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1. Confidential Enquiry into Maternal and Child Health Improving the health of mothers, babies and children www.cemach.org.uk Julie Maddocks North West & West Midlands Regional Manager for CEMACH Supervisor of Midwives julie.maddocks@cemach.org.uk

2. Mission Our aim is to improve the health of mothers, babies and children by carrying out confidential enquiries on a nationwide basis and by disseminating our findings and recommendations as widely as possible

3. Maternal and perinatal surveillance Maternal deaths during pregnancy up to 1 year Late fetal losses from 22 weeks, stillbirths and neonatal deaths up to 28 days Child health Children from 28 days to 18 years old Topic-specific projects related to morbidity Descriptive study Organisational survey Clinical audit Work programme

4. National Overview of Perinatal Mortality Challenges and Opportunities for Improving care 24th June 2009 London

5. Feedback Report following the Saving Mothers’ Lives Interactive Workshops North West of England Local Supervising Authority Summer 2008

7. The workshops were developed in light of the ‘Saving Mothers’ Lives’ The workshops focused upon the ten key recommendations featured within the ‘Saving Mothers’ Lives’ report. The purpose of this feedback report is to provide the LSA and those who attended with documentation of the individual and Trust wide actions identified.

8. Disseminate the findings of the CEMACH ‘Saving Mothers’ Lives’ enquiry Encourage participants to consider and plan ways in which they can implement the recommendations within their practice. Aim

9. Raise awareness of the recommendations arising from the enquiry and consider how they relate to midwifery supervision Identify the actions required by individual supervisors and Trusts to meet the standards and recommendations in order to improve maternity care Provide an opportunity for supervisors to share their perspectives on the organisation of care and develop strategies to augment service development Enable supervisors of midwives to explore how they can support and influence the implementation of the top ten recommendations To provide the Local Supervising Authority and individual Trusts with a written report, following the events, that incorporates the actions proposed for both individual supervisors and the Trust as a whole. This report can be used by Trusts to inform the local audit process when establishing baselines and working towards the ‘auditable standards’ identified within the “Saving Mothers’ Lives” report. Objectives

10. Small groups Facilitated by Link supervisors and CEMACH Case Histories Structured Questions Feedback Summary notes Workshop

11. Which recommendation(s) does this case relate to? Are there deficiencies in the care provided when measured against the recommendations? Do you believe that there may be similar deficiencies of care in your unit? What are the issues for Supervisors of Midwives? Are there examples of good practice within your unit for women with similar issues? How will you implement a change in the organisation, provision or delivery of care in your unit, in order to meet the recommendations? Please give an example of your actions for change as an individual professional and as a part of the larger organisation. Structured Questions

12. Pre-conception counselling and support, both opportunistic and planned, should be provided for women of child-bearing age with pre-existing serious medical or mental health conditions which may be aggravated by pregnancy. This includes obesity. 1a: Pre-conception care

13. This applies especially to women prior to assisted conception and other infertility treatments. 1b: Pre-conception care

14. Well structured preconception service for diabetic women DVD available for women at the Liverpool Women’s Hospital Spaces for preconception care in a medical clinic Good practice points

15. Currently, preconception care in the region is thought to be both patchy and sporadic. The preconception services available are for specific groups preconception care is delivered within or at the end of another clinic - as it does not receive dedicated funding. develop preconception services to be more inclusive and securing funding for dedicated clinics was integral to this. One issue central to the delivery of preconception advice was communication, both with women and their families, commissioners and also with the wider team of health professionals.

16. Maternity service providers should ensure that antenatal services are accessible and welcoming so that all women, including those who currently find it difficult to access maternity care, can reach them easily and earlier in their pregnancy. 2a: Access

17. Women should also have had their full booking visit and hand held maternity record completed by 12 weeks of pregnancy. 2b: Access

18. Choose and book system available to women Day assessment unit for women to attend at any gestation, publicised at booking Drop in community midwifery clinics Direct access to midwives Template letter for GP’s to make referrals to maternity services Maternity referral needed to access ultrasound scan services One stop shop for women who misuse substances, including comprehensive outreach, early booking and multidisciplinary care Good practice points

19. Making services accessible and welcoming to women was felt to be a priority. Most of the Trusts had audited when women were booking and accessing care and many were working towards completing booking by twelve weeks gestation

20. Pregnant women who, on referral to maternity services, are already 12 or more weeks pregnant should be seen within two weeks of the referral. 3: Access

21. The reasons why women may book late were thought to be varied and worthy of exploration at a local level. Advertising services and making midwives more accessible was recognised as a means of reducing late presentation for care –however, a need to review the late booking process and the follow up of women who do not attend for care was identified. It was acknowledged that in some Trusts, women who present for care after twelve weeks gestation are often not seen within two weeks.

