This retrospective audit of maternal critical care was undertaken during 2015 by a consultant midwife and intrapartum midwifery practice educator. The aim was to inform local health commissioners on the complexity of activity in a tertiary referral maternity and neonatal service in Belfast Health and Social Care Trust (BHSCT).
In the UK and Ireland during 2013–15, 556 women died during birth or up to 1 year postpartum, according to the Saving Lives, Improving Mothers' Care report (Knight et al, 2017). This indicated there was no change in the overall maternal death rate between 2010–2012 and 2013-2015, which remains at 8.8 women per 100 000, two-thirds of whom had pre-existing medical problems. The report showed a significant decrease in indirect maternal mortality, primarily due to a decrease in influenza deaths and deaths from maternal sepsis.
While it is essential to continue to audit cases of maternal mortality, a review of cases requiring maternal critical care, which occurs more frequently, should provide a more clinically relevant appraisal of the challenges and requirements in terms of maternity service provision and development.
Maternal critical care describes woman-centred multidisciplinary care, as opposed to the speciality-focused care provided by obstetric critical care. A systematic review of the literature indicated that there was no standard definition of maternal critical care and that admission criteria differed widely (Van Parys et al, 2010). Although the Intensive Care National Audit and Research Centre (ICNARC) provides valuable information about pregnancy-related intensive care unit (ICU) admissions (Royal College of Anaesthetists (RCA) and Maternal Critical Care Working Group, 2011), relatively little is known about women who receive critical care within maternity services.
The actual numbers of sick women are significantly underestimated, as many critically ill women are not admitted to designated critical care units, but are instead managed on maternity units (RCA and Maternal Critical Care Working Group, 2011). The Scottish Confidential Audit on Severe Maternal Morbidity (Healthcare Improvement Scotland, 2014) reported serious morbidity in 7.3 per 1000 births. The existing evidence suggests that 5% of women require critical care in maternity units (Wheatley, 2010) which is in keeping with the findings of this audit.
In recent years, different approaches have been applied to the classification of severe maternal morbidity and management-based decision-making, including the criteria for critical and intensive care (Baskett and O'Connell, 2009).
It is essential that commissioners and both maternity and critical care services design regional pathways that ensure a critically ill parturient may access equitable maternity and critical care, irrespective of location. Where possible, such pathways should facilitate mother and baby remaining together, unless prevented by a clinical reason, and define escalation arrangements (RCA and Maternal Critical Care Working Group, 2011). The maternity team at the tertiary unit where the audit took place has the necessary critical care competencies to care for these women; however, for many units, this remains aspirational. These arrangements need to take into account local configuration, size and complexity of maternity and critical care services.
In the local area where this audit took place, 1 in 5 mothers have a body mass index (BMI) greater than 30 kg/m2, and there has been an increase of 37% in diabetes in pregnancy over past 2 years. In comparison to the regional rate of 6.2%, 6.9% babies have low birth weight (Health and Social Care Public Health Agency, 2016). Women with social complexities and the needs of ethnic minority groups must also be considered.
The intrapartum environment has a zoned layout for complexity and comprises a four-bed alongside midwifery-led unit, a six-bed induction of labour area and 11 delivery suite rooms. Of these, two are adjacent and equipped specifically for maternal critical care, eight are designed for intermediate risk and one serves as a bereavement suite.
The objectives of this audit were:
Methodology
This audit examined the occupancy of two designated critical care rooms in 2014. The audit was limited to the women who occupied these rooms, although other rooms in the intrapartum environment were regularly used for similar complex cases and provision of critical care at times when these rooms were occupied.
The methodology included:
The levels of critical care assigned were defined by the standards within the document Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman (RCA and Maternal Critical Care Working Group, 2011) (Table 1), approved jointly by the RCA, Royal College of Midwives (RCM), the Obstetric Anaesthetic Association, the British Maternal and Fetal Medicine Society, the Royal College of Obstetrics and Gynaecology (RCOG) and the Intensive Care Society (ICS). The levels of support for critical care referenced therein were modified locally and agreed by obstetrics, anaesthetics and midwifery teams. This modification incorporated example scenarios from the service.
| Royal Jubilee Maternity services (RJMS) complexity level | Intensive Care Society level of support | Maternity examples (this list is not exhaustive) |
|---|---|---|
| 0 | Level 0: |
Care of low-risk mother |
| 1 | Level 1: |
|
| 2 | Level 2: |
Basic respiratory support |
| 3 | Level 3: |
Advanced respiratory support |
Results
During the 12-month audit period, 525 women were cared for in the designated critical care rooms. Of these, 515 maternity records were reviewed (7 sets of records had been returned to other HSCTs and 3 were unavailable). Regional maternity electronic care records were used to retrieve some relevant data in four of the missing ten occupancies, enabling 99% audit inclusion rate.
