During a caesarean birth, the midwifery team is required to work with multiple professions as part of a unique team dynamic (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010; Hewitt, 2014). This includes operating department practitioners (ODPs), who work as peri- and postoperative practitioners, a working relationship that is seldom acknowledged or considered in the literature. This is demonstrated by the Midwifery 2020 document (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010), which does not mention ODPs in its list of interprofessional collaborations involving midwives.
Evidence from government reports and reviews suggests that unsuccessful collaboration and a lack of a collegial culture between professions in surgical obstetrics significantly affects patient safety (Kirkup, 2015; Helmond et al, 2015; Knight et al, 2016; Symon, 2016). Accordingly, this evidence demonstrates that it is no longer safe or appropriate for health professionals to simply use their individual skills to achieve a common goal. More than one-quarter of births in the UK are reported to be by caesarean section (Norman et al, 2018), requiring the skills and expertise of ODPs and midwives. With numbers of caesarean sections rising annually (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010), the need to improve interprofessional teamwork and relations between the two professions to maintain patient safety in obstetrics has never been greater (Winter, 2015).
Examining the events of a clinical incident, this article will explore some of the contributing factors responsible for missing the signs of postpartum haemorrhage (PPH). It will analyse how a breakdown of effective interprofessional communication and lack of synergy between roles may have contributed to the outcome, with the goal of preventing such problems in the future. The aim of this article is to demonstrate areas for improvement and make recommendations, highlighting the need for enhanced interprofessional education and learning in perioperative obstetric care.
This critical reflection will be provided from the author's perspective as a now-qualified ODP, looking back at her experience as a third-year student. Driscoll's (2007) model of reflection will be used to analyse this clinical incident. This model has been chosen as it is widely considered to have a reader-friendly structure, with enough freedom for the writer to explore key concepts and themes (Bolton, 2014). Driscoll's reflective framework uses three sections: ‘What?’, ‘So what?’ and ‘Now what?’. The ‘What?’ stage involves the identification and description of the incident and main issues. The ‘So what?’ section prompts the writer to critically analyse and evaluate the event, assign meaning to what happened and discuss effects of actions. The ‘Now what?’ stage guides the reflector to apply and synthesise the findings in the ‘So what?’ section, by learning lessons and considering future implications and actions in practice (Driscoll, 2007; Bolton, 2014; Bassot, 2016). The value of using a reflective case study from the viewpoint of one of the practitioners involved is that it is a window into how the relationship between the professions is perceived (Gambrill, 2012; ter Maten-Speksnijder et al, 2012). This is particularly the case from the viewpoint of a student, who is a visitor in the obstetrics department and comes in with fresh eyes.
What?
A 32-year-old woman was admitted to theatre for an emergency caesarean section, after a prolonged labour and failure to progress. The caesarean section was carried out under a spinal anaesthetic and completed without any obvious complications. The woman was transferred to a one-bed maternity post-anaesthetic care unit and care was handed over to an ODP, who was employed by an agency and unfamiliar with obstetrics, and myself, at the time a student ODP. There was also a midwife present in the immediate post-operative period. An ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) assessment was completed regularly by the ODP and myself, as per Association of Anaesthetists of Great Britain and Ireland's (AAGBI) (2013a) guidelines. While visually inspecting the patient, I noted blood loss on the pad and sheet, and informed the registered ODP that I was concerned. This was not directly communicated to the midwife, although she was in the immediate vicinity and appeared to have heard my expression of concern. In the absence of a response, the midwife appeared more concerned with breastfeeding and initiating skin-to-skin contact between mother and baby, leaving the blood loss assessment to the ODP team. I was told by the ODP that as long as the woman's blood pressure, respiration rate and heart rate remained stable, there was no cause for alarm.
