 subjects scored high (>7) on HADS-anxiety and 5 of
39 persons scored high (>7) on HADS-depression and both grief scales. Second, fathers
had a significant positive relation between the period the baby lived and their PGS-score,
while this relation is not significant for mothers. As a result, couples with stillbirth
differ in the amount of grief. This difference disappears when the baby lives longer.
Last, from the structured interviews we learned that a standard protocol for aftercare
is of great importance, and that the guidance should be adjusted to the needs of the
parents.
After 3-4 years, perinatal grief is still present. Those with high scores on anxiety
and depression show symptoms of traumatic grief. We propose that filling out the PGS-33
and HADS should be included in standard protocols after perinatal death to identify
patients at risk. The participants expressed that psychological aid after perinatal
mortality is important and should be incorporated into standard care.
P49 The experience of Australian midwives caring for women with undiagnosed vasa praevia
during labour: a qualitative study
Nasrin Z. Javid1, Jon A. Hyett2, Caroline SE. Homer1
1Centre for Midwifery, Child and Family Health, University Of Technology Sydney, Sydney,
Australia; 2Royal Prince Alfred Women and Babies, University of Sydney, Sydney, Australia
Correspondence: Nasrin Z. Javid
Vasa praevia is a rare pregnancy complication that can cause stillbirth and early
neonatal death if it is not diagnosed antenatally. Caring for women with undiagnosed
vasa praevia during labour and birth is challenging and often traumatic. There is
no qualitative research that examines the experiences of midwives. The aim of this
study was to explore the experience of Australian midwives caring for women with vasa
praevia during labour.
A qualitative descriptive study was undertaken with Australian midwives who had cared
for at least one woman with vasa praevia during 2010-2016. Recruitment was mainly
achieved through Australian College of Midwives and snowball sampling recruited additional
midwives. Semi-structured in-depth interviews were conducted over the phone, digitally
recorded and transcribed. Interviews lasted 40-140 minutes. Data were analysed using
thematic analysis.
Twenty midwives were interviewed from public and private hospitals across Australia;
13 of these were involved in the care of the women with undiagnosed vasa praevia who
experienced a neonatal death (n = 6) or near miss (n = 7). The over-arching theme
was ‘A devastating and dreadful experience’ and included two themes of feeling the
personal impact and addressing professional processes. The personal impact included
‘feeling scared’, ‘feeling shocked’, ‘feeling guilty’, and these ‘took their toll’.
The professional processes included ‘working in organised chaos’, ‘challenges with
intrapartum diagnosis’, ‘feeling for the parents’, ‘feeling communication was hard’,
and ‘doing our best as we did not know’.
Our findings demonstrate the emotional impact experienced by midwives caring for women
with vasa praevia. Caring for women who have undiagnosed vasa praevia during labour
poses unique challenges for the midwives both at personal and professional level,
as they witness a healthy baby rapidly becoming sick and potentially dying.
Ethical approval for the study was granted by the Human Research Ethics Committee
of University of Technology Sydney on 9 March 2016 (HREC ETH15-0137). Written informed
consent was obtained by all study participants.
P50 A proposed method for increasing the diagnostic yield of placental tissue and
identification and measurement of placental chronic villitis
Louise Sutton1, Lisa Hogan1, Patrycja Abrmczuk1, Des Butler1, Sarah Clancy1, John
Gray1, Peter Kelehan1
Bon Secours Hospital Limerick at Barringtons, Georges Quay, Limerick, Ireland
Correspondence: Louise Sutton; Peter Kelehan
Chronic Villitis of unknown aetiology is an inflammatory disease of the placenta,
which is focal and local in its distribution. Identification is dependent on sampling,
and mild disease is recognized and quantified, depending on the number of tissue blocks
taken. Examination of four sections of placental parenchyma should identify more disease
than two.
We set out to show, in our prospective study, sampling two blocks of placental parenchyma,
whether taking a further two blocks increased yield and changed grade. We further
suggest a novel method that may also be used to increase yield in a retrospective
study and a method that more accurately measures extent of disease.
When initial diagnosis of chronic villitis was made on H/E sections of two tissue
blocks, two further random blocks were sampled from the placenta prior to disposal
and extra sections were taken for Immunohistochemistry and special stains. The four
blocks were then taken back to molten paraffin wax, flipped 180 degrees, recut and
extra sections taken. This yielded eight levels of tissue from each placenta for the
study. Slides were scanned using an Ion Film 2 SD Pro 9 Slide Scanner. Images were
printed onto A4 sheets, the total area of villous parenchyma and immunohistochemically
stained area were measured (cm2), subtracted, and a percentage calculated.
Twenty-one singleton and eleven twin placentas with chronic villitis were examined
in a nine-month prospective study period. Direct comparison of the histological appearance
and pattern of the two faces of each tissue block confirmed the structural heterogeneity
of the placenta and also showed variation of density of inflammation best appreciated
by immunohistology (Fig. 5). Statistical analysis showed no significant difference.
Staining for CD45 and CD 3 produced the best results.
Chronic villitis is a potentially recurrent placental disease with poor outcome. This
methodology can increase yield and accurate grading.
Ethical approval for the study was granted by Barringtons Hospital Ethics committee
and the University of Ulster, Colraine.
Fig. 5 (abstract P50).
Chronic villitis of placenta
P51 “Better safe than sorry”- Reasons for consulting care due to decreased fetal movements
Anders Linde1,2, Ingela Rådestad2, Karin Pettersson1, Linn Hagelberg2, Susanne Georgsson1,2
1Karolinska Institutet, Stockholm, Sweden; 2Sophiahemmet University, Stockholm, Sweden
Correspondence: Anders Linde
Experience of reduced fetal movements is a common reason for consulting health care
in late pregnancy. There is an association between reduced fetal movements and stillbirth.
We aimed to explore why women decide to consult health care due to reduced fetal movements
at a specific point in time and investigate reasons for delaying a consultation.
A questionnaire was distributed at all birth clinics in Stockholm during 2014, to
women seeking care due to reduced fetal movements. In total, 3555 questionnaires were
collected, 960 were included in this study. The open-ended question; “Why, specifically,
do you come to the clinic today?” was analysed using content analysis as well as the
complementary question “Are there any reasons why you did not come to the clinic earlier?”
Five categories were revealed: Reaching dead line 348 (43%), Receiving advice from
health care professionals 280 (35%), Undergoing unmanageable worry 196 (24%), Contributing
external factors 123 (15%) and Not wanting to jeopardize the health of the baby 18
(2%). Many women stated that they decided to consult care when some time with reduced
fetal movements had passed. The most common reason for not consulting care earlier
was that it was a new experience. Some women stated that they did not want to feel
that they were annoying, or be perceived as excessively worried. Not wanting to burden
health care unnecessarily was a reason for prehospital delay.
Worry about the baby is the crucial reason for consulting care as well as the time
which has passed since the women first experienced decreased fetal movements.
Ethical approval for the study was granted by Stockholm Research Ethics Committee
of Sweden (Reference; Dnr 2013/1077-31/3). Written informed consent was obtained by
all study participants.
P52 A pilot study exploring stillbirth stigma experiences in Australia and adapting
and validating a stigma scale
Danielle Pollock, Jane Warland, Tahereh Ziaian, Elissa Pearson, Megan Cooper
University Of South Australia, Adelaide, Australia
Correspondence: Danielle Pollock
The silence surrounding stillbirth has led to the wide belief that there is a stigma
associated with stillbirth. Research in other fields where stigma is known to be prevalent
such as HIV/Aids, suggests that stigmatisation often leads to a reduction in help-
seeking behaviours, increased isolation and limited social support. Each of the consequences
of stigma are also seen in stillbirth literature. Despite this, research regarding
stigma stillbirth is limited, and therefore often assumed. This assumption is demonstrated
by the WHO, and 2011 and 2016 Lancet series, all calling for action to reduce stigma
in stillbirth. However, the extent, type and experiences of stillbirth stigma have
not yet been established or explored.
A stillbirth stigma scale is being created as part of a larger mixed methods study.
When developing the scale a survey was included asking parents of stillborn babies
to describe their experiences during pregnancy, labour, and afterwards. The survey
was completed by n = 98 Australian bereaved parents with a further n = 36 who conducted
test-retest for scale validation.
Survey results suggest that antenatal education on stillbirth and fetal movements
was poor, with less than 12% of bereaved parents saying they were given enough information
to detect possible signs of stillbirth. Furthermore, qualitative analysis showed that
after care was minimal, with many bereaved parents stating that they sought psychological
help themselves. However, there were also positive stories of supportive hospital
care and memory creation practices. Further data analysis has yet to be conducted,
but will be presented at the conference.
While some improvements in care provision around the time of stillbirth have been
made, further antenatal education needs to occur. It is particularly important for
maternity care providers to give information to all women regarding stillbirth during
pregnancy especially the importance of awareness of fetal movements.
Ethical approval for the study was granted by UniSA HREC Research Ethics Committee
of 0000036071. Consent was obtained by all study participants before the completion
of the online survey.
P53 Umbilical cord thrombosis: association with stillbirth and opportunities for stillbirth
prevention
Jessica Liauw, Julie Robertson, Christof Senger, Jennifer Hutcheon
University of British Columbia, Vancouver, Canada
Correspondence: Jessica Liauw
Umbilical cord thrombosis has been associated with growth restriction, fetal distress,
and perinatal death. However, these associations are largely based on pathology case
reports and high-risk cohorts, which are vulnerable to selection bias. We aimed to
determine the associations between umbilical cord thrombosis and adverse perinatal
outcomes among all deliveries in one large center. Since prenatal diagnosis of umbilical
cord thrombosis has been reported, we also aimed to describe opportunities for stillbirth
prevention.
Our study population included all non-anomalous births ≥20 weeks’ gestation at the
Royal Victoria Hospital in Montreal, Canada (2001-2009). All placentas underwent routine
pathological examination. Umbilical cord thrombosis was correlated with obstetric,
neonatal, and pathology characteristics. We calculated odds ratios for the effect
of cord thrombosis on stillbirth, small for gestational age birthweight (SGA), and
neonatal death, adjusting for gestational age and maternal comorbidities. We determined
the proportion of stillbirths that had umbilical cord thrombosis and did not have
antenatal doppler studies, which were used as a surrogate for antenatal monitoring.
Among 27,940 deliveries, the incidence of umbilical cord thrombosis was 1 per 1000
(95%CI 0.6 to 1.4 per 1000). These were present in 41% of stillbirths, 11% of neonatal
deaths, and 11% of those with SGA. Umbilical cord thrombosis was significantly associated
with stillbirth (adjusted OR 166.4, 95%CI 62.3 to 444.4), and there was a trend towards
increased odds of neonatal death (adjusted OR 5.2, 95% CI 1.0 to 28.6). Umbilical
cord thrombosis was not associated with SGA (adjusted OR of 1.0, 95% CI 0.3 to 3.5).
Among stillbirths with no antenatal doppler studies, 16% had an umbilical cord thrombosis.
Umbilical cord thrombosis is strongly associated with stillbirth, controlling for
selection bias and possible confounders. It may be possible to prevent a proportion
of stillbirths via antenatal identification of umbilical cord thrombosis.
Ethical approval for the study was granted by the University of British Columbia/Children’s
and Women’s Health Centre of British Columbia Research Ethics Board (Reference; CW14-0341/H14-02809).
P54 How hard is it to grow a rainbow? The emotional and mental health complications
during a pregnancy after loss
Suzanne Maguire
Sands NI, Portadown, Northern Ireland
This research will highlight the serious impact the death of a baby has on a woman’s
mental and emotional health in a subsequent pregnancy. It emphasises a woman and her
partner’s increased risk of experiencing mental health problems and the possible difficulties
with their ability to bond with the baby. It asks how antenatal care can better support
people through this experience.
Research has been undertaken through the mediums of online forums and online surveys
as this reaches a wider audience and is more accessible. Published literature is also
utilised.
The death of a baby significantly affects a mother’s mental and emotional wellbeing
in a subsequent pregnancy. The results highlighted that a woman’s experience of pregnancy
and her ability to believe in the viability of the pregnancy, even when it is not
complicated, is hindered. The mother, and indeed her wider social network, may not
bond with the baby as a type of protection should loss happen again.
When a woman losses a baby either through stillbirth, neonatal death, or miscarriage,
her ability to view the world as safe and straightforward diminishes. Pregnancy, an
act which is supposedly one of the most natural things she can do, becomes an area
of heightened anxiety, depression, emotional turmoil, and unease. A subsequent pregnancy
was not an enjoyable experience for almost all women within this study. The poor mental
health of the mother may be alleviated somewhat through the care received from medical
staff. However, most mothers were offered no extra appointments or emotional support
throughout the subsequent pregnancy. Care and support needs to be available so the
mother can bond with her unborn child, therefore, paving the way for a stable and
loving relationship once the baby is born.
P55 Awareness of reduced foetal movements: a one-way street?
Suzanne Maguire
Sands NI, Enniskillen, Northern Ireland
This research focuses on the phenomenon of reduced foetal movements and asks whether
both sides - the mother and the medical professionals - view the episode with equal
significance. Recent campaigns aimed at mothers monitoring their babies movements
have been successful for raising awareness. However, has this raised awareness infiltrated
the medical profession?
Online forums and surveys have been used to establish how mothers felt their concerns
about reduced foetal movements were viewed. Published literature has also been utilised.
When a woman presents with reduced foetal movements, she is still sometimes met with
resistance. In a crowded maternity ward, and with pressures on staffing numbers, some
mothers have felt that they were wasting time with their concerns. A significant number
of women in this study were discharged without their concerns being alleviated and
some felt that they were not treated kindly. A few went on to experience the death
of their baby.
Research has shown that a change to a baby’s movements is one of three risk factors
to indicate an impending stillbirth or neonatal death. Successful campaigns have led
to women being aware of counting the kicks, watching for movement patterns, and the
importance of ringing a health professional if they are worried about their baby’s
movements. However, some women are still being told that a reduction in movements
is ‘normal’ and once a heartbeat has been detected they are sent home and told ‘not
to worry’. This is a false misconception, leads to confusion, and places unborn babies,
and sometimes their mothers, in serious harm. This paper argues that medical professionals
must place more importance on reduced foetal movements. However, with resources already
stretched, it questions how this can be done.
P56 Fetal movement awareness: reducing stillbirth in Scotland
Cheryl Clark, Bernie McCulloch, Angela Cunningham, Clare Willocks
Healthcare Improvement Scotland, Edinburgh, Scotland
Correspondence: Bernie McCulloch
In Scotland, 274 babies were stillborn in 2012 (a rate of 4.7 per 1000 births; see
Fig. 6). In 2013, Healthcare Improvement Scotland launched the Maternity and Children
Quality Improvement Collaborative (MCQIC), as part of the Scottish Patient Safety
Programme. A key aim of MCQIC is to reduce the Scottish rate of stillbirth by 35%
by 2019. The cause of stillbirth is complex but it is recognised that the need to
monitor fetal movement throughout pregnancy is an important health message for women.
Best practice suggests fetal movement should be discussed between 18–24 weeks gestation,
but baseline data for 12 sites between March to August 2014 showed this was not consistently
achieved.
Local test teams in every health board in Scotland were given tools to support measurement.
These included a clear operational definition of fetal movement discussion and a sampling
strategy and tools to display data in time sequence. Using the Model for Improvement,
maternity teams tested ideas on a small scale and collected data to confirm if the
changes resulted in an improvement. Change ideas included patient information leaflets
and pocket cards.
National aggregated data from 10 of 17 boards which have reported consistently from
March 2014 to December 2016 show discussion of fetal movement improved by 21%
In 2015, national outcome data showed 211 babies were stillborn, a 19.5% reduction
in the rate of stillbirth compared to 2012. Although no one factor or programme can
be attributed to this decline and the rate has slightly increased in 2016, it is encouraging
progress towards reducing the stillbirth rate in Scotland.
Fig. 6 (abstract P56).
