Royal Society of Medicine Forum: Ill mothers and critical care: the challenge in the 21st Century.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Thursday 17 June 2004. The meeting was chaired by Dr. Anita Holdcroft, Reader in Anaesthesia and Consultant Anaesthetist, Chelsea and Westminster Hospital, Imperial College London.

The report is to be published in The Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

The top 5 challenges of setting up critical care within a maternity unit.
Ka Yee Tseung (KYT). Senior Anaesthetic Sister. Labour Ward, Chelsea and Westminster Hospital, London

The Chelsea and Westminster Hospital is a teaching hospital with 460 beds, an intensive care unit (ICU), a general high dependency care unit, and a neonatal intensive care unit (NICU). The maternity unit is a tertiary referral center for high-risk obstetric care. During 1998 there were 3688 deliveries. The epidural rate for labour was 60.9%. The overall caesarean section (CS) rate was 21.8%, and this has increased to 30% in the past two years.

Advances in science and technology have led to our needing to set up a maternity HDU. More women are now able, despite high risk medical conditions, to conceive and carry their pregnancies to term, and more are undergoing CS; their care requires obstetricians and midwives with specialist skills and the appropriate environment. We follow the Guidelines on admission to and discharge from intensive care and high dependency units (DoH 1996). Recommendations set out in the Confidential Enquiry into Maternal Deaths (CEMD 1994-96) included the establishment of high dependency units to bridge the gap between intensive care units and general wards, and of recovery wards to deal with postpartum haemorrhage following CS.

Prior to creating a designated high dependency/recovery unit (HDU) in 2000, the following concerns had been expressed through the monthly Integrated Maternity Services Meeting (incorporating obstetric, midwifery and anaesthetic staff). There was a need for the provision of critical care within the labour ward for high risk obstetric patients with medical conditions. There were an unacceptable number of "near-miss" critical incidents relating to the standard of care for post-operative recovery patients, most frequently the late diagnosis of occult postpartum haemorrhage after CS. Particular areas of concern were identified including the absence of designated areas for high-risk patients and for those in the postoperative phase, resulting in patients being scattered throughout the postnatal ward. Close observation was difficult, and there was a lack of specific observations and haemodynamic monitoring by appropriately trained staff.

This presentation highlights five key challenges identified during the process of setting up our HDU: differing perceptions in a changing culture, demands on resources, a formal training structure, establishing guidelines and protocols in developing practices and a collaborative approach to building team relationships.

The maternity unit has 9 labour rooms and two water pools in its labour ward; there is a three room birthing unit and a five bedded recovery ward; the four bedded high dependency unit (HDU) is not yet operational. We have two operating theatres. The antenatal ward has 15 beds, the postnatal ward 21 beds; a day assessment unit was opened recently. Deliveries increased from 3688 in the year 2000 to 4545 in 2003. ICU admissions fell from 3.7% to 2.8%.

Mothers with high risk conditions who were admitted included among the non-operative group pre-existing cardiac conditions, cystic fibrosis, pre-eclampsia, diabetes, and ante-partum and post-partum haemorrhage. The operative group included CS, instrumental deliveries, manual removal of placenta, and cervical sutures.

The aim of our maternity Recovery/HDU will be to offer women and their families a consistently high level of individual, medical, and psychological care, delivered by staff who understand the physiology and pathology unique to obstetric patients.
A HDU working party consisting of obstetricians, physicians, midwives, anaesthetists, neonatologists and consumers has met monthly. We agreed that the HDU would exist for patients requiring more observation and/or nursing care than on a general ward; it would not normally include patients requiring ventilation or invasive monitoring (Sheppard and Wright 2000).

Care Level 1. Patients at risk of deterioration in their conditions or those recently relocated from higher levels of care whose needs can be met on an acute ward with advice and support from the critical care team.

Care Level 2. Patients requiring more detailed observation or intervention, including post-operative care or support for a single organ system, and those stepping down from a higher level of care (Intensive Care Society 2002).

A facility was also required for patients too sick for care on a general ward to step up to care intermediate between that and the ICU, and for others where appropriate to step down from ICU to HDU.