Although all present conversed with the woman and her partner, the midwife and ODP participated in their own distinct tasks with little-to-no discourse with each other. From an ODP perspective, access to the mother was limited, as the midwife was concerned with initiating feeding and the baby was obstructing our access to the mother. I also felt that interrupting the mother as she and her partner bonded with the baby was intrusive. Consequently, the ODP and I were unable to monitor the mother as closely as we would have with non-maternity postoperative patients. After 20 minutes of stable recovery time, the woman suddenly deteriorated: her blood pressure decreased and she rapidly presented with hypovolaemic shock. At this point, the Trust's obstetric major haemorrhage protocol, similar to that produced by the Obstetrics Anaesthetists' Association (2017) was initiated and help sought from senior staff. The patient was resuscitated and transferred to theatre, where she had an emergency hysterectomy and a subsequent stay in critical care.
Primary PPH is defined as excessive bleeding from the genital tract in the first 24 hours after birth (World Health Organization (WHO), 2012). Shamain (2014) argues that being able to detect early warning signs of PPH is a necessity in preventing maternal death. Delays in recognition, diagnosis and treatment of PPH are shown to have a direct effect on the severity of bleeding, and a moderate bleed in an obstetric patient can rapidly progress to a major haemorrhage without detection (Haeri and Dildy, 2012; Yentis and Malhotra, 2013; Briley et al, 2014; Hancock et al, 2015). Indeed, WHO (2012) states that major PPH is largely avoidable with timely and appropriate management. Consequently, it is essential for senior staff to be available, equipment and resources to be ready and emergency protocols to be initiated at an early stage, to prevent staff errors, rapid deterioration and death (Davies and Bogod, 2013; Royal College of Obstetricians and Gynaecologists (RCOG), 2016; Crafter, 2017). Considering this, I believe that the failure of both the ODP and the midwife to recognise that the woman had significant per vaginal blood loss at an early stage was a major contributor to her hypovolemic shock, emergency hysterectomy and her subsequent postoperative admission to critical care.
So what?
Specialist knowledge and training
According to RCOG (2016), the amount of total blood loss, from both intrapartum and postpartum phases, dictates what treatment protocol should be used. My placement Trust's policy dictated that blood loss after a caesarean section should be measured by visually inspecting the maternity pad and bedding. The ODP and I followed this policy as part of our postoperative checks. This method is widely used because of its simplicity and relative ease (Al-Kadri et al, 2014); however, visually inspecting bedding and pads to measure blood loss has been consistently shown to be inaccurate and generally underestimated (Haeri and Dildy, 2012; Gabel and Weeber, 2012; Fawcus et al, 2013; Al-Kadri et al, 2014). According to Al-Kadri et al (2014), this inaccuracy is significantly worsened when staff possess limited training and experience. RCOG (2016) states that as most women can readily cope with a 500 ml blood loss, it is not until a patient loses over 1000 ml that a protocol of emergency measures should be initiated. Due to our lack of experience and the inaccuracy of this method, it is likely that these guidelines could not be properly followed and that the blood loss was underestimated, contributing to the late recognition of PPH.
In most clinical settings, hypotension, tachycardia, oliguria and tachypnoea are certainly some of the identifiable signs of hypovolaemia (Hardman and Bedforth, 2013). Close monitoring of any patient is of course essential during recovery and a requirement of the AAGBI (2013a) recommendations; however, the care of the obstetric patient is unique, due to physiological changes during pregnancy. The total blood volume increases by 20% (Scrutton and Kinsella, 2009) in pregnancy, causing standard symptoms and signs of hypovolaemia to be masked until late on, when decompensation and deterioration can be rapid (Scrutton and Kinsella, 2009; Yentis and Malhotra, 2013). Due to a lack of underpinning knowledge, I was therefore given incorrect clinical advice by the ODP, which meant that we were relying on detecting physiological signs of deterioration that were inappropriate for an obstetric patient, leading to the late detection of PPH and a subsequent delay in treatment.
