maternity best practice toolkits - londonscn.nhs.uk...fetal fibronectin testing in women with...

June 2015

Maternity best practice toolkitsEnsuring equally good outcomes for all pregnant women and their babies

London maternity quality standards 4

Fetal fibronectin testing in women with threatened preterm labour 7

Outpatient induction of labour (IOL) in low risk women 10

Reducing stillbirth through improved detection of fetal growth restriction 27

Improving outcomes for major obstetric haemorrhage 29

Increasing the number of births at home and in midwifery led units (MLU) 31

Increasing the number of women who receive continuity of care 37

Early referral of pregnant women for antenatal maternity care 50

Proposed implementation plan: Toolkits and maternity networks 51

Table of contents

June 2015

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These best practice toolkits have been produced as part of the London Maternity Strategic Clinical Network’s strategy to identify areas of good practice for implementation across all maternity units in the capital, ensuring equally good outcomes for all pregnant women and their babies.

The toolkits undergo a formal yearly check (one year from publication) to ensure that the content and guidance remains accurate. In exceptional circumstances (for example, when there are significant changes to policy, context, legislation or infrastructure), the check may be brought forward. An immediate update may be required if there are safety or safeguarding concerns.

Fetal fibronectin testing in women with threatened preterm labour

Aim: To optimise understanding and uptake of fibronectin testing in women with threatened preterm laour in London

This toolkit includes information on the role fFN testing, principles for its use and key auditable standards.

Outpatient induction of

labour (IOL) in low risk women

Aim: To optimise understanding and uptake of outpatient IOL for low risk women

This toolkit includes a definition, criteria and guidelines for outpatient IOL, including information provision, methods of IOL, staff skills and competencies and auditable standards.

Reducing stillbirth through

improved detection of fetal growth restriction

Aim: To improve the detection of fetal growth abnormalities in London through the use of customised growth assessment and protocols

This toolkit contains information on the role and successful implementation of customised charts, the Growth Assessment Protocol (GAP) and key auditable standards.

Improving outcomes for

major obstetric haemorrhage

Aim: To implement excellent practice across all units in London to ensure equally good outcomes for all women with major haemorrhage

The toolkit includes a London wide definition for adoption locally, best practice recommendations, referral pathways and auditable standards for implementation.

Increasing the number of births at home and in midwifery led units (MLU)

Aim: To increase the number of eligible women accessing midwifery led settings in London (midwifery led units and home births)

The toolkit reinforces the recommendations from the recent NICE Intrapartum Care clinical guidelines1. It is designed to assist healthcare professionals in increasing the number of eligible women accessing MLUs and home as place of birth, and includes London-wide definitions for birth place settings, best practice recommendations, referral pathways and auditable standards for implementation.

Increasing the number of women

who receive continuity of care

Aim: To increase the number of women accessing continuity of midwifery care in London

This toolkit demonstrates best practice, models of care, auditable standards, key factors for successful implementation and accompanying case studies.

Early referral of pregnant women

for antenatal maternity care

Aim: To improve timeliness of referrals and ensure that women access maternity care as early as possible during pregnancy

This toolkit includes a referral proforma containing an agreed minimum dataset which can be shared with a booking unit at the time of referral or self-referral into maternity care.

Introduction

June 2015

1. Intrapartum care: Care of healthy women and their babies during childbirth, NICE, www.nice.org.uk/guidance/cg190 (2014).

https://www.nice.org.uk/guidance/cg190

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London maternity quality standards

The standards in the following table have been developed by NHS England London Maternity Strategic Clinical Network (SCN) from the previous work carried out by London Health Commission.

Nearly all the standards are inpatient and workforce-related, and they are not to be taken as an exhaustive list of the requirements for running an effective maternity service. However, we consider that collectively, they indicate the minimum level of care a mother would expect to receive in a maternity unit in the capital to ensure she has a successful birthing experience.

Publication of the standards does not preclude NHS England (London region) from adding standards in future should we consider that in the light of changes in the evidence base, the wellbeing of mothers and babies in London would be enhanced by introducing further safeguards. In due course, the Maternity SCN intends to introduce standards to address other areas of maternity care outside the trust inpatient sphere.

Primarily, the purpose of the standards in the following table is to provide a guide to those involved in commissioning maternity health services as to what to expect of maternity services in trusts. The standards can also serve as a guide for existing providers and for potential providers of maternity services to the public.

Derivation of London Maternity SCN standards

Numerous nationally applicable standards exist which are intended to promote successful outcomes in maternity settings. These standards originate from a range of sources that include National Institute for Health and Care Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG), the Obstetric Anaesthetists Association and from findings such as Cochrane reviews.

The London quality standards for maternity services are based on standards such as those detailed above, and were developed by a multidisciplinary panel that included clinicians, patients and service user groups on behalf of the London Health Commission. In 2013, the panel reviewed all maternity services in the capital including labour, birth and immediate postnatal care and developed a case for change, followed by a set of quality standards for London.

These Maternity SCN standards are derived from the London quality standards. They were selected for inclusion as the Maternity SCN considered the particular challenges facing mothers in modern-day London.


May 2015

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Standard Source Auditable metrics1.) Obstetric units to be staffed to provide 168 hours a week (24/7) of obstetric consultant presence on the labour ward.

RCOG | Safer childbirth: Minimum standards for the organisation and delivery of care in labour1

» An effective system and process to record and review unit staffing levels at all grades and throughout the week.

» Compliance with number of consultant-delivered session for direct clinical care on delivery suite.

2.) Midwifery staffing levels should ensure there is one consultant midwife for every 900 expected births.


» An effective system and process to record and review unit staffing levels at all grades and throughout the week.

» Compliance with number of consultant delivered session for direct clinical care on delivery suite.

3.) All women to be provided with 1:1 care during established labour from a midwife, across all birth settings.

Cochrane Review | Continuous support for women during childbirth2

» An effective system and process to record levels of 1:1 care across all birth settings.

» Compliance with 1:1 care. provisions across birth settings.

4.) A midwife labour ward co-ordinator, to be present on duty on the labour ward 24 hours a day, 7 days a week and be supernumerary to midwives providing 1:1 care.

The King’s Fund | Improving safety in maternity services3

NHS Institute for Innovation and Improvement | NHS maternal death review4

» An effective system and process to record unit staffing levels at all grades throughout the week.

» Compliance with number of midwife labour ward co-ordinators on duty.

5.) Immediate postnatal care to be provided in accordance with NICE guidance, including: » Advice on next delivery during

immediate post-natal care, before they leave hospital.

» Post-delivery health promotion. » Care of the baby. » Consistent advice, active support

and encouragement on how to feed their baby.

» Skin to skin contact.Follow-up care is to be provided in writing and shared with the mother’s GP.

NICE CG37 | Postnatal care of women and their babies5

NICE CG190 | Intrapartum care: care of healthy women and their babies during childbirth6

NICE NG3 | Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period7

NICE CG98 | Neonatal jaundice8

NICE CG132 | Caesarean section9

For more information, please contact the London Maternity Strategic Clinical Network, [email protected].


1.) Safer childbirth: Minimum standards for the organisation and delivery of care in labour, Royal College of Obstetricians andGynaecologists (2007) | http://bit.ly/1ePw0Th. 2.) Continuous support for women during childbirth, Cochrane Review (2013) | http://bit.ly/1HKvcG4.3.) Improving safety in maternity services, The King’s Fund (2012) | http://bit.ly/1FtCnRO.4.) NHS maternal death review, NHS Institute for Innovation and Improvement (2010).5.) CG37: Postnatal care, NICE (2014) | http://bit.ly/1GkprnR.6.) CG190: Intrapartum care: care of healthy women and their babies during childbirth, NICE (2014) | http://bit.ly/1JqeaRX.7.) NG3: Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the postnatal period, NICE (2015) | http://bit.ly/1ePzS6T.8.) CG98: Neonatal jaundice, NICE (2014) | http://bit.ly/1GkpX5r.9.) CG132: Caesarean section, NICE | http://bit.ly/1AKkMcJ.

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Standard Source Auditable metrics6.) Obstetric units to have a consultant obstetric anesthetist present on the labour ward for a minimum of 40 hours (10 sessions) a week.

Units that have more than 5,000 deliveries a year, or an epidural rate greater than 35 per cent, or a caesarean section rate greater than 25 per cent, to provide extra consultant anesthetist cover during periods of heavy workload.

Obstetric units to have access 24/7 to a supervising consultant obstetric anesthetist who undertakes regular obstetric sessions.

OAA/AAGBI | Guidelines for obstetric anaesthesia services10

Clinical expert panel consensus


» Compliance with the stipulated minimum hours presence a week.

» An effective system and process to record and monitor the number of deliveries, epidurals and caesareans per month and to make projections for the year.

» An effective and system and process to provide appropriately qualified staff to cover periods of heavy workload.


7.) There should be a named consultant obstetrician and anaesthetist with sole responsibility for elective caesarean section lists.

OAA/AAGBI | Guidelines for obstetric anaesthesia services10


» An effective system and process for recording the incidence of caesarean section lists.


Consultant support

8.) Consultant-led obstetric units (where anaesthetic care is not primarily consultant delivered) should have a minimum of 12 consultant obstetric anaesthetist sessions for direct clinical care per week.

9.) Consultant support should be available 24/7 with a clear line of communication.

10.) Caesarean section lists and obstetric anaesthetic clinics should be covered by a named consultant with sole responsibility for the theatre list or clinic (ie cannot cover delivery suite at the same time).

» Compliance with number of consultant delivered session for direct clinical care on delivery suite.

» Compliance with number of consultant delivered sessions for elective caesarean section lists and clinics.

» Reasons for non-compliance and mitigating factors (ie non-consultant career grades, post CCT* fellows).



10.) Guidelines for obstetric anaesthesia services, Obstetric Anaesthetists’ Association/Association of Anaesthetists of Great Britain and Ireland for Obstetric Anaesthesia Services (2013) | http://bit.ly/1FuegTK.

* Certificate of completion of training

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Aim To optimise understanding and uptakeof fibronectin testing in women withthreatened preterm labour in London.

This toolkit has been produced as part of theLondon Maternity Strategic Clinical Network’s (SCN)strategy to identify areas of good practice in the network, and then to implement across all units to ensure equally good outcomes for women who are pregnant and their babies.

The remit for the toolkit is to present the principlesunderlying the use of fetal fibronectin (fFN) testingrather than an exhaustive guideline; it is envisagedthat all units will develop guidelines in line with theseprinciples.

Current management of threatenedpreterm labourBirth before 34 completed weeks of pregnancy is asignificant cause of perinatal mortality and morbidityin the UK.

Current interventions that would be consideredin a mother at high risk of imminent delivery of apremature baby include admission to hospital formonitoring, administration of steroids or tocolyticdrugs to the mother and possible transfer to aspecialist unit with appropriate staffing and expertiseto most successfully care for a baby born at theextremes of viability. In particular, steroids andin utero transfer to a specialist unit have beenassociated with improved neonatal outcomes.

However, the management of women who presentwith threatened preterm labour, defined as uterinecontractions but without cervical dilatation, iscomplicated by the fact that more than 50 per centwill eventually deliver at term. Intervening in thisgroup, who are not destined to deliver preterm,will therefore result in unnecessary exposure ofthe fetus to steroids, unnecessary admissionto hospital and possibly transfer to anotherunit.

Role of fetal fibronectin testingFetal fibronectin (fFN) is a glycoprotein which canbe detected in a woman’s cervicovaginal secretionsthroughout pregnancy, with low levels between 22and 35 weeks of gestation.

Fetal fibronectin concentrations greater thanor equal to 50ng/ml between 22 and 35 weeksgestation are associated with an increased riskof preterm delivery. Using a 50ng/ml cut-off, thefFN test has a negative predictive value (NPV) of99.2 per cent and a positive predictive value (PPV)greater than 40 per cent for delivery within 14 daysin symptomatic women.

The risk of preterm delivery can be further stratifiedas fFN levels of less than 10ng/ml are associated with an even lower risk, whilst the highest risk of preterm delivery is seen with fFN levels of greater than 200ng/ml. The accuracy in predicting spontaneous preterm birth within 7-10 days of testing among women with symptoms of threatened pretermlabour, before advanced cervical dilatation, hasbeen confirmed in large studies1-3.

The most useful aspect of these test characteristicsis that a negative fFN test makes it highly unlikelythat a woman’s symptoms of preterm labour willresult in delivery within the next 14 days (less than 1per cent).

If clinicians respond to this information appropriatelyand do not admit or treat women who havecontractions, without ruptured membranes or ahistory of preterm birth, and who have a negativefFN test, then a number of potential benefits may berealised

Greater efficiencies » Reduction in hospital admissions – Recent

Health Technology Assessment (HTA) review suggests fFN testing is associated with cost savings when admissions are avoided4.

» Reduction of in utero transfer rate (ambulance journeys)5.

» Reduction in planning and administrative time for arranging transfer.

» Drug treatment – reduction in the use of tocolytics (eg Atosiban) and steroids.

Improved maternal experience » Avoiding unnecessary hospital admission.

» Avoiding ambulance transfer to an unfamiliar unit.

» Providing reassurance that preterm delivery is not imminent.

Fetal fibronectin testing in women with threatened preterm labour: A best practice toolkit

November 2014

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Improved serviceReducing the number of beds blocked by unnecessary admission and transfer.