Leadership within the team is needed, as is a recognition of the expanded role of the midwife; there was initial anxiety on the part of midwives around the mechanisation of care, but competence and confidence is developing. Registered general nurses who then train as midwives have been found to be more adaptable to HDU work than direct entry midwives, who tend to enter the profession in the expectation of working with normal pregnancy and birth. Trainee physicians working in a maternity HDU lack knowledge of the special needs of the obstetric patient, and require support.

A 6-bed bay taken from the antenatal ward has supplied the necessary space; the day assessment unit is expected to reduce pressure on HDU beds. A five-bed recovery unit is working, and a four-bed HDU will become operational in due course. Necessary equipment includes suction, oxygen, a monitor incorporating oximetry, ECG, and blood pressure measurement, basic ventilation, Ivac, urinary catheter stand, and a bed with movement control in all directions. A refrigerator for blood products and trolleys for adult and neonatal resuscitation are located opposite the labour ward operating theatres. A specially assembled PET bag enables the urgent treatment of severe pre-eclampsia. The patient line incorporating telephone, email and television enables patients to maintain contact with the outside world.

The major problem for the medical team is poor communication, which can lead to inappropriate and untimely patient care. The midwife team faces staff shortage, in an environment where the midwife to patient ratio should be one or two to one; currently the ratio in the recovery ward can be as low as 1:5, preventing the 24-hour close observation which some patients need. We are looking into the role of health assistants to release midwives for the a vital work of the HDU; retention of staff is an important issue to be addressed.

For training a university course in high dependency care for midwives is used, and in-service training is provided by the consultant nurse of the ICU. Orientation within the unit is provided for all joining midwives, with training in the use of medical devices, and they are trained to standards 4 and 5 of the Clinical Negligence Scheme for Trusts. Clinical governance and obstetric and neonatal case meetings are being run.

We are planning for the midwife care of high risk mothers to be continuous throughout pregnancy, birth and the postpartum period, and guidelines and protocols are being reviewed, and published on the hospital intranet. Case notes, care plans and observation charts have been redesigned to provide a clear and continuous picture of the situation during a critical event; data entry will be the task of one midwife. Drug prescriptions are linked to the appropriate protocols. Audit will be essential when the HDU is up and running.

We recognise the importance of good communication between all concerned, including the mother and her partner; a mother's bonding with her baby, from whom she is probably separated, is a big issue, and we do everything possible to promote this and to facilitate breastfeeding. By means of a critical care outreach team we maintain all possible contact with the ICU, the NICU, the operating theatres, general practitioner, health visitor, physiotherapists, and counsellors. Consideration is given for car-parking and hotel service for partners.

Changes in attitude and understanding are a vital part of the training and the work in critical care. In the face of these challenges and the development of this service, in some areas we have not progressed as quickly as anticipated. However, we are confident that our targets will be achieved as we continue the development of the unit.

Maternal mortality and morbidity in the UK
Catherine Nelson-Piercy (CN-P) Consultant Obstetric Physician, Guy's & St. Thomas' Hospitals, London

Since the mid-1980s the gratifying decrease in the maternity mortality rates in England and latterly throughout the UK has levelled out and there has been a slight increase. Furthermore indirect deaths have overtaken deaths due directly to pregnancy. Worldwide there are over half a million maternal deaths annually. In England pre-eclampsia comes second to pulmonary embolism in frequency, with early pregnancy causes running third; haemorrhage is diminishing as a cause of death, but is still significant in terms of morbidity. Currently our maternal mortality rate is running at about 12 per 100,000; the leading direct cause of deaths is pulmonary embolism, and cardiac causes have significantly overtaken these and now lead the indirect statistics. Psychological causes, particularly suicide, are also playing an important part.

