Consultant Obstetrician and Gynaecologist – Clinical Director for Women’s Health
Royal London Hospital, Barts Health NHS Trust
Background: The covid-19 pandemic has the potential to adversely affect the health of pregnant women and their babies in a variety of direct and indirect ways – this toolkit aims to identify them and provide mitigation where possible.
- Changes to advice seeking / attendance due to social distancing and isolation. It is clear that social distancing and shielding for pregnant women, particularly in the third trimester, is likely to stay in place for some time.
Many services are reporting a reduction in attendances to maternity triage, and high DNA rates for face to face appointments. There are high levels of anxiety in society in general due to the pandemic, but particularly in pregnant women.
- Consider sending a letter to all booked women reassuring them and providing clear advice and points of contact.
- Use multiple social media channels to disseminate information further. Consider interactive sessions eg Instagram live, twitter live.
- Link with local service user groups and MVPs.
- Consider filming short videos to be disseminated on social media to inform women about service changes, reassuring them it’s safe to come to hospital for appointments
- Consider using shielding staff to run service helplines / email advice lines / respond to social media direct messages.
- Ensure availability of staff to provide clinical telephone advice with clear pathways to recommend attendance. Women should be advised to attend hospital if they are concerned, and particularly with symptoms of shortness of breath. Due to the high prevalence of covid-19, women may have both covid and another diagnosis, and it’s important other causes of pyrexia, particularly in postnatal women, are excluded.
- Link closely with ED services to ensure pregnant women are seen in the right place, by the right teams.
- Changes to services.
- The leadership team should benchmark their service against latest RCOG / RCM to ensure the unit is following evolving national guidance.
- Risks to service changes should be evaluated through completion of risk assessments which sit within the risk register. They need to be revisited regularly through ongoing governance structures.
- Staff should be encouraged to complete datixes for incidents or near misses due to service changes, in order to provide real time feedback and feed into ongoing evaluation.
- Where possible, appointments should be virtual, but there should be clear pathways for attendance in person if either the woman or the healthcare professional has concerns. Issues around DV and safeguarding need to be prioritised, particularly where the only phone number provided is the partner’s, or it’s difficult to get the woman alone.
- There needs to be robust safety netting for missed / delayed appointments. They need to be recorded within the woman’s electronic patient records. The clinical teams should inform the administrative team to follow up and reschedule the encounter.
- Service changes need to be clearly communicated to the whole multidisciplinary team, to prevent confusion for both staff and women. This can be done via different modalities – email, whatsapp groups, social media, staff huddles. Huddles can be conducted through video conferencing apps in order to maintain social distancing.
- Training – ensuring staff are trained both in management of covid-19 and are confident in intrapartum obstetrics.
- Multi-disciplinary training in obstetric emergencies should be offered to all staff, but with a particular focus on those redeployed or less familiar with intrapartum environments.
- Ensure good orientation for all staff unfamiliar with the environment with clear access to guidelines and protocols.
- Aide memoires should be developed for patients affected by covid-19 patients eg posters for donning / doffing, guides to managing obstetric emergencies / GA caesareans, all tested and refined through in situ simulation.
- There should be ongoing teaching and training involving the whole MDT – obstetricians, midwives, MCAs, anaesthetists, neonatal teams, theatre teams, HDU nurses. Many teaching sessions can be achieved through the use of videos / recorded sessions / video conferencing, plus presentations can be sent via email. Consider using an online platform that all staff can access where all resources can be stored.
- Any updates to guidance should be loaded onto shared drives and the intranet and disseminated through emails / closed social media channels / huddles.
- More than ever, we need to ensure that near misses are picked up quickly and acted upon – but also that we learn from good practice.
- Ensure continuation of embedded governance processes and structures, including the use of Datix, and multidisciplinary case reviews. Teams should look ahead to ensure there are enough staff available to provide cover for assurance and review processes. Nominated obstetric and midwifery governance leads should remain in post, with plans for backfill in the event of absence.
- In order to shorten meetings, and allow for social distancing at work, governance leads can pre-populate presentations containing the details of the case, including images, eg of CTGs where applicable. They can then be disseminated electronically. The presentations can then contain the outcome of the reviews, which can be placed on shared drives so that all staff have access to the learning.
- Case review meetings should always consider the psychological wellbeing of both the patient and staff involved in major or potentially traumatic incidents. Women at high risk of postnatal depression / PTSD should be contacted and offered a virtual birth reflections appointment. Line managers should feed back to staff regarding the outcome from the case reviews and offer support and signposting. When staff have contributed towards a positive outcome, emails of thanks should be sent.
- Teams should be encouraged to debrief following both covid-19 cases and other obstetric incidents, including well managed cases and near misses.
- Debriefs can be both “hot” – ie immediately following the incident, and “cold” – usually after a week or two has elapsed. Their purpose is to support staff and provide them with the opportunity to decompress / express emotion / grief. The Indigo study identified high levels of PTSD in maternity staff – it’s therefore important leaders and managers are aware of this and have clear mechanisms and structures for supporting staff, including identification of PTSD.