Currently, 47 per cent referrals to the Emergency Bed Service in London for in utero transfer are unsuccessful because there is no room; the median administrative time spent on these failed transfers is 340 minutes, involving discussions with between six and eight units6.

Principles for the use of fFN testing inthe London Maternity SCN

» Fibronectin is used in the management of women with threatened preterm labour and intact membranes.

» All network providers will have access to automated fetal fibronectin analysis.

» Network providers will have local guidelines for the use of fibronectin testing.

» A fibronectin swab will be used to sample cervicovaginal fluid in the posterior fornix in all women with symptoms of preterm labour between 22 and 35 weeks gestation, with intact membranes and cervical dilatation less than 3 cm.

» The swab should be taken prior to digital examination.

» If the test is negative, the risk of preterm delivery within 10 days is 1 per cent. Steroids, tocolysis and in utero transfer are therefore not indicated.

» If the test is positive, the risk of preterm labour is increased and steroids, tocolysis and in utero transfer (if necessary) should be considered.

» Ruptured membranes, recent sexual intercourse, placenta praevia, abruption, heavy vaginal bleeding, cervical suture or recent cervical manipulation increase the risk of a false positive test.

»

» If the test is reported as invalid on two occasions, fibronectin testing is contraindicated (eg digital exam performed) or fibronectin is negative but the woman is still contracting, then trans-vaginal ultrasound can be used to measure cervical length. The risk of preterm labour is very low if the cervix is greater than 15 mm.

» In utero transfer because of perceived risk of preterm labour (in women with intact membranes) should not occur from network providers without prior fibronectin analysis.

EducationThe benefits associated with fFN testing, outlinedabove, will not be realised unless clinicians performand interpret the test correctly. For instance, arecent HTA analysis found that cost savings wereonly achieved if clinicians did not admit women witha negative fFN test.

It is essential, therefore, that test implementation ismore extensive than purchasing the swabs and pointof care testing equipment.

All units will require a protocol that includes ongoingeducation about use and interpretation of findings.

AuditAuditable standards include:

» The proportion of women presenting with threatened preterm labour tested for fFN.

» The proportion of women with threatened preterm labour and a negative fFN who received steroids, tocolysis, were admitted to hospital and/or were transferred to another unit.

» The proportion of women with threatened preterm labour and a positive fFN who received steroids, tocolysis, were admitted to hospital and/or were transferred to another unit.



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References 1. Leitich H, Egarter C, Kaider A et al. Cervicovaginal

fetal fibronectin as a marker for preterm delivery: A meta-analysis. American Journal of Obstetrics and Gynaecology. 1999;180:1169-1176.

2. Tsoi E, Akmal S, Geerts L, Jeffery B, Nicolaides KH. Sonographic measurement of cervical length and fetal fibronectin testing in threatened preterm labour. Ultrasound in Obstetrics and Gynaecology. 2006; 27:368-372.

3. Abbott DS, Radford SK, Seed PT, Tribe RM, Shennan AH. (2013) Evaluation of a quantitative fetal fibronectin test for spontaneous preterm birth in symptomatic women. American Journal of Obstetrics and Gynaecology. 208:122.e1-6.

4. Deshpande SN, van Asselt ADI, Tomini F, Armstrong N, Allen A, Noake C, Khan K, Severens JL, Kleijnen I, Westwood ME. Rapid fetal fibronectin testing to predict preterm birth in women with symptoms of premature labour: A systematic review and cost analysis. National Institute for Health Research Health Technology Assessment Volume 17, Issue 40: September 2013.

5. Fenton A, Peebles D, Ahluwalia J. Management of acute in utero transfers: A framework for practice British Association of Perinatal Medicine. 25 June 2008 C.

6. Gale C, Hay A, Philipp C, Khan R, Santhakumaran S, Ratnavel N. (2012) In utero transfer is too difficult: Results from a prospective study. Early Human Development; 88:147-150.



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Aim To optimise understanding and uptake of outpatient induction of labour (IOL) for low risk women.

This toolkit has been produced as part of the London Maternity Strategic Clinical Network’s strategy to identify areas of good practice for implementation across all maternity units in the capital, thus ensuring equally good outcomes for all pregnant women and their babies.

The remit for the toolkit is to present the principles underlying the practice of outpatient induction of labour rather than it being an exhaustive guideline. It is envisaged that all units across London will develop guidelines in line with these principles.

The toolkit is intended to cover women with uncomplicated pregnancies and at low risk of developing intrapartum complications.

Background and rationaleInduction of labour (IOL) is a relatively common procedure with approximately 20-25 per cent of deliveries in the UK being induced. The induction rate in England continues on an upward trend as more women undergo induction of labour on a yearly basis. As a result there is more strain on maternity resources with often a deterioration in patient experience.

Although the majority of London’s hospitals are still new to the outpatient IOL procedure, the uptake is increasing. Twelve per cent of London hospitals have implemented the procedure for more than two years; 64 per cent of London hospitals have started the practice in the last two years, and 36 per cent plan to start using IOL in 2015.

A small number of audits conducted by London hospitals have concluded that the practice is safe and effective when compared to inductions in inpatient settings and there is no significant difference in fetal or maternal outcome. The audits also show that there is no significant difference between the outpatient and inpatient groups1 for caesarean section, admission to neonatal intensive care or maternal postpartum haemorrhage.

One London audit shows a small decrease in emergency caesarean section rates for the outpatient group and concluded that the only adverse outcome in the outpatient induction group was the higher rate of hyperstimulation 2.

Although studies of outpatient induction of labour are still limited, comparative studies to date show that the procedure carries a number of benefits for healthcare providers and women including

» Reduction in length of antenatal stay in hospital2

» Less strain on antenatal unit/resources

» Potential reduced financial costs2

» Higher maternal satisfaction

» Avoidance of unnecessary hospital admission

IOL definitionThere are many obstetric indicators for IOL but the most common reasons are for postdates pregnancies. [ >42/40 occurs in between 5 and 10 per cent of all pregnancies] where there may be an increased risk of stillbirth4. The procedure is routinely offered between 41+0 and 42+0 weeks.

Outpatient induction is the process of induction that starts as an inpatient or outpatient procedure for women who are then discharged either to home or to a setting where they do not have immediate access to the hospital, such as an outreach antenatal clinic or a birthing centre. Women then return to the hospital for the birth of their baby5.

It is essential that induction of labour in an outpatient setting is only carried out with safety and support procedures in place and in low risk women4.

Outpatient induction of labour in low risk women: A best practice toolkit

April 2015

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Guidelines for IOL in outpatient settingsCriteria for outpatient IOLIt is essential that there is a careful risk profiling of women eligible for outpatient Induction of labour and it is offered to low risk women who meet the following criteria:

» Uncomplicated pregnancy requiring induction for prevention of prolonged pregnancy (between 41+0 and 42+0 weeks).

» Woman has transport available and lives within 30 minutes of the hospital.

» Patient has a functional home telephone.

» Ability to communicate with labour ward staff.

» Number of previous births less than or equal to four.

» Reassuring pre and post prostaglandin fetal heart rate monitoring.

Information given to patientsWomen should be given clear verbal and written information on outpatient induction of labour containing4:

» The reasons for induction being offered.

» When, where and how induction could be carried out.

» The arrangements for support and pain relief.

» The alternative options if the woman chooses not to have induction of labour.

» The risks and benefits of outpatient IOL in specific circumstances and the proposed induction.

» That induction may not be successful and what options are available to the woman.

Recommended pharmacological methods of IOLVaginal PGE2 is the preferred method of induction of labour, unless there are specific reasons for not using it (in particular the risk of uterine hyperstimulation). It should be administered as a gel, tablet or controlled-release pessary. Costs may vary over time, and trusts/units should take this into consideration when prescribing PGE2.

The recommended regimens are4: » One cycle of vaginal PGE2 tablets or gel: one

dose, followed by a second dose a minimum of after six hours if the labour is not established (up to a maximum of two doses).

» One cycle of vaginal PGE2 controlled-release pessary: one dose over 24 hours.

Misoprostol should only be offered as method of induction of labour to women who have intrauterine fetal death or in the context of a clinical trial4.

Mifepristone should only be offered as a method of induction of labour to women who have intrauterine fetal death4.

Most of maternity units use vaginal PGE2 controlled-release pessary (Propess) for outpatient induction of labour as it has number of advantages. However, units might use tablets and gels.

Clear information must be given to women leaving the hospital regarding what to expect after the procedure, what to look for and when to return or contact the labour ward. The information should be given verbally and in writing. An information leaflet should be provided with a clearly marked 24 hour contact number included. (See appendix 2 and 3 as examples of best practice information leaflets.)

Staff skills and competenciesStaff performing an outpatient induction of labour must be able to demonstrate key skills. It is paramount that only staff trained in an outpatient induction procedure carry out the procedure and they must have attended appropriate annual mandatory education in the subject.

Staff providing the outpatient IOL service must also be competent in abdominal palpation and cervical assessment as well as having completed annual cardiotography training.

Auditable standardsEach unit as a minimum should audit against the following standards:

» Percentage of eligible women induced in an outpatient setting.

» Percentage of women given written and verbal information prior to and following the outpatient induction of labour procedure.



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» Re-presentation before the planned 24 hour review and reason for this.

» Place of birth.

» Induction to delivery time interval.

» Unexpected admission to neonatal unit (no >comparable inpatient induction group).

» Unplanned delivery at home.

» Delivery method after the induction of labour: • Percentage of normal vaginal delivery.• Percentage of caesarean sections.• Percentage of instrumental delivery.

» Number of failed inductions.

An example audit tool is attached in appendix 1.

Appendices: Examples of good practice

» Appendix 1 – South West London Maternity Network suggested audit tool for outpatient induction of labour

» Appendix 2 – Barking Havering and Redbridge University Hospitals NHS Trust induction of labour information leaflet

» Appendix 3 – Imperial College Healthcare NHS Trust – Induction of labour, information for women and their families

» Appendix 4 – South West London Maternity Network patient information leaflet

» Appendix 5 – South West London Maternity Network patient satisfaction survey for outpatient induction

References

1. Propess Abstract, North Middlesex Hospital audit.

2. Akmal S, Nightingale P, Dana S, Loudon J, Bennett P. Outpatient induction of labour in low risk primigravidae by slow release Dinoprostone.

3. Kelly AJ Alfirevic Z Dowswell T Outpatient versus inpatient induction of labour for improving birth outcomes: Cochrane Database of Systematic reviews 2009.

4. NICE clinical guideline CG70; Induction of labour.

5. NICE support for commissioning for induction of labour.

6. Henry A, Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial.

7. Biem SR, Turnell RW, Olatunbosun A randomized controlled trial of outpatient versus inpatient labour induction with vaginal controlled-release prostaglandin-E2: effectiveness and satisfaction. Journal of Obstetrics and Gynaecology Canada: JOGC. 2003;25(1):23–31.



13For more information, please contact the London Maternity Strategic Clinical Network, [email protected].

Appendix 1South West London Maternity Network:Suggested audit tool for outpatient induction of labour

1. Does this woman meet the inclusion criteria for SWL guidelines? Yes No If not, please record why:

2. Place of birth

3. Provision of information leaflet Yes No

4. Documentation of consent Yes No

5. Documentation of vaginal assessment prior to IOL Yes No

6. Offered a membrane sweep Yes No

7. Documentation of satisfactory maternal and fetal observations prior to discharge home Maternal observations Yes No Electronic fetal monitoring Yes No

8. Documentation of discharge advice given Yes No

9. Parity

10. Prostaglandin used Propess Prostin Tablet Gel Dose ml

11. Dilation of cervix when readmitted at 24 hours? cm

12. Additional prostaglandins required on re-admission Yes No

13. Method of membrane rupture ARM SROM

14. Syntocinon required Yes No

15. Analgesia

16. Mode of delivery Spontaneous vaginal birth Assisted delivery with forceps ventouse Caesarean section, urgent emergency

17. APGAR score 1 minute 5 minutes 10 minutes

18. Time interval from induction of labour to delivery (time)

19. Admission to neonatal unit? Yes No

20. Risk incident Yes No If yes, please detail

21. Patient satisfaction Was a patient questionnaire completed? Yes No Would she recommend outpatient induction to friends/family? Yes No


Appendix 2Barking, Havering and Redbridge University Hospitals NHS Trust: IOL information leaflet

What is induction of labour?Induction of labour (IOL) is the process of starting labour artificially. Nearly 20 per cent of births in the UK are induced, mainly when pregnancy has gone past the due date but also for various other reasons. At Queen’s Hospital, we offer induction of labour either in hospital or as an outpatient. This leaflet gives you information about outpatient induction of labour.

Outpatient induction of labour will only be offered to you if you have had a normal ‘low-risk’ pregnancy this time. You will normally be offered induction of labour if your pregnancy is 10 days past your due date. If you wish to have detailed information about induction of labour, please ask your midwife, who can also give you the leaflet called Induction of labour.

Why have an outpatient induction of labour?An outpatient induction of labour:

» Reduces the amount of time you will need to stay in hospital before your labour begins. » Allows you to stay at home and wait for labour to start. » Makes the process of induction more normal.

Who can have outpatient induction of labour?You may be offered an outpatient induction of labour if:

» Your pregnancy is ‘low risk’. » You have no medical or obstetric problems. » You have not had any gynaecological surgery. » You have a good understanding of English or you can speak English fluently. » You have a relative who will stay with you at home on that day. » You have transport to bring you to the hospital. » You live within 30 minutes (driving distance) from Queen’s Hospital

Your midwife will have a discussion with you about the outpatient induction of labour process and if you meet all the criteria you will be offered this method of induction.