22. All pregnant mothers from countries where women may experience poorer overall general health, and who have not had a full medical examination in the UK, should have a medical history taken and clinical assessment made of their overall health, including a cardiovascular examination at booking. This could be the GP. 4a: Migrant women

23. Women from countries where genital mutilation is prevalent should be sensitively asked about this and management plans for delivery agreed during the antenatal period. 4b: Migrant women

24. Health equity audit undertaken and changes being made in service provision Link midwives for asylum centres, posts funded by the PCT Good access to interpreters, with direct line to town hall Language cards available for most languages spoken within the local population Good practice points

25. All pregnant women with a systolic BP of =/> 160 require anti-hypertensive treatment. Consideration should also be given to initiating treatment at lower pressures if the overall clinical picture suggests rapid deterioration and / or where the development of severe hypertension can be anticipated. 5: Systolic hypertension

26. Midwife on outreach team Good relationship with critical care Midwives have specialist skills and knowledge Labour ward forum for obstetric anaesthesia Good practice points

27. A tendency to focus on obstetric problems and overlook other significant conditions and complications was sited as a cause for concern. Clinicians should be encouraged to ‘think outside the box’ and policy and guidelines should support the exploration of non-obstetric causes for hypertension.

28. Mothers must be advised that CS is not a risk-free procedure and can cause problems in current and future pregnancies. Women with previous CS should have placental localisation to exclude praevia and, if present, further investigation to try to identify praevia accreta. 6: Caesarean section

29. Many Trusts have a policy in place for placental localisation, however - the use of MRI scanning to assess abnormal placentation was thought to be difficult. Many Trusts do not have access to MRI and closing this gap in the service was acknowledged to be a challenge.

30. Providers and CDs must ensure that all clinical staff learn from any critical events and serious untoward incidents occurring in their Trust or practice. 7: Clinical skills

31. Daily multidisciplinary review of cases Monthly newsletter for staff Telephone number for the supervisor of midwives available to all, on the on call rota ‘Independent’ supervisors involved in serious untoward incident review Good practice points

32. Feedback to staff following serious untoward incidents was felt to be generally constructive Regional meetings were suggested as a means of further disseminating the lessons learned; it was thought that this would create an opportunity to share good practice, explore service development and facilitate collaboration on tools such as policies and care pathways.

33. All clinical staff must undertake regular, documented and audited training for: Identification, initial management and referral for serious medical & mental health conditions Early recognition and management of severely ill pregnant women Life support skills. 8: Training

34. Improving communication between professionals was a key theme and thought to be an important challenge. Input from senior members of the multidisciplinary team was recognised as vital in delivering effective care midwives’ ability to challenge decisions and contact senior members of staff for support and advice should be further developed.

35. The need to maintain focus on maternal wellbeing after delivery was discussed and the need for midwives to have clearly defined and effective referral pathways for ill postnatal women was agreed. Midwives must be reminded that their own professional judgement should take precedent over any ‘cut off’ time prescribed by management.

36. Midwives’ general knowledge of medical conditions

37. All trusts should adopt a modified early obstetric warning system to help timely identification of women who have, or who are developing, a critical illness. These charts should be used for pregnant women in eg gynaecology, emergency depts and critical care. 9: Early warning scoring

38. MEOWS chart in use within maternity Critical care team, incorporating midwives, which works across the Trust Good practice points

39. There was some debate about the frequency and timing of basic observations, including the need to perform them on women who were considered to be at low risk and particularly after discharge into the community Supervisors felt that there was a need to balance preserving normality with effective assessment of women’s well being. A review of relevant guidelines was suggested. Ultimately it was thought that there should be debate locally regarding the frequency and timing of observations. It was also suggested that triggers could be put in place to ensure that basic observations were carried out.

40. Guidelines are urgently needed for: The obese pregnant woman Sepsis in pregnancy Pain & bleeding in early pregnancy. 10: National guidelines

41. BMI recorded at booking Guideline and protocol to check swabs Trust wide electronic access to all guidelines Good relationship between early pregnancy unit and maternity Good practice points

42. Supervisors were confident that women’s body mass index was being assessed and recorded. Several Trusts had established guidelines for the care of obese women; at Liverpool Women’s Hospital women with a BMI of greater than 35 are referred for obstetric care within a dedicated clinic

43. The importance of well constructed, up to date guidelines for all staff The need for guidelines to be multidisciplinary and for all staff to be familiar with these was also highlighted The intranet allows easy access to guidelines across many Trusts

44. Sharing local policies and guidelines for the management of sepsis and obesity should be encouraged. Having common guidelines was thought to be advantageous and streamlining all guidelines and protocols would confer considerable benefits.

45. Strengthening communication Specific training needs Access to senior support Organisation of services Areas for policy development Overarching themes

46. Evaluation

47. How All Delegates Plan to Modify Practice 9% 0% 2% 26% Major Minor Seek More Information 29% No Need learnt Nothing Relevant Blank 34%

48. Thank You julie.maddocks@cemach.org.uk Tel: 0161 276 6837