The role of the midwife in providing

maternal critical care

Clare Fitzpatrick

Intrapartum Matron/Trust lead for critical care

Liverpool Women's NHS Foundation Trust

Definition for midwifery critical care

“The provision of concentrated care, both physical, psychological, and social on a one to one basis in

an acute situation, where a woman's condition has or is at risk of deteriorating and where

advanced management such as drug therapy, more invasive forms of monitoring and

interpretation of results are required on a frequent basis”

Billington 2007

Midwifery: delivering our future

• Working in many different ways to deliver the

complete midwifery package

• Responding to the call of providing women

centred care (Changing Childbirth, DOH 1993).

• Becoming a member of the high risk team

• Expertise and additional critical care knowledge

Standing nursing and midwifery advisory committee (1998)

The need for HDU in maternity services

• Midwives are increasingly in contact with women who have the potential to become critically ill because of:

– Medical advances resulting in women with significant pre-existing health problems considering pregnancy

– Increasing obesity

– Immigration

– Vulnerable groups

Advantages of a Maternal HDU

• Early recognition and treatment of complications

• Better use of staff

• Improved staff skills

• Continuity of care

• Training opportunities

Mabie & Sibai Am J Obstet Gynecol 1990 Ryan et al Anaesthesia 2000

The ethos of midwifery 80’ & 90s

Gregson 2003

Midwives should be able to work

interchangeably in any part of the

maternity service

In practise this meant that women

where being cared for by midwives

without the necessary skills and

training to ensure that optimum care

was being delivered

Midwifery Issues

• Impact of direct entry midwives

• In house core competency training

• General critical care courses

• Obstetric critical care courses

• Skill maintenance

• Shortage of midwives

Are all midwives capable?

• At the point of registration as a midwife no critical care skills are required

• CEMD have recommended that a multidisciplinary approach

• Very little work being undertaken, as to what contribution midwives could make in HDU

• MW recognised as the ‘experts’ of normal birth.

Towards Safer Childbirth

“As far as midwifery cover for such units is

concerned, it will be necessary to develop a cadre

of midwives who have particular experience and

expertise in the management of the critically ill

woman”

RCM & RCOG 1999

• Post registration based at local university at level 2/3.

• Midwives allocated study time (course based over 15 sessions)

• Course adapted at our request to include changes in physiology of pregnancy and to include a practical maternity example.

• 1 external week at local level 3 ITU

• Competency based framework assessment in workplace by critical care sign off mentor.

Post registration – midwifery training

CEMACH 03- 05

Detection of life threatening illness alone

is of little value.

It is the subsequent management

that will alter the outcome.

How do you select your MW team?

• Adequate post registration experience

• Willingness, enthusiasm and aptitude for additional study

• Team players

• The confidence to play an equal role with other professionals

• Direct entry MW may need additional support in general nursing skills – biggest issue at LWH

The Midwife Lead

• Ideally dual qualification in midwifery and critical

care

• Leadership, organisational and teaching skills

• The confidence to play leading role with other

professionals

Now you have your team, what next?

• Are they available 24/7?

• Are your staffing levels of suitably trained staff enough to provide the recommended ratio of care

– 1:1 antenatal

– 2:1 postnatal

• Ability to flex between DS complement and critical care to deal with peaks and troughs of activity

Team

The extended team – what is our role?

• Midwives with appropriate training and competencies to manage your workload enabling ill women to receive the best of both high tech care combined with woman, baby and family centred philosophy

• Multidisciplinary medical team including obstetricians and obstetric anaesthetists.

• Access is required to haematology and other disciplines.

• Input from other professionals such as dieticians and physiotherapists

Day to Day – what’s our job?

• Care for women in HDU

• Outreach

• Pre and post op visits

• Debriefing

• Teaching

• Mentorship

• Clinical Audit

• Performance monitoring

• Research

Day to day running

• Joint ward rounds each shift

• Top – toe assessments daily

• Holistic care

• Monitoring using ITU charts

• Daily management chart

summarising

– Problems

– Management plan

– Investigations needed

• Structured handover with

supporting documentation and

plan of care for step down ( cf.

NPSA/NICE)

LIVERPOOL WOMEN’S NHS FOUNDATION TRUST

OBSTETRIC DIRECTORATE

Critical Care Services

Outreach – Ward Visit (Patients at Risk)

Date of Admission (to Critical Care)

Date of Discharge (from Critical Care)

Patient Name (affix label)

Discharge Ward

Diagnosis:

Consultant

Date and Time of Visit

Number of days post discharge

Assessment of Physical Condition

Airway

Breathing

Circulation (include line assessment)

Conscious Level

Renal/wounds/drains/bowels

Other (significant blood results)

MEWS Score

LIVERPOOL WOMEN’S NHS FOUNDATION TRUST

OBSTETRIC DIRECTORATE

Critical Care Services

Outreach – Post Follow Up Revisit

Date of Admission (to Critical Care)

Date of Discharge (from Critical Care)

Patient Name (affix label)

Discharge Ward

Diagnosis:

Consultant

Date and Time of Visit

Number of days post discharge

Time Spent with patient

Level of Care Patient Requires

Level of Care Patient Received

Reason for Revisit

Comments

A = B = C = D = UO = Line Assessment =

Skill maintenance

• Work placement

• Mandatory training

– Airway management, resuscitation etc

• Competency assessment

– KSF

– Additional skills assessment

Midwife role ???

• Recognition

– Track and Trigger

system

– Escalation of

management

– Referral including

direct by MWs to

critical care team

• Admission

• Management

• Discharge

• Transfer

Difficulties we have encountered

• Perception of elitism

• Medical staff no confidence in MW ability

• Inflexibility with MW staff

• Difficulty in ring fencing

• HDU beds being unavailable due to peaks of

normal DS activity

• Releasing staff for training and updating

Benefits we have noticed

• Enthusiasm

• Staff feel better supported

• Better compliance and

recording of routine observation

• Early identification of the ill

patient

• Prompt treatment

– Particularly sepsis with

implementing sepsis care

bundle

• Increase in confidence of staff

• Decrease in readmissions to

HDU

• Better team work

• Mentorship

• Improved mandatory training

Have we made a difference at LWH ?

2005 - 13 external transfers from Obstetric HDU

to ITU

2011- 5 in total

5 to ITU for ventilation

3 level 2 transfers for plasmaphoresis,

Infectious disease management

Improved patient experience

Conclusions

• If you are looking after high risk women you will need High

Dependency Team and HDU facilities

• Don’t forget women deteriorate in other areas

• Staffing

• Training and skill maintenance

• Team approach

• Facilities

• Equipment

Useful Reading

• Critical Care in Obstetrics Best Pract Res Clin

Obstet Gynaecol. 2008Oct;22(5)

• Billington M Critical Care in Childbirth for

Midwives Balckwell Publishing, Oxford 2007

• DoH Facilities for Critical Care. The Stationary

Office 2003