Scottish Stillbirth rate 2006-2016
P57 Children’s Nurses’ experiences in delivering bereavement care to children and
families with life limiting conditions in the Irish context
Stacey Power1, Marcella Kelly-Horrigan2
1University College Dublin, Stilorgan Rd, Belfield, Ireland; 2NUI Galway, University
Rd, Galway, Ireland
Correspondence: Stacey Power
Healthcare providers influence the experiences of families during end of life care
and death of a child*. Nurses are best placed to provide bereavement support as they
have opportunities to build therapeutic relationships through closely and frequently
caring for the child and family. This relationship is essential within the delivery
of bereavement care. However, there is a dearth of information on nurses’ emic perspective
and experiences within this area.
The aim of this study was to gain a deeper understanding of the experiences of children’s
nurses’ (RCN) in delivering bereavement care to children and their families with life
limiting conditions, and what meaning they ascribe to their experience. In addition,
the aim was to explore what impact provision of bereavement care had on RCN’s as service
providers, and what their needs were in the provision of effective, supportive, quality
driven bereavement care to this population.
Using a phenomenological design guided by Heideggerian approach underpinned by Ricoeur’s
analytical framework, seven semi-structured interviews were conducted with RCN’s with
experience of delivering children’s palliative care and bereavement care in Ireland.
Interviews were taped and transcribed verbatim.
Three themes were identified; ‘being communicative and collaborative’, ‘being challenged’
and ‘being familiar’. These themes encompassed nurses’ experiences with both families
and healthcare professionals, highlighting the benefits for RCN involvement in the
delivery of bereavement care to promote overall best outcomes.
The findings support the role of RCN’s in the delivery of bereavement care to children
and families with life limiting conditions. It highlights the need for RCN’s to be
educated, up-skilled, supported, and included within the interdisciplinary team to
deliver bereavement care.
Ethical approval for the study was granted by LauraLynn Research Ethics Committee
(2016). Written informed consent was obtained by all study participants.
*denotes age from newborn to eighteen years
P58 Still aware lets share
Linda Doran
Tara’s Tiny Footprints, Castledermot, Ireland
As a parent who suffered the stillbirth of our daughter in 2006 at full term due to
an umbilical cord accident, I wish to raise awareness and educate people that stillbirths
happen in Ireland and to remove the taboo and stigma surrounding stillbirth in society.
In 2014 there were 164 stillbirths in Ireland a rate of 2.4% per live births, and
an estimated 2.6 million stillbirths occur every year worldwide (per WHO).
I aim to introduce an information leaflet that can be displayed in antenatal waiting
rooms, GP’s surgeries and public information areas that educates mothers to trust
their maternal instincts and seek professional reassurance if they are anyway concerned.
Not all stillbirths can be prevented however there are things you can do to reduce
your risk which could also be outlined in the leaflet. These include, attending all
antenatal appointments, good health and nutrition before and during pregnancy and
monitoring and being aware of your babies movements throughout the day.
The information leaflets will raise the subject of stillbirth and introduce the dialogue
and awareness into the conversation with medical staff, families and society. It will
educate parents on how to reduce the risk of stillbirth in a safe non alarming way.
It is assumed that stillbirths only happen in high risk pregnancies which is just
not true. A babies only direct link to the outside world is through its mother. We
need to empower women and give them the confidence to trust their instincts when something
feels wrong during their pregnancy and to act on it immediately. In 2014, the World
Health Assembly endorsed a target of a rate of 1.2% or fewer stillbirths in every
country by 2030. Let’s share and be still aware.
P59 The Irish childhood bereavement care pyramid – planning for siblings bereaved
through stillbirth
Orla Keegan1,2, Anne Marie Jones3,2, Celine Deane4,2
1Irish Hospice Foundation, Dublin, Ireland; 2Irish Childhood Bereavement Network,
Dublin, Ireland; 3Temple Street Children’s University Hospital, Dublin, Ireland; 4Beaumont
Hospital, Dublin, Ireland
Correspondence: Orla Keegan
Understanding of children’s bereavement needs in general and bereaved siblings in
particular are traditionally under-researched areas. The specific needs of siblings
bereaved through stillbirth are even less well understood. This presentation aims
to introduce the Irish Childhood Bereavement Care Pyramid (ICBCP) and to discuss its
potential for understanding bereavement experiences and the service implications for
siblings bereaved through stillbirth.
Development of ICBCP: Literature review, consultation, integration of feedback, dissemination
of findings
Additional literature review (siblings; bereaved; stillbirth)
The family and the passage of time are crucial contexts for support. All bereaved
children need to be met with empathy and understanding; adults have a responsibility
to inform themselves and respond. Smaller numbers of children develop more complex
needs and require formal supports – peer-based, voluntary groups or professional intervention.
The ICBN Pyramid provides a four level framework to indicate responses to children’s
bereavement needs. (Fig. 7)
There were 330 stillbirths in Ireland in 2014, (circa 300 annually). The number of
siblings bereaved in this way is estimated conservatively as upward of 3,000 over
ten years. A recent population-based longitudinal case-control study identified bereaved
siblings (any cause) under 13yrs at risk of developing a mental disorder, and most
likely to develop depression. Specific to the psychological impact of stillbirth a
systematic review identified long-term mental health impacts & hyper-vigilant parenting
as characterizing many bereaved children’s lives. The 2016 Irish National Standards
for Bereavement Care following Pregnancy Loss identify siblings as part of bereavement
care concern; implementation guidance on the most effective means to achieve this
is yet to be developed.
There are gaps in literature and the extent to which family, community, health services
& specialist services meet siblings’ needs is unestablished. The pyramid of bereavement
care situates bereaved siblings and provides an initial guide for support protocols.
Fig. 7 (abstract P59).
The Irish Childhood Bereavement Pyramid
P60 Women’s awareness of stillbirth and reaction to messaging around stillbirth risk
Janet Scott, Laura J. Price
Sands (the stillbirth and neonatal death charity), London, UK
Correspondence: Janet Scott; Laura J. Price
Women’s awareness of stillbirth and reactions to stillbirth messaging were explored.
Focus group sessions were conducted involving 40 women with no experience of stillbirth
(Table 9). Groups were shown four sample A3 posters and a leaflet. Discussions were
independently facilitated, with a note taker behind one-way glass.
Awareness of stillbirth was limited. Although most women considered they ‘sort of
knew’, none could define stillbirth accurately. Pregnant and previously pregnant women
recalled being told about alcohol, smoking and healthy eating, and receiving information
on miscarriage, cot death and Down’s syndrome. Some second- and third-time mothers
felt they knew enough and were less likely to read information. One younger woman
reported getting all her information from YouTube.
Women were surprised by stillbirth statistics. The incidence of stillbirth vs cot
death had the most impact, but some women said it simply made them feel less concerned
about SIDS. In general, women found statistics scary if they were not linked with
advice about risk reduction. Women were surprised that flu was a risk factor, and
many thought vaccination would be harmful. There was mixed reaction to information
on drinking, with the suggestion that ‘overstating’ the risk could damage trust in
other messages. Women were familiar with the smoking messages, though none realised
there was a link with stillbirth.
Women agreed that they wanted information on modifiable risk factors only. Women felt
information on non-modifiable risk factors such as ethnic group should be ‘known’
by health professionals.
Women across the UK were consistent in their knowledge and preferences. Messaging
around stillbirth needs to be subtle, focusing on how to reduce risk and have a safer
pregnancy. Imagery needs to reflect positive messaging and not imply loss or bereavement.
Statistics should be used with care and not in isolation.
The focus group research presented in this abstract was carried out by The Focus Group,
on behalf of Sands, the stillbirth and neonatal death charity. All participants gave
written consent to participate
Table 9 (abstract P60).
See text for description
Description
Location
Age range (years)
BME* (%)
n
Primigravidae
London
23-35
33
6
Secundi- and primigravidae
Manchester
33-45
33
3
Secundi- and plurigravidae
Bournemouth
32-40
0
7
Secundigravidae
Belfast
27-37
0
7
Secundigravidae
Glasgow
29-33
0
3
Secundi- and plurigravidae
Cardiff
25-28
0
6
Mothers with children, not currently pregnant but considering more children
London
36-43
12.5
8
*BME, black and minority ethnic
P61 Association of stillbirth rate with community access to skilled birth attendance
in rural Bangladesh
Louise Tina Day1, Johan P Velema1, Steven Withington1, Stacy L Saha1, Shafiul Alam1,
Nazimul Hossain1, Shirajum Munira1, Khaleda Jesmin1, Swapan Pahan1, Kristine Prenger1,
Dan Hruschka2
1Lamb Integrated Rural Health & Development, Parbatipur, Bangladesh; 2Arizona State
University, Tempe, US
Correspondence: Louise Tina Day
Reducing barriers to quality skilled birth attendance that reduces perinatal mortality
(PNM) is a continuing challenge. In the high stillbirth setting of Bangladesh, Medically
Trained Provider (MTP) deliver only 42% of births. LAMB Integrated Rural Health and
Development has been working to reduce PNM with Emergency Obstetric and Newborn Care
(EmONC) referral linkages from home to hospital. In LAMB community area, 2-3 Community
Skilled Birth Attendants (CSBA), who are designated as MTP, are posted to a 2-bed
Safe Delivery Unit (SDU) which functions 24 hours a day at Obstetric First Aid EmONC
level. One SDU covers a median community population of 28,500 and approximately 500
pregnancies/year.
To examine how establishing and strengthening community services are associated with
changes in stillbirth rates, we analyse the occurrence of stillbirths among 39,459
deliveries (2011-2014) in a rural Bangladesh community served by 19 SDUs. Stillbirth
rates were also analysed against key determinants using multivariate analysis.
Of all mothers who delivered, 70% had 3 antenatal visits and 65% delivered with MTPs
(national average 50%) with 17% delivered by SBA in the SDU-FWC (national average
CSBA deliveries 0.4%). Stillbirth rates (per 1000 births) varied considerably across
place of delivery (road deliveries 45.5, home 21.6, SDU-FWC by SBA 9.6, overall 22.2).
After adjusting for covariates, the risk of stillbirth was lower by 33% (adjusted
OR 0.67) for SDU-FWC delivery compared to homebirth.
National uptake of CSBA as delivery attendants remains low in Bangladesh, but placing
them in the enabling environment of a local SDU-FWC facility was associated with increased
local usage of their skilled care. This was associated with a stillbirth reduction
by one third compared to unskilled deliveries at home.
Ethical approval for the study was granted by LAMB Research Ethics Committee. (Reference;
6/REC/17)
P62 Sustaining perinatal audit in the high stillbirth rate setting – a 20 year journey
in rural Bangladesh
Louise Tina Day, Felicity Mussell, Hafiza Khatun, Renate Verbiest, Lipi Biswas, Rekha
Folia, Robyn Turner, Ruth Yvonne Lennox, Kristine Prenger, Christine Edwards, Beatrice
Ambauen-Berger, Stacy L. Saha
Lamb Integrated Rural Health & Development, Parbatipur, Bangladesh
Correspondence: Louise Tina Day
Bangladesh has a high population stillbirth (SB) rate of 36/1000 total births. LAMB
Hospital, a 150-bed hospital, serves northwest rural Bangladesh as part of LAMB Integrated
Rural Health and Development NGO providing Comprehensive Emergency Obstetric and Neonatal
Care for > 3000 deliveries/year.
We describe challenges faced and overcome during 20 years implementation of Perinatal
and Maternal Death Audit (PNMDA) in our busy, resource-limited setting with high staff
turnover and constant competing demands. Perinatal mortality rates were measured using
Perinatal Problem Identification Programme (PPIP) software.
The process now includes a number of key components that facilitate sustainability:
(1) Efficient data collection methods for quantitative analysis; (2) Inclusive regular
multidisciplinary meetings including near miss deaths for positive feedback; (3) Implementing
integrated patient and staff-friendly solutions to issues identified; (4) Caring for
Health Care Providers (HCP) including creative task shifting; (5) Emotional/Spiritual
care for families and HCP; (6) Using computerised data management software: PPIP and
locally customised FISH (Flow Information System Hospital). The process has also created
new opportunities, including (1) Involvement nationally in dissemination and training;
(2) Sharing data for International Stillbirth Comparison; (3) Developing next generation
of PNMDA champions.
Quantitative analysis of more than 50,000 babies born > 1000g during the years 2001
to 2017 has shown stillbirth rates falling from 55 to 30/1000 total births. The SB:
Neonatal Death ratio was 1.6 : 1.0 Patient associated “Avoidable Factors” were identified
in 85% of Stillbirths.
PNMDA is a valuable process in the high SB setting and can be sustained with creativity
and motivation. Maintaining a holistic attitude alongside quantitative analysis of
mortality rates and focusing on “caring for the carers” for the Health Care Providers
at high risk of emotional fatigue can make an important contribution to the provision
of respectful maternity services for families.
Ethical approval for the study was granted by LAMB Research Ethics Committee (Reference;
8/REC/17)
P63 Stillbirth and perinatal care: time to address the Italian gap. A professional
perspective
Claudia Ravaldi1, Miriam Levi2, Elena Angeli1, Gianpaolo Romeo2, Marco Biffino2, Roberto
Bonaiuti3, Alfredo Vannacci3
1CiaoLapo Onlus, Charity for Stillbirth and Perinatal Grief Support, Prato, Italy;
International Stillbirth Alliance, Prato, Italy; 2CeRIMP-Regional Centre for Occupational
Diseases and Injuries, Tuscany Region, Florence, Italy; 3Department of Neurosciences,
Psychology, Drug Research and Child Health (NeuroFarBa), University of Florence, Florence,
Italy
Correspondence: Claudia Ravaldi
Objectives: To assess current practices of Italian health care providers (HCPs) with
regard to stillbirth management and to explore their need to be trained in supporting
bereaved families.
750 HCPs were administered a multiple-choice questionnaire. The results related to
the items exploring behaviours and emotions of HCPs, and their opinions regarding
the need for professional training courses are reported.
Compliance of Italian HCPs with international guidelines recommendations; evaluation
of their cognition, emotions and behaviours with regard to stillbirth care.
The response rate was 89.9%; the majority (94.1%) were female, and mean age was 37.6
(SD = 10.4) years. Midwives were largely represented (72.8%). In case of stillbirth,
only slightly more than half routinely bathe and dress the baby before allowing the
parents to see them for as long as they need, whereas 44.4% usually send the child
away. More than half felt inadequate and some even felt to have failed to provide
support to the family when dealing with a stillbirth in the past. The need for professional
training courses was expressed by 90.2%, however, three-quarters had never previously
attended a course on perinatal bereavement care.
There is a substantial gap between the standards of care defined by the international
guidelines and the practices currently in place in Italy. Italian perinatal HCPs feel
an urgent need to be offered professional training courses to better meet the needs
of grieving families.
P64 You are not alone: ten years of self-help groups for Italian bereaved parents
Claudia Ravaldi1, Alfredo Vannacci1,2
1CiaoLapo Onlus, Charity for Stillbirth and Perinatal Grief Support, Prato, Italy;
2Department of Neurosciences, Psychology, Drug Research and Child Health (NeuroFarBa),
University of Florence, Florence, Italia
Correspondence: Claudia Ravaldi
Self-help groups are an important instrument for anyone who is affected by the loss
of a baby. Until 2006 no self-help group for parents affected by perinatal loss was
present in Italy. Since then CiaoLapo Charity organized several self-help groups in
different parts of Italy. Here we present our ten year experience, our method as well
as parents’ feedback.
Since 2007, 17 self-help groups were opened in Italy by trained CiaoLapo volunteers.
Self-help groups are usually managed by a bereaved parent specifically trained (at
least 2 years after their own loss) and by a counselor or a psychologist specifically
trained in grief and bereavement.
We collected data from participants and from facilitators, by written interviews,
during periodical meetings.
CiaoLapo self-help groups, called “Little Princes” were opened during the last 10
years in 17 Italian towns: Turin, Florence, Rome, Naples, Prato, Modena, Como, Bologna,
Udine, Pordenone, Genova, Milan, Varese, Cosenza, Bergamo, Perugia, Vicenza.
Attendance of parents to group is free of charge and open; before enrolment parents
need to attend a face to face meeting with a facilitator; attendance to groups usually
lasts a year. Parents can choose if they want to continue for a second year or if
they feel to be able to quit. Frequency might be different in different groups (usually
1-2 hours meeting every three weeks or monthly, sometimes twice a month). Groups could
be attended by both parents together, or by only one of them.
