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CHAPTER 18 AUDIT OF PREVIOUS RECOMMENDATIONS Angie Benbow, Research Midwife, the RCOG Clinical Audit Unit. Michael Maresh, Honorary Director of the RCOG Clinical Audit Unit.
This Chapter describes two recent surveys undertaken by the RCOG Clinical Audit Unit. The aim of these studies was to determine if key recommendations published in the Reports on Confidential Enquiries into Maternal Deaths were being implemented. They were conducted by means of a detailed assessment of a random 10% sample of consultant maternity units throughout the UK and, in addition, by a postal questionnaire to all maternity units.
Introduction
Over the last 10 years there has been an increasing emphasis on clinical audit and the development of evidence-based effective clinical practice. This has recently been reaffirmed by the Department of Health's' publication A First Class Service; Quality in the NHS.1 This not only recognises the requirement for all clinical staff to ensure they undertake audit and base their treatments on evidence but also highlights the key role of the Confidential Enquiries. The Confidential Enquiries into Maternal Deaths (CEMD), referred to as "the Report" throughout this Chapter, have long been recognised as a leading example of professional self-audit. It has not been possible, to date, to investigate systematically whether the recommendations for improving care, made in all Reports, are actually being implemented across the UK. That many of the recommendations were having to be made repeatedly from Report to Report suggested that they were not.
An earlier survey undertaken in 19932 supported this conclusion and identified that recommendations from the previous Reports were still not being universally implemented. In particular, the authors found that guidelines for the management of serious maternal complications were still not available in all hospitals. It also showed that there were still split-site hospitals providing maternity services and that some maternity units did not have access to blood transfusion facilities on site. In view of these findings, and in conjunction with the publication Maternal Mortality: the Way Forward3 and the RCOG's pamphlet Deriving Standards from the Maternal Mortality Reports4, a reaudit was considered necessary to ensure that the recommendations were being put into practice.
Method
This study involved (i) a postal survey of all maternity units in the UK and (ii) interviews at selected sites with key members of staff involved in the management of maternal complications.
(i) The postal survey A questionnaire was sent to the head of midwifery at all maternity units in the UK during November 1996. By May 1997 a 100% response rate was achieved, following one reminder letter or phone call. Two hundred and fifty-nine consultant maternity units were identified and used for this survey. Information collected from Midwifery and GP-led units has not been included in this review as it is incomplete and may not represent the national picture. The questions asked included the siting of the unit in relation to an acute general hospital, and the availability and siting of facilities and services such as an intensive care unit (ICU), a high-dependency unit (HDU) and blood transfusion facilities. All units were asked if they had agreed guidelines for severe hypertensive disorders, eclampsia, massive haemorrhage, thromboembolic disorders and severe genital tract infection and if they would forward a copy to the RCOG Clinical Audit Unit. In addition, they were asked if all staff had access to the Cochrane database and a copy of the CEMD Report and if they found the recommendations useful for developing guidelines. Separate validation of the data on blood transfusion services was obtained by telephoning the laboratory at all units with 1,000 or more deliveries who had reported no blood transfusion facilities on site.
(ii) The interviews A cross-sectional study of all maternity units in the UK included on the RCOG Clinical Audit Unit database in 1996 (n=325) was conducted between August 1996 and June 1997. Initial stratification identified units that were representative of each of the 11 health Regions in the UK. Further stratification, within each region, identified large and small units. For the purpose of this study, large units are those with more than 3,000 deliveries per annum. A 10% sample was used. The number of units to be included in the study in each health Region was calculated from the number of maternity units and the combined number of deliveries for each of the Regions. Thirty-two consultant maternity units were randomly selected.
In each of the units selected, the clinical director for maternity services, the clinical director for anaesthetics and the head of midwifery were approached for initial agreement to the study and to suggest suitable personnel to be interviewed. Although all units initially agreed, one unit was withdrawn midway through the study due to difficulties with access to key personnel. In total, 149 staff were interviewed in the 31 units. These included 30 consultant obstetricians, 18 Specialist Registrars in obstetrics, 30 consultant anaesthetists, 19 Specialist Registrars in anaesthetics, 31 senior midwives, "G" grade or above, and 21 "E" or "F" grade midwives. A semi-structured questionnaire was developed from the recommendations from previous Reports and RCOG publications3-4. The interviews were carried out by the RCOG research midwife. Results
Provision of services: Availability of facilities for consultant maternity units
The previous Report and the National Confidential Enquiry into Peri-operative Deaths ('1991-92)5raised concern that split sites or isolated maternity units may cause deficiencies in the provision of essential services; in particular, access to blood transfusion services and the provision of adequately staffed and equipped facilities such as an iICU, HDU and designated postoperative recovery areas.
