Clinical Certification for Maternity Services
In many cases pregnancy and labour proceed with a good outcome, with no intervention required apart from encouragement and support. However if, and when a medical intervention is required there is also a degree of risk to the mother and the baby or both. The Clinical Standard for Maternity Services uses many of the systematic reviews that have been undertaken recently within obstetrics and midwifery, and used the evidence based international clinical guidelines available, to produce a set of Clinical Standards which will provide a framework within which to focus patient safety risk management activities and encourage and support maternity services in taking a more proactive approach to risk management.
Maternity care has a number of features which have a relevance to safety, and make the need to strive for continuous improvement essential.
- Pregnancy and birth are normal physiological processes, but the transition from routine to emergency can occur rapidly and unexpectedly.
- Maternity services have to care for two (or more) lives
- Maternity care is delivered over a long period of time, in different settings and involving a large number of clinicians
- The experience a woman has of her pregnancy, labour and birth can have a profound effect on the mother, baby and family (positive or negative).
- There are also various demands placed on the maternity service, such as a woman’s ethnicity and socioeconomic factors, the rising birth rates, the increase in a mother’s age, her health and lifestyle, the control of the women to determine various aspects of her care such as location of the birth. All of which add varying degrees of complexity to the care that they will have to receive. (Safer Births 2008).
In order to implement an effective risk management framework it is extremely important for the maternity service to embrace the concept of proactive and reactive incident reporting. Reactively, staff need to utilise an incident reporting procedure to report which things have (or nearly have) gone wrong. These incidents then have to be analysed and learnt from. In the UK the Royal College of Obstetricians and Gynaecologists have produces a ‘trigger list’. A list of occurrences which could be deemed an adverse incident and should be reported; it includes things like an undiagnosed breech, shoulder dystocia, 3rd and 4th degree tears and unsuccessful forceps and ventouse deliveries.
RCOG Suggested trigger list for incident reporting in maternity
Blood loss >1500ml
Return to theatre
Intensive care admission
Unsuccessful forceps or ventouse
Readmission of mother
Stillbirth > 500 g
Apgar score < 7 at 5 minutes
Fetal laceration at caesarean section
Cord pH < 7.05 arterial or < 7.1 venous
Term baby admitted to neonatal unit
Undiagnosed fetal anomaly
European Congenital Anomalies and Twins (Eurocat)
Unavailability of health record
Delay in responding to call for assistance
Unplanned home birth
Conflict over case management
Potential service user complaint
Retained swab or instrument
Violation of local protocol
Once the information is being reported, then case reviews can identify where things may have been improved, and how lessons can be learnt. This should be done in a safe environment, where the main outcome is quality improvement and not blame and criticism. After all the large majority of staff go to work to help people and not to cause harm.
The Clinical Standards for Maternity Services have been formulated so that the maternity service can target some of the more high risk areas; and where, with some additional thought and attention, improvements can be made. For example, it has been documented that maternity services should:
- Have a standardised system for the management of evidenced based, clinical guidelines;
- Review the staffing levels and skill mix of staff on duty;
- Implement a more robust system for the handover of care between professionals and organisations; and
- Introduce the appropriate and systematic use of operating theatre checklists.
All these areas have within them, an element of risk, and the capacity to cause harm to the women and/or her baby.
Risk Aware Culture
Risk management needs to have a multidisciplinary approach, and should include all staff, and in particular, a cross section of staff groups. Having a senior obstetrician and senior midwife as champions within the area of risk, and who lead by example, is essential. Raising awareness and formulating a safety culture within maternity is also key, and can be encouraged by providing training and education – including emergency skills drills for all relevant staff, and having a debrief to discuss learning and improvement. Creating and fostering an environment of effective team work, where individuals feel confident to question, challenge, and – where necessary, bypass line management, will lead to an increase in reporting. But this will only happen if staff feel supported, valued, and part of a team which is mature enough to challenge practice and find areas for improvement. In addition, it is also essential to have a maternity specific forum where risk management can be discussed, where information can be shared and lessons that have been learnt communicated to all staff. Posters, staff newsletters and team briefs can all contain risk management information which will let staff know that information does not just fall into a big black hole and that it will be dealt with and that feedback will be given.
Working with key individuals within obstetric and midwifery practice will ensure that the Standards are fit for purpose that they can improve and evolve as the clinical practice does. It will also be possible to amend and adapt the Standards for specific countries and populations, where perhaps the routine antenatal care differs from that which we are used to in Western Europe, and where other factors, such as malnutrition, malaria, female genital mutilation and violence may need to be considered.