Communication and team working

A recent review of teamworking in maternity care [7] identified that good team communication, coordination and leadership were all evident in the best functioning teams. In one study of simulated eclampsia [8], more efficient teams were likely to have stated (recognized and verbally declared) the emergency (eclampsia) earlier, using closed‐loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged).

Integrating and teaching these simple team behaviours in clinical drills appears to be clinically effective [9]. This has been reiterated in a US study, which reported a statistically significant and persistent improvement of 37% in perinatal morbidity for the hospital exposed to a programme combining team training and clinical drills, whereas there were no improvements in the hospital exposed to team training only, or the control.

Good leadership is often invoked by reports, but can be nebulous in practice. Recent studies have demonstrated that leadership may best be established by the person who has the most experience of the emergency [10] and leadership may be more effective when the leader knows all the members of the multiprofessional maternity team and their relevant roles – before the emergency happens – from previous training together or from handover. Once again the leader should be mindful of the same three components of the situation as the rest of the team (team, situation, patient focus): establish the setting (using SBAR, i.e. situation, background, assessment, recommendation), allocate critical tasks with closed loops (directed–acknowledged–confirmed) and, if necessary, pass leadership to team members who are more experienced for the specific emergency at hand [11].

Women and their families also want similar information in an emergency. In recounted experiences, companions often informed women of the situation and the aims of treatment because they had heard loud and clear messages about the cause of the emergency, the condition of the baby, and the aims of immediate and ultimate management [11].

Local multiprofessional training for all staff annually, with teamwork training integrated into the clinical training, appears to be the most effective method of improving teamwork.

Documentation

This has already been mentioned briefly, but in all emergencies it helps to have someone looking at the clock, holding pen and paper, who is responsible for documenting the important facts as they happen. Remember that if, as is often the case, this person is fairly junior, he or she may not understand exactly what is going on and may fail to document key activity, and therefore it is imperative that senior members of the team ensure that all essential information is communicated. Once the emergency is over, notes should be written carefully and comprehensively and signed legibly. This is the best time to account for what has happened, and any relevant diagnosis, follow‐up care plan and prognosis for future pregnancies should be spelt out clearly whenever possible at this stage.

Risk management

After the emergency is over, reviewing the event with staff is hugely appreciated and very important: this is usually multidisciplinary but will sometimes be in small groups. Healthcare assistants and porters may need this support too and should not be forgotten. If everything went well, everyone should be congratulated; if some things were less than perfect, discussing why the difficulties were encountered and what might make things easier/work better another time is often helpful. This is a time for positive critical reflection; any negative feedback can wait and be dealt with privately.

Duty of candour

If the event has resulted in harm to the patients (woman/baby), then even if care was exemplary a senior doctor should speak personally to her and/or her partner/relative to express regret that the incident occurred and empathy for the current situation or outcome, and explain that such cases are reviewed to check everything was done that should have been and in a timely manor. Such dialogue should be recorded together with an offer to provide feedback to the patient/family should they so wish. This transparency and heightened communication and caring approach is directly driven from the NHS Litigation Authority and the Care Quality Commission with a statutory duty of candour for healthcare providers to comply since 2015 [12].

Emergency training

Over the last two decades the reduced duration of junior doctors’ training, combined with the dramatic cuts in their working hours, it is unsurprising that their clinical experience of obstetric emergencies is much less than that of their predecessors. They rely increasingly on training away from the bedside and there is no doubt that improving training for intrapartum emergencies is at least part of the potential solution to improving outcomes in the UK and further afield.

A review of effective training for obstetric emergencies published in 2009 [13] concluded that many of the courses then reviewed had common features: institution‐level incentives to train; multiprofessional training of all staff in their units; teamwork training integrated with clinical teaching and use of high‐fidelity simulation models. These themes have been echoed in a more recent review for obstetric training [14] that concluded that all maternity and neonatal health professionals should participate in in‐service training sessions. Furthermore, on‐site ‘in‐house’ training with low‐tech, highly realistic models is more readily implementable than offsite training at simulation centres and training integrated into institutional clinical‐governance and quality‐improvement initiatives is likely to have better results.

The various regional and national multidisciplinary training courses have different emphases, complement each other and supplement local training. A few illustrations of these specialist courses are listed here.

• ALSO (Advanced Life Support in Obstetrics). This course is geared to midwives, obstetric senior house officers and junior specialist registrars and deals with the main obstetric emergencies in a structured systematic fashion. Candidates should gain a sound understanding of the problems and the structured approaches in how to manage them (www.also.org.uk).
  
• mMOET (Managing Medical and Obstetric Emergencies and Trauma). This course is geared to a more senior and multidisciplinary group: obstetric consultant and senior specialist registrars (post MRCOG and at least specialty training year 5), anaesthetic consultant and senior specialist registrars, and senior accident and emergency doctors. These courses can also include midwives and obstetric physicians whose presence emphasizes and promotes the team approach that is so important in the obstetric emergency. This course runs candidates through approximately 25 emergency scenarios and skills and deals with more advanced and complex aspects of emergency obstetrics and emergency behaviour (www.moet.org.uk).
  
• MOSES (Multidisciplinary Obstetric Simulated Emergency Scenarios). This course focuses on emergency behaviour and team‐working dynamics as they apply to the obstetric patient, rather than training on knowledge or techniques. It involves midwives, anaesthetists and obstetricians who often attend together from the same department. This course is very different from, and complements, MOET or ALSO (blsimcentre@bartsandthelondon.nhs.uk).
  
• PROMPT (PRactical Obstetric Multi‐Professional Training). A training programme for maternity units, it was developed in Bristol, UK and can be purchased by maternity units, who then deliver the teaching locally.

Effects of emergency training

Whilst we increasingly rely on these training programmes, the current evidence supports an annual, local unit‐based, multiprofessional approach as these are most likely to translate into improved clinical outcomes. Not all training is productive and even the same teaching material delivered in different settings can have opposite results [15] but the best improvements to date have been reported from the PROMPT group, where there is evidence of significantly reduced preventable birth injury [16–19] and an associated 90% reduction in litigation costs [20]. These reductions have been replicated in pilot sites across the world, including developing world settings.