12.1 Interprofessional Team Communication, SBAR Handover & Human Factors

Interprofessional Team Communication, SBAR Handover & Human Factors

Maternity care is inherently complex, dynamic, and delivered by diverse multidisciplinary teams operating in high-stakes environments. The modern maternity workforce comprises registered midwives (RMs), consultant and trainee obstetricians, anaesthetists, neonatologists, maternity support workers (MSWs), theatre nurses, and allied health professionals. While technical proficiency in clinical skills is essential, national inquiries into maternity safety consistently reveal that the primary root causes of catastrophic outcomes—such as intrapartum asphyxia, unrecognized maternal collapse, or severe haemorrhage—stem from communication breakdown, toxic team dynamics, and failures in non-technical skills.

Under the Nursing and Midwifery Council (NMC) Future Midwife standards (Domain 5), every midwife must demonstrate advanced communication, collaborative leadership, and the ability to maintain interprofessional respect while fearlessly advocating for safety across multidisciplinary settings.

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Human Factors & Non-Technical Skills in Maternity Care

Human factors refers to the environmental, organizational, social, and individual characteristics that influence human performance, clinical decision-making, and safety behaviors in the workplace. In healthcare, human factors science recognizes that while healthcare professionals strive for clinical excellence, humans are inherently fallible and vulnerable to psychological, physiological, and environmental constraints.

Non-technical skills (NTS) are the cognitive and social abilities that complement clinical knowledge and technical dexterity. In maternity services, non-technical skills encompass five core domains:

1. Situational Awareness: Developing, maintaining, and updating an accurate mental model of what is happening around the patient, the team, and the wider unit.
2. Decision-Making: Formulating timely clinical judgments under conditions of uncertainty, time pressure, and incomplete information.
3. Communication: Exchanging clear, unambiguous clinical data and active listening across interdisciplinary boundaries.
4. Teamwork & Leadership: Coordinating actions, distributing tasks equitably, and resolving team conflicts constructively.
5. Stress & Fatigue Management: Recognizing the insidious impact of physical exhaustion, sleep deprivation, and acute psychological stress on clinical perception.

                    ┌──────────────────────────────────────────────┐
                    │      CORE NON-TECHNICAL SKILLS (NTS)         │
                    └──────────────────────┬───────────────────────┘
                                           │
         ┌──────────────────┬──────────────┴─────┬──────────────────┐
         ▼                  ▼                    ▼                  ▼
┌─────────────────┐┌─────────────────┐┌─────────────────┐┌─────────────────┐
│   Situational   ││    Cognitive    ││ Interprofessional││  Psychological  │
│    Awareness    ││  Load Balance   ││  Communication   ││     Safety      │
│                 ││                 ││                  ││                 │
│ • Perception    ││ • Task sharing  ││ • SBAR structure ││ • Speaking up   │
│ • Comprehension ││ • Dedicated     ││ • Closed-loop    ││ • Flat hierarchy│
│ • Projection    ││   scribes       ││ • PACE assertion ││ • Civility      │
└─────────────────┘└─────────────────┘└─────────────────┘└─────────────────┘

Cognitive Pitfalls & Biases in Acute Maternity Scenarios

High-pressure labour wards and emergency obstetric rooms are breeding grounds for cognitive errors:

• Loss of Situational Awareness (Tunnel Vision): Occurs when a clinician fixates intently on a single, isolated clinical task—such as struggling to secure difficult intravenous access during a massive postpartum haemorrhage—while completely failing to notice that the woman has become unresponsive, hypotensive, and tachycardic.
• Cognitive Overload: The human working memory can typically retain only four to seven items simultaneously. During simultaneous complex crises (e.g., severe shoulder dystocia alongside maternal seizure), clinical bandwidth is overwhelmed, causing omissions of vital steps unless emergency cognitive aids (checklists, prompt cards, dedicated scribes) are employed.
• Confirmation Bias: The dangerous psychological tendency to search for, interpret, and recall information in a way that confirms pre-existing expectations while actively dismissing contradictory evidence. For instance, a clinician may assume that repetitive, deep fetal heart rate decelerations on a cardiotocograph (CTG) are simply "sleep cycle variables" or positional, ignoring progressive loss of baseline variability and rising baseline tachycardia because the labour was previously low-risk.
• Authority Gradients & Fear of Speaking Up: A steep hierarchy—whether between a junior student midwife and a senior midwife, or a midwife and a consultant obstetrician—inhibits questioning. Junior team members who notice emerging danger frequently remain silent because they fear condescension, public humiliation, or punitive retaliation.
• Diagnostic Overshadowing: Wrongly attributing new, pathological symptoms to an already known, benign condition. For example, dismissing worsening epigastric pain and headache in labour as "musculoskeletal strain from pushing" rather than recognizing fulminant pre-eclampsia.

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Standardized Clinical Communication: The SBAR Framework

In unstructured clinical handovers or emergency telephone escalations, critical clinical parameters are often buried under narrative rambling or omitted entirely. Standardized communication tools create a shared mental model between the speaker and the listener.