Split sites - isolated maternity units
Postal survey
In 1997 91% (235/259) of maternity units were on the site of an acute general hospital. This compares with 86% (213/248) in 19932 as shown in Table 18.1. Nine per cent (24/259) of consultant maternity units stated that they were not on the site of an acute general hospital. These are referred to as isolated units. This compares with 14% (35/248) in 19932 as shown in Table 18.2. Wales no longer has any split-site consultant units. Table 18.1 - Comparison of 1993 data2 audit data against 1997 reaudit data.
Table 18.2 - Comparision of 1993 with 1997 data for number of isolated maternity units.*
Ten of these 24 units conduct between 300 and 2,999 deliveries per year, and the rest between 3,000 and 6,500. On-site intensive care facilities were available only in one of these units. For the remaining 23 units the distance to the nearest ICU ranged from 0.5 and 8 miles. 12 units stated that they had HDU facilities on site but the definition clearly differed between units. Seventy-nine per-cent (19/24) had blood transfusion facilities on site.
Provision of an ICU, HDU and postoperative recovery area facilities
The previous three Reports have recommended that facilities for intensive care and for high-dependency care be readily available. In the 1985-87 Report the recommendation was that large maternity units should provide a centralised high-dependency care area with trained staff and appropriate monitoring equipment. This was extended in the 1988-90 Report to include every consultant maternity unit. The last Report recommended that intensive care and high-dependency care facilities must be readily available in the same hospital as the maternity unit. In addition, every maternity unit undertaking caesarean sections should have a designated, staffed and equipped recovery area with staff specifically trained in post-operative care. Postal survey
In 1997 80% (206/259) of the consultant maternity units had an ICU on site. This compares with 76% (188/248) in 19932 as shown in Table 18.1. In 1997 62% (161/259) of units had an HDU on site compared with 41% in 19946. The number of units without an ICU on site are shown in Table 18.3, categorised by the number of births per annum.
Table 18.3 - Number of units who do not have an ICU on site by number of deliveries per annum. Interviews
All the obstetricians and midwives interviewed (n=100) were asked where women with complications were nursed. The majority, 59%, stated that ill women were nursed in a room within the delivery suite, 33% in a high-dependency area within the maternity unit, mainly on the delivery suite, with 4% stating they were transferred to ICU. The remaining 4% were unsure where ill women were nursed. The responses varied depending on the nature of the complication. For instance women were more likely to go to an ICU with eclampsia (15%) than with severe pre-eclampsia (4%) or if they had had a massive haemorrhage (3%). Asked if there was a designated, fully equipped recovery area, 88% of obstetricians and midwives stated yes; 10% use one of the delivery rooms but stated that equipment was available; and 2% stated that the women went straight back to the ward from theatre.
When anaesthetists' responses were included in the survey (total n=149) 94% of staff interviewed (140/149) stated that a skilled anaesthetic assistant was always available for all maternity theatre cases. When asked if any of the midwives caring for these women had had any further training in critical care, 20% (6/30) of consultant obstetricians, 16% (5/31) of senior midwives and 19% (4/21) of junior midwives stated that some of the midwives had undergone further training; 50% (15/30) of consultant obstetricians, 55% (10/18) of specialist registrar obstetricians, 77% (24/31) of senior midwives and 71% (15/21) of junior midwives said none had. The remaining staff, including all 49 anaesthetists, were unsure. Discussion
The provision of ICU and HDU facilities has shown an improvement since 19932. Eighty per cent of units had ICU facilities in 1997 compared with 76% in 19932. Similarly, the provision of HDU facilities has improved, with 62% of units having facilities in 1997 compared with only 41% in 19946. It is evident from these interviews that the majority of ill women are cared for within the maternity unit; but, only 15% of obstetricians and midwives considered that the midwives caring for these women had any further training in critical care. This training tended to have occurred before midwifery training and midwives have identified problems with maintaining skills. A study conducted in 1994 stated that the provision of monitoring equipment and training of midwives in its use was "very variable and often suboptimal"6. Despite the role anaesthetists have in the clinical management of ill women, none of those interviewed knew if the midwives had had any further training. Whilst senior anaesthetists were very supportive of the midwives' role and capabilities in caring for ill women, many were concerned and identified areas of weakness. Some maternity units have attempted to address this issue by setting up educational packages. The main problems appear to be in relation to identifying the level of training needs, the optimum number to train to maintain the service, the financial cost of training and the maintenance of skills.
