WorkshopReport

SHAPINGPRACTICETOPROMOTEVAGINALBIRTHINBC

FEBRUARY28,2018SURREYMEMORIALHOSPITAL

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Objectives1. To review rates of cesarean section stratified by Robson criteria (categories of risk) over the

previousfiveyearsamonghospitalsrepresentedatthemeeting;2. Toidentifybroadcategoriesofclinicalpracticethatcliniciansfromthesehospitalsbelievehave

promotedvaginalbirthamonghealthywomen;2.1. Todetailspecificprotocolsthathavebeendevelopedtosupportthesechanges;2.2. TodiscusstransferabilityoftheseprotocolstoothersettingsinBC;2.3. Toidentifyresourcesneededinhospitalstosupportthesechanges;2.4. Todevelopaplan forhealthauthorities tostandardizepractice inrelation to targeted

areas;2.5. Toidentifyanevaluationstrategyfortargetedareasofchange.

3. To agree on a forum for ongoing mentorship within health authorities by practice leaders inhospitalsthathavesuccessfullyinitiatedchangewithsustainedresults;

4. To develop key research questions arising from the discussion of promising practice changestrategiesthatwillformthebasisofavaginalbirthresearchprogram.

ShapingPracticetoPromoteVaginalBirthinBC

ReportonworkshoppresentedbyOptimalBirthBC,hostedbyFraserHealthAuthorityandfundedbytheMichaelSmithFoundationforHealthResearch

February28,2018,SurreyMemorialHospital

MorningSession(OpentothePublic)Welcoming remarks by Loraine Jenkins, Executive Director,Maternal, Infant, Child and Youth Health,FraserHealthAuthority,whonotedthechallengesfacedbyFraserinaddressingrisingcesareansectionrates.Shestated that thecontributors to the risingcesareansection ratearecomplexanddifficult tounderstand. She indicated that theworkshopwould provide an opportunity to gain insight from thehands-onexperiencesofcolleagues.Dr.PatriciaJanssenpresentedoverallcesareansection(CS)rates,plannedvaginalbirthaftercesarean(VBAC)ratesandCSratesamongnulliparouswomeneligibleforvaginalbirth,stratifiedbyhospitalsize.Invited representatives from hospitals that have demonstrated high vaginal birth rates during thepreviousfiveyearspresentedtheirrecommendationsforpromotingvaginalbirth.

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Terrace–SuccessesinVaginalDeliveries:ObstetricservicesinTerrace,BCDr.JacoStrydom,MB,ChB,M.Fam.Med,MCFP MaternityCareService

• Primarycareobstetricsprovidedbyagroupof4familypracticephysicians(FPs)• Highriskobstetriccoverage(includingCS)providedby1ObGynand1FP• Dedicatedandexperiencednurses(RNs)inLabour/Delivery• Prenatalclinic• PrimarycarenursingteamfromPublicHealthandChronicDiseaseManagementPrograms

2015/16 2016/17 2017-TotalDeliveries 292 323 246C/SectionRates 19.2% 21.9% 18.7%Elective 25(8.5%) 42(13%) 14(5.7%)Emergent 31(11.6%) 29(10%) 32(13%)PlannedVBAC 19 13 15SuccessfulVBAC 13(68%) 9(69.7%) 14(93.3%)WhyAreWeSuccessfulinPromotingVaginalBirth?

• Vaginaldeliveryistheultimategoalregardlessofpreviousexperience–thestaffarepassionateaboutthisandsetthetonetosustainthisculture

• Useofnarcoticsearlyinlabour• Lowepiduralrate(usedonlywhenallothermethodsofpainreliefexhausted)• Admissiondelayeduntilintrueactivelabour• True1:1nursingcare• Useofnon-pharmacologicalpainrelieftechniques,includinguseofgravityandpositioning• For women eligible for VBAC, information provided at initial visit but final decision made at

around 28 weeks (sometimes as late as 36 weeks). If not suited for our facility – option forreferraltobiggercentre