Although all the women who were cared for in the critical care rooms had some indication to warrant their occupancy in this area, 217 women (42%) scored critical care level 0 on completion of their episode. For example, this group could include women in preterm labour (before 37 weeks gestation) who received magnesium sulphate infusion for fetal neuroprotection, but who had a normal vaginal preterm birth and did not require any additional level of critical care support.
The criteria for critical care provision used within this audit (Table 1) demonstrates a rigorous analysis that should inform commissioners of both the complexities and acuity of severe maternal morbidity.
Within critical care levels 1, 2 and 3, there were 298 women (58% of total occupancies) (Table 2). Of these, 167 women (56%) required level 1 care, meaning that they had a condition (such as congenital heart disease or diabetes) that was at risk of deteriorating and needed a higher level of observation. A further 108 women (36%) required level 2 care which is defined as ‘[women] requiring invasive monitoring/intervention that includes support for a single failing organ system (excluding advanced respiratory support)’ (RCA and Maternal Critical Care Working Group, 2011:5) (Table 2). Examples from this cohort include massive obstetric haemorrhage, eclampsia, diabetic ketoacidosis and severe sepsis. Those requiring level 3 critical care defined as ‘[women] requiring advanced respiratory support (mechanical ventilation) alone or basic respiratory support along with support of at least one additional organ’ (RCA and Maternal Critical Care Working Group, 2011:5) (Table 1), which accounted for 23 women (8%) in this study, who were diagnosed with septic shock, aspiration pneumonitis, uterine rupture, bilateral pulmonary emboli, stage 5 renal failure (daily dialysis) and acute fatty liver disease.
| Level of Care | Maternity examples n (%) | |
|---|---|---|
| Level 0 |
217 (42%) | 515 reviewed occupancies in 365 days |
| Levels 1, 2 & 3 | 298 (58%) | |
| Level 1 |
167 (56%) | Cohort included: |
| Level 2 |
108 (36%) | Cohort included: |
| Level 3 |
23 (8%) | Cohort included: |
HELLP: Haemolysis, Elevated Liver enzymes, Low Platelet count
The lengths of stay for the 525 occupancies ranged from 2–163 hours (6 days, 19 hours) (Table 3). Regardless of critical care level, every woman in the critical care rooms required input from the multidisciplinary team, and one-to-one midwifery care in particular, during their entire length of stay. Transfers in from other maternity units, both in and outside the region, totalled 64 and are broken down by Trust in Table 4.
| Mean length of stay | Range (hours) | |
|---|---|---|
| Levels 1, 2 and 3 | 26 hours | 2–163 (6 days 19 hours) |
| Level 1 | 18 hours | 2–55 (2 days 7 hours) |
| Level 2 | 33 hours | 4–163 (6 days 19 hours) |
| Level 3 | 52 hours | 3–147 (6 days 3 hours) |
| Trust | Booking | n | Required level of critical care | Antenatal | Intrapartum | Postnatal | |||
|---|---|---|---|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | ||||||
| One | Trust One Unit 1 | 11 | 5 | 3* | 2 | 1* | 10 | 1 | 0 |
| Trust One Unit 2 | 8 | 0 | 3* | 4 | 1* | 6 | 2 | 0 | |
| Two | Trust Two Unit 1 | 6 | 3 | 3 | 0 | 0 | 6 | 0 | 0 |
| Trust Two Unit 2 | 7 | 1 | 3* | 3* | 0 | 6 | 1 | 0 | |
| Three | Trust Three Unit 1 | 10 | 4 | 2 | 4 | 0 | 9 | 1 | 0 |
| Trust Three Unit 2 | 9 | 3 | 4 | 1 | 1 | 9 | 0 | 0 | |
| Trust Three Unit 3 | 2 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | |
| Four | Trust Four Unit 1 | 5 | 0 | 4* | 1 | 1 | 5 | 0 | 0 |
| Trust Four Unit 2 | 4 | 2 | 1 | 1 | 1 | 3 | 1 | 0 | |
| Outside region | Outside region Unit 1 | 1 | 1 | 0 | 0 | 0 | 1 | 0 | 0 |
| Outside region Unit 1 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | |
There was evidence of a downward trend in transfers from maternity services to intensive care. In 2009-10, 35 women were transferred to ICU, decreasing to 16 women in 2010-11 and seven in 2014. In 2014, six of these women returned for ongoing critical care, further highlighting the trend for providing maternal critical care within the maternity service environment.
