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Healthcare watchdog, HSIB, has reviewed over 200 recommendations made in its maternity programme investigations to identify how risk assessment affects safety in maternity care during pregnancy, labour and birth. HSIB’s findings are published in its national learning report, Assessment of risk during the maternity pathway.
Recent reports, such as the Ockenden Review, have highlighted the importance of continual risk assessments taking place at each contact that the maternity team has with a pregnant woman/person ( mother) during pregnancy, labour and birth.
HSIB’s review found that pregnant mothers’ care is often based on initial ‘tick-box’ risk assessments, which are not adapted to recognise changes in their condition or the need for care. HSIB calls for maternity risk assessments to be more dynamic and responsive, so that every pregnant mother is treated as an individual and receives safe care.
What does HSIB say about risk assessments in maternity care?
In most pregnancies the mother’s risk is assessed for the first time at the booking appointment, when she is assigned a type of care (such as midwifery-led care) based on her medical history, risk factors and preferences. From then on, her risk and previous risk-related decisions about her care and place and type of birth should be reviewed on a regular basis. Safe and appropriate care during pregnancy, labour and birth depends on healthcare professionals recognising when changes in the individual’s condition changes their level of risk. HSIB found that in some of its maternity investigations (arising from harm to mother or baby) the mother’s care followed the original decisions that were made at the booking appointment with no change when her risk level changed later in the pregnancy.
HSIB found that problems often arose as a result of the pregnancy being described as low-risk or high-risk, instead of the focus being on the individual risks for the mother and baby. High risk is defined by the NICE guidelines simply as when ‘the likelihood of an adverse outcome for the woman or baby is greater than that of the normal population’. HSIB found that healthcare professionals found the either/or high risk or low risk decision restrictive, and that it led to an assumption that the risk level is fixed and cannot be changed. The labels were also seen as judgemental by some patients. Similarly, labelling the patient’s care as ‘midwifery led’, ‘obstetric led’ or ‘shared care’ was not always helpful as it predetermined the approach of maternity staff towards the patient’s care and led to potential conflict between healthcare professionals.
HSIB found that risk assessment systems rely on checklists to assess a pregnant patient’s level of risk, which include conditions such as venous thromboembolism (VTE), fetal growth, pre-eclampsia, gestational diabetes, preterm (premature) labour and perinatal mental health. However, screening risk assessments for some conditions in pregnancy have remained the same for some years and do not always consider how the patient’s risk is affected by combinations of risk factors or their absence.
HSIB noted that although risk is mentioned in various guidelines relating to specific conditions in pregnancy, there is no single national guideline for risk assessment in maternity care.
Common risk assessment themes in maternity care
HSIB’s review of its maternity investigations identified as an overarching theme the need for individualised (personalised) risk assessments for pregnant women/people to improve maternity safety. Specifically, the watchdog recommended that the NHS needs to address the following areas of concern to help reduce risk and enable hospitals and staff to provide safe maternity care.
Clinical oversight of a mother’s care during pregnancy and labour is needed to provide a holistic view of all the risks to the mother and baby. HSIB’s past risk assessment recommendations relating to clinical oversight have commonly arisen from clinicians focussing on a single risk factor instead of a more holistic assessment of the risk factors that were present. They also related to poor communication, sharing and handover between healthcare staff of critical information about the risks to mother and baby.
The term ‘triage’ describes the preliminary assessment of a patient to determine how urgently and what type of treatment they require. In maternity care, telephone triage involves giving advice to the mother over the telephone, such as when to go to the hospital or other place of birth or when to call back for a further review. Face-to-face triage takes place when patients arrive at hospital, and prioritises which patients should be seen first, depending on their condition and clinical need.
HSIB’s previous maternity investigation recommendations to NHS trusts relating to risk assessments and triage arose from issues including:
- calls being taken in a variety of locations by differing healthcare professionals instead of by trained staff on dedicated telephone triage lines;
- calls being answered by non-registered members of staff;
- clinicians having to perform telephone triage in addition to their other care duties;
- pregnant mothers being unable to reach the telephone triage service because there was no call-waiting, divert or answerphone system, or owing to confusion with multiple different contact numbers;
- the call handler couldn’t access the patient’s medical records and history, or could not record the details of the call.
