maternity services

Evaluation of

the obstetric

Consultant

on-site

out-of-hours

maternity services

Stockport & High Peak Activity 09/10

4,029 women delivered

4,075 live births

Normal births 62 %

Assisted vaginal births 13 %

Vaginal breech 0.5%

Elective C/S 11 %

Emergency C/S 14 %

16% births at home or in a birth centre

3% homebirths

maternity services

Evaluation of

the experienced

Obstetrician on-

site out-of-hours

ST 6/7

Staff and associate specialist

Consultant

EWTD

MMC

PMETB

maternity services

1992

On-call rota in O&G at SHH • Senior House Officer

• Senior SHO

• Registrar

• SR / Associate Specialist

• Consultant (at home)

2009

On-call rota in O&G at SHH• FY2 or SHO (GP trainee or ST1/2)

• ST or Staff Grade

• Consultant (at home)

• FY2 and ST3

• Consultant at home

to cover O&G in a unit with over 4000 births / year

maternity services

Mothers put at risk by inferior overnight care, maternity chief warnsDenis Campbell, health correspondent

The Guardian, 31 December 2010

“Obstetric care isn’t the same at 3am as it is at 3pm, and it should be.

This is a matter of huge concern.”

“The inexperience of doctors working night shifts in labour wards

can mean they lack the skills needed to ensure a baby’s safe

delivery, that women have unnecessary caesarean sections

and that some babies suffer catastrophic harm

during their birth.”

Anthony Falconer

President of the RCOG

maternity services

Mothers put at risk by inferior overnight care, maternity chief warnsDenis Campbell, health correspondent

The Guardian, 31 December 2010

PLENTY OF EVIDENCE

CEMD reports

Scottish near miss audits

CESDI reports

NPSA reports

Healthcare commission reports ….

Time of birth and risk of NND at term:

retrospective cohort study (BMJ 16 July 2010)

45% increased risk of NND due to IP anoxia

out of hours – one risk variable: lack of

immediately available senior clinicians

NPSA report (2006)

After midnight, increase in severe “fetal distress”

events with increase number of IP stillbirths

and babies born with severe disability

Welsh Perinatal Survey (1993-95)

IP complications are more common at night and

holiday periods when less experienced staff

available

Hospital at Night study (2004)

Level of activity remains the same

throughout 24 hours in ⇒Obstetrics, Paediatrics,

Intensive care, Acute medicine

maternity services

A key component of our Safety Improvement Project was

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Potential benefits team function / leadership

communication

training of junior doctors

timely intervention

improved outcomes

safer care for pregnant women and babies

SAFER BIRTHS KEY THEMES

Safe maternity teams

Staffing for safety

Training for safety

2 Consultants on-site 20.30 – 08.30 hours Monday and Tuesday

in post 01/09/2009

maternity services

First Activity Analysis Sept 09 – April 2010

Delivery Type Mon - Wed Thurs - Sat

Normal Births 213 (69%) 189 (63%)

Instrumental 44 (14.2%) 54 (18%)

Breech 4 (1.3%) 1 (0.4.%)

Emergency C/S 44 (14.2%) 56 (18.6%)

Total 309 300

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Interviews Labour Ward co-ordinators (10) and middle grades (8)

Middle grades ST3 x1

ST5 x2

ST6 x2

ST7 x1

MTI x1

Staff Grade x1

Delivery outcomes / CNST triggers

Emergency CS at full dilatation

Twin deliveries

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Interviews of middle grades (8)

1. Can you describe if and how you believe you are more supported in your

work when a consultant is in attendance on-site out-of-hours?

Give example(s)

2. In your experience, do you believe that having a consultant on-site out-of-hours reduces levels of work-related stress?

Give example(s)

3. In your opinion, what impact has the on-site out-of-hours consultant had on your skills’ development and your training?

Give example(s)

Is there anything else that you’d like to add?

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Interviews of Labour Ward co-ordinators (10)

1. Benefits to co-ordinator

2. Benefits to the team

3. Benefits to the woman

Give examples

Opportunity for additional comments

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Recurrent positive themes – positive outweighed negative

• Staff feel reassured / more confident / secure / calm environment

“I can feel very lonely at night.” ST3

“It can be very stressful for you to be on your own at night.” ST7

“It reduces your stress levels when you know there is a consultant on site with you.” – recurrent quote regardless of seniority

“I feel more confident in my co-ordinating role”

“It feels calmer and safer” “Reduces anxiety right from the beginning of the shift”

“The unit feels more relaxed, like the full team is available on Delivery Suite”

maternity services

Evaluation of on-site out-of-hours presence of

Consultant on the Labour Ward

• Joint decision making / timeliness of decision making

“The whole team is more confident, less likely to intervene early and

therefore supports normal birth.”

