The US Preventive Services Task Force (USPSTF) has issued a statement of recommendations on interventions to prevent perinatal depression. The group assesses evidence on the risks and benefits of treatments and provides a recommendation based on a balance of the two.

The USPSTF recommend that clinicians ‘provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions’. Interventions such as cognitive behavioral therapy and interpersonal therapy were seen to be effective in preventing perinatal depression in those that were at increased risk.

The statement highlights the need for addition research into how to identify women that are at risk along with other interventions such as physical activity, peer counseling and in-hospital perinatal education.

​The full statement can be found here. 

A study titled ‘Mother’s mental health after childbirth: Does the delivery method matter?’ has been published looking at the impact of unplanned cesarean birth on a mother’s mental health in particular the impact on postnatal depression. Information on 5896 women was assessed to determine the causal effect of an unplanned cesarean on the mother’s mental health.

The study found that unplanned cesarean births carry significant psychological risks including increased vulnerability to depression. The paper highlights that ‘From a policy perspective, this study highlights the importance of accounting for the psychological costs of unplanned caesarean deliveries when evaluating the costs and benefits of this procedure.’ along with recognizing the need to have appropriate services in place to support mothers and their mental health needs.

​The full paper is available here.  

A study titled ‘Secular changes in body height predict global rates of caesarean section’ has been published. The study proposes that as opposed to socio-economic, legal and cultural factors impacting the cesarean section rate it is the height of the mother and weight of the baby that has an impact.

The study involved the collection of data on cesarean section rates and on adult body height, obesity and diabetes and computing the annual average change in body height. The data for 2 birth year intervals was examined.

The findings of the study suggest that ‘difficulty of labour varies globally owing to variation in the size of the fetus relative to that of the mother’. It recommends that:

‘Benchmarks for ‘ideal' rates of C-section should take into account local environmental factors and the historical trajectory of socio-economic development [14]. We encourage a paradigm shift, away from purely cultural explanations of C-section rates, towards a combined biocultural perspective.

The study implies that the current focus on reducing cesarean section rates with equality of access to care, cultural changes and a shift in perspective may not be addressing a key factor impacting increases in cesarean section rates.

The full study can be read here. 

A study from the Cleveland clinic has been published looking at the impact of a newborns first bath on breastfeeding rates.

At the facility usual practice was to provide the initial bath within 2 hours of birth as part of the study the first bath was delayed until at least 12 hours after birth.

​Following the change in practice in-hospital exclusive breastfeeding increased from 59.8% to 68.2% with mothers continuing to breastfeed once home. This video explains the findings. 

The CQC have published the result of their latest survey which looked into the experiences of women receiving care from maternity services.

The survey included 17611 women who gave birth in February 2018 across NHS trusts in England reporting that overall women had positive experiences. Questions were asked on antenatal care, labour and delivery and postnatal care.

Some positive areas include:

• Their partners being involved during the birth
• Good communication during labour and birth
• Having confidence in those providing care

There were some areas where improvements can be made:

• Care after birth – the emotional changes that may be experienced, home visits by midwives and information about physical recovery
• Staff awareness of medical history of mum and baby

The results provide a breakdown as to how individual trusts performed against each question and details any outliers.

There were 9 trusts identified as performing better than expected, 5 categorised as worse than expected and 1 trust performing much worse than expected. Those trust that have been identified as worse than expected have been asked to outline the actions they will take to address the areas in which they are underperforming.

Full details of the study and results is available here. 

A study titled ‘Mother’s mental health after childbirth: Does the delivery method matter?’ has been published looking into the effects of caesarean section on a mothers mental health specifically focusing on caesareans that are unplanned. It used data from across the UK collected through the UK Millenium Cohort Study.

The result of the study indicate that women who had an unplanned caesarean delivery were more vulnerable to depression. They were 15% more likely to experience postnatal depression.

The author highlights the implications for service provision summarising:

‘From a policy perspective, this study highlights the importance of accounting for the psychological costs of unplanned caesarean deliveries when evaluating the costs and benefits of this procedure….. Additionally, it suggests the importance of providing appropriate services, such as professionally-based home visits and peer-based telephone support, to prevent the development of postnatal depression (Royal College of Obstetricians and Gynaecologists, 2017).’

The study is available here. 

An article ‘Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program’ has outlined the success of a programme aimed at improving trainee safety event reporting.

The programme provided financial incentives to trainees reporting 2 or more events with the objective to increase safety event reporting and improve patient safety. An education module was also provided to outline the importance of reporting and how to do so.

The article reported an increase in reporting from 0.5% of reports being submitted by trainees to 7% following the incentive programme. The types of events being reported by trainees differed to that of other health professionals contributing to a wider view of safety events. Following the financial incentive scheme report remained high in the year following.  

Read the full article here. 