• Clearcommunicationaboutplans• Teamworkandcollegialitybetweenphysiciansandnurses• Women-centredcare–involvedineverystepofdecisionmaking

Richmond–ShapingPracticetoPromoteVaginalBirth:RichmondHospitalDr.BrendaWagner(Obstetrics)andKaraThompson(Nursing) 2013/14 2014/15 2016/16-C/SectionRates(Total) 27.9% 30.6% 30.3%CS-EligibleNullips 16.8% 16.9% 24.7%CSEligibleMultipsplanningVBACs 52.3% 53.3% 66.9%

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WhyAreWeSuccessful?ConsistentApproachtoEarlyLabourManagement

• Allpatientsareencouragedtocalltheunitbeforecomingtothehospital• EarlylaboursupportandteachingdonebyRNs• LabourassessmentdonebyanRNintriage• Patientsareonlyadmittedoncetheyareinactivelabour

ConstantLabourSupportbyNurses

• Allwomaninactivelabourareprovided1:1laboursupportbyanRN• Non-pharmacologicalpainmanagementtechniquesareALWAYSofferedfirst• Patientsareencouragedtoambulateandusethebathorshower.Liberaluseofbirthingballs• Patients do not labour in bed. Telemetry allows for increased mobilization in labour when

continuousfetalmonitoringisindicated• Adherence to the 6 cm rule for active labour, i.e. don’t intervene prior to 6 cm to establish

labour• Evaluatinglabourprogressthroughchangeratherthanpre-definedtimelimits

CreativeApproachtoSecondStage

• Pushingstartswhenwomenhaveastrongurge• Womenpushinmultipledifferentpositions:supine,sidelying,handsandknees,toilet,birthing

stool,birthingball,onthebedinhandsandknees,inthetub,etc.• Minimizeepiduralusetomaximizeabilitytopushindifferentpositions• Nointerventionuntilpushinginmultiplepositions

Culture

• Startedwithanegativeculturethatwasnotevidenced-based• Changeoccurredwith:

o Multidisciplinaryroundsandopenrespectfuldiscussiono Multidisciplinaryeducationsessions(e.g.midwivesteachingdoctors)o Havingfuntogethero Respectingwhateveryonebringso Acknowledgingthatallquestionsaregoodquestionso Knowingweneedeachothero Holdingoneanotheraccountableforprovidingevidence-basedpracticeso Trauma-informedapproachforpatientcareandamongstaffo Collaborationbetweenjuniorandseniornurseso Normallabourchampionso Celebratingoursuccess

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NanaimoRegionalGeneralHospitalDr.JeffreySomerville(Obstetrics)MaternityCareService

• Average1,200births/year• CombinedLDRPunitwith15beds• Complementofmaternitycareprovidersandspecialists• On-site pediatricians, anesthesia, aswell as unit-specific operating room (OR)with useof the

mainORforperinatalpatientsrequiringgeneralanesthetic• Level2NICU

CaesareanDeliveryRatewithinRobsonGroups,NRGH:April1,2011-March31,2016

RobsonGroups 2011/12 2012/13 2013/14 2014/15 2015/16TOTAL 26.1% 25.9% 25.9% 24.1% 26.3%1.Nulliparouswomenwithasinglevertexpregnancyat37+weeksinspontaneouslabour

14.8% 12.5% 13.5% 17.5% 16.8%

2.Nulliparouswomenwithasinglevertexpregnancyat37+weekswithinducedornolabour

27.3% 41.8% 37.2% 32.9% 33.3%

5.Parouswomenwithauterinescarwithasinglevertexpregnancyat37+weeks

78.2% 77.1% 75.0% 75.4% 73.9%

WhyAreWeSuccessful?

