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Delivering Quality and Value Pathways to Success: a self-improvement toolkit Focus on normal birth and reducing Caesarean section rates

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Pathways to Success: a self-improvement toolkit Focus on normal birth and reducing Caesarean section rates Caesarean section (CS) has an important role in ensuring safe maternity care. How can we make sure that every Caesarean is appropriate, effective and efficient? The NHS Institute for Innovation and Improvement is working with NHS clinical staff to promote best practice in achieving low CS rates while maintaining safe outcomes for mothers and babies. This toolkit is designed to help maternity services review and assess their current practice in promoting normal birth and reducing CS rates. The toolkit also provides practical techniques to support sustainable changes in maternity services.

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Page 1: Pathways to success focus on normal birth

Delivering Quality and Value

Pathways to Success:a self-improvement toolkit

Focus on normal birth and reducingCaesarean section rates

Delivering Q

uality and ValuePathw

ays to Success: a self-improvem

ent toolkitFo

cus o

n n

orm

al birth

and

redu

cing

Caesarean

section

rates

For further information please visit www.institute.nhs.ukor email [email protected]

NHS Institute for Innovation and ImprovementCoventry HouseUniversity of Warwick CampusCoventryCV4 7AL

To order further copies contact [email protected] and quote code NHSIDQVToolkit-C-Section

Version 1 - 2006, Version 2 - 2010ISBN: 978-1-907045-93-6NHS Institute product code: NHSIDQVToolkit-C-SectionCopyright © NHS Institute for Innovation and Improvement 2010 All rights reserved

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© Copyright NHS Institute for Innovationand Improvement 2010

Focus on normal birth and reducingCaesarean section rates is published by the NHS Institute for Innovation andImprovement, Coventry House, Universityof Warwick Campus, Coventry, CV4 7AL

This publication may be reproduced andcirculated by and between NHS Englandstaff, related networks and officiallycontracted third parties only, this includestransmission in any form or by any means,including photocopying, microfilming, and recording.

This publication is copyright under theCopyright, Designs and Patents Act 1988. All rights reserved. Outside of NHS Englandstaff, related networks and officiallycontracted third parties, no part of thispublication may be reproduced ortransmitted in any form or by any means,including photocopying, microfilming, andrecording, without the written permissionof the copyright holder, application forwhich should be in writing and addressedto the Marketing Department (and marked‘re: permissions’). Such written permissionmust always be obtained before any part of this publication is stored in a retrievalsystem of any nature, or electronically.

ISBN: 978-1-907045-93-6

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1Introduction

01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

Introduction

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Introduction

‘This is a great toolkit that should really helpstaff and user representatives in NHS trusts to think about what affects their unit’s Caesarean rate and work together on a range of related actions to facilitate normalbirth and prevent unnecessary surgery’ Mary Newburn, Head of Policy Research, National Childbirth Trust & Honorary Professor, Thames Valley University

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Pathways to Success: a self-improvement toolkit

Focus on normal birth and reducing Caesarean section rates to a safe minimumCaesarean section (CS) has an important role in ensuring safe maternity care. How can we make sure that every Caesarean is appropriate, effective and efficient?

The NHS Institute for Innovation and Improvement is working with NHS clinical staff to promote best practice in achieving low CS rates while maintaining safe outcomes for mothers and babies.

This toolkit is designed to help maternity services review and assess their current practice inpromoting normal birth and reducing CS rates. The toolkit also provides practical techniques to support sustainable changes in maternity services.

The NHS Institute for Innovation and ImprovementThe NHS Institute for Innovation and Improvement (NHS Institute) was formed in 2005. It supports the NHS to improve health outcomes and raise the quality of care by speeding up the introduction of proven new ideas and improvements in healthcare delivery models and processes, medical products and devices, and healthcare leadership.

The High Volume Care Project1 part of the Delivering Quality and Value Programme at the NHS Institute, aims to discover how top performing healthcare organisations in the NHS and elsewhere deliver the highest quality care with the best resource utilisation, and to find effective ways of spreading that successful practice to other services.

The NHS Institute produced the ‘Focus on: Caesarean Section’2 document as one of a series in the High Volume Care programme. This initial series of care pathways were chosen on the basis that they occurred in large numbers and hence consumed high levels of resources. There was also marked variation across England in the performance of individual services.

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Why do Caesarean section rates matter?• In 2005-2006, over 135,000 CS operations were carried out in England3

• In 1990, the national average CS rate was 12%, in 2006 the average CS rate was 24%4

• In 2005-2006, the CS rate for individual services varied from about 16% to well over 30%3

• Following CS, the average length of post-natal stay varies from 3.5 days to 7 days.3

This increase in Caesareans has not been accompanied by a measurable improvement in theoutcome for the baby.5

What should the Caesarean section rate be?Many reasons have been put forward to explain the year on year rise in numbers of CS births.6

For instance, reduced working hours of trainee obstetricians may have limited theiropportunities to develop practical skills,7 the move to birth in a hospital setting8 and theincreased use of technology9,10 may have affected midwives’ confidence in managing normallabour and birth. Fear of litigation is often cited as a major driver for increased interventionrates in pregnancy and labour.11 Changes in evidence-based clinical practice, for example inthe management of women with breech presentations12 or women who are HIV positive,13

have led to an increase in the number of planned Caesarean sections recommended.Consumer demand or women exercising choice and requesting CS in the absence of any clear medical indication may also have played a part.14

No two maternity services are the same. However, variations in CS rates cannot be readilyexplained by differences in size, complexity of caseload or demography.15,16

Maternity service professionals have a strong history of identifying evidence-based care. For most, the debate is not about what constitutes best practice but about how to make the changes necessary in order to achieve it.

When we worked with services achieving low CS rates, there were clear common themes in their aims and approaches to delivering maternity care. They have shown that applyingevidence-based good practice and innovative models of care lead to lower CS rates and a better experience for women when a CS is appropriate. There was a general belief amongst clinicians involved in this project that maternity units applying best practice to themanagement of pregnancy, labour and birth will achieve a CS rate consistently below 20%and will have aspirations to reduce that rate to 15%.

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Benefits of promoting normal birth and reducing Caesarean section rates to a safe minimum

To women:• No interventions without benefit to mother or baby• Birth is seen as a positive experience• Women receive support from staff to optimise the chance of normal birth• Women in labour receive one-to-one professional support• Women feel empowered in making decisions with support from staff• Mortality and morbidity rates improve• Women are able to return home more quickly to their families.

To staff:• Staff derive a high level of satisfaction from providing high quality care and enabling

women to achieve the outcomes they want• There is a sense of pride in units• Working in a well-functioning team aids staff retention• Midwives spend less time on non-clinical tasks• Reduction in pressure of work on medical staff• There is a greater opportunity to acquire and maintain a portfolio of skills.

To the organisation:• Enhanced reputation attracts women to use the service• Recruitment and retention improves through increased staff satisfaction• Reduction in post-operative bed days gives opportunity for financial savings• Enhanced risk management reduces litigation.

To the commissioner:• Public money is spent according to clinical need• Savings made on CS can be redirected into improving maternity services• Savings from achieving optimal value for money in maternity services can be redirected

into other areas of need, e.g. children’s services, care of the elderly• Improvements in the long-term health of mothers and babies reduces the chronic

care burden.

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How was Focus on: Caesarean Section developed?The NHS Institute worked in partnership with NHS colleagues to identify maternity services that hadsucceeded in reducing or maintaining low Caesarean rates, and services that had high rates but hadrecognised a need to reduce them. Our small team visited a number of these units, held formal andinformal interviews with a wide range of staff and users, and spent time observing the processes ofcare. We identified with trusts those features that they believed have contributed to their success inmaintaining low CS rates.

The findings from the visits were validated in a co-production workshop where representatives of thetrusts met to discuss and prioritise the results. They identified three clinical pathways and a pathwayof organisational characteristics where changes in culture and practice might have the greatestbenefit in reducing CS rates. The pathways are:

• First pregnancy and labour

• Vaginal birth after Caesarean (VBAC)

• Planned Caesarean section

• Organisational Characteristics.

Each pathway describes a woman’s journey through maternity services, identifying the principles of care at each stage. They illustrate the behaviours and practices that trusts believe have contributed to their success. From these pathways we extracted the Top Ten Characteristics, to provide an overview of the principles that were considered highly important to success.

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Top Ten Characteristics of services aspiring to optimal care

‘We focus on keeping pregnancy and birth normal’

‘We are a real team – we understand and respect roles and expertise’

‘Our leaders are visible and vocal’

‘Our guidelines are evidence-based and up to date’

‘We all practise to the same guidelines – no opting out’

‘We manage women’s expectations and prepare them for the reality of labour’

‘We are proactive about VBAC, giving accurate informationabout risks and benefits’

‘If a Caesarean section is planned, the process is efficient and effective’

‘We get accurate, timely and relevant information on our performance’

‘We work closely with our users and stakeholders’

The draft pathways were then circulated to other maternity units, professional representative bodies, academic institutions and user representative groups for their comments before the findings were published in Focus on: Caesarean Section.

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Keeping first pregnancy and labour normal Women who experience a normal birth in their first pregnancy are highly likely to do the same insubsequent pregnancies. This pathway starts even before conception. Women are exposed tomessages about childbirth through family and friends, through the media and through existingcontact with health and social care professionals. Although it is difficult to influence the media, thereis an opportunity for all professionals within the health economy to promote and sustain practicesthat are likely to lead to normal outcomes in pregnancy and labour.

The birth outcome is influenced throughout the process and provision of maternity care. Midwivesare ideally placed to offer a continuous and consistent message in preparing women for labour.Although care for a normal birth is usually provided by midwives, optimising the chance for this tooccur requires genuine multidisciplinary teamwork.

This pathways ends with increasing the chance of normal birth for women who have risk factors.

Improving opportunities for vaginal birth after Caesarean (VBAC)Maternity units identified the management of women who have had one previous Caesarean ascritical to reducing overall CS rates. There is accumulating evidence to support VBAC as a safe optionfor most women. However, many professionals feel apprehensive about managing VBAC and womenoften believe another Caesarean is inevitable or preferable to their previous experience.

Women need accurate information about the events of their labour and birth and how these may affect their future births (including the possibility of VBAC), as soon as possible after the CS. This pathway begins in the postnatal period of the CS and finishes with the management of the next labour and birth. It focuses on optimising opportunities to give accurate information andempowering clinicians to use their skills to support these women to increase the likelihood of a vaginal birth.

The Pathways

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Women having a planned Caesarean sectionIf a decision is made in the antenatal period that CS is the appropriate means of birth, theprocess should be as efficient as possible to ensure optimal use of resources and to enhancethe experience for the woman and her family.

A planned CS has many requirements in common with other operations. There are importantopportunities to learn from best practice in pre-assessment, skill mix of theatre staff, earlymobilisation, pain relief and discharge planning derived from work in other specialties.

Length of post-operative stay is often used as an indicator for the efficient use of resources. In CS, the picture is more complex as the service continues to deliver care regardless of thesetting. This pathway ends with transfer home.

Organisational CharacteristicsMaternity services delivering high quality care that provides value for money cannot sustain an existence in isolation. They must be supported by an organisational infrastructurethat provides accurate and relevant information, has effective communication pathwaysupwards and downwards throughout the trust and fosters an open and just culture in clinical governance.

High performing maternity services often provide positive role models within their trust foradoption of evidence-based care, multidisciplinary team-working and involving their users in evaluating and developing their service.

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Developing Pathways to Success: a self-improvement toolkitThe NHS Institute is committed to identifying successful health care practices and supportingtheir rapid spread throughout the NHS.

Having identified the behaviours and practices that maternity services with low CS ratesbelieved were important in achieving this outcome, our team then addressed the task ofdisseminating this information to other trusts across the country.

The team worked directly with maternity units offering a wide range of service configurations,demographic characteristics and current CS rates to develop and test a tool that would assistthem to understand how their service works and to provide support in making sustainablechanges aimed at promoting normal birth and reducing CS rates to a safe minimum.

With their help, and advice from a number of other sources, we developed the Pathways toSuccess: self-improvement toolkit that contains:

• A self-assessment tool for each pathway and the Top Ten Characteristics

• Self-improvement Action Plans

• Tools for improvement

• Measures for improvement

• Facilitator’s guidance.

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Pathways to Success: self-assessment toolFocus on: Caesarean Section identified four pathways that were important in achieving low CS rates:

• First pregnancy and labour

• Vaginal birth after Caesarean (VBAC)

• Planned Caesarean section

• Organisational Characteristics.

Each pathway lists principles of care and examples of the behaviours and processes that trusts believehave contributed to their success.

The self-improvement toolkit is based on the same pathways. In each of these ‘self-assessmentpathways’ the rows address individual principles and describe a range of behaviours and processes,progressing from those associated with high CS rates on the left to those associated with low CSrates on the right. Each pathway reflects the wide range of behaviours and processes that we haveseen or have been reported to us during our observations.

This does not mean that all the boxes on the right side are automatically ‘best practice’ or indeedthat it is possible to provide a sound evidence base, but that these units believed they made animportant contribution to their success in maintaining low CS rates.

The pathways tool is designed to assist units in defining their own current service and identifying the characteristics of the service they aspire to. This will not necessarily be at the extreme of thespectrum. Each trust should define its own targets, taking into consideration its service configuration,priorities, resources etc.

When high performing maternity units reviewed the pathways we had described, they identified keyprinciples from each pathway that they considered to be of overarching importance in achievingsuccess. We have presented these Top Ten Characteristics in a similar self-assessment format.

