21 Aug Recommendations for Maternity Care in the Time of a Pandemic
Head of Research & Development
Baby Lifeline Training
MBRRACE-UK has published a rapid-report this week which has reviewed maternal deaths during March – May of this year, and in direct relation to care during this pandemic. They have set out recommendations for improvements to care – emphasising current guidance and setting out new recommendations. Whilst pregnant and postpartum women do not appear to be at greater risk of developing severe COVID-19 than non-pregnant women, there are clear areas of change that need to be addressed.
A third of the women who died may have had a different outcome if their care had been different. All the women included in the report who died from COVID-19 were in the third trimester of pregnancy, and the majority were from black or other minority ethnic groups. The report states that in the absence of a vaccine, prevention is crucial and social distancing, particularly in the third trimester when the virus seems to be more severe, is a key intervention for women to maintain.
Rapidly learning lessons when things go wrong has never been as important as it is now. Pandemics by their nature bring new challenges, and if systems are faulty then cracks can widen. We desperately need to look at this report in relation to current challenges, and also revisit old reports to strengthen systems and support professionals to give the best care possible at an uncertain time.
We owe it to every mother and baby to look intensively and transparently at services nationally and locally and assess for cracks. No family should suffer this pain, especially when it’s avoidable.
If we think something is unsafe or not working – speak up, change it, think of ways around it. Do not allow it to become the status quo, because it may have catastrophic consequences on families and the professionals caring for them.
“Overall, the women who died had 18 children from previous births, thus a total of 30 motherless children remain.”
Report’s Recommendations for Good Care During the Pandemic
- Multi-professional team care and obstetric leadership with daily review during pregnancy and after they’ve given birth. Impact: improving timely recognition of a woman who is becoming more unwell, aid decision-making around appropriate and timely birth, and identifying any complications after she has given birth.
- Consider pregnant or postpartum women for antiviral or other specific therapies for COVID-19. Only exclude women if there is a clear contraindication.
- Inform women who have COVID-19 of when to seek urgent medical attention – providing advice specific to them, and clearly (in their own language).
- If women are critically ill, make sure that communication with partners and families and facilitating visits is a priority.
- Ensure that women with mental health concerns are appropriately assessed, including face-to-face if necessary, and treated. These women must be able to access perinatal mental health services despite normal processes being changed due to the pandemic. A mental health specialist midwife or obstetrician needs to be involved in the triage process and review.
- If a woman is referred with mental health concerns on more than one occasion – this a red flag and a prompt clinical review should take place.
- Safeguarding guidance needs to reflect that actions, such as removing women and children to a place of safety, should be followed despite public health measures like lockdown.
Current Guidance Emphasised by the Report
Clear Advice and Increased Awareness of Increased Risk to BAME Backgrounds
- Women of BAME background, or with other risk factors such as hypertension, diabetes or raised BMI, should be advised that they may be at higher risk of complications of COVID-19. Women should seek advice without delay if they are concerned about their health (RCOG Coronavirus and Pregnancy Guideline 2020).
- Professionals should have awareness of this increased risk, and have a lower threshold to review, admit and consider multidisciplinary escalation of symptoms in women of BAME background (RCOG Coronavirus and Pregnancy Guideline 2020).
- When reorganising services, maternity units should be particularly conscious of evidence that BAME individuals are at particular risk of developing severe and life threatening COVID-19 disease (RCOG Coronavirus and Pregnancy Guideline 2020).
Managing the Care of Pregnant Women with Suspected or Confirmed COVID-19
- All pregnant women admitted with confirmed or suspected COVID-19 should receive prophylactic LMWH, unless birth is expected within 12 hours (RCOG Coronavirus and Pregnancy Guideline 2020).
- For women with severe complications of COVID-19, the appropriate dosing regimen of LMWH should be discussed in a multi-professional team that includes a senior obstetrician or clinicians with expertise in managing COVID-19 and VTE in pregnancy (RCOG Coronavirus and Pregnancy Guideline 2020).
- Senior decision-making doctors need to assess the woman, and after multi- disciplinary team discussion with senior colleagues in other units, decide on the best place for her on-going care; decisions must include the means and timing of inter- or intra-hospital transfer to ensure that the transfer is carried out safely and to a high standard (Saving Lives, Improving Mothers’ Care 2015).
- Signs of decompensation include an increase in oxygen requirements or FiO2 > 40%, a respiratory rate >30/ min, reduction in urine output, or drowsiness, even if oxygen saturations are normal. Escalate urgently if any signs of decompensation develop (RCOG Coronavirus and Pregnancy Guideline).
- Delay caused by bed pressures in critical care in not a reason to postpone critical care. Critical care support can be initiated in a variety of settings. (Saving Lives, Improving Mothers’ Care 2014).
Key Messages to Improve Care
Each vignette provided within the report provides an unforgettable message which should be read by all professionals caring for women. Owing to the length of a blog, I cannot include them here.
- Senior Obstetric Review
“It has been a recurring message of these enquiries that ill pregnant women need senior obstetric review; this is even more pertinent in the context of pregnant women with COVID-19.”
- Location of Care
“…as these enquiries have noted previously, critical care supportive treatment should always occur if beds are not immediately available.”