This error can be partly attributed to our lack of training, knowledge and competence in caring for an obstetric patient. The AAGBI (2013a) writes guidance and standards for recovery practitioners to follow, and acknowledges the need for specialist training for all registered recovery practitioners, providing specific competencies to meet in the UK National Core Competencies for Post-Anaesthesia Care (AAGBI, 2013b). However, although the AAGBI recognises the need for recovery practitioners to be specifically trained in paediatrics when working with children, no such recommendations are made for the post-anaesthetic care of the obstetric patient (AAGBI, 2013a). In fact, even in the guidelines issued by the Obstetric Anaesthetists Association (OAA) and AAGBI (2013), there is nothing in these guidelines about recovery staff being specifically trained in the needs of an obstetric patient (OAA and AAGBI, 2013). This is a significant safety concern, as obstetric patients have unique and complex needs that are not seen in the general surgical population (Yentis and Malhotra, 2013). Confirming this, RCOG (2016) and MBRRACE UK (Knight et al, 2016) both recommend that all staff involved in the care of obstetric patients should have specialist training and knowledge relating to this specific patient group, as a lack of knowledge and training has been proven to contribute to serious errors in this speciality (Monks and Maclennan, 2016). My experience demonstrates this to be true. Although my placement Trust provided obstetric training, ODPs and postoperative practitioners did not participate and did not train or learn with midwives. This may be because the Trust follows the guidelines from the AAGBI (2013a), which does not specifically recommend specialist training for these professionals.
Communication and role awareness
The midwife present in the immediate postoperative period would have known and understood the variations in a pregnant and postpartum woman's physiology, as midwives are highly skilled practitioners, specialising in the care of women throughout the childbearing continuum (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Had we consulted with the midwife and drawn on her specialist knowledge and experience, we may have not made the mistake of looking for inappropriate physiological markers. Considering our inexperience and lack of training in this area, consulting with her would have been valuable and much safer for the patient. On the other hand, despite there being another practitioner present, by not checking or engaging with my expression of concern, the midwife failed to consider the responsibility that she maintained to the new mother and her wellbeing (Nursing and Midwifery Council (NMC), 2015). It is also possible that the midwife did not know much about the role of a recovery practitioner, our skills or our lack of training in obstetrics, leading to the assumption that we did not require her input in this matter.
As the role of the recovery practitioner is to care for the postoperative patient, we were responsible for the care of the woman (AAGBI, 2013a; Hatfield, 2014). Midwifery input and collaboration is therefore important, to address the needs of the infant and the woman (Jackson, 2011; Michealides, 2011). The National Institute for Health and Care Excellence (NICE) (2012) and UNICEF UK (2012) therfore recommend that skin-to-skin and breastfeeding be initiated as early as possible after a caesarean section, to improve mothering skills, bonding and breastfeeding outcomes (Michealides, 2011; NICE, 2012; UNICEF, 2012). These recommendations were followed by the midwife immediately on admission to the recovery bay, while the ODP and I were receiving handover, monitoring the mother and checking her blood loss.
The AAGBI (2013a) and Hatfield (2014) both state that the patient's physiological wellbeing and observations, following the ABCDE approach, are always the postoperative practitioner's priority. Therefore, from our perspective, the emphasis should have been to ensure the mother was physiologically stable, not to initiate breastfeeding (Yentis and Malhotra, 2013). As inexperienced practitioners in obstetrics, our focus may have been compromised due to these perceived midwifery distractions. However, according to Saxton et al (2015), breastfeeding stimulates the mother to produce oxytocin, which enables the uterus to contract, reducing the risk of PPH. We were unaware of this, leading to the perception that the midwife was not prioritising the woman's health and was therefore obstructing care. This highlights our lack of knowledge in obstetrics, but importantly our lack of understanding of the importance of the role of our midwifery colleague and of breastfeeding in this situation.