A study conducted in Sweden has looked at the risk factors for obstetric anal sphincter injuries (OASIS) with a focus on operator related factors.

The study looked at data from one hospital over a 1 year period with 323 nulliparous women included. The results showed OASIS occurred in 17.6% of those women with 11.5% of deliveries performed by an obstetrician, 13.5% by a gynaecologist and 26.9% by residents. Risk of OASIS was 5 times higher when vacuum extraction was performed by residents.

The study highlights that it is the number of years’ experience as opposed to the number of procedures completed that impact the risk of OASIS suggesting that more training and supervision is required.

The study can be accessed here. 

An article from Contemporary OBGYN titled ‘Eight steps for narrowing the maternal health disparity gap’ has been written providing 8 steps they recommend taking to reduce the inequalities being seen in maternity care.

Within the US approximately 700 women die each year due to pregnancy related causes with 50,000 women experiencing a life-threatening childbirth related complication. There are significant racial differences in the rates of both maternal mortality and morbidity. Black women are 3-4 times more likely to die from pregnancy related causes compared to white women. Native American, Latina and Asian women also experience increased rates of maternal morbidity. Many pregnancy related deaths, up to 60%, could be preventable.

The article details 8 steps to narrow the disparities across care:

1. Improve communication between patient and provider
2. Address implicit bias through training
3. Implement a disparities dashboard to record womens race and ethnicity
4. Review morbidity and mortality metrics and address disparities identified
5. Standardise maternity care ensuring equal standards of care for all
6. Promote culture of equality
7. Develop new models of care including preconception care, group prenatal care and postpartum care
8. Engage key stakeholders including organisations, care providers and women

The article concludes that implementing the above will not just improve care for those belonging to racial and ethnic communities but for all women during childbirth.

The full article can be read here.

Safer Care Victoria has published its annual report for 2017-18. The report provides information about serious adverse events reported with the aim to understand what has been learnt and how care has been improved.

The report highlights events that resulted in the death of an unborn or a new-born baby including:

• Unsuccessful medical assistance delaying the start of emergency caesarean
• Misinterpretation of CTG
• Reduced movements
• Delayed recognition of unwell baby

Safer Care Victoria has a number of projected focused on improving the quality and safety of maternity care including:

• Publishing clinical practice guidelines
• Support for the #MovementsMatter campaign
• Assisting maternity services to monitor their own performance

Looking forward the Safer Care Victoria is aiming to deliver clinical governance training to all Victoria public health boards, promote medication safety and utilise learning from the Coroners court of Victoria.

Access the full report here. 

The NHS has recently released their plan for the Health Service for the next 5 years with details on progress towards a new service model, prevention of health inequalities, improving care and quality outcomes, tackling workforce pressures and enabling digital progress. Within the plans are provisions for maternity and neonatal care.

The plan sets out the NHS aim to achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025. Detailed in the plan is how this will be achieved including:

• The rollout out of the saving babies lives care bundle across all maternity units in England in 2019
• Supporting the establishment of Maternal Medicine Networks to help with access to specialist advice for women with acute and chronic medical problems
• Rewarding delivery of maternity safety actions through the Clinical Negligence Scheme for Trusts Maternity Incentive Scheme
• Focusing on preterm birth with development of specialist pre-term birth clinics and an expansion of the saving babies lives care bundle
• Ensuring all trusts in England with a maternity and neonatal service are part of the National Maternal and Neonatal Health Safety Collaborative by Spring 2019
• Aiming to have most women receiving continuity of care by March 2021
• Continuing to improve on learning lessons when things go wrong
• Providing access for all women to maternity notes and information online by 2023/24
• Increasing care and access to services for both mothers and fathers who experience mental health difficulties
• Improving access to postnatal physiotherapy
• Having all services begin accredited evidence based infant feeding programme by 2019/20
• Redesigning and expanding neonatal critical care services
• Developing the neonatal workforce

 
There are also several other areas of focus within the plan that effect maternity. The plan sets out increasing provisions for expectant mothers, and their partners to reduce smoking with a new smoke-free pregnancy pathway including focused sessions and treatments.

To improve equality of care there are plans to implement an enhanced and targeted continuity of carer model to help improve outcomes for the most vulnerable mothers and babies with the aim to achieve 75% of BAME women receiving continuity of care by 2024.

To help address staffing concerns a national workforce group including a chief midwifery officer will be set up to support the workforce implementation plan. Every nurse or midwife graduating will also be offered a five-year NHS job guarantee within the region where they qualify and medical school places and changes to training for doctors will be explored.

The plan also details provision to help support and retain the current workforce through skills development and career progression, promoting flexibility and wellbeing, addressing bullying and harassment and improved mental health support for doctors.

The full plan is available here with the specific Maternity and Neonatal provision starting on page 46. 

