Maternal Care Bundle safety spotlights

We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development.

We drew on insights from our independent investigations into maternal deaths since 2018 to shape discussions about the bundle’s ‘elements’ and its system-level interventions. This collaborative approach highlights the value of our investigative work, during which we speak with those directly affected, both families and healthcare professionals, to understand events from multiple perspectives. By doing so, we gain a deeper understanding of why events occurred and can identify system-wide improvements to make care safer for mothers and babies. In our strategy, we acknowledge how important fostering close relationships with families, trusts and wider stakeholders is to driving these improvements.

We have already published thematic learning around venous thromboembolism (VTE) in pregnancy, sudden unexpected death in epilepsy (SUDEP), pre-hospital and acute care during pregnancy and obstetric haemorrhage and this data has informed our contributions to the Maternal Care Bundle.

We hope trusts will find the following safety spotlights helpful as they start to embed the interventions outlined in the Maternal Care Bundle.

Early access to low molecular weight heparin (LMWH) for women with risk factors for venous thromboembolism in pregnancy

A thematic review of maternal deaths from venous thromboembolism (VTE) identified several women who died in early pregnancy, before accessing maternity care. 

A woman with a history of venous thromboembolism saw her GP, aware that she needed thromboprophylaxis. This was in very early pregnancy and before she had booked for maternity care. The GP sought advice from the obstetric team and was told that low molecular weight heparin (LMWH) would be recommended in pregnancy and post birth, but only after a live intrauterine pregnancy was confirmed by an ultrasound scan. This information led to delays in the woman starting LMWH; she collapsed and died at home in early pregnancy from a pulmonary embolism. 

• Is there awareness that thromboprophylaxis should be started as soon as pregnancy is confirmed by a positive test, without waiting for ultrasound confirmation? 
• How do GPs and other non-maternity care providers access urgent obstetric advice to enable the prompt initiation of LWMH in early pregnancy?

Sudden unexpected death in epilepsy (SUDEP) during pregnancy

A thematic review of maternal deaths involving women with epilepsy identified concerns with the management of epilepsy before, during and after pregnancy.

A woman with epilepsy from childhood went home from hospital after the birth of her baby. There was no routine offer of contraception prior to going home. 

There were also no specific postnatal pathways for women with epilepsy.  The woman was not offered a postnatal appointment to discuss contraception or get safety advice about epilepsy.  

A few months later, the woman found out she was pregnant again. This was unplanned. She collapsed and died at home during pregnancy, due to sudden unexpected death in epilepsy (SUDEP). 

• Does your service have a local multidisciplinary team for epilepsy in pregnancy? Does it support care for women with epilepsy before, during and after birth, involving the maternal medicine network for women with complex needs?
• In your service, are there any barriers to women getting advice about, and access to, effective contraception before they leave hospital or in the early postnatal period?
• Does your service have a specific postnatal care pathway for women with epilepsy? MBRRACE-UK (2020) recommends that awareness of sudden unexplained death in epilepsy (SUDEP), risk assessment and risk minimisation should be standard care for women with epilepsy before, during and after pregnancy.

Pre-hospital and acute care during pregnancy

A thematic review of pregnant or recently pregnant women identified themes relating to pre-hospital and acute care. This included, assessment using maternity physiological track and trigger tools, early communication and support from specialist clinical teams to support care and escalation.

A woman called an ambulance because she felt unwell and faint with a high temperature. She had been experiencing ‘flu like’ symptoms for the last week. She was 33 weeks pregnant.

The woman’s condition had deteriorated when the ambulance crew arrived, and they made the decision to transfer her to the nearest emergency department (ED) after making a pre-alert call (a call from the ambulance crew to the ED prior to arrival). She was taken into a cubicle area for further assessment. Her observations were scored using the national early warning score (NEWS2) tool with a plan to await a review.

The woman asked to go to the bathroom and collapsed on her way back to the cubicle. She was transferred to the resuscitation area where she rapidly deteriorated and had a cardiac arrest.

The obstetric, neonatal and midwifery teams were called to provide care for the woman and baby. The baby was born by caesarean birth during the mother’s cardiac arrest (resuscitative hysterotomy) and died shortly after birth. The woman did not respond to resuscitation and died.

• What are the barriers to using the pre-alert call information in a timely and effective way to mobilise and inform the appropriate multidisciplinary team? How does this support transfer to the most suitable location for assessment and ongoing care?
• How is the maternity team made aware of pregnant and recently pregnant women attending or being admitted to the hospital outside of a maternity service?
• Is the national maternity early warning score (MEWS) tool used in all locations to identify deterioration early in pregnant and recently pregnant woman and enable prompt referral to the required clinical team?
• How is a pregnant or recently pregnant woman escalated to clinical teams outside the emergency department in response to ongoing deterioration?

Safety spotlight on maternal haemorrhage

A thematic review of maternal deaths involving haemorrhage identified delays in identifying and treating blood clotting disorders.

A woman had her third baby by caesarean birth and experienced increased bleeding during surgery. This was surgically treated with a tamponade balloon, and the estimated blood loss was 2000ml. There were no urgent blood tests including clotting tests carried out as it was thought the bleeding had stopped. While waiting for transfer out of the operating theatre, she was still bleeding. The woman quickly deteriorated and had a cardiac arrest.

Blood products were requested and bedside coagulation tests done. The tests showed that the woman’s blood was not clotting and she was very anaemic. After further surgical management and multiple transfusions with blood products and components to help blood clot, she was transferred to the intensive care unit. She went on to have a further cardiac arrest and died.

• Do you always check coagulation with either point of care testing (POCT) (if available) or laboratory tests in all events of severe maternal illness, maternal collapse or cardiac arrest, and not just those associated with haemorrhage? Does your laboratory specifically measure Clauss fibrinogen?
• How often do you repeat coagulation testing? Is this after every cycle of blood coagulation product transfusion, after every 500ml-1000ml blood loss, and when there is ongoing clinical concern?
• When there is an ongoing obstetric haemorrhage, is there a pathway in your laboratory to prioritise analysis of blood laboratory samples, release blood components, and communicate results to the clinical team?
• Do you have a treatment algorithm to interpret and act on the results of coagulation tests including POCT?
• What do you use for early fibrinogen replacement (for example fibrinogen concentrate or cryoprecipitate) and how quickly can you give it when needed? Does the clinical team know how to reconstitute fibrinogen concentrate?

The short summaries used in these safety spotlights have been adapted to maintain anonymity.