CEMACH

Chapter 16: Midwifery

Grace Edwards

This Chapter was written in collaboration with Val Beale Local Supervising Authority Midwifery Officer NHS South West, Grace Edwards Consultant Midwife Liverpool Women's NHS Foundation Trust, Alison Miller, Programme Director and Midwifery Lead, CEMACH and Jane Rogers, Consultant Midwife, Southampton University Hospital Trust.

Introduction

The purpose of this Chapter is to inform all midwives of the key issues and implications for midwifery practice which have arisen from this Report and that need to be addressed. These findings and recommendations are based on the detailed assessment of all the relevant maternal deaths considered by the midwifery assessors for this Report.  In many of the cases in this triennium midwifery care was exemplary and showed evidence of true partnership working. However, some of the cases mentioned in this Report highlight pregnancies where midwifery led care was inappropriate.

This Chapter cannot provide an exhaustive overview of all the key findings and recommendations contained within this Report. However, although many midwives will wish to read the Report in its entirety, all should read and act on the findings and recommendations contained in this Chapter, the key overall recommendations highlighted in Chapter 1 and also in Chapter 17 - Issues for General Practitioners, as they are remarkably similar.

The role of the midwife

In order to explore the issues surrounding midwifery practice it is useful to revisit the definition of a midwife and boundaries of practice. According to the International Confederation of Midwives1, midwives are experts in normal childbirth, but also work in collaboration with other health professionals to ensure an effective service for women who may need to be referred for more specialist care. This emphasis on the midwife as an expert in normal birth is reiterated by the Royal College of Midwives, who state:

“The role of the midwife is to ensure that women and their babies receive the care they need throughout pregnancy, childbirth and the postnatal period. Much of this care will be provided directly by the midwife, whose expertise lies in the care of normal pregnancy, birth and the postnatal period, and the diagnostic skills to identify deviations from the normal and refer appropriately2”.

A midwife’s skill and expertise lies not only in providing expert care for healthy women but also in identifying when a medical opinion is appropriate. Since the last Report3 was published, in 2004, there have been many examples of midwives embracing its key recommendations by providing targeted and effective care for different groups of vulnerable women and their families. These include providing accessible, holistic, midwifery care for women through Children’s Centres or other local facilities which currently provide services in the 30% most disadvantaged areas of the country. In addition, there has been an increase in the number of midwives providing specialist care for particularly vulnerable women e.g. teenage girls, women experiencing domestic abuse, those seeking asylum or who misuse substances and those who have suffered female genital mutilation/cutting (FGM/FGC). Examples of these responses can be found at the end of this Chapter.

Overarching themes for midwifery practice

Maternity Matters, the recent implementation plan for the National Service Framework4 in England, describes two clear pathways of care that women may choose:

In both pathways the midwife will play a key role either leading care or working in partnership in maternity teams with obstetric and other colleagues. Similar initiatives exist in other countries of the UK. In Scotland the Scottish NHS Boards have embraced the principles outlined in ‘A Framework for Maternity Services in Scotland’ and ‘Report of the Expert Group on Maternity Services’ (2003)5. These reports endorse the promotion of pregnancy and childbirth as normal life events and advocate woman centred care, with service and care provider packages tailored to need. They recommend community focussed, midwife managed care for healthy women, with multidisciplinary maternity team care for complex cases. The All Wales Normal Birth Pathway8 is mentioned later in this Chapter as evidence of good practice.

Several key issues discussed here and elsewhere in this Report have implications for midwifery practice in either pathway. These can be divided into two main overarching themes:

Knowledge and skills
Midwifery led care

During this triennium there were relatively few deaths of women who had midwife only or midwife/GP only antenatal care, and for many this care was entirely appropriate. However, in a few cases it was not.

Twelve women whose deaths were classified as being directly related to pregnancy had midwifery led care, of whom three were assessed to be substandard because of poor midwifery practice. A further five women whose deaths were classified as being directly related to pregnancy had care shared between the midwife and GP yet, although care was deemed to be sub-standard in three of these deaths, there was no evidence of poor midwifery care.