Recommendations
Staffing Previous Reports and the National Confidential Enquiry into Perioperative Deaths (NCEPOD)5 have emphasised the need for 24-hour consultant cover and the discontinuation of inappropriate responsibility being given to, or taken by, by staff not qualified or skilled to do so.
Interviews - obstetricians and midwives
All obstetricians and midwives interviewed (n=100) stated that there was always an obstetrician of at least registrar experience readily available on site for consultation, or to attend, in the event of a complication or emergency. When asked what was the usual level of experience of the doctor on call during the day, it ranged from consultant (6%), senior specialist registrar (37%), specialist registrar (54%) and senior house officer (3%). Out of hours, during the night or at weekends, only 2% stated that a consultant was on site, 16% a senior specialist registrar, 78% a specialist registrar and 7% stated that senior house officers would be called to attend. Specialist registrar obstetricians' duties during the day varied, with 33% stating that they would be on call for maternity only, and 66% covering both maternity and gynaecology units. Out of hours, 11% covered maternity only, with 88% covering both maternity and gynaecology units. In 97% of these hospitals the maternity and gynaecology units were on one site. However, many of these hospital sites are geographically very large, and some specialist registrars in particular highlighted the problem of the time taken going between the maternity and gynaecology departments.
Asked how long it took from the obstetrician being called to arriving on the unit for an emergency, 60% stated the obstetrician would be based on the delivery suite and therefore immediately available. Thirty-nine per cent said they would attend within five minutes providing they were not committed on the gynaecology unit, in which case the attendance time was variable. On further questioning, this did not appear to be a regular problem.
In all units a consultant obstetrician was always on call for consultation or to attend if required. During the day they stated they could attend within 15-20 minutes, often much less. At night and at week-ends, particularly Saturday afternoons, some said they would have difficulty getting in within 30-40 minutes. However, none of their colleagues interviewed highlighted that time was a problem with attendance.
Interviews - anaesthetists
An anaesthetist of at least one year's experience was always available for the maternity unit. They usually had 18 months' anaesthetic experience andwere available when both the senior staff and the trainees themselves had agreed they were competent to practise in maternity.
In 58% (18/31) of the units there was a dedicated anaesthetist, covering the maternity unit only, during the day. In 19% (6/31) the anaesthetist also covered the ICU and in a further 23% (7/31) the anaesthetist covered maternity and the general hospital as well. When asked what level of anaesthetist was most likely to attend to deal with a complication, 17% of all staff interviewed (n=149) stated that it would be the consultant, 71% said a senior specialist registrar and 9% a specialist registrar or the SHO during the day. At night or at the weekend, however, only 3% indicated that the consultant would attend whilst 70% said a specialist registrar and 23% an SHO. All staff interviewed stated that in an emergency, the anaesthetist on call would attend within 10-15 minutes and 86% stated that, if called, a consultant would attend within, at most, 15-20 minutes during the day and 30-40 minutes during the night and at week-ends.
All 31 units had 24-hour consultant anaesthetist cover for maternity. In 27 of these units there were dedicated consultant maternity sessions. These varied between two and eight sessions per week. When asked, 24 (80%) consultants stated that they were based on the delivery suite during these sessions. All units had a consultant lead for obstetric anaesthesia.
Discussion
An obstetrician and anaesthetist of specialist registrar grade, or equivalent, were always available to attend for emergencies. All the staff interviewed were satisfied that the response time was adequate and no-one highlighted any serious deficiencies in the service. However, anecdotally, there was occasionally some disquiet as to the level of skills and competencies of some staff caring for ill women. These concerns were raised by, and about, each group interviewed. There was 24-hour cover of consultant obstetricians and anaesthetists and there was general agreement about the accessibility to consultant staff both for advice and to attend in an emergency. No problems were highlighted in consultant staff attending for an emergency and they would attend within 30 minutes, usually less. It was reassuring to note that all units had a consultant lead for obstetric anaesthesia.
Recommendation
Dealing with maternal emergencies
It is important that all practitioners know how to deal with emergencies. The 1988-90 Report emphasised that new medical and midwifery staff should have an induction course and that their continuing education programme should include regular rehearsals of emergency procedures, especially in cardio-pulmonary resuscitation.
Interviews
All obstetricians were asked if junior doctors were instructed in how to deal with maternal emergencies and whether this instruction was formal or informal. Ninety-three per cent (28/30) of consultants and 89% (16/18) of specialist registrars said that junior doctors were instructed in maternal emergencies, with over 50% of both consultants and specialist registrars stating that this instruction was formal. In addition, all obstetricians were asked if senior obstetricians updated their skills in dealing with obstetric emergencies, for example undertaking basic life support or an advanced life support in obstetrics course. Fifty-three per cent of consultants and 39% of specialist registrars stated that senior obstetricians did update. When midwives were asked if they were instructed in how to deal with maternal emergencies, 68% ( 21/31) of senior midwives and 57% (12/21) of junior midwives stated that they were, with 42% of senior midwives and 33% of junior midwives stating that this instruction was formal. All anaesthetists were asked if there were any training sessions in dealing with emergency situations for obstetric and midwifery staff. Forty-seven per cent (14/30) of consultant anaesthetists and 37% (7/19) of specialist registrar anaesthetists stated that training sessions took place.
