MNSI highlights fetal monitoring, triage, workload and training failures in midwifery-led maternity care

The Maternity and Newborn Safety Investigations programme or MNSI has published its national learning report:  Factors affecting the delivery of safe care in midwifery units.

MNSI’s analysis of 92 maternity safety investigations carried out by its predecessor, HSIB, highlighted that failings in fetal monitoring by intermittent auscultation (IA), telephone triage, safety-critical scenario training and over-burdened midwives were common factors affecting the safety of the midwifery-led care of these mothers and their injured babies. 

MNSI’s thematic analysis focussed only on the midwifery unit care of 92 mothers whose babies’ injuries had met their investigation criteria. Of the 92 babies, 11 died within the first week of life (neonatal death), 19 died during labour (stillbirth), and 62 babies needed therapeutic cooling after suffering a brain injury.

What is midwifery-led maternity care?

Midwifery units, such as birth centres or midwife-led units, are staffed by midwives and support workers. Midwifery units may be located in a separate building or location from the hospital, but are part of an NHS trust’s maternity service and their midwives work in partnership with the multidisciplinary team. Unlike hospital obstetric units, where obstetric doctors, midwives and other maternity professionals work together, in a midwifery unit the midwives take primary professional responsibility for their patients’ care.

Pregnant women who choose to give birth in a midwifery unit are usually healthy and have been assessed as low risk for labour and birth complications. However, safe maternity care depends on continual reassessment of the mother’s risk status, which can change at any time during their pregnancy, labour and birth. If their risk increases during labour, the mother and her baby may need to be transferred to a (doctor-led) obstetric unit to ensure that they receive necessary medical, surgical, anaesthetic or neonatal care. 

According to MNSI, 22.5% of birthing mothers who begin their maternity care in freestanding midwifery units and 26.5% in alongside midwifery units ultimately need transfer to an obstetric unit. First time mothers are even more likely to need transfer from freestanding midwifery units (36%) and alongside midwifery units (40%). All of the mothers and babies in the investigations analysed by MNSI had needed transfer from a midwife-led unit to an obstetric (doctor-led) unit or neonatal unit to receive additional care. Reasons for transfer included: an undetectable or abnormal fetal heart rate; lack of progress in the second stage of labour; risks arising from the unborn baby’s presentation or position; the presence of meconium; vaginal bleeding; or the need for pain relief.

MNSI reiterated that the analysis and their findings were not intended to influence mothers in their birth choices, nor to compare between different types of maternity unit. NICE guidance indicates that antenatal care for all pregnant women/birthing people should include a personalised discussion to support them in deciding where to have their baby.

What safety themes did MNSI identify in their report on midwifery-led maternity care?

MNSI’s report identified four themes which commonly arose in HSIB’s maternity safety investigations into the deaths and brain injuries of babies involving midwifery-led care. MNSI reiterated that these themes are not new and they are also relevant to other birth settings, such as hospital obstetric units. They encouraged maternity care providers from all birth settings to take action to address the safety risks associated with them to promote safe care.

Workload

MNSI highlighted the safety risk to mothers and babies in midwifery units from workload pressures and inadequate staffing levels.  They repeated HSIB’s previous warnings that when work demands exceed capacity, healthcare staff many have to sacrifice thoroughness for efficiency. MNSI found workload and capacity issues affected 43% of the maternity incidents they analysed, and often resulted in delays in care and/or safety-critical monitoring tasks during a woman’s labour.

Safe maternity care in midwife-led units was also affected by workload and capacity issues within the obstetric units and ambulance services on which the midwifery unit relied for the safe and timely transfer of a mother or baby.

MNSI reiterated that NICE guidance recommends safe staffing levels during labour and birth to be one midwife for each woman in labour. Midwifery staffing levels should also allow for fluctuations in demand. MNSI found that midwifery units are commonly staffed by just one or two midwives and a maternity support worker.

Monitoring the fetal heart rate by intermittent auscultation (IA)

In a midwife-led unit, midwives rely on intermittent auscultation (IA) to help them assess the unborn baby’s wellbeing and whether the mother needs to be transferred to an obstetric unit during labour.

