3 QUALITY AT COUNTIES MANUKAU HEALTH
Implementation of the Growth Assessment Protocol (GAP) BY JOYCE COWAN, NZ GAP LEAD EDUCATOR, MIDWIFE
Being small for gestational age (SGA) is strongly associated with stillbirth. A New Zealand study on stillbirth at term showed that 37% of stillborn babies were growth restricted (Stacey et al, 2012)33, and New Zealand data (PMMRC, 2014)34 reports that for all stillbirths of growth restricted babies during 2007-2012, only 22.6% were recognised as SGA antenatally. Antenatal detection with timely delivery can lead to significant risk reduction (Gardosi, Giddings, Clifford, Wood & Francis, 2013)35.
CM Health is currently introducing the GAP programme into maternity care. In May and June this year 74 midwives attended training sessions at Middlemore, following on from workshops previously been held in 2014 and 2015. The GAP programme consists of the following elements: 1. Implementation of evidence based protocols and guidelines 2. Training and accreditation of all staff involved in clinical care (includes standardised fundal height measurement and use of customised growth charts) 3. Rolling audit and benchmarking of performance Use of customised standards better identifies the babies that are not reaching their growth potential, and more accurately identifies those pregnancies at risk of increased perinatal morbidity and mortality than does use of population growth standards, which do not adjust for individual maternal characteristics. A recent Australian study showed that detection of fetal growth restriction was doubled with the use of customised growth charts (Roex, Nikpoor, Van Eerd & Dekker (2012)36. The Growth Assessment Protocol (GAP) was pioneered by the UK based Perinatal Institute and has recently been linked with a significant reduction in stillbirth (Gardosi et al., 2013).
Course attendees.
While CM Health and Tairawhiti have been the first to implement GAP, there are several other DHBs considering adopting the programme. Initial workshops are provided by the Perinatal Institute educators, and then continued by the local trainers supported by the Perinatal Institute and a link team comprised of obstetric, ultrasound and midwifery leaders. Feedback from midwives attending the workshops has been very positive and further education sessions are planned for obstetric and ultrasound staff.
Stacey, T., Thompson J. M.D., Mitchell E.A., Zuccollo J.M., Ekeroma A.J., & McCowan L.M.E. (2012). Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth: Findings from the Auckland Stillbirth Study. Australian and New Zealand Journal of Obstetrics and Gynaecology; 52: 242-247. 34 PMMRC (2014). Eighth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2012. Wellington: Health Quality & Safety Commission. 35 Gardosi J., Giddings, S., Clifford, S., Wood, L. & Francis, A. (2013). Association between reduced stillbirth rates in England and regional uptake of accreditation training in customised fetal growth assessment. BMJ Open; 3:e003942. 36 Roex, Nikpoor, van Eerd, Hoddyl & Dekker ( 2012) Serial plotting on customised fundal height charts results in doubling of the antenatal detection of small for gestational age fetuses in nulliparous women. Australian and New Zealand Journal of Obstetrics and Gynaecology 2012; 52: 78–82. 33
68 CMH MATERNITY QUALITY AND SAFETY PROGRAMME