This book helps all those working in maternity services to improve the quality of the care they offer. Improvement is driven by clinical effectiveness and increasing patient demands, and for each area of practice described this book outlines the service organisation needed to achieve this improvement. The goal is to help clinicians take responsibility for developing services that meet the needs of their patients as well as managing their individual medical conditions. The book demonstrates that much can be achieved within current resources and without major additional expense. Different approaches are demonstrated, but the key issue is the patient pathway. Trainees, clinicians, managers and commissioners of services will find this book of practical value. There should be a copy on the shelves of every hospital obstetric unit.
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Maternity services in the UK enjoy high-quality, safe service, yet there is room for improvement. The maternity dashboard provides the seven pillars that underpin clinical governance and that includes: the work place, the work force, evidence-based guidelines, education and training, clinical audit, monitoring risk incidents and complaints. These seven pillars should stand on the foundation of the professional commitment of those who work in maternity units, who should cooperate with each other to enhance team work that will deliver compassionate care that builds confidence about the quality and safety of care among the women who use the service. Clinical indicators in the maternity dashboard provide continuous monitoring. If there is a reduction in the number of women admitted to the intensive care unit and the number of postpartum hysterectomies following massive postpartum haemorrhage, one could also expect fewer women to be transfused.
Much of the work of a clinical director carries a large element of common sense and much of this chapter is familiar territory to the experienced clinical director. The views of many groups and individuals need to be considered when drawing up a local maternity services strategy. Broadly, they can be categorised into: the patients or users of the service, the commissioners, policy makers and regulatory bodies, and the professionals who deliver the service. Women who use maternity services form the most important interest group. All maternity services strategies will have to take into account government policies, standards set by professional bodies and limits set by regulators. The third element of strategy development is to obtain the views of all staff groups involved in delivering the service. The most valuable component of a risk management system is incident reporting and it remains so during the implementation of strategic change.
Prepregnancy care for women with social needs should enable women to protect and control their fertility and to ensure any pregnancies are intended and optimally timed for good medical and social outcomes. In 2006, the USA published recommendations and guidelines on preconception care for all women, but these guidelines do not specifically address the needs of socially disadvantaged women. All reproductive healthcare professionals must be trained and must be able to take a full social history in both the prepregnancy and maternity setting. Provision of reproductive health care, including prepregnancy care, for women with social problems should be incorporated into strategic planning and reflected in staffing levels and skill mix. Complementary services including information, education and social and health care should be provided for socially disadvantaged men and partners of socially disadvantaged women. Development of routine service provision is a priority and such services should be subject to audit.
Early pregnancy services should be modelled in such a way that they are accessible to deal with all the problems of early pregnancy, such as bleeding and medical conditions such as hyperemesis gravidarum, and also to facilitate routine antenatal care before the 12th week of pregnancy. The National Institute for Health and Care Excellence (NICE) antenatal care guideline recommended that booking with maternity services should take place before 12 weeks of pregnancy. The model of care for all early pregnancy events should be composed around the women's journey. It is important to have local care pathways in place for initial assessment, investigations for contributing causes and focused treatment. All clinical staff must undertake regular, written and documented audited training for the identification and initial management of referral for serious medical and mental health conditions that may affect pregnant women or recently delivered mothers.
To bring conformity at a national level, the UK National Screening Committee integrated different screening programmes into three main domains, each reflecting the stages of the health screening lifecycle. These domains are the fetal, maternal and child health group, the adult screening and cancer screening programmes. High-quality guidance, specifically policy and programme standards, is a necessity for trusts offering a screening service and, for easy access. There is much commonality between the Down syndrome screening and fetal anomaly screening programme standards, in that good screening programmes need a central coordinating group. In understanding the complexities of the woman's journey through the Down syndrome and ultrasound screening system, a number of care pathways have been produced. Since 2001, a succession of national audits has been undertaken that have proved fruitful in terms of improving services. The past 30 years have seen astonishing advances in antenatal screening.