• Practice ismultidisciplinary and collaborative among obstetricians, registeredmidwives (RM),andFPs

• Structuredprenatalclassesavailableinthecommunity• Aviduseofoxytocinwithepidurals• OBsskilledatassistedvaginalbirths• OBs’scopeofpracticeincludesprimarymaternitycareaswellasspecialtyconsults• Priorto34weeksgestation,womenwhowishtopursueaVBACarereferredforanobstetrical

consultbythewoman’sprimarymaternitycareprovider(FPsandRMs)• Communicationprocessestosupportcollaboration:

o Call-outprocessfornotifyingPediatricso Perinatalemergencycall-outtreetoalertPediatricsandthemainOR

• CultureimprovedsignificantlywithintroductionofMOREOBandclinicalchampions–promotedacultureoflearningtogether

• OBcollaborativegroup(developedbytheDepartmentofFamilyPractice) improveddiscussionanddebaterelatedtoevidence-basedpracticeandshiftedtopatient-centeredfocus

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• Increased rateof trialof labourattributed toRMssharingpracticephilosophyand techniqueswithphysicians–thishasincreasedcomfortlevelwithVBACsamongtheteam

• Active quality improvement committee that reaches out to colleagues – midwives regularlyattend

Fort St. John – Healthy Mothers and Healthy Babies: Working together toimproveperinataloutcomesDr.GlenHamill(FamilyPractice),KathleenJulian,RN(BirthingCentreLead)andDanielleQuiringRN(formerBirthingCentreLead)MaternityCareServices

• FortSt.Johnservicesapopulationof+/-47,000• AveragedeliveriesinFortSt.John=650/year• Thereare10physiciansworkingintheprenatalclinic/birthingcentre(3whohaveadvancedOB

skills),1OBGYN,1pediatrician,and5FPanesthetistsCesareanBirthRatesatFortSt.JohnHospitalBirthingCentre

• Pre-clinic:26-32%• 2014(firstyearofclinic):27.8%• 2015:20.8%• 2016:19.7%• 2017:18.5%Inductionrateshavedecreasedby38%sincetheprenatalclinicopened

WhyAreWeSuccessful?TheGoals

• Initially not to decrease caesarean section rates but to ensure patients were receivingcomprehensive,evidence-basedandappropriatecare

• ToincreaseteamfunctioningandsupportaculturetooptimizepatientcarePrenatalClinicStarted in 2014due to loss ofmaternity care physicians. Comprisedof a unit clerk, primary careRN,dietician,anddiabeticeducator.Variousretrospectivechartreviewsshowthatgroupprenatalcarehasstatisticallysignificantresults,including:

• Reductionofpretermbirths• Increasedbirthweights• Decreasedmaternalweightgain• Reducedoddsoffetaldemise

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• Shorterhospitalstays• Increasedlikelihoodtoexclusivelybreastfeed• Increasedpatientknowledge• Increasedsatisfactionwithprenatalcare• Decreasedcaesareansectionrate

HighlightsoftheRNPosition

• Continuityofcareandeducationforeachpatient• Preparesallroutinelabwork,ultrasounds,careplans,prenatalregistry(SOGCGuidelines)• Appropriate and timely referrals for dietician, diabetic educator, anesthetic consult and OB

consult• Mentalhealthreferrals,MCFDreferrals,andcommunitysupportconnections• “Watchdog”-asecondcheckforalllabandultrasoundresults• Newideastostreamlineand/orimprovetheclinic

TheRules

• Inductionoflabouro Unit-specificprotocoldevelopedo Anyinductionnotforpostdates(41-42weeks)needsconsultationpriortobookingo Patienteducation

• ConsultsaretoOBGYNorOBadvancedpracticeFPs• IfanOBadvancedpracticeFPisworkinginlabouranddelivery,aconsultisstillneededtogoto

caesareansection• Electivecaesareansectionsrequireaconsult,especiallyiflessthan39weeks• Consultsmustbeappropriate• TrialoflabourafterCS(potentialVBAC)requireaconsult

Financial

• 2poolsoffunds:prenatalandlabour&deliveryunits• Fundsdividedamongthephysiciansaccordingtohowmanyshiftsworkedina3-monthperiod• AnyORproceduresorconsultsfalloutsideofthepoolandarepaidonanindividualbasis• “Special”patientfundsgointothepool

ComprehensiveCarePlans

• BMI• Gestationaldiabetes(patientworksheetsincluded)• Mentalhealth• Drugabuse/substancemisuse• Methadone

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• Limitedsupports/<19yearsofageTheseplanshavepromotedbetterhealththroughtheantepartumperiod.

