Confidential regional enquiry into mature stillbirths and neonatal deaths--a multi-disciplinary peer panel perspective of the perinatal care of 238 deaths.

AIM OF STUDY

To examine the sub-optimal factors relating to the care of stillbirths and neonatal deaths of birthweight 2.5 kg and above.

DESIGN

Regional confidential enquiry into stillbirths and neonatal deaths by multi-disciplinary panel.

METHODS

All 238 stillbirths and neonatal deaths of 2.5 kg and above in West Midlands Region, UK in the year 1991 were studied. Documents from each death were peer-reviewed by four assessors, one from each of the 4 disciplines, selected randomly from a pool of 24 senior obstetricians, paediatricians, general practitioners and midwives. Panel consensus for each death was reached to identify relevant factors related to sub-optimal care which might have prevented or would reasonably be expected to prevent an adverse outcome (Grades II & III sub-optimal care).

RESULTS

A total of 149 (62.7%) deaths were considered by the panel to have grade II or III factors. Of these, 151 (68.9%) were found in the antepartum period, 44 (20.1%) in the intrapartum period and 24 (11.0%) in the postpartum period. The majority (78.1%) of these factors involved clinical practice of care providers. Factors related to patient/family, equipment and staffing constituted 19.6%, 1.4% and 0.9% respectively. Important sub-optimal factors identified were lack of appreciation of antenatal and intrapartum risks factors (17.8%), the failure of proper interpretation and management of antepartum and intrapartum cardiotocography (12.8%), failure of adherence to accepted practice or standard care (12.8%), inadequate skills in neonatal resuscitation (4.5%) and adverse patient-related factors (19.6%).

CONCLUSION

Substantial scope exists for confidential multi-disciplinary peer review audit of current obstetric and neonatal care in the region in formulating a strategy to reduce perinatal mortality.