‘The gap in training for postoperative practitioners in a unique and challenging speciality is not widely known or acknowledged. An important part of interprofessional working relationships is the understanding of different colleagues' skill remit, knowledge and role and, importantly, any deficits in training and knowledge’
NICE (2012) and AAGBI (2013a) guidelines were both followed in this case, but these seemed to contradict, as did the priorities of the midwife's role and the ODP's role. Beament and Mercer's (2016) research, and the analysis of the death of Elaine Bromley (Oresanu and Fischer, 2008), demonstrate that speaking up to prioritise safety is essential in preventing harm. As the patient's advocate, assertiveness and communicating the needs of the patient is an important part of any practitioner's duty (Wilson, 2012; Association for Perioperative Practice (AfPP), 2016; Ilhan et al, 2016; NMC, 2016). It was therefore necessary for us to communicate with the midwife, and assert that the woman's needs and our role in her care needed prioritising. This was not done; nor did the midwife communicate the rationale for her practice and assert its importance in the care of the new mother. Poor interprofessional communication led to a deficit in understanding of the importance of each role and gave the impression of each professional obstructing the other. This caused confusion, which consequently inhibited the early detection of PPH.
Now what?
This case highlighted a lack of understanding of different professional roles and a deficit in training and education in obstetrics for different professional groups. It is my observation that the gap in training for postoperative practitioners in a unique and challenging speciality is not widely known or acknowledged. An important part of interprofessional working relationships is the understanding of different colleagues' skill remit, knowledge and role and, importantly, any deficits in training and knowledge (Suter et al, 2009; Sims et al, 2015). Indeed, to optimise the skills and expertise of all the professionals working in obstetrics, Shamain (2014) calls for a recognition of all the skills and limitations of every professional group, across Trusts and in policy. Knowing both a colleague's specialist skills and any deficits in training would allow another professional with the necessary knowledge to fill that deficit by offering their individual professional insight, complementing and enhancing practice for themselves and their colleague (Reeves et al, 2010; Eisler and Potter, 2014; Sims et al, 2015). It is argued that it is only then that the skills and knowledge brought in from different professional perspectives can be synthesised, providing a more effective, holistic approach to patient care and enhancing patient safety (Moaveni et al, 2008; Reeves et al, 2010; Eisler and Potter, 2014).
‘Bringing different professional groups together to learn as a team can give each group new insight and ideas, synthesising their differences and individual skill sets to provide a more holistic approach to patient care, with huge benefit to the patient's overall wellbeing’
Interprofessional learning acknowledges that different health professionals approach patient care from different angles and perspectives (Feltham et al, 2016), as seen in this case study. Bringing different professional groups together to learn as a team can give each group new insight and ideas, synthesising their differences and individual skill sets to provide a more holistic approach to patient care, with huge benefit to the patient's overall wellbeing (Wicker, 2011; Kaplan et al, 2015). Interprofessional learning has been proven to help health professionals learn about each other's roles, limitations and expertise; promotes effective teamwork; enhances communication and facilitates the allocation of tasks (Hawley, 2007; Wooding, 2013; Engel and Prentice, 2013).
Simulation training has become increasingly acclaimed and used in healthcare over recent years and is recommended to enhance interprofessional working relationships (Ricketts, 2011; Helaby, 2013; Ulrich and Mancini, 2014). Simulation training offers an opportunity for staff from multiple professions to collaborate, learn and practice new clinical skills and emergency situations, in a risk-free environment (Hope et al, 2011; Tolsgaard et al, 2013; Struksnes and Engelien, 2016). Several large-scale reviews have indicated that simulation training is an effective learning style and an ideal way of enhancing interprofessional collaboration and learning; but fundamentally they show that its success is dependent on a few key factors (Dawe et al, 2014; Fung et al, 2015; Adib-Hadjbadherry and Sharifi, 2017; Hegland et al, 2017). One essential factor that all these reviews agree on is that learners must have adequate knowledge of the clinical skill that is being simulated. This reflects professional standards dictating that practice should be evidence-based (Health and Care Professions Council (HCPC), 2016; NMC, 2016). Additionally, having underpinning knowledge allows the practitioner to understand why they should perform tasks a certain way, providing a robust rationale for actions and omissions in clinical practice (Ostergaard and Rosenburg, 2013). Feedback from training programmes that incorporate both theory and practice elements has been largely very favourable (Russell et al, 2006; Thistlethwaite, 2012; Shoushtarian et al, 2014; Adib-Hadjbadherry and Sharifi, 2017). Therefore, an inclusive interprofessional education programme, incorporating both classroom theory learning and simulation training (to address the deficiencies of using just one educational approach) would be advisable (Shoushtarian et al, 2014; Adib-Hadjbadherry and Sharifi, 2017).