“The pathways tell us what units saw as an important part of keeping the CS ratelow, not what is right or wrong.”

Cathy Walton, Consultant Midwife, Kings College Hospital

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Self-improvement Action PlansThis template leads participants through the process of developing an action plan for each ofthe pathways. Working in small multidisciplinary groups the action plan enables colleagues toplan systematic changes to their service provision. It encourages participants to assess the gapbetween their current position and their aspiration, focusing clearly on what must change andhow this can be achieved.

These plans can then be prioritised and co-ordinated to form the basis of a longer term actionplan for the service.

Tools for ImprovementThis section describes a number of tools to support and assist services in making changes. It includes examples of service improvement tools, scenarios, case studies reflecting successfulpractice and of documents that can be adapted to specific needs.

Measures for ImprovementAs part of any service development, it is important to know if the changes made have resultedin real improvements. This section provides useful information on choosing suitable measureswith examples applied to specific pathways.

Running Workshops: Facilitator’s Guidance The self-improvement toolkit has been developed for use in the context of multidisciplinaryworkshops (see ‘field testing’ section). This section provides guidance useful to units wishing to use the pathways in their own workshops. It contains:

• Guide for Facilitators

• Guide for Team members

• Suggested agenda and description of activities

• Do you know the answers? (a series of questions designed to help you kick start your workshop and explore how much is known about your services)

• Frequently asked questions

• Additional resources are available in the Resource Pack.

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Field testing the toolkit

The self-assessment workshopAt each stage of the development of the tool we asked people to comment and contribute toits contents. Once the self-assessment pathways were completed in prototype we engagedwith a first wave of six trusts that were enthusiastic to review their practice and reduce theirCS rates. With each trust we carried out a workshop where groups of staff from all disciplinesand at all levels in the maternity service could come together to explore what their service wasreally like and how it compared with the culture and practices in trusts that had low CS rates.

“We found it a great afternoon and a very useful discussion that continued in the unit afterwards.”

Liz Ross, Clinical Midwifery Manager, York Hospitals NHS Trust

Guidance for Facilitators Our experience in conducting the first wave of testing provided us with the material to develop a facilitator’s guide for staff to be able to run their own workshops unsupported. The facilitator’s guide has been widely circulated to groups of maternity staff, educators,managers, commissioners and lay representatives who have provided feedback on its contentand reviewed how they might use it in their own organisations. Several trusts successfullyhosted their own self-assessment workshop using the facilitator’s guidance. They haveprovided feedback on the experience and in some cases the workshop has been directlyobserved by a member of our team.

“I particularly liked the clear layout, in a ‘what to do and how to do it’ format.The ’Frequently asked questions’ were particularly helpful.”

Susie Weekes, Practice Development Midwife, Gloucester Hospitals NHS Trust

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The self-improvement workshopWe further developed this process in a second wave of workshops, designed to supportservices that have carried out the self-assessment process or have already identified a priority area that they wish to address. This process combines individual preparation with a multidisciplinary workshop to help staff and users define the gap between their currentservice and the position on the pathway spectrum that they aspire to. Using the actionplanning sheets and supporting tools, small groups of participants were able to work throughan action plan for one or two principles within an hour during the course of a workshop.

“It was a very positive experience. By the end of the session we had a clear idea of what we had to do and some quick wins that we could get on with.”

Fiona Ghulastians,Midwife Facilitator, West Middlesex University Hospital NHS Trust

Validation by high performersWe also tested the self-assessment pathways tool with high performing trusts that had notparticipated in the development of Focus on: Caesarean Section. They were able to confirmthat their spectrum of behaviours and processes corresponded well with those on the rightside of the pathways. However, each trust was able to identify new ideas or possible changesthat would be of benefit to their service.

“We take ideas from anywhere, we are not always top-down. We are willing to be different – we are very much a ‘can do’ trust”

Alison Whitham, Midwifery and Gynaecology Manager, King’s Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust

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Practical advice on using the toolkit 2

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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How can you use Pathways to Success? Practical advice on using the self-improvement toolkit

To use this toolkit effectively, please consider the following points carefully.

Sustainable service change needs real commitment. Form a core team with:

• Multidisciplinary membership

• Clinical leaders

• Appropriate expert knowledge and support

• Clear reporting and communication pathways

Outcomes can be improved by preparation in advance:

• Decide what you aim to do

• Consider who should participate

• Decide what they should be briefed about in advance

• Do you need to appoint leaders and scribes ahead of the workshop?

The toolkit was designed to be used in a workshop environment. It can be used in otherways but the best results come from:

• Multidisciplinary groups

• Representation from all levels of staff

• Input from all parts of your service (e.g. community, separate birth centres)

• User involvement

• Protected time

Remember; in your service, everyone knows and can contribute something, no-one knows everything.

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Self-assessment workshopInitial steps for maternity services wishing to explore their current practices related toCaesarean section rates.

Aims: To make a detailed assessment of current culture, behaviours and processes. To stimulate ideas and aspirations for your future service.

Other benefits: an opportunity for enhanced multidisciplinary understanding of the service you provide.

Self-improvement workshopFor services that have carried out an assessment of their current position or that haveidentified specific issues on Caesarean section that they wish to address.

Aims: To position your current maternity services against services that are successful in maintaining low CS rates.To agree what your service should aspire to.To agree priorities for change.To develop a detailed action plan.

Other benefits: an opportunity to benefit from exchanging examples of successful practice and using service development tools.

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There are different ways of using the workshops. Choose your agenda. Decide which workshop or which elements of the process have most relevance for you.

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Decide with the core team which pathway to study. Your particular service or priorities maypoint to specific pathways.

Whatever your priorities or interests, we recommend that you always carry out a Top TenCharacteristics assessment. This tool has been used in a number of valuable ways:

• As an introduction to the process

• As an eye-opener to reveal your current position

• To provide a ‘helicopter view’ of the whole service

• To act as a barometer of progress by repeating this assessment at key points in your journey.

“It helped us see how we vary in perceiving the same service.”

Manager, The Princess Alexandra Hospital NHS Trust

Put participants at their ease:

• This can be an interesting and enjoyable experience

• Everyone’s contribution is valued

• Individual contributions in the workshops will be confidential and everyone owns the final outputs.

Be clear about what the pathways are and are not:

• They describe practice seen or reported in a range of maternity services even when there is no evidence base to support it

• The boxes on the right side reflect the position of units with low CS rates

• The pathways do not dictate how individual services should function.

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Manage the expectations of participants:

• Share with participants the aims and priorities of the core team

• Be realistic about what can and cannot be achieved at a single session

• Be open about timescales and resources available to support their proposals.

At the end of each session:

• Identify some quick wins

• Celebrate the progress you have made

• Explain how the work will be taken forward

• Clarify how progress will be communicated to everyone.

The toolkit can:• Share what has been learned from other trusts

• Facilitate reflection on the culture and care pathways of your organisation or team

• Stimulate discussion about the strengths and weaknesses of your service

• Show up any differences in perception between staff groups, managers or users

• Help you to understand the complexities of your organisation and how they contribute to care

• Help you to understand how a service with a more progressive approach might look

• Identify practices or behaviours you would like to change

• Provide you with tools and case studies to share good practice and resources

• Question some of your current practices.

The toolkit is not intended:• To be imposed for external audit or performance management (although it may

provide material to support these)

• To apportion blame when results show that an organisation or team would benefit from development.

“The feedback from the session was extremely positive, they wanted more!”

Jacqueline Dunkley-Bent, Head of Midwifery & Women’s Services, Consultant Midwife,Guy’s and St Thomas’ Hospitals

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Self-improvement Action Plan Template:

Pathway:

Principle:

Where are we now?

Where do we want to get to?

What do we need to change?

Who will do (and lead) the work?

When will we complete this?

What tools will we use?

How will we measure success?

What will be the impact? (Quality and value, reduction in CS rate)

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This template leads participants through the process of developing an action plan.

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Tools for Improvement

Once you have agreed where you want to get to it is important that you identify the rightsolutions for your service. A selection of tools and ideas to help you make changes arehighlighted in this Toolkit. They provide evidence of success that you may be able to adapt to your needs. Examples from each pathway are shown in the relevant pathway sections. A more comprehensive range is available in the Resource Pack.

ScenariosThese stories are illustrations of behaviours and processes in maternity care.

They are pathway specific but often address more than one principle within a pathway.

Scenarios can be used to:

• Gain the engagement of participants at the start of a workshop or meeting

• Act as examples for the self-assessment process

• Provide a ‘safe’ platform for discussion of difficult topics where participants are unwilling to discuss their own services initially

• Raise questions that you should answer in your self-improvement plans.

Example of scenario: VBAC“Melanie had her first baby by emergency Caesarean section. She had a long labour butdid not progress beyond 8cm dilatation. The epidural sited for analgesia was not adequatefor the operation so she had a general anaesthetic.

After delivery she was tired and in pain. Her attempts to breastfeed left her with crackednipples so she abandoned this.

She is now booking with you at twelve weeks in her second pregnancy. She is adamant that she does not wish to go through a similar experience of labour and delivery again.Unless you can promise her a straightforward normal birth she wants a Caesarean sectionand she certainly isn’t interested in breastfeeding.

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What can you, as the midwife, offer her to increase her chances of a normal birth?

As the obstetrician or midwife, what information would you give her about the risks and chances of success of VBAC?

How can you address her views on breastfeeding?”

Service improvement tools

Every single person is enabled, encouraged and capable to work with others to improve theirpart in the service (Discipline of Improvement in Health and Social Care)

These tools draw on experience in a variety of areas including business and industry and havealready been applied successfully to other areas of healthcare.

They focus on processes and behaviours that are relevant to all the pathways but some techniqueshave relevance to specific areas.

Service improvement tools can be used to: • Identify what changes are needed

• Understand the processes needed to achieve change

• Ensure engagement of staff and users

• Demonstrate, celebrate and sustain success.

Case studiesThe case studies are examples of practice in maternity services that we have seen or been told about.

Most describe improvement journeys related to specific points in a pathway but the underlying principles are relevant to many areas.

Case studies can be used to: • Reflect on your practice

• Provide material for group discussion

• Identify key features and interventions that are relevant to your service.

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Example of Case study: ‘Walking the floor’“We meet regularly with our Maternity Services Liaison Committee and value the opportunity towork with our users and stakeholders. Prior to our meeting we take the members of the MSLC toour postnatal ward and invite them to ‘walk the floor’. Here they have the opportunity to talkdirectly with women who have just had their babies using our services. These discussions withwomen then form the basis for our meeting with the MSLC members”.

Jacqueline Dunkley-Bent, Head of Midwifery, Guys and St Thomas Hospital Foundation Trust

Why don’t you?These are examples of innovations you could try in your organisation. They are often unstructuredexamples of what you could do but with little detail. They are designed to provoke thoughts of whatmight be possible rather than giving you a definitive message about what you should do. Theyshould help you to think ‘outside the box.’

Example of Why don’t you? Letter

Why don’t you …

... talk to women after their CS and design a letter to give to them before they go home.

We asked a focus group of women what information they would like to receive after CS that would prepare them for their next pregnancy and birth. They said:

‘Being debriefed on the first one’

We suggested that they could have a letter detailing the reasons for their CS and implicationsfor their next birth. They said:

‘A copy of the letter should also go to the Community Midwife and GP.’

We asked them what they would want to be included in this letter. They said:

‘What went wrong / why it happened like it did?

‘What are the chances of it happening again?’

‘What can I could do to try to avoid it?’

‘Need to address that women feel it was their fault’

’Most women don’t know that they can request to see their notes’

‘It would be good for women to know that they can come back at any time to access information’.

With thanks to the Women’s Focus Group, East Sussex Hospitals NHS Trust

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Examples of key documentationThese are documents that direct, support, challenge or inform current maternity care. They will be useful as reference tools for standard setting or for ‘positioning’ your organisation within thewider context.

Sources of information for users These examples of user information demonstrate good practice in communication with and involvement of users. They may be appropriate for direct use in your service or provide a structure for your own local information.

Examples of informationMIDIRS Informed Choice

National Childbirth Trust: NCT Info centre

Understanding NICE guidance: Information for pregnant women, their families and the public

Royal College of Obstetricians and Gynaecologists: Information for patients

Templates Templates can be used to save you time in preparing documents. Most are already being used somewhere within a maternity service but have been provided in a format so that you can adapt them for your own use.

26 Focus on normal birth and reducing Caesarean section rates

Topic

Text Description

We will:

Insert your commitment to your users

It would help us if you could:

Insert what the users could / should do themselves

Thank you for your support and co-operation

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Measures for Improvement

As you work on the pathways it is important to know if the changes you have made haveresulted in real improvements. This section provides some useful tips and examples ofmeasures to help you along your improvement journey.

All improvements involve a change, but not all changes are improvements (Goldratt)

Key Steps to MeasurementFollow these simple steps for a successful measurement plan:

It is important that you collect a mixture of both quantitative and qualitative data to really understand your current services.

1. What is our aim?As a team you need to decide what you want to improve (i.e. which principle?).

Example: Mothers and babies return home as soon as clinically safe and appropriate.

2. What do we want to focus on?Once you have decided what your aim is you then need to decide which particular aspect you wish to focus on.

Example: The length of stay for women undergoing a planned Caesarean section.

3. What are the appropriate measures?

Use the SMART technique when starting to think about developing measures - make sure you apply these principles to your measures

S - Specific

M - Measurable

A - Attainable

R - Realistic

T - Timely

Example: Percentage of women discharged within 56 hours of a planned Caesarean section.