Discussion
In many Trusts the statutory cardio-pulmonary resuscitation lectures were mainly undertaken by resuscitation officers employed by the local Trusts. While the interviews were being conducted, several resuscitation officers were contacted, and they stated that they had very few consultants of any discipline attending the sessions.
Collaborative, multidisciplinary practice sessions or "drills" for dealing with emergency situations are undertaken by all the emergency services and many A&E departments. This allows all members of staff, and especially new and junior staff, to know and understand their specific roles and responsibilities in an emergency. The domestic, portering and clerical staff must also be included as they are important members of any emergency team. All obstetricians, anaesthetists and midwives were asked if they undertook any practice sessions. No practice or drills occurred in any of the units involved in the interviews. However, a few consultant obstetricians and consultant anaesthetists were hoping to address this issue. Recommendations
Clinical guidelines for the management of severe maternal complications
The use of evidence-based, interdisciplinary, clinical management guidelines is essential. Successive Reports and publications have recommended that such guidelines are introduced and disseminated3,4,7,8. These should be regularly reviewed and updated by an interdisciplinary team and drawn to the attention of all staff, including community midwives, ambulance personnel and staff in A&E Departments. The guidelines should also be displayed in a prominent place and immediately accessible to all staff.
Postal survey
All consultant-led units were asked if they had clinical guidelines for the management of; severe preeclampsia, eclampsia, massive haemorrhage, thromboprophylaxis and severe genital tract infection, see Table 18.4. They were asked to forward a copy of these guidelines to the RCOG Clinical Audit Unit.
Table 18.4 - Availability of clinical guidelines for the management of major complications - by 11 health Regions in the UK - 1997. Interviews
All of the units whose staff were interviewed had some of the guidelines under review. From the staff interviewed, 75% (36/48) of obstetricians and 83% (43/52) of midwives considered these had been drawn up by a multiprofessional group. Six consultant obstetricians stated that the clinical guidelines in their own unit were developed by medical staff only, mainly obstetricians with anaesthetist input if required. Of these six units, three are large tertiary referral centres and three are large district general hospitals. In total these six units conduct approximately 23,700 deliveries per annum.
Anaesthetists were asked if they were routinely involved in the development of guidelines. Eighty per cent (24/30) of the consultant anaesthetists surveyed, and 58% (11/19) of specialist registrar anaesthetists, stated that they were routinely involved. The six consultant anaesthetists who said they were not involved in the development of guidelines all practised within units that stated that they had a multiprofessional guideline development group.
It is imperative that staff dealing with an emergency are not faced with the dilemma of trying to decide from a multiplicity of guidelines which they should comply with. For instance, the consultant the woman is booked with, or the consultant who is on call that day, may have differing views on the management of a particular condition. Therefore, there should be one set of guidelines agreed on by all the senior staff involved. It was reassuring to note that all those interviewed stated that the guidelines were agreed by all consultant obstetricians and consultant anaesthetists involved in the management of ill pregnant or recently delivered women.
Guidelines need to be readily accessible. All those interviewed stated that the guidelines were kept on the delivery suite, although only 20% (30/149) thought that a copy was also kept on the antenatal and postnatal wards. Making the guidelines available to all clinical areas will help to alert staff to any changes in management, thereby assisting in their implementation.
All staff were asked when their local guidelines were last updated and if there was a fixed schedule for revision. Seventy-two per cent (107/149) of staff thought the guidelines had been updated within the previous 12 months, 5% (7/149) longer than 12 months and 22% (33/149) were unsure. Of the latter, 14 were senior members of staff. Asked if they had a fixed schedule for revision of these guidelines, 23% (34/149) of interviewees thought they were reviewed annually, 42% (63/149) stated that they had no schedule for revision, 4% (6/149) had a rolling programme and 31% (46/149) were unsure. On further enquiry those who stated they did not have a fixed schedule tended to fit into a rolling programme. The term "rolling programme" encompassed a diversity of methods. These ranged from reviewing a different guideline, or a small number of guidelines, on a monthly or three-monthly basis, when new evidence was produced or when requested by a member of staff. Only 42% (63/149) of those interviewed stated that the units in which they practised had any formal means of dissemination of new or updated guidelines, the most common forum being meetings, mainly perinatal mortality, clinical audit and delivery suite meetings. Dissemination to the medical staff usually took the form of sending a copy to them. In 70% of cases new medical staff were given copies on arrival. As well as these meetings, midwifery staff tended to be informed by ward briefings, notice boards and communication books. It was often stated that they had to sign a "list" confirming that they had read the guideline, but no one was able to explain the purpose of the list or how this assisted in the dissemination of midwives' knowledge of the guidelines. Nevertheless, 87% (27/31) of senior midwives and 38% (8/21) of junior midwives felt they were involved in the development of their local guidelines. The remainder of those interviewed considered that they did not have any formal means of dissemination and tended to be informed by word of mouth or that the guidelines "just arrived one day".