LabourandDelivery&DevelopingaCulturePrenatalClinicattachedtolabourwardgivesnumerousadvantages:

• Timingofdecisionmaking-minutesinsteadofhours• Interactionwithstaffincreasedmakingforbettercultureandteamapproach• More interactionswithpatients, improving theenvironment, atmosphere, decreasing anxiety,

andamorepersonableapproach• Timefordebriefinganddiscussions

VaginalBirthTheplanthisyear istoeducatepatients,bothverballyandinwritingatprenatalappointments,aboutassistedvaginaldeliveriesandcaesareansections.

• Thiswillallowthepatienttogivenotjustinformedconsentbuteducatedinformedconsent• Theywillbeabletoasktherightquestions

DotheRightThingTogether!

• Everyonehassomethingtheyknow• Everyonehassomethingtoshare• Everyonehassomethingtolearn

Langley–ShapingPracticetoPromoteVaginalBirth:TheLangleyExperienceDr. EricaPhelps, (Obstetrics),Dr. BethWatt (Family Practice), TinaBlaney (Midwifery),Donna Adhemar (Nursing, Patient Care Coordinator) and Tanya Jantzen (Nursing,PerinatalClinicalEducator) 2013/14 2014/15 2016/16-C/SectionRates(Total) 21.8% 24.9% 22.7%CS-EligibleNullips 21.6% 26.9% 29%CSEligibleMultipsplanningVBACs 68.7% 69.7% 60.7%WhyAreWeSuccessful?TEAMApproach:T – TogetherE – EveryoneA – AchievesM– More

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PrinciplesofTeam-BasedHealthCare:SharedGoals

• Theteam–includingthepatient–workstoestablishsharedgoalsthatreflectpatientandfamilypriorities,andthatcanbeclearlyarticulated,understoodandsupportedbyallteammembers.

ClearRoles

• Clear expectations for each team member’s functions, responsibilities, and accountabilities,whichoptimizetheteam’sefficiencyandoftenmakesitpossiblefortheteamtotakeadvantageofdivisionoftasks–teamisgreaterthanthesumofitsparts.Holdingeachotheraccountableforthecarethatwedelivertogether.

• Dedicatedteamthatsupportsclientsthroughthebirthing journey.Theunitculture is tocrossmonitorandgiveandreceivesupportandadvicefromeachother.

• Focusisonevidence-basedlabourmanagement:o Strongadvocacyforintermittentauscultation(IA)forfetalhealthsurveillance.Theuseof

IA promotes mobility/position changes during labour and hydrotherapy as a copingstrategy. Only IA is used in low risk deliveries. Regular,multi-disciplinaryworkshops onfetalhealthsurveillancepromoteIAasastandardofcareinnormallowriskpregnancies.

• Use of Baby Pause is expected to encourage team discussion throughout patient’s care andpromotepatientsafety

• Establishment of accurate EDCs for postdates inductions with thorough discussion ofrisks/benefits

• Experiencedmaternitynursesprovideprenatalclasses.Strongnursingleadership.Staffengagethe leadership team in regard to difficult situations, including escalation, trigger tools, andquality review.Nurses empowered to collaboratemore effectivelywith the entire teamafterimplementation of the MOREOB program. Nurses are proactive in advocating for activemanagementof labour for their patients. Labour support is a priority; continuous 1:1 nursingcareinactivelabour.

• Midwifery-supportedbirthshave increased substantiallyasa resultof the strongpartnershipsthat have developed with the obstetrical and nursing groups where respect for each other’sexpertise is paramount. Midwives undertake home labour assessments that keep women inearlylabourathome.Midwivesattendqualityreviewmeetings.

