Calling for help early
Trainees in all disciplines are often reluctant to call for senior help, partly due to not recognising the severity of the situation and partly due to concerns about wasting the time of seniors. With all emergency events, and in particular with obstetric emergencies, escalation and appropriate help should be summoned as soon as possible. Remember, help will not arrive instantly.
Using all available resources
Team resources include staff, observations, equipment, cognitive aids and the facilities in the local area. It is the team leader’s role to continually consider the appropriateness of utilising available, untasked staff or equipment to optimise the patient’s care and prevent a bottleneck in the treatment pathway.
Debriefing
Wherever possible it helps to have a facilitated debrief following an adverse clinical event. It is best if the debrief is viewed as a normal part of the process of dealing with all obstetric emergencies rather than being reserved for catastrophic events. The aim of a debrief is to summarise any particular issues or problems that the team had, and reflect on how the team performed. Some organisations have set templates to facilitate this. It gives the opportunity for individuals, teams and organisations to continually develop.
Whilst a ‘hot’ debrief immediately after the event may be useful in certain situations, it is not always ideal. Some situations in obstetrics can be emotionally draining, especially when maternal or neonatal outcome is poor. A balance must be established whereby formal debrief and feedback to all involved team members occurs within a reasonably short timeframe. All team members must be aware of looking out for the emotional needs of colleagues who may have been particularly emotionally traumatised during an emergency situation.
4.10 Summary
In this chapter we have given a brief introduction to human factors and described how lack of awareness about the importance of communication, situation awareness, leadership, team working and decision making can lead to patient harm and adverse events. It is really important for you to use every opportunity to reflect on and develop your own performance and influence the development of others and the team. Appropriate debriefing is included in the scenarios for the mMOET course, which may be used to help you to incorporate this process into your own clinical practice.
4.11 Further reading
1 Bromiley M. Just a Routine Operation. https://vimeo.com/970665. Clinical Human Factors Group, www.chfg.co.uk (last accessed February 2022).
2 Flin R, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to Non‐technical Skills. Abingdon: CRC Press, 2008.
CHAPTER 5 Recognising the seriously sick patient
Algorithm 5.1 Scottish national MEWS chart: (a) front of MEWS chart
Source: Scottish patient safety programme, Maternity and Children quality Improvement programme. © The Improvement Hub
Learning outcomes
After reading this chapter, you will be able to:
Identify the current causes of maternal mortality and morbidity and the issues with their detection and treatment
Describe a systematic approach to monitoring using early warning charts to aid recognition of women at risk
Recognise ‘red flag’ symptoms and their need for an urgent response by the obstetric team and other specialties
5.1 Introduction
Recurrent themes in mortality and morbidity reports identify that suboptimal care may have contributed to the deaths described in these reports. With more than two thirds of cases having pre‐existing co‐morbidities and indirect deaths exceeding direct, the importance of coordinated care across specialties is emphasised. Failure to recognise symptoms and signs of potentially life‐threatening conditions, delay in acting on findings and delay seeking help from appropriate specialists are all of particular concern. Attention is therefore focused on ways to improve the recognition of, and timely response to, clinical signs of the deteriorating patient.
The diagnosis of a severe life‐threatening condition in a pregnant or recently pregnant woman is challenging when the onset is insidious or atypical. This is compounded by the sick pregnant woman presenting to a non‐obstetric area such as the emergency department where staff are not familiar with pregnancy physiology. The different response to impending critical illness through vital signs can be missed in these circumstances.
Not only ‘high risk’ women become critically ill. Often it is not possible to predict if or when this might happen to any obstetric patient. The relative rarity of life‐threatening events in pregnancy reinforces the need for multiprofessional working and training involving emergency department staff and acute physicians.
The lessons that apply to all health professionals dealing with pregnant women can be summarised as follows:
Understand the physiological adaptations of pregnancy in order to be able to recognise the pathological changes of serious illness – it is important to be able to distinguish between common discomforts of pregnancy and the signs of serious illness so that these signs are not missed (Table 5.1)
Focus on getting things right the first time – high‐quality history taking, physical examination, meticulous recording of basic observations and findings, and acting on those findings without delay
Remember the red flags, including repeated presentation or readmission during pregnancy
Ensuring good communication and timely, effective referrals between professionals
Table 5.1 Physiological changes and normal findings in pregnancy
Source: RCP (Royal College of Physicians). Acute Care Toolkit 15: Managing Acute Medical Problems in Pregnancy. London: RCP, 2019. © Royal College of Physicians
| Indicator | What’s normal in pregnancy? |
|---|---|
| Heart rate | An increase of 10–20 beats per minute, particularly in third trimester |
| Blood pressure | Can decrease by 10–15 mmHg by 20 weeks, but returns to pre‐pregnancy levels by term |
| Respiratory rate (RR) | Unaltered in pregnancy If RR >20 breaths per minute, consider a pathological cause |
| Oxygen saturation |
Unchanged throughout pregnancy
|