Recommendations
The following sections consider specific guidelines in more detail. The clinical guidelines received from the study sites and those in response to the postal questionnaire were evaluated by use of a guideline assessment tool developed for the purpose9.
Massive haemorrhage
Every Report has featured massive haemorrhage as a cause of death. Although the incidence of death by haemorrhage has decreased, it remains a major complication. Successive Reports have emphasised the need for guidelines for the management of massive haemorrhage and for all those who care for pregnant women to be familiar with them.
Postal survey
Ninety-three per cent (240/259) of consultant maternity units in the UK stated that they have clinical guidelines for the management of massive haemorrhage. This compares with 82% (204/248) in 19932 as shown in Table 18.1.
Interviews
All staff interviewed (n=149) in 31 units stated that a guideline for the management of massive haemorrhage was available in their unit. The RCOG4 has recommended that uncross-matched blood should be available within 10 minutes and cross-matched blood within 30 minutes. When asked, 95% of staff stated that uncross-matched blood, O RhD-negative, was immediately available, 74% stated that ABO-compatible RhD-negative blood was available within 10 minutes and 50% stated that full cross-matched blood was available within 45 minutes. However, in two large tertiary maternity units, conducting 4,500 and 5,500 deliveries annually, there were difficulties in getting essential services out of normal working hours. In order to overcome any difficulties one of these units has developed a system in collaboration with the laboratory service, for immediate delivery of requests and samples to the laboratory. This ,in combination with a priority coding, ensures rapid attention. This system is audited regularly. The other unit, at the time this study was undertaken, was having problems that were potentially serious.
The RCOG further recommended that for women who have a massive haemorrhage the early involvement of anaesthetists and haematologists is essential3,4. All the obstetricians interviewed stated that they can readily get advice from a consultant haematologist, and 78% of all staff interviewed stated that anaesthetists are routinely involved in the management of these cases.
Placenta praevia
The potential problems associated with placenta praevia have been repeatedly emphasised in previous Reports. One of the recommendations has been that an elective or emergency caesarean section for placenta praevia should be performed, or directly supervised, by a consultant obstetrician.
Interviews
Twenty per cent of all staff interviewed (n=149) stated that the consultant obstetrician always performed or assisted at caesarean section for placenta praevia, 13% stated that they did if the case was elective and 61% stated that consultants did not routinely operate for either.
Asked who routinely did perform caesarean section for placenta praevia, 28% of staff stated that a senior registrar would perform both elective and emergency, 36% that a specialist registrar performed both and 15% that the senior specialist registrar operated if surgery was elective and the specialist registrar if it was an emergency. This was apparently irrespective of the degree of placenta praevia, the position of the placenta or any previous caesarean section.
Sixteen (53%) of the consultant obstetricians stated that they routinely performed or assisted at elective caesarean section for placenta praevia. Of these, 11 consultants stated that they also routinely attended for emergency cases. However, none had complete agreement from all their colleagues interviewed in the same unit. In only five of these units was the statement that the consultant obstetrician routinely undertook these cases confrmed by the consultant anaesthetists and senior midwives. The remaining 11 units conduct, in total, over 41,000 deliveries per annum. Six of these units are tertiary referral centres.
The interview also asked about the grade of the anaesthetist attending for caesarean section for placenta praevia. Ten per cent (3/30) of consultant anaesthetists stated that a consultant would attend for both elective and emergency cases, whilst 43% (13/30) said they would attend for elective cases only. The remaining 47% (14/30) stated that a consultant did not routinely attend for either. These figures were confirmed by the specialist registrar anaesthetists who stated that the majority of cases were undertaken by specialist registrars. However, all staff interviewed considered both a consultant obstetrician and a consultant anaesthetist should be able to attend within 15-20 minutes during the day and within 30-40 minutes out of normal working hours.