Antenatal care for women with a low-risk pregnancy is predominately provided by midwives supported by maternity support workers and other professionals. The National Institute for Health and Clinical Excellence (NICE) has published guidance on the routine care of the healthy pregnant woman, outlining a schedule of appointments and the type of screening available. The care pathway provides details of antenatal care for women with an uncomplicated pregnancy. The establishment of Maternity Direct under the aegis of NHS Direct in certain parts of the country has led to a reduction in antenatal admissions. Midwives are the specialists of normality, and are trained to diagnose pregnancy and assess and monitor women holistically throughout the antenatal period. The majority of maternity services are using the Royal College of Obstetricians and Gynaecologists (RCOG) Maternity Dashboard. Maternity services should audit the percentage of women who booked by the 12th completed week of pregnancy.
Women with pre-existing medical and obstetric problems are at increased risk of complications in pregnancy. Such high-risk pregnancies result in increased maternal, fetal and neonatal morbidity and mortality. In 2008, the National Institute for Health and Clinical Excellence (NICE) issued guidelines for routine antenatal care of healthy pregnant women. Common medical conditions that confer a higher risk to the pregnancy but are often unrecognised at referral are obesity and mental health disorders. Integrated care pathways can be used as tools to incorporate local and national guidelines into everyday practice, manage clinical risk and meet the requirements of clinical governance. Training programmes for midwives, obstetricians, GPs and psychiatrists should include perinatal psychiatric disorders. The needs of the local population must be taken into account when planning a service in terms of providing the correct care, particularly in areas where there are large numbers of women from migrant and ethnic minority populations.
During the antenatal period conditions unique to pregnancy may develop, such as pre-eclampsia, gestational diabetes mellitus and obstetric cholestasis, in addition to the less commonly encountered new pathologies, whether medical, surgical or mental. There are several evidence-based guidelines available to assist the clinical management of conditions arising in pregnancy. These include guidelines published by the Royal College of Obstetricians and Gynaecologists (RCOG), which include pregnancy-related conditions, such as obstetric cholestasis. Providers of maternity services must consider women from minority ethnic groups, who may need access to translated written information and professional translators. Optimal patient care requires a continuous cycle of training aimed at all components of the multidisciplinary team. Training obstetricians to become leads in high-risk obstetrics or maternal medicine involves completion of the appropriate Advanced Training Skills Modules (ATSM) or subspecialty training. Regular audit is necessary to ensure that national and local standards of care are being met.
Managing risk in antenatal care is dependent upon the identification of risk factors through clinical risk assessment during pregnancy to identify the care that is appropriate to individual women's needs. All guidelines need to be reviewed at regular intervals to incorporate new evidence and issues identified through audit and adverse event reporting. National Institute for Health and Clinical Excellence (NICE) guidelines and interventional procedures guidance provide evidence-based information for use by clinicians and pregnant women to make decisions about appropriate treatment in specific circumstances. The aim of pregnancy care pathways is to ensure that there are clear pathways in place to address the needs of pregnant women with various health problems during pregnancy, intrapartum and postnatally in accordance with national guidelines. Service providers should ensure that the staff mix provides multidisciplinary teams with agreed shared objectives.
This chapter explores how policies, current standards and practices can be integrated to improve women's access and promote confidence and trust in the services provided as well as having a maternity workforce which use resources effectively. For safety and quality of care, protocols and care pathways are recommended, but midwives and obstetricians need to remember that each woman's care is individual and her journey through the labour is dynamic. The professionals agree that each organisation should have locally agreed clinical guidelines for midwifery-led labour care for low-risk women. Service planning has to support both low-risk and high-risk labour care pathways with equity. Any birth environment should have a monitoring tool for staffing levels. There are many sources recommending audits on labour care and outcomes: Royal College of Midwives (RCM) birth centre standards, Safer Childbirth, and Standards for Maternity Care.
All women, regardless of whether their pregnancies are high or low risk, should be treated with respect and should be in control of and involved in what is happening to them in labour. Intrapartum causes of maternal mortality are extremely rare; nevertheless, good intrapartum care and monitoring of the woman with a high-risk pregnancy is essential in ensuring a good maternal and fetal outcome. In the UK, the National Institute for Health and Clinical Excellence (NICE) has published comprehensive guidelines on the intrapartum care of the woman at low risk at term. All maternity units and labour wards should have a lead named midwife, obstetrician, paediatrician and anaesthetist. It is imperative that staffing levels and competencies of staff on labour wards comply with national standards. Guidelines provide a framework from which healthcare providers can design clinical care pathways and organisational structures to improve care of the high-risk woman in labour.