CiaoLapo groups are open to parents grieving for different type of pregnancy and perinatal
loss. The main keywords for attendants are: empathy, comprehension, share, respect,
attention, help. Both professionals and parents increased their knowledge on this
instrument for perinatal grief.
P65 From head to heart learning in perinatal bereavement care
Daniel Nuzum1,2,3, Mary Jo Corcoran1,3
1Department of Clinical Pastoral Education, Cork University Hospital, Cork, Ireland;
2Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland;
3Association of Clinical Pastoral Education (Ireland) Ltd., Dublin, Ireland
Correspondence: Daniel Nuzum
Perinatal bereavement raises deep spiritual questions for many bereaved parents. Attending
to the spiritual needs of bereaved parents requires healthcare chaplains to demonstrate
a high level of spiritual skill and sensitivity. Clinical Pastoral Education (CPE)
is an experiential reflection–action-integration model of learning used in the education
of pastoral care students.
Following theoretical input, students were facilitated to experience loss through
the awareness of attachment by sharing their personal stories of hope and attachment.
During this time each student passed a ball of wool through the group, thereby spinning
a ‘web of attachment’ between them. Music and a recorded foetal heartbeat were playing
in the background. Without warning the music and heartbeat stopped and the students
were asked to drop the web of wool, which fell silently to the floor. The students
were invited to reflect and to note their feelings and experiences.
There were six students and two supervisors in the participating group. The awareness
and expression of hopes, attachments and expectations brought the students into the
world of expectant parents. Following a creative and reflective silence the participants
were able to express feelings of abandonment, fear, loss, sadness, anger, shock, emptiness
and loneliness. The participants demonstrated skills of empathic awareness and spiritual
sensitivity as they applied their learning in subsequent role play.
The use of multisensory and experiential teaching methodology and pedagogy as part
of the CPE process enabled pastoral care students to gain a deeper understanding,
awareness and learning in the area of perinatal bereavement and loss. They had entered
the world of bereavement. This experience when integrated into clinical practice will
enable students to care more empathically for bereaved parents and to attend to deep
spiritual questions.
P66 Preliminary analysis of respectful care after stillbirth: results from a multi-country
survey (US, Canada, Australia and New Zealand)
Emma Sacks1, Frances Boyle2, Aleena Wojcieszek2, Dell Horey3, Lynn Farrales4, Vicki
Flenady2
1Johns Hopkins University, Washington, DC, USA; 2Centre of Research Excellence in
Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia;
3Latrobe University, Melbourne, Australia; 4Department of Family Practice, University
of British Columbia, Vancouver, Canada
Correspondence: Emma Sacks
Stillbirth is traumatic for families yet the study of respectful care after stillbirth,
especially as related to dignified care of the infant who is stillborn, is still very
new.
Secondary analysis was conducted on data from an international, online survey of parents
who experienced stillbirth, disseminated primarily through member organisations of
the International Stillbirth Alliance. The survey covered topics relating to experiences
of stillbirth and included quantitative metrics asking whether parents and stillborn
infants were treated with respect, as well as open-ended questions about care experiences.
Analyses included descriptive statistics and thematic analysis.
A total of 906 mothers residing in Australia (n = 416), New Zealand (n = 44), US (n = 391)
and Canada (n = 55) completed the questionnaire. The majority (approximately 80%)
reported being treated with kindness and respect “always” or “most of the time”, but
almost 20% experienced respectful care either “never” or “only sometimes”. Patterns
were similar across the four countries; the only statistically significant difference
was respondents from the US less frequently reporting respectful care of the stillborn
infant (p = 0.05). Surprisingly, mothers with losses later in pregnancy (40+ weeks’
gestation) reported less respectful care. However, in more recent stillbirths (within
last 5 years) mothers reported fewer negative experiences, suggesting improvements
over time. Qualitatively, mothers largely expressed wanting more time with their stillborn
infants and many felt rushed without good explanation for the urgency. Mothers commonly
stated that many of their questions were not answered, including why certain events
occurred, options for burial/cremation, autopsies and concerns over their own health.
While care practices are improving, many mothers reported non-respectful care at some
point. Lack of communication, including lack of informed consent, is critical to improving
care after stillbirth. More research is needed on the burden of disrespectful care
(including in low-income settings) and the care practices desired by families.
Ethics approval was granted by the Mater Health Services Human Research Ethics Committee
on 29th November 2013 (Ref #HREC/13/MHS/121) and by the University of British Columbia
Office of Research Services, Behavioural Research Ethics Board on 22nd December 2014
(Ref #H14-02784). Completion of the anonymous online survey indicated consent to participate
in the study.
P67 Fetal deaths in Brazil: spatial distribution of a time series
Flavio Ibiapina, Aline Veras, Raimunda Magalhães, Rosa Almeida
University of Fortaleza, Fortaleza, Brazil
Correspondence: Flavio Ibiapina
In a country of continental dimensions such as Brazil, discussing the distribution
of fetal deaths by region contributes to the planning of public policies. This study
aims to describe the causes of fetal death according to groups of preventable causes
in different regions of Brazil from 2001 to 2014.
An ecological study focused on a spatial analysis of records of fetal deaths from
2001 to 2014 in a national database. Fetal mortality rates were calculated and aggregated
by Federation Units. Data normality was checked by the Shapiro-Wilk test. For spatial
analysis, a neighborhood matrix was created using the contiguity criterion. A Moran
Map was created and it displays four associations: Q1 (high-high), with locations
with a high incidence rate and a neighbor with a high incidence rate; Q2 (Low-Low),
neighboring regions with low rates; and Q3 (high-low) and Q4 (low-high), with locations
with non-similar neighborhoods, reflecting transition areas. A Lisa Map was created
in QGIS 2.18.3 to identify aggregates (Fig. 8).
465,050 deaths were analyzed. The average death rate was 11.3 deaths/thousand births.
The Northeast region has the highest average rate: 12.9/1000 births. In the Northeast
and North regions, deaths that could have been avoided by adequate care of the fetus
and newborns were predominant. The Southeast region presented a prevalence of deaths
that could have been avoided by adequate care of the woman during labor. In the South
region, there was a predominance of deaths that could have been avoided by adequate
care of the woman during pregnancy. The spatial analysis showed a rate distribution
in two periods. Significant clusters and areas of greatest risk for fetal death in
Brazil are identified.
Interventions aimed at reducing fetal mortality depend on structural changes related
to living conditions and on direct actions defined by public health policies.
Fig. 8 (abstract P67).
© [2017] [Ibiapina, Flavio et al]
P68 Perinatal palliative care – a guide to anticipatory bereavement care for parents
Heather McGovern-Silver
Silverleaf Consulting Services, Llc., Severna Park, MD, USA
Parents who are given the news that their baby has a life-threatening diagnosis often
experience feelings of fear, anxiety, isolation, and the vast unknown. Overwhelmed
and consumed by questions, they search for answers often turning to the internet for
information, causing more confusion and complications. A culture needs to be created
to support and guide families with the right tools and appropriate resources to provide
insight for a healthy journey through loss.
A search of available literature shows gaps across many healthcare systems for providing
psychosocial and spiritual support, which research has linked to parents having a
negative emotional impact. The purpose of this presentation is to provide and discuss
research based findings and clinical expertise to offer best practices immediately
following diagnosis, providing anticipatory bereavement, giving options for pregnancy,
birth, legacy building and aftercare of mom and baby.
In our almost 60 years combined clinical experience parents and families who have
received appropriate anticipatory bereavement care share a sense of peace and memories
of compassionate caregiving. Those families who felt their needs were not met frequently
suffer from unresolved grief. The reviewed research, along with our expert clinical
social work and bedside nurse experience, give us the passion to provide insight into
walking alongside these special families as they prepare for the birth and death of
their precious babies.
Families who are given the opportunity to process the difficult news of a life-threatening
pregnancy diagnosis, presented with a guided approach for decision making which includes
physical, emotional and spiritual options and needs are able to have control over
many decisions and actions in an “out of control” situation. They often report having
a positive experience within a healthcare system and feel well cared for, even when
there is a negative outcome.
P69 Perinatal autopsy for stillbirth ≤ 20 weeks
Karen Gibbins1, Jessica Comstock2, Yajing Xiong3, Robert Silver1
1University Of Utah, Salt Lake City, UT, USA; 2Primary Children’s Intermountain Healthcare,
Salt Lake City, UT, USA; 3University of Utah School of Medicine, Salt Lake City, UT,
USA
Correspondence: Karen Gibbins
Utility of perinatal autopsy in ascertaining a potential cause of death is well established
in evaluation of stillbirth after 20 weeks gestation. However, autopsy is not routinely
performed prior to 20 weeks’ gestation, and these early fetuses may be too immature
to glean useful information. Our objective was to describe our experience with perinatal
autopsy in fetuses ≤ 20 weeks’ gestation.
Descriptive study of 211 fetal autopsy reports with gestational age listed as 20 weeks
or fewer (2000-2015). Demographics, indication for delivery (antepartum stillbirth
(AS), intrapartum stillbirth (IS), or termination for fetal anomalies), mode of delivery,
gestational age estimates, degree of maceration, and autopsy findings were abstracted.
Autopsy findings were categorized by organ system and recorded as normal, abnormal,
or unable to determine.
Mean gestational age was 17.4 weeks. 67% were stillbirths, 13% previable spontaneous
labor, and 20% terminations. Delivery was via spontaneous vaginal delivery in 191
(92%), Cesarean delivery in 2 (1%) and dilation & evacuation (D&E) in 13 (6.3%). Maceration
ranged from none in 31% to grade IV in 42%. Anomalies were detected in 122 (58%):
skeletal anomalies in 30%, head and neck 23%, abdominal 22%, chest 21%, cardiac 21%,
genitourinary 13%, and central nervous system (CNS) 8%. Only 10 fetuses (5%) were
too macerated or damaged to permit useful evaluation. Detection of anomalies by gestational
age is shown in Fig. 9. In fetuses with grade IV maceration, 39 (46%) had an anomaly
detected. In D&E cases, anomalies were detected in 54%, although 38% were unable to
be evaluated. CNS anomalies were unable to be evaluated in 110 (55%).
Fetal autopsy yields useful results in fetuses below 20 weeks’ gestation. Due to rapid
postmortem liquefaction of the brain in fetuses, CNS autopsy is limited, but other
organ systems remain discernable, even with significant maceration.
Ethical approval for the study was granted by all Institutional Review Boards (IRB)
of participating centers. University of Utah IRB approval #00093587, initial approval
date 8/23/2016; Intermountain Healthcare IRB approval #1050257, initial approval date
7/14/2016.
Fig. 9 (abstract P69).
Anomalies detected at each gestational week
P70 Risk factors for stillbirth due to placental insufficiency at term
Karen Gibbins1, Robert Silver1, Halit Pinar2, Corette Parker3, Vanessa Thorsten3,
Donald Dudley4, Radek Bukowski5, George Saade6, Deborah Conway, Carol Hogue8, Barbara
Stoll8, Robert Goldenberg9
1University Of Utah, Salt Lake City, UT, USA; 2The Warren Alpert Medical School of
Brown University, Providence, RI, USA; 3RTI International, Durham, NC, USA; 4University
of Virginia, Charlottesville, VA, USA; 5Yale-New Haven Hospital, New Haven, CT, USA;
6University of Texas Medical Branch, Galveston, TX, USA; 7University of Texas, San
Antonio, TX, USA; 8Emory University, Atlanta, GA, USA; 9Columbia University, New York,
NY, USA
Correspondence: Karen Gibbins
Placental insufficiency (PI) is a leading cause of stillbirth (SB). At term, SB due
to PI (PISB) can be prevented by delivery if detected. Our goal was to compare exposures
between women with term PISB and women with live births (LB).
The Stillbirth Collaborative Research Network (SCRN) conducted a population based,
case-control study of SBs and LB from 2006-2008. This analysis includes term births
only and compares PISB to LB. PISB was ascertained using the Initial Cause of Fetal
Death (INCODE) classification tool developed by the SCRN. We compared demographic,
obstetric, and prenatal factors. Analyses were weighted to account for the original
study design, differential consent for participation, and availability of placental
histology. Weighted frequencies, crude odds ratios (ORs), and adjusted ORs (aORs)
are reported.
After weighting, there were 1550 term LB to compare to 25.1 PISB. Non-Hispanic black
race (aOR 5.64, 95% CI 1.47-21.58) and Hispanic ethnicity (aOR 3.73, 95% CI 1.07-13.07)
were associated with increased odds of PISB (Table 10). Maternal birth in the United
States had a lower risk of PISB (aOR 0.18, 95% CI 0.06-0.54). Women without insurance
had much higher odds of PISB than women (aOR of 18.32, 95% CI 2.80-119.92). Medical
conditions with increased risk of PISB include asthma (aOR 2.84, 95% CI 1.03-7.79),
diabetes (aOR 7.22, 95% CI 1.90-27.41), and hyperthyroid disease (aOR 9.48, 95% CI
2.26-39.73). Pregnancy specific factors including nulliparity (aOR 6.85, 95% CI 2.74-17.15)
and antenatal bleeding (aOR 7.80, 95% CI 2.54-23.93) also increased risk of PISB.
At term, multiple factors are associated with increased risk of PISB. Although some
risk factors are disease states, many risk factors suggest decreased access to care
(race/ethnicity, lack of insurance, non-native birth) and systemic disparities.
Ethical approval for the study was granted by all Institutional Review Boards (IRB)
of participating centers. University of Utah IRB approval #00014353, initial approval
date 9/25/2005. Intermountain Healthcare IRB approval #107704, initial approval date
10/19/2005. Written informed consent was obtained by all study participants.
Table 10 (abstract P70).
Prenatal and antenatal differences in women with SBs, with and without evidence of
placental insufficiency by INCODE*
PI by INCODEN = 121
Non-PI SBN = 391
p-value
Prenatal care
110 (95.7)
345 (93.5)
0.395
BMI (kg/m2)
28.5 (7.1)
27.6 (6.8)
0.213
Obese
41 (37.6)
94 (31.1)
0.216
Maternal comorbidities
HTN
17 (14.8)
37 (10)
0.154
Asthma
8 (7.0)
38 (10.3)
0.289
Seizures
0 (0)
6 (1.6)
0.344
DM
7 (6.1)
20 (5.4)
0.781
Hyperthyroid
3 (2.6)
1 (0.27)
0.043
Hypothyroid
2 (1.7)
8 (2.2)
1.000
Kidney disease
1 (0.9)
6 (1.6)
1.000
Sickle cell
0 (0)
4 (1.1)
0.577
Autoimmune disease (SLE/APS/RA/UC/Crohn’s)
2 (1.8)--
0 (0)--
0.055--
Mental illness
11 (9.6)
26 (7.0)
0.370
UTI
23 (20)
49 (13.2)
0.075
Blood clotting disorder
2 (1.7)
3 (0.8)
0.340
ART
4 (3.4)
14 (3.7)
1.000
Alcohol
3 (2.5)
10 (2.6)
1.000
Tobacco
20 (16.8)
42 (10.9)
0.089
Drug use
4 (3.4)
11 (2.9)
0.759
Abuse (physical, sexual, or emotional)
2 (1.9)
5 (1.6)
1.000
Antenatal bleeding
11 (9.6)
35 (9.5)
0.980
GHD
28 (23.1)
45 (11.5)
0.001
SGA
48 (39.7)
64 (16.4)
<0.001
Gestational age of SB
29.4 (6.6)
28.1 (6.6)
0.056
Intrapartum demise
6 (5.5)
38 (11.0)
0.086
HTN = hypertension; DM = Diabetes mellitus; SLE = Systemic Lupus Erythematosus; APS = Antiphospholipid
syndrome; RA = Rheumatoid arthritis; UC = ulcerative colitis; ART = Assisted Reproductive
Technology
Data are reported as n (%) or mean (SD). P-values are generated via t-test, chi-square
test, or Fisher’s exact test.
*Dudley DH et al. A new system for determining the causes of stillbirth. Obstet Gynecol
2010; 116: 254-260.