The gold-standard communication tool mandated across the NHS and international healthcare is the SBAR framework: Situation, Background, Assessment, and Recommendation. Developed originally by the United States military and adapted for high-risk industries, SBAR bridges the communication gap between different professions (e.g., midwives who frequently present holistic, descriptive clinical narratives, and physicians who require succinct, problem-focused diagnostic summaries).

Closed-Loop Communication & Read-Back

In acute obstetric resuscitations (e.g., eclamptic seizure, postpartum haemorrhage, umbilical cord prolapse), verbal orders must adhere to closed-loop communication:

1. Sender initiates: Senders direct the order to a named individual: "Midwife Emma, please administer 10 units of intramuscular Syntocinon now."
2. Receiver acknowledges and repeats (Read-Back): The named receiver repeats the order precisely before or while acting: "Administering 10 units of intramuscular Syntocinon now."
3. Sender verifies: The sender confirms: "Correct."
4. Receiver confirms completion: The receiver announces when executed: "10 units of IM Syntocinon administered into the left vastus lateralis at 14:22."

This eliminates auditory confusion, double-dosing, and unperformed emergency tasks.

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Graded Assertiveness: The PACE Framework & CUS

One of the greatest hazards in maternity care occurs when a junior midwife or trainee detects an impending disaster, but their attempts to raise the alarm are ignored, minimized, or dismissed by a senior clinician. Inquiries into maternity failures (such as Morecambe Bay and East Kent) repeatedly identified instances where midwives recognized life-threatening fetal compromise, but deferential language allowed senior staff to walk away without intervening.

To eliminate deferential hesitancy, midwives are trained in graded assertiveness protocols. The most widely adopted model is the PACE framework:

                          ┌───────────────────────────┐
                          │   EMERGENCY (STOP & ACT)  │  Level 4
                          ├───────────────────────────┤
                          │      CHALLENGE (FIRM)     │  Level 3
                          ├───────────────────────────┤
                          │       ALERT (DIRECT)      │  Level 2
                          ├───────────────────────────┤
                          │       PROBE (INQUIRE)     │  Level 1
                          └───────────────────────────┘

The 4 Stages of PACE

1. P — Probe: Gently raise an inquiry to prompt cognitive reflection without overt confrontation.
   • Example: "Mr. Smith, have you reviewed the CTG trace over the past 40 minutes? Do you notice the reduction in baseline variability?"
2. A — Alert: State the emerging clinical reality and risk directly, focusing on the clinical data.
   • Example: "I am alerting you that the CTG is now pathological under NICE guidelines. The baseline is 170 bpm with recurrent late decelerations and absent cycling. The fetus is showing signs of compromise."
3. C — Challenge: Issue a direct, firm challenge to the planned inaction or inappropriate decision, referencing clinical safety.
   • Example: "I challenge continuing this Syntocinon infusion. Increasing the oxytocin dose in the presence of an abnormal CTG is contrary to national guidance and poses an immediate danger of uterine rupture and fetal acidosis. We must stop the infusion and perform fetal blood sampling or expedite birth."
4. E — Emergency: Intervene decisively to halt the hazard immediately, stepping in to protect life and invoking higher authority.
   • Example: "This is an emergency. For the safety of the mother and baby, I am stopping the Syntocinon infusion immediately. I am pulling the emergency buzzer and bleeping the consultant obstetrician and labour ward coordinator right now."

The CUS Tool

An alternative rapid escalation model developed by TeamSTEPPS is the CUS framework:

• C — "I am Concerned..." (States the clinical worry)
• U — "I am Uncomfortable..." (Signals that safety parameters are being breached)
• S — "This is a Safety issue!" (A universal, hard-stop trigger that requires all team members to pause and re-evaluate immediately)

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Structured Handover Protocols & Bedside Transfer of Care

The transfer of patient care—whether during shift changeovers, transfer from a community birth centre or alongside midwifery unit (AMU) to an obstetric unit (OU), or transfer to the operating theatre—represents a critical vulnerability for communication breakdown.

Key Handover Modalities

• Unit Shift Handover: Multidisciplinary meeting (Labour Ward Coordinator, Obstetric Registrar, Anaesthetic Registrar, Neonatal Team) reviewing all women on the unit, highlighting high-risk clinical pathways, staffing capacity, theatre availability, and anticipated emergencies.
• 1-to-1 Midwifery Handover: The direct bedside transfer between oncoming and offgoing midwives.
• Transfer from Home/AMU to Obstetric Unit: Pre-alert telephone SBAR call followed by a formal face-to-face multidisciplinary bedside briefing upon arrival.

Principles of Safe Bedside Handover

Evidence indicates that bedside handovers (conducted at the woman's bedside rather than in a closed staff room) offer profound safety advantages:

• Involving the Woman and Partner: The woman hears what is being reported, validates clinical facts, clarifies symptoms, and feels respected as an active partner in care.
• Physical Verification: Vital signs, fluid balances, IV infusions (checking drug labels and pump flow rates), epidural settings, and CTG traces are co-inspected and signed off by both midwives.
• Protected Time: Handovers must occur in an environment free from unnecessary interruptions, telephone distractions, or non-urgent clinical queries.
• iSoBAR Adaptation: Many UK trusts utilize iSoBAR (Identify/Introduce, Situation, Observations, Background, Assessment, Readback/Recommendation) to structure complex obstetric transfers.