Summary of Maternity service changes in COVID pandemic
The NHS has released the “Clinical guide for the temporary reorganisation of intrapartum maternity care during the coronavirus pandemic” addressing the significant challenge for the NHS of the coronavirus pandemic while balancing the need to continue to deliver a safe maternity service.
The challenge of COVID-19 will inevitably mean that some clinical staff are deployed to areas of hospitals they do not usually work in. At the same time, many midwives, obstetricians, anaesthetists and support staff are in self-isolation, temporarily reducing the available maternity workforce, with varying and sometimes significant impacts felt locally. This latest document is aimed at helping units negotiate this balance.
- Maternity care, especially intrapartum care, is a core non-elective service that needs adequate staffing and access to facilities. The principle must be to maintain the safety and wellbeing of women and their babies. This means preventing avoidable perinatal mortality and morbidity (including issues relating to mental health and wellbeing). At the same time, services should aim to maximise choices for women within the constraints of the available staffing and facilities. They should continue to provide a personalised risk assessment for all women and agree with them a package of care.
- Providing safe services also means balancing the response to COVID-19 with the continuing need to manage obstetric risk.
- RCOG guidance provides staffing options for obstetrics and gynaecology services during the COVID-19 pandemic. At the very least a maternity service must be able to respond to emergencies; as a rough guide this means having a workforce similar to that generally seen at weekends.
- Midwives and maternity support workers are required to care for pregnant women and their babies and should only be redeployed within maternity care.
- Obstetricians should not be redeployed beyond the point where doing so would put the operation of an emergency service at risk, eg inability to maintain the emergency caesarean section and operative vaginal delivery service. Access to clinically indicated elective caesarean section also needs to be maintained to avoid further increases in emergency work.
- NHS England and NHS Improvement guidance advises trusts to ensure that services supported by anaesthetists that cannot decrease clinical activity (eg emergency surgery, obstetrics) are safely staffed, Again, this means not beyond the point where doing so would put the operation of an emergency service at risk, including inability to maintain an epidural service for women in labour.
- Neonatal services may be reorganised locally in line with the national neonatal critical care surge guidance.
- Many trusts have reported imposing restrictions on visitors. While it may be necessary to restrict numbers for reasons of infection control, women should have access to one birth partner during labour (from the point of admission to labour ward or birth centre) and birth in line with World Health Organization advice.
- Birth partners must be asymptomatic; if they are not, the woman must be asked to nominate another person.
Faced with a shortage of clinical staff, the safest option may be to consolidate care in fewer places by closing specific services temporarily. Such decisions must be influenced by a risk assessment and only made after considering:
- alternative options, such as deploying returning retirees and independent midwives
- a progressive approach, thereby keeping as many options available for as long as possible – suspending certain options, particularly place of birth, will have a significant impact on some women and should be avoided unless absolutely necessary to ensure a safe service. Women must still be able to make decisions about the care they receive in line with the principles of informed consent. The withdrawal of services must be temporary and must be clearly communicated to women and their families.
Place of birth choices in midwifery services
- Alongside hospital midwifery units, freestanding midwifery units and home birth teams provide a safe option for many women as set out in National Institute for Health and Care Excellence (NICE) guidance. A decision on whether to maintain, limit or withdraw these services should not be taken lightly and will involve careful balancing of a number of considerations:
- A proportion of women need to transfer from home or a freestanding unit to the obstetric unit. This usually requires a response from an ambulance service, which may also currently be stretched. This means transfers from home to hospital may not be sufficiently quick to ensure the safety of mother and baby.
- Where a home birth service is in operation, trusts or LMS may need to develop a clear standard operating procedure with their regional ambulance service. This could include local alternative transport pathways for women where a timely response is likely to be delayed. Women should always be given information that reflects locally agreed pathways for transfer to enable informed decision-making.
- If a trust decides to suspend a freestanding midwifery unit, home birth service or redeploy an alongside midwifery unit (eg for use by women with COVID-19 symptoms) to guarantee safety, it should consider maintaining at least one midwifery care option. Trusts may also consider how they can offer the same style of care in the obstetric unit, perhaps by moving equipment such as birthing pools.
Understanding the impacts and potential risks relating to women’s mental health and wellbeing during this period is vital, and a personalised care approach can support this. This needs to cover a range of issues, including:
- acknowledging the pandemic is likely to increase anxiety among pregnant women, given it brings further uncertainty
- understanding the impact of changes in service provision and therefore birthing choices for women with a history of birth trauma, tokophobia, etc and the risks to their mental health; as well as the risks to women without such a history
- the importance of robust plans for women identified as at risk of, or experiencing, complex/severe mental health problems in the intrapartum period and beyond. The ‘red flags’ identified through MBRRACE reports need to be understood and addressed, to ensure that women experiencing mental ill health at this time can still access specialised mental health care if required. Maternal mental illness remains one of the leading causes of maternal death.
- Trusts should also consider how they will respond to more women choosing to stay at home as long as possible and subsequently experiencing an unplanned home birth (babies ‘born before arrival’) during this time.
Suspending obstetric units
- Occasionally busy obstetric services close temporarily to manage demand. Such a decision must be taken in line with existing processes, in conjunction with other trusts in an LMS or maternity clinical network, as they are likely to be experiencing similar pressures.
Suspending access to certain interventions
- A shortage of obstetricians or anaesthetists may mean there is insufficient capacity to meet demand. In extreme circumstances, there may no option other than to temporarily suspend access to elective procedures. Trusts should make every effort to avoid this situation and, in particular, should work as a LMS or maternity clinical network to keep options open, either by pooling staff or by making transfers of care available to women.
- Women who are being induced can require long periods of admission and have higher levels of subsequent interventions during labour. Indications for induction of labour may need to be reviewed and limited to women who have a clear clinical indication. It may be possible to improve outpatient provision of induction of labour, depending on the availability of transport
Engaging with service users and their families
- Trusts or LMS must work with their MVP service user chair to develop their plans. This does not need to be a long process – one of the benefits of standing MVPs is the ability to mobilise input quickly.
- Trusts or LMS must communicate temporary changes to service provision clearly and transparently, including on a public-facing website, so that women can make informed decisions about the care they receive.
- Trusts should consider establishing telephone or video call helplines for women with concerns or requiring advice about accessing the services they need.