« Previous | Contents | Next »
Listen
Implementing A Framework for Maternity Services in Scotland
Assessing and Managing Risk
1. Risk is not easy to assess in maternity care. Nevertheless, maternity care professionals must take all possible steps to identify and effectively manage risk, with a view to minimising potential harm. Risk assessment and management should therefore become core functions of care in pregnancy and childbirth.
2. Assessing and managing risk within maternity services is a complex and dynamic process. There is no such thing as 'zero risk' for women who are pregnant or giving birth - an element of risk applies to all pregnancies and childbirth. This must be explicit in developing local strategies and practice.
Principles |
2.1 Each maternity network should develop risk management and assessment as core elements of practice. They should: develop a risk management strategy develop and implement protocols and guidance related to risk assessment and management set up multi-professional labour ward forums to explore risk issues develop critical incident reporting procedures establish 'emergency-drill' procedures through which maternity care professionals are able to explore and rehearse responses to critical incidents instigate processes of audit to monitor, assess and evaluate practice.
|
3. Skills of risk assessment and risk management need to be held not only by professionals in specialist centres or consultant-led maternity units, but also by all those involved in delivering maternity services across a wide variety of locations. Particular emphasis on training practitioners in community maternity units (CMUs) and those in remote and rural locations will be necessary.
Principles |
2.2 Services should ensure that practitioners in CMUs and remote and rural locations gain access to training on skills related to risk assessment and management. 2.3 Midwife-led settings for childbirth, including home births, CMUs attached to non-obstetric general hospitals and standalone CMUs, should have the same risk-management strategies. These should ensure that women who experience complications during labour or postnatally, including those who need epidural analgesia, are transferred to consultant-led units. |
4. CMUs need an adequate safety net to manage risk and deal with emergencies. Midwives and, where appropriate, general practitioners (GPs) require appropriate arrangements for consultation, referral and on-site resuscitation and stabilisation to be in place to manage complications in pregnancy prior to transfer. Island hospitals should offer emergency interventions when necessary and in exceptional circumstances.
Principles |
2.4 CMUs should have appropriate risk assessment and management procedures in place to manage acute emergencies effectively. 2.5 In exceptional circumstances, remote and rural island hospitals may offer caesarean section if appropriate facilities and trained personnel are available. |
5. A review of research into midwife-managed care in childbirth indicated that there is no evidence this is less safe or effective than consultant-led care, and with the right infrastructure in place, midwife-led care ensures good outcomes for women with low-risk pregnancies. It is the preferred choice for many. This research is summarised in the reference report.
Risk assessment and management
6. The mother and baby are the focus of risk assessment and management. Risk assessment should be based on the understanding that certain risk factors may rule out a particular option for childbirth rather than determine where the mother should deliver, and should be reviewed regularly throughout the pregnancy.
Principles |
2.6 Risk assessment should be based on exclusion rather than inclusion criteria. |
7. Risk assessments carried out in clinical areas have tended to concentrate on clinical issues such as general medical and surgical health and obstetric history. These are unquestionably important, but consideration must also be given to non-clinical factors, such as:
geography and predicted weather conditions
nature, condition and use of available emergency equipment
nature of emergency back-up and support
transfer arrangements.
Principles |
2.7 In addition to clinical factors, services should also consider non-clinical factors in risk assessment. |
8. Attention must also be paid to the existing evidence from research and audit which demonstrates that avoiding medical interventions in women with low-risk pregnancies has positive outcomes. Problems may arise in any pregnancy, however. Some of them will be serious or life-threatening, with one in 1,000 mothers per year requiring admission to intensive care units in Scotland. Services must ensure they have assessed risks in each case and planned responses appropriately.
Helping women to assess risk, weigh evidence and take decisions
9. Women have to make difficult decisions about their maternity care, taking into account a complex range of factors. They may have to consider issues such as demographics and available evidence, weighing them against their previous experience, personal circumstances, expectations and needs. They will also weigh the risks and benefits of pursuing a particular type of care against the other options available.