The prevalence of obesity in the general population has increased markedly over the past few decades, accompanied by a parallel increase in the prevalence of obesity in pregnancy. The Centre for Maternal and Child Enquiries (CMACE) in the UK has developed national consensus standards of care for women with maternal obesity and these are available to clinicians and commissioners as CMACE/Royal College of Obstetricians and Gynaecologists (RCOG) guidance. Maternity services should develop a clinical care pathway for maternal obesity that takes into account locally agreed strategies for management. An appropriately trained health professional should provide dietary counselling to women who are obese. Maternity services will need to identify the prevalence of maternal obesity within the local maternity unit population to ensure adequate midwifery workforce planning. Maternity units should carry out regular audits of practice against locally agreed standards for women with obesity in pregnancy.
The birth of an infant who has a possible hypoxic ischaemic encephalopathy (HIE) is a source of great concern to the parents, obstetricians and paediatricians. Hypoxic cerebral brain injury that occurs in the perinatal period is recognised as a cause of severe long-term neurological deficit in children; it is often referred to as cerebral palsy. The absence of information and specific guidelines on HIE means that advice provided to women has to be collated from evidence-based effective antenatal and perinatal care that maximises the opportunity to deliver a healthy baby. Approaches to the prevention of HIE include the antenatal administration of corticosteroids to women in preterm labour, as this has been shown to reduce perinatal mortality, respiratory distress and intraventricular haemorrhage by over 50%. All units should have a regular continuing programme of in-service training including cardiotocography (CTG) interpretation, drills on emergency ('crash') caesarean section and neonatal resuscitation.
Risk management aims to reduce poor outcomes by first identifying adverse events, creating a database to identify common patterns, and developing a system of accountability to prevent future incidents. Staffing of the labour ward may be the single most important risk. Birthrate Plus is a tool for assessing midwifery staffing that can identify shortfalls. Healthcare trusts collect a large sample of data on births related to their complexity, ranging from a simple, straightforward birth to an emergency caesarean section, and the average birth time is measured. Training may be the single most effective part of system implementation for reactive and proactive risk management. Training for staff in the core skills needed to handle emergency situations makes an important contribution to safety, although Towards Better Births found that there was a wide variation in trusts' training programmes, including the multiprofessional nature and attendance levels.
Providers of maternity care have a responsibility to assist the woman and her partner in making an informed choice of place of birth. The options include the home, a midwifery-led maternity unit or a consultant-led hospital delivery suite. With the acknowledgement that healthy mothers have healthy babies that grow into healthy adults, maternity services were included in the National Service Framework (NSF) for Children, Young People and Maternity. Policy considerations regarding place of birth must look beyond studies of perinatal mortality; issues such as selection of women, staffing and cost are also important. Unless future evidence dictates otherwise, home birth is an option that should be open to appropriately selected women who are at low risk of obstetric complications and at low risk of being transferred to hospital having laboured at home.
Understanding of the occurrence and severity of likely neonatal complications is important when planning antenatal care and birth, and in counselling parents. Babies of women with diabetes should remain with their mothers unless there is a clinical complication or there are abnormal clinical signs that warrant admission for intensive or special care. Combined maternal and fetal hypothyroidism is associated with abnormal neurodevelopmental outcome. The most severely affected babies have mental restriction and motor impairment. Babies of mothers with epilepsy have a two- to three-fold higher risk of congenital malformations, mainly associated with antiepileptic drugs. Clinical management of psychiatric illness during pregnancy and lactation encompasses an assessment of the risk of exposure of the mother and neonate to medication during pregnancy. Maternal bacterial infection may be associated with poor condition at birth and neonatal bacteraemia or meningitis with a risk of long-term neurological sequelae or even death.