P71 Predicting pregnancy outcome in women with a history of prior stillbirth
Nicole Graham1,2, Louise Stephens1,2, Edward Johnstone1,2, Alexander Heazell1,2
1Maternal and Fetal Health Research Centre, Division of Developmental Biology and
Medicine, Faculty of Biology Medicine and Health, University of Manchester, Manchester,
UK; 2Departement of Obstetrics, St Mary’s Hospital, Manchester, M13 9WL, UK
Correspondence: Nicole Graham
Efforts to reduce stillbirth in high-income countries have focussed on improving care
for women at increased risk. One such group is women who have had a stillbirth in
their preceding pregnancy, who have an almost 5-fold increased risk. The origins of
this increased risk are not well understood. This study aimed to explore the relationship
between the cause of index stillbirth and subsequent pregnancy outcome.
A retrospective cohort study was conducted; cases were included if the stillbirth
was investigated and the subsequent pregnancy care was in the same tertiary maternity
unit. Stillbirths were classified using the ReCoDe system. All women had ultrasound
assessment of placental biometry and uterine artery Doppler at 23 weeks’ gestation
in the subsequent pregnancy followed by regular assessment of fetal growth.
120 cases were identified, 13 were excluded (mothers were still pregnant/outcome data
incomplete). In this cohort (n = 107), there were no recurrent stillbirths, but 16
adverse outcomes (15%) including 2 second trimester miscarriages and 1 neonatal death.
Overall, thirteen infants delivered preterm (<37 wks’) and eight infants were admitted
to the neonatal intensive care unit. Fetal growth restriction was identified in 7
out of 16 adverse outcomes.
In the 16 adverse outcomes, the prior stillbirth was associated with placental dysfunction
in 11 cases and fetal anomaly in 1 case. No adverse outcomes were seen with prior
unexplained stillbirth. 6 cases of adverse outcome had an abnormal placental ultrasound,
all of which had placental dysfunction in the index stillbirth.
Adverse outcome is more likely if the index stillbirth was associated with placental
insufficiency. Placental ultrasound can detect recurrent placental abnormalities in
a significant proportion of subsequent pregnancies. Conversely, unexplained stillbirths
or those associated with fetal anomaly or infection are less likely to have adverse
outcome in a subsequent pregnancy.
Ethical approval for the study was granted by South East Coast- Surrey Research Ethics
Committee (Ref 16/LO/1666).
P72 Abnormal placental cord insertion and risk of intrauterine fetal death: a systematic
review and meta-analysis
Khadijah Irfah Ismail1, Ailish Hannigan2, Keelin O’Donoghue3, Amanda Cotter1
1Obstetrics and Gynaecology, Graduate Entry Medical School, University Of Limerick,
Limerick, Ireland; 2Biostatistics Department, Graduate Entry Medical School, University
of Limerick, Limerick, Ireland; 3Obstetrics and Gynaecology, University College Cork,
Cork, Ireland
Correspondence: Khadijah Irfah Ismail
Abnormal placental cord insertions including velamentous cord insertion (VCI) and
marginal cord insertion (MCI) have been associated with adverse pregnancy outcomes
including small for gestational age infants, preterm birth and intrauterine fetal
death. We systematically reviewed and meta-analysed studies of abnormal placental
cord insertions and the association with intrauterine fetal death.
Embase, Medline, CINAHL, Scopus, Web of Science and Cochrane Databases were searched
in September 2016 (from inception to September 2016). Studies which contained the
following: singleton pregnancies, VCI, MCI and intrauterine fetal death. Potentially
eligible studies were reviewed by two authors independently. The quality of included
studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Summary
risk ratios with 95% confidence intervals were calculated.
Four studies were available for analysis of VCI compared to non-VCI for the outcome
intrauterine fetal death. No studies reporting the outcome intrauterine fetal death
comparing VCI, MCI and normal placental cord insertion were identified. Meta-analysis
of the four studies showed a statistically significant increased risk of intrauterine
fetal death (pooled RR, 3.64; 95% CI, 1.39 -9.57, P = 0.009) for the VCI group compared
to the non-VCI group with evidence of significant heterogeneity (χ2 = 14.7, P = 0.002,
I2 = 80%), so a random effect model was used (Fig. 10).
The available evidence suggests an association between VCI and intrauterine fetal
death. The association with MCI remains unclear. Further studies to identify the risk
of intrauterine fetal death with MCI are needed.
Fig. 10 (abstract P72).
See text for description
P73 My Baby’s Movements: A stepped-wedge, cluster-randomised controlled trial testing
a mobile application intervention aimed at lowering stillbirth rates
Vicki Flenady1, Glenn Gardener1, David Ellwood2, Philippa Middleton3, Fran Boyle1,
Caroline Crowther4, Michael Coory1, Chris East13, Emily Callander6, Adrienne Gordon7,
Jonathan Morris7, Victoria Bowring8, Alison Kent10, Sue Vlack9, Glyn Teale5, Lisa
Daly1, Sarah Henry1, Hanna Reinebrant1, Aleena Wojcieszek1, Frederik Froen11, Jane
Norman12
1Mater Research Institute- University of Queensland, Brisbane, Australia; 2Griffith
University, Brisbane, Australia; 3South Australian Health and Medical Research Council,
Adelaide, Australia; 4University of Auckland, Auckland, New Zealand; 5University of
Melbourne, Melbourne, Australia; 6James Cook University, Townsville, Australia; 7University
of Sydney, Sydney, Australia; 8Stillbirth Foundation Australia, Annandale, Australia;
9School of Population Health, University of Queensland, Brisbane, Australia; 10Australian
Capital Universities, Canberra, Australia; 11Norwegian Institute of Public Health,
Oslo, Norway; 12Tommy’s Centre for Maternal Fetal Health, University of Edinburgh,
Edinburgh, Scotland; 13Monash University, Melbourne, Australia
Correspondence: Vicki Flenady
Stillbirth is a major global public health problem. Maternal perception of decreased
fetal movements (DFM) is often the only warning sign. The My Baby’s Movements (MBM)
trial aims to reduce stillbirth rates using a mobile platform to enhance maternal
knowledge about decreased fetal movement and encourage timely health-care seeking
behaviour combined with a clinician education program on management of DFM.
A stepped-wedge, cluster-randomised design, involving 26 hospitals (8 clusters) and
260,000 women in Australia and New Zealand (ANZ) over a 3-year period (2016-2018).
The primary outcome measure is stillbirth rates after 28 weeks’ gestation will be
reduced by 30%. Satisfaction with the app is sought from users through a brief survey
incorporated into the app.
The MBM mobile application has been developed, after pilot testing including iterative
cycles of testing and improvement. App content is based on the ANZ DFM Clinical practice
guidelines and brochure for women. MBM implementation is underway with results due
in 2019. Initial feedback from users is very positive. The SWCRCT is an ideal design
for large scale trials required to address stillbirth providing a pragmatic while
robust evaluation model.
The My Baby’s Movements trial will generate information about fetal movement awareness,
health promotion and perinatal health outcomes associated with a mobile application
intervention. Preliminary data suggests that the mobile phone app is well received
by users.
Ethical approval for the study was granted by the Mater Health Services Human Research
Ethics Committee (Reference; HREC/14/MHS/141 AM02) and seven additional HREC’s across
Australia and New Zealand.
P74 Post-hospital care after stillbirth in Australia and New Zealand: how well are
women’s needs met?
Fran Boyle1,2,3, Jade Ratnayake4, Dell Horey1,2,3,5, Vicki Flenady1,2,3
1Centre of Research Excellence in Stillbirth, Brisbane, Australia; 2Mater Research
Institute - University Of Queensland, South Brisbane, Australia; 3International Stillbirth
Alliance, Bristol, UK; 4School of Public Health, University of Queensland, Herston,
Australia; 5College of Science, Health & Engineering, La Trobe University, Melbourne,
Australia
Correspondence: Fran Boyle
The Lancet 2016 Ending Preventable Stillbirths series focused attention on the importance
of respectful and supportive care for parents faced with the tragedy of stillbirth.
Most studies of care after stillbirth centre on the hospital stay. Research into care
once parents leave hospital is scarce. This paper reports on mothers’ experiences
and perceptions of post-hospital care after stillbirth in Australia and New Zealand
and identifies areas of unmet need.
The data source was a large multi-country survey of parents who had experienced stillbirth
conducted between December 2014 and February 2015. An online questionnaire was distributed
through member organisations of the International Stillbirth Alliance, including parent
support organisations in Australia and New Zealand. Responses to rating scale items
about the type and quality of post-hospital services received by women and an open-ended
question asking how care might have been improved were analysed.
460 mothers from Australia and New Zealand completed the survey. Less than half (47%)
viewed their follow-up care positively and almost one-third (30%) rated their follow-up
care as “poor” or “very poor”. More recent stillbirths (within the last 5 years) were
associated with more positive ratings of follow-up care. Most mothers (79%) provided
a free-text response about how care could have been improved. The importance of sensitive,
respectful care that began in the hospital and followed women into the community was
paramount. Prominent themes included: “not being forgotten”; “being treated as a mother”;
and “pathways to support”.
Post-hospital care after stillbirth appears to fall short of best practice for many
mothers. A need exists for more comprehensive bereavement training for hospital staff
and attention to organisational aspects of care to support the hospital-to-home transition.
Explicit recognition of the role of hospital staff in facilitating ongoing support
for women is required.
Ethics approval was granted by the Mater Health Services Human Research Ethics Committee
on 29th November 2013 (Ref #HREC/13/MHS/121) and by the University of British Columbia
Office of Research Services, Behavioural Research Ethics Board on 22nd December 2014
(Ref #H14-02784). Completion of the anonymous online survey indicated consent to participate
in the study
P75 Understanding parents’ decision-making needs for autopsy consent after stillbirth:
a view from Australia and New Zealand
Anne Schirmann1,4, Fran Boyle1,2,3, Dell Horey1,2,3,5, Dimitrios Siassakos3,6, Ingrid
Rowlands4, David Ellwood1,3,7, Vicki Flenady1,2,3
1Centre of Research Excellence in Stillbirth, Brisbane, Australia; 2Mater Research
Institute - University Of Queensland, Brisbane, Australia; 3International Stillbirth
Alliance, Bristol, UK; 4School of Public Health, University of Queensland, Brisbane,
Australia; 5College of Science, Health & Engineering, La Trobe University, Melbourne,
Australia; 6Academic Centre for Women’s Health, University of Bristol, Bristol & Southmead
Hospital, Bristol, UK; 7Griffith University and Gold Coast University Hospital, Gold
Coast, Australia
Correspondence: Anne Schirmann
Supporting parents in autopsy decision-making is an essential but challenging part
of quality care after stillbirth. Parent-centred information that is clear, consistent
and sensitive is needed to guide decisions and minimise the likelihood of later regret.
Developing effective decision support tools requires understanding of the complex
decision environment in which parents’ deliberations take place and the range and
nature of influencing factors.
Data were from the ISA Lancet survey, a large multi-country survey of parents of stillborn
infants conducted between December 2014 and February 2015. An online questionnaire
covered various topics related to the experience of stillbirth and was distributed
through ISA member organisations, including parent support groups in Australia and
New Zealand. The framework method was used to qualitatively analyse mothers’ responses
to open-ended questions about autopsy.
460 mothers from Australia and New Zealand participated: 454 mothers provided one
or more free-text responses referencing autopsy yielding more than 1,200 data segments
for analysis.
The data confirmed the immensely difficult decision that autopsy consent entails.
Mothers had a strong need for answers coupled with a strong need to protect their
baby. Four “decision drivers” were confirmed: preparedness for the decision; parental
responsibility; possible consequences; and role of health professionals. Each had
the capacity to influence a decision for or against autopsy. Also prominent were the
“aftermath” of the decision: receiving the results; and decisional regret or uncertainty.
The influences on parents’ decision-making regarding autopsy are complex and multifaceted.
The range of influences implies the need for tailored information that addresses different
parent needs. These findings are an initial step in the development of a decision
support tool applicable to Australian and New Zealand settings.
Ethics approval was granted by the Mater Health Services Human Research Ethics Committee
on 29th November 2013 (Ref #HREC/13/MHS/121) and by the University of British Columbia
Office of Research Services, Behavioural Research Ethics Board on 22nd December 2014
(Ref #H14-02784). Completion of the anonymous online survey indicated consent to participate
in the study.
P76 Women who seek care for decreased fetal movements - maternal characteristics and
onset of labour
Anders Linde1,2, Karin Pettersson1, Ingela Rådestad2
1Karolinska Institutet, Stockholm, Sweden; 2Sophiahemmet University, Stockholm, Sweden
Correspondence: Anders Linde
Pregnant women seeking care due to decreased fetal movements are relatively common
in obstetric care. The aim of this study was to investigate characteristics of women
who seek consultation due to decreased or altered fetal movements in late pregnancy
and onset of labour.
All women with a simplex pregnancy (gestational week 28+), who sought care in Stockholm,
Sweden, in 2014 due to concerns for decreased or altered fetal movements were asked
to complete a questionnaire. Information on perinatal outcome was collected from medical
records. The control group comprised of women who gave birth after the pregnancy week
of 28 + 0 during 2014 in Stockholm.
A total of 2683 women with decreased or altered fetal movements and 26041 women in
the control group were included. Women who sought care due to decreased or altered
fetal movements were younger, ≤ 19-24 (p = 0.005) and more often primipara (p < 0.001)
compared with the women in the control group. Women born in Sweden sought care more
often than women born outside Sweden (p < 0.001). Women with a low educational level,
primary school or equivalent, did not seek care to the same extent as women with a
higher educational level; (p < 0.001). A higher proportion of women who sought care
had a BMI between 30 to 34.9 compared to women in the control group; (p < 0.001).
One in four women who sought care for decreased or altered fetal movements had the
delivery induced compared to 17.4 percent of the women in the control group (p < 0.001).
A dose-response effect was noted for the number of times women sought care and rate
of induction.
Pregnant women seeking care due to decreased or altered fetal movements are induced
more often compared to women who do not seek care for decreased fetal movements.
Ethical approval for the study was granted by Stockholm Research Ethics Committee
of Sweden(Reference; Dnr 2013/1077-31/3. Written informed consent was obtained by
all study participants.
P77 Fetal growth restriction among stillbirths and its antenatal detection in Ireland:
a national clinical audit
Paul Corcoran, Edel Manning, Irene O’Farrell, Sarah Meaney, Richard Greene
National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
Correspondence: Paul Corcoran
Fetal growth restriction may be the greatest contributing factor to stillbirth but
antenatal detection of it during routine maternity care is poor. We sought to estimate
the prevalence and the level of antenatal detection of fetal growth restriction among
stillbirths in Ireland.
As part of a national clinical audit of perinatal mortality, contributors in all 20
Irish maternity units completed and submitted detailed notification forms related
to stillbirths in 2011-2015. We calculated the stillbirth rate per 1,000 births using
several criteria for defining stillbirths. We derived customised birthweight centiles
using the Gestation Related Optimal Weight (GROW) software. Stillbirths <10th customised
birthweight centile were considered small for gestational age (SGA) and those <3rd
centile were considered severely SGA.
There were 1,547 notifications of stillbirths delivered in 2011-2015 after 24 weeks
gestation or with a birthweight ≥500g. Depending on the case-definition criteria,
the stillbirth rate ranged from 3.4 to 4.7 per 1,000 births. Forty-two percent (637/1535)
of the stillbirths were severely SGA and 54.6% were SGA (837/1535) see Fig. 11. SGA
was more prevalent among the stillbirths complicated by multiple pregnancy, maternal
hypertension and congenital anomaly and in stillbirths delivered pre-term. Antenatal
detection was at 20% (167/833) for SGA and 25% (478/633) for severely SGA. Antenatal
detection in the 20 maternity units was broadly consistent with the national level.
Antenatal detection varied little across a range of factors but was almost twice as
common if a congenital anomaly was present (29% vs. 16%).
Antenatal detection of fetal growth restriction among stillbirths in Ireland is poor.
Standardised ultrasound services involving two examinations and customised fetal growth
charts should be provided for all pregnant women in Ireland.
Ethical approval for the NPEC national clinical audits of obstetric outcomes was provided
by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (Reference:
ECM 4(g) 05/08/08)
Fig. 11 (abstract P77).