10. Women must have the right information on which to base decisions. They should have access to the best available evidence presented in non-technical terms related to their care at appropriate times during their care episode. This will give them the opportunity to make truly informed choices about their care, based on advice and support from maternity care and other professionals.
Principles |
2.8 Women should have access to the best available evidence relative to their care throughout their care episodes, delivered by experienced and knowledgeable maternity care and other professionals. 2.9 All services should ensure they have appropriate treatment and referral pathways in place to meet the needs of women and babies who become ill at any time during the pregnancy and after the birth. 2.10 Acute maternity services should ensure they have clear arrangements for access to adult intensive care facilities in a general hospital. Hospitals with consultant-led units should have ready access to adult intensive care, high-dependency and neonatal intensive care facilities. 2.11 Consultant-led units should have in place a maternal and neonatal resuscitation service, a full obstetric and anaesthetic service and access to epidural analgesia in labour. |
Risks associated with levels of care
11. The
Framework for Maternity Services in Scotland identified the different levels of maternity and neonatal care that exist to meet the needs of Scotland's different communities (Table 1).
Table 1 Levels of intrapartum care in Scotland
| Location of delivery | Lead carer | Clinical situation | Care need and delivery | Suggested Number of deliveries |
Ia | Home (planned) | Midwife (GP) | Normal pregnancy and labour | Suitable home facility with back-up from the Scottish Ambulance Service (paramedics) and supporting advice from a linked maternity unit | |
Ib | Stand-alone community maternity unit | Midwife (GP) | Normal pregnancy and labour | Appropriately equipped midwifery unit for normal care and agreed transfer guidelines to a linked maternity unit | |
Ic | Community maternity unit adjacent to non-obstetric hospital | Midwife (GP) | Normal pregnancy and labour | As Ib above. Medical staff (surgeon/GP) appropriately trained to perform emergency caesarean section | |
Id | Community maternity unit adjacent to maternity unit | Midwife (GP) | Normal pregnancy and labour | As Ib above | |
IIa | Consultant-led maternity unit with no neonatal facility | Consultant Obstetrician (plus midwife) | Low-risk pregnancy and labour | Maternity unit care with monitoring facilities and anaesthetic cover with no access to paediatric facilities on site | <1,000 |
IIb | Consultant-led maternity unit with on-site neonatal facility | Consultant Obstetrician (plus Midwife) | Low- to medium-risk pregnancy and labour | Maternity unit care with monitoring facilities, access to anaesthetic and paediatric cover, but transferring out as required to special care baby unit or neonatal intensive care in a larger maternity unit | <1,000 |
IIc | Consultant-led maternity unit | Consultant Obstetrician (plus Midwife) | Low- and most-high risk pregnancies and labour | Full maternity unit and support services with easy access to special care baby unit/neonatal intensive care and access to adult high dependency care and adult intensive care | 1,000-3,000 approx. |
III | Consultant-led specialist maternity unit | Consultant Specialist in Maternal Fetal Medicine (Midwives/others) | Complex and high- risk pregnancies and labour | As for level IIc, but with on-site neonatal intensive care and access to neonatal surgery and adult intensive care | <3,000 |
12. Risk assessment and management mechanisms, based on the principle that all women should receive individualised, holistic care, should be in place to guide service provision in all settings. A comprehensive list of inclusion and exclusion criteria for each kind of unit, based on risk assessment and management principles, can be found in Appendix 2.
Principles |
2.12 All maternity units should ensure that their level of service is consistent with the risk assessment exclusion examples shown in Appendix 2. |
13. Principle 22 of the
Framework states that all maternity care professionals must have a clear understanding of the concept of risk assessment and management. Women also need this understanding. They need to be involved in risk assessment and given unbiased information, based on the very best available evidence. A consensus about the right level of maternity care can then be forged between the woman and the professionals caring for her, which balances risks against maternal choice and needs.
Principles |
2.13 Maternity care professionals should assist the pregnant woman to understand the concept and nature of risk management to help her make a decision about where and how she should give birth. |
« Previous | Contents | Next »