This chapter describes the level of service required from anaesthesia departments providing services for obstetric units. In addition to clinical duties, consultant anaesthetists are involved in teaching, training, administration, research and audit. The Obstetric Anaesthetists' Association (OAA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) jointly published Guidelines for Obstetric Anaesthesia Services. These guidelines aim at developing national standards for maternity care. A clear line of communication from the duty anaesthetist to the on-call consultant should be assured at all times. All obstetric departments should provide and regularly update clinical protocols, which should be readily accessible. Obstetric units with an anaesthesia service should have a nominated consultant responsible for training in obstetric anaesthesia and there should be induction programmes for all new members of staff, including locums. There should be an audit programme in place to audit anaesthetic complication rates, such as accidental dural puncture.
This chapter provides guidance for clinicians, midwives, managers and commissioners as to the main aims and principles of postnatal care and how these should be delivered. Several national guidelines on postnatal care can be considered under: planning the content and delivery of care, maternal health, infant feeding and maintaining infant health. Coordinating services in the postnatal period is made more difficult by the transfer of care between health professionals and clinical settings. It is essential that staff involved have the necessary training and are competency tested in certain issues pertaining to the postnatal period. The postnatal environment should promote a healthy parent-infant relation ship and should support the wider family. Various neonatal screening tests are carried out in the postnatal period: newborn hearing tests, blood spot tests and newborn physical examination for developmental dislocation of the hip, congenital heart disease.
This chapter is based mainly on Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. Women want to be cared for by skilled staff who show empathy and support for them and their partner, and who give them privacy and time. Several publications are available that provide guidance and set standards for the care of women and families experiencing pregnancy loss. Clear pathways between secondary care and the primary care team are essential to ensure that bereaved parents receive good care at all times. Staffing levels should ensure that parents receive continuity of carers. Carers must have training to enable them to support grieving parents, and must themselves be well supported. The bereavement service as a whole should be audited regularly to ensure that it provides comprehensive, culturally sensitive management and support for families who have experienced an early or mid-pregnancy loss, stillbirth or neonatal death.
This chapter explores the reasoning behind the need for an up-to-date, easy-to-use data demonstration system, the first use of a maternity dashboard in England and subsequent developments. These innovations include a simple way of using data from maternity packages and an electronic dashboard system that extracts data from maternity software and other data packages relevant to the specialty. The primary reason for the use of a dashboard should be to provide information, to support governance and to reduce risk. Other benefits that should be considered are the fact that the data collected can be used as part of the audit for processes such as the Clinical Negligence Scheme for Trusts (CNST), commissioning for quality and innovation (CQUIN) and, more recently, quality, innovation, productivity and prevention (QIPP). The process of dashboard development is a rapidly growing area and the chapter aims to outline the essentials for a successful end product.
In the East of England, the strategic health authority (SHA) sets up ten clinical pathway groups in early 2008 to design the clinical vision for all aspects of health care from the newborn period to the end of life. The purpose of the clinical pathway group was to develop the strategy and vision that was clinically led and evidence-based. The vision set out by the Maternity and Newborn Clinical Programme Board in the Towards the Best, Together report is to plan and deliver a maternity and newborn service for the East of England that will ensure the best outcome for mothers and babies. The key aim is to improve the quality of service, safety, outcomes and satisfaction for all women through offering informed choice around the types of care throughout pregnancy, birth and postnatally. The key challenge to date has been that of clinical engagement.
The Royal College of Obstetricians and Gynaecologists (RCOG) published its document Standards in Maternity Care in 2008 which is being used widely by commissioners, providers and policy makers. The document sets out the principles of quality-assured maternity services. This chapter identifies some key indicators as exemplars, although it is recommended to make use of the whole document. Prepregnancy care for women with social needs is essential. Prepregnancy care can improve outcomes in high-risk pregnancies regardless of whether the high-risk status is of medical or social aetiology. From a public health perspective, the identification of anomalies can improve perinatal morbidity and mortality, as conditions may be identified early in pregnancy and managed accordingly. Current approaches for the prevention of hypoxic ischaemic encephalopathy include antenatal identification and monitoring of fetal growth restriction and electronic fetal monitoring accompanied by intrapartum fetal blood sampling.