Optimal birthweight and normal range compared to actual birthweights of stillbirths
in Ireland, 2011-2015
P78 Analysis of stillbirth as a major public health problem in Mali
Mamadou Berthe
Direction Nationale De La Santé, Marseille, France
Stillbirths estimated at 2.6 million in 2015 in developing countries are a public
health problem. It is defined as the total number of stillbirths in the total number
of births reported over a given period. A stillbirth is defined by WHO as a lifeless
born fetus weighing ≥ 1000g and gestational age is ≥ 28 weeks of amenorrhea.
Thus, we proposed this analysis of the routine data of stillbirths registered in health
facilities in Mali over a period of nine years.
This is a retrospective descriptive cross-sectional study. We used routine data from
1 January 2008 to 31 December 2016 in the Community Health Centers (first level of
the health system) and Reference Health Centers (the first reference).
In total 94495 deaths were reported by first-level health institutions with an average
of 10497, a median of 9934, the extremes range from 8449 in 2009 to 13448 in 2008
(see Table 11).
From 2008 to 2016 4 102 691 deliveries and 94475 stillbirths, ie a rate of 2,30%.
The region of Sikasso has the highest rate (2.88%), followed by Gao and Timbuktu respectively
2.87 and 2.70.
These data from the routine health information system can be supplemented by an analytical
study to better explain these high stillbirth rates in the country in order to take
adequate measures.
Table 11 (abstract P78).
Distribution by region of the number of stillbirths, number of deliveries and stillbirth
rates from 2008 to 2016 in Mali
Regions
Number of stillbirths
Number of deliveries
Rate of stillbirths
Kayes
9531
499617
1,91
Koulikoro
16965
751892
2,26
Sikasso
24210
840856
2,88
Ségou
15476
648786
2,39
Mopti
8926
432395
2,06
Tombouctou
2083
77135
2,70
Gao
1414
49195
2,87
Kidal
96
4999
1,92
Bamako
15774
797816
1,98
Mali
94475
4102691
2,30
P79 Framework for respectful care after stillbirth
Dell Horey1,2,3,4, Fran Boyle2,3,4, Vicki Flenady2,3,4, Anne Schirmann2,5
1College of Science, Health & Engineering, La Trobe University, Bundoora, Australia;
2Centre of Research Excellence in Stillbirth, Brisbane, Australia; 3Mater Research
Institute - University Of Queensland, South Brisbane, Australia; 4International Stillbirth
Alliance, Bristol, UK; 5School of Public Health, University of Queensland, Herston,
Australia
Correspondence: Dell Horey
Care after stillbirth is a main focus area of the new Centre of Research Excellence
(CRE) in Stillbirth in Australia. This area of practice is complex, multifaceted,
not well-defined and largely informed by evidence that is fragmented. The use of diverse
approaches to describe or define areas of practice is common across health-care and
is recognised as a significant impediment to high quality research evidence by creating
barriers to evidence synthesis and research collaboration. Such challenges are evident
in several systematic reviews related to care after stillbirth published in recent
years that include recommendations that either encompass the broad scope of care after
stillbirth or focus on isolated aspects of care. It can be difficult to consolidate
key messages from different reviews because of the different approaches taken.
In other health areas, one successful strategy used to overcome similar problems has
been to develop conceptual frameworks to guide research directions. The CRE aimed
to develop a framework focussing on the goals of respectful care after stillbirth
that could describe different activities and how they interact.
We used a multi-stage process involving clarification of the goals of respectful care
after stillbirth through a review of the literature and analysis of parent responses
to a large online multi-country survey about stillbirth. The initial draft framework
was presented to parents and clinicians at the 2016 Perinatal Society of Australian
and New Zealand (PSANZ) conference in Townsville.
The framework for respectful care after stillbirth addresses four main goals of care:
good communication; shared decision-making, recognition of parenthood; and effective
support. Each goal has associated practice areas (Fig. 12).
The framework shows how the context for respectful care can be used to conceptualise
and evaluate different strategies to support parents who experience stillbirth and
those that care for them.
Ethics approval pertaining to survey data was granted by the Mater Health Services
Human Research Ethics Committee on 29th November 2013 (Ref #HREC/13/MHS/121) and by
the University of British Columbia Office of Research Services, Behavioural Research
Ethics Board on 22nd December 2014 (Ref #H14-02784). Completion of the anonymous online
survey indicated consent to participate in the study. Ethics approval was not required
for other data sources, which were drawn from published materials available in the
public domain.
Fig. 12 (abstract P79).
Framework for respectful care after stillbirth
P80 “Anticipating death at birth”: perinatal palliative care in a maternity hospital
setting
Anna Maria Verling1,2, Orla O’Connell1,2, Noirin Russell1,2, Keelin O’Donoghue1,2,3
1Pregnancy Loss Group, Department of Obstetrics & Gynaecology, University College
Cork, Cork, Ireland; 2Cork University Maternity Hospital, Cork, Ireland; 3Irish Centre
for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork,
Ireland
Correspondence: Anna Maria Verling
Perinatal palliative care involves the provision of supportive care for a baby and
their family during pregnancy and after delivery when a life limiting condition is
diagnosed. The uncertainty these parents face requires a comprehensive and individualised
approach from the time of diagnosis through delivery and beyond, which in our hospital
is provided by the multidisciplinary bereavement team.
This was a retrospective review from 2012-2016 of all pregnancies with prenatally-diagnosed
life-limiting fetal anomaly, which resulted in stillbirth or neonatal death. We excluded
pregnancies diagnosed within 1-2 weeks of delivery, or those where the team had limited
involvement. Cases were identified from birth registers and clinic records, with data
supplemented by individual chart review. Data were analysed using Microsoft Excel.
There were 73 pregnancies with life-limiting fetal anomaly (including 10 multiple
pregnancies) where parents chose to continue their pregnancy and were managed by the
multidisciplinary team. Diagnosis was at a median gestation of 20 weeks (range; 12-28)
and included anencephaly (9), major trisomy (20), renal agenesis (9), triploidy (4),
thanatophoric dysplasia (2) and complex congenital heart disease (6). Thirty-eight
infants (38/73; 52%) were stillborn and delivered at a median gestation of 32 weeks
(range;23-40 + 2). The remaining infants delivered at a median gestation of 36weeks
(range; 28-39). Twenty-four died on the first day of life, 9 died between day 2 and
6 and two infants died at home on days 7 and 11 respectively.
The multidisciplinary team approach is based on respect, dignity and compassion which
focuses on parental choice. Working with parents collaboratively affirms the value
of their baby’s life and also their identity as parents. With 14 pregnancies managed
by the team in a maternity setting annually, skilled expertise has developed in caring
for families following antenatal diagnosis of life-limiting fetal anomalies.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference No: ECM 6(aa) 06/01/15).
P81 Audit of quality of care provided to parents who experienced stillbirth in a hospital
setting
Claire Everard1,2, Simon Long3, Keelin O’ Donoghue1,2,4
1Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University
College Cork, Cork, Ireland; 2Cork University Maternity Hospital, Cork, Ireland; 3Department
of Computer Science, Cork Institute of Technology, Cork, Ireland; 4Irish Centre for
Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
Correspondence: Claire Everard
Clinical audit is a valuable tool which can shape education, improve healthcare delivery
and pinpoint areas for future research. Our aim was to develop a customised audit
tool to review of the quality of care provided to parents who experience stillbirth
in our hospital.
A literature search was performed and audit tools from various organizations were
reviewed. A consultant obstetrician and midwife agreed the data points, using the
National Clinical Guidelines and the National Bereavement Standards for reference.
The audit tool was developed by a software engineer. Data were entered via a secure
web form interface and charts were automatically generated and updated as new data
were entered.
We report findings of the first forty charts audited. With the exception of two mothers
(2/40; 5%) all deliveries occurred in the delivery suite/theatre setting. Infant birth
weights ranged between 210 to 5400 grams. A plan of care was documented in 97.5% (39/40)
of hospital charts when a stillbirth diagnosis was made and the infant’s name was
recorded in all obstetric notes with the exception of one (1/40; 2.5%). In 85% (34/40)
of cases mother’s vital sign documentation was recorded, but in 37.5% (15/40) there
was no evidence of lactation care recorded. Only 20% (8/40) of obstetric charts had
a fully completed stillbirth checklist which is local hospital policy for the multi-disciplinary
team. Of those reviewed, 45% (18/40) had a post mortem. Contact with the community
professionals was inconsistent, with 75% of general practitioners and only 62.5% of
public nurses having documented contact from the hospital after stillbirth.
It is crucial that care around the time of stillbirth is reviewed to ensure that parents
receive both meaningful and evidence-based healthcare, enabling them to recover from
this life-altering event.
P82 Development of an electronic audit tool to review quality of care in stillbirth
Claire M. Everard1,2, Simon Long3, Keelin O’ Donoghue1,2,4
1Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University
College Cork, Cork, Ireland; 2Cork University Maternity Hospital, Cork, Ireland; 3Department
of Computer Science, Cork Institute of Technology, Cork, Ireland; 4Irish Centre for
Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
Correspondence: Claire M. Everard
Stillbirth is a devastating clinical outcome of pregnancy for parents and healthcare
staff. Research has shown that poor and uncoordinated care affects parents’ recovery
and impacts future pregnancies. It is vital for maternity units to review the quality
of care provided for bereaved parents. Audit is a valuable tool to determine whether
a unit is giving good care and support to bereaved parents, and identifies possible
improvements. Our aim was to develop a customised audit tool for review of the quality
of care provided to parents who experience stillbirth.
A literature search was performed and audit tools from various organizations were
reviewed. A consultant obstetrician and midwife agreed the data points, using the
National Clinical Guidelines and the National Bereavement Standards for reference.
The audit tool was developed by a software engineer, and loaded onto a tablet PC.
Data was entered via a secure web form interface and charts were automatically generated
and updated as new data was entered.
In a pilot study, obstetric charts were inputted into the audit tool, and some changes
made to the format. Next, the audit tool was peer-reviewed by the hospital bereavement
team and the Pregnancy Loss Research Group. The final customised audit instrument
consists of 76 questions designed to record the management of bereaved parents during
stillbirth diagnosis, delivery, investigation and follow–up. It takes approximately
one hour to complete each chart on the audit tool.
This new audit tool captures a large amount of information about the quality of care
which parents bereaved by stillbirth receive. The next phase of this audit instrument
is to input the data for CUMH stillbirths from 2008 to 2016. If this audit tool provides
valid, accurate and user-friendly data, it will be considered for national use and
integration into the electronic health record.
P83 The challenge of classifying the unexplained
Anna Maria Verling1,2, Indra San Lazaro1,3, Sarah Meaney1,3, Keelin O’Donoghue1,2,4
1Pregnancy Loss Research Group, Department of Obstetrics & Gynaecology, University
College Cork, Cork, Ireland, Cork, Ireland; 2Cork University Maternity Hospital, Cork,
Ireland; 3National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland;
4Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College
Cork, Cork, Ireland
Correspondence: Anna Maria Verling
Stillbirth is one of the most common adverse pregnancy outcomes. Classification of
stillbirth is an essential component of clinical practice and crucial for stillbirth
prevention. There are over 30 systems available for perinatal mortality classification
globally. No one system has been adopted as a standard, which makes international
comparison impossible. This study aimed to evaluate concordance between a selection
of international stillbirth classification systems.
All stillbirths between 2008 and 2015 (n = 298) were identified following a retrospective
chart review. Eight were excluded due to insufficient data. Cause of death was assigned
according to five classification systems; National Perinatal Epidemiology Centre Classification
(NPEC); Wigglesworth; Tulip; Relevant Conditions at Death (ReCoDe); Cause of death
and associated conditions (Codac).
With the exception of Wigglesworth, the most common cause of death in the remaining
four classification systems was from placental causes (28.6%, 39.7%, 36.2%, and 36.3%).
In all classifications systems the percentage of stillbirths from congenital anomaly
was approximately 24%. Using Wigglesworth, two thirds of stillbirths were unexplained
or unclassifiable (62.8%; n = 182); this is significantly higher than the other four
systems (Tulip 21.7%, ReCoDe 22.1% and Codac 23.1%) with NPEC having the lowest percentage
of these cases (20%; n = 58). Of the 182 cases of unexplained stillbirth classified
by Wigglesworth, between 45.8% and 61.6% were identified as having a cause of death
related to the placenta within the other four systems.
The value of any classification system is in its ability to identify cause of death
and determine contributing factors, however our findings show that at least half of
the cases identified as unexplained in Wigglesworth can be attributed to placental
conditions within the other four systems. A classification system with low rates of
‘unexplained’ stillbirth is imperative to identify and develop preventative policies
and guidelines in maternity care.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference No: ECM 6(aa) 06/01/15).
P84 Developing and implementing the national Perinatal Mortality Review Tool (PMRT)
for the UK
Jenny Kurinczuk1, Elizabeth Draper2, David Field2, Marian Knight1, Charlotte Bevan3,
Thomas Boby1, Peter Brocklehurst4, Ron Gray1, Sara Kenyon4, Brad Manktelow2, Janet
Scott3, Judy Shakespeare1, Lucy Smith2, Peter Smith1, Derek Tuffnell5, Hannah Knight6,
Alan Cameron6, Zarko Alfirevic6, Mandy Forrester7, Karen Luyt8, Alexander Heazell9,
Dimitrios Siassakos8, Claire Storey8, Tracey Johnston10
1National Perinatal Epidemiology Unit, University Of Oxford, Oxford, UK; 2University
of Leicester, Leicester, UK; 3Sands, London, UK; 4University of Birmingham, Birmingham,
UK; 5Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK; 6Royal College
of Obstetricians and Gynaecologists, London, UK; 7Royal College of Midwives, London,
UK; 8University of Bristol, Bristol, UK; 9University of Manchester, Manchester, UK;
10Birmingham Women’s Hospital, Birmingham, UK
Correspondence: Jenny Kurinczuk
Parents report that in many instances when a stillbirth occurs a local, structured
review of the care provided is not conducted and this is confirmed by evidence from
national confidential enquiries. As a consequence parents are not always given a meaningful
explanation of why their baby died and the opportunity for service improvement is
missed. Based on the work led by the Department of Health and Sands we have been commissioned
to develop and implement the national Perinatal Mortality Review Tool (PMRT). The
goal of the PMRT is to provide a structure to the process of local perinatal death
review thereby improving the quality of the review, maximising learning, and improving
service delivery and information for bereaved parents.
The PMRT will be integrated within the MBRRACE-UK system which collects surveillance
data about all perinatal deaths in the UK. The tool is based on the principle ‘review
once, review well’ by guiding the local multi-disciplinary team through a structured
process which considers all aspects of care from pre-conception through to bereavement
care and parent follow-up. The views of parents are being incorporated based on evidence
from the PARENTS study.
The PMRT has been scoped by a multi-disciplinary team and software development is
underway to incorporate the tool into the MBRRACE-UK system. User engagement will
guide development at all stages as the tool is iteratively developed and released.
Alongside the tool we are developing training materials to support the conduct of
high quality reviews and how to use the PMRT as part of the review process. Piloting
is in planning with roll out anticipated by the end of 2017.
The PMRT has the potential to improve information for parents, as well as leading
to service improvements and consequently reduce the stillbirth rate in the UK.
P85 Care of families pregnant after stillbirth: results of an international consensus
statement
Noor Niyar N. Ladhani1,5,6, Megan E. Fockler1,4, Louise Stephens2, Jon F. R. Barrett1,5,6,
Alexander Heazell3
1Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, Canada; 2Central
Manchester University Hospitals NHS Trust, Manchester, UK; 3Tommy’s Stillbirth Research
Centre and Maternal and Fetal Health Research Centre, Central Manchester University
Hospitals NHS Trust, Manchester, UK; 4Lawrence S. Bloomberg Faculty of Nursing, University
of Toronto, Toronto, Canada; 5Division of Maternal–Fetal Medicine, Department of Obstetrics
and Gynaecology, University of Toronto, Toronto, Canada; 6Maternal Fetal Medicine,
Sunnybrook Health Science Centre, Toronto, Canada
Correspondence: Noor Niyar N. Ladhani
Stillbirth has a pervasive impact on families, including during subsequent pregnancies.
