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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

IUD (Intrauterine Fetal Death) (658)

Warning
Please report any inaccuracies or issues with this guideline using our online form

This aim of this guideline is to standardise care of those women presenting to maternity triage with an intrauterine death. It should be used to counsel women sensitively about her options and identify those at risk of medical complications in whom immediate intervention may be required. 

Definitions1:

  • Late fetal losses – the baby is delivered between 22+0 and 23+6 weeks of pregnancy showing no signs of life, irrespective of when the death occurred.

  • Stillbirths – the baby is delivered from 24+0 weeks gestation showing no signs of life. If Intrauterine death had been diagnosed (usually by ultrasound) prior to 24 weeks and delivery does not take place until 24 weeks this should be classified as a late fetal loss or miscarriage as appropriate.

  • Early neonatal deaths – death of a live born baby (born at 20 weeks gestation of pregnancy or later or ≥ 400g where an accurate estimate of gestation is not available) occurring before 7 completed days after birth.

  • Miscarriage: The spontaneous expulsion from the uterus of a fetus that shows no signs of life before 24 weeks gestation

Diagnosis

  • Take a full history

  • Enquire about fetal movements noting that passive movements after IUD can be felt.

  • Perform basic maternal observations and an antenatal check including maternal heart rate, respiratory rate, blood pressure, temperature, urinalysis and abdominal palpation

  • Diagnosis should be made by real time ultrasound assessment of fetal cardiac pulsation.

  • A second person trained in ultrasound scanning should be present where possible.

  • Where views are difficult to obtain colour doppler and umbilical cord doppler can be used

  • If possible and confident to do so perform a single measurement such as head circumference HC/ abdominal circumference AC or  femur length FL to date pregnancy at this stage 

  • Fetal hydrops, intra-fetal gas or overlapping skull bones may be seen and evidence of these should be documented.

  • If possible try to have support with patient at the time of USS  – if not, once the diagnosis is confirmed offer to call a relative or friend for support

  • Ensure that serious pathology has been excluded such as chorioamnionitis, pre-eclampsia, coagulopathy and abruption

  • Women should be strongly advised to take immediate steps towards delivery if there is sepsis, pre- eclampsia, placental abruption or membrane rupture

  • Take urgent bloods for Full blood count,  group and save and coagulation, CRP and baseline UE/LFT

  • All women should have a have Kleihauer undertaken as soon as possible after presentation as the haemorrhage may have occurred some time before presentation. This allows diagnosis of any feto-maternal haemorrhage as possible cause of the IUD and allows timely administration of Anti-D should the woman be Rhesus negative.

  • Where feto-materal haemorrhage has occurred the dose of Anti-D should be altered and a repeat Kleihauer should be performed at 48 hours to ensure fetal cells have been cleared.

Management

Vaginal delivery

  • A vaginal delivery can be achieved in 90% of women in 24hours following induction of labour with an IUD

  • Benefits include recovery time and less time to discharge as well as reduced risks for future pregnancies.

  • Those with group-B strep do not need intrapartum antibiotic prophylaxis

  • If concerns regarding sepsis and infection follow appropriate antibiotic therapy guidance

Caesarean section

  • On occasions maternal request for c-section can be considered along with her previous medical and obstetric history

  • Those with a previous c-section should be discussed with the obstetric consultant on call and arrangements made to see an obstetric consultant to discuss delivery options.

  • Those with 1 or 2 c-sections can be advised that IOL is safe but does come with a risk of uterine rupture.

  • Those with 3 c-section scars or atypical scars should be advised that the safety of IOL is unknown

Expectant management

  • 85% of women with a confirmed IUD will labour spontaneously within 3 weeks

  • This is an uncommon management option

  • Women who choose expectant management should be warned about the increasing risk of medical complications with prolonged expectant management and should be seen twice a week to exclude DIC and sepsis. The risk of DIC is 10% within the first 4 weeks and 30% thereafter. 

  • Women should also be warned that the appearance of the baby may deteriorate and the value of post mortem examination can be affected with prolonged expectant management.

Investigations following IUD (following admission to Labour ward)

Reasons for intrauterine death will include congenital malformation, congenital fetal infection, antepartum haemorrhage, pre eclampsia and maternal diabetes mellitus. Intrapartum causes will be secondary to placental abruption, maternal and fetal infection, cord prolapse, uterine rupture and hypoxia-acidosis.

Directing investigations to detect causes and their indications are listed below

  • Full blood count FBC, urea and electrolytes UE, liver function tests LFT’s , coagulation screen , Creactive protein CRP 
    To detect pre eclampsia, sepsis and it’s complications such as multi organ failure and disseminated intravascular coagulopathy DIC. 

  • Kleihauer
    To detect late feto-maternal haemorrhage – in all women, not just rhesus negative. Where feasible this should be carried out as soon as possible to diagnosis of IUFD in all women. 

  • Bacteriology , maternal blood cultures, mid stream urine specimen, high vaginal swab , cervical swab 
    Indicated if maternal fever and sepsis, flu like symptoms or abnormal liquor including prolonged rupture of membranes.

  • Maternal serology 
    If maternal fetal infection suspected  e.g fetal hydrops can use booking serum for baseline serology. Parvovirus B19. rubella, CMV herpes and toxoplasma gondii . Treponemal serology can be checked on booking bloods. Consider checking other virus’ if the woman has travelled abroad to endemic areas.