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4. What is the definition of the measure?Is the data you need already collected through existing systems? Ensure you develop a clear definition of what you want to measure. Failure to develop a clear definition can lead to confusion and misunderstanding.

Example: Start of process: time and date of admission for a planned Caesarean section (as recorded on information system).

End of process: time and date of discharge following a planned Caesarean section (as recorded on information system).

5. What is our baseline?It is important to understand how you are currently performing.

Example: 65% of women are discharged within 56 hours.

Just establishing your baselines and targets can really motivate and excite your teams.

6. What is our target? Agree as a team what you want to achieve. Make sure your timescales are realistic. You may want to consider incremental targets.

Example: 75% of women are discharged within 56 hours (short term goal).90% of women are discharged within 56 hours (long term goal).

7. Over what period will we collect the data?Ensure you collect a sufficient amount of data over a period of time to allow you to see the changes.

Example: We want to look at 100 planned Caesarean births, we do 400 planned Caesarean births a year and therefore will look at a three month period (1st February to 30th April).

8. How will we collect the data?Will you collect the data manually or from an existing information system? Is the data collected routinely? Be careful to check that any data from an information system is what you really need.Does it fit with your definition?

Example: Local maternity information system.

Remember, crude measures of the right things are better than precise measures of the wrong things.

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Leng

th o

f St

ay (h

ours

)

Week0

10

20

30

40

50

60

70

80

Target - 56 hours

9. How often will we collect it?

Example: Weekly.

10. Who will collect the data?Designate someone to be responsible for the collection and collation of your data.

Example: Information lead.

11. How will I present the data?

How do you turn your data into useful information? A picture tells a thousand words and ismuch easier to read than a table of numbers. Simple line graphs (or run charts) are easy to produce and are very powerful.

Example: Run chart.

You may decide to undertake a simple audit of women who stayed longer than 56 hours to understand and categorise the reasons why this has happened.

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For further information on how to develop measures and how to present your data please refer to the Improvement Leader’s Guide on ‘Measures for Improvement’. This can be found at:www.institute.nhs.uk

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Measurement Plan Template

Principle

What is our aim?

Measure

Definition

Baseline

Target

Over what period will we collect the data?

How will we collect the data?

How often will we collect the data?

Who will collect the data?

How will we present the data?

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Celebrating Success

It is important that you celebrate and share your successes - this will give an incredible boostfor further improvements.

How can we celebrate and share our successes?

Identify five things that you do really well

These may be from a clinical pathway or from the Top Ten or Organisational Characteristics.

• Which principles did staff identify you did well during the self assessment?

• What have you done that is different?

• Can you explain your success?

Next, think about who you can tell about your successes!

Share your successes with colleagues, users, stakeholders, networks, forums and othermaternity units.

• How about presenting your work at an event or writing an article?

• Explain the work that has been done, what has been achieved and what is hoped to be achieved in the future.

Sharing your successes is a vital method of helping other maternity units learn from you and ultimately, achieve results. Each NHS maternity service is at a different stage on the journey towards providing optimal care. For most, the debate is not about what constitutes best practice, but about how to make the changes necessary in orderto achieve it, with all the pressures and constraints that day-to-day working brings. Sharing your success story will help strengthen practice and provide ideas for improvingit further.

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Running workshops:facilitators guidance

3

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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Workshop Facilitators Notes

Running workshops - facilitators guidance The self-improvement toolkit is designed to help you assess where your maternity servicecurrently is on a spectrum of processes and behaviours associated with achieving a lowCaesarean section rate.

It will allow you to debate how your unit could aspire to work in the future and what youwould have to change to achieve that. It also offers tools to assist you in developing yourservices. These workshops are the first step on this journey.

The toolkit is constructed on the ‘Top Ten’ Characteristics and the four pathways developed in Focus on: Caesarean section, published in October 2006.

The first part of the toolkit is a self-assessment tool. It is intended to be used within maternityservices at a multidisciplinary workshop, where each member of the team has the chance tocontribute equally. This pack contains the information you need to run your own workshops;you may wish to adapt it for your own particular service.

The self-improvement workshop is the second step in the process, designed to help servicesdevelop an action plan that is based on current position and a mutually owned vision of the future.

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Self-assessment workshopInitial steps for maternity services wishing to explore their current practices related toCaesarean section rates.

Aims:

• To make a detailed assessment of current culture, behaviours and processes.

• To identify aspirations for your future service.

Other benefits: An opportunity for enhanced multidisciplinary understanding of theservice you provide.

Self-improvement workshopFor services that have carried out an assessment of their current position or that haveidentified specific issues on Caesarean section that they wish to address.

Aims:

• To position your current maternity services against services that are successful in maintaining low CS rates.

• To agree what your service should aspire to.

• To agree priorities for change.

• To develop a detailed action plan.

Other benefits: An opportunity to benefit from exchanging examples of successfulpractice and using service development tools.

Who will own the process?Each maternity service should identify a small core team of committed professionals who are prepared to lead and guide the process. As a minimum this team should include a midwife leader, an obstetrician leader and a manager. Additional membersmight include an educator or an information analyst. As facilitator, you may be part of this team or will be working closely with it to ensure you share common goals.

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Self-assessment workshop

What are we aiming for?The core team should decide which pathway to discuss during the workshop. This may be influencedby the configuration of your service, any existing priorities, or the mix of staff who will attend. We recommend that you should always include the Top Ten Characteristics assessment.

How far down the improvement road can you reasonably expect to go? We suggest that in the firstworkshop you should be able to achieve a detailed assessment of where you are now and to begin to identify aspirations for your future service.

The core team should also identify how the work will proceed after the workshop and be prepared to commit to next steps at the end of the sessions.

How do I organise a workshop? The process works best with a diverse range of staff disciplines and grades.

• Identify the people that you think should attend (see below)

• Make sure they have enough notice to be able to do so

• Give them information on the aims of the workshop.

Think about your regular meetings, could you arrange the workshop as part of one?

Who should attend?Think about all the people who contribute to your service. Make sure that all groups who deliverfirst-hand care are invited:

• Clinical staff from all disciplines: midwives, nurses, maternity support workers, obstetricians, anaesthetists, etc.

• Support staff: clerical, IT

• Managers

• Service users

It is helpful to involve trainees and staff who rotate between maternity units.

We have piloted this process with up to 40 people at a time.

How long will the process take?Allow at least two hours. Participants have told us how much they valued the opportunity fordiscussion. The toolkit contains a suggested timetable.

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Sample background slides

• The pathways identify a range of behaviours

• The last column identifies practice witnessedin trusts with a low CS rate

• Each trust must decide which changes (if any) are right for its organisation

Why look at Caesarean section?

• Average LOS after CS varies from 3.5 to 7 days

• CS rate has doubled in 15 years - from 12% to >24%

• In England variation in CS rate between units of <15% to >30%

• No associated improvement in outcomes for babies

• Uncertain impact on long term health of mothers

Getting started on the day

Step 1 - Do you know the answers?As people arrive for the workshop, use the Do you know the answers exercise (on page 44) as an ice breaker. Ask them to discuss the 8 questions with their neighbours. This will help tostart debate and raise individual awareness of gaps in knowledge.

It will allow you to get started and engage your audience while the latecomers are arriving.

Step 2 - Background to the pathways and the self-improvement toolkitAt the start of the workshop make sure you allow time to explain the background to thetoolkit and introduce the pathways. See example slides below.

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Step 3 - Explaining the processTo get the maximum benefit from the workshop it is essential that all the participants feelcomfortable with the process. Please explain clearly that:

• Everyone is a valuable contributor

• There are no right and wrong answers

• It does not matter if part of the pathway is unfamiliar to individuals

• The workshop is a protected environment and comments from individuals will not be repeated outside of the workshop.

Show the audience an example of a pathway. Explain that the white boxes look at individualprinciples of care associated with the woman’s journey in that particular pathway. The shaded boxesin each row show behaviours and processes from those associated with high CS rates on the left tothose associated with low CS rates on the right. This does not mean that all the boxes on the rightside are automatically ‘best practice’, simply that units believed they were important to their successin maintaining low CS rates.

Explain again that the aim of the workshop is to establish where your organisation currently sits onthe pathways and to identify where you would like to be in the future.

The tool is not designed to dictate patterns of care to units, it is for each individualorganisation to decide what practice it should aim for and what changes should and could be delivered to achieve this.

Finally, ensure everyone is aware of the time available for each task. See the Suggested Agenda for timings.

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Step 4 - Getting down to workAsk your audience to work through the Top Ten Characteristics, deciding as individuals whichstatements best describe their service. Ask them each to fill in a record sheet. At the end of theallocated time, collect these up and collate this information into a picture of your organisationto feed back to everyone at the end of the workshop. In the Resource Pack there is aspreadsheet to present this information for you.

Example of Record Tool in Resource Pack

We focus on keeping pregnancy and birth normal

We are a real team - we understand each others roles and expertise

Our leaders are visible and vocal

Our guidelines are evidence-based and up to date

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Then ask your participants to divide into small groups, we recommend groups of four to eight people.

You may want to consider in advance who should be in each group to ensure a goodmixture of skills and experience and to manage any difference in expectations.

Give each group a copy of the ‘How to use the tool - a guide for team members’ (found onpage 45) and each member a copy of the chosen pathway.

Ask each group to identify a leader who will ensure everyone has an opportunity to contributeand a scribe to make notes of their discussions.

When the groups are settled, ask each member to spend ten minutes looking individually atthe pathway and to make an assessment of where the service is currently. Then, as a group, tolook at each of the principles in turn, exploring the individual assessments and trying to reacha consensus. Ask the groups to think specifically about any areas of difference or difficulty inunderstanding. Why did they think this occurred?

The groups should then try to look at the behaviours and processes to the right of their currentposition and debate where they would aim to move their service to.

As facilitator, • try to keep an eye on how the discussions are going

• be prepared to prompt or question assumptions

• check that the group leaders are ensuring all participants have an opportunity to speak

• ensure that they are sticking to the task.

There will be different views; constructive challenge is part of mature organisational behaviour,however, if this is hindering progress:

• encourage the group to look for areas where they can agree

• suggest that they move on to another area and return to the topic later

• recommend a separate meeting outside the workshop to address areas of concern.

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Step 5 - Sharing the resultsGive each group a chance to feed back to the whole workshop. Ask them about their experience of working together on this task as well as the conclusions they came to. Ask for the notes taken by the scribes so that you can review all the outputs later and ensure nothing important was missed.

Step 6 - Agreeing next stepsAsk the members of your core team to speak for five minutes about how the work will betaken forward. This should include agreeing the way forward, offering an opportunity for staffand users to contribute to the work; and making a commitment to a timetable for progress.

Step 7 - Feedback of Top Ten profile

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Suggested Agenda - Description of Activities

Self-assessment Workshop2 hour workshop

Participants: maternity services staff from all disciplines: midwives, obstetric doctors, maternity supportworkers, administrative support staff, service managers, risk managers, students and user representatives.

Recommended group size: 15 - 40 (for larger groups consider having two facilitators)

1. Do you know the answers? Informal discussion with neighbours before formal work begins.10 minutes

2. Presentation: description of the pathways, brief background to the ‘Focus on’ methodology and explanation of how the toolkit was made (what it is and what it isn’t).10 minutes

3. All participants look at the Top Ten Characteristics individually and identify where on the pathwaythey think their service is now. Collect up the assessment sheets and collate during step 5 below.15 minutes

4. Divide into small groups (4-8 people), ensuring an appropriate multidisciplinary mix. Each team appoints a leader and a scribe / raporteur.5 minutes

5. Each small group chooses a single clinical pathway (or Organisational Characteristics if desired). Individual members read through the pathway and make an assessment of current position. The group then discusses and makes a group decision on their position.30 minutes

6. The group looks at the pathway to decide where they would like their service to be.Why have they made that choice? If not at far right column, why not? Prepare feedback.20 minutes

7. Feedback from groups:

• What did we learn?

• Where are we now?

• Where would we like to be?

• Were there any surprises?

• Did the group reach consensus?

• What was good / not so good about the experience?20 minutes

8. Next steps5 minutes

9. Feeding back the results of the Top Ten Characteristics assessment 5 minutes

Any additional time available for the workshop should be allocated to steps 5, 6 & 7.

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AGENDA - Self-assessment Workshop

Pathways to Success: Focus on normal birth andreducing Caesarean section rates

(Trust name, department etc)

(Date and Place)(Time from/to)

1. Do you know the answers?

2. Background to the pathways and how to use the self-improvement toolkit

3. The Top Ten Characteristics. How does your service compare?

4. Group work: the pathways - where are we and where do we want to be?

5. Feedback from the groups

6. Next steps

7. The Top Ten Characteristics - your answers

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Do you know the answers?

1. The national average Caesarean section rate is 25%Do you know what your CS rate is?

2. What percentage of your clients try for a VBAC and areactually successful?

3. Do your facilities provide the right environment to supportnormal labour and birth? Is medical equipment out of sight?

4. The labour ward should be used for women in labour only.How many women on your labour ward last month were not in labour?

5. How much time do your midwives spend on non-clinical tasks?

6. What percentage of clinical staff are aware of monthly CS ratesand trends?

7. Organising planned Caesarean sections efficiently minimisesdelays and clinical risks.Do you have a clearly defined process for managing plannedCaesarean sections?

