P1252428399IEOxd - PowerPoint PPT Presentation

Title: P1252428399IEOxd


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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_at_cemach.org.uk
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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
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Work programme

• 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

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National Overview of Perinatal Mortality

• Challenges and Opportunities for Improving care
• 24th June 2009
• London

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Feedback Report following the Saving Mothers
Lives Interactive Workshops North West of England
Local Supervising Authority Summer 2008
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Trust SOM/Trainee
Blackpool, Fylde Wyre Hospitals NHS Foundation Trust 3
Bolton Hospitals NHS Trust 1
Central Manchester Manchester Children's University Hospitals NHS Trust 3
Countess of Chester Hospital NHS Foundation Trust 2
East Cheshire NHS Trust 2
East Lancashire Hospitals NHS Trust 12
Halton St Helens PCT 3
Lancashire Teaching Hospitals NHS Foundation Trust 8
Liverpool Women's NHS Foundation Trust 8
Liverpool John Moores University 1
Mid Cheshire Hospitals NHS Foundation Trust 1
Nobles Hospital 2
North Cheshire Hospitals NHS Trust 3
North Cumbria Acute Hospitals NHS Trust 14
Salford Royal NHS Foundation Trust 3
St Helens Knowsley Hospitals NHS Trust 6
Stockport NHS Foundation Trust 1
Tameside Hospital NHS Foundation Trust 4
The Pennine Acute Hospitals NHS Trust 4
University Hospital of South Manchester NHS Foundation Trust 4
University Hospitals of Morecambe Bay NHS Trust 8
Wirral University Teaching Hospital NHS Foundation Trust 14
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• 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.

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Aim

• 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.

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Objectives

• 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.

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Workshop

• Small groups
• Facilitated by Link supervisors and
• CEMACH
• Case Histories
• Structured Questions
• Feedback
• Summary notes

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Structured Questions

• 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.

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1a Pre-conception care

• 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.

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1b Pre-conception care

• This applies especially to women prior to
  assisted conception and other infertility
  treatments.

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Good practice points

• Well structured preconception service for
  diabetic women DVD available for women at the
  Liverpool Womens Hospital
• Spaces for preconception care in a medical clinic

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• 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.

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2a Access

• 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.

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2b Access

• Women should also have had their full booking
  visit and hand held maternity record completed by
  12 weeks of pregnancy.

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Good practice points

• 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 GPs 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

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• 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

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3 Access

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

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• 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.

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4a Migrant women

• 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.

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4b Migrant women

• Women from countries where genital mutilation
  is prevalent should be sensitively asked about
  this and management plans for delivery agreed
  during the antenatal period.

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Good practice points

• 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

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5 Systolic hypertension

• All pregnant women with a systolic BP of /gt
  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.

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Good practice points

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

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• 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.

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6 Caesarean section

• 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.

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• 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.

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7 Clinical skills

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

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Good practice points

• 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

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• 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.

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8 Training

• 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.

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• 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.

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• 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.

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• Midwives general knowledge of medical conditions

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9 Early warning scoring

• 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.

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Good practice points

• MEOWS chart in use within maternity
• Critical care team, incorporating midwives, which
  works across the Trust

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• 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
  womens 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.

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10 National guidelines

• Guidelines are urgently needed for
• The obese pregnant woman
• Sepsis in pregnancy
• Pain bleeding in early pregnancy.

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Good practice points

• 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

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

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• 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

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• 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.

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Overarching themes

• Strengthening communication
• Specific training needs
• Access to senior support
• Organisation of services
• Areas for policy development

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Evaluation
All delegates Yes No Blank
7a. SML Individual 94 3 3
7b. SML as a whole 94 0 6
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(No Transcript)
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Thank You

• julie.maddocks_at_cemach.org.uk
• Tel 0161 276 6837