ACOG have recently released a Practice Bulletin on Gestational Hypertension and Preeclampsia covering recommendations for prenatal assessment and perinatal management, including delivery. ObGProject has provided a summary of the bulletin including:

• Inpatient v outpatient management
• How to measure BP
• Fetal and Maternal assessment
• Delivery v expectant management
• Expectant management for severe preeclampsia

ObGProject also provide a test on the bulletin to allow you to check your understanding of the guidance both of which are available here.

The full ACOG practice bulletin list can be found here. 

The vision for maternity services in England and Wales was outlined in the report of the National Maternity Review (2016). This envisaged a service that is

‘…safer, more personalised, kinder…; where every woman has access to information to enable her to make decisions about her care…’

In 2014, the UK government published ‘Personalised Health and Care 2020. Using Data and Technology to Transform Outcomes for Patients and Citizens’. This envisaged the better use of data across health & social care and that pregnant women will use apps to access their maternity records by 2018.

​Central to these reports is the harnessing of data to provide better, more personalised and more accessible & responsive services. Substantial work has been undertaken. However, as a clinician at the coalface, and a user of health and social care services, there has been very little ‘effective’ change in the last 10 years. This is puzzling given the blistering pace of digital transformation in other industries. At the heart of this puzzle is the imperative to transform health records, the primary source of data.

The phrases ‘Electronic health records (EHRs)’ and ‘Digital health records’ are used interchangeably. At My CaPl, we make a very clear distinction between these two tools.

An electronic health record is a computerised version of paper health records. You put data in, you get same data out and the computer adds little value beyond a write-read medium. Such computerisation is a necessary first step to creating a digital health record – where the computer transforms and adds value to the data. In effect, we consider a digital health record to be an electronic health record + substantial use of algorithms, big data analysis and / or artificial intelligence (AI).  This distinction is vital: the computerisation of health records has potential benefits but comes at a price.

The Medscape Electronic health records report (2016), for instance, found that erosion of the physician-patient relationship is physicians' most prominent gripe regarding EHRs. In the report, 57% of respondents said that EHRs reduce face-to-face time with patients, and 50% noted a reduction in the number of patients they can see. There is also an emerging association between the use of EHRs and physician burn-out.

​This price is worth paying if there are substantial gains through ‘digitization’ and automation. Otherwise, widespread adoption of EHRs in an already stretched service could be catastrophic. It is no surprise that clinicians balk at the adoption of EHRs.

​An effective maternity digital records platform should have 2 components: a user-friendly, woman-owned component that is seamlessly linked to a clinical component. Computers & smart phones should be harnessed to provide automated risk assessment and care planning in order to reduce the risk of error, reduce variations in care and facilitate alternative models of care. 

The platform was the subject of a Maternity Safety Innovation project funded by the UK Department of Health, which concluded that it could be integrated into existing digital systems in two different NHS Trusts.

​Women will carry their full maternity records on their smart phones and have access to automated individualized clinical risk assessment, antenatal care plans and evidence-based information including animated videos. Woman-centred tools such as contraction timer, kick counter and birth plan template make the Pregnancy CaPl app a consumer product as well as a clinical record. The clinician component has been developed in collaboration with obstetricians and midwives across 4 continents with a focus on safety, simplicity and UK guidelines. 

​We view digital platforms like Pregnancy CaPl as a first step in the digital transformation of maternity care. Artificial intelligence and big data analysis will be used to support emergency, intra-partum and post-natal care. Wearable devices will allow remote monitoring, moving information from the woman to her phone to hospital systems and applying algorithms and AI to support decisions. We believe that such systems can cut the cost of antenatal care by 30-50% while improving pregnancy outcomes. We remain conscious of issues like acceptability but at the very least, women will have a choice. 

Dr Paul Ayuk
BSc (Hons), MB.BS (Hons), MRCOG, PhD
Consultant Obstetrician & CEO
www.mycapl.com

The RCOG has released a scientific impact paper on antenatal and postnatal analgesia to help clarify advice on pain relief. The paper covers paracetamol, Nonsteroidal anti‐inflammatory drugs (NSAIDs), Codeine, Dihydrocodeine (DHC), Tramadol and Morphine.

Paracetamol
Considered safe for use throughout pregnancy and during breastfeeding. 

NSAIDS
Where possible avoid use throughout pregnancy. If clinically indicated lowest effective dose for shortest possible period advised if required before 30 weeks. Recommended to avoid after 30 weeks. Ibuprofen and diclofenac preferred choice for postnatal analgesia but should be avoided in certain circumstances.

Opioids
Can be used during pregnancy and breastfeeding short term to treat moderate to severe pain when paracetamol not effective. Recommends the lowest possible dose for shortest possible period. Important to inform neonatal team if intrapartum women have received long term opioids as it can lead to neonatal respiratory issues. Postnatal use of opioid analgesics appropriate if woman in more severe pain.  