8. Women should be able to make an informed choice about theirmode of birth.Can you provide accurate facts and figures about risks andbenefits to support their decision?

Focus on: Normal birth and reducingCaesarean sections

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Each pathway has six columns. On each row, the first box states principles on which topperforming organisations base their care, allowing them to maintain low CS rates. Thecorresponding boxes show a range of behaviours occurring in maternity units.

As you read across the rows you will see that there is a progression of ideas and practices. The column on the far right represents behaviours adopted by trusts that are ‘high performers’in keeping their CS rates low while achieving good outcomes.

Individual assessmentEach member of the group should start by making an individual assessment for each principlein the pathway. Choose the description of behaviours you think best fits your organisation orteam. Do this on your own without discussion. This is your opinion of your service. If you can’tdecide between two of the descriptions tick both. This will give you an indication of thecurrent CS profile for your organisation.

Group assessment Choose one of your group to lead the discussion and make sure that everyone has theopportunity to contribute, and choose a scribe to make notes of your discussions. Look ateach principle in turn, explore the individual assessments and then try to reach a groupconsensus. Once you have identified where you are compared to these ‘high performers’, startdiscussing where you as an organisation want to be. Ask yourselves what can realistically betaken forward and improved within your service? There are tools and case studies that canhelp you achieve your goals and move towards those behaviours.

We do not expect that as an individual or a team you will agree with all the suggested‘successful practice’ shown in column five. It is important that you discuss why thesebehaviours are not appropriate to your service when you decide where your unit wants to goand how you can get there.

The objective is to stimulate debate and enable you to focus on areas you would like tochange. The toolkit is not designed to dictate how you should run your own unit.

Be prepared to share your comments and views with the wider audience.

How to use the toolkit - a guide for team members

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Self-improvement workshop

This step follows on from the self-assessment workshop where groups of staff and users had theopportunity to assess their present service against the behaviours and processes of a number ofmaternity services with a range of CS rates.

That process may have helped you to agree priorities for service change.

You may have identified specific areas for improvement through other channels.

This workshop will help you achieve the next steps.

Before starting, take time to review your present situation. Have you got a core team (see page 35)that is committed to driving this process and owning its outputs? Do you have good communicationchannels for reporting the work you are doing?

The self-assessment process used the Top Ten Characteristics to help you produce an overview of your service. A similar process looking at your chosen pathway will have given you informationabout the variety of perceptions about your clinical behaviours and processes and offered your staff examples of a wide range of practices reported or observed in other organisations to help you decide on the service you aspire to.

What are we aiming for?• To share an accurate overview of your service (Top Ten Characteristics)

• To describe your current service against each of the principles in the chosen pathway

• To determine where your service could and should aspire to move, using the processes and behaviours described in the pathways

• To identify the barriers to success; what has to change?

• To agree an outline action plan that has tasks, timescales, named responsibilities and outcome measures.

Identifying quick wins can be very motivating for getting the work started.

How do I organise this workshop? In addition to the principles of multidisciplinary involvement and breadth of experience outlinedabove, there may be key individuals whose involvement is critical to the process you wish to focus on.For example, anaesthetic expertise is vital to the Planned Caesarean pathway. Consider where andhow you can engage users in your discussions.

Think carefully about numbers of people involved in any one pathway. The self-assessment process isabout broadening horizons and stimulating debate, this process is now about focusing on specificobjectives and tasks.

It is important that everyone leaves the workshop with a clear understanding about the way forward and their role in it.

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How long will the process take?Working through a complete pathway to the production of an outline action plan will takebetween two and six hours depending on the pathway chosen, the tools you look at and the degree of detailed discussion. Realistically, you may decide to tackle only part of a pathway or part of the process in one session. Alternatively you can divide the work upamongst the small groups of participants as long as you allow ample time for feedback anddiscussion in the whole group.

Preparation before the dayTo make the best use of time together we recommend that your participants do some workindividually before the day of the workshop. Send each participant a copy of; ‘How to use thetoolkit - a guide for team members’, the Top Ten Characteristics, and the specific pathway youplan to discuss in that particular group.

Ask everyone to make their own personal assessment of the current position of the service and to start thinking about where on the pathway they aspire to be.

Decide, in discussion with the core team, who should lead the groups in the workshop. Brief these people in advance about the aims of the workshop and the process you areplanning (see next section).

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Step 1 - Introduce the workshop• Present the aims for the workshop that have been agreed by the core team

• Ensure that all participants understand the aims

• Outline the stages in the process and the timetable for the session.

To get the maximum benefit from the workshop it is essential that all the participants feelcomfortable with the process. Please explain clearly that:

• Everyone is a valuable contributor

• There are no right and wrong answers

• It does not matter if part of the pathway is unfamiliar to individuals

• Participants are free to express themselves within the workshop but at the end of the process must take responsibility for areas of the agreed action plan under their name.

Step 2 - Explaining the processThere may be people in the workshop who did not attend the self assessment workshop. It isimportant that you provide a background to the work and explain how the pathways work. This will also help as a refresher. See “Explaining the process” on page 38 for further information.Also, if you have previously run a self assessment workshop you will already have a Top Ten profilewhich you can share with participants and will help with explaining the background to the work.

Step 3 - Getting down to workIn the group, discuss together where your service currently sits in the spectrum of behavioursillustrated. When you have reached agreement, use your own words to describe your service in the Where are we now? boxes on the action plan. Then consider where you think the serviceshould aspire to move to and fill in the Where do we want to get to? boxes.

Step 4 - Setting prioritiesIf the core team has already determined some priority work streams to be taken forward in the action planning, share these with the participants now. These are the ‘must do’s’.

Ask them to return to their small groups and assign all the priority areas amongst the groups(depending on the time available). Ask them to work through the action planning sheet for eachpriority area.

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Step 5 - Sharing the resultsGive every group a chance to feed back to the whole workshop. Ask them about theirexperience of working together on this task as well as the conclusions they came to. Ask for all the scribes’ notes and the action planning sheets so that you can review all the information later and ensure that nothing important was missed.

Go back to the spreadsheet of the Top Ten Characteristics and highlight your service’s strengthsand weaknesses. Will the action plans improve your position as a whole service? You cancontinue to use this tool following the workshop at key milestones in your action plans tomeasure your progress.

Step 6 - Agreeing next stepsAsk the members of your core team to speak for five minutes about how the work will betaken forward. This should include confirming priorities, ensuring that the most appropriatepeople have committed to the plan, and making a commitment to a timetable for progress.This should include a clear communication plan to everyone who has been involved.

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Example of Action Plan for the PlannedCaesarean section pathway

There is pre-assessment for all women. This is midwife-led according to a protocol.

Where are we now?Women with risk factors for anaesthetics are sent round to the Labour ward to speak to an anaesthetist.Healthy women come up to the antenatal clinic a few days before their CS. The duty midwife takes blood tests and gives them a supply of Ranitidine. This is an extra visit with no antenatal check. The midwife doesn’t work on Labour ward and can’t deal with any queries. She calls a doctor to answer a woman’s questions.

Where do we want to get to?There is an anaesthetic advice clinic to which women can be referred antenatally according to guideline.The pre-assessment visit combines a normal antenatal check with preparation for CS.The professional seeing the woman for pre-assessment can answer her questions about the operation, its risks and benefits, the postnatal effects and implications for the future.The expected date of discharge is discussed and agreed, subject to clinical considerations.Each woman receives written information covering all these issues.

What do we need to change?Set up a specialist anaesthetic referral antenatal clinic for women with anaesthetic risk factors.Develop a protocol for a midwife-led visit to combine antenatal check with preparation for CS.Decide on appropriate environment and midwife staffing for CS preparation visit. Day AssessmentUnit (DAU)Consider need for multi-site use of the protocol.Ensure that all staff members involved use and are comfortable with the same factual information.

Who will do (and lead) the work?Obstetric anaesthetist Day Assessment midwife (lead)Labour ward midwifeObstetric doctor

When will we complete this?October 2007

What tools will we use?Obstetric Anaesthetists Association guidelinesNICE guidance on antenatal careMapping the patient’s journey (NHS Modernisation Agency)

How will we measure success?Percentage of women who have a pre-assessment visit.Audit of delays on admission for CS.

What will be the impact? (Quality and value, reduction in CS rate)Reduction in variation of length of stay through planning discharge with each woman.Increase in satisfaction with service through greater involvement in planning.Consistent information to women.Avoidance of delays through early identification of risk factors.Possible minor reduction of CS rates through freeing midwife time to spend with women in labour.

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Suggested Agenda - Description of Activities

Self-improvement Workshop2 hours 30 minutes to 4 hours

Participants: Targeted participants appropriate to the pathway you will address. Consider thepossible role of people from every discipline and at all levels in the service to ensure you have full involvement.

Recommended group size: 10 – 25 (for larger groups consider having two facilitators or afacilitator for each pathway)

1. Aims of the workshop: what you plan to achieve and how the work will be organised.Reminder of how the pathways were derived and how they should be used.10 minutes

2. Individuals record their own Top Ten Characteristics (TTC) assessment and hand it in. Show previous summary slides of TTC if available or derive new summary slides. (Discussion of pathway-specific scenario with neighbours).20 minutes

3. Leaders gather their small groups of 4-8 people, ensuring an appropriate multidisciplinary skillmix. Each group discusses the designated pathway and identifies where they think their service isnow and where they aspire to move to. They complete the Where are we now? in their own wordsand Where do we want to get to? boxes on the action planning sheet.30 minutes

4. Groups reviewing the same pathway come together to exchange views and reach a consensuson their position and aspirations. These groups then agree the priority areas within theirpathway and allocate each one to a small group.30 minutes

5. Small groups reconvene to work though the action planning sheet for each of the priority areas.30 to 120 minutes

6. Plenary session with feedback from each group on progress with action planning. Each group identifies one quick win. Review of gaps in the Top Ten Characteristics and how this will be addressed.20 minutes

7. Next steps10 minutes

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AGENDA - Self-improvement Workshop

Pathways to Success: Focus on normal birth andreducing Caesarean section rates

(Trust name, department etc)

(Date and Place)(Time from/to)

1. Aims for the workshop

2. What does our service look like? Results of the Top Ten Characteristics

3. Where are we now and where are we trying to get to?

4. Confirming the common vision: people who have worked onthe same pathway now get together

5. Action planning the priority areas

6. Feedback and review of the Top Ten Characteristics

7. Next steps

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Does it matter which staff groups undertake the self-assessment?The tool is designed to generate discussion and therefore it works best if there is a mix ofstaff. This gives you the chance to get other professionals’ points of view and build a morecomplete picture of how your service works. Involving a large cross section of staff(midwives, doctors, managers, support workers, clerical staff and students) is likely tomake your assessment more accurate and give a clearer idea of where you want to be.

How large should each group be?The tool has worked well when groups of four to eight people have discussed a pathwayin detail then fed back their thoughts and ideas to the whole workshop of up to fortyparticipants.

Our trust provides maternity services on more than one site, howshould we use the tool?Many trusts provide a range of services across different geographical sites. The views andexperiences of all staff, whether working in a birthing centre or an acute unit, areinvaluable when looking at promoting normal outcomes for women. Behaviours andprocesses on one site may influence outcomes on another. Giving staff prior informationabout the aims of the workshop will help them to have a better understanding of howthey fit in and how they can contribute.

We didn’t always feel we could answer all the questions. Why was this?Not all of the steps in the clinical pathways are relevant to every service but think carefullybefore deciding that a statement doesn’t apply to you. It may be that you need a different mix of people in your group to give you a broader picture of your whole service and how it all fits together.

Sometimes we couldn’t agree on what the statements meant?It is really important to take time to read the tool thoroughly as individuals, deciding whereyou think you are before discussing it with your group. It is quite likely that individuals willhave different interpretations of the statements - sometimes this relates to differentperceptions from managers and clinicians and from midwives and obstetricians.Generating discussions about these differences will add value to your conclusions.

We didn’t always feel there was a progression between the statements.Focus your attention on teasing out what sort of behaviours might lie beneath thestatements and what that sort of service might look like. Even if you believe that there issome inconsistency of progression you should be able to explore how you could move tothe next level.

What happens if we feel that we are between two columns, or thatmore than one column applies?This may well happen. Try to use similar ideas and language to make your own statementabout where your service is now and what you would like it to look like. The toolkit canstill help you to achieve the changes.

Frequently Asked Questions

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We couldn’t always agree where we are. Does this matter?Sometimes it can be difficult to pinpoint where you are. The tool highlights that youdon’t always know what happens in all areas of your service. It should still increase yourawareness and focus where you want to be.

What is the benefit of having the first boxes in the tool when thebehaviours are likely to be associated with higher CS rates?The tool describes practices or beliefs that have been seen in maternity units. Mostpeople have a good idea as to what constitutes best practice but not all people can seehow to move from one set of behaviours to another.

Having a wide spectrum of behaviours to explore can help you identify what happens inyour own service and decide what you need to change to move on.

Is the final column always what we are aiming for?The tool is not designed to dictate patterns of care to trusts but to share what we havelearned from others. It provides the opportunity for you to debate why the final columnmay not be the place for you and to decide what changes are appropriate and feasible.It should stimulate discussion about the strengths and weaknesses of your organisationand make you aware of varying practices, as well as give you lots of food for thought.

Do we need to score where we are?No. Staff using the tool have told us that attaching numbers to the boxes on thepathways is not helpful. Not all the elements of the pathways are of equal importancebut each contributes to the wider picture.

