Assessment of risk during the maternity pathway

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

This national learning report draws on findings from the maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’).

Risk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway.

This thematic review examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included.

The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.

The seven identified areas are as follows:

1. The language used to discuss and document risk assessments should encourage a dynamic and holistic assessment of the individual pregnant woman/person’s risk (‘dynamic’ means the risk is continually assessed to allow for unknown factors and to handle uncertainty, while ‘holistic’ refers to looking at other factors that might be relevant) that promotes the need for maternity care to be provided by multi-professional teams.
2. Telephone triage services should support 24-hour access to a systematic structured risk assessment of pregnant women/people’s needs.
3. Telephone triage services should be operated by appropriately trained and competent clinicians who are skilled in the specific needs required for effective telephone triage.
4. Face-to-face triage in maternity units should use a structured approach to prioritise pregnant women/people to be seen in order of clinical need.
5. Clinicians should be enabled to proactively monitor and recommend the place of labour care and birth for pregnant women/people based on the individual’s specific care needs during the course of their pregnancy and labour.
6. Each pregnant woman/person should be helped to understand their individualised risk associated with a vaginal or caesarean birth after a previous caesarean birth, based on their specific risk factors and care needs.
7. Pregnant women/people whose labour has been induced need clinical oversight and an individualised plan of care for maternal and fetal monitoring.

This thematic review also includes prompts for NHS trusts to consider how these risks may be mitigated:

1. Are risk assessment and screening documents designed and presented in a consistent and logical way?
2. Does the language used in risk assessment and screening documents avoid binary definitions of risk, and instead promote dynamic and holistic risk assessments supporting a multi-professional approach?
3. Does risk assessment and screening documentation support a holistic consideration and documentation of risk, or does it focus on only single risk factors?
4. Do telephone triage services facilitate 24-hour support for systematic risk assessment?
5. Are clinicians equipped with the appropriate training, skills and competencies to manage an effective telephone triage service?
6. Is a structured approach used so that pregnant women/people are seen in order of clinical need within your maternity face-to-face triage service?
7. Are there frequent opportunities to revisit and recommend the place of birth based on the pregnant woman/person’s individual needs?
8. Does your risk assessment tool encourage clinicians to think about the most suitable place of birth when a pregnant woman/person in labour is admitted?
9. Do processes support holistic risk assessments to be revisited during labour to proactively assess the most suitable place for fetal monitoring and birth?
10. In antenatal discussions with pregnant woman/people, are structured tools used to support individualised care planning and decision-making when planning a birth after a previous caesarean birth?
11. Is there an opportunity to revisit these discussions when there is a change in circumstance, such as induction of labour?
12. Are clinicians encouraged to make individual plans, taking into consideration a pregnant woman/person’s and baby’s risk during the induction of labour process and including frequency of observations, fetal monitoring and place of induction?
13. Is there a system to prioritise pregnant women/people requiring induction of labour according to clinical need, and to ensure appropriate escalation and action when there are delays?