- Immediately following a safety critical incident, senior team members (eg consultant, managers on call) should attend. Staff should be offered to be relieved of their duties for the rest of the shift. Key questions to ask staff include – “are you safe to travel home”? “What support structures do you have”? “When are you on duty next?” People react differently and some staff need time off, whereas for others, they prefer to be at work. It’s important to recognise this and have a supportive culture that promotes an individualised approach.
- Cold debriefs can be achieved remotely, through video conferencing apps, facilitated by an independent member of the governance team.
- Keeping the Intrapartum Setting Safe.
There is a risk that staff are more prone to human error due to working in unfamiliar circumstances and environments / equipment, experiencing high levels of stress and fatigue. Due to high clinical complexity and unfamiliarity, patients affected by covid-19 also have the potential to distract staff’s attention from other patients.
- Establish team of the shift – introductions at handover with clear role identification, providing oversight of activity to whole team (including MCAs, theatre teams, anaesthetists).
- There should be clear escalation policies disseminated to all staff – who to call, and when. Eg consultant obstetrician to be asked to either attend or delegate additional staff if there are long waits in maternity triage, or a second obstetric theatre is opened.
- Consider additional training for all intrapartum band 7 midwives who will be providing shop floor leadership and guidance for staff. Identification of “covid champions” – staff who can co-ordinate the care of covid patients in the intrapartum setting, acting as one of the runners (along with an MCA) in the event of a theatre case. Consider upskilling band 6 midwives during quiet periods who have the potential to be band 7s in the event of staff shortages.
- Consider changes to obstetric staff structures during periods of high activity. Eg 2 consultants to be on call and available on delivery suite instead of 1 during periods of peak activity – one to be task focussed, the other to maintain situational awareness of the unit. Consider moving to a full shift pattern with 168 hours of cover to provide clinical leadership and support for junior staff.
- There should be regular safety huddles at the labour ward board between the obstetric, anaesthetic, and midwifery teams, in order to retain situational awareness and ensure everyone has the same mental model. Consider moving the board to an area that means these important safety mechanisms can continue, whilst allowing social distancing. Ensure staffing for obstetric theatres is maintained when planning anaesthetic and nursing cover across the hospital, including dedicated coordinators for obstetric theatres. If teams for second theatres are located away from obstetric theatres, consider implementing 2222 calls, eg for grade one caesarean sections, and for opening second obstetric theatres.
- It is important to maintain effective team briefs both prior to lists and before procedures, particularly when wearing full PPE.
Leadership in a crisis situation needs to change from the more usual consensus building approach seen within the NHS, to one of command and control. Although the workload can be delegated, key decisions all need to come through a small dedicated team of leads, in order to prevent confusion and conflicting messages being sent to staff and patient. It’s important that leaders across disciplines work together with shared goals – to keep woman and babies safe, and support staff through a period of anxiety and change. Kindness and compassion should be at the heart of all maternity units. Units with strong leadership have midwives and obstetricians working closely together, making collaborative decisions about all aspects of maternity care. They also forge strong links across other specialities, including anaesthetics, neonatology, critical care, emergency care, and medicine.
- There needs to be clear and visible leadership with regular multidisciplinary walks around the shop floor, inviting conversation and feedback from staff.
- The leadership team should send positive messages to staff, thanking them for their hard work, and reassuring them that the leadership team are focused on keeping both the patients, and staff, safe. This includes clear messaging about working in maternity – ie that as obstetricians and midwives we deal with less covid-19 than other doctors / nurses, that we are lucky to be able to continue working to bring life into the world. Good leadership has a focus on kindness – reassuring staff that they are cared for – eg with appropriate levels of PPE and positive workplace cultures. It also retains a focus on caring for pregnant women, who are vulnerable, anxious, and need compassionate care more than ever.
- There should be high levels of presence, both in person, and remotely eg through social media> This needs to be disseminated across the leadership teams to prevent burnout.
- Good leaders have openness to feedback, flexibility and willingness to change.
- Promoting Psychological Safety
Patient safety can be potentially jeopardised at times of high stress, particularly when conflict develops between staff members. Whilst recognising many staff are under significant stress, often outside the workplace, it’s important to retain a culture of civility. This needs to be openly discussed, and disseminated to all teams.
- The leadership team need to acknowledge the anxieties and pressures that staff are under – in addition to concerns about changes to their workplaces, they have worries about home schooling, elderly parents, sick relatives. It’s important to give clear messaging that it’s ok not to be ok – and that during the pandemic, everyone will have days where they struggle to deal with the huge life changes brought about by social distancing.
- When units first start dealing with covid-19 it leads to high levels of anxiety amongst staff, which in turn can affect behaviours. This settles as it becomes more familiar and normal – the leadership team need to be present and visible during this time, listening to concerns, and reassuring staff.
- Units should promote health and wellbeing including recognising signs of burnout / trauma in staff and signposting to available help. Some units have set up staff gyms in unused areas (eg antenatal education rooms), promoting exercise as a good way to maintain mental health.
- There should be provision of adequate supplies and rest facilities including food, toiletries, on call rooms.