The big story: streamlining critical care

By Hollie Ewers on 03 September 2018 Midwives Magazine Maternity Services Evidence-based guidelines

New evidence-based guidelines and a joined-up approach will improve the care of pregnant women who require treatment from acute and critical care services.

A renewed focus on the vital roles of team-working, core skills and an early warning system are the key features of new guidelines for the care of pregnant women who become unwell.

Care of the critically ill woman in childbirth: enhanced maternal care replaces the 2011 standards, Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman.

Published in August, the new document is the culmination of several years’ work led by the Obstetric Anaesthetists’ Association (OAA) and is published jointly by the OAA, the Royal College of Anaesthetists, the RCOG, the RCM, the Intensive Care Society and the Faculty of Intensive Care Medicine.

It summarises the latest evidence-based recommendations on the care of pregnant or recently pregnant women who require treatment in acute hospital maternity and critical care specialist services.

The impetus for the new guidelines has come in part because practitioners had found the 2011 version unwieldy and difficult to work with. ‘The idea was to produce a much more streamlined document,’ says Carmel Lloyd, RCM head of education and learning. ‘It is much clearer in its intention and draws attention to the key factors rather than providing a lot of dense information that people find difficult to work their way through.’

Fragmented care

The new guidelines concentrate more on up-to-date practice and, in a key feature, link the strength of the recommendations to the quality of the evidence. The document also gives real-world examples of the experiences of women who became seriously ill during childbirth. ‘The striking thing about these stories is how fragmented their care can become when it moves out of the maternity setting into critical-care settings,’ says Carmel. ‘In this way, the new guidelines encourage more joined-up thinking, and highlight the important moments when everybody has to work together in the interests of women and their babies.’

While the document aims to promote more focused care, it also introduces new content, such as the core skills that midwives, and other health professionals, are expected to have when working with women who become critically ill during or after pregnancy. In particular, it sets out the knowledge that any practitioner needs in order to provide enhanced maternal care, which is the treatment given to women who fall very sick for a short period but who are not so severely ill that they require critical care.

Finally, it throws a spotlight on the importance of an early warning system. Pregnant women’s health can deteriorate rapidly, so promptly picking up on the indicators can make all the difference – the sooner a multidisciplinary team acts, the sooner critically ill women can get better.

‘We welcome these new guidelines,’ says Carmel. ‘Midwives have been waiting for this information for some time. It’s one of those areas where guidance enables people to provide more consistent care. And when everybody is working together, that tends to mean you get better outcomes.’

Key recommendations

  • Enhanced maternity care and working in teams: women in childbirth should get the same care as other critical patients, which means staff need to know the early warning signs and how to step up care. These core skills, called enhanced maternal care (EMC), mean any practitioner can care for women whose health worsens either during or after childbirth but who doesn’t need to go to a critical care unit. EMC also requires maternity and critical care teams to work side by side.
  • Education and training: everybody working in maternity care – including midwives, obstetricians, anaesthetists and nurses – should be properly trained to care for critically ill women. Existing teaching and training is normally enough, but some curriculum changes may be needed. To provide this, critical care and maternity services need to work together locally and regionally.
  • An early warning system: all acute care services should have a system in place for women who are pregnant or within 42 days of birth. The guidelines set out the vital components of an early warning system, with the hope that these become the norm for obstetric units nationwide.
  • Where care is delivered: most critically ill women can be cared for safely on the maternity unit. In some cases, the critical care outreach team will be able to assist. If a woman needs to go to a critical care unit after childbirth, her baby should normally be kept with her.
  • Care in the general critical care unit: a named lead should liaise between critical care and maternity services. The teams should also have shared care principles. The maternity team needs to review women in general critical care units at least once every 24 hours. All units should base their follow-up services on NICE guidelines.