Fifteen women whose deaths were classified as Indirect had midwife only antenatal care, and although overall care was judged to be substandard in three cases, in only one of these cases was there evidence of substandard midwifery care. In the other two cases the substandard care occurred following appropriate midwifery referral to obstetric care.  There was no evidence of substandard care in three other women who died from Indirect causes and who had midwife/GP only care.

Of the eleven women who died later after pregnancy of direct causes, so called Late Direct deaths, one woman had midwife only care and two had had midwife/GP care. Although the latter two cases were considered to have suboptimal factors, these were not midwifery related. Of the deaths from Coincidental causes, eight women had midwife only care, one being associated with sub optimal midwifery care. There was no substandard care for the six women who died of Coincidental causes and who received joint midwife/GP care.

In summary, in only five of the 36 cases of women who had midwifery led antenatal care and who died of Direct, Indirect, Coincidental or Late Direct causes was midwifery care judged to be substandard. There appear to be no cases of poor midwifery care amongst the 16 women who died and who had received joint midwifery/GP led care.

However, these few case do highlight the problem of inappropriate midwifery led care being provided for known or potentially higher risk pregnant women. The last Report3 highlighted the need for a national guideline to help identify those women for whom midwifery led care would be suitable. It is understood that, for England and Wales, the National Institute for Health and Clinical Excellence (NICE) are in the process of preparing this as part of their forthcoming update of the clinical guideline for the routine management of healthy pregnant women6.

Another issue concerning midwifery care revolved around a failure to recognise deviations from normal, thus failing to refer the woman for medical opinion. In these cases a number of risk factors were identified which highlighted the need for joint medical and midwifery care and, although there were clear indications requiring referral to an obstetrician or other specialist, inappropriate midwifery led care continued. For example:

 An underweight, young non English-speaking refugee who also had a low haemoglobin (Hb) was booked for midwifery led care. Her husband, who had very poor English himself, was used as her interpreter. She was admitted later in pregnancy with bleeding and abdominal pain. Constipation was diagnosed, despite abnormal liver function tests, and she was sent home under midwifery led care. She was readmitted some weeks later, late in pregnancy with abdominal pain and, despite a further abnormal blood assay, no senior medical opinion was sought and she was again discharged. Some days following this she was admitted, in extremis, in liver and multi-organ failure, her unborn baby having died in the meantime. Despite the severity of her condition, her care was still uncoordinated and, although she was visited by a critical care senior house officer (SHO) she remained on the delivery suite. The woman died two days later of disseminated intravascular coagulation related to fatty liver of pregnancy.
Professional accountability and competence

In the majority of cases where the woman had a new or underlying medical or psychological problem, appropriate referrals for medical opinion were made. However, in many of these cases the midwives involved then appeared to consider that they had done enough and believed the woman was no longer their responsibility. On the other hand, some midwives were worried that their concerns were being ignored by medical staff. For example:

An older parous woman who was obese, smoked, had a long gap since her last pregnancy and a blood pressure (BP) of 150/89 mm/Hg was booked for midwifery led care. She presented with severe headaches and vomiting near term which required opiates for relief. On admission her midwife was unhappy with the junior doctor’s lack of concern but “resigned herself to the fact that he knew best”. A subarachnoid haemorrhage was eventually diagnosed but she deteriorated and died a few days later.

This case illustrates an important point raised in many other cases as well. It is important that midwives should always seek a consultant opinion, and if necessary second consultant opinion, if they have continuing concerns about a woman in their care. If a midwife is still concerned following discussion with a medical consultant, support can be sought from a supervisor of midwives and the midwifery manager. Midwives have a duty of care for women, even when the pregnancy deviates from normal. This is reiterated by the Nursing and Midwifery Council, which states:

“You are personally accountable for your practice. This means that you are answerable for your actions and omissions, regardless of advice or directions from another professional7”.
Midwifery Learning Point

If a midwife remains worried following a medical opinion, s/he should have no qualms about contacting relevant senior medical personnel directly, such as the obstetric consultant on call. The Supervisor of Midwives is available for support and advice.