“You wouldn’t phone a consultant at night just to discuss a case. You

just manage.”

“Consultants are more part of the team and are leading the team.“

“Women are not left without clear management plans in labour”

“Consultants make a definite plan”

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Recurrent positive themes – positive outweighed negative

• Less interventions / safe care / best care “It’s better and safer for the women, it prevents delays.”

“A trainee will have recourse to deliver by section if in doubt. With the consultant there, they may not.”

“Their presence makes me more confident.”

“Decisions are made quicker, seeing a situation develop”

“Assessing constantly what’s going on”

• Training – learning opportunitiesMore opportunity to discuss cases, get observational skills signed off

Increased training opportunities – rotational / breech deliveries

“Trials are very stressful for me and having the consultant there helps.” ST3

“Trials in theatre always make me nervous. It helps having a consultant here with you.” ST6

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Negative themes – positive outweighed negative

• Communication issues between consultant and midwives

midwife – consultant

consultant – trainee doctor

• Supervise more and actively do less

• Consultant presence depends on interest in obstetrics

“If the consultant is not there, you push yourself more.” ST6

(CS at full dilatation with bad tears, struggled, would have asked for senior help if on site)

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Delivery outcomes / CNST triggers

Emergency CS at full dilatation

Twin deliveries

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours)

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours)

89 emergency CS at full dilatation in study period (16%)

(A) 6 – all failed instrumentals

(B) 19 – failure to progress 8

failed instrumental 8

presumed fetal compromise 2

other (brow) 1

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Emergency CS at full dilatation

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours)

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours)

(A) 6 – all failed instrumentals

• OA, NB forceps no descent BW 3.22 kg (locum+C)

• OA, NB forceps no descent BW 4.04 kg (C+ST1)

• OT, Kiellands rotation to OA, no descent BW 3.05 kg (C+ST3)

impacted head, uterine tears

• OP, NB forceps no descent BW 3.68 kg, uterine tears (ST6+ C)

• OP, Kiellands rotation to OA, no descent BW 4.25 kg, uterine tears (ST6+C)

• OP, NB forceps no descent, maternal respiratory arrest, difficulty in delivery of head BW 3.36 kg (locum+C)

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Emergency CS at full dilatation

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours)

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours)

(B) 8 failed instrumentals – with 2 instruments used in 3 cases

• Evidence of poor assessment and technique (4 cases)

• Position not defined

• Use of Kiwi for OP / OT position

• Use of forceps despite no descent with ventouse

• Maternal morbidity – vaginal tears, episiotomy and CS scar

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Emergency CS at full dilatation

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours)

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours)

Training issues

• Reluctance to attempt instrumental delivery?

8/19 “failure to progress” – yet fully dilated

• Inappropriate use of 2 instruments in all 3 cases

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Delivery outcomes / CNST triggers

Emergency CS at full dilatation

Twin deliveries

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours)

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours)

54 sets of twins delivered during the study period, with 1 in-utero transfer

9 elective CS delivery

45 spontaneous onset or induction of labour with over 70% (32) delivering outside 08.30-17.00 hours

(A) 10

(B) 14

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Twin deliveries

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours) n= 10

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours) n= 14

Mode of delivery (A) (B)

Em CS 3 (30%) 6 (43%)

Spont vag 2 (20%) 4 (29%)

Instrumental 5 (50%) 4 (29%)

If vag del, twin 2 breech 4 2

No emergency CS deliveries for twin 2

Reasons for em CS

(A) placenta praevia +prem labour, breech x2 in labour, presumed

fetal compromise

(B) presumed fetal compromise (3), failure to progress (2), breech x2 (1)

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

Twin deliveries

Study period 01/09/2009 – 31/08/2010

(A) on-site consultant (Monday & Tuesday 20.30-08.30 hours) n= 10

(B) no on-site consultant (Wed & Thursday 20.30-08.30 hours) n= 14

Consultant presence

(A) Present for all twin deliveries, except 1 midwife delivery

(B) Attendance requested for 3 (1 in 5 deliveries)

1 consultant on-site already – busy night, severe PET 31w

undiagnosed breech – delivered by the time of arrival

failed intubation – APH, transverse lie (ST3)

• Wonderful training opportunity – reflected in number of vaginal

deliveries

• Wonderful care provision for the women

maternity services

Evaluation of on-site out-of-hours presence of Consultant on the Labour Ward

FACTS

• Physical presence of Consultant staff in an emergency situation

improves outcome and reduces negligence claims

• To-date – no SUI during Consultant out-of-hours shift

“There should be no difference between day and night cover.”

“It shows we are a Trust putting money into good staffing with

Consultants on site 24 hours a day.”