Pandemic changes affected maternity care for women who had stillbirths

Changes due to Covid may have lead to increased numbers of stillbirths (POOL/AFP via Getty Images)

Changes to maternity services during pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, an investigation has found.

According to the Healthcare Safety Investigation Branch changes to the way women were looked after during their pregnancy meant some women may not have had the same level of checks while others did not have face to face appointments.

The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019.

The HSIB launched a probe examining the care of 37 cases.

Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic.

In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.”

As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight.

During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic.

HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received.

The study stressed that the proportion of consultations undertaken remotely was not known and “the impact of remote consultations is not clear from this review”.

However, it said there was evidence that remote consultations resulted in fewer opportunities for physical examinations, meaning trends in how the baby was growing could be missed.

After 28 weeks’ gestation, not all consultations included measuring from the mother’s pubic bone to the top of the womb (a standard measure to inform baby growth), while there was a “lack of recording and plotting” of this information, HSIB said.

Some face-to-face appointments were postponed until later in the pregnancy, while in some remote consultations clinicians did not have access to clinical notes or ultrasound scan reports.

On three occasions this resulted in ultrasound scans being cancelled or not being made available, and in one case there was a significant change to the intended birth plan.

In one of the cases, the mother “chose not to attend the appointment after considering the risks of Covid-19 against the risk of not attending the appointment and on balance chose the latter”.

The HSIB said many of the safety risks identified in the review were already known to maternity services and exacerbated by the pandemic, for example, the level of staffing in maternity units.

Other issues noted were challenges in interpreting and implementing rapidly changing national guidance on Covid, difficulties in communication by phone, and workforce demands in the NHS, which led to absence and sickness.

A lack of oxygen to the baby during labour was identified as a cause of death for 10 babies.

When it came to contact with the NHS during labour, 19 babies had no signs of life on the first visit to hospital.

But 11 of these women and pregnant people had made telephone contact for healthcare advice and were advised to remain at home.

For five babies, the heart rate was identified during a visit to hospital, then no signs of life were found at the next hospital visit several hours later or the following day.

Kathryn Whitehill, principal national investigator at the HSIB, said: “We recognise that the current maternity system has had success through national initiatives in reducing the number of stillbirths and that throughout the pandemic thousands of babies were delivered without any problems.

“However, our review did highlight the extreme pressure maternity services were under – they had to balance the risks associated with uncertainty and emerging evidence on Covid-19 transmission with the clinical assessments that are needed to monitor the safety of patients.

“Our recommendations are aimed at identifying where there might be gaps in safety management and supporting the system to take a proactive approach in ensuring the wellbeing and effective care of women and pregnant people and their babies across the country.”

For 10 babies in the review, the cause of death was related to the function and structure of the placenta. Two babies died following placental abruption, which is the separation of the placenta from the uterine wall before birth.

One died following uterine rupture, while three died following complications with the umbilical cord.

Among the recommendations made by the HSIB is one for NHS England and NHS Improvement to lead work to “collate and act on the evidence on the risks and benefits associated with the use of remote consultations at critical points in the maternity care pathway”.

Another recommends that the Department of Health and Social Care commissions a review “to improve the reliability of existing assessment tools for foetal growth and foetal heart rate to minimise the risk for babies”.

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