• Leadership from obstetricians support evidence-based practice, home births and informedmaternalchoice.

• Obstetricteamislocatedjustdownthestreetandmemberssharesameofficesoareconstantlycommunicatingwithoneanotherregardingpracticeandcarechallenges

• GroupofFamilyPracticephysicianshavecreateda“new”sustainablemodelformaternitycareattheLangleyMaternityClinicwherethefocusisonexcellenceinprimarymaternitycare.Thepatientpopulationhashighsocialrisk, includingrecentimmigration,mentalhealthissues,and

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poverty. Theclinic isdown thehall from thebirthingunit. Theclinichasadjacencies to socialwork for seamless integration of care. Strong collaboration with obstetrics, pediatrics,anesthesia,midwiferyandsocialwork.TheFPheadoftheclinicalsoactsasleadfortheDivisionof Family Practice, enabling closed loop communication and easy rounding. Leadership fromfamily practice is provided through perinatal rounds,MOREOBmeetings, quality improvementrounds and Langley Maternity Clinic meetings, for which attendance from family practicephysiciansisrequired.Thefamilypracticegroupworkstogetherasateamintheoffice,notjustindividuals sharing a physical location. Sharing patients allows for multiple views and input.Physicianssupporteachotherandholdeachotheraccountabletobestpractice.

MutualTrust

• Team members earn each other’s’ trust, creating strong norms of reciprocity and greateropportunitiesforsharedachievement

• Strong,well-attendedquality improvementmeetings, suchasmortalityandmorbidity rounds,perinatalcommitteemeetingswithparticipationfromtheinterprofessionalteamonamonthlybasis

• Theteammemberswork together throughMOREOBprogramactivities,TakeFivesessionsandsocialevents

• All teammembers encouraged to escalate concerns, nurses comfortable escalating concernsthroughhierarchy

EffectiveCommunication

• Theteamprioritizesandcontinuouslyrefinesitscommunicationskills.Ithasconsistentchannelsfor candid and complete communication,which are accessed and used by all teammembersacrossallsettings.TheseincludeCHAT/SBARMaternal/FetalClassificationCommunicationToolandWalkingtheCubetoolforlearningconversationsaswellasMOREOBworkshops.

MeasurableProcessesandOutcomes

• Theteamagreesonand implements reliableandtimely feedbackonsuccessesand failures inbothfunctioningoftheteamandachievementoftheteam’sgoals–usedtotrackandimproveperformanceimmediatelyandovertime.

AfternoonSession(ByInvitation)DiscussantsThe morning session was reviewed by discussants Dr. Michael Klein, Professor Emeritus in theDepartmentofFamilyPracticePhysician,andSaraswathiVedam,ProfessorofMidwifery,UBC.

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Dr.Kleinmadethefollowingobservations:• The increasingly important role played bymidwives

in helping to alter the culture of practice, includingkeeping women out of hospital until labour is wellestablished, and the increasing acceptance ofmidwivesbyallprovidergroups.

• TheabilityofhospitalstomaintainlowCSrateswithandwithoutregularuseofepidurals.Itmeansthatifthe care is sophisticated and team-based, epidurals can be used without leading to adverseoutcomes.Ontheotherhand,as inRichmondHospital,keepingepiduraluse lowandsupporthighcanleadtooutstandingresults.

• Team-basedcareiskey.Ifthereisacoherentphilosophyofcareandcareiscollaborative,goodresultsfollow.

• LangleyhasthefirstOBgroupusinggroupprenatalcare.This istheessenceofcoherentcare.Theyhavethesamephilosophyandwillhaveastrongpositiveinfluenceontheirinstitutionandonperinataloutcomes.