What happens on the day?Your midwife or doctor will book an appointment for you to attend the Obstetric Assessment Unit at Queen’s Hospital for your induction of labour.

Please remember to bring your hand-held notes with you and an overnight bag just in case you need to stay in hospital.



Step 1When you arrive in the Obstetric Assessment Unit you will have your pulse, blood pressure, temperature and urine checked. The midwife will also read your notes and make sure that the outpatient induction of labour checklist is completed.

The midwife will discuss the process of induction of labour with you and answer any questions you may have. The midwife will also examine and measure your tummy to check your baby’s size and the way your baby is lying. The midwife will also check that your baby is ok by monitoring the baby’s heart beat on a CTG machine for about 30 minutes. The machine also monitors contractions.

Step 2When the midwife is happy with the observations and CTG monitoring she will ask if it is ok to perform an internal examination (vaginal examination) to check the neck of the womb (cervix).

If the neck of the womb is closed, then the inducing drug Propess will be inserted into the vagina. Propess is a very small flat tampon containing inducing drugs which will remain inside your body for 24 hours. The tape from the tampon will be kept fixed on your thigh. After the Propess tampon is inserted you will need to lie down for about 30 minutes. The Propess tampon will absorb the moisture from your vagina which makes the tampon swell and settle into place. This reduces the chance of it falling out.

The Propess tampon string will lie just outside the vagina and it is important that you take care not to pull or drag on it. You also need to take care when:

» Wiping yourself after going to the toilet. » After washing. » Getting on and off the bed.

Step 3When the Propess has been given, your baby’s heart rate will be monitored again for 30 minutes. When this has been completed and the midwife is happy with your observations you will be encouraged to walk around the hospital or go for a snack for the next two hours.

If your water breaks, you experience any tightenings, bleeding or if you have any concern you should return to the Obstetric Assessment Unit immediately.

Step 4After two hours you should return to the Obstetric Assessment Unit (OAU) and the midwife will check baby’s heart beat. You will be given the opportunity to ask the midwife any questions and if everything is ok you will be able to go home. You will be given the option to either come back to OAU at 4 pm for a further check-up of baby and yourself or ring the OAU for a telephone assessment (Tel: 01708435000 ext 2596).

Step 5You can continue with your day to day activities and eat and drink as normal. Following your assessment at 4 pm, either on OAU or by telephone, there are no concerns or signs of labour, you can stay at home and return the following morning to the antenatal ward for admission.



You should contact the helpline immediately 01708503742 if you experience anyof the following:

» Your tummy starts to tighten every 5 minutes (contractions). » You have any vaginal bleeding. » You think your waters have broken. » The Propess falls out. » You are worried.

What happens when I go home?The Propess you have been given works by ‘ripening’ your cervix – this means the cervix softens, shortens and begins to open up. You will commonly feel a period-like ache while this happens, but sometimes tightening of the womb can occur and even labour can start. It is ok to stay at home during this time, but if the contractions become distressing or come every 5 minutes you should phone up and come in to Triage.

Are there any side effects?Propess can occasionally produce some side effects which are usually mild and include: nausea, vomiting, dizziness, palpitations and fever. If any of these occur to a distressing level you should phone up and come in to hospital (see below)

There is a rare chance you may be very sensitive to the Propess and start contracting very frequently and strongly:

» More than five times in 10 minutes. » A run of contractions each lasting more than two minutes. » Severe abdominal pain.

If this happens you must contact the number below and make your way immediately to hospital (You should remove the Propess tampon using the tape).

Helpful telephone numbersHelpline number 01708503742Triage number 01708435000 Ext 2704

For a translated, large print or audio tape version of this document please contact the Patient Advice and Liaison Service (PALS) on 0800 389 8324.

References » Dowswell T, Kelly AJ, Livio S, Norman JE, Alfirevic Z. Different methods for the induction of labour in

outpatient settings. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007701. DOI: 10.1002/14651858.CD007701.pub2.

» Kelly AJ, Alfirevic Z, Dowswell T. Outpatient versus inpatient induction of labour for improving birth outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2 Art. No.: CD007372. DOI: 10.1002/14651858.CD007372.pub2

» Induction of labour. An update of NICE inherited clinical guideline D. July 2008. National Institute for Health and Clinical Excellence.

Compiled by - Miss Arpita Ray (Consultant Fellow in Clinical Leadership).


Appendix 3Imperial College Healthcare NHS Trust: IOL | Information for women and their families

IntroductionThis leaflet has been provided to help answer some of the questions you and your family may have about induction of labour (IOL) and to help you make an informed decision about your IOL.

This information is based on a national evidence-based clinical guideline on induction of labour (National Institute for Clinical Excellence [NICE] guidelines 2008). It does not specifically look at the care of women who are pregnant and have diabetes, women who are giving birth to more than one baby, or women who are already in labour.

What is induction of labour?Labour is a natural process that usually starts on its own, however, sometimes labour needs to be started artificially and this is called induction of labour. About 20 percent of pregnant women are currently induced in the UK.

Why might I be offered an induction?An obstetrician (doctor) or midwife will only recommend an induction if it benefits you and your baby. There are several reasons why you might be offered induction when your waters are intact:

1) To avoid prolonged pregnancy, which is when the pregnancy lasts 42 weeks or longer (14 days or longer than your expected date of delivery). This is the most common reason for induction.

The placenta is where the oxygen is transferred from the mother’s blood to the baby’s blood and where the food passes from mother’s blood to the baby’s blood during pregnancy. This may become less efficient with prolonged pregnancy and result in stillbirth, although the overall risk of stillbirth remains low. Therefore, IOL is recommended routinely to all women between 40 weeks + 10 to 13 days, if their labour has not started naturally.

The risk of stillbirth increases from:0.9 in 1000 pregnancies by 40 weeks of pregnancy1.3 in 1000 pregnancies by 41 weeks of pregnancy1.6 in 1000 pregnancies by 42 weeks of pregnancy2.1 in 1000 pregnancies by 43 weeks of pregnancy

Because there is no precise way to identify those pregnancies at risk of stillbirth, induction of labour is currently recommended to all such women by 42 weeks.

2) Advanced maternal age - There is some evidence (references are given at the end) that the stillbirth rate increases with advanced maternal age. If you are 40 years or older, the risk of still birth increases as follows:

1.8 in 1000 pregnancies by 40 weeks of pregnancy2.6 in 1000 pregnancies by 41 weeks of pregnancy3.2 in 1000 pregnancies by 42 weeks of pregnancy4.2 in 1000 pregnancies by 43 weeks of pregnancy

For this reason, you may be offered IOL if you are 40 years old or older at around 40 weeks in your pregnancy (gestation). We will discuss this with you in detail in the antenatal clinic.

3) If you or your baby’s wellbeing is causing concern - You will be offered IOL in circumstances when delivering your baby would be beneficial to the health of baby or mother, such as the presence of diabetes, high blood pressure, growth problems of the baby, and other such conditions. Please note that if your baby is larger than expected, you should not routinely be offered induction for this reason alone.

181 Figures are taken from the Hospital Episode Statistics for Maternitys.net.


What is membrane sweeping?You will be offered a membrane sweep to help you go into labour naturally before 42 weeks. This involves your obstetrician or midwife placing a finger into your cervix and making a circular, sweeping movement to separate the membranes that surround your baby, or massaging your cervix if this is not possible.

Membrane sweeping does not cause any harm to you or your baby although it may cause some discomfort, pain or bleeding. It may stimulate the natural production of prostaglandins (hormones), which might promote softening of the cervix and in time trigger active labour.

You will be offered a membrane sweep between 40 and 41 weeks at your antenatal appointments to reduce the need for induction of labour. If labour does not start after this, you can ask for additional membrane sweeps especially if you have had a baby before.

What are the risks or disadvantages of IOL?Induction promotes birth before your body is ready for labour, so compared to natural labour, some interventions are more common. When reviewing the figures quoted below, remember that you have not gone into spontaneous labour and are being induced to avoid problems.

Compared to spontaneous labour without complications, induction of labour1: » Is a longer process. » Increases the need for an epidural for pain relief (currently about 80 per cent of our women (delivered

at QCCH and St Mary’s) who are induced have regional analgesia). » May provoke too many or prolonged contractions, which can diminish your baby’s oxygen supply and

lower your baby’s heart rate - very rare (less than 1 per cent). » Increases the need for an instrumental birth (10 per cent for spontaneous labour versus 15 per cent

for induced labour nationwide but slightly higher in our maternity units as more women choose to use epidurals for pain relief).

» Increases the need for caesarean section delivery but this is very dependent on the reason for the induction, rather than the induction itself.

If the process of IOL does not work, we will discuss other options with you, one of which is a caesarean section delivery. Therefore, IOL is only recommended if the benefits outweigh the risks.

What happens if I need to be induced?Your midwife or obstetrician will explain in detail the reasons why they recommend induction of labour. It is important that you understand the IOL process and ask any questions you might have.

Your assessment will include examination of your belly (abdomen) to see how your baby is lying in your womb, and listening to your baby’s heart beat. Following this, you will most likely be offered an internal examination to assess your cervix (neck of the womb), and a membrane sweep. We will then arrange a date of IOL for you at the reception desk in the antenatal clinic.

How long should IOL last?It is different for each pregnant woman and depends on how ready the neck of your womb and your baby are for birth. In general, if this is your first pregnancy (you have not given birth before) and the neck of your womb is not ready (cervix is closed and hard), it may take up to two to three days from the start of the IOL to the birth of your baby.



How will I be induced?IOL is carried using the following methods:1) Softening and shortening of your cervix (neck of the womb) called cervical ripening. This is usually achieved by inserting prostaglandins (hormones) into the vagina.2) Breaking the waters around your baby in the womb (if they have not broken already during ripening). This is called artificial rupture of membranes (ARM).3) Using an oxytocin infusion drip to enhance the contractions to widen your cervix. This is called cervical dilatation.

Your labour might start after cervical ripening by the prostaglandins and you may not need the following two steps. However, if this is your first pregnancy or the neck of your womb is not ready at all, you are more likely to go through all steps as above.

ProstaglandinsWe use two types of prostaglandins: pessary and gel. We prefer to use a prostaglandin pessary, especially if this is your first pregnancy or the neck of the womb is not ready at all.

Pessary is a slow release prostaglandin which is inserted into your vagina once and works over 24 hours. It prepares the neck of the womb for labour. You may also get contractions during this process. We will advise you to keep the pessary in for 24 hours. The pessary may need to be removed if:

» You are in real labour (which is when you have regular, three or four contractions every ten minutes and the neck of your womb is opened 3 cm or more).

» You are having too many contractions (five or more contractions every ten minutes). » You are having too long contractions (one contraction lasting about two minutes). » Your baby’s heart beat is no longer normal. » You start bleeding. It is normal to get a tiny amount of blood with some mucousy discharge after an

internal examination.

The possibilities of what might happen once prostaglandin pessary is inserted: » You may go into labour and the neck of your womb may start opening. If this happens, we will remove

the pessary. » Your waters may break without you being in labour. If this happens, you will need an oxytocin infusion

drip to start the contractions. The prostaglandin pessary may be left inside while you are waiting for the drip.

» The neck of your womb will soften and shorten but you may not have gone into labour. If this happens, your waters will need to be broken and then you will need an oxytocin infusion drip to start the contractions.

If an oxytocin infusion drip is planned for your induction, you may choose to have an epidural anaesthesia before the drip. Epidural anaesthesia will not make the oxytocin drip less effective.

Prostin E2 ® (Dinoprostone) gel is also effective in preparing the neck of the womb for labour. However, if one gel does not make the neck of the womb ready, you may need another gel. Some women need a third application of gel but this is very rare. There has to be at least a six-hour period in between the prostin gels. This period may be longer if you are having contractions or if the labour ward is very busy. It works the same way as prostaglandin pessary.

Artificial rupture of the membranes (ARM)This is also known as breaking the waters and can be used if the cervix has started to ripen. A small hole is made in the membranes using a slim sterile plastic instrument (single use) during an internal examination performed by the midwife or obstetrician. Having your membranes broken should encourage more effective contractions.



Use of oxytocinSometimes prostaglandins or breaking the waters is sufficient to start a labour, but many women require oxytocin. This drug is given using a drip into a vein in the arm. It causes the womb to contract, and is usually used after the membranes have broken either naturally or artificially. The dose can be adjusted according to how your labour is progressing. The aim is for the womb to contract regularly until you give birth.

When using this method of induction, it is advisable to have your baby’s heart rate monitored continuously using a cardiotocogragh machine (CTG). The contractions can feel quite strong with this type of induction – the midwife will ask you how you are coping and tell you about different methods of pain management. However, we will offer you an epidural for pain relief before starting an oxytocin drip.

Can I be induced and still have a home birth or go to the birth centre?If your labour is induced, you will not be able to have your baby at home or in the birth centre. This is because your baby’s heart beat and the frequency of your contractions will need to be monitored continuously after having prostaglandin and/or oxytocin drip.

What happens if induction does not work?If you do not go into labour after induction, your midwife and obstetrician will discuss your options with you and check you and your baby thoroughly. This happens in about five to ten percent of women having IOL. Depending on your wishes and circumstances, we may offer you:

» Another method of IOL. » Defer the IOL for a later date if circumstances allow. » Caesarean section delivery.

