Safety netting in midwifery

The report on lessons learnt following the UK and Ireland confidential enquiries into maternal deaths drew attention to the need to provide ‘safety net advice’ to women in the drive to prevent maternal deaths (Knight et al, 2021). The report highlighted the need to be aware of red-flag symptoms (which may indicate a serious condition) and ensure that women and their families are made aware of what they should look out for and what symptoms should be reported. This article explores the concept of safety netting in healthcare and its relevance to midwifery practice. The teaching of safety netting is considered and a personal reflection from a student midwife is included. Finally, a new midwifery-specific framework for safety netting is proposed and a clinical scenario is used to demonstrate the application of this framework to practice.

Safety netting is a practice common in healthcare settings across some specialties and is well established within general practice, emergency medicine and paediatric emergency medicine (Gray et al, 2019; Greenhalgh et al, 2020). Edwards et al (2019a) stated that safety netting advice is information shared with a service-user (or their carer) designed to help them identify the need to seek further help if their condition fails to improve, changes or if they have concerns about their health. This definition is used for the purpose of this article.

Some definitions have a slightly different focus. Jones et al (2019) defined safety netting as a practice that includes techniques on communicating uncertainty, providing information on potential red-flag symptoms and may include plans around future appointments. However, even within specialties in which safety netting is well-established, there is little agreement about the type of information that should be contained as standard within safety netting advice and when it should be given. Moreover, there seems to be little training available to clinicians regarding what information should be given routinely and whether this information should be conveyed in a written or verbal form or both (Jones et al, 2013).

Safety netting is recognised as an important aspect of communication and safe practice within some areas of healthcare (Colliers et al, 2022) but seemingly without an agreed standard, formula or framework on which to base practice. Safety netting can also be regarded as a method of dealing with uncertainty (Edwards et al, 2019a). Nobody can predict the future and health can sometimes deteriorate unexpectedly; therefore, it is important to highlight what to look out for in a way that gives the patient increased confidence in self-care, deciding what actions to take and when to seek further assistance. An example that many people may be aware of is the discharge information provided for patients, families and carers by accident and emergency departments following a head injury (National Institute for Health and Care Excellence (NICE), 2019a). This information includes details of what care and supervision is required at home, expected recovery and symptoms to look out for and report.

The crux of safety netting is providing essential information regarding risks, symptoms and normal outcomes effectively, with routes of escalation if new symptoms or concerns develop. In this way, it supports risk management, professional accountability and clinical governance (Public Health England, 2021). This article will explore safety netting and consider its application in current midwifery practice.

Safety netting in midwifery

The concept of safety netting is particularly relevant in midwifery given the fundamental nature of midwifery care, which depends on working in partnership with women to recognise and support normal physiological processes and act upon deviations from these (Nursing and Midwifery Council (NMC), 2018). Safety netting could be used to empower women by strengthening their capability to care for themselves, in line with midwives standards of proficiency (NMC, 2019). However, safety netting is not a term used in key midwifery documents and textbooks.

The NMC (2018) code requires midwives to provide information that is clear and appropriate for the person receiving it. There is an abundance of guidance on different aspects of maternity care, including national and local guidelines that include information that should be given to women. Therefore, there is an assumption that midwives will provide women with appropriate information to help them recognise what is within normal parameters and what is not. This is easier when the midwife is in attendance, for example, in established labour when there is the continuous presence of a midwife or during an antenatal appointment. However, midwives must also ensure women have the right information to make decisions about their health and wellbeing (or their babies), even when they are not there in person. Providing clear information to ensure that women understand when and how they should seek further assistance is fundamental to safe care. This became even more important through the COVID-19 pandemic, when face-to-face appointments were reduced and more appointments were conducted through online platforms or by telephone. Additionally, media reports of the NHS being under pressure may have been a barrier to seeking healthcare (Mulholland et al, 2020).

Midwives must be able to provide accurate, effective and timely information to women and their families that enables them to make decisions about their health and wellbeing (NMC, 2019), but it is not clear whether midwives would consider this to be safety netting. The term is important because it encourages midwives to think about how specific information can act as a safety net, preventing women from ‘falling through the gaps’ and ensuring that they have all the information they need to keep them safe. Midwives do use information in this way on a day-to-day basis. For example advice for women to be alert to signs and symptoms of pre-eclampsia during an antenatal appointment is frequently given during antenatal appointment, in accordance with national guidance (NICE, 2019b). As a result, women may be familiar with advice to report headaches, visual disturbances, severe pain below the ribs, vomiting or sudden swelling of the face, hands or feet. Student midwives will learn how to recognise complications such as pre-eclampsia during pre-registration preparation at university (NMC, 2019; De Montfort University, 2022), where they may study the rationale and underlying physiological significance of such symptoms. They will need to learn how to use this information to fulfil their role when advising women (NMC, 2020). They also learn from the midwives that supervise them on practice placements, when they see how midwives communicate with women and provide this information.