Refusing a blood transfusion
The problems associated with the management of haemorrhage in women who refuse blood transfusion were highlighted in the last Report, which also contained guidelines for the management of such women. Although there are many women who are fearful of receiving contaminated blood, absolute refusal to have a blood transfusion, irrespective of the outcome, is unlikely in most women, except those who have strong religious beliefs.
Interviews
All obstetricians and midwives were asked if there was any written guidance for the clinical management of such cases. Twenty-two per cent (22/100, involving nine units) stated that there was some form of guidance. The remaining 78% either stated none was available or were unsure. Asked if there was a system in place in which they could get advice on the management of such cases, 34% stated yes and 66% stated no or were unsure.
Nine units stated that they had written "guidance" for the management of these cases, but only one, a district general hospital, had included in its guideline the recommendation from the previous Report. In the remaining ten units, three had disclaimer forms which the women, who were identified on grounds of their stated religion, were asked to sign. The remaining seven units did not have any reference within the guidelines they supplied.
Postal survey
All units were requested to forward a copy of the guidelines under review and 147 (57%) supplied a copy of their guideline for the management of haemorrhage. The need to involve an anaesthetist was mentioned in 69% (101/147) of guidelines and 62% (91/147) mentioned consulting a haematologist. Twelve (8%) of the guidelines were taken directly from the 1991-93 Report.
Only 1.4% (2/147) had any recommendations for the management of women who refuse blood transfusion. These were taken from the previous Report.
Discussion
The number of units with a guideline has improved since 19932 although this should be 100%. The interviews have highlighted that there are problems with the access to blood supplies as only 50% of staff stated that cross-matched blood was available within 45 minutes. Guidelines for the management of women who refuse blood products do not appear to be widely available. Recommendations
Severe hypertensive disorders and eclampsia
Previous Reports have highlighted problems with the management of both severe hypertensive disorders and eclampsia. They have repeatedly emphasised that all units should have a lead consultant, clear management guidelines based on current evidence and ready access to a Regional advisory service led by a consultant with special expertise.
Postal survey
Eighty-nine per cent (230/259) of consultant-led maternity units had guidelines for the management of severe hypertensive disorders and 94% (243/259) for the management of eclampsia. This compares with 91% (225/248) for eclampsia in 19932. These figures are shown in Tables 18.1 and 18.4.
Interviews
Ninety-nine per cent (99/100) of obstetricians and midwives interviewed stated that there was a guideline available in their unit for the management of severe hypertensive disorders and eclampsia. All anaesthetists (n=49) were asked if they were routinely involved in the management of severe hypertensive disorders and eclampsia. Eighty per cent stated they were routinely involved with cases of severe hypertension and 88% with eclampsia. In addition, 80% of consultant anaesthetists said they were involved with the development of guidelines for the management of these cases.
All obstetricians and midwives (n=100) were asked if the guidelines contained details for the management of fluid balance and drug management. In the case of severe hypertensive disorders, 87% stated they contained details for fluid management and 93% for drug management. For eclampsia, 86% thought there were details on fluid management and 87% for drug management. Seventy-nine per cent stated that magnesium sulphate was the drug of choice for eclampsia and 17% used diazepam. Those units who were not using magnesium sulphate stated that this was in the process of being introduced.
In the case of severe hypertensive disorders 70% of consultant obstetricians stated that the management was collaborative. This was confirmed by 71% of senior midwives and 80% of consultant anaesthetists. However, only 44% of specialist registrar obstetricians and 47% of specialist registrar anaesthetists believed this to be the case. There was greater agreement regarding the management of eclampsia, with 85% of all consultants, 73% of all specialist registrars and 81% of all midwives stating that the care was collaborative. Overall, 64% of obstetricians and midwives stated that the consultant obstetrician was more likely to take overall responsibility in the case of severe hypertensive disorders, but with the management of eclampsia 47% stated that it would be the consultant obstetrician and 50% stated that the responsibility for care would be collaborative. All obstetricians and midwives were asked if their unit was a regional referral or advisory centre for severe hypertensive disorders and, if not, if referrals were made or advice was sought from other units. Forty-three per cent stated they were a regional referral centre and 32% said referrals were made to other units. Of the 16 consultants who stated that the units in which they practised were not regional referral centres, only two said they asked for advice from another unit. The remaining fourteen consultants said they managed these cases in house, that they would ask advice very rarely and could not state when they last had. In addition, they said that they only transferred women when a neonatal cot was required. These 16 units (52% of sample) conduct approximately 45,800 deliveries annually.