ProfessorVedamsummarizedthemorning’sdiscussionofstrategiesasfollows:

• Teamculture:sharedgoals,trust,communication• Intentionaldatacollection(measurableoutcomes)• Leadership• Individualizedevidence-basedcare• Debriefs,accountability,constructivefeedback• Multi-disciplinaryrounds,QI/QA,andeducation• Harmonizedapproachandmessaging• One-to-onecare• Prenatalpreparation&informeddecisionmaking• Safetybroadlydefined(psycho-emotionalandphysical)

Shenotedthefollowingclinicalcomponentsofcaretopromotevaginalbirth:• Hydrotherapy• Mobilityandpositionchanges(telemetry,balls)• Judicioususeofepidurals(needforoxytocin,forceps)• Hightouch,lowtechnologyskills• Stayoncall• Crossconsultation• IAvs.electronicfetalmonitoring• Delayedadmissionwithanticipatoryguidance

The Maternity Care Discussion Group(MCDG) is a multidisciplinary discussiongroup with 1,700 members who discussclinical practice, research, self-help andanalysis of the maternity literature. Tojoin, just email:mklein@mail.ubc.ca andstateyourdisciplineandlocation.

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ProfessorVedamaskedthefollowingquestions:• Whatistheimpactofcareonwomen’scatecholamines,comfort,psyche,andtransitionoftheir

newborn?• Whatistheimpactofenvironmentthroughlighting,privacy,appearanceandlayoutofthebirth

setting?• ShouldtherebeaMamaPauseinadditiontoBabyPause?• Whatistheimpactofrelationship-basedcare/continuityofcare?• Does presentation of risk include both absolute risk and risk in the context of culture and as

definedbythepatient?• Howdoesindividualskilllevelandphilosophyaffectsuccessinasharedcallmodel?

Shenotedthatincludingthepatientvoiceinperson-centredcarecouldinvolve:

• Patientfeedbackloops–socialmedia• PatientsatQI/QAmeetings• Patientdebriefs• Measuringpatientautonomyandrespect• Impactonpatient’sobstetricalsequelae,especiallyamongwomenplanninglargefamilies

GeneralDiscussionamongWorkshopParticipantsPrenatalEducation

• InNanaimo,structuredprenatalclassesavailableinthecommunity.• In Richmond, virtual tours are available, incorporating teaching. An important component of

careisphysicianendorsementofprenatalclasses–improvesuptake.• Fort St. John and Terrace identified that building community connections are key aspects of

prenatal education. They watch social media groups to be aware of the dialogue andappropriateness of information transfer. Prenatal groups formothers are an important socialfabric.

PrenatalCare

• Beginningearlyinpregnancy,Langleyencouragesuseofdoulas.• Insomesettings,childrenarepermittedtoattendprenatalvisits.Thisoccurredafterfeedback

fromthecommunity.• Inothersettings,educationisprovidedona1:1basis.

Trauma

• EducationabouttraumafromatraumaspecialistwasbeneficialinRichmond.Thisinformationisnotnormallytaughttophysiciansornurses.

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• Educationteachesuseoflanguagetoavoidre-traumatization.• EducationregardingtraumamustenhancephysicianandRNtraining.

PatientEngagement

• Gotolaywebsites(administeredbypregnantwomen)andobservehowchangeisadopted.• IncludepatientsinMOREOBworkshopstoassistineducationofcareproviders.• AsatisfactionsurveyismandatedbytheCollegeofMidwivesofBC–isthereopportunityfora

standardizedsurveyinBC?PriorityStrategiesBasedonmorningpresentationsandafternoondiscussions, feasibility,andavailableevidence,prioritystrategieswereidentifiedasfollows:

1. Embeddingservicessuchasantepartumclinicsandprenatalclassesinhospitalmaternityunits,sothatpracticesarealignedwiththeclinicalsetting.