This audit revealed that 45% of women requiring maternal critical care were from outside of the HSCT's residential postcodes (Figure 1).
Discussion of findings
Complexity and risk factors for women, including age profile, long-term comorbidities and increasing BMI, have grown considerably in the last few decades (Knight et al, 2017). Safety remains the highest concern in maternity care (Department of Health, Social Services and Public Safety for Northern Ireland (DHSSPSNI), 2012). The local commissioning group has committed to the 22 objectives of the Strategy for Maternity Care in Northern Ireland (DHSSPSNI, 2012), including a strategic shift towards providing more care in the community, more midwife-led care and tackling inequalities. Under objective 18 (safe labour and birth outcome), this tertiary unit will be the regional centre for the most complex cases, as well as providing services for the local population. Although critical care was not part of the regional maternity strategy, the provision, configuration and costings of maternity services continue to be of public and political interest in Northern Ireland.
The findings of this audit show that haemorrhage (40%), hypertensive disorders (16%) and sepsis (12%) were the main reasons for maternal critical care, in keeping with other studies (Knight et al, 2017).
The service budget agreement in Northern Ireland is based on the number of births, not the complexity of women, and there continues to be concern about the lack of robust data to inform commissioning. The cost of services continues to rise, with increasing numbers of high-risk and complex pregnancies requiring careful monitoring and judicious intervention and support.
Ongoing prospective data indicates that women with complexities, including life-limiting malignancies, significant disabilities, transplant histories and cerebrovascular accident in pregnancy, continue to require critical care in this tertiary referral maternity service. These women are referred in order to receive the expertise both for mother and baby that is often not available elsewhere within the region.
Recommendations
The recommendations of this audit include:
Limitations
The audit was limited to the occupancy of the two designated critical care rooms, although the authors were aware that the demand for critical care regularly exceeded this environmental capacity.
Provision of maternal critical care presents challenges for the multidisciplinary team in terms of the development and maintenance of skills and competencies. This audit did not measure confidence levels among any of the disciplines.
Conclusion and implications for practice
The demographic trends of increasing maternal age, obesity, and rising rates of caesarean section are factors recognised to be associated with increased maternal morbidity (Knight et al, 2017).
This tertiary unit is compliant with the MBRRACE-UK (Knight et al, 2017) recommendation that there should be adequate, equitable provision of appropriate critical care support for the management of a woman who becomes unwell, and critical care unit facilities that are appropriately equipped and staffed by teams of senior obstetricians, anaesthetists and midwives.
These clinicians should be skilled in looking after seriously ill women; however, undergraduate midwifery training does not always provide enhanced critical care competencies. As a result, a core cohort of midwives based in the intrapartum environment provides maternal critical care at the Trust.
Implications for midwifery practice include pre- and post-registration training, skill mix and workforce planning. The RCM is compiling an ‘Enhanced maternity care competencies framework’ to ensure that more midwives have the appropriate skills to care for critically ill women. Joint multidisciplinary education relating to recognition of acute illness and deterioration should also be considered to enhance teamwork and sharing of knowledge and skills.
At local level, the Trust has updated multiprofessional training in keeping with recent changes to PRactical Obstetric Multiprofessional Training (PROMPT, 2017) version 3, which includes the provision of new chapters on maternal critical care, incorporating teamwork, local context and sustaining local multiprofessional training. PROMPT (2017) has also produced a Care of the Critically Ill Pregnant Patient training package, which the Trust is preparing to implement.
Transfers to achieve an upgrade of care in specialist units or for particular interventions are justified (RCA and Maternal Critical Care Working Group, 2011). As a result of 45% of women being transferred to the Trust from other services in the region, it has been noted that written guidance and training programmes on the transfer of critically ill pregnant or postpartum women are lacking (Knight et al, 2017).
In complex and rare conditions, MBRRACE-UK (Knight et al, 2017) recommend that an early multidisciplinary meeting must be held to plan pregnancy and birth care. The results of this audit were received favourably by local commissioners and had a positive impact on the provision of maternity funding for the Trust, which has encouraged the team to continue to prospectively identify complexities and audit provision of maternal critical care.
This audit recommends a standardised approach to data collection and agreed definitions of maternal critical care, in order to identify the incidence of the need for maternal critical care provision with greater accuracy. This should be established routinely to inform commissioning decisions and future service planning.