HSIB identified issues with face-to-face triage arising from:
- inconsistency in where the face-to-face triage assessment took place;
- lack of access to dedicated triage and assessment facilities outside working hours, such as monitoring by computerised CTG;
- unclear processes for escalation of pregnant mothers;
- triage systems failing to prioritise pregnant mothers with the most urgent needs to ensure that they are seen first;
- assessing the mother with ‘symptom-specific’ triage proformas instead of holistic assessment.
RCOG is currently preparing guidance on triage for maternity units. HSIB recommends that healthcare providers’ risk assessments are simple to use, so that clinicians will complete them thoroughly and avoid ‘tick-box fatigue’.
Place of birth
HSIB found that decisions about whether birth takes place at home, in a midwifery unit or obstetric-led unit are complex and multifactorial but may be based on whether the mother was considered low risk or high risk at their booking appointment, before any pregnancy-related risks develop. Once the decision is made it sets expectations which can be difficult to change later in pregnancy.
HSIB found that risk assessments for pregnant mothers planning home births were not always carried out at the beginning of their intrapartum (in labour) care. Clinicians who were caring for a birthing mother outside the maternity unit couldn’t always access their medical records or other guidelines and tools, leaving them unable to make decisions about when to escalate the mother’s care.
Pregnant women were sometimes taken to a low-risk birth setting when they needed obstetric-led care. Instead of reassessing the patient’s risk status or recognising that their needs had changed, there was a tendency to ‘stick to the original plan’. HSIB also found poor communication of the mother’s risks between teams and delays in seeking obstetric review or moving the mother to the safest place to give birth, even when events in labour increased her risk. Staffing issues, available rooms or other pressures affecting the maternity unit as a whole can delay a mother’s transfer to an obstetric-led unit during labour, prioritising the needs of the maternity unit over the needs of the individual.
Women who have previously had a caesarean section (or other uterine surgery) are at increased risk of uterine rupture in labour. Uterine rupture or breakdown of the previous uterine scar is life-threatening to both mother and baby. They should be individually assessed to see whether they are suitable for VBAC and be counselled by a member of the maternity team about the risks and benefits of their birth options, including their personal chance of successful VBAC, and the alternative option of caesarean section. These discussions and decisions must be documented and should include decisions such as the place of birth, method of fetal monitoring, induction of labour and contingency plans in case the plan for VBAC is discontinued.
HSIB found that the advice given to pregnant women who were considering VBAC about the risks and benefits of their birth options was inconsistent and depended on the clinician’s own experience. Most mothers were advised that there was a 72-75% chance of planned VBAC being successful. However, they were not always told that their personal chance of success was significantly reduced by individual risk factors, such as their age, high BMI, lack of previous vaginal births or the reason for their previous caesarean. HSIB noted that the RCOG information leaflet given to pregnant women does not set out the lower success rates associated with some individualised risks. The timing of these important conversations also varied, in some cases only taking place when the mother was already tired and distressed in labour.
HSIB also found that the mother’s maternity records often did not include specific and previously agreed plans for how the maternity team should manage induction or augmentation of VBAC labour or the circumstances in which VBAC should be abandoned to allow intervention.
Induction of labour (IOL)
Induction of labour (IOL) involves starting labour by using medications and techniques, such as prostaglandin tablets, pessaries or gels. Oxytocin can also be given during IOL to increase the frequency of contractions.
HSIB’s review of its maternity investigations found that IOL was an area in which it had made many recommendations to NHS trusts relating to risk assessments.
HSIB found that, in recent years, changes in national guidance have led to an increase in IOL rates without any increase in maternity unit capacity and workforce. 39% of births in England involve IOL but many maternity units cannot accommodate the number of patients who are planned for IOL. HSIB found that ‘low-risk’ mothers were commonly offered an appointment for their IOL based on availability rather than their individual risk assessment and reason for IOL. There was no difference in IOL treatment for high risk mothers with complex pregnancies compared with those at low risk. There was limited obstetric (doctor) oversight of women undergoing IOL. Increasingly complex pregnancies were managed by midwives during IOL, leading to concerns about whether pregnant women/people were being fully counselled about their treatment options and individual risks. In many cases, HSIB found that families did not recall any discussions about risk, either when IOL was booked or was underway.
If you or your child has suffered serious injury as a result of negligent maternity care, or you have been contacted by HSIB, HSSIB,MNSI or NHS Resolution, you can talk to our experienced solicitors, free and confidentially, for advice on how to respond or make a claim, by contacting us here.
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