If we all commit to doing the same thing with no opting out, doesthis affect choices for women?The tool enables you to explore the complexities of your organisation and understandthe care you provide. Consistency of approach doesn’t close down care options butmakes it clearer which options are available. If all your staff are consistently employingthe best practice and giving consistent information the women using your service willreceive good care. They in turn will be able to give you valuable feedback.

The guidance suggests that we can involve users in the assessment.How do we do this?Each discussion group would benefit from having an experienced maternity service userin it. This will broaden discussions even further. It is useful to invite someone whoalready has background information on your service such as your user member on yourlabour ward forum or a member of your Maternity Services Liaison Committee.

What happens if we don’t have the resources to make changes?Not all changes cost money. Many of the changes described in the tool do not requireadditional funding. Sometimes it is not about changing what you do but when you doit. Getting a fuller understanding of where your service is now and where you want togo to will help you prioritise what resources you have. Using the toolkit will save youtime as we are able to share what others have already tried and tested. If other trustshave made it work there is a good chance you can too.

Can other people audit our service using this tool?No. The tool should be used to promote discussion and exploration of the way a servicefunctions by the people that work in it.

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Top Ten

4

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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Top Ten Characteristics

The Top Ten Characteristics brings together key features from all of the pathways to illustratethe culture of your whole maternity service.

‘This is a powerful exercise that everyone should do. It gives a helicopter view of your service and will help you agree priorities and measure your progress.’Richard HallettCo-chair, Maternity Services Liaison Committee, East Sussex Hospitals NHS Trust

These pathways reflect the practices and behaviours we have seen and heard. Moving fromleft to right, the process supports lower Caesarean section rates.

You may not agree with all these statements - you will need to decide what changes are rightfor your organisation.

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Focus on normal birth and reducing Caesarean section rates 57

Alth

ough

uni

que

to e

ach

wom

an, b

irth

is se

en a

s a

norm

al li

fe e

vent

whi

chre

quire

s no

inte

rven

tion

unle

ss c

linic

ally

pro

ven

to

be o

f ben

efit.

Staf

f com

mun

icat

e fr

eely

an

d le

arn

toge

ther

. The

y tr

ust

each

oth

er a

nd c

an c

halle

nge

each

oth

er c

onst

ruct

ivel

y an

d op

enly.

We

are

all p

oten

tial l

eade

rs.

We

cham

pion

our

ser

vice

an

d al

l wor

k to

mak

e it

even

bet

ter.

Ever

yone

has

an

oppo

rtun

ityto

con

trib

ute

to g

uide

line

deve

lopm

ent.

Evid

ence

-bas

ed c

are

isad

opte

d w

here

ver a

vaila

ble

and

guid

elin

es c

over

our

en

tire

serv

ice.

We

all u

se th

e sa

me

guid

elin

esin

our

pra

ctic

e. V

aria

tions

are

reco

rded

and

just

ified

. Sta

fffe

el e

mpo

wer

ed to

cha

lleng

eea

ch o

ther

’s pr

actic

e.

Staf

f rec

ogni

se th

at p

regn

ancy

and

birt

h ha

ve th

e po

tent

ial

to b

e no

rmal

and

are

wor

king

tow

ards

this.

Staf

f com

mun

icat

e w

ell w

ithea

ch o

ther

and

sha

re te

achi

ngan

d tr

aini

ng. T

hey

gain

mut

ual

resp

ect b

y un

ders

tand

ing

each

othe

r’s ro

les.

Our

lead

ers

are

cham

pion

s fo

rou

r ser

vice

. We

feel

val

ued

and

are

enco

urag

ed to

disc

uss

and

try

out n

ew w

ays

ofw

orki

ng.

Gui

delin

es a

re p

rodu

ced

by

a gr

oup

of s

taff

. Som

e ke

ygu

idel

ines

are

evi

denc

e-ba

sed

and

prod

uced

to C

NST

2st

anda

rds.

We

have

evi

denc

e-ba

sed

guid

elin

es b

ut a

llow

sta

ff to

use

othe

r evi

denc

e-ba

sed

guid

ance

they

are

mor

efa

mili

ar w

ith. V

aria

tions

re

mai

n un

chal

leng

ed.

Staf

f rec

ogni

se th

at s

ome

elem

ents

of t

he m

anag

emen

tof

nor

mal

pre

gnan

cy a

ndla

bour

can

enh

ance

the

care

of h

igh-

risk

wom

en.

Clin

ical

info

rmat

ion

is sh

ared

amon

gst s

enio

r sta

ff b

ut it

ispa

ssed

dow

n fr

om m

idw

ife

to m

idw

ife o

r doc

tor t

o do

ctor

. The

re a

re s

epar

ate

trai

ning

ses

sions

for m

idw

ives

and

doct

ors.

We

have

iden

tifia

ble

lead

ers.

Ther

e ar

e cl

ear c

hann

els

ofco

mm

unic

atio

n an

d st

aff a

reab

le to

raise

con

cern

s.

Ther

e is

som

eone

in c

harg

e of

pro

duci

ng a

nd c

ircul

atin

g al

l our

gui

delin

es. T

hey

are

regu

larly

upd

ated

.

All

seni

or s

taff

hav

e sig

ned

up to

our

gui

delin

es b

ut

som

e do

not

cha

nge

thei

rpe

rson

al p

ract

ice.

Ther

e is

a pr

otoc

ol fo

rm

anag

ing

norm

al p

regn

ancy

and

labo

ur. O

nce

any

devi

atio

noc

curs

, wom

en b

ecom

e hi

gh-r

isk o

bste

tric

cas

es.

“We

are

care

ful w

hat w

e sa

y.W

e do

n’t l

ike

to a

sk q

uest

ions

- we

feel

we

are

bein

gtr

oubl

esom

e.”

Com

mun

icat

ion

occu

rs o

nly

with

in s

taff

gro

ups.

Inci

dent

sar

e re

port

ed u

pwar

ds b

ut w

edo

n’t g

et fe

edba

ck.

Thos

e in

cha

rge

neve

r see

m

to b

e ar

ound

unl

ess

ther

e is

a cr

isis

.

New

or u

pdat

ed g

uide

lines

appe

ar fr

om ti

me

to ti

me

– w

e fin

d ou

t by

chan

ce.

Our

gui

delin

es a

re n

otac

cept

ed b

y so

me

seni

or s

taff

so a

re fo

r inf

orm

atio

n on

ly.

Staf

f bel

ieve

that

birt

h is

only

norm

al in

retr

ospe

ct.

The

obst

etric

sta

ff a

re in

volv

edin

eve

ry la

bour

.

Staf

f gro

ups

don’

t mix

.

“Mid

wiv

es h

ide

thin

gs

from

us.

..”“D

octo

rs in

terf

ere

with

our

case

s….”

Ther

e is

a bl

ame

cultu

re.

Som

etim

es w

e do

n’t k

now

who

is in

cha

rge.

We

have

som

e gu

idel

ines

bu

t the

y ar

e no

t rev

iew

edre

gula

rly.

“Thi

s gu

idel

ine

was

writ

ten

for s

omeo

ne e

lse –

it d

oesn

’tap

ply

to m

e.”

“I th

ink

ther

e ar

e so

me

guid

elin

es b

ut I

have

n’t

actu

ally

see

n th

em.”

We

focu

s o

n k

eep

ing

pre

gn

ancy

an

d b

irth

no

rmal

We

are

a re

al t

eam

– w

eu

nd

erst

and

an

d r

esp

ect

role

s an

d e

xper

tise

Ou

r le

ader

s ar

e vi

sib

le

and

vo

cal

Ou

r g

uid

elin

es a

re

evid

ence

-bas

ed a

nd

u

p t

o d

ate

We

all p

ract

ise

to t

he

sam

eg

uid

elin

es –

no

op

tin

g o

ut

Top Ten CharacteristicsTh

ese

pat

hw

ays

refl

ect

the

pra

ctic

es a

nd

beh

avio

urs

we

hav

e se

en a

nd

hea

rd. M

ovi

ng

fro

m le

ft t

o r

igh

t, t

he

pro

cess

su

pp

ort

s lo

wer

Cae

sare

an s

ecti

on

rat

es.

You

may

no

t ag

ree

wit

h a

ll th

ese

stat

emen

ts –

yo

u w

ill n

eed

to

dec

ide

wh

at c

han

ges

are

rig

ht

for

you

r o

rgan

isat

ion

.

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Page 60: Pathways to success focus on normal birth

Wom

en a

re s

uppo

rted

to

expl

ore

thei

r fe

elin

gs f

orla

bour

and

birt

h. W

e kn

owth

at w

omen

fee

l pre

pare

d an

d co

nfid

ent

abou

t th

eir

own

labo

ur.

We

wor

k w

ith w

omen

to

agre

e pe

rson

al b

irth

plan

s if

ther

e ar

e co

ncer

ns a

bout

child

birt

h.

Each

wom

an is

wel

l brie

fed

post

nata

lly o

n th

e re

ason

s fo

r he

r C

S an

d th

eim

plic

atio

ns f

or t

he f

utur

e.

In h

er n

ext

preg

nanc

y, a

llm

idw

ives

are

abl

e to

lead

the

disc

ussi

on o

n V

BAC

at

the

book

ing

appo

intm

ent.

Wom

en a

nd s

taff

are

ful

lyin

form

ed p

artn

ers

info

llow

ing

an a

gree

d pa

thw

ayth

at o

ptim

ises

qua

lity

of c

are

and

reso

urce

util

isat

ion.

Ther

e ar

e da

ily c

linic

al c

ase

revi

ews

open

to

all s

taff

.

Less

ons

lear

nt f

rom

adv

erse

inci

dent

s in

form

ser

vice

deve

lopm

ent.

Mon

thly

clin

ical

info

rmat

ion

is p

rese

nted

as

Stat

istic

alPr

oces

s C

ontr

ol c

hart

ssh

owin

g tr

ends

. The

y ar

eav

aila

ble

on t

he in

tran

et.

Mid

wiv

es s

uppo

rt w

omen

inpr

epar

ing

for

norm

al la

bour

follo

win

g a

fixed

pro

gram

me.

Ther

e ar

e fo

rmal

sup

port

serv

ices

for

wom

en w

ithun

derly

ing

fear

s an

dco

ncer

ns.

Wom

en a

re b

riefe

d on

the

reas

ons

for

thei

r C

S so

on

afte

r th

e bi

rth.

Each

wom

an d

iscu

sses

the

man

agem

ent

of h

er n

ext

birt

h w

ith a

doc

tor

orsp

ecia

list

mid

wife

ear

ly in

her

next

pre

gnan

cy.

Ther

e is

an

effic

ient

pat

hway

how

ever

del

ays

ofte

n oc

cur

beca

use

plan

ned

CS

is a

low

prio

rity

on la

bour

war

d.

Ther

e ar

e re

gula

r m

eetin

gs

for

the

disc

ussi

on o

fin

tere

stin

g cl

inic

al c

ases

.

Ther

e is

a p

roce

ss f

ordi

ssem

inat

ing

lear

ning

fr

om a

dver

se in

cide

nts.

The

mat

erni

ty in

form

atio

nsy

stem

pro

duce

s cu

stom

ised

mon

thly

clin

ical

ly r

elev

ant

figur

es t

hat

staf

f ca

n ac

cess

dire

ctly.

Preg

nanc

y cl

asse

s ar

e re

adily

acce

ssib

le b

ut f

ocus

on

wha

tm

ight

go

wro

ng.

Whe

n w

omen

ask

for

a

CS

we

try

to f

ind

out

wha

t is

beh

ind

the

requ

est.

VBA

C is

rep

rese

nted

as

a hi

gh-r

isk

proc

ess

that

m

ust

be s

anct

ione

d by

a

cons

ulta

nt o

bste

tric

ian.

All

clin

ical

sta

ff g

ive

cons

iste

nt in

form

atio

n an

d ad

vice

abo

ut d

eliv

ery.

Ther

e is

an

agre

ed p

athw

aybu

t th

is is

inef

ficie

nt f

or

the

wom

an a

nd t

he s

taff

. Fo

r ex

ampl

e, w

omen

are

adm

itted

on

the

day

ofop

erat

ion

and

wai

t fo

r th

eir

preo

pera

tive

inve

stig

atio

nsbe

fore

sur

gery

.

Clin

ical

cas

e re

view

s ar

e ad

hoc.

We

do n

ot h

ave

time

for

regu

lar

mee

tings

.

We

do n

ot g

et in

form

atio

non

tre

nds

in o

ur a

dver

sein

cide

nts.

Mon

thly

per

form

ance

stat

istic

s ar

e co

llect

ed a

ndw

idel

y pu

blic

ised

.

Wom

en in

the

ir fir

st

preg

nanc

y ar

e of

fere

d a

clas

s ab

out

labo

ur a

fter

34

wee

ks.

Mat

erna

l req

uest

for

a

CS

is a

gree

d on

ly a

fter

a

seco

nd o

pini

on.

In t

heir

subs

eque

ntpr

egna

ncy,

wom

en d

iscu

ssm

ode

of d

eliv

ery

with

aco

nsul

tant

late

in p

regn

ancy

,sh

ortly

bef

ore

a C

S is

boo

ked.

Th

e in

form

atio

n gi

ven

isin

cons

iste

nt a

nd t

hesu

bseq

uent

adv

ice

varie

s by

clin

icia

n.

Indi

vidu

al t

eam

s ha

ve c

usto

man

d pr

actic

e ar

rang

emen

ts

for

plan

ned

CS.