It is well known that pregnancy increases the risk of thromboembolic disease (TED), but sometimes forgotten that this risk commences with the pregnancy; hence the role of general practitioners and physicians in providing pre-pregnancy care for these women. The risk factors which increase in pregnancy are clotting factors (especially fibrinogen), decreased fibrinolysis, decreased endogenous anticoagulants, venous stasis, and operative delivery; but it must not be forgotten that causes which operate outside pregnancy also operate within it: obesity, age, thrombophilia, and previous TED. It must be faced that age is a factor; politically correct or not, 35 is becoming old for pregnancy. The risk for age over 35 is more than double that for age under 20. While it is satisfactory that deaths following CS have decreased, note that antenatal deaths from TED have remained unchanged for 50 years. Vaginal delivery may be low risk for women who are young and slim, but a 45 year-old woman who is obese is definitely at increased risk of TED and deserves prophylaxis.

Significant causes of TED are easily ignored in the first trimester: hyperemesis, miscarriage, ovarian hyperstimulation syndrome and surgery for ectopic pregnancy for example. Blood loss and transfusion are potent causes, and it is easy to forget to restart heparin after these events. Deaths from pulmonary embolism are more common at this stage than they are in the third trimester, and other risk factors which are commonly overlooked are immobility, inflammation and infection, PET, and nephrotic syndrome. Well-known RCOG guidelines were published in 1995 and 2001, and this year as a result of Confidential Enquiry into Maternal Deaths (CEMD) data I was asked to publish a guideline on thromboprophylaxis antenatally and after delivery, amending dosage.

The indirect causes of maternal death are often overlooked. Most important among these are pulmonary hypertension of any cause, severe mitral stenosis, Marfan's syndrome with a dilated aortic root, and women with artificial heart valves, where anticoagulation is a problem. Other conditions associated with the increasing cardiac death rate are cyanotic congenital heart disease, ischaemic heart disease (the smoking epidemic has now caught us up along with hypercholesterolaemia, increasing age, and obesity), arterial dissection, and peripartum cardiomyopathies, which are more common in black women and multipara, and are associated with hypertension and multiple pregnancy. Such medical conditions are becoming relatively more important than the direct causes of maternal death.

Morbidity.

Maternal deaths are now happily rare in the UK, but at 1.2 per cent the incidence of morbidity is about 100 times that of mortality. Pre-eclampsia (PET), haemorrhage, and sepsis account for most of the morbidity, a marked difference from the pattern of fatalities. Raised booking blood pressure and being black are well known markers for PET; induction of labour and social exclusion of any cause increase the risk of severe morbidity. Definitions of severe maternal morbidity have included admission to an ICU, a clinician's impression, and organ dysfunction. The definition needs to be firmed up, the incidence estimated, predictors determined, and the longer term outcomes examined.

Critical care.

The keys to helping these women are accurate identification of those at risk; accurate diagnosis; prompt protocol driven multidisciplinary treatment, and liaison with other specialties, particularly obstetric anaesthesia, haematology, and microbiology. We must never be too proud to admit when we don't know something.

"Intensive care is not a place, it is a service." Intensivists must be involved early, and they are always willing to move to a patient when there is no free ICU bed. An HDU is the best place for sick women in and around pregnancy, but this involves midwives, a lot of training, equipment and expense. Furthermore we must help to remove the fear which afflicts midwives in these situations, and the essential training in resuscitation and support will do this, while saving lives; drills, necessarily repeated as midwives come and go, are also vital. Each hospital should establish protocols for the disposal of seriously ill pregnant women as they arrive - labour ward or accident and emergency - according to the condition with which they are suffering; a woman bleeding with an abruption goes to the labour ward, a cardiac arrest needs A & E.

Because it is so rare we have at St. Thomas' a protocol for early action after a maternal death. The report to the new Confidential Enquiry into Maternal and Child Health
(CEMACH) is best done immediately, while the details are fresh in one's mind. Our checklist includes linking to the CEMACH midwife, informing involved obstetricians, midwives, neonatologists and any referring hospital, as well as items which are too easily omitted, such as contacting the patient's GP and the coroner. A multidisciplinary review is held.

"When things go wrong in obstetrics they go wrong fast. They fall off a cliff. One minute mother and baby are happily savouring the view from the top, and the next they are tumbling over the edge and free falling onto the rocks far below". (Adapted from "Midwives - a novel" by Chris Bohjalian).