A current lack of clear care pathways for healthcare providers means that care provided
varies widely and that many families do not receive coordinated, compassionate, and
knowledgeable services. There is increasing evidence that families are not satisfied
with existing care pathways and that specialized care is needed during pregnancies
after stillbirth.
In October 2015, a consensus meeting was held in Canada. The meeting was a platform
to discuss the current evidence, management, and challenges related to pregnancy care
after stillbirth internationally, and an opportunity to develop a consensus statement
on care of women and their families in pregnancies subsequent to stillbirth.
Representation from nine countries and several specialties were present, including
Maternal Fetal Medicine, Obstetrics, Midwifery, Nursing, and Social Work. The meeting
also included parent representation from perinatal loss organizations. Recommendations
were developed for six priority areas, including:
Screening and Investigations - e.g. role of prenatal screening and antiphospholipid
antibody testing
Medical Therapies – e.g. role of aspirin and anticoagulation
Monitoring in Pregnancy – e.g. regimens for monitoring fetal growth
Mode/Timing of Delivery – e.g. indications for early term delivery and mode of delivery
Psychosocial Care Considerations – e.g. family-centred care and specialist-led clinics
Other Considerations – e.g. stillbirth definitions and international considerations
The consensus statement provides guidance for care providers caring for families in
pregnancies after stillbirth and will be endorsed by medical, nursing, allied health,
and perinatal loss organizations.
Pregnancy after stillbirth presents unique challenges for families and care providers.
Optimized medical surveillance, interventions, and psychosocial support by knowledgeable
healthcare providers are crucial. The consensus statement findings represent the group’s
collective analysis, evaluation, and expert opinion on the best possible way to care
for women and their families in subsequent pregnancies.
P86 Risk factors for stillbirth
Jennani Magandran1,2, Emily O’Connor1,2, Sarah Meaney1,3, Anna Maria Verling1,2, Noirin
E Russell1,2, Keelin O’Donoghue1,2,3,4
1Pregnancy Loss Research Group, Cork, Ireland; 2Cork University Maternity Hospital,
Cork, Ireland; 3National Perinatal Epidemiology Centre, Cork, Ireland; 4Irish Centre
for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
Correspondence: Jennani Magandran
In Ireland, the stillbirth rate is 4.5 per 1,000 births. Knowledge of stillbirth may
be affected by personal or clinical experience as well as provision or absence of
dedicated staff training and education. This study sought to determine the background
knowledge of stillbirth among healthcare professionals.
A cross-sectional survey examining knowledge of stillbirth risk factors in healthcare
professionals working in a large, tertiary-level maternity unit with 392 midwifery
and 54 medical staff was performed. A detailed questionnaire on stillbirth risk factors
was distributed to a random sample of staff members. Descriptive analysis was performed
using SPSS v23.
Two hundred and twelve surveys were completed by a cohort of 167 midwives (79%) and
45 doctors (21%). Of these, 93.4% were female (n = 198). Half of participants correctly
identified the rate of stillbirth and 62.3% correctly identified the definition of
stillbirth in Ireland. Forty-four per cent had attended a stillbirth delivery. Questions
and statements regarding risk factors for stillbirth are summarised in Table 12. The
most common correctly identified risk factors for stillbirth were smoking (98%), pre-existing
hypertension (91.7%), obstetric cholestasis (89.4%), previous history of stillbirth
(84.7%), BMI > 30 (82%), recurrent pregnancy loss (76.2%) and maternal age > 35 (75.5%).
Less well recognised risk factors included previous caesarean section (29.6%) and
maternal influenza A infection (35.5%)
Although many risk factors were correctly identified, there was a lot of variation
in knowledge and awareness of established stillbirth risk factors among midwives and
doctors in our centre. Many respondents were uncertain regarding the relevance of
risk factors and left questions unanswered. Dedicated education for healthcare professionals
regarding stillbirth risk factors is essential to optimise patient care.
Ethical approval for the study was granted by Clinical Research Ethics Committee of
the Cork Teaching Hospitals (Reference No: ECM 6(aa) 06/01/15).
Table 12 (abstract P86).
Correct identification of known risk factors for stillbirth and answers regarding
statements on stillbirth in 212 Irish healthcare professionals
Risk factors for Stillbirth
True (%)
False (%)
Don’t know (%)
Unanswered (%)
Previous caesarean section delivery
59 (29.6)
125 (59)
15 (7)
13 (6.1)
Previous stillbirth
172 (84.7)
23 (10.8)
8 (3.8)
15 (7.1)
Recurrent pregnancy loss
154 (76.2)
37 (17.5)
10 (4.7)
9 (4.2)
Obstetric cholestasis
185 (89.4)
14 (6.6)
8 (3.8)
5 (2.4)
Influenza A
70 (35.5)
67 (31.6)
60 (28.3)
15 (7.1)
Maternal smoking
202 (98)
3 (1.4)
1 (0.5)
6 (2.8)
Pre-existing hypertension
187 (91.7)
9 (4.2)
8 (3.8)
8 (3.8)
Maternal age over 35 years
154 (75.5)
41 (19.3)
9 (4.2)
8 (3.8)
BMI over 30
140 (82.4)
17 (8)
13 (6.1)
42 (19.8)
True statements regarding stillbirth
Maternal age >40 doubles risk
132 (62.3)
35 (16.5)
35 (16.5)
10 (4.7)
Sleeping in right lateral position increases risk
24 (11.3)
154 (72.6)
30 (14.2)
4 (1.8)
Multiple pregnancy increases risk
140 (66)
44 (20.8)
20 (9.4)
8 (3.8)
Black women have 4-5 times higher risk than Caucasian women
45 (21.2)
78 (36.8)
82 (38.7)
7 (3.3)
Down syndrome increases risk of stillbirth at term
84 (39.6)
89 (42)
31 (14.6)
8 (3.8)
Primiparity doubles the risk
28 (13.2)
137 (64.6)
35 (16.5)
12 (5.6)
Risk increased beyond 39 weeks in primigravida > 40 years old
136 (64.2)
55 (25.9)
16 (7.5)
5 (2.4)
Inter-pregnancy increase of BMI by 5units
89 (42)
47 (22.2)
68 (32)
8 (3.8)
False statements regarding stillbirth
Risk with obstetric cholestasis 10%
116 (54.7)
37 (17.5)
52 (24.5)
7 (3.3)
IUGR is a factor in 40% of cases
166 (78.3)
16 (7.5)
23 (10.8)
7 (3.3)
80% of stillbirth occurs in high-risk pregnancies
92 (43.4)
89 (42)
24 (11.3)
7 (3.3)
40% of stillbirths at term due to placental abruption
117 (55.2)
50 (23.6)
40 (18.9)
5 (2.4)
Commonest cause of stillbirth 24-28 weeks is infection
112 (52.8)
42 (19.8)
50 (23.6)
8 (3.8)
Recreational cannabis use increases risk by 20%
119 (56.1)
32 (15.1)
56 (26.4)
5 (2.4)
Equal risk between GDM and IDDM patients
52 (24.5)
117 (55.2)
38 (17.9)
5 (2.4)
P87 Process of developing guidelines for health professionals who support parents
who have had a loss from a multiple pregnancy
Judith Rankin1, Louise Hayes1, Judy Richards1, Lisa Crowe1, Claire Campbell2, Nicholas
Embleton2
1Newcastle University, Newcastle upon Tyne, UK; 2Newcastle upon Tyne Hospitals NHS
Foundation Trust, Newcastle upon Tyne, UK
Correspondence: Judith Rankin
Parents who lose one baby from a multiple pregnancy experience mixed emotions of enormous
grief for the baby who died along with hope and joy at the birth of their surviving
baby. In our qualitative work, staff reported that they felt they lacked confidence
in supporting bereaved parents in this situation. We describe here the development
of guidelines for health professionals involved in supporting parents after the loss
of a baby from a multiple pregnancy.
We worked with health professionals and parents to develop the guidelines using a
co-design approach. Transcripts of interviews from our previous study were reviewed
to identify ‘training points’, factors that were important in determining whether
or not parents felt supported by health professionals at the time of their bereavement,
and areas where health professionals felt they lacked confidence. Draft guidelines
were circulated to health professionals, patient representatives and representatives
from relevant patient organisations. These individuals were then invited to attend
a workshop to discuss the draft guidelines and agree changes. The final version of
the guidelines has been disseminated.
We identified behaviours and actions that staff can adopt that parents find helpful
around the time of a bereavement which were incorporated in the guidelines: Recognising
that the pregnancy is a multiple pregnancy; Acknowledging the bereavement; Providing
emotional support to parents; Providing appropriate information to parents; Providing
as much continuity as possible; Offering memory making; Handling cot occupancy sensitively;
Preparing parents for discharge from hospital.
Health professionals often lack confidence in supporting parents who have experienced
a bereavement from a multiple pregnancy. We worked with health professionals and parents
to develop guidelines for staff working in this area. The guidelines will be revised
in response to feedback on their use and we will assess their impact on staff knowledge
and confidence.
P88 Stillbirth in Ireland, 2015 – a national clinical audit into mortality due to
stillbirth
Irene O’Farrell, Paul Corcoran, Edel Manning, Sarah Meaney, Linda Drummond, Paulette
deFoubert, Richard Greene
National Perinatal Epidemiology Centre, UCC, Cork, Ireland
Correspondence: Irene O’Farrell
Mortality due to stillbirth is a significant measurement of the outcome of obstetric
care. For this reason, in 2011, the National Perinatal Epidemiology Centre (NPEC)
established the first national clinical audit of stillbirth in Ireland.
Anonymised data on stillbirths that occurred between January 1 and 31 December 2015
were collected by contributors from each of the 19 maternity units in Ireland using
a validated and standardised notification form. National rates per 1,000 births and
corresponding 95% confidence intervals were calculated.
In total in 2015, 294 stillbirths were reported to the NPEC, representing a rate 4.5
per 1,000 births. The most common causes of death in stillbirths were major congenital
anomaly (n = 79, 27%) and placental conditions (n = 71, 24%). Antepartum deaths accounted
for 270 of stillbirths (92%) and intrapartum deaths accounted for 18 (6%), the pre-delivery
life status of the baby was unknown for 6 stillbirths (2.0%). Labour was induced for
over two-thirds of women who experienced antepartum stillbirth (n = 178, 67%; unknown
for 6 cases) whereas labour was spontaneous for 17% (n = 45). Vaginal cephalic delivery
was the most common mode of delivery (n = 160, 59%) for women experiencing antepartum
stillbirth.
Robust clinical audit of perinatal outcomes are vital for monitoring and improving
patient care. The establishment of a confidential enquiry for deaths due to stillbirth
should be considered in order to enhance the lessons which may improve care. Anonymised
placental histology reports on perinatal death should be submitted to the NPEC as
part of this audit: this would facilitate standardised interpretation and classification
of placental conditions.
Ethical approval for the NPEC national clinical audits of obstetric outcomes was provided
by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (Reference:
ECM 4(g) 05/08/08)
P89 Incorporation of vasa praevia screening into a routine anomaly scan
Elizabeth Daly- Jones1, Lisa Story2, Alexandra Drought1, Ciara Mckenna3, Philippe
De - Rosnay1, Millicent Nwandison1, Neil Sebire4, Dr Philippe Jeanty5, David Nyberg3
1West Middlesex University Hospital, West London, UK; 2St Thomas’ Hospital, London,
UK; 3The Medical Chambers Kensington, London, UK; 4Editor of The fetus.net, Nashville,
Tennessee, USA; 5Great Ormond Street Hospital, London, UK
Correspondence: Elizabeth Daly- Jones; Lisa Story
Vasa praevia (VP) has a reported fetal mortality of 60% if not recognized before attempt
at vaginal delivery. Prenatal detection by ultrasound is possible in nearly all cases,
but can be notoriously difficult unless there is a high index of suspicion. We report
our experience in detection of VP using a structured protocol as part of the routine
fetal anomaly scan at 20-22 weeks
Patients attending anomaly screening at a single centre over a 5 year period (2012-2016)
underwent assessment for VP using a structured protocol as a part of a routine fetal
anatomy scan. Suspected cases of VP were then re-scanned by a specialist sonographer
and subsequently followed up. The diagnosis of VP was assigned by documentation of
fetal vessels beneath the membranes, within 20 mm of the internal cervical os.
24690 anatomy scans were performed during the study period and 56 of these were identified
as potential VP at the 20 -22 week anomaly scan. Of these, 20 were confirmed by the
ultrasound specialist at 28 weeks or later. In five patients the only risk factor
was a velamentous insertion. All 20 patients had planned caesarean delivery but one
patient bled at 35 weeks before planned delivery and this fetus died. Another patient
experienced bleeding and an emergency caesarean delivery at 31 weeks 3 days, and this
baby lived. The remaining 18 had caesarean delivery as planned. Placental histology
was available in 11 cases. No case of VP was unexpectedly found at delivery during
the study period (100% detection).
The incidence of vasa praevia in this unselected population is 1:1234. Fetal mortality
was 5% for cases detected prenatally. It is therefore recommended that routine assessment
should be incorporated into routine anomaly screening using a structured protocol
similar to the one presented here.
P90 Still birth saga: trends of etiology over a period of ten years in a tertiary
care hospital in India
Neelam Aggarwal
N aggarwal, Pgimer, Chandigarh, India
Although India shares the highest magnitude of still births among all south east Asian
countries but as per NHS -4 there is marked achievement in health status of women.
We studied causes of all still births(SBs) who delivered in our institute over last
ten years and analyzed the trends.
Objective:
To analyze the etiology of still births and their changing trend over a period of
10 years period.
This is a retrospective cohort study of all still birth delivered in a tertiary care
referral institute (PGIMER) of northern India over ten year period from 2007 to 2016.
The data was collected from monthly and annual perinatal audits and causes of stillbirths
along with details of each case were systematically reviewed. Cusick test for trend
was used to analyze the changing trends over these years.
There were 54160 total births during study period and out of these 3620 were SBs.
The still birth rate ranged from 62 to 73.6 per 1000 total births. The major causes
of still births were hypertensive disorders (27.58%), antepartum hemorrhage (19.5%),
and congenital anomalies (9.34%). Other causes were poor maternal condition (7.98%),
unexplained (7.75%), intrapartum still births (3.55%), rupture uterus (2.29%).Among
all still births 53.4% of women had intrauterine fetal death before reaching the hospital.The
autopsy rate has raised over years and it was 42% in 2016.
There was no significant change in trends of still birth rate over the years. Even
the etiology of still births is almost same over years which may be attributed to
being a referral institute.Hypertensive disorder of pregnancy and related complications
remained the single most major preventable cause of still birth
P91 Association of posttraumatic stress following stillbirth with being blamed for
the stillbirth, as mediated by maternal age and in-hospital support
Allison Badgley, Lauren Christiansen-Lindquist, Carol J. Rowland Hogue
Emory University, Atlanta, GA, USA
Correspondence: Lauren Christiansen-Lindquist
About 1 in 200 pregnancies in the United States end in stillbirth, resulting in substantial
psychological morbidities for bereaved mothers and their families. Factors occurring
during and immediately after the stillbirth have been reported to have the biggest
impact on the later development of posttraumatic stress (PTS) symptoms in bereaved
mothers, highlighting the importance of support received in the hospital.
We investigated the relationship and possible mediators between maternally reported
support received from hospital staff and PTS symptoms (measured with the Impact of
Events Scale [IES], range 0-75), from SCRN-OASIS follow-up maternal interviews of
a sample (n = 254) of mothers in the Stillbirth Collaborative Research Network study
who had a stillbirth 6 months to 3 years prior to follow-up. At the follow-up interview,
women were asked about events surrounding their earlier loss. Multivariable generalized
linear models were weighted by propensity scores for loss to follow-up and included
potential confounders and interactions (see list in accompanying Fig. 13).
The average IES score for participants reporting no in-hospital staff support was
31.4 (std = 17.5), compared to 27.1 (std = 16.1) among those reporting support from
nurses and other hospital staff (p = 0.111). However, PTS symptoms and associations
with support varied by age at index event and blame status. The support/PTS association
was not significant among women aged under 25, but was significant for women 35 or
older who reported having felt blamed for their loss. Hospital staff support was significantly
associated with lower PTS symptoms in all women aged 25-34, especially among those
who reported having felt blamed by others (see accompanying Fig. 13).
