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Table 4 Examples in the largest subgroups of identified SSF which were considered to address important issues

From: The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands

SSF Subcategory Examples (caregivers involved)
Use of guidelines Not used, without stating the reason -Evaluation of suspected Intra Uterine Growth Restriction (IM) *
   -Post-mortem examinations (G)*
   -Post-partum bladder care (N) *
   -Fentanyl administration (A) *
   -Postnatal paediatric consult when child lives > 1 hr after induction for congenital anomaly (G) *
   -Rectal temperature measurement after axillary measured temperature > 37.5 °C (N) *
Normal practice Incomplete use -History taking (IM) *
   -Insufficient time for good care during labour (N) *
   -Follow-up cease-smoking-advice (IM) *
  Not used, without stating the reason -Evaluation of polyhydramnios (G) *
   -Admission to ICU of critically ill patient (G) *
   -Care management program for patient with borderline personality disorder (IM) *
   -Interval between antenatal visits longer than advised (G) *
Documentation Base-line data not in patient record -Base line data on folic acid use, height, weight, ethnic background (IM,G) *
   -Results laboratory tests and ultrasound investigations (M, G) *
  Considerations/management not in patient record -Decision to perform a Caesarean Section (G) *
   -Choice for particular medication (G) *
Communication Insufficient within the same echelon and equal professional level -Handover of maternity care from general practitioner to independent midwife (GP) *
   -Information on the management of a urinary tract infection from general practitioner to independent midwife (GP) *
   -Exchange of patient information between the obstetric, genetics and pathology departments (G,CG,Pa) *
  Insufficient between echelons -Information from medical specialist to GP and IM after referral mother or child (G) *
   -Conflicting interpretations of post-mortem examination in patient letters to general practitioner and independent midwife (Pa) *
  1. * G,P,M,N,A,CG,GP,Pa,IM = respectievelijk: gaecologist, pediatrician, midwife, nurse, anaesthetist, clinical geneticist, general practitioner, pathologist, independent midwife.