Can I choose not to be induced?Your obstetrician will explain in detail the reasons why they recommend IOL. However, if you do not wish to be induced at this time, you should tell your midwife or obstetrician. We will then ask you to come to the hospital for monitoring so that we can check how you and your baby are. We will test your baby’s heart beat using a CTG and you will have a scan to check the water around your baby.

Please note that these methods are not very reliable to show us which pregnancies are at high risk for stillbirth. Because of these limitations, we offer IOL to all pregnancies before 42 weeks gestation (two weeks after your expected date of delivery).

How often you come to the hospital for monitoring depends on your situation, and the midwife and obstetrician will discuss this with you.

Why might my induction be delayed?We understand that when your induction is delayed, this can make you feel distressed and upset. However, the midwife or obstetrician will give you reassurance and try to keep you informed about arrangements for your induction. The arrangements are dependent on your individual circumstances and those of the labour ward.

Your IOL may be delayed if all midwives are busy caring for other patients at that time and/or there is no bed available. Birth is unpredictable and we have women arriving as emergencies 24 hours a day. We, as midwives and obstetricians, have a responsibility to care for mothers and babies on our unit and ensure safe deliveries. This may impact on the plan for your IOL, either delaying the start of your induction or delaying the process of your induction if it has already started. If you are unhappy at any time, please ask to speak to the senior midwife on duty.



What are the arrangements for induction of labour at Queen Charlotte’s and Chelsea Hospital?We will give you a date and time to come to the hospital. You do not need to phone us to confirm.

» On the day of admission for your induction, please come to the Lewis Suite (day assessment unit) at 08.00am.

» If all is well and you are living close to the hospital, you may be allowed to go home. We will ask you to come back for assessment 12 hours later if this is your first pregnancy, OR four to six hours later if you had a vaginal birth before. We will give you detailed instructions on what to expect and what to do if you go home.

» If you stay in hospital, you will be admitted to the Edith Dare Ward after prostaglandin insertion.The Lewis Suite is located on the first floor of Hammersmith Hospital (opposite the birth centre). The telephone number is 020 3313 3349.

What are the arrangements for induction of labour at St Mary’s Hospital?We will give a date and time to come to the hospital. There is no need to phone to confirm.

» On the day of the admission for your induction, please come to Day Assessment on the labour ward at 08.00am.

» Following the insertion of the prostaglandin pessary you will then stay in hospital, and be admitted to the Alec Bourne Ward.

Occasionally on admission to Day Assessment you may be transferred to Alec Bourne Ward for the insertion of the prostaglandin pessary.

How do I make a comment about my treatment?We aim to provide the best possible service and staff will be happy to answer any of the questions you may have. If you have any suggestions or comments about your visit (either positive or negative), please speak to a member of staff, email our patient complaint coordinators at [email protected] or contact our patient advice and liaison service (PALS) who will listen to your concerns and queries and are often able to help sort out problems on your behalf. You can phone the PALS team on 020 3312 7777 (St Mary’s Hospital) or 020 3313 0088 (Queen Charlotte’s and Chelsea Hospital), email them at [email protected] or visit www.imperial.nhs.uk/pals).

Alternatively, you may wish to express your concerns in writing to: Chief executive’s office, Imperial College Healthcare NHS Trust, Trust HeadquartersThe Bays, South Wharf Road, London W2 1NY

If you have any further questions about induction of labour or about information in thisinformation sheet, please contact the antenatal clinic:

Queen Charlotte’s and Chelsea Hospital 020 3313 3926St Mary’s Hospital 020 3312 1443Maternity Helpline 020 3313 1888

Referenceshttp://guidance.nice.org.uk/CG70/PublicInfo/pdf/English)http://www.nice.org.uk/nicemedia/pdf/CG070FullGuideline.pdfhttp://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1475

Advanced maternal ageJoseph KS, Allen AC, Dodds L, et al. The perinatal effects of delayed childbearing. Obstet Gynecol 2005; 105:1410–1418.Jacobsson B, Ladfors L, Milsom I. Advanced maternal age and adverse perinatal outcome. Obstet Gynecol 2004; 104:727–733.Bahtiyar MO et al Stillbirth at Term in Women of Advanced Maternal Age in the United States: When could the antenatal testing be initiated? Amer J Perinatol 2008; 25(5): 301-304.


Appendix 4South West London Maternity NetworkIOL | Information leaflet

Being induced with Propess – going home during the process (outpatient induction)Having a baby is a very special time in the life of a woman and her family, and we want to make sure that if is a positive and safe experience. In most pregnancies the labour starts naturally between 27 to 42 weeks, Here at (insert name) Hospital, low-risk women who have chosen to be induced when their labour has not started by (insert gestation) to 42 weeks, are able to go home during the induction process. (This is known as outpatient induction).

If you have chosen not to be induced, this process is not relevant to you. Please talk to your midwife or doctor about other ways to manage your pregnancy until the birth of your baby.

If you have had a healthy straightforward pregnancy (and do not suffer from any medical conditions) and you have chosen to be induced because your pregnancy has continued at least 10 days beyond your estimated due date, we will offer you an outpatient induction.

Going home during an induction is not recommended for some women, for example, if you are over 40 years old, overweight (with a BMI over 30), over 42 weeks pregnant, have had a previous Caesarean birth, this is not your first pregnancy, or your waters have already broken.

Inducing labour usually takes time, sometimes several days, and may follow a number of steps. These could include softening (or ripening) your cervix (the neck of the womb), breaking your waters and giving you a hormone drip through your vein to make your contractions start. You may not need all of these steps, and this information leaflet is about the process of softening your cervix using a drug called Propess.

We understand that you may be disappointed about being induced, so it is important that you feel it is the right thing for you and your baby. If you do choose to go ahead with the induction, we will do all we can to meet your birth plan wishes as closely as possible. Please ask us if you have any questions.

Common questions

Why is my labour being induced? About one in five women have their labour started artificially by induction. In most cases this is done because their labour has not begun by ……weeks. The main reason that induction is recommended is because some studies have shown that babies are at slightly more risk of developing problems during pregnancy and labour if they remain in the uterus after 41 weeks and five days [reference].

Can I avoid having my labour induced? Having your labour induced is your choice. Some women would like to avoid being induced with drugs (due to the disadvantages – see below) and choose to have a membrane sweep (which may help the cervix to soften without any further intervention) or do nothing and wait for their labour to start naturally.

Membrane sweep (‘stretch and sweep’) This involves a midwife or doctor placing a finger inside your cervix and making a circular sweeping movement to separate the membranes from the cervix. It can be carried out at home or at an outpatient appointment. A stretch and sweep:

» Increases the chance of labour starting naturally within the next 48 hours and can reduce the need for further induction of labour.

» May be uncomfortable and cause a small amount of bleeding. » Is not recommended if your membranes have ruptured (waters broken). » Does not increase the risk of infection to you or your baby.



What happens in hospital? You will be asked to come to [insert ward and time] on the day your labour is to be induced. A midwife will check your vital signs (your temperature, pulse, blood pressure and breathing rate) and record your baby’s heartbeat (CTG). The midwife will then carry out a vaginal examination to assess your cervix before inserting a vaginal pessary, called Propess.

How will I be induced? Your labour will be induced with a vaginal pessary, called Propess. The pessary can stay in your vagina for 24 hours.

What is Propess? Propess pessary contains an active ingredient (dinoprostone) which is a natural hormone also known as prostaglandin. The pessary looks like a very small tampon and is inserted into the vagina. What are the benefits of going home after having a Propess pessary inserted? Going home means that you can return to a comfortable and familiar environment. Research shows that women are more likely to go into labour if they are relaxed within their own surroundings.

Who can have an outpatient induction? We recommend an outpatient induction if:

» Your pregnancy has been straightforward. » You live within 30 minutes of the hospital. » You have access to a telephone. » You understand the process.

What you need to be aware of once the pessary is in place If the string from the pessary moves to the outside of your vagina, you should be careful not to pull or drag on it as this may cause the pessary to come out. South West London Maternity Network

Please take special care: » When wiping yourself after using the toilet. » While or after washing yourself. » When getting on or off a bed.

It is very unlikely that the pessary will come out, but if it does it will need to be put back in. If it has fallen onto a clean surface you can replace it yourself. Otherwise, you should come to (insert ward) to have it put back in.

Tell the midwife if: » Your waters break. » You don’t feel your baby moving as much as usual. » Your contractions are coming more than once every five minutes. » You are worried. » The pessary falls out.

If any of the above happens, please call our midwifery team on [insert telephone number] and come into the labour ward.

Suggestions to help yourself at home » Carry on as usual. Try to do things to take your mind off wondering when your labour will start. » Go for a walk if you feel like it. » Make sure you eat and drink as usual. » Rest and sleep as much as possible − induction can be a slow process. » Arrange to have an adult with you.



Suggestions for coping with contractions at home » Have a warm bath. » Take long, deep breaths through your contractions – focus particularly on breathing out. » Keep mobile and try different positions to get more comfortable. » Try sitting or leaning on a birth ball. » Emotional and physical support from your birth partner can help. » Ask someone to give you a massage. » Aromatherapy can help (on the recommendation of a qualified aromatherapist). » Listen to music or relaxation downloads.

Once your contractions start, there is no need to come to hospital straight away unless: » The contractions are every two minutes or very strong. » You have continuous pain in your stomach. » Your waters break. » You have vaginal bleeding. » Your baby is not moving as usual.

If you are concerned about anything while you are at home, please call our midwifery team in the labour ward on (insert number).

After 12 hours You should call the midwife on (provide ward and telephone number) between (insert times) to discuss your progress and receive advice.

What happens 24 hours after the pessary is inserted? After the Propess is inserted you will be asked to return the following day to (insert ward) at (insert time) to have it removed and have a vaginal examination. If your cervix is ready, your waters will be broken. If the cervix is not ready, the midwives will discuss a further plan with you. South West London Maternity Network

Artificial rupture of the membranes (ARM) ARM, or breaking your waters (amniotic fluid), is part of the induction process. It needs to be carried out before the hormone drip can be used.

» It is done during an internal examination so may be uncomfortable. » It may increase the strength and frequency of contractions quite significantly, which can be more

difficult to cope with. » It does not hurt your baby, but your baby may become distressed due to an increase in the strength

of contractions. » The midwives can see the colour of the amniotic fluid which can help them assess your baby’s well-

being. » You will need to keep a maternity pad on afterwards until your baby is born. » You are still encouraged to keep moving about.

Syntocinon hormone drip Syntocinon is an artificial hormone which is used to represent the natural hormone oxytocin. It can be given on the labour ward, after your waters are broken, as part of the induction process. The drip increases the strength and frequency of your contractions and can cause too many contractions or very strong contractions. If that happens, the drip will be slowed down or turned off. Your baby’s heartbeat will need to be monitored continuously to check that he or she is coping with the effects of the syntocinon. You do not have to be in bed when you are being induced − it is still possible to be out of bed with a monitor and drip attached.



Advantages of having your labour induced » It can benefit the health of your baby as the placenta may not work as well once you go two weeks

beyond your due date. » It is a planned date (but you could go into labour naturally before then). » If you are being induced after your due date, you are no more likely to need a Caesarean section

than if you go into labour naturally.

Disadvantages of having your labour induced » Syntocinon-induced contractions are stronger than natural contractions and you are more likely to

need an epidural to be able to cope with the pain. » Syntocinon-induced contractions may distress your baby. » Breaking your waters may distress your baby. » Synthetic oxytocin can interfere with the release of natural oxytocin during labour and early

breastfeeding, so you and your baby may need extra support with getting breastfeeding started. » Induction may not always be successful and you will need a Caeasarean section if this is the case.

Your care will be reviewed by a senior doctor and a plan will be discussed with you. » You will need more internal examinations to assess your progress and plan your treatment. You may

find this uncomfortable. » You may spend some of the time on an antenatal ward with other women who are in labour. » Your partner may be sent home while you are on an antenatal ward. » There can be a delay between the induction starting and your labour becoming established. Your

labour may take up to three days. » Occasionally there may be a delay with your induction due to other cases on the labour ward. You will

be kept informed.

Information and communication You will be kept fully informed about what is happening at all stages, and your wishes will be taken into account. Please do ask if you do not understand anything or you want us to explain anything.


Appendix 5South West London Maternity NetworkPatient satisfaction survey for outpatient induction

We value your comments and suggestions so please complete this questionnaire by ticking the boxes that apply. It will help us to improve our service.

1. Were you satisfied with the explanation given to you about outpatient induction of labour? Yes No

2. Was it more convenient to return home rather than stay in the hospital? Yes No

3. Did you have any problems following the instructions? Yes No

4. Were you comfortable having your induction done as an outpatient? Yes No

5. Overall how satisfied were you with the treatment? Very satisfied Satisfied Dissatisfied Very dissatisfied

6. Would you be recommending this process to your friend/family? Yes No

Please provide any comments or suggestions you feel may be of help to us.

Thank you for your response. Kindly return the completed form to your midwife.

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Aim To improve the detection of fetal growth abnormalities in London through the use of customised growth assessment and protocols.

This toolkit has been produced as part of the London Maternity Strategic Clinical Network’s strategy to identify areas of good practice for implementation across all maternity units in the capital, ensuring equally good outcomes for all pregnant women and their babies.

This toolkit presents the evidence that the implementation of antenatal detection of fetal growth restriction is an effective way of reducing the number of stillbirths. In practice, the Growth Assessment Protocol (GAP) is the best described intervention combining three core elements including GROW and a package of support. It is envisaged that all maternity units will adopt the package across London.