Plan

ned

CS

is a

low

prio

rity

on la

bour

war

d.

Seni

or s

taff

dis

cuss

pr

oble

m c

linic

al c

ases

be

hind

clo

sed

door

s.

If th

ere

is a

n in

cide

nt w

epr

efer

to

deal

with

itin

form

ally

rat

her

than

repo

rtin

g it.

Mat

erni

ty p

erfo

rman

ce d

ata

is c

olle

cted

for

man

agem

ent

purp

oses

onl

y.

We

do n

ot p

rovi

de a

nypr

epar

atio

n fo

r la

bour

for

wom

en in

the

ir fir

stpr

egna

ncy.

If a

wom

an a

sks

for

a C

S in

he

r fir

st p

regn

ancy

we

agre

e –

it’s

her

choi

ce.

Wom

en, t

heir

mid

wiv

es a

ndth

eir

obst

etric

ians

exp

ect

the

next

del

iver

y to

be

by C

S.

VBA

C is

onl

y co

nsid

ered

at

the

insi

sten

ce o

f in

divi

dual

wom

en.

Ther

e is

no

agre

ed p

athw

ayfo

r w

omen

hav

ing

a pl

anne

d C

S.

Ther

e ar

e ad

hoc

arra

ngem

ents

with

labo

urw

ard.

Ther

e is

no

form

al c

linic

al

case

rev

iew

.

Adv

erse

inci

dent

rep

ortin

g is

spa

rse.

Ther

e ar

e no

det

aile

dpe

rfor

man

ce f

igur

es

for

mat

erni

ty.

We

man

age

wo

men

’s

exp

ecta

tio

ns,

we

pre

par

e th

em f

or

the

real

ity

of

lab

ou

r

We

are

pro

acti

ve

in r

eco

mm

end

ing

V

BA

C, g

ivin

g a

ccu

rate

info

rmat

ion

ab

ou

t ri

sks

and

ben

efit

s

If a

Cae

sare

an s

ecti

on

isp

lan

ned

, th

e p

roce

ss is

effi

cien

t an

d e

ffec

tive

We

get

acc

ura

te,

tim

ely

rele

van

tin

form

atio

n o

n

ou

r p

erfo

rman

ce

A BA B

58 Focus on normal birth and reducing Caesarean section rates

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Page 61: Pathways to success focus on normal birth

Use

rs a

ctiv

ely

enga

ge

with

the

ser

vice

thr

ough

a

num

ber

of d

iffer

ent

chan

nels

and

hel

p to

in

form

ser

vice

dev

elop

men

t.

We

faci

litat

e us

ers

to a

ct

as p

eer

supp

ort

e.g.

for

brea

stfe

edin

g.

Prov

ider

s an

d co

mm

issi

oner

sw

ork

toge

ther

to

agre

e qu

ality

impr

ovem

ent

targ

ets

for

the

serv

ice.

Our

reg

ular

use

r sa

tisfa

ctio

nsu

rvey

s ar

e us

ed a

s a

basi

s fo

r a

serv

ice

impr

ovem

ent

actio

n pl

an.

Use

r re

pres

enta

tion

on t

heM

SLC

ref

lect

s ou

r co

mm

unity

.

Our

com

mis

sion

ers

rega

rd t

he m

ater

nity

se

rvic

e as

hig

h pr

iorit

y an

d se

t qu

ality

mea

sure

s.

We

carr

y ou

t pa

tient

sa

tisfa

ctio

n su

rvey

s.

The

resu

lts a

re f

ed b

ack

to s

taff

.

Ther

e ar

e re

gula

r fo

rmal

dis

cuss

ions

with

co

mm

issi

oner

s ab

out

mat

erni

ty s

ervi

ces.

Th

ese

do n

ot in

clud

e qu

ality

mea

sure

s.

Som

eone

car

ries

out

occa

sion

al p

atie

nt

satis

fact

ion

surv

eys

but

we

don’

t he

ar

abou

t th

e re

sults

.

Ther

e ar

e ad

hoc

dis

cuss

ions

with

com

mis

sion

ers

abou

tm

ater

nity

ser

vice

s.

We

repl

y to

com

plai

nts.

We

have

diff

icul

ty

in m

aint

aini

ng u

ser

invo

lvem

ent

on

our

MSL

C.

Our

com

mis

sion

ers

rega

rd m

ater

nity

ser

vice

s as

low

prio

rity.

We

wo

rk c

lose

ly

wit

h o

ur

use

rs

and

sta

keh

old

ers

A B

Focus on normal birth and reducing Caesarean section rates 59

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Page 62: Pathways to success focus on normal birth

Top Ten Characteristics – Individual Record Sheet W

e fo

cus

on

ke

epin

g p

reg

nan

cy

and

bir

th n

orm

al

We

are

a re

al t

eam

– w

eu

nd

erst

and

an

d r

esp

ect

role

s an

d e

xper

tise

Ou

r le

ader

s ar

e vi

sib

le

and

vo

cal

Ou

r g

uid

elin

es a

re

evid

ence

-bas

ed a

nd

u

p t

o d

ate

We

all p

ract

ise

to

the

sam

e g

uid

elin

es

– n

o o

pti

ng

ou

t

We

man

age

wo

men

’s

exp

ecta

tio

ns,

we

pre

par

e th

em f

or

the

real

ity

of

lab

ou

r

We

are

pro

acti

ve in

re

com

men

din

g V

BA

C,

giv

ing

acc

ura

te in

form

atio

nab

ou

t ri

sks

and

ben

efit

s

If a

Cae

sare

an s

ecti

on

is

pla

nn

ed, t

he

pro

cess

is

eff

icie

nt

and

eff

ecti

ve

We

get

acc

ura

te, t

imel

yre

leva

nt

info

rmat

ion

o

n o

ur

per

form

ance

We

wo

rk c

lose

ly

wit

h o

ur

use

rs a

nd

st

akeh

old

ers

A B A B A B

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Top Ten Characteristics - Self-improvement Action Plan

We work closely with our users and stakeholders

Where are we now?• We do an annual user satisfaction survey and present the results at staff meetings• Our MSLC (Maternity Services Liaison Committee) meets irregularly• There is a user representative on the Labour ward forum• Meetings with the PCT are focused on activity only

Where do we want to get to?• A range of channels for user input. Start a focus group to address specific areas of development• All information leaflets to have user input• Increase membership of MSLC to reflect local community • Discussions with PCT include quality measures and opportunities for women’s choice

What do we need to change?• Strategy for involving hard to reach groups of users• Develop communication chain for publicising user feedback • Develop quality indicators with PCT

Who will do (and lead) the work?• Head of midwifery (lead)• Clinical Director• Maternity risk manager• Lay chair MSLC

When will we complete this?• March 2008

What tools will we use?• Maternity services focus group case study and terms of reference• User involvement audit• Modernising maternity care - a commissioning toolkit for England• Charter Mark Standards• We will / you will poster template

How will we measure success?• Audit of complaints• Audit of MSLC (user involvement audit)

What will be the impact? (quality and value, reduction in CS rate)• Reduction in complaints• Improved job satisfaction for staff• More effective relationship with commissioners

Worked example

Focus on normal birth and reducing Caesarean section rates 61

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For further information on how to develop measures and on how to present your data, please refer to the Improvement Leaders Guide on ‘Measurement for Improvement.’ This can be found at: www.institute.nhs.uk

Why not revisit the results of the Top Ten Characteristics exercise to see how staff think youhave progressed since your first workshop? This is a very powerful tool to show your progress.

Initial ResultsThe health and social care communities work in partnership to promote the concept of normal pregnancy and childbirth.

New ResultsThe health and social care communities work in partnership to promote the concept of normal pregnancy and childbirth.

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OrganisationalCharacteristics

5

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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Organisational Characteristics

The Organisational Characteristics looks at how your maternity service fits together as a wholeand how it sits within your trust.

‘The pathways support issues that are not often discussed or even acknowledged within an organisation - the culture of your organisation is paramount in reducing Caesarean section rates.’Alison WhithamMaternity and Gynaecology Manager, King’s Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust (CS rate 14%)

These pathways reflect the practices and behaviours we have seen and heard. Moving fromleft to right, the process supports lower Caesarean section rates.

You may not agree with all these statements - you will need to decide what changes are rightfor your organisation.

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Organisational Characteristics

We

have

con

sist

ent,

evid

ence

-bas

ed in

form

atio

nth

at a

ll m

embe

rs o

f st

aff

use

whe

n di

scus

sing

cho

ices

inm

ater

nity

car

e. W

omen

are

activ

e pa

rtne

rs in

dec

isio

nsab

out

thei

r ca

re.

All

staf

f fr

om t

he c

linic

aldi

rect

or t

o th

e ho

usek

eepi

ngst

aff

are

focu

ssed

on

achi

evin

g th

e op

timal

outc

omes

for

mot

her

and

baby

. It

is p

art

of t

heir

job

desc

riptio

n.

Our

lead

ers

are

high

ly v

isib

le.

We

look

to

them

as

role

mod

els.

Sta

ff t

rust

eac

h ot

her

and

can

chal

leng

e ea

ch o

ther

cons

truc

tivel

y an

d op

enly.

Ever

yone

is e

ncou

rage

d to

cont

ribut

e to

gui

delin

ede

velo

pmen

t. G

uide

lines

cove

r ou

r en

tire

serv

ice

and

are

evid

ence

-bas

ed w

here

poss

ible

. The

y ar

e av

aila

ble

elec

tron

ical

ly a

nd e

very

pr

int-

out

is d

ated

. Var

ianc

efr

om g

uide

lines

is r

ecor

ded

and

audi

ted.

Our

man

ager

s ha

ve r

egul

arse

ssio

ns w

ith t

he b

oard

to

rev

iew

our

ris

ks. W

e fe

elth

ey a

re f

ully

info

rmed

. W

e ca

n gi

ve y

ou e

xam

ples

of

impr

ovem

ents

tha

t ha

veco

me

thro

ugh

our

risk

repo

rtin

g.

We

have

evi

denc

e-ba

sed

info

rmat

ion

avai

labl

e bu

t no

t al

l wom

en r

ecei

ve it

. W

e en

cour

age

wom

en t

ow

rite

birt

h pl

ans

and

we

try

to r

espo

nd t

o th

eir

requ

ests

.

Our

sen

ior

staf

f ar

e co

mm

itted

to

achi

evin

g op

timal

out

com

es b

ut

whe

n ne

w s

taff

join

the

uni

tth

ings

wob

ble

for

a w

hile

.

Staf

f co

mm

unic

ate

wel

l an

d sh

are

teac

hing

and

tr

aini

ng. W

e ga

in m

utua

l re

spec

t by

und

erst

andi

ngea

ch o

ther

’s ro

les.

Gui

delin

es a

re c

onsu

lted

on b

y a

grou

p of

sta

ff.

They

are

reg

ular

ly u

pdat

ed.

CN

ST 2

sta

ndar

ds a

re a

pplie

dto

som

e gu

idel

ines

onl

y.

Ther

e’s

a go

od c

linic

al

gove

rnan

ce s

truc

ture

in

mat

erni

ty b

ut n

o ch

anne

l fo

r sh

arin

g le

arni

ng w

ithot

her

serv

ices

. We

have

ra

pid

acce

ss t

o th

e tr

ust

boar

d if

som

ethi

ng g

oes

serio

usly

wro

ng.

We

resp

ect

wom

en’s

view

s bu

t w

e ha

ve d

iffer

ent

inte

rpre

tatio

n of

ris

ks a

ndch

oice

s. T

he o

utco

me

depe

nds

larg

ely

on w

hich

cl

inic

ian

you

talk

to.

We

set

clea

r ai

ms

and

stan

dard

s bu

t w

e ar

e to

obu

sy t

o re

flect

on

the

serv

ice

we

are

actu

ally

del

iver

ing.

We

know

who

is in

cha

rge

and

whe

re t

o fin

d th

em.

In t

heor

y, a

nyon

e ca

n ap

proa

ch t

he s

enio

r m

idw

ifeor

doc

tor

but

in r

ealit

y th

ere

is c

omm

unic

atio

n on

ly a

t th

e to

p.

Ther

e is

a n

omin

ated

per

son

who

pro

duce

s an

d ci

rcul

ates

our

guid

elin

es. S

ome

are

avai

labl

e as

pap

er f

orm

at,

som

e el

ectr

onic

for

mat

. Se

nior

sta

ff h

ave

sign

ed

up t

o th

em b

ut d

o no

t al

way

s ch

ange

the

ir pe

rson

al p

ract

ice.

Whe

n th

ere

is a

ser

ious

pr

oble

m a

nd t

he t

rust

boa

rdis

invo

lved

it f

eels

ver

y un

fair

on u

s; w

e’ve

oft

en b

een

rais

ing

conc

erns

for

mon

ths.

It is

diff

icul

t to

exp

lain

ris

ksan

d m

ake

them

mea

ning

ful

to w

omen

. It

is u

nkin

d to

frig

hten

the

m w

ith a

ll th

e de

tails

, we

are

ther

e to

pro

tect

the

m a

nd lo

okaf

ter

them

.

We

expe

ct a

ll he

alth

pr

ofes

sion

als

to k

now

w

hat

high

qua

lity

care

is

, we

don’

t sp

ell i

t ou

t fo

r th

em.

“We

are

care

ful w

hat

we

say.

We

don’

t lik

e to

ask

que

stio

ns.”

New

or

upda

ted

guid

elin

esap

pear

fro

m t

ime

to t

ime

– w

e fin

d ou

t by

cha

nce.