Discussion Although nearly all units surveyed did have clinical guidelines the figure should have been 100% and units without guidelines need urgently to address this and also to ensure the guidelines are known to all staff involved in maternity care. The guidelines were clearly being kept up to date, with the interviewees revealing a universal change to the use of magnesium sulphate since the publication of the Collaborative Eclampsia Trial showing this to be the preferred treatment10. It was also of concern that the management of some severely ill women was still not considered to be a collaborative effort.
Recommendations
Thromboembolic disorders
Previous Reports have emphasised the need for vigilance with regard to the risk factors for thrombo-embolic disorders, particularly in relation to caesarean section, with the use of prophylactic measures in vulnerable women. The last Report endorsed the recommendations from the 1995 RCOG working party on prophylaxis against thromboembolism12, which was circulated to all members and fellows of the RCOG. The standards for this section of the audit are based on the RCOG report.
Postal survey
Sixty-six per cent (171/259) of consultant maternity units in the UK stated that they had clinical guidelines for the management of thromboembolic disorders. Table 18.4.
Interviews
All obstetricians and midwives were asked if there were guidelines available to identify women at risk of developing thromboembolic disorders, and, in addition, whether prophylactic measures were used for women who had had a previous thrombosis.
Ninety-seven per cent (29/30) of consultant obstetricians, 94% (17/18) of specialist registrar obstetricians, 48% (15/31) of senior midwives and 52% (11/21) of E/F grade midwives stated that they had guidelines for identifying women at risk. All consultant obstetricians, 78% (14/19) of specialist registrar obstetricians, 48% (15/31) of senior midwives, 52% (11/21) of E/F grade midwives, 97% (29/30) of consultant anaesthetists and 95% (18/19) of specialist registrars in anaesthetics stated that prophylactic measures were used for women at risk, the remaining 21% (32/149) of staff being unsure if prophylactic measures were used.
The RCOG working party report stated that "caesarean section is a major risk factor for pulmonary embolism and the risk appears greater after an emergency procedure"12. All the consultant obstetricians interviewed stated that they used the RCOG risk assessment profile for categorising risk to the individual woman.
All obstetricians, midwives and anaesthetists were asked if prophylactic measures were used for women undergoing an elective or emergency caesarean section and what form these took. Ninety-one per cent (136/149) stated that prophylactic measures were used for women who had a caesarean section. Those who stated that they used prophylactic measures (n=136) were asked what methods they utilised, whether anticoagulants, such as low molecular weight heparin, and/or mechanical methods, such as thromboembolic stockings or pneumatic leggings. In the case of elective caesarean sections, 16% (22/136) stated that anticoagulants were used in all cases, with 63% (86/136) saying that they were used for women who were classed as high-risk cases only. With the use of mechanical methods, 39% (53/136) stated they were used in all cases, with 46% (62/136) saying they were used in high-risk cases only. Similarly, following emergency caesarean sections, 25% (34/136) stated that all women were given anticoagulants, with 57% (77/136) stating they were only used for women considered to be at high risk. Forty-nine per cent (66/136) stated that mechanical methods were used in all cases and 37% (50/136) in high risk-cases only.
Despite caesarean section being a recognised risk factor and emergency procedures increasing this risk further, it appeared that not all staff were fully conversant with the need for thromboprophylaxis, with only 91% (136/149) stating that it was used after a caesarean section. The RCOG working party report states that women fulfilling the risk assessment profile for moderate and high risk should receive anticoagulants. An emergency caesarean section, without other risk factors, is considered to be a moderate risk factor. Although all consultant obstetricians stated that they followed the RCOG recommendations, only 20% (6/30) used anticoagulants for every woman undergoing an emergency caesarean section and only 67% (20/30) did so for women considered to be at high risk.
Discussion
Despite the RCOG recommendations being available to all Members and Fellows since 1995 it is of concern that only 66% of consultant maternity units have guidelines for the management and prophylaxis of thrombo-embolic disorders. Nevertheless, in the units which participated in the study, there appears to be a fair amount of consistency between the groups interviewed. In view of the lack of randomised controlled trials into thromboprophylaxis in pregnancy and childbirth the recommendations of the RCOG working party are based on authoritative consensus opinion. One particular area of concern has been in the use of anticoagulants following caesarean section. In order to address this, a randomised controlled trial on the use of low molecular weight heparin is proposed and the pilot study is underway13.
Recommendations
Infection
Previous Reports have emphasised that infection must never be underestimated as it still remains a cause of maternal mortality. The RCOG recommends that guidelines are available for the management of women with suspected major sepsis4 and that antibiotics are given in all cases of emergency caesarean section.
Postal survey
Twenty per cent (53/259) of consultant maternity units in the UK stated that they had clinical guidelines for the management of severe genital tract infection (Table 18.4 ).