2. Linkingservicesacrosstheperinatalcourseofcaresothatphilosophiesarealigned.3. MandatingasecondopinionbeforeelectiveCS;potentiallyforemergencyCSaswell.4. ImplementingconsultsfromexpertsinnormallabourpriortoCS.5. Makingavailableanexpertinlabourmanagementinlabourunits.6. UndertakingpeerreviewofbirthsafterCS.7. Makingeducationinterdisciplinarytopromoteacultureofworkingtogether.8. Provisionofresourcestosupportunitstodevelopandimplement interprofessionaleducation,

includingcomprehensiveeducationonphysiologicbirth.9. Broaderaccesstoprenataleducation.10. Promotionofpsychologicalcomfort forwomenwithattentionto languageandenvironmental

factors:a. Earlypregnancyassessmentfortraumahistory,toolsandreferralsfortreatmentb. Postnataldebriefingtoassessfortraumaexperiencedduringlabourandbirthc. Education for perinatal care providers re: recognition and management of trauma to

preventre-traumatizingexperiences.11. Development of Ministry of Health standards for building construction and development of

birthingspacestopromotemovementandactivityduringlabour.12. Useofcreativenon-pharmacologicalapproachestosecondstage.13. Development of standards of care for perinatal nursing education (mentorship, modelling,

conveyanceoftacitknowledge).14. Coaching of practitioners on how to promote vaginal birth by interprofessional champions

travellingtohospitalsaroundBC.15. Streamlineandsimplifyworkloadassociatedwithdocumentationforpointofcarestaff.

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16. Individualizeearlylabourmanagement.17. Assessment of patients for adverse childhood experiences ACE questionnaire as part of

obstetricalriskassessment.18. Build toolboxofstrategies topromoteculturechangethroughenhancing trustandpromoting

multidisciplinaryteamwork.19. Createadebriefingpolicywithpatientsaftertheirbirth.20. UndergoaTakeFivetypeofdebriefwithpatientparticipation:

a. Whatwentwell?b. Whatdidwelearn?c. Whatwouldwedodifferentlynexttime?d. Didwehaveanysystemsissues?e. Whoisgoingtofollowuptoaddressproblems?

PriorityStrategiesConsolidatedandDelegatedTocontinuethediscussionofoperationalissues,feasibility,andresourcestofacilitatepracticechange,priority strategies were consolidated and potential agencies with authority to implement thosestrategieswereidentifiedasfollows:MinistryofHealth

1. Ensure broader accessibility to prenatal education through resources for development ofalternativestrategiesfordelivery,includingmHealth.

2. Achieveeffectiveuseofbirthingspaces topromotecomfort,movement,andactivity, throughdevelopmentofevidence-basedstandardsfortheirdesignandconstruction.

3. Resourcestosupporthospitalsandhealthauthoritiestodevelopinterprofessionaleducationintopicalareasappropriatetopromotingphysiologicbirth:a. Atoolboxofstrategiestopromoteacultureofinterprofessionalismthroughenhancement

oftrustandteamworkb. Non-pharmacologicalapproachestosecondstagec. Astandardizedapproachtoearlylabourmanagementd. Standardsforcontinuingeducationintheworkplace(mentorship,modelling,conveyance

oftacitknowledge)e. Streamlinedandsimplifiedpointofcaredocumentation.

4. Attain efficient use of educational resources through support and endorsement of aninterprofessional team of champions/experts who would provide coaching to maternity careproviderteamsathospitalsregardingimplementationofpolicies,protocols,training,anduseofphysicalspacetopromotevaginalbirth.

5. Promoteacceptabilityofservicesthroughdevelopmentofpolicyforengagingthepatientvoiceinplanningchangeandevaluatingexperiences.

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PerinatalServicesBC1. Ensure broaderaccessibility to prenatal education through implementation and evaluation of

alternativestrategiesfordelivery,includinguseofonlinetechnologiesandmHealth.2. Developmentoftrainingmodulesappropriateforpromotingphysiologicbirthformaternitycare

providers, including non-pharmacological approaches to second stage, early labourmanagement,andmentorshipandmodellingfornewmaternitycareprofessionals.

3. Promote safetyby establishing guidelines for obtaining a second opinion for elective CS, andpotentiallyforemergencyCS.

