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Objective To understand challenges in care after stillbirth and provide tailored solutions. Design Multi‐centre case study. Setting Three maternity hospitals. Population Parents with a stillborn baby, maternity staff. Methods Thematic analysis of parent interviews and staff focus groups and service provision investigation. Outcomes 1 Themes; 2 Triangulation matrix; 3 Recommendations. Results Twenty‐one women, 14 partners, and 22 staff participated. Service Provision: Care for parents after stillbirth varies excessively; there are misconceptions; post‐mortem does not delay follow‐up. Presentation: Women ‘do not feel right’ before stillbirth; their management is haphazard and should be standardised. Diagnosis: Stillbirth is an emergency for parents but not always for staff; communication can seem cold; well‐designed bereavement space is critical. Birth: Staff shift priorities to mother and future, but for parents their baby is still a baby; parents are not comfortable with staff recommending vaginal birth as the norm; there are several reasons why parents ask for a caesarean; better care involves clear communication, normal behaviour, and discussion of coping strategies. Post‐mortem: Parents are influenced by discussions with staff. Staff should ‘sow seeds’, clarify its respectful nature, delineate its purpose, and explain the timescale. Follow‐up: It is not standardised; parents wish to see their multi‐professional team. Conclusions There is unacceptable variation in care after stillbirth, and insensitive interactions between staff and bereaved parents. Understanding parents' needs, including why they ask for caesarean birth, will facilitate joint decision‐making. Every bereaved parent is entitled to good, respectful care. Tweetable abstract Care too varied & interactions often insensitive after stillbirth; national pathway & training urgently needed Plain Language Summary Why and how was the study carried out? Previous studies have shown that improving care after stillbirth is important for families. We investigated the opinions of bereaved parents and maternity staff to find ways to improve care. At three hospitals in 2013, all women who experienced a stillbirth were invited to an interview along with their partners. Thirty‐five parents of 21 babies agreed to participate. Twenty‐two obstetricians and midwives took part in focus group discussions. What were the main findings? Care was often not as good as it should and could be. Communication with parents was not always as sensitive as they would have liked because staff did not have appropriate training.Some women reported they did not ‘feel right’ before going to hospital. Once they arrived, there was no standard approach to how care was given. Sometimes there were long delays before the death of the baby was confirmed and action was taken.After it had been confirmed that the baby had died, staff focussed on the mothers’ needs, but the parents’ priorities were still with their baby. There were several reasons why parents asked for a caesarean birth that staff had not considered.Staff influenced parents’ decisions about post‐mortem examinations. Parents found it helpful when staff explained the respectful nature and purpose of the examination.After discharge from hospital, there was no consistent plan for how follow‐up care would be given. Parents would have liked more information about their next hospital appointment. What are the limitations of the work? The parents interviewed depended on their memories of the details of the care, which happened some time ago. In staff group discussions, junior doctors may not have spoken openly because there were senior doctors present. Further research is necessary to understand and improve care globally. What is the implication for parents? Every bereaved parent is entitled to the best possible care after stillbirth, but some do not get good care. Parents and staff made suggestions that can help to develop processes for how care is given after stillbirth. These suggestions can also inform staff training, so that every single parent is treated respectfully and participates in decision making., Tweetable abstract Care too varied & interactions often insensitive after stillbirth; national pathway & training urgently needed This paper includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14765

OBJECTIVES:Following a perinatal death, a standardised multidisciplinary review should take place. Learning from these deaths and engaging parents in this process could help prevent future perinatal deaths in line with United Kingdom (UK) national and international targets to reduce the number of such deaths by 2020. Moreover, it would support parents in understanding events around the death of their baby. An earlier study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death - PARENTS 1 study) found that parents would endorse the opportunity to give feedback into the perinatal mortality review process (PNMR). In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.METHODS:We followed a two-round Delphi technique to reach a consensus on core principles; including a national consensus workshop and an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent support groups, managers and commissioners) in stillbirth, neonatal and bereavement care (n=22). To develop recommendations for parental engagement, participants discussed four key areas including: receiving feedback from parents; format of the PNMR meeting; the parental pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent, anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critical). It had been agreed a priori, in compliance with established Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, that 'Consensus' would be achieved if over 70% scored the principle as 'critical' (score 7 to 9) and less than 15% scored the principle as 'not important' (score 1 to 3). Principles where Consensus was achieved would be included in the core recommendations.RESULTS:Twenty-five of the 29 invited stakeholders participated in the consensus meeting and the subsequent online questionnaire in June 2017 (86.2% response rate). Consensus was agreed on 12 core principles. Ninety-six percent agreed that it was of critical importance that there should be a face-to-face explanation of the PNMR process; 72% considered parents should be offered the opportunity to nominate a suitable advocate; 92% believed responses to parents' comments should be formally documented; 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process is monitored; and 100% of stakeholders voted that a plain English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.CONCLUSIONS:Key national stakeholders were unanimously supportive of parental engagement and agreed on core principles to make it feasible, meaningful and robust process. A six-month pilot of parental engagement in the perinatal mortality review process (PARENTS 2 Study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, findings will inform the national standardised perinatal mortality review tool (PMRT).

Two samples with contrasting garnet microstructures are examined in this paper. The first is a typical deformed garnet porphyroclast in an upper-amphibolite facies shear zone that affects the eclogites of the Glenelg–Attadale inlier of NW Scotland. The second sample a typical garnet porphyroblast from the Schneeberg Complex of the N-E Italian Alps. Garnet is critical to many thermobarometers and major element, trace element and isotopic zoning patterns together with inclusion assemblages are used to infer metamorphic histories. Many mantle models suggest that majoritic garnet is a major component of the mantle transition zone and may control mantle rheology. Thus understanding processes within garnet is of particular importance and requires microstructural data. The microstructures of two contrasting garnet grains are mapped using automated electron backscatter diffraction. In both cases there is a very strong crystallographic preferred orientation, with measurements clustered round a single dominant orientation. Each garnet grain is divided into domains with similar orientations, limited by boundaries with misorientations of 2° or more. In both samples most of misorientation angles measured across orientation domain boundaries are significantly lower than those measured between random pairs of orientation domains. One sample is a deformed garnet that shows considerable distortion within the domains. Lines of orientation measurements within domains and across domain boundaries show small circle dispersions around rational crystallographic axes. The domain boundaries are likely to be subgrain boundaries formed by dislocation creep and recovery. The second sample is a porphyroblast in which the domains have no internal distortion and the orientation domain boundaries have random misorientation axes. These boundaries probably formed by coalescence of originally separate garnets. We suggest that misorientations across these boundaries were reduced by physical relative rotations driven by boundary energy. The example of the garnet microstructures shows two of the key elements of EBSD analysis: 1. The misorientation information generated by measuring the spatial variation in orientation can be used to test conceptual, numerical or analytical models for the processes that produce a microstructure. 2. Microstructural analysis can be carried out in nearly all crystalline materials.