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NHS England unveils ‘care bundle’ to reduce stillbirths

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NHS England has published a “coherent” set of new guidance, which are focused on key elements of best practice to help reduce the number of stillbirths across the country.

The Saving Babies Lives Care Bundle follows a two-year programme of work involving extensive engagement with clinical experts.

“This is the first time guidance specifically for reducing the risk of stillbirth… has been brought together in a coherent package”

Matthew Jolly

The care bundle – combining a small number of focused interventions based on “best available evidence and practice” – forms part of a government drive to halve the rate of stillbirths from 4.7 per thousand to 2.3 per thousand by 2030.

There are currently over 3,000 stillbirths in England every year – equivalent to one in every 200 babies and more than double the rate of nations with the lowest levels. In addition, there is around a 25% variation in stillbirth rates across the country.

The guidance is intended to address the variation by bringing together four key elements of care – reducing smoking in pregnancy, enhancing detection of foetal growth restriction, improving awareness of the importance of foetal movement and improving foetal monitoring during labour.

For example, an information and advice leaflet on reduced foetal movement is being launched and will be provided to all women by week 24 of their pregnancy. It will contain “clear messaging” consistent with national guidelines, said NHS England.

“We would expect trusts to use this guidance to provide the best possible care to mothers, babies and their families”

Cathy Warwick

It is the first time that guidance specifically for reducing stillbirths has been brought together in a “coherent” package, said NHS England, noting that would support commissioners, providers and professionals in “making care safer for women and babies”.

The bundle was developed by NHS England in partnership with the Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, British Maternal and Fetal Medicine Society and the stillbirth and neonatal death charity Sands.

The move follows recent publication of the recent National Maternity Review report and MBRRACE-UK’s report into antepartum stillbirth.

Professor Jacqueline Dunkley-Bent, NHS England’s head of maternity, children and young people, said: “Having a baby in this country is now safer than ever before, but for some mums that’s not the case, and the ‘care bundle’ and new national maternity review will help all families receive excellent maternity care.”

Dr Matthew Jolly, national clinical director for maternity and women’s health at NHS England, added: “Saving babies’ Lives’ provides clinicians with the best available clinical approaches to tackling stillbirth across four key elements of care.

“Though many NHS maternity care providers already follow much of this best practice, this is the first time that guidance specifically for reducing the risk of stillbirth and early neonatal death has been brought together in a coherent package,” he said.

“The UK’s progress on preventing avoidable stillbirths has, to date, been scandalously slow”

Charlotte Bevan

RCM chief executive Cathy Warwick said it was “not acceptable” for England to lag behind other western European countries on stillbirth numbers.

“The four key interventions outlined by NHS England are key to ensuring consistent care and in helping to reduce stillbirths,” she said.

“All trusts should be working to the same standards of care and we would expect them to use this guidance to provide the best possible care to mothers, babies and their families,” she added.

However, Professor Warwick repeated the RCM’s call for more staff to improve patient safety.

Cathy Warwick

Cathy Warwick

Cathy Warwick

“England remains 2,600 full-time midwives short of the number it needs,” she said. “So while this guidance is welcome and valuable, we must have the right numbers of staff to ensure it is implemented correctly.”

Charlotte Bevan, senior research and prevention advisor at Sands, noted that recent analysis by MBRRACE-UK suggested six out of 10 deaths might be prevented if basic antenatal guidelines were implemented.

“The UK’s progress on preventing avoidable stillbirths has, to date, been scandalously slow, four times slower than countries like the Netherlands,” she said.

She added: “The focus of the care bundle provides a long-overdue opportunity to reinforce best practice and ensure safer care both in pregnancy and during labour to protect babies’ lives in the future, and we urge trusts across the country to implement it straight away.”

The four key interventions outlined include:

  1. Reducing smoking in pregnancy – All women should be offered a test at their antenatal booking appointment to establish the level of carbon monoxide they are exposed to, as well as referral to support to stop smoking. This will ensure smokers and those exposed to smoke are fully aware of the risks to their unborn baby and are supported to make an informed decision about quitting or staying away from smoke. Latest figures show just over one in 10 women smoke during pregnancy, which is below the national target set for 2015, but masks wide geographical variation – figures from NHS Central London reveal around one in 100 women continue to smoke, but in NHS Blackpool it is one in four.
  2. Enhancing detection of foetal growth restriction – Growth of babies should be monitored and recorded on growth charts and an algorithm should be used to indicate the level of monitoring required. Of the one in 200 babies that are stillborn, growth restricted babies are the single largest preventable group.
  3. Improving awareness of the importance of foetal movement – Women and their partners should be better informed and more empowered to monitor their baby’s movements by clear, consistent advice. An information and advice leaflet on reduced fetal movement will be provided to all pregnant women. Providers should also have protocols in place to manage care effectively for women who report reduced movement.
  4. Improving foetal monitoring during labour – there should be annual training and assessment for staff on cardiotocograph interpretation and use of auscultation during labour. A buddy system for CTG interpretation should also be implemented so that ‘fresh eyes’ can detect any potential problems during labour.
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