Midwives are also responsible for ensuring they are competent in their own practice and should highlight any perceived training needs during their supervisory reviews. This should be recorded for future reference. In some cases there were issues around midwives failing to recognise common, non-pregnancy related medical conditions, and/or failing to appreciate the severity of others. There were a worrying number of cases where, despite obvious symptoms, basic observations such as temperature, pulse and blood pressure were not taken, or ignored. In some cases, these simple measures would have alerted the midwife to more sinister pathology. For example:

A woman with a family history of hypertension had a BP of 140/90 mm/Hg at term. She had a straight-forward birth but complained of a severe headache a few days after birth. Despite the continuation and severity of the headache, the midwife did not check her BP or refer her for medical opinion. The woman collapsed and died of a subarachnoid haemorrhage a few days later.

Another woman was transferred home a few hours after a straight-forward birth with a transient pyrexia, tachycardia and low BP which were recorded in the hospital notes but not recorded on the discharge summary. The first community midwifery visit was two days later when the midwife did not take the woman’s temperature or record her pulse rate. The midwife also failed to realise the significance of a sore throat and red area on the woman’s abdomen, despite the woman saying she felt "feverish". The midwife did not plan to visit for a further four days; the woman died from septic shock in the meantime.

A young parous woman developed diabetes which warranted control by insulin. She was referred appropriately for joint medical and obstetric care. However, her blood sugars remained erratic and the baby was macrosomic at birth. After birth, without apparent discussion, her care was presumed to be midwifery led and no monitoring of her blood sugar or urine took place. There is no evidence of discussion or planning of her care with the diabetes team for postnatal care or preconception advice and no communication with the GP. She was discharged from midwifery care but died some weeks later from multi organ failure following diabetic complications.

However, it is important to reiterate that there were also examples of sensitive, holistic, care for women who were seriously or terminally ill, as evidenced below:

A young woman was diagnosed with a brain tumour in the second trimester following a short history of severe headaches. An inter-uterine death was diagnosed shortly after and the woman died a few weeks later. Her midwifery care was excellent and the midwife was with the woman when she died. The hospice staff commented about the excellent partnership working and communication from the midwifery team.

There were a number of cases where midwives showed a lack of experience and insight into the seriousness of the mother’s condition. This lack of experience and knowledge was also evident in several cases of women with complex pregnancies. There were examples of lack of provision of adequate pain relief, lack of joined up care and a lack of engagement with other professionals e.g. oncologists, the palliative care team, surgeons and physicians. In some cases it seemed that both midwives and obstetricians had not ascertained the complete picture and so had not appreciated the severity of the woman’s illness. For example:

A young healthy primigravida was admitted at term with reduced fetal movements. Hypertension was noted on admission but labour was not induced for some days. During this time severe anaemia was discovered and treated by transfusion but no senior medical advice was sought. During labour the woman became pyrexial and required a caesarean section for failure to progress. Following birth she was obviously ill but her care was given to an agency midwife. Despite involvement of the specialist registrars (SPRs) in obstetrics and anaesthesia there was no immediate action for her labile BP, tachycardia and rapidly falling Hb. It does not appear her temperature was recorded in the postnatal period despite being markedly febrile antenatally. The obstetric consultant was contacted, but did not attend until she suffered a cardiac arrest from which she could not be resuscitated. A hysterectomy was attempted but she died of heart failure following prolonged haemorrhage.

This case highlights factors seen in a number of other cases i.e. a lack of baseline observations, poor midwifery care, poor communications between professionals and a failure to appreciate the seriousness of the woman’s condition.

Box 16.1  Key physical signs that may suggest serious illness, and that warrant immediate medical referral.

The following signs should alert all health professionals including midwives, GPs, junior doctors and obstetric and other consultants that serious illnessis a possibility:

There have been questions raised as to whether contemporary midwifery education adequately prepares midwives for adverse pregnancy outcomes or serious unrelated problems in pregnancy. It is impossible to comment on this issue, but a recommendation will be made to the Nursing and Midwifery Council (NMC) that these questions may be investigated.

