Risk of Stillbirth and Infant Death Stratified by Gestational Age
1. Project Overvie · • Pregnancy Loss and Infant Death Alliance (PLIDA) • Sands –Stillbirth...
Transcript of 1. Project Overvie · • Pregnancy Loss and Infant Death Alliance (PLIDA) • Sands –Stillbirth...
2/12/2018
1
Women`s Health Symposium
February 9th, 20181
France Morin, RN, BScN, MScNPerinatal Consultant
Champlain Maternal Newborn Regional Program (CMNRP)
At the end of this session, you will be able to:
• Describe the methodology used to develop the new evidence-
based recommendations.
• Provide an overview of the new evidence-based
recommendations.
• Apply the recommendations in your practice when caring for
families experiencing an early pregnancy loss in the
Emergency Department.
• Discuss current services available for early pregnancy losses in
tertiary hospitals within our region.
2
1. Project Overview
3
4
• Develop recommendations for ED healthcare providers and
staff regarding the provision of compassionate care to
patients presenting with a confirmed early pregnancy loss
(less than 20 weeks gestation).
• Develop tools / reference materials for ED health care
providers and staff
• Early pregnancy loss: < 20 weeks gestation
- Recommendations may be applicable to other settings that care
for late pregnancy loss and infant death
• Out of Scope: medical management, educational materials
5
• While 25,000 patients in Ontario attended an ED
experiencing a pregnancy loss in 2015, this however
represents less than 1% of ED all visits – ED healthcare
providers and staff may not have a lot of experience
dealing with pregnancy loss.
• The medical management of pregnancy loss may be
familiar practice, however, the way in which psychological
and emotional support should be provided is not.
• Significant barriers include inexperience with, and the lack
of knowledge of perinatal bereavement care strategies and
communication skills.
6
2/12/2018
2
Name Title/ Position Organization
Doreen Day Senior Program Manager Provincial Council for
Maternal and Child Health
Olha Lutsiv Program Analyst Provincial Council for
Maternal and Child Health
France Morin Perinatal Consultant Champlain Maternal
Newborn Regional Program
Laura Zahreddine Masters of Nursing Candidate Health Quality Ontario
7
The Project Team was supported by an Expert Advisory Panel.
Role of the Expert Advisory Panel included:
• Guiding the development of the recommendations/ materials
• Providing content expertise
• Providing feedback on the recommendations and materials created
• Acting as a liaison between the project team and experts in the field, when required
8
Name Title/ Position Organization Sonia Baruzzo Social Worker (Obstetrics); Patient Advisor The Ottawa Hospital
Nadine Duhil-Enns Midwife Family Midwifery Care
Josh Gohl Registered Nurse (Emergency Department); Patient Advisor Guelph General Hospital
Batya Grundland Family Physician; Maternity Care Lead for Family Practice Obstetrics Women's College Hospital
Terri Irwin Director, Quality Standards Health Quality Ontario
Kate MacWilliams Registered Nurse (Emergency Department); Clinical Educator St. Joseph’s Health Centre Toronto
Barbara Matteucci Founder of Butterfly Run Quinte; Doula; Patient Advisor Butterfly Run Quinte
Howard Ovens Emergency Physician, Chief of Department of Emergency Medicine Sinai Health System
Gareth Seaward Obstetrician (Maternal-Fetal Medicine Specialist); Vice-Chair of Quality
Improvement and Patient Safety in Department of Obstetrics and Gynaecology
Sinai Health System
Elaine Senis Social Worker (Emergency Department) St. Michael's Hospital
Lindsey Sutherland Family Physician (Primary Care, Obstetrics, Emergency Medicine, Hospital
Medicine)
Chatham-Kent Health Alliance
Heather Tempest Registered Nurse (Labour and Delivery, Early Pregnancy Clinic) North York General Hospital
Melissa Theriault Nurse Practitioner (Emergency Department) Hôpital Montfort
Jackie Thomas Obstetrician/ Gynecologist; Founder of Early Pregnancy Clinic Sinai Health System
Catherine Varner Emergency Physician Sinai Health System
Ashley Waddington Obstetrician/ Gynecologist (Early Pregnancy Clinic) Kingston Health Sciences Centre
Jo Watson Nurse Practitioner; Operations Director of Women & Babies Program;
Director of Pregnancy and Infant Loss Network (PAIL)
Sunnybrook Health Sciences Centre
Arthur Zaltz Obstetrician/ Gynecologist; Chief of Department of Obstetrics & Gynecology
and Women & Babies Program
Sunnybrook Health Sciences Centre
9
2. Methodology
10
1. Literature Review
2. Current Practice Review
3. Patient Engagement Survey
4. Expert Advisory Panel Consensus
11
• Databases: PubMed, CINHAL, EMBASE, Cochrane Library
• Literature obtained from communications and outreach
to the field
• Qualitative and quantitative studies, position statements
from professional organizations, evidence based
practice guidelines
12
2/12/2018
3
13
Total of 142 Articles
Total of 142 Articles
16 Records WITH
Emergency Room
16 Records WITH
Emergency Room
Pregnancy Loss
Pregnancy Loss
BereavementBereavement
EmpathyEmpathy