- Prevention and management of thromboembolism
“Emerging data and clinical experience point to a greatly increased prevalence of thrombotic disease in patients with COVID-19 (Klok, Kruip et al. 2020), particularly those admitted to intensive care where acute inflammatory state, hypoxaemia and immobility also predispose to thrombosis (Bikdeli, Madhavan et al. 2020). Pregnant women have further increased risk for thromboembolic events particularly in the 3rd trimester, which increase further with caesarean birth (Royal College of Obstetricians and Gynaecologists 2015).”
- Staffing and Equipment
“Attention to skills, knowledge and supervision is needed when acute settings are staffed with those unfamiliar with the area. Consideration should be given to establishing a minimum standard of orientation before working in a new clinical environment.”
- Treatment with antivirals or other therapies for COVID-19
“None of the women who died from complications of COVID-19 were treated with antivirals or other medical therapies for COVID-19… It has been a repeated message of these reports that pregnant or postpartum women with medical problems should be treated the same as non-pregnant women, unless there is a clear reason not to, and this applies equally in the management of COVID-19.”
- Advice to stay at home/self-isolate
“Advice to stay at home appears to have been over-emphasised, and this was clearly coupled with anxiety about attending hospital, and the impact of visiting restrictions which meant women could have no partner visit until they were in established labour… it is clear that women needed to know when to go into hospital, or, as a minimum, when to telephone their midwife for advice.”
It is noted that it is particularly important for women from BAME backgrounds need to seek urgent medical help earlier.
- Communication, contact and care of families
“Some women did not see their babies before they died, and in several instances partners were unable to see women before they died. In at least two instances, partners were left at home completely unsupported and clearly unaware, in one instance due to language difficulties, how ill their partners had become. Communication with partners and families, including via an interpreting service if necessary, and facilitating visits between women and their partners must be a priority when women are critically ill. This is an essential part of end of life care.”
- Good care
The MBRRACE-UK team documented an incident where, sadly, the woman died despite good care. Points to consider:
- Appropriate advice to return if symptoms worsened on her first visit to hospital
- Correctly admitted to the maternity unit when symptoms worsened
- Good communication between teams throughout
- Care was escalated in a timely manner
- An early decision for a Caesarean birth meant that she was able to see her baby before she died.
Four women died by suicide from March to May.
“Pregnancy and birth are extremely vulnerable times for those with mental health disorders or prior childhood adversity.”
“It was evident that changes to service provision as a direct consequence of the pandemic meant that women were not able to access appropriate mental health care. Receipt of the specialist care they needed may have prevented their deaths.”
“Specialist perinatal mental health services should remember the need to alter thresholds for assessment during pregnancy and the early postpartum.”
The care highlighted in the report echoes previous messages identified in previous reports:
- Awareness of the pattern of rapid deterioration of perinatal mental illness
- Downgrading of symptoms
- Recognition of red and amber flags.
- The importance of professionals listening to the views of family members and including those views in the overall assessment and management
Postnatal Care & Future Service Planning:
- Women received only a single postnatal midwife visit due to COVID-19 guidelines, and that visits from Health Visitors appeared to have stopped.
- Women had clear mental health symptoms at the time of their postnatal midwife review
- Assessors felt that there could have been a risk assessment about the need to further postnatal midwife review rather than an assumption that there would only be a single visit.
“Professionals should never give up trying to develop therapeutic relationships that will enable those subject to abuse to seek support.”
The report emphasises the need to ensure women can be removed to a place of safety even in the context of public health measures such as lockdown. In addition, where a violent offender is released from custody, communication should include the wider multidisciplinary team working with the woman, including social services.
Although pregnant women seem to be at no greater risk than non-pregnant women of having severe COVID-19, the pandemic has impacted care for pregnant and postpartum women, and the rapid-report has highlighted areas which need to be addressed promptly.
Areas found to have impacted care for the women who sadly died have been highlighted by reports before it, and some are already included in current guidelines. Rigorous assessments of care need to be carried out to identify cracks in the system to protect women and babies from falling through them.
Bikdeli, B., M. V. Madhavan, D. Jimenez, et al. (2020). “COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up.” J Am Coll Cardiol [Epub ahead of print].
Klok, F. A., M. Kruip, N. J. M. van der Meer, et al. (2020). “Incidence of thrombotic complications in critically ill ICU patients with COVID-19.” Thromb Res 191: 145-147.
Knight, M., S. Kenyon, P. Brocklehurst, et al. (2014). Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford, National Perinatal Epidemiology Unit, University of Oxford.
Knight, M., M. Nair, D. Tuffnell, et al. (2015). Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. . Oxford, National Perinatal Epidemiology Unit, University of Oxford
Royal College of Obstetricians and Gynaecologists and The Royal College of Midwives (2020). Coronavirus (COVID19) Infection in Pregnancy: Information for healthcare professionals. London, Royal College of Obstetricians and Gynaecologists.
Royal College of Obstetricians and Gynaecologists (2015). Green-top Guideline 37a: Reducing the Risk of Venous Thromboembolism During Pregnancy and the Puerperium. London, RCOG.