MNSI’s analysis of HSIB’s maternity safety investigations identified poor reliability of intermittent auscultation (IA) as a common factor in maternity incidents in midwife-led units. There are various ways to monitor an unborn baby’s heart rate during labour, but midwife-led care usually relies on listening via IA to monitor the fetal heartbeat during labour when the mother has a low risk of complications.

MNSI referred to previous research into the birth-related deaths of babies in midwifery units which revealed that IA was used to monitor the baby’s heart rate in 72% of cases. Issues with the timing, recording, interpretation and acting upon concerns with IA were identified in the care of more than half of the mothers, and in nearly a third of those cases were “probably or almost certainly relevant to the outcome for the baby”.

MNSI’s analysis of HSIB’s investigations involving midwifery-led maternity care identified that in the care of 49% of those mothers, intermittent auscultation (IA) did not comply with national guidance. This often coincided with high midwife workloads. IA requires the midwife to listen, count and record the number of heartbeats heard over one minute. The midwife listens through a hand-held Pinard stethoscope, which is placed on the pregnant woman’s abdomen, or hears   audible sounds of the baby’s heartbeat produced by an electronic hand-held ultrasound device called a Doppler. Simultaneously, the midwife must also feel the pregnant woman’s pulse to avoid the risk of mistaking the mother’s heartbeat for the baby’s heartbeat.  MNSI points out that carrying out intermittent auscultation as set out in the guidance involves sustained attention over a 12-hour work shift, overcoming physical challenges with the mother’s position and listening over high levels of background noise, and suggests that correct IA may be difficult to achieve in practice.

Despite NHS guidance setting standards for staff who carry out fetal monitoring, previous reviews into the accuracy of IA have found midwives using different techniques, failing to recognise abnormalities in the baby’s heart rate and wide variations in the ways midwives counted a baby’s heartbeat from the same recording.   MNSI reported similar findings in  their thematic analysis, including midwives apparently using intermittent auscultation correctly but failing to detect the deterioration in the baby’s health, and instances where the mother’s heartrate was mistaken for the baby’s, contributing to the baby’s poor outcome.

Preparation and training for safety-critical scenarios

MNSI noted that many of the 92 investigations that they analysed relating to maternity safety incidents in midwifery units involved predictable safety-critical scenarios, such as a pregnant mother or her baby needing to be transferred urgently to an obstetric (doctor-led) unit, or a baby needing resuscitation at birth. In 43% of the maternity incidents, work systems and processes had not worked as intended in predictable safety-critical scenarios and had hindered the staff’s ability to respond to the situation.  This had led to delays in care or treatment. MNSI also found that difficulties with access to equipment, inadequate training and preparation had hindered staff’s ability to respond to the predictable midwifery emergency when a baby is born needing resuscitation. MNSI found that midwifery units had not carried out risk assessments in advance to identify and deal with weaknesses in the systems and processes that they would rely on in such scenarios, and recommended that they need to be better prepared.

Telephone triage

Another common theme in MNSI’s analysis of maternity safety investigations arising from midwife-led care related to failings during telephone triage. This is the important assessment that is made by a midwife when the pregnant mother telephones for advice with concerns about their pregnancy or because they have gone into labour. Telephone triage may be provided by midwives in the midwifery unit where the mother intends to give birth or by a central triage service.

NICE guidance recommends that women are encouraged to telephone for advice when labour begins rather than attend the maternity unit in person. Information gathered by the midwife from the mother during telephone triage, combined with available clinical records about the pregnancy, should enable the midwife to make a decision about the mother’s risk and the nature and urgency of the care that she needs. Previous HSIB maternity national learning reports have identified the importance of correct risk assessment during telephone triage and the need for telephone triage services to be operated by appropriately trained, competent clinical staff.  

MNSI identified that telephone triage contributed to 14% of the midwifery unit maternity incidents in the investigations they analysed. They found that the quality of documentation, advice and communication during triage calls was variable, and that information was more likely to be lost, with resulting safety risks, where the pregnant woman had previously spoken to different members of staff at different locations. Safe telephone triage was further hampered by inaccessible handwritten and/or electronically recorded clinical information, difficulties with assessing risk over the telephone, confusion caused by giving the pregnant woman multiple contact numbers and, until very recently, the lack of consistent standardised guidance.

If your child has cerebral palsy or neurological disability as a result of medical negligence or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.