Royal College of Obstetricians and Gynaecologists

Noted (AI summary) • The Faculty of Intensive Care Medicine will highlight the case of Ms. Chloe Ulett in its tri-annual Safety Bulletin, which is distributed to all Fellows and Members. • The Safety Bulletin will signpost open access resources and highlight the utility of testing ammonia levels in encephalopathy of unknown cause. • The Faculty will draw attention to this being the second Regulation 28 Report in recent years stressing the need to test ammonia levels in patients who present in extremis with an unknown cause, referencing the Rohan Godhania case.

Noted (AI summary) The team reviewed the MNSI report, process, and findings and concluded that their investigation process was correctly followed. A note has been added to their investigation record to highlight the findings of the inquest. The RCOG highlights the Scientific Impact Paper (SIP) number 73, second edition, which addresses impacted fetal head at caesarean birth and sets out detailed descriptions of safe technique. The ABC (Avoiding Brain Injury in Childbirth) programme incorporates these techniques and will be rolled out to maternity units in England as part of a national programme by NHSE.

Noted (AI summary) The RCOG expresses condolences and explains their guideline development process, stating that the Shoulder Dystocia guideline will be updated to include a section on alternative maneuvers but that there is not currently enough evidence to recommend the shoulder shrug maneuver. They emphasize the importance of effective training using existing recommended maneuvers.

Noted (AI summary) Somerset NHS Foundation Trust has developed supportive guidance for families regarding Section 17 leave from inpatient units, which is currently out for feedback and will be shared at an operational meeting for approval. They also describe planned training for mental health staff on menopause. NHS England acknowledges concerns about menopausal care and highlights increased awareness and demand. They describe training programmes, awareness sessions and e-learning packages that have been launched, some since Anne's death, to improve resources for healthcare practitioners. NICE expresses condolences and states that the concerns raised are not directly attributable to NICE but are addressed to other organizations. They reference existing NICE guidance and quality standards related to suicide prevention and menopause, and indicate that the menopause guideline was recently updated and will remain under surveillance. The RCOG extends condolences and recognises the concerns raised, highlighting that management of the menopause is covered in the core training curriculum for Obstetricians and Gynaecologists, including a Special Interest Training Module and the Diploma of the Royal College of Obstetricians and Gynaecologists. Kenny & Murphy Ltd sold the incident site in March 2024 and has no influence over tenants there. However, they have discussed electrical safety with tenants at their other sites and provided them with relevant leaflets and documents.

Noted (AI summary) The RCOG acknowledges the coroner's concerns regarding the lack of guidance on managing abnormal antenatal CTGs, emphasizes the need for individualised care plans and refers to NHS England guidance on computerised CTG use. NICE acknowledges the coroner's concerns and will consider reviewing the evidence on antenatal CTG interpretation and actions, and will work with others to see if they can produce a practice guide to inform practitioners.

Noted (AI summary) NHS England expresses condolences and describes the Maternal Medicine Networks established across England; they support revision of the Royal College of Pathologists’ guidelines for urgent reporting of LFTs to incorporate different levels for pregnancy. UHBW will await national guidance from the Royal Colleges regarding a recommended reference range for urgent reporting of LFTs in pregnancy, and then set up a task and finish group to implement these across the Trust. If no national guidance is available, UHBW will look to change the reference range locally. The RCOG acknowledges the concerns raised and highlights existing online learning resources and escalation protocols, while suggesting the Royal College of Pathologists review its guidance on urgent reporting levels of LFTs for pregnant women. The Royal College of Pathologists states that its guidance on communicating critical pathology results is advice to pathologists and that individual cut-offs should be agreed locally with clinicians. The need to agree local cut offs with clinicians will be emphasised in the next revision of this document.

Noted (AI summary) The NMC is carrying out Fitness to Practise investigations, has shared the PFD report with the GMC, and will develop and publish a scenario to inform student midwives and midwives about hyponatraemia for the start of the next academic year. NHS Sussex confirms that University Hospitals Sussex NHS Foundation Trust (UHSx) and East Sussex Healthcare NHS Trust (ESHT) have implemented policies regarding fluid management and hyponatraemia in labour, developed and delivered training and education, and are auditing compliance with fluid balance charts. A leaflet has been developed advising mothers about fluid intake in early labour and shared learning about hyponatraemia and fluid balance in labour with the Regional Maternity Team at NHS England in 2022. The Royal College of Obstetricians and Gynaecologists expresses condolences and outlines its role in supporting maternity services through educational initiatives and clinical guidance. It refers to existing NICE guidelines and other resources related to fetal monitoring, intrapartum care, and hyponatremia, and suggests the Royal College of Midwives also be informed. The Department of Health and Social Care highlights the publication of an NHS Resolution report on hyponatremia and notes the rollout of the Brain Injury Reduction Programme across maternity units in England.

Noted (AI summary) NHS England refers to the RCOG guidance on assisted vaginal birth and highlights the need for clinicians to be aware of the guidance and assess the advantages and disadvantages of available delivery techniques; the results of the ROTATE trial will be carefully reviewed. Following inaccurate assessments of fetal head position by clinicians prior to starting procedures, RCOG advises that ultrasound assessment of the fetal head position prior to application of forceps is more reliable than clinical examination. Updated RCOG Green-top Guideline No. 26 provides recommendations to support practitioners around the use of instruments for assisted vaginal births.

Noted (AI summary) The Resuscitation Council UK (RCUK) will emphasize the need to exclude major bleeding as the cause of collapse before giving fibrinolytic drugs for suspected PE in pregnancy. They will review and update the next print run of the RCUK Advanced Life Support Manual, teaching materials on the ALS course concerning pregnancy, and the Obstetric Cardiac Arrest Quick Reference Handbook. The RCOG outlines existing training and guidance related to ultrasound assessment in early pregnancy and the management of gynecological emergencies, emphasizing that excluding ectopic pregnancy is a routine part of the first scan. They state that competencies are outlined in CiP 9 and 11 and detailed knowledge criteria appears in knowledge areas 3, 13, 10, 11, 12, 14 and 15 in their MRCOG membership examination.

Noted (AI summary) The RCOG acknowledges the concerns and explains that CTG training is already part of the curriculum. They highlight existing e-learning resources and suggest a new proposal could be trialled at the RCOG. The RCM outlines the role of midwives and their responsibilities according to NMC guidelines. They reference existing resources and studies related to CTG interpretation.

Noted (AI summary) The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG. The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The guideline was amended to state to abandon the procedure when there is no descent even after the 1st pull.