They

are

for

info

rmat

ion

only

– n

ot e

very

one

agre

esw

ith t

he c

onte

nt.

Our

man

ager

s su

ppor

t us

inid

entif

ying

and

rep

ortin

g ris

ksbu

t no

thin

g se

ems

to c

hang

eas

a r

esul

t.

Mos

t w

omen

don

’t r

eally

wan

t ch

oice

the

y w

ant

reco

mm

enda

tions

fro

m

the

prof

essi

onal

s.

Recr

uitm

ent

and

rete

ntio

n is

diff

icul

t –

we

take

the

sta

ffw

e ca

n ge

t.

Staf

f gr

oups

don

’t m

ix.

“Mid

wiv

es h

ide

thin

gs

from

us…

.”

“Doc

tors

inte

rfer

e w

ith

our

case

s….”

We

have

som

e gu

idel

ines

bu

t th

ey a

re n

ot r

evie

wed

regu

larly

.

Man

y pe

ople

don

’t u

se t

hem

or k

now

wha

t is

in t

hem

.

We

are

relu

ctan

t to

fill

in

inci

dent

for

ms;

the

re

is s

till a

bla

me

cultu

re in

th

is t

rust

.

Wo

men

are

em

po

wer

ed t

om

ake

info

rmed

ch

oic

esab

ou

t th

eir

mat

ern

ity

care

Staf

f sh

are

a co

mm

on

eth

os

and

asp

irat

ion

s fo

rh

igh

qu

alit

y ca

re

Mat

ern

ity

care

is d

eliv

ered

by

a m

ult

idis

cip

linar

y te

amw

ith

hig

h le

vels

of

mu

tual

tru

st a

nd

res

pec

t b

etw

een

pro

fess

ion

s

Ther

e is

an

em

bed

ded

an

d s

ust

ain

able

mo

del

o

f g

oo

d c

linic

al p

ract

ice

Ther

e is

a r

ob

ust

clin

ical

go

vern

ance

str

uct

ure

thro

ug

ho

ut

the

tru

st

Focus on normal birth and reducing Caesarean section rates 65

Thes

e p

ath

way

s re

flec

t th

e p

ract

ices

an

d b

ehav

iou

rs w

e h

ave

seen

an

d h

eard

. Mo

vin

g f

rom

left

to

rig

ht,

th

e p

roce

ss s

up

po

rts

low

er C

aesa

rean

sec

tio

n r

ates

. Yo

u m

ay n

ot

agre

e w

ith

all

thes

e st

atem

ents

– y

ou

will

nee

d t

o d

ecid

e w

hat

ch

ang

es a

re r

igh

t fo

r yo

ur

org

anis

atio

n.

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Page 68: Pathways to success focus on normal birth

We

have

a r

obus

t co

stin

gm

odel

and

bud

get

sett

ing

proc

ess

that

allo

ws

us t

oun

ders

tand

and

con

trol

inco

me

and

expe

nditu

re.

We

are

deve

lopi

ng c

linic

alou

tcom

e m

easu

res

as a

loca

lpe

rfor

man

ce in

dica

tor.

Ther

e ar

e ef

fect

ive

form

al

and

info

rmal

com

mun

icat

ion

chan

nels

up

and

dow

n th

eor

gani

satio

n. E

very

one’

sop

inio

n is

res

pect

ed, w

e ar

e ab

le t

o ch

alle

nge

each

othe

r. U

sers

hel

p to

sha

pe

our

serv

ices

.

Clin

ical

info

rmat

ion

isci

rcul

ated

wid

ely

ever

ym

onth

, usi

ng t

rend

cha

rts

and

Stat

istic

al P

roce

ss C

ontr

olfo

rmat

s w

here

app

ropr

iate

. O

ur c

linic

al in

form

atio

nin

form

s se

rvic

e de

velo

pmen

t.

Cod

ing

info

rmat

ion

is

deriv

ed a

utom

atic

ally

fr

om t

he m

ater

nity

info

rmat

ion

syst

em.

It is

reg

ular

ly a

udite

d fo

rco

mpl

eten

ess

and

accu

racy

.

We

have

a b

asic

cos

ting

mod

el t

hat

allo

ws

us t

oun

ders

tand

the

impa

ct o

fva

rianc

e in

our

act

ivity

,st

affin

g et

c. W

e us

e a

bala

nced

sco

reca

rd t

o re

view

per

form

ance

.

The

team

is in

clus

ive,

ope

n an

dch

alle

ngin

g. O

ur m

anag

ers

seek

our

opi

nion

s an

d ke

ep

us in

form

ed b

ut w

e ar

efr

ustr

ated

tha

t w

e ca

nnot

influ

ence

or d

rive

chan

ge in

the

orga

nisa

tion.

Use

r vi

ews

are

rout

inel

y so

ught

and

val

ued.

We

rece

ive

mon

thly

list

s of

figur

es a

bout

our

clin

ical

perf

orm

ance

. It

is p

ossi

ble

toge

t sp

ecifi

c in

form

atio

n fr

omou

r m

ater

nity

sys

tem

.

All

staf

f un

ders

tand

the

impo

rtan

ce o

f co

ding

and

use

prom

pts

to im

prov

e ac

cura

cy.

Info

rmat

ion

is r

ecor

ded

in r

eal

time.

Clin

icia

ns a

nd c

oder

sm

eet

regu

larly

. Ad

hoc

audi

tsar

e ca

rrie

d ou

t.

We

are

activ

e pa

rtne

rs in

budg

et-s

ettin

g an

d co

ntro

lou

r ex

pend

iture

. We

belie

vew

e pr

ovid

e an

app

ropr

iate

clin

ical

ser

vice

but

we

have

no d

etai

led

info

rmat

ion

onou

r in

com

e.

With

in t

he u

nit

we

com

mun

icat

e w

ell a

nd

have

goo

d m

ultid

isci

plin

ary

rela

tions

hips

. We

do s

ome

user

sur

veys

but

hav

e no

ong

oing

cha

nnel

for

us

er v

iew

s.

We

have

a s

impl

e in

form

atio

n sy

stem

tha

tsu

pplie

s us

with

bas

ic

figur

es b

ut is

not

res

pons

ive

to o

ur c

hang

ing

need

s.

Staf

f ac

cept

the

nee

d to

part

icip

ate

in c

odin

g bu

tdo

n’t

unde

rsta

nd t

heim

plic

atio

ns o

f de

lays

or

inac

cura

cies

.

We

agre

e ou

r bu

dget

bas

edon

ly o

n ex

pend

iture

, not

on

our

inco

me.

Ove

rspe

ndin

g is

from

unm

et c

ost

pres

sure

s.C

linic

al q

ualit

y is

not

use

d as

a p

erfo

rman

ce m

easu

re.

Our

man

ager

s w

ill t

ell u

s if

ther

e ar

e im

port

ant

thin

gs

we

need

to

know

.

We

prob

ably

und

erst

and

our

busi

ness

bet

ter

than

any

one

but

no-o

ne a

sks

us f

or o

urid

eas

or in

put.

Lim

ited

info

rmat

ion

abou

tou

r se

rvic

e is

col

lect

ed a

ndfe

d up

war

ds, i

t se

ldom

com

esba

ck in

a f

orm

tha

t is

rel

evan

tto

clin

icia

ns.

Reco

rdin

g in

form

atio

n fo

rco

ding

is a

n ex

tra

task

for

clin

ical

sta

ff –

we

real

ly d

on’t

have

the

tim

e.

Ever

y ye

ar w

e ar

e ca

ught

by

surp

rise

whe

n ou

rex

pend

iture

goe

s ou

t of

cont

rol.

We

don’

t kn

ow h

owou

r cl

inic

al o

utco

mes

com

pare

with

oth

er u

nits

.

We

get

on w

ith o

ur o

wn

jobs

,w

hat

happ

ens

in t

he r

est

ofth

e tr

ust

is n

ot o

ur b

usin

ess.

“As

clin

icia

ns, w

e sh

ould

focu

s on

the

par

ticul

arw

oman

we

are

carin

g fo

r at

that

mom

ent,

we

don’

t ca

reab

out

stat

istic

s.”

“Peo

ple

in c

odin

g do

n’t

unde

rsta

nd o

ur c

linic

alab

brev

iatio

ns.”

“Clin

ical

sta

ff d

on’t

unde

rsta

nd w

hy c

odin

g is

impo

rtan

t.”

Mat

ern

ity

serv

ices

pro

vid

eva

lue

for

mo

ney

Effe

ctiv

e co

mm

un

icat

ion

and

info

rmat

ion

en

han

ced

ecis

ion

-mak

ing

Tim

ely,

rel

evan

tin

form

atio

n is

use

d t

oin

form

clin

ical

pra

ctic

e an

d s

ervi

ce d

evel

op

men

t

Acc

ura

te a

nd

com

pre

hen

sive

clin

ical

cod

ing

is u

sed

to

en

sure

the

corr

ect

Hea

lth

care

Res

ou

rce

Gro

up

ing

(H

RG

)

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Focus on normal birth and reducing Caesarean section rates 67

Organisational Characteristics - Individual Record Sheet

Wo

men

are

em

po

wer

ed

to m

ake

info

rmed

ch

oic

esab

ou

t th

eir

mat

ern

ity

care

Staf

f sh

are

a co

mm

on

eth

os

and

asp

irat

ion

s fo

rh

igh

qu

alit

y ca

re

Mat

ern

ity

care

is d

eliv

ered

by

a m

ult

idis

cip

linar

y te

amw

ith

hig

h le

vels

of

mu

tual

tru

st a

nd

res

pec

t b

etw

een

pro

fess

ion

s

Ther

e is

an

em

bed

ded

an

dsu

stai

nab

le m

od

el o

f g

oo

dcl

inic

al p

ract

ice

Ther

e is

a r

ob

ust

clin

ical

go

vern

ance

str

uct

ure

thro

ug

ho

ut

the

tru

st

Mat

ern

ity

serv

ices

pro

vid

eva

lue

for

mo

ney

Effe

ctiv

e co

mm

un

icat

ion

and

info

rmat

ion

en

han

ced

ecis

ion

mak

ing

Tim

ely,

rel

evan

t in

form

atio

n is

use

d t

o

info

rm c

linic

al p

ract

ice

and

ser

vice

dev

elo

pm

ent

Acc

ura

te a

nd

co

mp

reh

ensi

vecl

inic

al c

od

ing

is u

sed

to

en

sure

th

e co

rrec

tH

ealt

hca

re R

eso

urc

eG

rou

pin

g (

HR

G)

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Organisational Characteristics - Self-improvement Action Plan

There is an embedded and sustainable model of good clinical practice

Where are we now?• The midwife with the lead for clinical risk writes the guidelines• She discusses them with senior midwives in the relevant areas and the Obstetrician she thinks is most

involved. Some guidelines are referenced. They don’t say how good the evidence is• Some senior staff don’t look at the guidelines they just tell us what they want done. Some junior staff

do different things they have been taught elsewhere• New guidelines are stuck to the back of the staff changing room door so that they catch people’s

attention. There is no record of who has seen them

Where do we want to get to?• This is an important area. We need someone to take charge of the process but allow more people to get

involved in deciding the content. We want all our guidelines to be up to date, with clear evidence andreferences

• Once we have agreed a guideline, everyone reads it and everyone uses it• For complex cases, a print-out of the guideline goes into the clinical record as a practical tool and any

variance from it is recorded

What do we need to change?• Agree who is in charge and make sure the responsibility is clear in their job description and time is

allocated appropriately• Set up a guideline development group to meet regularly. Decide membership and terms of reference• Make an up to date list of guidelines - whether they are evidence-based and when they should be

reviewed. Agree a rolling programme of review and development• Look at our communication channels to decide how we can check that everyone appropriate has seen and

agreed the guidelines

Who will do (and lead) the work?• Clinical risk midwife (Lead)• Practice development midwife• Obstetric consultant with an interest in training• Administrator, Antenatal clinic

When will we complete this?• October 2007

What tools will we use?• CNST standards• Protocol and guideline development check-list• RCOG and MIDIRS guidelines

How will we measure success?• Trends in adverse incidents (reduction in incidents related to failure to follow guidance)• Clinical record audit of variance against guidelines

What will be the impact? (quality and value, reduction in CS rate)• Reduction in litigation (demonstrating evidence-based practice)• Reduction in complaints (better communication, consistency of information to women)• Possible reduction in CS rate (e.g. consistent management of VBAC, use of fetal blood sampling)

Worked example

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Principle Measures

Women are empowered to make informedchoices about their maternity care

• Percentage of women who contribute to their birth plan (target:100%)

Staff share a common ethos and aspirations for high quality care

• Recruitment, retention and sickness absence rates

Maternity care is delivered by amultidisciplinary team with high levels of mutual trust and respect betweenprofessions

Effective communication and use of information enhance decision making

• Multidisciplinary attendance at clinical review meetings

• Multidisciplinary attendance at trainingdays

• Trends in complaints

There is an embedded and sustainablemodel of good clinical practice

• Percentage of guidelines that are referenced to best practice and reviewedannually (target: 90%)

There is a robust clinical governance structure throughout the trust

• Maternal and perinatal mortality and morbidity rates

• Litigation claims

Maternity services provide value for money • Income and expenditure against HRG 4 definitions

Timely, relevant information is used to inform clinical practice and servicedevelopment

• Percentage of clinical staff who are aware of monthly CS rates and trends (target: 90%)

Accurate and comprehensive clinical coding is used to ensure the correct Healthcare Resource Grouping

• Accuracy of HRG attributions

• Depth of coding (target: upper quartile)

Organisational CharacteristicsMeasures for Improvement

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Organisational Culture Example Tools

Scenario: Eva - third degree tearEva presents on labour ward at term. She is in labour. The midwife looking after her notices that thehand held notes mentions a 3rd degree tear with her last baby. The obstetrician is informed and inorder to prevent a further 3rd degree tear, recommends that Eva has a Caesarean section.