Background and rationaleStillbirth rates in the United Kingdom have shown little change over the last 20 years, and the rate remains among the highest in high income countries. In England and Wales, the stillbirth rate is 4.7 per 1,000 live births. London has the highest stillbirth rate of all regions in the United Kingdom at 5.3 stillbirths per 1,000 live births1.

A recent review has suggested that in terms of the economic impact on the National Health Service, the annual costs in England and Wales for investigation and care immediately following stillbirth is almost £6 million, whilst antenatal costs in a next pregnancy are approximately £15.1 million. Combined with litigation costs (£1.6 million), this figure rises to £16.7 million for the UK health service2.

Reducing stillbirth rates has been identified as both a key national and local priority for the NHS and Strategic Clinical Networks, and is supported by the National Outcomes Framework3.

Risk factorsRisk factors associated with stillbirth include maternal obesity, ethnicity, smoking, pre-existing diabetes, and history of mental health problems, antepartum haemorrhage and fetal growth restriction (birth weight below the 10th customised weight percentile).

The evidence shows that fetal growth restriction (FGR) is by far the single strongest risk factor for stillbirth after 34 weeks gestation, and it accounts for approximately 50 per cent of all stillbirths before 34 weeks gestation.

However, the early detection of fetal growth problems can substantially reduce the risk of stillbirth. Findings from a cohort study in the West Midlands between June 2009 and May 2011 showed that the relative risk of stillbirth can be halved (from 6.5 to 3.4) when FGR is detected antenatally4.

Role of customised growth chartsCustomised antenatal growth charts are designed to provide a more accurate representation of fetal growth and improve the recognition of babies that are pathologically small. The charts take account of height, weight, ethnicity, parity of the woman. They are used to plot fundal height measurements and estimated fetal weight following an ultrasound scan and predict the fetal growth curve for each pregnancy.

Customised assessment of birth weight and fetal growth has been recommended in national guidelines from the Royal College of Obstetricians and Gynaecologists5.

Customised charts improve outcomes by

» Improving the detection of fetal growth problems

» Avoiding unnecessary ultrasound referrals, enabling resources to be focused towards high-risk pregnancies

» Reducing anxiety by reassuring mothers when growth is normal

The customised chart is calculated using computer software. In the UK, Gestation Related Optimal Weight (GROW), software is available from the Perinatal Institute, and as part of the comprehensive growth assessment protocol (GAP) which is designed to provide quality assurance.

The regional implementation of GAP accreditation training between 2008 and 2011 in three regions (West Midlands, Yorkshire and Humber and the North East) was associated with a significant reduction in stillbirths due to fewer deaths of babies with FGR and a substantial increase in antenatal detection.

Reducing stillbirth through improved detection of fetal growth restriction: A best practice toolkit

November 2014

28

By 2012, the West Midlands had seen a 22 per cent reduction in the stillbirth rate, equivalent to 92 fewer deaths a year. Extrapolated to the rest of the UK, it is estimated that the GAP programme has the potential to save more than 1,000 babies a year6.

Growth assessment protocol (GAP)Since 2013, GAP has been adopted by more than half of UK maternity units.

GAP training comprises three core elements, including the GROW charts and a package of support:

1.) Implementation of evidence based protocols and guidelines

» Customised growth charts and birth weight centiles via specialised software

» Evidence based template in the use of fetal growth assessment charts including referral criteria for adapting into local protocols

2.) Training and accreditation of all staff involved in clinical care

» GAP trainers who deliver “train the trainer” sessions

» E-learning and test package » Competency document for peer assessment » Online training and competency log

3.) Rolling audit and benchmarking of performance

» Data collection tool to determine FGR rates and antenatal detection rates

» Reporting and benchmarking of unit based rates of FGR and detection

» Audit tool to log missed cases

Auditable standardEach unit should audit the proportion of babies with IUGR identified during the antenatal period (percentage of babies detected <10th customised centile) and missed cases of IUGR.

ImplementationThe Perinatal Institute’s programme for reducing stillbirths through improved detection of fetal growth restriction is recommended by commissioning guidance from NHS England7.

The GAP programme is available to Trusts directly from the Perinatal Institute and information on the small cost and timescale for implementation and maintenance is also available at www.perinatal.org.uk/gap or on telephone 0121 607 0101.

Key factors to aid the successful lo-cal implementation of the GAP pro-gramme

» Ensure training and accreditation of all staff using GROW (target of 75 per cent in the first year)

» Nominate trust champions to provide local leadership in implementation, drawing on a range of specialties such as a midwifery manager (e.g. head of midwifery, supervisor of midwives, clinical risk manager, matron), an ultrasonographer and an obstetric/fetal medicine lead.

References / further reading1. Office for National Statistics, Birth summary tables,

England and Wales 2014, London ONS (2013): http://bit.ly/YEe9qp.

2. Mistry H, Heazell A, Vincent O, Roberts T. A structured review and exploration of the healthcare costs associated with stillbirth and a subsequent pregnancy in England and Wales. BMC Pregnancy and Childbirth 13:236 (2013).

3. NHS Outcomes Framework 2013 / 14, Department of Health. (2012). http://bit.ly/1tp5jXG.

4. Gardosi J, Madurasinghe V, Williams M, et al, Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013;346:f108.

5. Green-top Guideline No 31: The investigation and management of the small–for-gestational-age fetus, Royal College of Obstetricians and Gynaecologists. (2013) http://bit.ly/1kY1592.

6. Gardosi J, Giddings S, Clifford S, Wood L, Francis A, et al, Association between regional stillbirth rates and regional uptake of accreditation training in customised fetal growth assessment. BMJ 2013;3: 003942.

7. Our ambition to reduce premature mortality: A resource to support commissioners in setting a level of ambition, NHS England. (2013) http://bit.ly/1oUZxOn.

8. NICE Clinical Guideline 62, Antenatal care. NICE (2008). http://bit.ly/1s4z4LF.

9. Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal mortality 2006: England, Wales and Northern Ireland. CEMACH, 2008.

10. Clifford S, Giddings S, Southam M, Williams M, Gardosi J, The Growth Assessment Protocol: a national programme to improve patient safety in maternity care. Midwifery Digest 23:4 2013.


Reducing stillbirth through improved detection of fetal growth restriction: A best practice toolkit

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http://www.perinatal.org.uk/gap

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Aim To implement excellent practice across all units to ensure equally good outcome for all women with major haemorrhage.

Background and rationaleMajor obstetric haemorrhage is still a cause of serious maternal morbidity and mortality, accounting for over 30 per cent of all obstetric related admissions to intensive care.

This toolkit has been produced as part of the London Maternity Strategic Clinical Network’s (SCN) strategy to facilitate a systematic approach throughout the network. The aim is to implement excellent practice across all units to ensure equally good outcome for all women with major haemorrhage. Standardisation of health care processes and reduced variation in practice has been shown to improve outcomes and quality of care.

London wide definitionThere is a large variation in how major obstetric haemorrhage is defined. To be able to compare outcome data a standardised definition should be adopted by all units.

Definition major obstetric haemorrhage » Objectively recorded blood loss equal or

exceeding 1.5 litres (swabs, pads etc. weighed, liquor deducted). The basis for this definition is that a total blood loss of 1.5 litres equals one quarter to a third of maternal blood volume and is the point at which patients start to develop physiological signs of impaired organ perfusion.

» All cases requiring blood transfusion of 4 units or more.

» All cases requiring unplanned interventional radiology to control haemorrhage.

Quality standardsIt is assumed that all units have local guidelines for the management of major obstetric haemorrhage. The remit for this toolkit is to ensure that important quality indicators are represented within the local guideline to ensure equally excellent care throughout London.

Guidelines must include » Maternal blood loss > 1.5 litres should activate

a major haemorrhage protocol. Within the protocol there must be clear determination of individual responsibilities.

» The suggested time frame for escalation to consultant level should be in accordance with consultant attendance for other emergencies. Early escalation to senior level should be encouraged.

» Additional physiological triggers based on defined MEOWS chart criteria (e.g. HR increase, fall in BP and O2 Sats) should be included, as well as measured blood loss.

» Each obstetric unit must have access to on-site blood banking and O neg blood 24/7. This includes immediate support from consultant haematologists.

» There must be a protocol for the treatment of ante-partum anaemia with support from haematology.

» All women with a previous Caesarean section must have their placental site determined to detect abnormal placentation, if necessary with MRI scan. There must be an ante-partum assessment tool to identify women at risk for haemorrhage.

» Evidence of regular participation of all staff in multidisciplinary skills and drills sessions (at least once/year); organised as a core component of mandatory training and including training in quantitative measurement of blood loss.

» Evidence of regular multidisciplinary mortality and morbidity meetings to discuss learning points from major haemorrhage cases to share good practice.

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Referral pathwaysProtocols must identify clear lines of communication with haematology, intensive care and interventional radiology in case of unexpected obstetric haemorrhage. If a hospital does not provide services like cell salvage or interventional radiology, referral pathways must be easy to activate and include contact details. Pathways should be defined for the following scenarios:

» For women identified as high risk for major obstetric haemorrhage; they should be managed in an appropriate centre with early referral to achieve this as necessary.

» Women who refuse blood products and need access to cell saving facilities. Rapid access to interventional radiology, including emergency transfer.

» For women with morbidly adherent placenta who need delivery at a regional centre.

» For access to level 3 intensive care facilities for the critically ill mother.

Auditable standardsEach obstetric unit should audit their management of obstetric haemorrhage as part of a multidisciplinary morbidity and mortality review. The aim is to develop a London wide dashboard to compare outcomes, share examples of good practice and to reduce variations in outcome within London maternity services.

London maternity dashboard data » Overall number of cases of major obstetric

haemorrhage (according to London wide definition) and blood transfusion requirements for each individual case.

» Number of cases requiring unplanned interventional radiology.

» Peri-partum hysterectomy.

» Number of cases admitted to level 3 ITU care with major obstetric haemorrhage as the reason for admission.

» Number of cases referred to tertiary centre for the management of acute major obstetric haemorrhage.

Further reading1. Saving Mothers Lives: Reviewing maternal deaths

to make motherhood safer CEMACE, BJOG 118 (Suppl 1), 1 – 203.

2. National Patient Safety Agency and RCOG- Placenta praevia after caesarean section care bundle: background information for health professionals. London: NPSA 2010.

3. Knight M et al Trends in postpartum haemorrhage in high resource countries: a review and recommendations from the International Postpartum Haemorrhage Collaborative Group. BMC Pregnancy Childbirth 2009;9:55.

4. Prevention of postpartum haemorrhage. Clinical Guideline No 52 RCOG London 2009.

5. The role of emergency and elective interventional radiology in postpartum haemorrhage. Good Practice Guideline No 7 RCOG London 2007.

6. Intrapartum Care. National Institute for Health and Clinical Excellence (NICE) CG55; 2007.

7. Caesarean section. NICE CG132; 2013.

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Aim To increase the number of eligible women accessing midwifery led settings in London (midwifery led units and home births).


This toolkit presents the evidence that midwifery led settings improve maternal outcomes, increases maternal satisfaction and uses resources more effectively. It also reinforces Department of Health policy and national guidance that pregnant women should be offered a wide range of choice of maternity services including choice of where to give birth and information to support the choices available. This should be available to all women including those of social complexity.

The toolkit is intended to cover healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications1 (‘eligible women’).

Background and rationaleThe evidence shows that midwife-led settings lead to better outcomes for women at low risk of developing intrapartum complications. The Birthplace in England study was a large cohort study that compared outcomes for births in different settings. The study found that for women at low risk of complications in birth, birth is as safe for babies in freestanding midwifery units (FMUs) or alongside midwifery units (AMUs) as it is in obstetric units, but with a lower rate of intervention and a decreased use of pain relief. It has also been demonstrated that planning to give birth outside an obstetric unit is more cost-effective than planning to give birth in an obstetric unit1.

Yet, despite all of the evidence associated with midwifery led settings, the proportion of women birthing in midwifery led units has only shown a small increase in recent years. This is in spite of the number of services providing Birth Centre facilities increasing from 16 to 23 in London.

Approximately 45 per cent of women at the end of pregnancy are eligible to access midwifery led settings3,4, however, the average midwifery led birth rate stands at 15 per cent in London. It ranges from between 1.4 per cent in a unit without a midwifery led unit to 23.9 per cent where there is both an alongside and an associated freestanding midwifery led unit.

The home birth rate has also continued to decline on a year by year basis5.

A recent maternity services survey of all women’s perception of choice in London, found that less than half of women considered that they were offered a choice of giving birth in an alongside or freestanding midwifery unit, whilst only a quarter of women perceived that they were offered a choice of giving birth at home6.

A further report has also highlighted that women from lower socio-economic groups in the UK report a poorer experience of care during pregnancy, have a higher likelihood of hospital admission, transfer during labour and unplanned caesarean delivery7.

Increasing midwifery led birth rates and ensuring all women are made aware of this choice at booking has been identified as a priority for maternity services and the Strategic Clinical Network.

London wide definitionsThere is variation in how birth place settings are defined. To be able to compare outcome data standardised definitions should be adopted by all units.

Place of birth settings » Alongside midwifery unit (AMU) - An NHS

clinical location offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. During labour and birth diagnostic and treatment medical services, including obstetric, neonatal and anaesthetic care are available, should they be needed, in the same building, or in a separate building on the same site. Transfer will normally be by trolley, bed or wheelchair8.