Interviews
All obstetricians and midwives were asked if their unit had guidelines for the management of women with suspected severe infection. Thirty-one per cent (31/100) stated that they had management guidelines, 43% (43/100) did not and 26% (26/100) were unsure. In addition, all obstetricians, midwives and anaesthetists were asked if prophylactic antibiotics were given to women undergoing a caesarean section. Eighty-two per cent (122/149) stated that antibiotics were given. Of these, 97% (119/122) stated that they were always used in emergency caesarean sections and 88% (107/122) said they were also used in elective cases.
Several of those interviewed stated that they did not have guidelines for the management of infection because each case was dealt with separately. The 31 members of staff who said they had management guidelines for severe infection, represented 21 maternity units. The guidelines supplied by these 21 units were reviewed and only two of the units had specific guidelines detailing the management of women with severe infection. Of the remaining 19 units, 13 made reference to screening for infection following pre-labour spontaneous rupture of the membranes and the use of prophylactic antibiotics following caesarean section. The guidelines from the other six units made no reference to infection at all. The staff most likely to deal with the problem of infection in the first instance, particularly in the early postnatal period, are the specialist registrars and E/F grade midwives at ward level, but 39% (7/18) of specialist registrars and 57% (12/21) of midwives were unsure if any guidelines even existed.
Discussion
It would seem from the lack of guidelines that the problem of infection is not given the consideration that the RCOG recommends.
Recommendations
Overall conclusions
This study shows that there has been an encouraging improvement in the provision of facilities and services in the maternity services throughout the UK and that many of the recommendations from the Reports have been implemented. Nevertheless, there will always be improvements to be made and this study has highlighted some areas in which these should be made as soon as practicable. Recommendations have been made at the end of each section and all maternity units, not just consultant units, are encouraged to implement these. The two main issues are concerned with the communication between all those responsible for the care of women during childbirth, particularly in relation to the development, dissemination and implementation of clinical guidelines, and the care of ill women during pregnancy and childbirth, particularly the education, training and maintenance of skills of all those responsible for their care.
The key message is that there is a commitment to the continuous improvement in the quality of care within the maternity services. The advent of clinical governance, with its assurance that quality will resume its rightful place at the heart of the NHS, will assist all those involved in maternity care to continue this process.
References
1. Department of Health. A First Class Service: Quality in the new NHS. London: Department of Health; 1998. 2. Hibbard, B. & Milner, D. Reports on Confidential Enquiries into Maternal Deaths: an audit of previous recommendations. Health Trends 1994; 26:26-8. 3. Patel, N. (ed.) Maternal Mortality - The Way Forward. London: Royal College of Obstetricians & Gynaecologists; 1992. 4. Royal College of Obstetricians & Gynaecologists. Deriving Standards from the Maternal Mortality Reports. London; Royal College of Obstetricians & Gynaecologists; 1994. 5. The Report of the National Confidential Enquiry into Perioperative Deaths 1991-1992. The National Confidential Enquiry into Perioperative Deaths. London; 1993. 6. Cordingley, J. J. & Rubin, A. P. A survey of facilities for high risk women in consultant obstetric units. International Journal of Obstetric Anesthesia 1997; 3:156-60. 7. Royal College of Obstetricians & Gynaecologists, Clinical Audit Unit. Effective Procedures in Maternity Care Suitable for Audit. London: Royal College of Obstetricians & Gynaecologists; 1997. 8. NHS Executive. Clinical Guidelines: Using clinical guidelines to improve patient care within the NHS. NHS Executive; 1996. 9. Royal College of Obstetricians & Gynaecologists, Clinical Audit Unit Guideline Appraisal Tool: criteria for evaluating maternity unit guidelines. Derived from Instrument as: Cluzeau F, Littlejohn J, Grimshaw J, Fader G. Draft Appraisal Instrument for Clinical Guidelines, in RCGP The Development and Implementation of Clinical Guidelines 1995, Report 26. London: Royal College of Obstetricians & Gynaecologists; 1997. 10. The Eclampsia Trial Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995; 345: 1455-63. 11. Management of Eclampsia, Green Top Guideline No 10. London: The Royal College of Obstetricians & Gynaecologists; November 1996. 12. Royal College of Obstetricians & Gynaecologists Report of the RCOG Working Party on Prophylaxis Against Thromboembolism in Gynaecology and Obstetrics. London: Royal College of Obstetricians & Gynaecologists; 1995. 13. Prevention of Pulmonary Emboli and Deep Venous Thromboses After Casearean Section with Low Molecular Weight Heparin - The PEACH Pilot study 1998. Contact: Peter Brocklehurst, Perinatal Trials Service, National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford.
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