Receiving support in the hospital from nurses and other staff may be especially effective
in preventing post-traumatic stress among vulnerable populations of bereaved mothers
who may feel blamed for their loss, particularly if they are 25 or older.
The SCRN-Outcomes after Study Index Stillbirth (OASIS) study was approved by Institutional
Review Boards at all participating sites, including Emory University (Study 763-2005
(IRB00000764)). Women with stillbirth who had participated in the original SCRN case-control
study were contacted 6 months to 3 years after index delivery if they had provided
written consent for further contact.
Fig. 13 (abstract P91).
a Adjusted* mean change in IES score** attributable to reporting in-hospital support
among women who felt blamed others for their stillbirth. b Adjusted* mean change in
IES score ** attributable to reporting in-hospital support among women who did not
feel blamed by others for their stillbirth. *Adjusted for: maternal age, education,
marital status, trait anger, time since loss, and interaction of in-hospital support
with age and blame. **Impact of Event (IES) Scores <zero indicate fewer post-traumatic
stress symptoms than the mean for the group
P92 Prevalence of maternal disseminated intravascular coagulation after intrauterine
fetal death and correlation with maceration grade - a retrospective cohort study
Dana Muin, Vanessa Koller, Helmuth Haslacher, Herbert Kiss, Anke Scharrer, Alex Farr
Medical University Of Vienna, Vienna, Austria
Correspondence: Dana Muin
Disseminated intravascular coagulation (DIC) is a clinicopathological syndrome characterised
by generation of fibrin clots and concomitant consumption of platelets and coagulation
factors, leading to organ failure and contributes to high mortality, if left untreated.
Obstetrical conditions associated with DIC include maternal septic shock, placental
abruption, amniotic fluid embolism, as well as preeclampsia and HELLP and acute fatty
liver. Fetal maceration has first been proposed as a trigger for DIC in 1901, when
DeLee reported about “temporary haemophilia” in a woman who had developed a bleeding
disorder after placental abruption and stillbirth of a severely macerated fetus.
The present study was designed to retrospectively evaluate the incidence of coagulopathy
in a study cohort over 14 years and correlate the findings with fetal maceration grade
using three different DIC-scoring systems.
Coagulation test results (platelet count, fibrinogen, D-Dimer, prothrombin time) were
reviewed, scored and correlated with fetal maceration grade
Ten (10.2%) women suffered minor postpartum haemorrhage (PPH), three (3.0%) women
suffered major PPH, two of which had clinically verified overt DIC (maceration grades
I in both cases). Erez-Score resulted in DIC (score ≥26) in ten (10%) women, Clark-Score
resulted in DIC (score ≥3) in four (4%) women and ISTH-score resulted in DIC (score
≥5) in three (3%) women. All women (n = 2; 2%) in the study population with documented
overt DIC were correctly identified by all three scores. Erez-Score showed a statistically
significant correlation between women tested positive for DIC (score ≥ 26) and fetal
maceration grades 0 and 1 compared to fetal maceration grades 2-3 (p <0.05).
Combination of three DIC-scores (ISTH, Erez et al., Clark et al.) achieve the highest
sensitivity in detecting women with clinically overt DIC. Low fetal maceration grade
is significantly correlated with overt and non-overt DIC test-results by the Erez-Score.
Ethical approval for the study was granted by Medical Research Ethics Committee of
the Medical University of Vienna, Austria (Reference Number 1231/2017). Written informed
consent was obtained by all study participants.
P93 Understanding patient satisfaction as a measure of quality in perinatal bereavement
care in Spanish hospitals
Paul Cassidy1,2
1University Complutense Madrid, Madrid, Spain; 2Umamanita, Madrid, Spain
The objective of the study was to identify the aspects of care that had the greatest
predictive power over patient satisfaction.
The study used a cross-sectional descriptive design with an online questionnaire,
which included a series of objective measures of care (postmortem contact, mementoes,
terminology, birthing method, pathology studies, negligence, etc.) and subjective
evaluations of care quality using a battery of statements, measured on a Likert scale.
The study included women who had experienced fetal death ≥16 weeks gestation (stillbirth
or termination of pregnancy) and within 2 years prior to participation in the study.
Based on a series of theoretical considerations related to grief and care, multiple
sequential (forward method) regression was used to assess the ability of IVs (objective
and subjective) to predict satisfaction.
Responses from 615 women were analysed. Following appropriate testing for multicollinearity
and singularity, a significant regression equation was found for both sets of IVs
(objective and subjective). The final combined equation (F(8, 581) = 213.701, p <0.001)
had an R2 score that explained 74.9% of the variance (see Table 13). 7 subjective
variables were retained by the model, of which the 4 that made the strongest contribution
to satisfaction were: ‘feeling that HPs listened’, ‘doctors and nurses working well
as a team’, ‘being well-informed about procedures’, and ‘being emotionally supported
by nurses/midwives’. Only ‘incidence of reported or perceived negligence’ was retained
from the set of objective variables.
The results suggest that satisfaction with perinatal bereavement care is a complex
construct, whereby listening skills, coordination of care and effective information
permit women to feel in control of decisions. The dominance of subjective measures
suggests that satisfaction had more to do with the way that outcomes (e.g. having
postmortem contact, keeping linking objects, having an autopsy conducted, etc.) were
arrived at than the outcomes themselves.
Ethics approval for the project was not required from the institution for non-clinical
studies, however data was collected within an ethical framework.
Table 13 (abstract P93).
Final regression model summary
Change statistics
Independent variables*
R
2
Std. Error of the Estimate
R Square Change
F Change
Sig. F Change
Stand.
co-eff. Beta
1
I felt that the professionals listen to me
.585
.855
.585
817.328
.000
.223
2
The doctors, nurses and midwives seemed to work well as a team
.664
.770
.079
135.874
.000
.189
3
In general they kept me/us well-informed of all steps and procedures
.699
.730
.035
67.293
.000
.159
4
Incidence of ‘reported’ or ‘perceived’ negligence**
.720
.704
.021
43.840
.000
.166
5
I felt emotionally supported by the midwives/nurses
.736
.685
.016
34.150
.000
-.134
6
I felt that I had control over decisions related to medical aspects of care (type
of birth, medication)
.743
.676
.007
15.032
.000
.093
7
Even though I lost my baby, they (professionals) treated me like a mother
.747
.671
.004
9.798
.002
.087
8
There was one professional who guided me/us through the whole process
.749
.669
.002
4.837
.028
.062
n = 582
Method: Forward
Durbin-Watson: 2.024
(F(8, 581) = 213.701, p <0.001)
*Translated from Spanish by the author
**2.5% of respondents stated that they made a claim due to negligence and a further
23.3% replied that they believed there to be negligence, but didn’t report it (n = 608/MR = 7)
P94 The exploration of the emotional impact of perinatal bereavement support on midwives
caring for grieving parents
Felicity Agwu Kalu
Rotunda Hospital, Dublin, Ireland
Midwives and other healthcare professional are expected to respond appropriately to
the needs and expectations of grieving parents around the time of loss and in subsequent
pregnancies after the loss to enable them to cope with their loss. However, the provision
of effective bereavement support is challenging for some midwives because midwives
not only have to provide significant and varied amount of emotional support to bereaved
parents but also have to cope with their own emotional responses to the grief of parents.
Aim of the study
To explore the emotional impact of perinatal bereavement support on the midwives caring
for grieving parents.
The objectives of the study were:
To identify the factors that affect emotional well being of midwives caring for bereaved
parents
To identify emotional support needs of midwives to promote their abilities to provide
effective support to grieving parents
Data were collected through a structured questionnaire from three maternity hospitals
in Ireland. 268 midwives completed the questionnaire (71% response rate). Ethical
approval was received from three maternity hospitals, which were the research sites.
The results of the study showed that the emotional strength of midwives were significantly
related to their abilities to provide effective care to grieving parents (N = 268,
r = .378, p < .01). However, not all midwives had the emotional strength to remain
calm while providing bereavement care.
Midwives are emotionally challenged while providing perinatal bereavement care to
grieving parents. Organisations therefore need to provide adequate emotional support
and personal development opportunities to midwives caring for bereaved parents to
promote their emotional wellbeing and consequent abilities to provide effective care
to bereaved parents.
An ethical approval for the study was granted by The Rotunda Hospital, National Maternity
Hospital, and Coombe Women & Infants University Hospital Research Ethics Committees
(REC-2013-009 & REC-2013-018). This study was an anonymous survey. It was clearly
stated on each of the participant’s information leaflet that, by voluntarily completing
and returning the questionnaire, the participant was consenting to participate in
the research
P95 Systematic review: what are parents’ and healthcare professionals’ experiences
of care after stillbirth in low and middle income countries
Clare Shakespeare1, Abi Merriel2, Danya Bakhbakhi1, Claire Storey3, Dimitrios Siassakos2
1North Bristol NHS Trust, Bristol, UK; 2University of Bristol, Bristol, UK; 3International
Stillbirth Alliance, Bristol, UK
Correspondence: Clare Shakespeare
Stillbirths have a profound impact on women, families, and healthcare workers. The
burden is highest in low and middle income countries (LMICs) where an estimated 98%
of stillbirths occur. There is need for respectful and supportive care for women,
partners and families after bereavement. Previous reviews have focussed mainly on
high income, Westernised settings.
A systematic review of quantitative, qualitative and mixed-method studies of parents’
and healthcare professionals’ experiences of care after stillbirth in LMICs was carried
out. Studies were screened and data extracted in duplicate. Data was analysed using
the Sandelowski meta-summary technique to identify themes which could inform guidelines
for health care workers and improve the provision of care.
Studies were identified from Africa, Asia, Latin America and Europe. Emerging themes
identified include:
Women want supportive, respectful and empathetic care by skilled health care professionals,
with explanation and counselling both during and after delivery. Receiving this can
positively influence their experience.
Women may experience feelings of guilt, or feel that they carry much of the emotional
burden alone, and may fear negative social consequences and isolation due to their
reproductive status. Support by partners, families and the community throughout the
process from diagnosis to recovery at home is desired by women.
Spiritual and religious support is important, especially for women who rely on religious,
spiritual or supernatural explanations for what has happened to them.
Both staff and patients believe there is a need for specific training in caring for
women who experience perinatal loss.
More research is needed in a range of LMICs. Although there will always be cultural
differences to consider, there are sufficient similarities with themes identified
in reviews from high income settings to consider the development of an international
consensus for care after stillbirth for women and families in all settings.
P96 Risk assessment and management of diabetes in pregnancy and associated stillbirth
– an audit in North Bristol
Kate Dodd, Katie Cornthwaite, Dimitrios Siassakos
North Bristol NHS Trust, Bristol, UK
Correspondence: Kate Dodd
Diabetes in pregnancy is a key risk factor for stillbirth, with gestational diabetes
affecting around 5% of pregnancies in the UK. It can cause fetal complications including
macrosomia, polyhydramnios, delivery complications and stillbirth.
Patients are risk-stratified at their booking appointment and those that are high-risk
are offered further investigation for diabetes in their pregnancy and increased monitoring
for possible complications. Early detection of diabetes is vital for initiation of
appropriate management to optimise patients’ antenatal care.
We retrospectively investigated notes of patients who had a stillbirth that delivered
at North Bristol NHS Trust between February 2013 and October 2016 using a proforma.
We analysed the data using simple statistical tests.
Of 52 notes obtained, 39 were included. One patient had pre-existing diabetes. Sixteen
were diagnosed as having definite risk factors for gestational diabetes, whilst a
further 12 patients had indeterminate risk factors. Of these, seven patients (43.8%)
were offered screening for gestational diabetes and 5 underwent the screening – all
of which were negative.
On post-mortem examination, one fetus showed evidence of macrosomia and three showed
evidence of diabetes. Of these cases: one mother had one episode of significant glycosuria
but no other risk factors for diabetes; one had risk factors for gestational diabetes
but not screened; one had no risk factors for diabetes; and the macrosomic fetus was
born from the patient with pre-existing diabetes.
Diabetes in pregnancy is a major risk factor for stillbirth and it is fundamental
that patients are correctly risk-stratified for diabetes at their booking appointment,
with high risk patients receiving appropriate screening and management.
With this project, we aim to enhance the care of women by improving the risk-stratification
identification process and arrange appropriate follow-up investigations and management
to inform antenatal care and ultimately to reduce the risk of stillbirth.
Ethical approval for the audit was granted by the audit team at North Bristol NHS
Trust prior to the project being undertaken
P97 Saving Babies Lives: risk assessment and surveillance for fetal growth restriction
in women who have experienced a stillbirth
Kate Dodd, Danya Bakhbakhi, Dimitrios Siassakos
North Bristol NHS Trust, Bristol, UK
Correspondence: Kate Dodd
Around 3600 stillbirths occur in the UK annually - one of the highest rates in high
income countries.
In 2014, the ‘Saving Babies Lives’ bundle was developed and supported by NHS England
and the Royal Colleges, and developed using MBRRACE reports to improve prevention
of stillbirths, including risk assessment and surveillance for fetal growth restriction.
Impaired fetal growth is a major risk factor for stillbirth and detection of growth-restricted
fetuses is vital for recognition and appropriate management to prevent stillbirths.
‘Saving Babies Lives’ aims for all women to be risk-stratified for fetal growth restriction,
and all high-risk women should have serial growth scans. All low-risk women should
be assessed for growth restriction using had symphysis-fundal height (SFH) measurements
and referred for further assessment if indicated.
We retrospectively investigated notes of women who had experienced a stillbirth in
a hospital in Bristol between February 2013 and October 2016. We used the Saving Babies
Lives’ recommendations to identify if women met the criteria for fetal growth surveillance
and were managed appropriately.
Of 52 notes obtained, 39 were included. Although all 39 patients had SFH measurements
taken, none had measurements plotted on growth charts. Thirty-six patients (92.3%)
were suitable for SFH measurements used to measure fetal growth. Twelve patients were
deemed high-risk of growth restriction and all had serial growth scans. No patients
were mis-straified. Five high-risk patients (12.8%) had evidence of fetal growth restriction,
with no low-risk patients showing evidence growth restriction.
Plotted SFH measurements and serial growth scans are fundamental in the detection
and management of fetal growth restriction and its impact on stillbirths. We aim to
enhance our care of women by improving the documentation of measurements and risk-stratification
to reduce the risk of stillbirth by adhering to guidance from the ‘Saving Babies Lives’
bundle.
Ethical approval for the audit was granted by the audit team at North Bristol NHS
Trust prior to the project being undertake
P98 Association between delays in obstetric care and stillbirth: a case-control study
Marley Martins1, Flavio Ibiapina2, Ocilia Carvalho1, Antônio Viana Junior1, Raimunda
Magalhães2, Herlânio Carvalho1
1Maternidade-Escola Assis Chateaubriand – Universidade Federal do Ceará, Fortaleza,
Brazil; 2University of Fortaleza, Fortaleza, Brazil
Correspondence: Marley Martins, Flavio Ibiapina
Stillbirth is a sensitive indicator of the quality of and accessibility to health
care among pregnant women at all levels of care. This study aims to assess the association
between delays in the care provided to pregnant women seeking obstetric care and stillbirth
in a reference tertiary maternity hospital in Northeastern Brazil.
Case-control study with 65 participants (35 controls and 30 stillbirths) conducted
at the Assis Chateaubriand Maternity Hospital (Federal University of Ceará) from January
to April 2017. Live births occuring on a same day were selected as controls. Controls
were matched to cases (1 to 1) on gestational age at birth. Five controls refused
to participate in the interview. There were 5 intrapartum and 30 antepartum deaths.
Pearson’s chi-squared test and Fisher’s exact test were used to compare the groups.
Statistical significance was set at p < 0.05.