Adopting a care pathway approach

Care pathways, within a managed and functioning maternity and neonatal care network, are good examples of how care may be co-ordinated, woman centred and clinically driven. They may provide the best evidence based approach for the management of pregnant women, particularly those whose maternities are medically and/or socially complex. They are also useful for ensuring effective communication links across disciplines and may be used to underpin many key local and national agendas simultaneously. They are not rigid documents and clinicians are free to use their own professional judgement as appropriate.

A good example of a care pathway is the all Wales Normal Birth Pathway8 which includes telephone advice, a patient information sheet, an active labour pathway and partograms. Initial findings have shown a marked increase in normal birth, with a corresponding reduction in caesarean section with no difference in mortality or morbidity9 .

A correct emergency response

The wrong emergency response was evident in several cases. In some cases the woman was taken by the paramedics to the nearest Emergency Department (ED) despite knowing she was pregnant. In other cases the midwife did not know the emergency telephone number to summon help or the paediatric emergency team were summoned to a maternal collapse, resulting in a crucial delay in resuscitation. In one case the cardiac arrest team was unable to get into the labour ward for a significant length of time because it did not know the security code for access. On several occasions the wrong emergency trolley, trolleys missing vital equipment or trolleys in the wrong place led to a delay in resuscitation. For example:

A morbidly obese woman with a BMI over 40 suffered from severe asthma. Her Hb fell to less than 7 d/l in pregnancy and although she was transfused, the cause for this was not investigated and it remained very low. She was delivered by elective caesarean section with no clear indication. After birth, despite severe breathlessness and evidence of oxygen desaturation, she was transferred from the theatre to the postnatal ward where she collapsed four hours later. There was a delay in resuscitation as the emergency trolley was not kept on the postnatal ward and time was lost in locating and fetching the relevant equipment. Resuscitation, once started, was unsuccessful. 

Several important issues arise from this case. There seemed to be no medical indication for the caesarean section; indeed, given her morbid obesity, a risk assessment should have been undertaken. Following the operation although it was evident that she had complex postnatal needs she was transferred from the recovery area too quickly. There was lack of an identified care plan and there appeared to be an inappropriate skill mix and lack of experience in caring for women with medical complications.

Some cases involved agency staff who seemed to be unaware of emergency drills. Midwives have a responsibility to ensure that they are familiar with emergency procedures, but it is acknowledged that this is often difficult to ensure. 

Communication issues

Whilst most midwives are autonomous practitioners of normal birth, they do need to recognise professional boundaries and refer appropriately for advice to ensure true woman centred care. This was not always the case. In several of the cases reviewed there were communications issues across the primary/ acute care interface. In some instances this was because GPs failed to give midwives information about relevant medical or social histories, e.g. serious medical conditions or substance misuse. There were several comments from midwives who had gleaned most of their information from the women themselves. This often meant that the midwives were not completely aware of the prognosis, particularly for very rare conditions. For example:

A woman presented with a rare pre-existing blood disorder in early pregnancy. She was cared for by a consultant haematologist with substantial input from the community midwives. However, the midwives gained all their knowledge about this condition from the woman herself and she painted a positive picture of her prognosis. The midwives were shocked to learn from another source that the woman had died some weeks after birth and they had never been included in any of the communications concerning this woman’s care.

Although there were some very good examples of partnership agency working, particularly with substance abuse and teenage pregnancy teams, there were equally as many examples of poor communications between such agencies and midwives resulting in uncoordinated care for women. True woman centred care involves working collaboratively with other professionals and not working in isolation.

Maternity Matters5 highlights the central role for midwives within maternity services with the statement “all women will need a midwife, but some need a doctor too”. However, when midwives do refer for a medical opinion they are often not included in the subsequent discussion of care that takes place between the hospital staff and the GP. Midwives should be recognised as equal partners in care and should be included in all communications.

Although in many cases there were excellent examples of internal reviews following a maternal death, this was not always the case. It was also not always evident who was involved in such reviews. In some cases it was clear the review only involved those directly associated with the woman’s care and lessons may not have been widely disseminated to others in the maternity service. If lessons are to be learnt it is important that all clinical staff are aware of the findings of such reviews, particularly those who may not readily access e.g. GPs and community midwives. The Supervisor of Midwives network is an opportunity to disseminate findings to midwives.

