NHS pandemic care ‘may have affected women who had stillbirths’

Some face-to-face appointments were postponed until later in the pregnancy while some medics did not have access to notes.

NHS pandemic care ‘may have affected women who had stillbirths’

The Covid pandemic may have affected the quality of NHS care given to women who went on to have stillborn babies, investigators have said.

A study by the Healthcare Safety Investigation Branch (HSIB) into 37 cases found that remote consultations may have driven down the ability to carry out some key pregnancy checks, while some women opted not to attend appointments for fear of catching Covid.

The review was prompted by an increase in stillbirths after the onset of labour referred to the HSIB between April and June 2020 – 45 compared with 24 in the same period in 2019.

None of the women or pregnant people were recorded as having the virus, but the study found the pressures and changes as a result of the pandemic may have affected the care they received.

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.

Three times 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.

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.”

For 10 babies (27%) 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.

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 (14%) 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.

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”.

Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said: “The pandemic has put huge pressure on all healthcare services but despite this maternity staff have maintained a high standard of care to pregnant women and their babies.

“We are aware that during the first peak of the pandemic, some pregnant women had difficulty accessing maternity services or presented late with reduced foetal movements – which can be a sign their baby is unwell, and of women missing antenatal appointments.

“This may have been due to confusion around whether these appointments were essential, fear of attending a hospital or not wanting to burden the NHS.

“Ahead of the second wave, we issued clear advice to NHS services to ensure women were encouraged to attend day assessment and triage services if they had concerns about their wellbeing or that of their babies.

“We also recommended a full schedule of antenatal care be offered wherever possible, with appointments offered in-person especially for those from black, Asian or minority ethnic communities and women living with medical, social or psychological issues.

“Antenatal care is essential and face-to-face appointments are necessary to support a healthy pregnancy.

“We understand during the pandemic more remote appointments have been taking place and would welcome further investigation to see the impact of remote consultations during pregnancy.

“Anyone who has concerns or worries about their or their baby’s health – including the baby’s movements – should seek medical advice immediately.“

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