Shared learning database

Ashford & St Peters NHS Foundation Trust (ASPH)
Published date:
October 2014

This submission relates specifically to the NICE Intrapartum care guideline (CG190). It places the guideline in the context of care of women with low risk pregnancies in labour. Consideration is given to care through the intrapartum pathway within a midwifery led environment.

The risk of intervention and transfer is significantly reduced through care pathways that are supported by criteria based upon current literature findings. These encompass; robust antenatal risk assessment of suitability; admission triage by experienced midwives and one to one midwifery care in a non-clinical environment. This acknowledges the physiology of labour which is facilitated and supported by expert practitioners. There is continued provision of homebirth as a choice for women.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

1. To provide women within the low risk category who have been appropriately risk assessed with the choice of an alternative birth environment (Birth Centre).
2. Improve outcomes and experience for mothers and babies by reducing likelihood of intervention and the associated risk and cost of instrumental births and surgical delivery.
3. Reductions in length of hospital stay, resulting in decrease in cost to the NHS and reducing the impact of separation for women and their families.
4. For midwives to develop their skills, confidence and competence in spontaneous vaginal birth - it is intended that sharing these skills and experiences will enhance the culture of normality within the wider maternity unit and community by reinforcing and improving midwives' knowledge and skills base when caring for women in spontaneous labour in order to maximise their chance of achieving a spontaneous vaginal delivery

Reasons for implementing your project

The maternity service at ASPH historically provides an obstetric led labour ward; Triage; antenatal clinic (ANC)/day assessment unit (DAU); an antenatal and postnatal ward with a 9 bedded special care baby unit (SCBU). In addition there is a community midwifery service providing the antenatal midwifery led and home birth service for the low risk population; and with the support of Supervision occasionally provide a homebirth service for women with high risk pregnancies.

The main labour ward has 7 labour rooms, 1 pool room and 3 'home from home' rooms'. Prior to the availability of the birth centre low risk women in spontaneous labour were seen by the triage service. ASPH has a significant high risk population, as we also have a Level 3 Neonatal Intensive Care Unit (NICU) ? the only one in Surrey, to which we receive both in utero and ex utero referrals from a wide geographical area.

It is projected that 1/6 of our 4,100 (approx. 700) women will deliver in the new birth centre. The experience to date has demonstrated that this will improve care for women throughout the service. The care of the women who require care in the high risk labour ward environment has been enhanced by ensuring that women are looked after in the area most appropriate to meet their needs. Low risk women experience a reduction in intervention rates when cared for within a culture of normality receiving one to one care from experienced midwives with excellent clinical competencies and decision making skills. Barriers to implementation of the process included;
- Completion of a successful business case and obtaining planning permission to commence building.
- Implementing a philosophy of normal birth alongside a high risk obstetric unit.

How did you implement the project

The senior midwifery management team produced an excellent business case and were awarded £1.5 million to build a new 'alongside Birth Centre'; with additional funding for 10 full time band 6 midwives. On nearing completion of the birth centre build, a lead midwife (team leader) for the new service was recruited (February 2014) and expressions of interest to support low risk women in spontaneous labour invited from existing, experienced band 6 midwives, who have successfully completed their preceptorship period. This includes achieving competencies in cannulation and perineal suturing, amongst other skills and, understanding their philosophical approach to caring for women in spontaneous 'normal' labour and having a spontaneous vaginal birth.

It was decided that a core team of 9 midwives (working 12 hour shifts) and a team leader (band 7) 9-5pm Monday - Friday will be based in the birth centre and be supported by a team of community midwives who rotate in to the birth centre as part of their role (approx. 16).

The core team will cover at least one of the two 12 hour shifts required each day and night in order to establish and embed the standard of care, and underpin the clinical expertise and experience, expected for all women coming through the birth centre; this in context to there being only 2 midwives in the birth centre overnight and at weekends and the need for the midwives to have expert clinical judgement and decision making skills - with the support of 24 hour on call Supervisor of Midwives - see attached operational and clinical guideline.

Our birth centre operational and clinical guideline was developed after researching other birth unit guidelines and criteria, looking at current evidence and local statistics in relation to women's experience of spontaneous vaginal birth; national guidance regarding management of spontaneous vaginal birth and was compiled by the lead midwife for the birth centre and the Supervisors of Midwives, who also ratified the guideline along with the Associate Director of Midwifery.

With a shared philosophy and understanding of the evidence supporting normal birth, the birth centre service is expected to offer an alternative environment for all women with low risk pregnancies. This philosophy is implemented in context to the risk of intervention and transfer being reduced through care pathways that are supported by criteria based on current literature findings.

Key findings

Progress and evaluation of results has been possible through audit and is ongoing; initial main results include demonstration of improving outcomes and normal experiences for nulliparous women; an increase in waterbirth rates and reduction in requests for pain relief - see key statistics below from 5th May (opening) ? 31st August 2014:

- 159 births- 49% nulliparous/ 51% multiparous
- 22.5% average intrapartum transfer rate - reasons for transfer: AntePartum Haemhorrhage; Meconium (1st & 2nd stage); slow progress; abnormal Fetal Heart rate
- No transfers for pain relief alone; 1%
- Following transfer from Birth centre 46% SVD's; 53% had instrumental delivery's and 7% had LSCS's

Key learning points

- Irrespective of population a commitment and belief underpinned by sound understanding of the physiological process of childbirth improves women's' ability to labour and birth normally.
- Guidelines that are robust and underpinned by midwifery supervision ensure safe care for women and empower midwives to provide this.
- Ongoing audit of all notes within a new service provides a mechanism for risk management issues to be addressed swiftly and effectively ensuring a continual learning environment for staff. Ensuring transparency and critically reflective practice continually improves outcomes and experience for women is fundamental to success.

Contact details

Alex Bell
Midwife Team Leader
Ashford & St Peters NHS Foundation Trust (ASPH)

Is the example industry-sponsored in any way?