Being a 'near miss' maternal morbidity: a patient's view
Gillian Walters (GW)

Catherine Nelson-Piercy's account of Gillian Walters' illness.

Gillian has had a fetal death at 22 weeks due to severe pre-eclampsia with HELLP, a syndrome characterized by haemolysis, elevated liver enzyme levels and a low platelet count, and she came under my care for the first time. She was diagnosed as having anti-phospholipid syndrome, and in her next pregnancy did very well on aspirin and heparin. She had a vaginal delivery at 37 weeks complicated by placental abruption, and was transferred to the HDU where a catastrophic fall in her platelet count was identified. The heparin was discontinued, could not be restarted because of her very low platelet count, and after 10 days she suffered a massive pulmonary embolism; despite heparin she had a further pulmonary embolism, which was thrombolysed. She was left with severe incapacitating pulmonary hypertension and right heart failure. She underwent thromboembolectomy at Papworth Hospital, the only centre in the country capable of the procedure. Damage due to the heart-lung bypass has necessitated multiple plastic surgical procedures to a leg, and she was only able to undertake the full care of her baby when she was seven months old. She had been a difficult patient, and we must admit to having been difficult doctors.

Gillian Walters speaks.

I had to deliver that first baby myself; Catherine told me that if and when I was next pregnant I should make sure to get in touch with her again, as a complicated course was not unlikely. I was pregnant again several years later, and came under the care of a consultant obstetrician and Catherine as obstetric physician. You can imagine my reaction when I was told at the the 20-week ultrasound that the fetal heart could not be detected, and I should return after one month! The scan was repeated urgently and my confidence was restored.

What interested the professionals I found intrusive; the right hand did not always know what the left hand was doing, and it seemed necessary for me to remember the results of tests and other information myself. Information overload was rendering me powerless, so I made sure to ask my questions repeatedly until I got the answers. I argued the point over induction of labour, which was proposed at 37 weeks, being determined not to have my baby on St Valentine's Day. In the event she was born normally two days before that, sidestepping the detailed birth plan in my maternity notes.

My family had left by the time I was transferred to the HDU, and I felt very much alone, not least because my baby girl had to be admitted to the NICU. Although I realised that I was ill, her condition was my first priority, and however wonderful was the view from my room of the Thames and the Houses of Parliament, what I wanted was to go home. When the baby was fit to leave hospital I insisted on going with her, although against medical advice; it was not long before I was back in the general medical HDU following some sort of fit which my health visitor observed and dealt with very promptly. I understood that I had a complication of deep vein thrombosis, but I missed the understanding care which I had received in the maternity HDU, and was disturbed by the machinery supporting the other patients with their various disorders. I was frustrated there by ward rounds when nobody spoke to me, and would have to ask for clarification by a doctor later. After some hours this would be forthcoming, though I would usually have to ask for some translation of medical jargon in order to get full value from that five minutes out of the 24 hours. And I insisted on seeing my medical notes as is my right, with or without a doctor's consent. Given time (which was rare) I could understand some of what had been written there. Hard to believe that this was why one doctor stopped writing notes about me!

I arrived breathless for an out-patient check-up, and knew for sure that I was going to be advised to go back into hospital; I was to be married the following day, the third time this had been arranged, and was able to keep that appointment, was admitted to Papworth Hospital the following day and had my operation there. I am grateful for the advice I was given; it saved my life to be a wife and mother, but the resistant infection in my leg and the associated disability and fear sapped my confidence terribly.

As I told a friend later "I tried to have a baby, but being me it went a bit pear-shaped".

Discussion.

(Professor Leslie Page) Q: Should training courses be set up and guidelines established for midwives keen to work in critical care? The loss of midwives from critical care to working with normality is now a staffing issue, as is midwife to patient ratio of 1:1 or 1:2 . (C N-P) Also midwives well trained and experienced in critical care are in a buyer's market, and can move to other jobs wherever they wish. A: Staff from a recovery ward and from the various disciplines involved can provide in-house training. (KYT) We are having to consider easing the staffing problem by employing registered general nurses with HDU experience, with midwives in a supervisory role carrying out their duties for mother and baby.

