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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.