If safety netting is to be effective in helping people to safely identify the circumstances in which they need to seek further help, midwives need knowledge based on high-quality evidence about what to expect and what signs and symptoms might indicate a problem. This is often already available; for example, there is good evidence around the normal parameters for lochia following birth from the original BLiPP study (Marchant et al, 1999) and subsequent research (Marchant et al, 2002; Chi et al, 2010; Fletcher et al, 2012), although there do not appear to be any recent studies. Although lochia varies widely from woman to woman (Steen et al, 2020), the evidence provides objective information on normal parameters regarding amount, colour, consistency and duration of loss. This evidence, combined with clinical experience, means that midwives can confidently provide women with the right information to help them recognise when they need to seek professional help.

However, this is not always the case. For example, there remains a lack of evidence around what constitutes the start of established labour (Hanley et al, 2016). There remains no definitive test for identifying labour onset and women and clinicians may have different perceptions on when labour has started (Hundley et al, 2020). Therefore, despite clinical guidelines, advising women on the best time to access care in labour is not always simple. Confirming normality and identifying deviations or the difference between low and high risk are discussed, but in reality, this is not always straightforward and leaves ambiguity. Midwives sometimes have to deal with what Dahlen (2016) calls the ‘grey zone’. Safety netting may be more difficult in such circumstances, but can still be a powerful tool to assist midwives and women to navigate uncertainty in a way that maintains safety through timely and appropriate intervention, yet prevents unnecessary referral and medicalisation.

Models promoting safety within midwifery and obstetrics

A literature search of CINAHL, the British Nursing Database and Medline (key words: safety net/ting, safety net/ting, safety-net/ting AND midwife; midwives; midwifery; maternity; pregnancy; antenatal; intrapartum; antepartum; postnatal; postpartum; birth and childbirth) was unable to identify any models of safety netting specifically for use in midwifery practice. However, literature on safety netting in medicine, in particular general practice, suggests that frameworks or tools have been developed. These include tools to assist in structuring safety net information (Silverston, 2020) and to assess clinicians' individual practice (Edwards et al, 2019b). However, literature on safety netting models in obstetric settings were not found.

This is surprising, as there are a number of frameworks that focus on the prompt detection of deviations from normal and escalating concerns with appropriate speed. For example, the Birmingham Symptom Specific Triage System (Horton et al, 2018) has now been rolled out at a national level to provide a framework to stratify women who attend their local service for assessment of potential complications during pregnancy, so they can be assessed with appropriate speed. This is one example where the provision of a set structure to conduct assessments and guide appropriate pathways has been effective in improving triage times and safety and has been evaluated by midwives (Beckmann et al, 2014; Kenyon et al, 2017; Horton et al 2018; Moudi et al, 2022). This model provides a framework for assessing the urgency of attention required for the presenting complaint. However, it does not provide a framework for giving information on when service users should seek further support and hence lacks this element of safety netting.

There is increased awareness of human factors and how these contribute to the management of situations and emergencies (Khan and Hinshaw, 2022). Tools can be extremely useful to guide practice. For example, the ‘situation, background, actions and recommendation’ tool is already widely used in healthcare to promote effective handover (Müller et al, 2018). The use of prompts such as checklists, for example, in the context of postpartum haemorrhage, can standardise protocols and improve outcomes, including time to respond and escalation (Young and Maclennan, 2019).

A model for safety netting

From these examples, it would be reasonable to suggest that safety netting would benefit from a structured framework allowing information to be given in an agreed format to provide an expected approach to situations. A safety net framework would make it easier for midwives to provide information that can enable women to recognise deviations from the expected trajectory and thus facilitate more timely escalation of concerns. Silverston (2020) proposed the mnemonic ‘SAFER’ as a framework for safety netting in primary care situations. However, it may not be entirely appropriate for use in midwifery. SAFER is based on an illness mode, and the language and process reflect this. For example, A stands for alternative diagnosis and F represents any specific findings that the patient needs to be aware of.

It is possible that SAFER could be adapted to make it more appropriate for maternity care and for use by midwives. However, the authors of this article propose a simple-to-remember model based on what, why, who, when and how, for midwives to use with women when providing safety net information. The rationale for this model comes from an understanding of what information women need during pregnancy, birth and the postnatal period. Women need information on:

• ‘What’ to expect in terms of normal physiology or as part of the normal process of healing or recovery
• ‘What’ is outside of these parameters and needs to be reported, and why
• ‘Who’ to inform and seek advice and support from if this happens
• ‘When’ and ‘how’ a healthcare professional should be informed.