» Freestanding midwifery unit (FMU) - An NHS clinical location offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care.

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General practitioners may also be involved in care. During labour and birth diagnostic and treatment medical services including obstetric, neonatal and anaesthetic care, are not immediately available but are located on a separate site should they be needed. Transfer will normally involve car or ambulance8.

Normal birth » Normal birth - Without induction, without

the use of instruments, not by caesarean section and without general, spinal or epidural anaesthetic before or during delivery9.

Recommendations for action » In order to meet the choice agenda, ensure

your maternity service accommodates an AMU and can facilitate home birth.

» Facilities for midwifery led settings should include a comfortable, clean and safe setting that promotes the wellbeing of women, families and staff, respecting women’s needs, preferences and privacy; with a physical environment that supports normal birth10.

» Facilities should include space for furnishing and equipment commensurate with the promotion of normal birth10.

» The environment must protect and promote women’s privacy and dignity, respecting their human rights and facilities should be provided to maintain adequate nutrition and hydration in labour. Sufficient pools should be made available for use in labour and or birth10.

AMU and FMU staffing considerations » It is recommended that safe staffing levels of

midwives and support staff are ring fenced to prevent unit closure. These should be maintained, reviewed and audited annually10.

» Staffing establishments should be able to ensure that women have one to one care in labour10.

» One whole time equivalent (WTE) consultant midwife for every 1:900 normal births11 is recommended, and the consultant midwife provides leadership.

» Each unit has an appropriate skill mix that supports MLU activities. As a minimum, midwives (bands 6 and 7) should have levels

of experience that are relevant to autonomous practice and decision making; maternity support workers with relevant training and an administrator10.

Guidelines must be evidence based and include

» All women should be given evidence based information and advice about all available settings (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit) when she is deciding where to have her baby, so that she is able to make a fully informed decision. This includes information about outcomes, risks, benefits and consequences for the different settings1.

» Use the following principles when discussing risks and benefits with the woman:

• Personalise the risks and benefits as far as possible.

• Use absolute risk rather than relative risk (for example, the risk of an event increases from one in 1000 to two in 1000).

• Use natural frequency (for example, one in 10).

• Be consistent in the use of data.• Include both positive and negative framing.• Be aware that people interpret terms such

as ‘rare’ in different ways; use numerical data if possible.

• Consider using a mixture of numerical formats2.

» Give the woman the following information, including local statistics, about all local birth settings:

• Access to midwives and medical staff.• Access to birthing pools, active birth

equipment, entonox, other drugs and epidural analgesia.

• The likelihood of being transferred to an obstetric unit, the reasons why this might happen and the time it may take1.

» Advise eligible multiparous women that planning to give birth at home or in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit1.

»



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» Advise eligible nulliparous women that planning to give birth in a midwifery-led unit (freestanding or alongside) is particularly suitable for them because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit. Explain that if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby1.

» Ensure that there are robust protocols in place for transfer of care between settings.

» Each unit should implement criteria from the NICE clinical guideline1 for access to a midwifery led setting and should follow a standardised pathway for women at low risk of developing intrapartum complications (midwifery led units and home births).

» There must also be a clear pathway for women who are not eligible for AMU or FMU settings but wish to receive midwifery led care in those environments.

Referral pathwaysPathways should be defined for the following scenarios:

» Referrals directly from general practice to midwifery led units.

» For women who choose to self refer to midwives.

Auditable standardsEach maternity service should audit birth outcomes. The aim is to develop a London wide dashboard to compare outcomes, share expertise from centres of excellence and to improve equality within London maternity services.

Each unit as a minimum should audit against the following standards:

» Percentage of women offered evidence based written information (including outcomes, risks, benefits and consequences for the different settings) about planning place of birth.

» Percentage of women offered the choice of planning birth at home or in a midwifery unit.

» London Quality Standards for maternity services11.

» The number of women receiving intrapartum care and the number of births in each setting.

» The number of primips utilising AMUs and FMUs.

» The number of transfers including the:• Reason.• Speed of transfer and whether this met

local standards.• Reasons for non-transfer when clinically

indicated.

» The number and length of time that the AMU and FMU are closed and the home birth service is suspended.

» Percentage of unexpected admissions to NICU.

» Percentage of water births.

AppendicesFurther resources to support this toolkit are available in the appendices and include:

» Appendix 1 - Midwifery led pathway for eligible women accessing midwifery led settings.

» Appendix 2- Decision tree for place of birth - for midwives to use to help to provide women with information during birth place discussions.

Note: Appendix 1 and Appendix 2 are largely based on the work previously undertaken by Barnet and Chase Farm hospitals.



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References 1. NICE Clinical Guideline 190, Intrapartum care.

NICE (2014). www.nice.org.uk/guidance/CG190

2. NICE Clinical Guideline 138, Patient experience in adult NHS services: improving the experience of care for people using adult NHS services, NICE 2012. www.nice.org.uk/guidance/cg138

3. Sandall J, The contribution of continuity of midwifery care to high quality maternity care, RCM, 2014. www.rcm.org.uk/clinical-practice-and-guidance/position-statements2

4. Sandall J, Murrells T, Dodwell M, Gibson R, Bewley S, Coxon K, et al.The efficient use of the maternity workforce and the implications for safety and quality in maternity care: a population-based, cross-sectional study. Health Service Delivery Res 2014;2(38).

5. London LSA annual report to the Nursing and Midwifery Council,1 April 2013 to 31 March 2014, NHS England, 2014 www.londonlsa.org.uk/pdf/annual_report/London_LSA_Annual_Report_2013-2014.pdf

6. Rogers C, Maternity services survey: Women’s perception of choice with respect to place of birth in London, SCNG, 2014.

7. Lindquist A et al. Experiences, utilisation and outcomes of maternity care in England among women from different socio-economic groups: findings from the 2010 National Maternity Survey, BJOG, 2014, DOI: 10.1111/1471-0528.13059.

8. The birthplace in England study, NPEU 2007, www.npeu.ox.ac.uk/birthplace/component-studies/tdc

9. Maternity Care Working Party. Making normal birth a reality. NCT, RCM, and RCOG, 2007. www.rcog.org.uk/womens-health/clinical-guidance/making-normal-birth-reality

10. Standards for birth centres in England: A standards document, RCM, 2009.

11. London Health Programmes, London quality standards: Acute emergency and maternity services, quality and safety programme, 2013. www.londonhp.nhs.uk/wp-content/uploads/2013/06/London-Quality-Standards-Acute-Emergency-and-Maternity-Services-February-2013-FINALv2.pdf

Further reading » Birth Centre Resource: a practical guide, RCM,

2009.

» Coxon, K, Birth Place Decision Support Guide, KCL, 2014. https://kclpure.kcl.ac.uk/portal/files/33242518/Birth_place_decision_support_Generic_2_.pdf

» Department of Health, NHS Choice Framework 2014-2015, 2014. www.gov.uk/government/publications/nhs-choice-framework

» Freestanding midwifery units, Busting the Myths, RCM, 2011. www.rcm.org.uk/clinical-practice-and-guidance/position-statements2

» NICE Quality Standard 22, Antenatal Care, NICE2012, www.nice.org.uk/guidance/QS22

» NICE Public Health Guidance 110: Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors, NICE, 2010. www.nice.org.uk/guidance/cg110

» RCOG, RCM, RCOA, RCPCH, Safer Childbirth- Minimum Standards for the Organisation and Delivery of Care in Labour, RCOG, 2007. www.rcog.org.uk/en/guidelines-research-services/guidelines/safer-childbirth-minimum-standards-for-the-organisation-and-delivery-of-care-in-labour

» Staffing Standard in Midwifery Services Position Statement, RCM, 2009. www.rcm.org.uk/college/standards-and-practice/position-statements/

» Which?, Birth choice. www.which.co.uk/birth-choice.



http://www.nice.org.uk/guidance/CG190

http://www.nice.org.uk/guidance/cg138

https://www.rcm.org.uk/clinical-practice-and-guidance/position-statements2


http://www.londonlsa.org.uk/pdf/annual_report/London_LSA_Annual_Report_2013-2014.pdf



http://www.npeu.ox.ac.uk/birthplace/component-studies/tdc

http://www.npeu.ox.ac.uk/birthplace/component-studies/tdc

http://www.rcog.org.uk/womens-health/clinical-guidance/making-normal-birth-reality



http://www.londonhp.nhs.uk/wp-content/uploads/2013/06/London-Quality-Standards-Acute-Emergency-and-Maternity-Services-February-2013-FINALv2.pdf



https://kclpure.kcl.ac.uk/portal/files/33242518/Birth_place_decision_support_Generic_2_.pdf



https://www.gov.uk/government/publications/nhs-choice-framework

https://www.gov.uk/government/publications/nhs-choice-framework



http://www.nice.org.uk/guidance/QS22



https://www.rcog.org.uk/en/guidelines-research-services/guidelines/safer-childbirth-minimum-standards-for-the-organisation-and-delivery-of-care-in-labour/




http://www.rcm.org.uk/college/standards-and-practice/position-statements/%0D

http://www.rcm.org.uk/college/standards-and-practice/position-statements/%0D

http://www.which.co.uk/birth-choice


Appendix 1

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Appendix 2 should be used alongside the NICE Intrapartum Care clinical guideline, Appendix L, Place of Birth – Decision Aid: www.nice.org.uk/guidance/cg190/evidence/cg190-intrapartum-care-appendices2iBrocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, et al. (2011) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal; 343(d7400):1-13.

Appendix 2

http://www.nice.org.uk/guidance/cg190/evidence/cg190-intrapartum-care-appendices2

http://www.nice.org.uk/guidance/cg190/evidence/cg190-intrapartum-care-appendices2

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Aim To increase the number of women accessing continuity of midwife care in London.


This toolkit presents the evidence that continuity of midwife care improves maternal and infant outcomes, improves maternal experience of care and uses resources more effectively.

It also reinforces Department of Health policy and the NHS Mandate that “every woman has a named midwife who is responsible for ensuring she has personalised, one-to-one care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concern”1.

Current National Institute for Health and Care Excellence (NICE) antenatal2 and postnatal quality care standards both state women should have a named midwife.

In the postnatal period, this person is referred to as a named healthcare professional3.This should be available to all women including those of social complexity4.

The toolkit is intended to cover all pregnant and childbearing women in all maternity units across London.

Background and rationaleA woman who receives care from a known midwife is more likely to:

» Have a vaginal birth. » Have fewer interventions during birth.

» Have a more positive experience of labour and birth.

» Successfully breastfeed her baby.

» Cost the health system less.

A woman who receives care from a known midwife is less likely to:

» Experience preterm birth.

» Lose their baby before 24 weeks’ gestation.

This applies to low and mixed risk populations of women5.

Other studies have found that women who carry social complexity and find services hard to access in particular value continuity6 and increased advocacy and care co-ordination7. Women also experienced increased agency and control, and more empathic care8.

Comments from mothersThe below comments are direct quotes, received from the Family and Friends Test at Guy’s and St Thomas’ NHS Foundation Trust.

“Fantastic midwife team. Have had an appointment to meet all the midwives but also having an assigned midwife to do home visits is so appreciated. Given me a lot of confidence as this is my first pregnancy and continuous contact during past weeks is excellent.”

“Like flexibility of home visits and comfortable by consistency of midwife so don’t have to repeat medical history/situation which makes visits more efficient.”

“The care I have received from the valley team midwives has been excellent. Completely different to the care I received three years ago with my first. I feel very well looked after and feel as though they really got to know me and my baby as always saw the same person. All women should have this level of maternity care.”

There appears to be a cost-saving effect for midwife-led continuity of care as compared to other care models, in which the estimated mean cost saving for each maternity episode is £12.38.

However, the level of implementation of continuity of midwife care and the number of women who have a named midwife who cares for them throughout their pregnancy and birth is unknown. In the last national survey of 23,000 women’s experiences of maternity care in England in 2013, 34 per cent of women saw the same midwife every time during pregnancy, and 27 per cent during the postnatal period.

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In 2010, 25 per cent of women had previously met the staff who cared for them during their labour and birth. Women who saw the same midwife were more likely to have all their questions answered, given enough time, felt listened to, and felt involved with their care9.

Increasing continuity of midwife care has been identified as a priority for maternity services and the Strategic Clinical Network. For example, south west London commissioners have already stated their expectation that women with uncomplicated care should have no more than two midwives providing antenatal and postnatal care within a community setting.

DefinitionMidwife continuity of care (MCOC) models provide midwifery care by one named midwife or a small group of midwives for each woman. This may be throughout pregnancy, birth and postnatal periods or for defined periods, such as during the antenatal or postnatal periods.

This continuity of care allows each woman to get to know her midwife/small group of midwives. This contrasts with shared care models, where responsibility is shared between different healthcare professionals and women may not know their care providers or previously have met the person who will be caring for them in labour.

Examples of modelsAntenatal continuityWomen are booked by a named midwife who will see them for the majority of their antenatal care, with back up provided by a ‘buddy’ midwife. This model is particularly useful for ‘out of area’ women, that is, those who return to another community area for postnatal care.

Antenatal and postnatal continuityWomen are seen in the community for booking and scheduled antenatal care by a named midwife or buddy. The same midwives provide postnatal care for the woman following the intrapartum period. This model may be orientated around GP surgeries or children’s centres for care delivery

Team midwifery careAntenatal, intrapartum and postnatal care is provided by a small team of midwives (typically six to eight, though team size may vary) in collaboration with doctors in the event of identified risk factors. Intrapartum care may be provided in a hospital, midwifery led unit or the woman’s home.