4. Measureand reportonaspectsof culture thateffectively promote interprofessional trustandteamwork.

5. Constructguidelinestosupportpsychologicalsafetyandcomfortforwomen:a. Early pregnancy assessment for trauma history, using the ACE questionnaire and other

tools,followedbyreferralsfortreatmentb. Postnataldebriefingtoassessfortraumaexperiencedduringlabourandbirthc. Educationforperinatalcareprovidersregardingrecognitionandmanagementoftrauma

topreventre-traumatizationduringlabourandbirthd. Partnerwith theFacultyofMedicine,SchoolsofNursing fordevelopmentof curriculum

fortrainingontrauma-informedcare.6. Attain efficient use of educational resources through implementation and evaluation of an

interprofessional teamof champions/expertswho coachmaternity care teams at hospitals todevelopor promotepolicies, protocols, training, andphysical space to promote vaginal birth.CouldinvolvepartnershipswithMidwives’AssociationsofBCandtheDoctorsofBC.

7. Promoteacceptabilityofservicestowomenthroughdevelopmentofprotocolstoengagethemin planning and evaluation, including participation in quality improvement exercises,participation in “Take Five” discussions after non-routine events, and routine debriefing aftereachbirth.CouldinvolvepartnershipswithSPORnetworks,thePatientVoicesNetworkandtheInstituteforPatient-andFamily-CenteredCare.

HealthAuthorities

1. Promote efficiency and streamlining of services, including collaborative care, by embeddingprenataleducationclassesandantenatalclinicsinhospitals.

2. Promotesafetyby implementingprotocols forobtainingasecondopinion forelectiveCS,andpotentiallyforemergencyCSaswellasconsultsfromexpertsinnormallabour.

3. Implement interprofessional education in topical areas appropriate to promoting physiologicbirth:a. Buildingtrust,teamwork,andapositivecultureb. Earlylabourmanagementc. Standards for continuing education in the workplace (mentorship, modelling and

conveyanceoftacitknowledge)

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d. Non-pharmacologicalapproachestosecondstagee. Useofprotocolstostreamlineandsimplifydocumentationatpointofcare.

4. Supportpsychologicalsafetyandcomfortforwomenbyimplementing:a. Routineantenatalassessmentfortraumahistory,usingtheACEquestionnaireandother

tools,followedbyreferralsfortreatmentforallwomenwhoneeditb. Postnataldebriefingtoassessfortraumaexperiencedduringlabourandbirthc. Educationforperinatalcareprovidersregardingrecognition,andmanagementoftrauma

to prevent re-traumatization during labour and birth (i.e. use of language, breathingexercises,supporting/facilitatingself-regulation).

5. Promote acceptability of services to women through including them in quality improvementexercises,routinedebriefinginthepostpartumperiod,participationinthe“TakeFive”approachtonon-routineevents,andinclusioninrounds,relevanttopromotingvaginalbirth.

FinalReflectionsDr.GlenysWebster,DirectorofWomen's,MaternalandEarlyChildhoodHealth,BCMinistryofHealthnoted that although her department is small, she is committed to helping develop approaches topromote vaginal birth, including working with Perinatal Services BC and Optimal Birth BC to worktowardssomeofthechangessuggestedinthisworkshop.PotentialNextSteps

• PresentfindingstoPSBCandMOH• SetupameetingwithworkshoporganizersandPSBC/MOHwiththeobjectiveofformulatinga

strategytoworkwithhealthauthoritiestoachieveidentifiedgoals• Set up an informalwebinar-based community of practice inwhich health authorities/hospital

representativesmeetforsupport/adviceonimplementingchange• Evaluation of the outcomes from the workshop, i.e. engage participating sites to share the

impactoftheconferenceonpracticechangesandculturewithafollow-upsessionin1-2years.Thiscouldlinkwellwithacommunityofpractice.

• Publicationofworkshopfindingsinpeer-reviewedliterature

The Shaping Practice to Promote Vaginal Birth workshop waspresented byOptimal Birth BC andmade possible through fundingfrom the Michael Smith Foundation for Health Research. Theworkshopwas hosted by the FraserHealth Authority,with supportfromtheUniversityofBritishColumbia.