This could form a framework for safety net information and advice. It is important to remember that there are two ‘whats’ because they represent both what is to be expected if everything is within normal parameters and what is different to those expectations and should be acted upon. Therefore, the authors suggest this framework as an aid memoir for robust, clear safety net information and advice.

The clinical scenario in Box 1 describes the story of Lily following a perineal repair for a second degree tear.

Box 1.ScenarioLily is para 1 following an uncomplicated vaginal birth in hospital with a second degree perineal tear and some labial grazes. These were repaired using local anesthetic and haemostasis was achieved with no evidence of haematoma. The midwife who completed the suturing discussed hygiene with Lily, including washing hands before and after changing pads, regularly changing pads and using clean water to wash herself regularly and to pat dry to avoid irritation.Lily had an early discharge home with her daughter and partner. The first postnatal visit at home by a community midwife was uneventful and both Lily and her daughter were well and without concerns. At the next postnatal visit on day five, the midwife noted that while Lily stated she was coping well and had no concerns, she was very uncomfortable when sitting and struggling to move properly. Lily declined examination and stated that she thought it would probably start to feel less sore soon. No observations were performed but Lily appeared well. She was given advice to keep the area clean, take regular analgesia and call if things became worse. A follow up visit was arranged for day seven.At the day seven visit, the midwife arrived to find Lily in significant pain, pale and feeling unwell. Examination showed a low grade pyrexia of 37.5oC, with raised respirations of 22 and a heart rate of 98 beats per minute. In addition, perineal inspection revealed the area was red and inflamed with some yellow discharge. A phone call was made to the local maternity unit to arrange for Lily to be assessed. On attending this appointment, she was examined and admitted for blood cultures, wound swab and commenced on intravenous antibiotics. She remained in hospital for 3 days and was discharged with a course of oral antibiotics.Note: This scenario is fictitious although it bears some resemblance to the author's practice experiences. A pseudonym has been used.

Clinical scenario

In the scenario outlined in Box 1, three questions should be considered:

• What safety net information and advice was given?
• Did Lily have all the information she needed?
• Why did she not contact her midwife or another healthcare professional when she had increased pain and felt unwell?

The what (2), why, who, when and how framework can be used to consider safety net information that could have been provided to Lily. This might vary in different areas and in conjunction with different national and local guidelines. An example is provided in Table 1.

Table 1 shows how the framework provides Lily with clear, specific, individualised information and advice. This is in contrast to the advice given by the midwife in the scenario (Box 1) to ‘keep the area clean, take regular analgesia and call if things became worse’. It is not that this advice was wrong, but it lacked clarity and detail about what Lily should look out for and why, and lacked specific instructions about who to call and when. For example, it was not clear how she could let someone know when the community midwives were off duty.

The proposed framework is simple to understand and can be a basis for conversations with women and families and then used to structure documentation. It would appear to be suitable for any aspect of midwifery care and lends itself to adaptation for individualised care. It can also be used in midwifery education with student midwives as a learning tool. Student midwives can be encouraged to ask what (2) why, who, when and how. This will help them to develop a comprehensive understanding of both universal care and the identification of additional needs in line with midwifery standards of proficiency (NMC, 2019), as well as help them learn about safety netting with women and families. Box 2 shows a student midwife's perspective on the theory and practice of providing safety net advice.