Midwives’ responsibility for vulnerable or higher risk women

The number of deaths among women who are vulnerable and/or socially excluded remains unacceptably high. These include teenagers, women who are socially excluded, non English speaking women, refugees and women seeking asylum women with mental health problems and women who misuse drugs and/or alcohol. In addition there was evidence of uncoordinated care for women with complex pregnancies, women who are seriously ill or have a terminal illness and women who are obese.

As mentioned earlier, the use of any national guidelines or local protocols, and care pathways,  will help focus care on the woman and her family, promote continuity of care and reduce fragmentation.

Chapter 13 discusses the issues raised by women who were subject to domestic abuse. Although often recorded in the notes there was little evidence to show that any support had been offered. Nineteen of these women were killed by their partners. Midwives should by now be routinely asking women about domestic violence during pregnancy, but should be appropriately trained to undertake this. As a result of the recommendations in the last Report3, The Department of Health for England has produced an excellent handbook, ‘Responding to domestic abuse: a handbook for health professionals10’,which every midwife should familiarise herself with. A short summary of key recommendations for the identification and management of domestic abuse in pregnancy are given in the Annex to Chapter 13.

Obesity

There is growing evidence that obesity in pregnancy is associated with increased risk. In this Enquiry, for 2003-05, more than a half of all the women who died from Direct or Indirect causes, for whom information was available, were either overweight or obese. More than 15% of all women who died from Direct or Indirect causes were morbidly or super morbidly obese.

A BMI of below 18.5 is underweight, between 18.5 and 24.9 is an indication of healthy weight, 25 to 29.9 is overweight, a BMI of over 30 is referred to as obese, over 35 is known as morbid obesity, and over 40 indicates extreme obesity11.

More than half of all the women who died from Direct or Indirect causes, for whom information was available, were either overweight or obese. More than 15% of all women who died from Direct or Indirect causes were morbidly or super morbidly obese.

Seventy three per cent of women who died from cardiac disease, seventy two per cent of those who died from sepsis and sixty five per cent who died from thromboembolism were overweight or obese. Conversely only 33% of women dying of ectopic pregnancies or other early pregnancy deaths, or from anaesthesia, and 38% who died from other Indirect causes were overweight or obese.

For many women with obesity or, particularly, morbid obesity there was no explicit care plan for birth, neither had a risk assessment been carried out. Such severe obesity not only compromises a woman’s underlying general health but also causes logistical problems. Resuscitation was delayed in one case because the ambulance services were unable to remove the woman from her house and for other women a lack of suitably sized blood pressure cuffs led to delayed diagnosis of pre-eclampsia. In other cases the physical size of the mother masked clinical symptoms or caused problems with access at operation. And, as in previous Reports, there were several cases where caesarean sections had to be done on two beds pushed together as the weight of the woman exceeded the maximum safe weight for the operating table.

It is recommended that all obese women of child bearing age be counselled about this wheneve possible, and offered advice and support to reduce their weight gain prior to pregnancy.

Smoking

The 2005 Infant Feeding Survey12 found that 33 per cent of all women in the United Kingdom smoked at some time in the year before pregnancy or during pregnancy. These included 16 per cent who smoked before pregnancy but gave up, mainly on confirmation of pregnancy and 17 per cent who smoked throughout pregnancy. This was a slight decrease from 2000 when 35 per cent smoked at some time in the year before pregnancy and 20 per cent smoked during pregnancy.

The percentage who smoked at some time in the year before pregnancy ranged from 20 per cent of women in managerial and professional occupations to 48 per cent of those in routine and manual occupations and 35 per cent of those who had never worked. Linked to this was differences by age. The percentage of women smoking before or during pregnancy ranged from 68 per cent of women aged under 20 to 21 per cent of those aged 35 or over.

A smoking history was not documented for 67% of the women who died which makes further analysis of the increased contribution of smoking in pregnancy to maternal mortality impossible. It also highlights the need for better awareness amongst health professionals as well as better record keeping.