Midwifery group practice case load careAntenatal, intrapartum and postnatal care are provided by a named midwife, with secondary backup midwife/midwives providing out of hours cover, along with assistance and collaboration with doctors in the event of identified risk factors.

Auditable standardsIn the Cochrane review, levels of continuity (measured by the percentage of women who were attended during birth by a known carer) varied between 63 and 98 per cent5.

The CQC 2010 and 2013 national surveys established baseline data10:

» Proportion of women who saw the named midwife/back up midwife every time during pregnancy - 34 per cent.

» Proportion of women who were attended during birth by a known midwife - 25 per cent.

» Proportion of women who saw the named midwife/back up midwife every time during the postnatal period - 27 per cent.

Using the measures stated above identifies the percentage of women in a service that have continuity of care in:

» Pregnancy and labour and birth.

» Pregnancy, labour and birth and the postpartum period.

Regular audits will benchmark women’s experience of continuity of care and quality of care.



mailto:[email protected]

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Key factors for successful implementation All models

» A woman and her individual needs should be central to model design and should be the focus of any business case.

» There should be robust engagement with the midwives who will be providing the care, as they may be able to offer practical solutions to implementation challenges.

» IT and clerical systems should support the aim that the majority of midwifery care is provided by a named midwife, and should consider this from a woman’s first point of contact or referral to services. Investment in this should be considered part of the programme of change.

» A back up midwife (or midwives) whom the woman has met on more than one occasion during her pregnancy is always available.

» Women should have access to phone numbers which allow them to communicate easily with their named midwife.

» MCOCs should use the same clinical guidelines, protocols and decision making frameworks as the rest of the maternity service to ensure consistency, continuity of care and best practice.

» An interdisciplinary collaborative approach means midwifery care continues to be provided by the named midwife, even when complications arise.

» Midwives should have an agreed midwifery philosophy of care, vision for the model and ways of working together.

» Targeting MCOCs towards those with specific needs or priority groups in the local community (eg pregnant teenagers, women with increased social needs or who find services hard to access) can help support implementation by addressing health inequalities.

» It may be preferable to introduce new models in a staged fashion to ensure that all systems are functioning, and there are no unexpected obstacles.

» Midwives may require educational input to reskill them into independent decision making if they have been working in a hospital model.

Teams and case load models » The named midwife provides care from early

in pregnancy (usually booking visit) through labour and birth, up to two weeks postnatal.

» One-to-one care for labour and birth is provided by the named or back up midwife.

» There is sufficient investment for all midwives to have 7-day a week access to birth equipment, phones, pagers, IT systems.

SustainabilityIt is essential that any model being designed is woman centred, however, should also meet the needs of both the midwives and the service. The following points have been identified as central to promoting sustainability of a MCOC model10.

All models » Management support for the model is critical

to drive through change and maintain it in the face of challenges.

» There should be a midwife team leader with sufficient time allocated to fulfil that role.

» Managers should ensure there are opportunities for professional development, reflection and debriefing.

» Clinical supervision should support good decision making and enable the maintenance of professional relationships with women, avoiding the development of co-dependency.

» Ongoing formal and informal communication is crucial, including regularly scheduled team meetings.

» There should be clear reporting lines and escalation processes to line managers and obstetricians.

» To encourage multi-disciplinary working, there should be specific relationships with named medical staff in place as appropriate.

» Succession planning should be continuously reviewed to allow good handover between midwives. This may include the use of preceptor midwives on rotation to different clinical areas.

» All models of care should be subject to audit of key outcomes and women’s experience.




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Teams and case loads models » The optimal size of a team (6-8 whole

time equivalent) allows midwives sufficient protected time away from working and on-call demands. Anecdotal evidence suggests that teams smaller than six have a high risk of burnout and may experience difficulty covering all aspects of care.

» The size of the case load should not exceed 35-42 women a year per each whole time equivalent midwife. Case loads should be smaller when there are known complexities in care.

» Allowing midwives the opportunity to self-manage their working week can further develop skills for successful implementation and adaption to on-call. This may include how teams manage on-call working, a typical working day and time off. HR systems and processes should work with this aim rather than restrict the potential for flexible working.

» Midwives with experience of community working and significant clinical experience are likely to be important in establishing good working practices, and decision making. This should not preclude less experienced midwives from joining teams, but skill mix should be considered in terms of support for these midwives.

» Early enthusiasm for team and case load working may lead to less rigorous approaches to protected time off; this should be addressed specifically and early during implementation, as there may be a risk for burn out.

Midwives have identified key factors for achieving optimal work experiences within MCOC models. These are not only about successful relationships with the women they care for, but also the relationships they have with their peers, medical colleagues and managers11:

» The ability for midwives to develop meaningful professional relationships with women through continuity of care.

» Supportive relationships at work and at home.

» Positive working relationships and occupational autonomy allowing midwives the ability to organise their working lives with maximum flexibility through negotiation.

This includes:• Positive and supportive relationships with

midwifery colleagues in MCOC models.• Collaborative relationships with medical

colleagues and midwifery peers at the hospital.

• Managers who facilitate professional development, interpersonal confidence and skills, assistance with debriefing and reflection.

AppendicesPractical case studies to support this toolkit are available in the appendices:

» Appendix 1 - Guy’s and St Thomas’ NHS Foundation Trust | Continuity of care models for pregnant women with medical and psychological conditions.

» Appendix 2 - Imperial College Healthcare NHS Trust | Achieving antenatal and postnatal continuity.

» Appendix 3 - King’s College Hospital NHS Foundation Trust | Case loading midwifery care.

» Appendix 4 - Royal Free London NHS Foundation Trust | Antenatal and postnatal continuity for complex women.




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References 1. Department of Health, The Mandate: A mandate

from the Government to the NHS Commissioning Board: April 2013 to March 2015. In: Department of Health, editor: Crown Copyright, 2012.

2. National Institute for Health and Care Excellence, Quality standard for antenatal care, QS22. London, 2012.

3. National Institute for Health and Care Excellence, Quality standard for postnatal care, QS37. London, 2013.

4. National Institute for Health and Care Excellence, Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors, NICE clinical guideline CG 110, London, 2010.

5. Sandall J. Soltani H. Gates S. Shennan A. Devane D. (2013) Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews (8):CD004667.

6. McCourt C, Pearce A. (2000) Does continuity of carer matter to women from minority ethnic groups? Midwifery, 16:145-54.

7. Finlay S, Sandall J. (2009) “Someone’s rooting for you”: continuity, advocacy and street-level bureaucracy in UK maternal healthcare, Soc Sci Med, 69(8):1228-35.

8. Rayment-Jones H. Murrells T. Sandall J. (2015) An investigation of the relationship between the case load model of midwifery for socially disadvantaged women and childbirth outcomes using routine data-a retrospective, Observational study, Midwifery, 31:4,409–417.

9. Care Quality Commission. Women’s experiences of maternity care in England; Key findings from the 2010 & 2013 NHS trust survey. London: Care Quality Commission, 2010 and 2013.

10. NSW Ministry of Health (2012) Midwifery continuity of carer toolkit, The Nursing & Midwifery Office. http://www0.health.nsw.gov.au/pubs/2012/midwifery_cont_carer_tk.html.

11. Leap N. Dahlen H. Brodie P. Tracy S. Thorpe J. (2011) ‘Relationships-the glue that holds it together’: midwifery continuity of care and sustainability. In L. Davis, R. Daellenbach & M. Kensington (Eds.), Sustainability, Midwifery and Birth. New York: Routledge.



http://www0.health.nsw.gov.au/pubs/2012/midwifery_cont_carer_tk.html

http://www0.health.nsw.gov.au/pubs/2012/midwifery_cont_carer_tk.html



Appendix 1: Case study | Guy’s and St Thomas’ NHS Foundation Trust

Guy’s and St Thomas’ NHS Foundation TrustContinuity of care models for pregnant women with medical and psychologi-cal conditions Providing women with continuity of care from a small team of midwives has ensured high risk women have a multidisciplinary care plan. This improves access to specialist care whilst promoting normal birth, preventing unnecessary appointments, readmissions and the likelihood of pre-term birth.

Outline of serviceA risk assessment of all maternity referrals is completed prior to the booking appointment. If a medical or psychological condition is referenced in the referral form, a woman is allocated to the high risk case load midwifery team. There are two midwifery teams (Thames and Tower), and both are hospital based. Each team has seven midwives (six band 6 and one band 7). Between them, they care for approximately 700 women per year. The booking midwife is responsible for coordinating the antenatal and postnatal care, liaising with the relevant specialists. The aim for the case loading team is to provide as much intrapartum care as possible. At busy times, care can be provided by a midwife either on the obstetric or midwifery led birth centre. Antenatal appointments are one stop, multidisciplinary consultations. The Thames team cares for women with blood disorders, diabetes, cardiac, lupus, cancer, skin and gastrointestinal conditions, such as Crohn’s disease. The Tower team cares for women with renal, fetal cardiac, mental health, sickle cell disorders and multiple pregnancies.

Key messages for successChallenges EnablerReorganising existing midwifery staffing to establish the case loading midwifery teams.

» Clear and engaging recruitment process (eg job descriptions outlining role and responsibilities and internal meetings with staff to discuss and share the benefits of the case loading team model for high risk women).

» Value based recruitment – a strong commitment to each other and to providing the best possible care to women with high risk conditions.

» Engaging broader stakeholders, such as commissioners and maternity service liaison committee.

» Creative use of existing vacancies to redesign the service provision. Organising the rotas. » Identify timings of specialist clinics and ward rounds and organise case

loading team member to attend. » Rotas are organised in such a way that a midwife is able to visit any

woman who is an inpatient or outpatient and can lead parent education for high risk women.

Wellbeing of team and retention.

» Annual away day, including a programme of consultant led discussions. » Encouraged to access other developmental opportunities, such as

examination of the new born, supervisor of midwife course and trust-based leadership courses.

» Timely and meaningful appraisals. » Weekly team meetings. » Ensuring the team have office space.

Maintaining skills and ensuring appropriate development of staff (eg exposure to normality).

» Established an annual development programme specific to high risk case load midwifery team.

» Joint statutory mandatory training programme to ensure broader skills kept up to date.

» Weekly multidisciplinary meetings with relevant specialist consultants.



Appendix 1: Case study | Guy’s and St Thomas’ NHS Foundation Trust

Guy’s and St Thomas’ NHS Foundation TrustContinuity of care models for pregnant women with medical and psychologi-cal conditionsModel in detail

How is the model funded?There was no new funding required for staffing for this project. Staff posts came from the reorganisation of existing posts from our obstetric and midwife led birth centres.

How often do women see their named midwife?Team continuity is the focus of this model of care however, antenatal care is provided by the same midwife approximately 65 per cent of the time. Continuity of care varies more in intrapartum (where it can drop to 30 per cent due to the current size of the case load) and postnatal, depending on complexity of care and geography. A review and prioritisation are being conducted for both teams, for a list of conditions to achieve a much better continuity of care ratio antenatally through to labour and immediate postnatal care.

Antenatal care for all women in high risk teams is provided in the hospital based antenatal clinic. A proportion of the women looked after are from outside the local catchment area. Postnatal continuity is best for women who live in the area however, all women are seen on the wards for immediate postnatal care.

How do women contact their midwife?Each team holds one group mobile phone, and this is factored into the rota.

Is there any outcome data?The teams were established in 2007 following a research evaluation of case loading midwifery by King’s College London and GSTT. Each year data is collected on process metrics such as access, continuity and compliance with care plan completion. All women have an agreed multidisciplinary care plan in their notes, and there is timely referral to the high risk team. Very good outcomes are achieved generally for high risk women however evidence is being gathered continually. A research project to evaluate the health outcomes benefits of the Thames and Tower teams is being explored.

ContactMitra BakhtiariMidwifery Matron/Community/Hospital Clinics/Supervisor of midwivesGuy’s and St Thomas’ NHS Foundation [email protected]




Appendix 2: Case study | Imperial College Healthcare NHS Trust

Imperial College Healthcare NHS TrustAchieving antenatal and postnatal continuityWithin one year 82 per cent of women’s antenatal and postnatal appointments were with the named midwife or buddy within the specified teams.

Outline of serviceThe geographical patch for community midwifery for Imperial has been divided into 7 areas and in each area there is a team of 8 whole time equivalent midwives. One midwife in the team will book a woman for her pregnancy care and plan to see her throughout her pregnancy. After the birth the same midwife will see the woman for postnatal care. When this named midwife is not available she will have a specific ‘buddy’ midwife who will take over care. Intrapartum homebirth care is offered by the team but not by a specific midwife. Intrapartum hospital care is not covered by the team.

Key messages for successChallenges Enabler

» Capturing activity in the community.

» Ensuring continuity of care between community and hospital (ie avoiding risk from ‘lost or missing’ information between points of care delivery).

» Midwives spending time travelling between hospital and community areas collecting and delivering paperwork and specimens or duplicating appointment paperwork.

» Review of IT systems and diary management: Midwives were provided with IT devices to allow remote access to hospital systems so no time lag in information held in any area. This was supplemented by Courier services to community clinics.

Midwives working for long periods in hospital model may find decision making in the community difficult.

» Training sessions before starting in the community on autonomous decision making, team building and homebirth skills.