Box 2.A student midwife's perception of learning about safety nettingAs a third-year student midwife, I was not familiar with the term ‘safety netting’, despite witnessing it since the beginning of my midwifery course and, more recently, providing it myself. For example, when a woman presents to the antenatal clinic, we discuss signs and symptoms of pre-eclampsia, and the necessary contact numbers are highlighted for any concerns. Additionally, the importance of fetal movements and the actions to take if these change are always discussed. This happens regardless of the current pressures facing midwives, including time restraints and staff shortages. This highlights the crucial role of safety netting, even more so when midwifery services are stretched.Safety netting can only be safe and effective if it can work for all the service users we care for. Therefore, it should incorporate universal maternity care, additional needs and facilitate individualised information and advice for service users from different backgrounds and cultures. It must be absent of discrimination and recognise diversity. Knight et al (2021), showed that there remains more than a four-fold difference in maternal mortality rates among black women and an almost two-fold difference among women from Asian backgrounds when compared to white women. At a recent conference, I learnt that it is important to recognise how some conditions can present differently on darker skin (Mukwende et al, 2020), for example, neonatal jaundice or areas of inflammation (Ménage et al, 2021). This is relevant when informing women on what to look out for. Advising breastfeeding women to look out for a red area on the breasts as a possible sign of mastitis may not be appropriate for women with dark skin tones (Raynor et al, 2021) and information needs to be individualised and culturally appropriate. The use of visual resources as learning aids can be particularly useful, as students may not yet have witnessed certain conditions. Resources that encompass ethnic diversity in maternity care would be effective in ensuring student midwives and midwives can give safety netting advice that is individualised and safe.An area of safety netting I have noticed is lacking in practice is mental health, and particularly how to differentiate mental health conditions from ‘postnatal blues’. I have learnt that 10–20% of women develop a mental illness during pregnancy or within the first year after having a baby (Public Health England, 2019). This includes antenatal and postnatal depression, obsessive compulsive disorder, post-traumatic stress disorder and postpartum psychosis. A report found that between 2016 and 2018 in the UK, 13% of maternal deaths during or up to 6 weeks after pregnancy were a result of psychiatric disorders, the majority of which occur in the postnatal period (Knight et al, 2021). Additionally, maternal suicides are the leading cause of direct deaths occurring between 6 weeks and 1 year after the end of pregnancy (Knight et al, 2021).Recent research on mental health has focused on midwives' ability to screen and refer for mental health disorders. However, many women and babies are discharged from midwifery care 10–14 days after birth, highlighting the importance of safety net information to help women feel competent and confident to recognise and self-refer indications of mental health disorders, particularly when there is less contact with healthcare professionals. This was further affected by the pandemic, during which there was a reduction in face-to-face midwifery appointments, and further reliance on women's abilities to self-refer. In such circumstances, the need for safety netting is even more important.Universities make efforts to teach evidence-based theory, including signs and symptoms of complications such as pre-eclampsia, mastitis and postnatal depression, among many others. However, the term ‘safety netting’ is something I have not often, if ever, heard. As I progress through my training, I observe and learn from different midwives. Although clinical guidance is followed, they may have different ways of doing things. As I reach the end of the course, I will collate the variations I observe and assess what suits my practice. However, as with many other aspects of the course, it may be beneficial to be taught a model or theoretical framework for safety netting, particularly one that works within the current realities and challenges of midwifery practice.

Implications for practice

In practice, midwives need to consider how this framework can be used. Standard proformas for documentation can be created or it can be used as an aide memoir for providing and documenting safety net information. However, it is not envisaged that this model of safety netting would be used for every possible issue. This would not only be impractical, but also add to midwives' ever-increasing documentation (Cooper et al, 2021). Instead, clinical teams might use national and regional reports on maternal and neonatal morbidity and mortality to consider where safety netting is most needed. They could also evaluate the reasons for emergency admissions in pregnancy, and postnatal readmissions following discharge, at a local level. These data could be used to aid decisions on how best to target safety netting. The aim should be increase women's ability to recognise, detect and act on symptoms that indicate specific complications, increasing the chance of these complications being dealt with promptly. For example, in the postnatal period, safety netting might focus on early recognition of conditions such as wound infection, postnatal depression, mastitis or neonatal dehydration.

Conclusions

Safety net advice has been highlighted as a key priority in maternity care as part of a strategy to avoid maternal deaths. Although it is a familiar term in some areas of medicine, it is unfamiliar in maternity care, and in particular within midwifery practice. Midwives do provide safety net information and advice to women and families, but midwifery does not have a robust framework on which to base this information. While many midwives develop their own ways of communicating, this risks missing out key information and makes it difficult for student midwives to learn. The simple, intuitive model proposed in this article would work alongside evidence-based clinical guidelines and lend itself to personalised safety netting, including local and contextual information about who to contact and how, as well as why this is important.

It is hoped that using this model will improve the teaching and learning aspects of safety netting, guide communication and record keeping and enhance safe care for women and families. However, testing and evaluation are required. The next steps will be to use the model in midwifery education as a teaching and learning aid and to introduce it into areas of practice for evaluation by clinicians and service-users. In this way, the model can be developed and adapted as necessary to ensure that it supports women and families effectively and is also user-friendly.

Key points

• All midwives provide women and families with information and advice, as an important aspect of high-quality safe care.
• Safety netting is information designed to help people to seek timely appropriate support when their condition deteriorates or if they have health concerns.
• Safety netting is a useful concept in midwifery practice, but has been underexplored until now.
• A clear, simple framework for safety netting has the potential to ensure that information and advice is clear, comprehensive and individualised.
• The proposed framework has the potential to support teaching and learning around safety netting.