Accessing care

This Report demonstrates that late booking and poor or non attendance for antenatal care are absolute risk factors for maternal death. Table 16.1 shows some of the characteristics of the women who received less than optimal care this triennium.

The Recorded Delivery13 Report reinforces these findings and indeed those of previous Reports where it was demonstrated that women from ethnic groups, a deprived background or who are single parents were more likely to recognise their pregnancy later, access care later and consequently book later for antenatal care.

There is a real need for midwives to identify the needs of these women and target and provide care appropriately. Sadly, and despite previous recommendations, only a handful of women in this Report, who were known to be at higher risk and who had defaulted from care were actively followed up.

Table 16.1 Characteristics of the women who were poor or non attenders for antenatal care and whose pregnancy was 12 weeks of gestation or more; Direct and Indirect deaths; United Kingdom: 2003-05

Characteristic
Women who were
poor or non-attenders
at antenatal care
Overall
number of
women
  n (%) n (%)
Domestic abuse 13 (81) 16 (100)
Known to child protection
services or social services  
26 (81) 32 (100)
Substance misuse 21 (78) 27 (100)
Black Caribbean 4 (57) 7 (100)
Single unemployed 19 (56) 34 (100)
Both partners unemployed 14 (47) 30 (100)
Black African 12 (40) 30 (100)
No English 9 (35) 26 (100)
White 31 (17) 183 (100)
At least one partner in
employment 
9 (5) 165 (100)

 

Conclusions

Although there are lessons to be learnt for midwifery practice, particularly around failure to recognise serious illness, a failure to act appropriately and lack of communication, there is also evidence of positive and innovative responses to the recommendations made in the last Report.

Some organisations have developed partnerships with local councils and children centres to develop targeted services aimed at support vulnerable families as shown in Box 16.2 and Box 16.3.

Box 16.2

Working in partnership

In Liverpool, close partnership working with statutory agencies has led to the development of locally based comprehensive services for women including:

For further information contact Grace Edwards (Consultant Midwife)
Liverpool Women's NHS Foundation Trust
Telephone: 0151 708 9988

This response to the recommendations of the last triennium report is evident across the UK.

Box 16.3

Partnership working: Sure Start

The midwifery team in Southampton worked in conjunction with the Sure Start programme to enable women from vulnerable groups and their families to access Sure Start services with the aim of providing easier access to midwifery services in the community. The social model provided by midwives ensures that women have continuity of care throughout pregnancy, birth and afterwards for up to six weeks. One of the primary aims was to reduce the incidence of babies born with a low birth weight.

For women cared for by these teams there was a reduction in the incidence of babies with low birth weight from 12.6% in 2003 to 7.9% in 2006. Caesarean section rates decreased from 22% to 18% in the same period; smoking rates reduced from 34% to 29% and breastfeeding rates increased from 51% to 68%.

For further information contact Jane Rogers or Suzanne Cunningham (Consultant Midwives)
Southampton University Hospitals Trust
Telephone: (023) 8079 4209

Other examples of good practice may be found in ‘Modernising Maternity Care - a commissioning Toolkit for England’ 14.

In Blackburn a dedicated caseloading team of midwives is successfully targeting vulnerable women as shown in Box 16.4.

Box 16.4

Caseload midwifery for vulnerable women

Blackburn Midwifery Group Practice are a team of caseload midwives who provide one to one care for the most vulnerable families in a deprived area of East Lancashire. The referral criteria include women who are abused or who have had severe perinatal mental health problems. The midwives aim to maximise health outcomes by providing intensive support to women in the antenatal and postnatal period.

The team promote normal, positive birth outcomes and frequently work with women who have had previous traumatic births. The statistics demonstrate higher than average normal birth rates and lower use of epidural and instrumental deliveries.

For further information contact Sheena Byrom (Consultant Midwife)
East Lancashire Hospitals NHS Trust
Telephone: 01254 263555

There has never been a more optimal time for midwives to re-establish the profession as the experts in normal birth. But it is essential that practice is evidenced based, woman centred and embedded in partnership with other health professionals. Practice parameters must be clear and communication pathways effective to ensure that care for each woman is appropriate, timely and effective.