Specifically, for postnatal analgesia codeine has been associate with some reported fetal complications. DHC, Tramadol and morphine can all be used but lowest effective dose for shortest possible period is recommended.

The paper summarises:

‘Analgesics should be used at the lowest effective dose for the shortest possible duration to minimise any potential risks to the mother, developing fetus or neonate. When stronger analgesia is required, DHC should be used in preference to codeine because of the concerns regarding toxicity, as detailed in the case reports published.’

The full paper can be access here. 

​The PReCePT programme is aiming to ensure at least 85% of all eligible mothers are receiving magnesium sulphate across all maternity hospitals in England by 2020. The project is designed to help reduce the number of babies with cerebral palsy by providing mothers with magnesium sulphate to mothers during preterm labour. The video below is with a mother who received magnesium sulphate explaining why she supports the programme.

The ACOG presidents blog has recently published 2 posts on the rising rates of maternal mortality and how it can be reversed.

One titled Critical Steps to Reverse Rising U.S. Maternal Mortality Rates highlights the progress towards the passing of the ‘Preventing Maternal Deaths Act’ in the US and how it will help with the creation or expansion of maternal mortality review committees in all states. It also discusses the Alliance for Innovation in Maternal Health (AIM) and the expansion of that programme.

The second post ACOG Battles Maternal Mortality in Texas Through Maternal Site Surveys outlines the launch of the Levels of Maternal Care programme in Texas. As part of the programme facilities that provide maternal care underwent surveys to received level of maternal care designations. Observations from the survey include:

• Collaborate with ACOG as a resource and mentor
• Quality programmes important for reducing severe morbidity and mortality
• Teamworking is important

​The two posts highlight the work being done to combat maternal mortality but also recognise that there is still much more to do. 

The Third Australian Atlas of Healthcare Variation 2018 has been published. The report explores variations in healthcare across Australia investigating unwarranted variations and providing actions to reduce variation.

The report this year has looked at neonatal and paediatric health amongst other topics including information on early planned caesarean sections without a medical or obstetric indication. The Atlas highlights recent research showing increases in both short-term and long-term effects for children born via caesarean section before 39 weeks. It is the recommendation of certain organisations and Australian states to wait until 39 weeks gestation if there are no medical reasons for earlier birth. Data of sufficient quality was available from 4 states on the topic.

The atlas found that:

‘between 42% and 60% of planned caesarean sections performed before 39 weeks’ gestation did not have a medical or obstetric indication, and between 10% and 22% of caesarean sections performed before 37 weeks did not have a medical or obstetric indication.’

The rates were generally higher for privately funded patients compared to publicly funded.

There are 7 recommendations in the atlas relating to early planned caesarean section without medical indication including:

• Informed consent for planned early caesarean sections by providing long-term and short-term risks
• Relevant colleges to provide evidence-based guidance on early planned caesarean section without medical indication
• Local hospital systems to review reporting rates of early planned caesarean section

The full list of recommendation and the remainder of the atlas can be view here. 

A study has been published by BMC Pregnancy and Childbirth looking at labour outcomes in caseload midwifery. The study conducted in North Denmark looked at births allocated to caseload midwifery over a 3 year period. Out of 13,115 births there were 2679 allocated to caseload midwives.

Findings of the study include:

• Shorter duration of labour in caseload group
• Decreased risk of 1st and 2nd degree lacerations in caseload group
• Apgar scores less favourable in caseload group

The study concludes:

‘We found that most outcomes were equal across models of care but there seemed to be a small but unexpected finding of more augmentation and adverse neonatal outcomes in caseload midwifery.’ 

 The full study can be read here. 

The RCOG has published its latest workforce report providing an update on recommendations and actions to address workforce issues.

The report highlights that 9 out of 10 obstetric units have a gap in their middle-grade rota, there is a 30% attrition rate from the O&G training programme, 54% of those on O&G specialist register are international medical graduates and there are disproportionate litigation rates for those working in O&G. The report also highlights high rates of bullying and undermining.

Included in the report is an update on recommendations from the 2017 report including:

• Increased support for SAS and trust doctors with representaition on RCOG comittees
• Working group on how to retain consultants considering early retirement
• Maternity workforce planning
• Return to work support
• Increased support for new consultants

Also provided is an update on the work of the RCOG supporting our doctors task group which includes work on a peer to peer support service, development of workplace behavior champions network and complaints handling work.

The full report can be viewed here. 

​A short film has been produced by a young mum after her experiences during her pregnancy. The film aims to encourage medical professionals to provide more support to young mums. Watch it below

The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists are working together to launch a new programme to work with local maternity units to support multi-professional learning helping to improve joint working.

The partnership will be supported and funded by the Department of Health and Social Care and will support the implementation of recommendations from each baby counts reports to support the provision of safe maternity care.

The full report can be found here.