3 QUALITY AT COUNTIES MANUKAU HEALTH
Perinatal Review Process BY DEBBIE DAVIES, PERINATAL LOSS MIDWIFE SPECIALIST
Perinatal mortality is reviewed nationally by the Perinatal and Maternal Mortality Review Committee and presented at an annual national conference. This is well attended by CM Health staff. Follow up on the recommendations from the PMMRC is now incorporated into CM Health’s Quality and Safety Governance Group’s Workplan.
In addition CM Health has its own perinatal and maternal mortality meeting four weekly, where local cases are discussed and recommendations to improve outcomes are made. They are run over three hours and a range of professionals attend this multidisciplinary meeting. It is now business as usual for CM Health to have a Perinatal Loss Midwife Specialist. This has been so successful that other DHBs are looking into or have appointed similar positions. From the initial major changes in the first two years, our service has continued to consolidate over the last twelve months.
Further Progress improving management of perinatal deaths Enhancement of the processes surrounding family care in the situation of perinatal loss by: • Improving our family space with additions to the area that make it a more comfortable place for whaanau at this very sad time. • Offering Korowai, made by a group of volunteer ladies from Papakura Marae, to our families. This has been a particularly touching gift to be able to offer, most especially for our families from Maaori origin. • Continuing to have a good working relationship with Baby Loss New Zealand. • Some families have chosen to use the services of Heartfelt (a free photography service) which has provided some precious memories and comfort to families at this particularly difficult time. • Utilising the two “Cuddle cots” donated through Middlemore Foundation. These cool cots enable families to be able to have their deceased baby with them in the ward. For many families keeping baby close to them is really important and it is a cultural expectation for some of our communities.
Continued improvement in providing care for Counties women and whaanau by: • Improving identification of perinatal losses as Serious Adverse Events (SAE), where appropriate, with the process that follows. The resulting recommendations are continuing to be implemented and are expected to impact on the care of individual women to improve outcomes in their subsequent births as well as bring about general practice change where indicated.
Korowai made and gifted by volunteers.
66 CMH MATERNITY QUALITY AND SAFETY PROGRAMME
• Focusing on education, continuing to reach new graduate midwives, nurses working in maternity, neonatal care and gynaecology, house officers, registrars. Two workshops have been run: ’Unexpected Outcomes in Pregnancy and How to Care for a Family When Their Baby Dies.” Thirtyeight staff members attended these workshops and represented various areas in the organisation as well as