It is acknowledged that interprofessional collaborative learning must begin early in the training of healthcare students to develop the necessary skills (Chan and Wood, 2010; Wong et al, 2016). Interprofessional education programmes are still considered to be in their infancy and their long-term effects on healthcare culture and safety is yet to be investigated (Saxell et al, 2009; Darlow, 2015Meleis, 2016). However, as students become registered practitioners, incorporating interprofessional training programmes into undergraduate healthcare degrees is said to be vital to encourage a culture of synthesised, integrated, holistic and safer care in the future (Curran et al, 2010; Pardue, 2013; Seymour and Barrow, 2014; Mahler et al, 2015, Catling et al, 2016).
As a relatively nascent profession, the role and scope of practice of the ODP is constantly evolving (Robinson and Straughan, 2014; Wordsworth, 2015). Midwifery is also advancing and evolving as a profession (Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). According to Vukmir (2016), the use of customary practices among experienced practitioners is widespread, potentially inhibiting practitioners' ability to acknowledge new scopes of practice and role boundaries. Consequently, it becomes apparent that it is not enough to just incorporate undergraduate students in interprofessional education, but to maintain safety in the more immediate future, all practising professionals should be included.
Engaging all professionals working in obstetrics, both students and existing staff, in obstetric simulation training, combined with theoretical classroom-based learning would significantly improve outcomes for patients. Providing this inclusive facility would give the ODP profession and all postoperative practitioners the obstetric training that is lacking in the guidelines for this professional group. Importantly, it would help create a mutual understanding of each profession's roles, for both current and future practitioners. It would open the lines of communication between our professions, synthesising our unique skill sets and roles, with the aim of addressing the safety concerns highlighted in this case study.
Conclusion
Our unique, specialist and highly skilled professions have great potential to have an effective and dynamic interprofessional working partnership. To achieve this, lessons must be learnt from practice. The perception of segregation between the professions in practice is notable and is highlighted from the underlying voice of ‘us and them’ displayed throughout this reflection. This existing culture must be acknowledged and highlighted, for it to be challenged and safety concerns resolved. Additionally, analysis of this clinical incident has highlighted some concerning gaps in practice and policy, affecting the safe delivery of care for the postoperative obstetric patient.
Obstetrics requires specialist training to maintain optimum patient safety. There appear to be recommendations for training of recovery staff and separate training for midwives, but ODPs working in obstetrics seem to have slipped through the net, with no guidelines indicating that they need specialist training. Evidence highlighted in this article indicates that improving interprofessional education in obstetrics could improve patient outcomes and enhance the synthesis and quality of collaborative care between midwives and ODPs. Although many Trusts may have obstetric training programmes, this article highlights the need for them to be fully inclusive across professional groups and across all Trusts.
Based on the evidence and analysis in this case study, there is a need for research into how all professionals who work in obstetrics in the UK are trained. Research into how midwives and ODPs work together, and an exploration of existing knowledge and perceptions of each other's roles, would provide empirical baseline evidence to devise a robust, inclusive interprofessional training programme in obstetrics. Additionally, this evidence would strengthen the case for change, compelling local and national policy to alter accordingly. The priority at the core of both our professions is patient safety and welfare. I believe that learning lessons from this case study will lead us to learn and work together more efficiently to achieve this common goal. BJM