126 Records WITHOUT Emergency
Room
126 Records WITHOUT Emergency
Room
Pregnancy Loss
Pregnancy Loss
BereavementBereavement
EmpathyEmpathy
Examples of guidelines used:
• National Perinatal Association (NPA)
• The National Institute for Health and Care Excellence (NICE)
• The Society of Obstetricians and Gynaecologists of Canada (SOGC)
• Queensland Clinical Guidelines (QCG)
• American College of Obstetricians and Gynaecologists (ACOG)
• Canadian Paediatric Society (CPS)
• Pregnancy Loss and Infant Death Alliance (PLIDA)
• Sands – Stillbirth and Neonatal Death Charity
14
• Policies, brochures and any materials currently used in
EDs were sought out through outreach to:
- LHIN Leads
- TC LHIN ED Leads
- PCMCH Maternal Newborn Advisory Committee (MNAC)
- Canadian Perinatal Programs Coalition (CPPC) Listserv
- Maternity Care Discussion Group (MCDG) Listserv
- Canadian Association of Perinatal and Women’s Health
Nurses (CAPWHN) Listserv
- BestStart Listserv
- ER and OB Social Workers and Educators across Ontario
15
Objective: to better understand the experience of families who
had received care for an early pregnancy loss in an ED
Approach:
• mixed quantitative and qualitative online survey
• distributed via Facebook, Twitter, PCMCH website
• survey open for 2 weeks in March
• Eligibility:
- ectopic pregnancy or pregnancy loss <20 weeks in the last 12 months
- received care for the pregnancy loss in an ED in Ontario
• thematic analysis of qualitative data
16
N = 52 participants
17
East (e.g., Ottawa, Kingston, Peterborough)
Greater Toronto Area (e.g., Toronto, Peel)
North (e.g., Thunder Bay, Sudbury, Parry Sound)
West (e.g., London, Hamilton, Waterloo, Niagara, Brant)
18
3
10
10
20
9
2/12/2018
4
19
0
7
7
13
17
The themes that emerged about what families want, include:
• Empathy –acknowledgement of feelings of loss and emotional pain; extra sensitivity in communication, language (e.g., “baby”), and overall provision of care (e.g., ultrasound)
• Information – options and risks/benefits (e.g., D&C); what to expect and next steps; follow-up care
• Referrals – social worker, spiritual care, mental health services, support groups
• Timeliness – communication of diagnosis; frequent checks/ not being left unattended for long period of time
• Privacy– not being forced to wait for the diagnosis in the main waiting area; privacy
20
3. Recommendations
21
28 Recommendations:
1. Environmental Considerations (1)
2. Communication Strategies & Considerations (5)
3. Cultural, Religious & Spiritual Considerations (1)
4. Informational Needs (4)
5. Psychological Needs & Supports (5)
6. Memories & Mementoes (3)
7. Disposition of Fetal Remains (5)
8. Discharge Considerations & Follow-up (3)
9. Training & Support of Healthcare Providers and Staff (2)
22
23
Recommendations are available on the PCMCH website (http://www.pcmch.on.ca/health-care-providers/maternity-care/pcmch-
strategies-and-initiatives/early-pregnancy-loss-emergency-department/)
4. Tools and Resources
24
2/12/2018
5
1. Summary of Recommendations
2. Bereavement Checklist
3. Communication Strategies for Breaking Bad News
4. Communicating with Families Experiencing a Pregnancy Loss
5. Bereavement Package and Mementoes
6. Normal Grief Response
7. List of Pregnancy Loss Resources for Families and Healthcare
Providers
8. Discharge Teaching for Patients Experiencing an Early
Pregnancy Loss
25 26
27 28
29 30
2/12/2018
6
31 32
33
Recommendations and tools are available on
the PCMCH`s website:
www.pcmch.on.ca
34
5. Dissemination
35
1. Social Media – Facebook, Twitter, PCMCH
Website
2. Conferences (CAPWHN)
3. ED LHIN Leads
4. Professional Associations
5. Regional Maternal Child Networks
6. Obstetrical and ED Educator List Serve
36
2/12/2018
7
6. Implementation
37
• The MOHLTC has supported the Pregnancy and
Infant Loss Network at Sunnybrook Health Sciences
to implement these recommendations
• They will begin by doing a needs assessment survey
with Emergency Department educators to find out
what they should focus on
38
7. Current Services Available for Early Pregnancy Losses
39
• Referrals for patients with NON VIABLE pregnancies in the first
trimester (missed abortion, incomplete abortion, ectopic pregnancies)
• Runs 5 days per week (Mon-Fri)
• Patients usually seen within 24-48 hrs
• Counselling re: management options
• Investigations required:
- Formal ultrasound scan (will accept referral if the U/S is pending)
- CBC and quantitative BhCG
- Type and screen
• Fax referral to 613-548-1330
40
• Outpatient service provided by a group of OB/GYNs (General and Civic campuses)
• Referrals for patients in early pregnancy (< 20 weeks) seen in ER: - pregnancy complications (e.g. vaginal bleeding, abdominal pain or cramping)
- have been diagnosed with a pregnancy loss or miscarriage
• Patients usually seen in OB/GYN office within 24-48 hrs
• Investigations: ultrasound, lab work
• Counselling re: management options
• Pts are followed until pregnancy complications are resolved. They are then encouraged to follow up with their own primary care provider
41 42