Agenda item

The Consultant Obstetrician and Gynaecologist (COG) at Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) delivered a presentation on the Early Pregnancy Assessment Unit (EPAU), which provided context as to:

·  The service itself and how it could be accessed;

·  Care and support for people who miscarry;

·  How the Trust worked to decrease the risk of repeat miscarriages; and

·  How patient feedback was addressed by the Trust.

In response to questions from Members, the COG stated that:

·  It was recognised as best practice for an Early Pregnancy Unit to have a quiet room, where patients and their families could receive bad news and where staff could break this bad news. Prior to the pandemic, the Emergency Gynaecology Unit and the Early Pregnancy Unit were located on a different hospital ward; however, during Covid, the use of the wards was changed, with Gynaecology moving to a different ward and the new physical environment not being as bespoke for the service. As such, BHRUT was working to re-establish the quiet room which was present on the previous ward. 

·  In the new ward, women and families that received bad news would be taken to a quiet area in a side room; however, this was not currently bespoke.

·  In regards to the decreased miscarriage rate in 2022/23 in comparison to during the pandemic, the birth rate had also recently dropped, with a direct link between a lower miscarriage rate and lower birth rate.

·  There were some staff who were trained in mental health first aid, to support both staff members and patients. The staff that worked within the Early Pregnancy Unit were expected to have communication skills training, including around breaking bad news and in recognising patients who were in mental health distress.

·  BHRUT had links with SANDS (a bereavement charity) and its Bereavement midwives did provide close support in terms of links with the Adults and Perinatal mental health services. The vast majority of this staff also had experience of working within the maternity service; as there were close links with the perinatal mental health service, it was very easy to make a direct referral into these clinics. BHRUT also had the facility for inpatient referral to the Adult mental health services, for mental health crises as a result of an early pregnancy problem.

·  There were referral criteria into the Perinatal mental health unit, with all midwives having a certain level of training in looking after patients who did have mental health concerns. There were two levels of the perinatal mental health service, with one being midwife-led and one being for women with more severe mental health illnesses, with these women being eligible to be seen within the joint consultant and perinatal psychiatric service. There was no waiting list to be seen in the joint clinic, with the service also being recognised as being a best practice model.

The Integrated Care Director (ICD) for Barking & Dagenham at NELFT stated that NELFT was the provider of the perinatal infant mental health services (PIMS), which operated across all four London areas in the outer northeast London programme. Delivery was across the community and in the acute service. There was also a maternal mental health specific pathway, known as the Tulip service. The PIMS service was essentially the first point of access into the perinatal mental health remit, with patients either being managed within the PIMS service or through the Tulip service. The Tulip service was commissioned during the pandemic and extended the reach agreement of the perinatal infant mental health service.

In response to further questions from Members, the COG stated that:

·  One of the areas of quality improvement work was around flow through the service; the service was well known through social media advertising and BHRUT did not want to delay people’s presentation with an early pregnancy problem. The COG also detailed the patient journey and flow through the service and the possible routes that this could take depending on the patient’s needs. For those who had experienced a miscarriage, the COG also detailed their patient journey and support received, dependent on the type of miscarriage that they had experienced.

·  There was a range of risk factors for early pregnancy problems, with miscarriage being a very common occurrence and arising in 30% of pregnancies. The COG detailed these risk factors, such as having had a previous miscarriage, a previous ectopic pregnancy, predisposing medical conditions, being older in age, smoking and some previous predisposing sexually transmitted infections. The service encouraged women to either see their GP early or to present themselves early to the Early Pregnancy Unit in these instances, or where these women had any concerns, anybody could present themselves to the service through self-referral. The COG also detailed some of the advice and guidance that was provided in these circumstances, as well as reassurance that the vast majority of women who had early pregnancy loss would go on to have a healthy pregnancy in the future. The COG also discussed the criteria around whether somebody was considered to have a recurrent miscarriage and the patient journey and support that would be provided in these cases.

·  Ideally, women would present themselves for midwifery care at around nine weeks, in order that there was time for the screening tests that needed to be undertaken as part of the antenatal service, and in line with national targets for presentation to maternity services. At this point, a woman would be risk assessed, which would also include history of previous pregnancies and pregnancy loss. Unless somebody had been diagnosed with an underlying medical condition, there was usually no additional antenatal treatment or care that was recommended for somebody who had had early pregnancy loss or somebody who had had a pregnancy loss in the second trimester previously. From around 13 weeks to 20 weeks, there was some additional support that would be put in place, but for under 12 weeks, the vast majority of women would not need anything additional in their antenatal care; however, community midwives would discuss this as part of a person’s antenatal care and provide tailored advice. People could also approach the Early Pregnancy Unit if they were unsure about anything.

·  Individuals who had experienced recurrent miscarriage could be offered genetic testing, to help identify if there were any genetic causes for miscarriage. Screening for other genetic conditions could also be undertaken during first trimester screening, with these women being looked after within the Fetal Medicine Unit; the COG detailed the various means of support provided and diagnostic means through this. The Fetal Medicine Unit worked very closely with King’s College and had developed links with the fetal medicine network across the local maternity system, such as with Barts and the Homerton.

·  If young people had experienced miscarriages but did not want to present to the service, whilst they should be encouraged to access the service, they could also talk to a trusted adult, or approach their school nurse, GP or wellbeing services within sexual health services. It would also be important to consider safeguarding, as well as their ability to access contraception services, for example, if they had experienced an unplanned pregnancy.

·  Caring for staff was essential, particularly as obstetrics and gynaecology as a speciality had a very high attrition rate, with one of the reasons for this being the stress involved in the job. Within the Fetal Medicine Unit, there were regular debriefing sessions led by a Bereavement team; the Trust was looking to extend this into the Early Pregnancy Unit as it was now recognising more and more the emotional burden that could impact staff within this unit.

·  The pandemic had brought more recognition of the need for more emotional wellbeing services for staff; BHRUT also had quite extensive psychological support services and if it was recognised that staff were in distress, the Trust could also arrange for events where staff could discuss any concerns that they had. BHRUT had implemented “Schwartz Rounds” during the pandemic, where staff could share their stories and where collective learning could take place. Much support during the pandemic had been modified to take place online and the Trust was now thinking about how it could run this face-to-face. The Trust was rolling out nursing advocates, who were trained in delivering psychological support and who could be accessed by staff for support.

·  Compassion fatigue was a very well recognised phenomenon. There were different ways that the Trust could identify this, such as through complaints and incident reports; for example, if an individual was identified on a recurrent basis, this would be flagged up early, or if there was a particularly emotionally difficult complaint, then the COG would intervene directly to find out what was happening and ensure that support could be provided.

·  The Trust could also monitor burnout and compassion fatigue, through means such as monitoring staff sickness levels, absenteeism, staff being late and staff cancelling shifts. If an individual had been identified as being particularly at risk, a conversation would be had with their line manager through a supportive route, ensuring that the individual was signposted to the necessary services to support their wellbeing. As a last resort and if the individual needed a break from working in their area, the Trust also had the facility to do this. Teams were also very close knit and were able to identify and provide support to their team members who may be suffering from burnout.

The Committee recommended that more work be undertaken to support fathers and partners during miscarriages and pregnancy loss, as it affected the whole family unit. It also recommended that more work be undertaken to support EPAU access for more vulnerable populations, including teenagers.