  • Maternal HBA1c
    May indicate type 1 or 2 DM. GDM patients may still have a normal HBA1c

  • Thrombophilia screening
    Lupus anticoagulant and anticardiolipin antibodies should be performed at a later date (e.g post natal follow up) as pregnancy may affect the results

  • Fetal and Placental swabs for microbiology
    Fetal ear and maternal and fetal surfaces of placenta should be swabbed.

  • Placental tissue for karyotyping 
    Offer to all women - written consent is required . Cultures can sometimes fail.
  • Post mortem examination

    We would encourage all women to have a full post mortem. This may lead to changes in future pregnancy management in up to 20% of cases. 

    Ideally this should be discussed by the on call consultant. If a full post mortem is not wished then the pros and cons of a limited post mortem should be discussed. Written consent is required. 

    If PM is declined, the baby should be examined by the on-call obstetrician and the findings documented.

Management after 24 weeks

The majority of women are suitable for vaginal delivery

Those with active bleeding, evidence of abruption or sepsis should be admitted. 

 Where no indications for admission and observation exist 

Administer Mifepristone 200mg orally + arrange admission to LABOUR SUITE 24-48 hours later

 

  • Care should be provided by an experienced midwife in a private room where partners can stay overnight

  • Prescribe all medications on a kardex to avoid delays on admission

  • Side effects of mifepristone include abdominal cramp, rashes and headaches

  • Contraindications include severe asthma, porphyria, renal or liver failure.

  • Benefits include reduced time spent in hospital, reduced number of misoprostol doses and reduced risk of retained placenta

  • Women should be encouraged to attend the department sooner if they have a fever, bleeding, pain or feel otherwise unwell – give contact number for labour suit directly. They will need support during this time

  • If any concerns regarding sepsis initiate appropriate therapy- see antibiotic guideline

  • If there are any patient concerns these women should be brought to labour suite immediately

  • Women should be advised to avoid non steroidal analgesics

  • Women should be warned about the possibility of feeling passive fetal movements

Labour suite

  • 4 hourly observations to be completed either on a MEWS chart or the partogram from admission to labour suite.

  • Partogram to be used and fully completed once labour commenced

Administer Misoprostol 50micrograms every 4 hours per vagina (5 doses)

 

  • If after the 1st round of misoprostol (all 5 doses) delivery has not occurred inform the obstetric registrar who should perform a pelvic examination

    The obstetric consultant should advise a subsequent plan

    Repeat Misoprostol regime

    OR

    3mg prostin per vagina and repeat at 6 hours. If still undelivered / not in established labour a further discussion with the obstetric consultant should occur
  • Labour should be actively managed and this includes the second and third stages

  • ARM should not be performed unless discussed with senior obstetrician and very rarely before 4cm dilation as this may slow progress and increase the risk of infection. A potential exemption may be in the case of massive abruption and IUD where ARM may hasten the process.

  • If there is delay in the second stage there should be a low threshold for consultant involvement as the lack of tone may make delivery of the baby more difficult.

  • Active management of the third stage should occur in line with PPH risk assessment

  • If the placenta appears incomplete and bleeding is ongoing evacuation of retained products of conception should be performed under anaesthetic.

  • Care should be tailored to individual requests and needs where feasible.

Determining sex of baby

This can be potentially difficult due to hydrops or maceration. Advise parents about this potential difficulty when appropriate

2 experienced healthcare professionals (midwives, obstetricians, neonatologists or pathologists ) should examine the baby if determination of sex is difficult. In some cases determination of sex may not be possible and pathology / karyotype will have to be awaited.  

Prior to discharge

  • Post mortem examination should be discussed by the consultant on duty where possible – if not a senior doctor comfortable in discussing PM could take consent. Parents should be given written information by their midwife prior to a final discussion. Parental consent for PM must be documented in notes – also if declined.

  • Perform a thromboprophylaxis risk assessment.

  • Check rhesus status and ensure anti-D given if appropriate.

  • Offer lactation suppression with cabergoline 1mg single dose - contraindicated in hypertensive women.

  • Arrange for immediate discharge letter, appropriate venous thromboembolism risk assessment, pain relief and iron if required.

  • Inform the community midwife / general practitioner and the woman’s lead consultant.

  • Ensure all antenatal appointments have been cancelled

  • Offer counselling services and support group information ( family bereavement service). The Child Bereavement Service will see families ≥23 weeks. Before this gestation referral should be made to SANDS or the Miscarriage Association.

  • Discussion regarding contraception should occur before discharge

  • Clear contact details for MAU or Labour Ward should be given to the parents in case of any postnatal concerns.

  • Written information should be given to the parents to let them know a review of their pregnancy and delivery will take place. They should be given written information on how to contribute if they have specific questions they wish addressed.

  • A Datix should be completed for all losses ≥22 weeks

Follow up

This should be arranged by the lead consultant for that patient. On occasions a consultant colleague with significant involvement in the case may take over this responsibility.  

Follow up normally occurs 8-12 weeks following the event but patients should be informed that this can be re-arranged if they do not feel able to attend at that stage. 

Management plans for future pregnancies should be documented in the patient’s notes  

Editorial Information

Last reviewed: 04/12/2018

Next review date: 01/12/2023

Author(s): Laurie Anderson.

Approved By: Obstetrics Clinical Governance Group

Document Id: 658

References
  • Late intrauterine Fetal Death and Stillbirth, RCOG Green Top Guideline 55, October 2010.

  • MBRRACE-UK Mothers and Babies- reducing Risk through audits and Confidential enquiries across the UK