the role of the royal college of midwives in in leading practice frances day-stirk royal college of...

The role of the Royal College of MidwivesThe role of the Royal College of Midwives in in

leading practiceleading practice

Frances Day-StirkFrances Day-StirkRoyal College of Midwives

Director Learning Research & Practice DevelopmentDirector Learning Research & Practice DevelopmentInternational OfficeInternational Office

Developing guidelines for midwife-led care

Rio de Janeiro 4 November 2009Rio de Janeiro 4 November 2009

The voice of midwifery in the United Kingdom

Professional organisation and trade union for midwives led by midwives for midwives

The vast majority of the midwifery profession are members. 

represents the interests of midwives in all four UK countries individually and collectively. 

promote excellence, innovation and leadership in the care of childbearing women, the newborn and their families, nationally and internationally. 

Strategic intentions

As part of the strategy to promote the midwifery profession and support midwifery practice, the Royal College of Midwives (RCM) developed several of approaches

Aim: to improve midwifery practice and encourage a national standard of practice, by producing quality reference (d) documents for local use

Key initiatives

RCM Evidence Based Midwifery peer-reviewed research journal – launched 2003

promotes the dissemination, implementation and evaluation of midwifery evidence locally, nationally and internationally.

publishes papers - qualitative or quantitative research studies, philosophical analyses and systematic reviews. 

Midwife-led care has an underpinning philosophy of labour as a normal physiological process. It also recognises that, for the woman, labour is not ‘just normal’ but actually extraordinary: as a ‘good’ or ‘bad’ experience it has great implications for her psychological well-being and her relationships with her family

Wiklund et al 2008; Lemola et al 2007; Waldenstrom et al 2004; Simkin 1992

‘Hands-on’ guidance for midwives doing home birth (2003)

Common concerns when developing home birth practice

Guidance on practical information –Antenatal preparation, labour and postnatal care in the home environment

Evidence-based midwifery led care in labour

o First two editions- developed for use in one NHS Trust, UK(Helen Spiby & Jane Munro)

o Third edition- commissioned by the Royal College of Midwives

intrapartum care in midwifery-led environments, midwifery-led schemes

Guiding principles

o Process for developing and evaluating guidelines should focus on outcomes valued by users

o The guidelines should be based on best available evidence and include a statement about the strength of evidence

o A sound method of critical analysis should be adopted

o The guidelines should be flexible and adaptable

o There is evidence of user involvement and other appropriate professionals

The Process

o Suitability screeno Scopeo Literature searcho Grading of recommendationso Audito Peer Reviewo Declaration of interestso Supporto Disclaimer

Context and philosophy

o Evidence base to midwifery care

o Clinical practice guidelines

o Midwifery-led approaches to care

o Information and involvement in decision-making

Identifying topics for inclusion

o Preparatory surveyPreparatory surveyusefulness & acceptability to midwivesusefulness & acceptability to midwives

o Identification of topics via stakeholdersIdentification of topics via stakeholdersMidwives - Evidence Based Midwifery Midwives - Evidence Based Midwifery

Network & Royal College of MidwivesNetwork & Royal College of MidwivesWomen - via User Groups at national Women - via User Groups at national

levellevel

Literature review

o prospective randomised controlled trialsprospective randomised controlled trials

o midwives’ research and reviews exploring midwives’ research and reviews exploring women’s viewswomen’s views

o professional bodies (RCM & RCOG) and professional bodies (RCM & RCOG) and government policy directivesgovernment policy directives

o expert opinionexpert opinion

Search strategy

o Search of electronic Search of electronic databases databases

o Cochrane, Medline, CINAHL, Cochrane, Medline, CINAHL,

MIDIRSMIDIRS

o Guideline databases and Guideline databases and collectionscollections

o Hand searching of six key Hand searching of six key journalsjournals

o English language papers or English language papers or abstractsabstracts

o Publication periodPublication period

o Separate search strategy Separate search strategy each topiceach topic

o MeSH headings and keyword MeSH headings and keyword termsterms

Formulation of recommendations

o Critical appraisalCritical appraisal

o Research conducted in settings & contexts Research conducted in settings & contexts relevant to midwifery-led carerelevant to midwifery-led care

o Two authors peer reviewed each sectionTwo authors peer reviewed each section

o Presented as a narrative and in bullet Presented as a narrative and in bullet pointspoints

o No grading of evidenceNo grading of evidence

Evaluation

o Peer reviewPeer review

o Use of the AGREE toolUse of the AGREE tool

o Midwifery guideline expertsMidwifery guideline experts

o Service users/representativesService users/representatives

Guideline titles

o Birth EnvironmentBirth Environmento Latent PhaseLatent Phaseo Supporting Women in LabourSupporting Women in Labouro Supporting and Involving Women’s Birth CompanionsSupporting and Involving Women’s Birth Companionso The Use of Water for Labour and BirthThe Use of Water for Labour and Birtho Pharmacological Pain ReliefPharmacological Pain Reliefo Fetal Heart Rate MonitoringFetal Heart Rate Monitoringo Assessing Progress in LabourAssessing Progress in Labouro Rupturing MembranesRupturing Membraneso Positions for Labour and BirthPositions for Labour and Birtho Persistent lateral and posterior fetal positions at the onset of Persistent lateral and posterior fetal positions at the onset of

labourlabouro Second Stage of LabourSecond Stage of Labouro Care of the PerineumCare of the Perineumo Third Stage of LabourThird Stage of Labouro Suturing the PerineumSuturing the Perineumo Immediate Care of the NewbornImmediate Care of the Newborno Early BreastfeedingEarly Breastfeeding

Birth Environment Practice Points

Go to website

http://www.rcm.org.uk/college/standards-and-practice/practice-guidelines/

Working in ‘in an environment that is open and participative,

where ideas and good practice is shared, where education and research is valued’

Scally & Donaldson 1998

Can mean learning how to ‘start stopping’

Evidence based midwife-led care & clinical governance

Hospital is an alienating environment for most women, in which institutionalised routines and lack of privacy can contribute to feelings of loss of control and disempowerment

Lock and Gibb 2004; Steele 1995

Control, or lack of it, has been found to be important to women’s experience of labour and their subsequent emotional well-being

Green et al 1990; Simkin 1992

The home-like environment is associated with lower rates of analgesia, augmentation and operative delivery, as well as greater satisfaction with care

Hodnett et al 2005

The environment

Because of the high level of intervention

associated with electronic fetal monitoring, intermittent auscultation with a hand held instrument is the recommended method for the woman who is healthy and has had an uncomplicated pregnancy

NICE 2007; MIDIRS 2005; RCOG 1993

Fetal heart rate monitoring

Current evidence does not support the use of the admission CTG in low risk pregnancy. It should not be used routinely

NICE 2007; MIDIRS 2005; Blix et al 2004; Impey et al 2003; Mires et al 2001

Midwife-led care has been found to have as good outcomes as medical-led and shared care, met with greater satisfaction from the women and reduced obstetrical intervention rates

Hatel et al 2009; Campbell et al 1999; McVicar et al 1993; Shields et al 1998; Turnbull et al 1996; Hundley et al 1994; McVicar et al 1993

Obrigado

www.rcm.org.uk

http://www.rcm.org.uk/ebm/

http://www.rcm.org.uk/college/standards-and-practice/practice-guidelines/

Acknowledgements

Jane Munro & Mervi Jokinen