Recruitment and retention of suitably skilled midwives.

» Midwives who were already working in community and antenatal clinic were the source of staffing for this project. Stopping all hospital midwifery led clinics of women who live in the geographical patch freed up some resource and converting the workload in the community into this model freed up the rest.

» Midwives undergoing preceptorship are rotated into these teams, which offer the midwives experience and expose them to ways of working they may not have considered before.

Moving care into the community and away from hospital.

» Creating links with Children’s Centres allowed delivery of care across the community.

Ensuring continuity of care actually happens.

» Midwives manage their own workload and diaries, this allows them to flex to meet the needs of the women. On a typical day the midwife will work 9am – 5pm but may flex around start and finish times. She will be required to be on-call 5 times per month.



Appendix 2: Case study | Imperial College Healthcare NHS Trust

Imperial College Healthcare NHS TrustAchieving antenatal and postnatal continuity

Model in detail

How is the model funded?There was no new funding required for staffing for this project. Staff posts came from re-organisation of existing posts in the community and antenatal clinic. Staffing is arranged in each team in the following way:2 whole time equivalent (wte) band 7 midwives. One who manages the team on an operational level and one who is the lead for vulnerable women and complex needs. There are five wte band 6 midwives and two midwifery support workers at band 3.The teams also support the case loading team midwives with their home births as well as attending any that arise from their own women and so each team has one midwife on-call per night.Money was required for the investment in IT and required a business case to be approved by the Trust board.

How do women access the service?Women may be referred by their GP or self-refer into the service. Referrals are received centrally at the Trust and then sent on to the appropriate team for them to arrange the booking. The appropriate team is the one in the same area as the woman lives. It is not linked to who the woman’s GP is.

Where are women seen?Appointments are at the local children’s centres. Women may be seen at home in the postnatal period but will also be offered clinic appointments.

How often do women see their named midwife?The KPI that the service has set for itself for this is 90 per cent of appointments the woman has in the antenatal and postnatal period should be with the named midwife or buddy. The structure has been in place for about a year and currently they are achieving 82 per cent in these specific teams.

What happens when women develop complications?Each team has a named obstetrician that they refer women to. This supports clear communication and multi-disciplinary working.

How do women contact their midwife?The woman has the mobile phone number of her midwife.

Is there any outcome data?The Friends and family test score has changed from 38 pre-implementation to 83.

ContactPippa Nightingale Head of Midwifery Queen Charlotte’s and Chelsea Hospital and St Mary’s [email protected]




Appendix 3: Case study | King’s College Hospital NHS Foundation Trust

King’s College Hospital NHS Foundation TrustCase loading midwifery careAchieving 18 per cent caesarean section rate, 30 per cent homebirth rate and 88 per cent exclusive breastfeeding at six weeks.

Outline of serviceThe Lanes Midwifery Practice is a group of six midwives who provide continuity of care from booking to up to 28 days postnatally, including attending the woman for her birth regardless of location. Women access the service by being booked at the GP where the service is based. The team have a 1:36 midwife to woman ratio.

Key messages for successChallenges EnablerObtaining the funding to start the service.

» Engagement with a local GP practice who were keen to have midwives providing this service for their women meant that there was an opportunity to share the start-up costs of the project. The surgery funded equipment and provided premises for the midwives – office and clinical room. The rest of the funding was obtained by using vacancies in the general community and engaging the commissioners in the project who were willing to fund some additional midwifery places (approximately two).

Midwives working for long periods in hospital model may find decision making in the community difficult.

» Midwives have enhanced induction, attending study days on topics such as homebirth and water birth, and spend considerable time working with other members of the team at the start, especially being supported with on-call. This has demonstrated that experience is not necessarily required but an interest in normality and home birth is essential.

» The team recruit and interview their own midwives from within the existing staffing which encourages team working and realistic expectations in candidates.

Recruitment and retention of suitably skilled midwives is a constant challenge partly due to the perception of the demands of the on-call requirement.

» The teams retain control over their working week not working set hours and create their own rota. This helps offset the demands of on-call.

» Midwives undergoing preceptorship have been rotated into these teams, which offered the midwives experience and expose them to ways of working they may not have considered before. (This has stopped for unrelated reasons).

» Midwives are not expected to work all day and be on-call and potentially up all night. Overnight on-call is split between two midwives.

Midwives need community bases to see women.

» The midwives have an office at the GP which enhances the delivery of care in the community.

Other staff’s perception of this being an elite service where midwives have different conditions of work undermines team working.

» The team is managed by the community matron and the team support as required the general community on-call rota encouraging sense of team working.

» Midwives who have worked in the team previously spread the team ethos and knowledge when working elsewhere.



Appendix 3: Case study | King’s College Hospital NHS Foundation Trust

King’s College Hospital NHS Foundation TrustCase loading midwifery care

Model in detail

How is the model funded?There was some new funding required for staffing for this project. Some posts came from re-organisation of existing posts in the community and some from working closely with PCT/commissioners on the project, as above. Staffing is arranged in each team in the following way: Six whole time equivalent (WTE) midwives, one of whom is a band 7 who manages the team on an operational level and provides clinical leadership. There are five WTE band 6 midwives and one part-time midwifery support worker at band 3. The teams also support the other case loading team midwives and wider community with their home births as required. Each midwife is on-call three times per week and so each team member needs to carry a full set of birth equipment at all times.

How do women access the service?Women may be referred by the GPs at the surgery at the team’s base or self-refer into the service but must be booked with the link GP practice. There can be problems of capacity as the midwives can only book three women per month and local women are known to change their GP to access the midwives’ service. If the number of women exceeds capacity of the team they attend an antenatal clinic in the local area.

Where are women seen?Appointments are at the office which is at the GP surgery or at home.

How often do women see their named midwife?Women see their named midwife at booking and for the majority of their antenatal visits. The midwives have a partner that will see the woman for one to two visits in the antenatal period and efforts are made to introduce the woman to the rest of the team to increase the chances of her having met the midwife who attends her birth.

What happens when women develop complications?The team has a named obstetrician to whom they refer women. This is set up with an open-door communication policy, so they can email and ring about cases as needed. This supports clear communication and multi-disciplinary working and prevents inefficient use of clinic appointments.

How do women contact their midwife?The woman has the mobile phone number of her midwife and can use it to speak to a midwife from the team 24 hours a day.

Is there any outcome data?Ninety-two per cent of women were attended by Lanes midwives and 51 per cent of women had their named midwife for some or all of their labour. Thirty-six per cent of women were high risk at booking, and 50 per cent at labour onset. Homebirth rate: 30 per cent; LSCS rate: 18 per cent; instrumental birth rate: 17 per cent; attempted VBAC rate: 87 per cent; labour in water rate: 26 per cent; induction of labour rate:14 per cent; epidural rate: 20 per cent.

ContactTracey MacCormackMatron for Community and Antenatal Services King’s Denmark Hill [email protected]




Appendix 4: Case study | Royal Free London NHS Foundation Trust

Royal Free London NHS Foundation TrustAntenatal and postnatal continuity for complex womenImproving outcomes for complex women – increasing birth weight, reducing neonatal complications and improving women’s engagement with services.

Outline of serviceThe Unity team is a small team of midwives who provide antenatal and postnatal case load care to women with complex needs who are booked with the Royal Free London (Hampstead site). Care is led by a named midwife with a buddy, and the team is clinically led by the named midwife for safeguarding. Intrapartum hospital care is not covered by the team.

Key messages for successChallenges EnablerForty per cent of women using the service are from outside the geographical area of the hospital: co-ordination of care is therefore extremely complicated across different boroughs.

» Midwives carrying their own diaries and organising their own clinics and workloads is an essential aspect to support continuity and therefore ensure that midwives who know women well can co-ordinate and liaise with relevant agencies.

» The clinical leadership of the named midwife means that there is also continued representation and support even when the named midwife is away.

This is a highly complex group of women who require skilled and knowledgeable midwives.

» Midwives have an enhanced induction into the team attending study days on topics such domestic violence. They also spend considerable time working with the clinical lead for the service at the start of their placement with the team. This has demonstrated that experience is not necessarily required but an interest in working with this client group is essential.

Because the group is not resourced to provide Intrapartum care ensuring the correct care plan is delivered at the birth and women are picked up by the team postnatally has been difficult.

» Introduction of a universally applied checking process for admissions to labour ward ensured women and care plans were not ‘missed’. It also ensured the team were notified of their women having given birth and could offer support to the hospital staff.

» The team use a ‘red folder’ on labour ward to communicate essential information.

» The team visit the maternity wards daily to assist with communication, support staff and women and a smooth transition back into the community.

This is a group of women who find it difficult to engage with services.

» Creating links with Children’s Centres allows midwives to run their own clinics in them which are close to the woman’s community.

Other staff’s perception of this being an elite service where midwives have different conditions of work undermines team working.

» Unity team is managed by the community matron and the midwives participate in the general community on-call rota encouraging sense of team working.

» Midwives who have worked in the team previously spread the team ethos and knowledge when working elsewhere.



Appendix 4: Case study | Royal Free London NHS Foundation Trust

Royal Free London NHS Foundation TrustAntenatal and postnatal continuity for complex women

Model in detail

How is the model funded?There was no new funding required for staffing for this project. Staff posts came from re-organisation of an existing case load project in the community. This had been geographically based and although targeted at the same group of women had led to struggles with access and boundaries. The Unity team is organised in the following way:3.6 whole time equivalent midwives. 1 is a band 7 who leads the team operationally and the rest band 6’s. Each carrycarries a case load of 35 – 40 women per year. They also have a band 8A clinical lead who is also the named midwife for safeguarding, who carries a case load of 30 women per year. The team also support the community team midwives with their home births and so are on-call periodically.

How do women access the service?Women may be referred by their GP or self-refer into the service. Referrals are received centrally at the Trust and then sent on to the team for them to arrange the booking. Women may also be picked up at booking and referred onto the team.

Where are women seen?Appointments are generally at the local Children’s Centre, which is seen as critical for success of the service. Women may be seen at home occasionally in the antenatal period if this will assist in engagement.

How often do women see their named midwife?Continuity is described as very good but figures are not available for this to date.

What happens when women develop complications?As all women have a degree of complexity in their pregnancy multi-disciplinary working is critical and so is supported by fortnightly MDT meetings.

How do women contact their midwife?The woman has the mobile phone number of her midwife and her buddy.

Is there any outcome data?There has been a noticeable improvement in the degree of engagement from women with services and less evidence of chaotic behaviour. In addition there is an anecdotal trend towards babies having increasing birth weight and less severe withdrawal symptoms where substance abuse is an issue. There are plans to audit these outcomes formally and undertake and evaluation with the women who use the service.

ContactJude BaylySafeguarding MidwifeRoyal Free Hampstead NHS [email protected]




London early referral/self referral pregnancy proforma

First Name: Family Name: Date of birth NHS Number: Address Postcode

GP Name: GP Address:

Preferred title: Mrs/ Miss/ Ms GP telephone: Mobile Number : Other number :

OK to send texts to mobile phone? YES/ NO

Interpreter Needed? YES/ NO Preferred Language:

Blood Pressure: / Heart Sounds: Normal/ Abnormal/ Not checked

First Day of Last Period: Number of previous deliveries: Reasons if Booking after 12 weeks pregnant:

Past Pregnancies

Having First baby □

Other pregnancies normal □

Or

Caesarean Section □ Premature Baby □ Previous Womb Surgery □

Pre-Eclampsia /Eclampsia □

Postnatal depression □

3 or more miscarriages □

Miscarriage after 13 weeks □ Baby born with abnormality □

Shoulder Dystocia □ Placenta Accreta □

Stillbirth □

Neonatal death □

Other Maternity Problems:

Medical History

None □ Or High Blood Pressure □ Diabetes □

Other Hormone disorder □

Epilepsy □

Heart disease □

Kidney disease □

Liver disease □

Severe Asthma □

Blood Clotting Disorder □

Autoimmune Disease □

Deep Vein Thrombosis □

Tuberculosis □

Haemoglobin disorder □

Psychiatric illness including

depression □ Other Medical/Surgical problems:

Social Information

None □ Or □ Smoker □

Alcohol/ Substance Misuse □

Domestic Violence □

Learning Disability □

FGM □

Children on protection register □

Has a Social Worker □

Social Worker name if known

…………………………………………….

Other relevant social/ domestic circumstances:

Current Medication:

Allergies:

Pan-London Early Referral/Self-referral pregnancy proforma

Print Name: ………………………………………………………... Signature: …………………………………………………………...…

Please tick if you are booking your own pregnancy directly: □ Date: …………………………………………………….

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Proposed implementation plan: Toolkits and maternity networks

Maternity Strategic Clinical Network

London Maternity Strategic Lead-ership Group

Maternity Commissioning Advisory Group

Collation of data, benchmarking and shared learning

London Maternity Networks (x5) London Maternity Networks (x5) London Maternity Networks (x5)

Maternity network audit of toolkits 1 and 2

(Sep 2015)


(Jan 2016)


(Apr 2016)

Maternity Strategic Clinical Network

London Maternity Networks (x5)Design

Maternity Strategic Clinical Leadership Group

London Maternity Networks (x5)Design input

Toolkit development and sign off

Toolkit implementation and audit plan sign off

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seThe below diagram outlines the processes for development and implementation of the London Maternity Strategic Clinical Network.

maternity best practice toolkits - londonscn.nhs.uk...fetal fibronectin testing in women with...

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