There were no statistically significant differences between the groups regarding socioeconomic
and obstetric variables. The delays assessed were: absence or inadequacy of antenatal
care (54.3 × 33.3%, p = 0.074), patient unaware of the signs of risk (20 × 3.3%, p = 0.045),
problems with patient transportation (22.9 × 10%, p = 0.148), difficult access for
geographic reasons (42.9 × 30%, p = 0.208), delayed diagnosis of obstetric status
(28.6 × 6.7%, p = 0.023), lack of trained personnel (31.4 × 6.7%, p = 0.013), delayed
initiation of treatment (74.3 × 40%, p = 0.005), regulatory difficulties/referral–counter-referral
(17.1 × 23.3%, p = 0.377), lack of resources/infrastructure (45.7 × 20%, p = 0.026).
In the stillbirth group, most delays in obstetric care were related to the patient/family,
the health system/infrastructure and the health team.
P99 Pregnancy after loss: women’s challenges and resources needed
Francine Demontigny1,2, Chantal Verdon2, Emmanuelle Dennie-Fillion2
1Université Du Québec En Outaouais, Gatineau, Canada; 2Center of Studies and Research
in Family Intervention, Gatineau, Canada
Correspondence: Francine Demontigny
From the pre-pregnancy to the postnatal period, future mothers having experienced
a previous perinatal bereavement undergo alternating emotions ranging from happiness
to fear and anxiety. Whereas some attention has been paid to the needs of mothers
during future pregnancies, little has been done to create resources for them. Purpose.
Explore mother’s needs in a pregnancy following perinatal bereavement.
A qualitative research was carried out with 8 women in the context of a focus group.
From pregnancy to the postpartum period, women identified various challenges met in
regards to the pregnancy. These challenges related to the concepts of conflicting
emotions as well as a sense of urgency “making up for lost time”, fear of the unknown,
loss of naivety, isolation as well as inadequately trained professionals and resources
to help them cope. Following these interviews, a support group for couples experiencing
a future pregnancy was set up to meet the needs of this specific population. An online
space to promote sharing and peer support was created as well.
Professionals can provide better support for couples experiencing a pregnancy after
perinatal bereavement. Recommendations for nursing and midwifery practice, education
and future research are identified.
P100 Abnormal placental cord insertion and risk of adverse pregnancy outcomes: results
from a prospective cohort study
Khadijah Irfah Ismail1, Ailish Hannigan2, Keelin O’Donoghue3, Amanda Cotter1
1Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick,
Limerick, Ireland; 2Biostatistics Department, Graduate Entry Medical School, University
of Limerick, Limerick, Ireland; 3Obstetrics and Gynaecology, University College Cork,
Cork, Ireland
Correspondence: Khadijah Irfah Ismail
Placental cord insertions (PCI) are categorised as central/eccentric (>2cm from placental
margin), marginal (<2cm from placental margin) or velamentous (insertion into the
membranes), with marginal and velamentous classified as abnormal PCI. A recent meta-analysis
suggests an increased risk of intrauterine fetal death (IUFD) with velamentous cord
insertion. We examined the association of abnormal PCI with adverse pregnancy outcomes
including IUFD.
This prospective cohort study examined 1005 placentas from consecutively delivered
singleton pregnancies in a tertiary centre. All the placentas were examined following
delivery. Standardised images of each placenta were taken. Distance of PCI to the
placental margin was measured digitally using ImageJ software. Outcomes including
small for gestational age (SGA) infants (<10th centile), low birthweight (<2500g),
preterm labor (<37 weeks gestation), IUFD and emergency cesarean section (CS) were
compared across groups (central, abnormal PCI) using logistic regression, adjusting
for maternal age, parity and smoking status. Odds ratios (OR) and 95% confidence intervals
were estimated using SPSS.
The rates of velamentous and marginal cord insertions in a total of 1,005 singleton
pregnancies were 3.6% (n = 36; 95% CI = 2.5–4.9%) and 6.4% (n = 64; 95% CI = 4.9–8.1%),
respectively. Abnormal PCI were found to be significantly associated with an increased
risk of SGA after adjusting for maternal age, smoking status and parity (Table 14).
Preterm labor was more common in the abnormal PCI group (5.1% vs 10.0%, p = 0.04)
but the adjusted OR was not significant (Table 14). There was no difference in emergency
CS rate across groups. There was one case of IUFD in the cohort with normal PCI and
a non-SGA fetus.
In this large prospective cohort, we were unable to assess the association of abnormal
PCI with IUFD. Due to the rarity of IUFD, a much bigger study is needed to assess
its association with abnormal PCI.
Ethical approval for the study was granted by Health Service Executive Research Ethics
Committee of University Hospital Limerick (REC Reference 32/13). Written informed
consent was obtained by all study participants.
Table 14 (abstract P100).
Maternal Characteristics and pregnancy outcomes across groups (Normal PCI and Abnormal
PCI)
Normal PCI (n = 905)
Abnormal PCI (n = 100)
p-value
Maternal age≥35 years
332 (36.7%)
30 (30%)
0.19
Parity
0
331 (36.7%)
39 (39%)
0.33
1
299 (33.1%)
26 (26%)
2+
272 (30.2%)
35 (35%)
Smoker
127 (14.8%)
22 (22.7%)
0.04
Birth weight<2500g
32 (3.5%)
11 (11.0%)
<0.001
SGA infant
120 (13.3%)
21 (21.0%)
0.035
Gestational age < 37 weeks
46 (5.1%)
10 (10.0%)
0.04
Emergency CS
147 (16.2%)
18 (18.0%)
0.65
P101 Factors contributing to bereaved parents of stillbirth consent to post-mortem
examination and reflections of their decision: a qualitative analysis
Erin Mccloskey, Alex Cohen, Hannah Blencowe
London School Of Hygiene & Tropical Medicine, London, UK
Correspondence: Erin Mccloskey
One of the most difficult decisions bereaved parents face with the sudden loss of
their child is to decide whether they wish to conduct a post mortem examination (PME)
to determine the cause of death. Although PMEs remain the gold standard in revealing
a stillbirth’s cause of death, consent rates have decreased. This project explores
bereaved parents’ decisions to accept or reject a post mortem examination and their
responses related to the results.
This secondary qualitative analysis explores a dataset which 22 parents were interviewed
comprising of 25 respondents. Three interviews comprised of both mothers and fathers.
Thematic analysis with an essentialist/realist approach was utilized as it identifies
and reports patterns from experiences, meanings and reality of the participants within
the data set. NVivo10 was used to manage the data.
Ten couples expressed a strong desire to find out the cause of death gave consent
to a thorough PME. Parents who gave consent prioritized determining the cause of death
by means of genetic testing to confirm they could try for another baby. One couple
gave consent to a limited PME, because they felt it wasn’t necessary to have a thorough
investigation. Eleven couples refused PMEs because of the lack of support and empathy
from staff and time constraints to bury the child. Parents reported psychological
distress from panic attacks and depression to more severe mental health issues.
Consent to PME was largely dependent upon the parents’ rapport with healthcare staff
and how PME was explained to them. Bereaved parents should not experience inadequate
and unsupportive care as it may affect consent rates. Despite how respondents felt
about consenting to PME, all parents felt the need to improve stillbirth bereavement
policies by educating the public through means of participating in studies to honor
their child.
This study is a secondary qualitative analysis. Ethical approval for the study was
granted by the University of Manchester Research Ethics Committee (Project, 09392).
Written informed consent was obtained by all study participants.
P102 Investigations undertaken following a stillbirth across Australian hospitals
Hanna Reinebrant1, Glenn Gardener1, David Ellwood2, Michael Coory1, Kassam Mahomed3,
Yee Khong4, Adrienne Gordon5, Alison Kent6, Vicki Flenady1
1Mater Research Institute-University Of Queensland, Brisbane, Australia; 2Gold Coast
University Hospital, Gold Coast, Australia; 3Ipswich Hospital, Ipswich, Australia;
4South Australian Pathology, Adelaide, Australia; 5Royal Prince Alfred Hospital, Sydney,
Australia; 6Centenary Hospital for Women and Children, Canberra, Australia
Correspondence: Hanna Reinebrant
Every day six babies are stillborn in Australia with 30- 50% classified as unexplained.
A cornerstone to developing effective intervention strategies to prevent stillbirth
is the accurate identification of cause of death based on appropriate investigations.
In this study we aimed to determine use of the comprehensive national clinical practice
guidelines on investigations for stillbirth.
A prospective multi-centre study of all stillbirths excluding terminations of pregnancy
was undertaken across 23 largely tertiary level maternity hospitals. Data were entered
by hospital staff using a purpose-built online database and classified according to
the Perinatal Society of Australia and New Zealand (PSANZ) system.
541 stillbirths were included; 49% were ≥28 weeks’ gestation and 16% were intrapartum.
A comprehensive maternal history was reported as available in 84% and external examination
by the clinician in 88%. Testing for feto-maternal haemorrhage was undertaken in 69%.Placental
histopathology was undertaken in 94%. While autopsy was offered to parents in 95%
of stillbirths, only 51% had an autopsy. Amniocentesis was performed in 19%. 41% of
stillbirths remained unexplained.
The recommended stillbirth investigations showed reasonable compliance across tertiary
settings in Australia. Although some areas for improvement were shown, including the
fundamental component of taking a comprehensive maternal history. Autopsy rates remain
low despite the national educational program (IMPROVE), on recommended investigations
and information materials for families. The proportion of unexplained stillbirths
is high and efforts to improve investigation and classification of stillbirths remains
an important issue in Australia.
P103 How do mobile pregnancy applications address decreased fetal movement as a risk
factor for adverse perinatal outcomes and stillbirth?
Lisa Daly1, Vicki Flenady1, Han Le2, Janine Roberts2, Kirsten Gibbons1
1Mater Research Institute - The University Of Queensland, Brisbane, Australia; 2The
University of Queensland, Brisbane, Australia
Correspondence: Vicki Flenady
Maternal perception of fetal movement is an indicator of fetal wellbeing, while a
perceived decrease in fetal movement (DFM) has clinical significance as a predictor
of pregnancies at risk of adverse outcomes, including stillbirth. Increasingly, pregnant
women are turning to digital sources of health information to build knowledge, track
data, share experiences and seek reassurance. Mobile applications intended for use
during pregnancy offer information about fetal movement, and may influence behaviour
of women experiencing DFM.
A systematic review was conducted to assess how mobile “pregnancy” applications address
decreased fetal movement, utilise evidence-based information, and encourage health
care-seeking behaviour. The search strategy identified eligible mobile applications,
with inclusion criteria based on accessibility, reach, relevance and quality. Two
reviewers extracted data from eligible mobile apps using predefined, standardized
formats, investigating the content explicitly linking DFM and adverse perinatal health
outcomes.
Based on inclusion criteria, 24 mobile applications relevant to pregnancy were included
in the review; all were available in English, had more than 100,000 installations,
and had high user quality ratings. All applications provided information about DFM.
However, explicit linkage of DFM to potential adverse health outcomes was slim: only
two mobile applications in the sample explicitly linked DFM to each of the following
adverse outcomes: low birthweight, fetal growth restriction, emergency delivery and
pre-term birth. Four apps linked DFM to higher risk of stillbirth.
This review is the first to assess information about fetal movement available in the
mobile applications used globally by millions of pregnant women. Women experiencing
DFM may act more quickly to investigate concerns if aware of potential, related adverse
perinatal outcomes. In development of antenatal education, clinicians, hospitals and
health systems should consider the content of mobile applications and their contribution
to patient knowledge and decision making.
P104 Is area-based socio-economic deprivation associated with stillbirth in Queensland,
Australia? A retrospective population-based study, 1994-2011
Susannah Hopkins Leisher1,2
1Columbia University Mailman School of Public Health; Mater Research Institute, University
of Queensland, Brisbane, Australia; 2International Stillbirth Alliance, Bristol, UK
About 2.7 million babies are stillborn every year. While 98% occur in low- and middle-income
countries, in high income countries huge disparity exists for disadvantaged women.
The primary objective of this study was to examine the association between area-based
socio-economic deprivation and stillbirth risk. Secondary objectives were to explore
changes over time, and association between deprivation and both cause-specific and
gestational age-specific stillbirth.
A retrospective population-based study, including singleton births included in the
routine birth data set between July 1994 and December 2011 in the Queensland, Australia.
Of 928,313 births, 893,648 were included in descriptive analysis and 890,084 in regression
analysis.
This study found that greater deprivation is associated with a higher risk of stillbirth.
The adjusted risk increased by 5% for every quintile increase in deprivation (22%
higher among most-deprived than least-deprived births, and 36% higher among births
of at least 28 weeks’ gestation). For every cause and gestational age period, the
risk of stillbirth was higher in the most-deprived than the least-deprived quintile.
The risk of stillbirth due to perinatal infection, hypertension, and antepartum hemorrhage
was more than twice as high among the most-deprived as least-deprived. The gestational
age risk was isolated to term births where the risk of stillbirth was increased by
13% for every quintile increase in deprivation. There was also evidence of a decreased
risk of stillbirth among most-deprived as compared to least-deprived quintiles over
time.
Results suggest that one driver of high stillbirth risk in Queensland is area-based
inequity, possibly related to differing access to, demand for, or quality of prenatal
services. Improved access to and quality of perinatal services in the most-deprived
areas are needed. The higher risk for term stillbirth and stillbirth due to antepartum
hemorrhage, perinatal infection, and hypertension should be explored.
The Australian Institute of Health and Welfare Human Research Ethics Committee (HREC)
and Queensland Health Central Office HREC approved the original study of which this
study forms a part (#EC2009/3/34 and #HREC/05/QHC/009). Specific approval for this
study is documented in #HREC/15/MHS/36 and #HREC/15/MHS/36/AM07, and by the London
School of Hygiene and Tropical Medicine MSc Research Ethics Committee (#10280). The
data was routinely collected and had been de-identified; hence, it was deemed unnecessary
to obtain informed consent. However, due to at-risk populations (pregnant women and
fetuses), extra precautions were taken. Continuous variables were converted to categorical
and continuous versions deleted. Combining variable categories and primary and secondary
suppression of data were used to protect the confidentiality of births represented
by small (non-zero) counts
P105 BHRUT Multidisciplinary Strategies to Reduce Stillbirths and Term IUD
Celia Burrell
Barking Havering and Redbridge University Hospital, Romford, Essex, UK
The UK stillbirth rate fell slightly from 0.54% (2000) to 0.47% (2013), but remains
higher than other European countries. UK is ranked 24th of the 50 highest income countries
worldwide (Lancet Reducing Stillbirth Series 2016). BHRUT stillbirth rate was 0.59%
(2011) falling to 0.4% (2013). BHRUT aims to reduce stillbirth and neonatal death
by 50% by 2030 (‘Sign Up To Safety Campaign’ 2014).
Method: To discuss the Bereavement Team and Risk Management Team Multidisciplinary
Strategies to reduce stillbirth and term IUD rates.
Results: (1) IMPROVEMENT IN TEACHING -INTRODUCTION OF FETAL LOSS STUDY DAY (2015).
Annual multidisciplinary study day teaches staff to improve communication, provide
sensitive and supportive care, with feedback and talks from bereaved women.
(2) INTRODUCTION OF CENTRAL MONITORING CTG AND A SPECIALIST CTG MIDWIFE (2016).
Supports midwives and doctors with CTG interpretation during intra-partum and antenatal
care. Includes ‘Fresh Eyes’ hourly CTG review in labour, to identify CTG misinterpretation
to escalate and expedite delivery.
- REVIEW STILLBIRTH, IUD AND FETAL LOSS >24 WEEKS.
Introduce proforma to review cases, and launch RCA investigation after Serious Incidents
Group review. Lessons learnt are widely disseminated.
(3) SERVICE IMPROVEMENT: INTRODUCTION OF CONSULTANT-LED BEREAVEMENT CLINIC (2015).
Introduction of new guidelines; improvement in communication with proforma -women
submit questions for RCA; review and discuss case notes (investigations -postmortem);
practice the duty of candour; provide individualised/tailored management; and empowers
women with additional support in subsequent pregnancy.
BHRUT Multidisciplinary strategies have resulted in dramatic improvements:
- No CTG Misinterpretation Related SI or RCA declared past 8 months (August 2016-April
2017);
-New Proforma resulted in greater communication, empowerment and involvement of bereaved
women in RCA investigations and management plan in subsequent pregnancy.
(Lessons Shared– Abstract published as Poster Presentation at MBRRACE 2016 & EBC launch
2016)