(A midwife trainer in HDU care) Granted the value of continuity of carer there must still be a place for the midwife who is enthusiastic about this specialism; they need to be given recognition and time for education. Some come with ICU experience; we can only provide one week's training, for which there is little management support.

(Q - various delegates) Some mothers with pre-eclampsia need HDU care antenatally. Women in an HDU who go into labour should be transferred to a labour ward; it is then a great advantage for them if their HDU-trained midwives can accompany them and deliver their babies. Likewise mothers who are transferred to HDU after the birth can benefit if they can have continuity of care from the midwife who was with them during the labour. We are fortunate in having two rooms with two beds, where both baby and partner can room in. (GW) When I was in the HDU or the ICU I did not differentiate between the various roles of the members of staff; I just appreciated the care I received. (Wendy Savage) In this shortage situation better a trained nurse than a half-trained midwife. (An obstetric anaesthetist disagrees) A mother at high risk, even when unconscious, is in need of midwife care, whatever the staff shortage. Example: a HDU nurse was unaware that a woman who had been given magnesium sulphate should have her reflexes checked; a midwife would have known that.

(CN-P) The morbidity statistics clearly show that increasing age is a factor for pre-eclampsia, sepsis, and haemorrhage. So women must be honest about the price they may pay for leaving their child-bearing until their careers are established. They deserve the information, if not a warning. However it is true that with the small numbers of patients there can be no confidence intervals in the statistics. (Wendy Savage) The message to the public should be "Have your babies before the age of 35". This would also obviate the need for a lot of fertility treatment.

(CN-P) Being black and being obese (both of which are associated with diabetes) are separate but overlapping risk factors. Irrespective of race, the co-existence of three or four risk factors means that a woman, whether white or black, is at risk. This applies as much to long time Brixton families as to immigrants.

(CN-P) I have described the critical conditions and care of an immigrant woman with rheumatic heart disease. She was told and accepted that she had a 90% risk of dying in the following year if untreated, and a 10% risk of dying on the table if operated upon. It is not unusual for this and other cardiac disorders to arrive in the UK undiagnosed; the identification of such disease and possibly the advice to avoid pregnancy belong in the realm of general practice; when a woman so affected unwittingly becomes pregnant the cultural imperative to have babies kicks in. It is particularly sad when the such conditions could have been cured before pregnancy. Often women will repeatedly decline TOP, even women with pulmonary hypertension who are told that their risk of dying during the pregnancy is 50%, and although the offer should be repeated, the impression must never be given that a pregnancy is worthless.

(Beverley Beech) What about the risk of not having continuity of carer? Fragmented care too often leads to errors of management. (CN-P) The CEMD comments that continuity played a part in almost all cases, sometimes positively, despite the death. The shortage of staff can only aggravate these tendencies. (Chair) Where there cannot be continuity of carer a good handover is vital. (Wendy Savage) We should be able to sell continuity of care to the NHS as being cost-efficient. (A dissenting view pointed out that an independent opinion can detect omissions in continuous care).

(CN-P) The CEMD laments fragmentation of care, poor communication, and system failures; we must all take note of these comments and improve the care we give. I regret the loss of continuity which used to be provided by GP antenatal care; at present the lack of midwives means that they are too busy, too stressed, to attend fully to the detail of care as they would if there were enough of them. Private midwifery does the job, but the NHS will never be able to afford that standard.

(GW) In my case continuity of carer was not on offer, but I was easily able to accept the reasons given for this, and I felt satisfied when a 5 to 10 minute hand over on changes of shift took place; of my three midwives I valued most the one with the calmest personality, although she was only with me for 20 minutes.

(CN-P) It is doubtless true that intervention-free labours, when and only when appropriate, would reduce the need for some high dependency care, but the confidence women need to take this on is being destroyed during adolescence by the horrors they see in television documentaries and soap operas.