Following the CS the postnatal midwife reviews the previous delivery notes as detailed in the hospitalobstetric notes. There is no mention of a 3rd degree tear only a small 2nd degree stitched under localby an SHO. Eva remembers being sutured in the labour room last time and says that apart fromhaving to have antibiotics for an infection she had no other problems.

• What organisational issues are reflected in this clinical incident?

• As the labour ward co-ordinator what immediate steps would you take to investigate the issues?

• Who should be involved in this discussion?

• How could you ensure it will not happen again?

Service Improvement Tools

Statistical Process ControlUse your data more effectively to help you understand your processes and identify change when it occurs.

Run charts display a particular measurement serially over time. (e.g monthly CS rate). This is easier to see than referring to sheets of printed figures.

Statistical process control (SPC) charts are a method of displaying data over time that can helpyou understand whether your performance is changing and why. The technique, invented 80 yearsago by Walter Shewhart uses a run chart to plot data against time. The chart also shows the average(mean) of the readings and upper and lower control limits, usually set as three standard deviationsfrom the mean.

Common cause variation is the random variation that occurs in any particular measurement as anintrinsic part of the process (e.g. daily postnatal bed occupancy).

Special cause variation is when the process varies outside the upper or lower control limits. Thisindicates that something unusual has happened. By identifying this quickly and studying the reasons,you may be able to identify improvements that will prevent a recurrence. Over time you will reducevariation and the upper and lower control limits will get closer together.

If there are eight or more consecutive points above or below the centre line or heading consistentlyin one direction, that indicates a change in the process. The mean and the control limits are then re-plotted from the start of the change noted.

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Looking at this another way,

• single point variations only matter if they fall outside the control limits.

• there is a trend in the data only when seven or more consecutive points fall on one side of the mean or consistently rise or fall.

The advantage of this technique is that it can alert you quickly when something goes wrong and prevent you assuming something has changed when it probably hasn’t!

Template: Return on investment Prioritisation GridImpact (increased Quality, reduced CS rates) x Resources required (what do we need to change)

Focus on normal birth and reducing Caesarean section rates 71

1 2 3

Large impact 3

Moderate impact 2

Small impact 1

High resources Moderate resources Low resources

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Case studies

Walking the Floor We meet regularly with our Maternity Services Liaison Committee and value the opportunity to work with our users and stakeholders. Prior to our meetingwe take the members of the MSLC to our postnatal ward and invite them to‘walk the floor’. Here they have the opportunity to talk directly with womenwho have just had their babies using our services. These discussions withwomen then form the basis for our meeting with the MSLC members.

Jacqueline Dunkley-Bent, Head of Midwifery, Guy’s and St Thomas’ Hospital

Why don’t you………

Set up a Clinical Forum?A clinical forum can be used to explore:

• approaches to care

• standards of care

• user and staff satisfaction

and provide:

• Clinical updating that is evidence-based.

• Changes to practice

How it worksOne member of staff describes the care they gave to a woman. They reflect on the known best practice and provide evidenced based information for the group to review. The staffmember then raises one of two questions for discussion and invites the group to explore theissues. Any actions that come out of the discussion should be documented and allocated.

What you need• A relaxed environment

• A multidisciplinary group of participants (could this include users?)

• Someone who can act as facilitator or debrief if required

• Start with someone who is comfortable and confident with speaking about clinical care

• Start with cases that focus on the normal

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Key documentsDepartment of Health (1999), Making a Difference: strengthening the nursing, midwifery and health visiting contribution to health and healthcare, HMSO: London

Department of Health (2000), The NHS Plan: a plan for investment, a plan for reform, HMSO: London

Department of Health (2006), Our Health Our Care Our Say, HMSO: London House of Commons Health Committee Report (2003), Choice in Maternity Services Ninth Report of Session 2002-03 Volume 1, HMSO: London)

NHS Litigation Authority, Clinical Negligence Scheme for Trusts Maternity Standards National Patient Safety Agency, (See January 2007 issue for maternity concerns)

Royal College of Midwives (2000), Vision 2000, London: Royal College of Midwives

Royal College of Midwives (2002), Working Better Together - a good employment guide formidwives (3rd ed), Royal College of Midwives: London

Royal College of Obstetricians and Gynaecologists / Royal College of Midwives (1999), TowardsSafer Childbirth: Minimum Standards for the Organisation of Labour Wards, London:RCOG/RCM

User involvementMIDIRS Informed Choice, (www.infochoice.org/)

Royal College of Obstetricians and Gynaecologists, Information for Patients, (www.rcog.org.uk)

National Childbirth Trust (www.nct.org.uk)

User involvement: North East Wales NHS TrustTo find ways in which women could become more closely involved in service planning acommunications group was set up whose activity included running focus groups of womenwho had recently used the maternity services. The work was developed in Partnership with theNCT and the public and patient manager at the Trust. This has built stronger relationshipsbetween service users, staff and partner organisations. The women involved said they feltempowered and valued.Dawn Cooper, Head of Midwifery & RCM award winner 2006

Focus on normal birth and reducing Caesarean section rates 73

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First Pregnancyand Labour

6

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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Keeping first pregnancy and labour normal

‘Following the pathway initiated good debate between doctors and midwives which you don’t often have time or the opportunity for.’Obstetrician,York Hospitals NHS Trust

This pathway begins even before a woman is pregnant and ends with the birth of her baby.

These pathways reflect the practices and behaviours we have seen and heard. Moving fromleft to right, the process supports lower Caesarean section rates.

You may not agree with all these statements - you will need to decide what changes are rightfor your organisation.

Pre-pregnancy

Booking

Antenatal care

Labour and birth

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Pre-

pre

gn

ancy

Car

e ne

twor

ks a

re e

stab

lishe

dbe

twee

n m

ater

nity

ser

vice

san

d ot

her

spec

ialis

t ag

enci

es.

Chi

ldre

n ce

ntre

sta

ff o

ffer

info

rmat

ion

abou

t he

alth

ypr

egna

ncy

and

norm

al b

irth.

Mid

wiv

es b

ased

in c

omm

unity

sett

ings

pro

vide

out

reac

hse

rvic

es.

Prof

essi

onal

s w

ork

with

repr

esen

tativ

es o

f ha

rd t

ore

ach

grou

ps t

o im

prov

eac

cess

to

serv

ices

.

Bo

oki

ng

Wom

en h

ave

acce

ss t

o a

mid

wife

at a

ny ti

me,

incl

udin

gpr

e-pr

egna

ncy.

The

y bo

okdi

rect

ly w

ith a

mid

wife

inpr

egna

ncy.

Mid

wiv

es le

ad t

he n

eeds

and

risk

asse

ssm

ent

for

all

wom

en. W

omen

are

boo

ked

unde

r a

mid

wife

for

mid

wife

ry-le

d ca

re u

nles

s a

refe

rral

is n

eces

sary

. The

re is

no n

amed

obs

tetr

icia

n.

An

ten

atal

Mid

wiv

es a

re e

asily

acc

essi

ble

in C

hild

ren’

s C

entr

es /

com

mun

ity s

ettin

g. T

here

are

flexi

ble

arra

ngem

ents

acco

rdin

g to

the

need

s of

the

loca

l pop

ulat

ion.

Wom

en c

anha

ve a

cho

ice

in th

e pl

ace

and

time

of t

heir

book

ing

visi

t.

Mid

wiv

es a

re m

ovin

g fr

om

GP

surg

erie

s in

to c

omm

unity

sett

ings

e.g

. Chi

ldre

n C

entr

es.

We

targ

et h

ard

to r

each

wom

en.

Wom

en c

hoos

e to

boo

kdi

rect

ly w

ith a

mid

wife

or

heal

th c

are

prof

essi

onal

of

choi

ce.

The

book

ing

mid

wife

mak

es a

risk

and

need

s as

sess

men

tus

ing

guid

elin

es a

nd a

sses

ses

appr

opria

tene

ss o

f m

idw

ifery

-le

d ca

re. T

here

is a

nam

edob

stet

ricia

n.

Wom

en a

re o

ffer

ed a

cho

ice

of h

ome

or h

ealth

car

e se

ttin

gfo

r th

eir

book

ing.

Mid

wiv

es w

ork

in t

radi

tiona

lm

odel

s of

car

e. T

here

is s

ome

liais

on w

ith e

xter

nal

agen

cies

.

Wom

en a

re n

ot a

war

e th

atth

ey c

an b

ook

dire

ctly

with

a

mid

wife

.

A s

enio

r m

idw

ife r

evie

ws

all b

ooki

ngs

and

dete

rmin

essu

itabi

lity

for

mid

wife

ry-le

dca

re. T

here

is a

nam

edob

stet

ricia

n.

Indi

vidu

al m

idw

ives

hav

eth

eir

own

pref

erre

d bo

okin

gar

rang

emen

ts.

Mid

wiv

es w

ork

in t

radi

tiona

lm

odel

s of

car

e. T

here

is

no li

aiso

n w

ith e

xter

nal

agen

cies

.

Som

e G

P pr

actic

es a

llow

wom

en t

o bo

ok d

irect

ly w

itha

mid

wife

.

An

obst

etric

ian

revi

ews

mid

wiv

es’ b

ooki

ngs

and

dete

rmin

es s

uita

bilit

y fo

rm

idw

ifery

-led

care

. The

re

is a

nam

ed o

bste

tric

ian.

All

wom

en a

re b

ooke

d in

a

heal

th c

are

envi

ronm

ent

clos

e to

hom

e e.

g. t

he

GP

surg

ery.

Wom

en r

ecei

ve c

onfli

ctin

gin

form

atio

n fr

om d

iffer

ent

agen

cies

.

Wom

en g

et a

dis

tort

ed v

iew

of p

regn

ancy

and

birt

h fr

omth

e m

edia

.

Wom

en c

an o

nly

acce

ss a

mid

wife

via

the

ir G

P.

Ever

y w

oman

has

to

bebo

oked

und

er a

con

sulta

ntob

stet

ricia

n ev

en if

she

isas

sess

ed a

s lo

w r

isk.

Ther

e is

a s

ingl

e pa

thw

ay

for

book

ing

with

all

wom

ense

en a

t a

book

ing

clin

icw

ithin

a h

ospi

tal.

The

hea

lth

an

d s

oci

al

care

co

mm

un

itie

s w

ork

in

par

tner

ship

to

pro

mo

te

the

con

cep

t o

f n

orm

alp

reg

nan

cy a

nd

ch

ildb

irth

All

wo

men

are

ab

le t

oac

cess

a m

idw

ife

dir

ectl

y

Mid

wiv

es d

eter

min

e th

eap

pro

pri

ate

pat

hw

ay a

tb

oo

kin

g

An

ten

atal

car

e is

off

ered

in

co

nve

nie

nt

and

app

rop

riat

e se

ttin

gs

First pregnancy and labourTh

ese

pat

hw

ays

refl

ect

the

pra

ctic

es a

nd

beh

avio

urs

we

hav

e se

en a

nd

hea

rd. M

ovi

ng

fro

m le

ft t

o r

igh

t, t

he

pro

cess

su

pp

ort

s lo

wer

Cae

sare

an s

ecti

on

rat

es. Y

ou

may

no

t ag

ree

wit

h a

ll th

ese

stat

emen

ts –

yo

u w

ill n

eed

to

dec

ide

wh

at c

han

ges

are

rig

ht

for

you

r o

rgan

isat

ion

.

Focus on normal birth and reducing Caesarean section rates 77

Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 77

Page 80: Pathways to success focus on normal birth

Each

wom

an is

info

rmed

of

all o

ptio

ns f

or p

lace

of

birt

hin

clud

ing

hom

e bi

rth

as a

rea

lch

oice

. The

re is

a g

radu

alye

arly

incr

ease

in u

ptak

e.Th

ere

is a

con

tinui

ngdi

scus

sion

abo

ut p

lace

of

birt

h th

roug

hout

pre

gnan

cy.

All

mid

wiv

es s

uppo

rt a

nden

cour

age

the

upta

ke

of c

lass

es. T

hey

are

wel

lat

tend

ed a

nd le

d by

a

birt

h ed

ucat

or o

r m

idw

ife.

Mid

wiv

es u

se t

he o

ppor

tuni

tyof

eac

h co

ntac

t to

info

rm a

ndpr

epar

e w

omen

for

birt

h.

NSF

impl

emen

tatio

n is

wel

les

tabl

ished

. The

pat

hway

tow

ards

nor

mal

birt

h is

activ

ely

prom

oted

with

in th

e se

rvic

e.Th

e m

ultid

iscip

linar

y te

amfo

cus

on a

chie

ving

nor

mal

outc

omes

. We

lear

n fr

om

each

oth

er to

ach

ieve

this.

All

wom

en a

re o

ffer

ed

stre

tch

and

swee

p no

ear

lier

than

41+

3. F

ull d

iscu

ssio

nan

d in

form

atio

n en

able

s ea

ch w

oman

to

mak

e a

deci

sion

to

awai

t ev

ents

or

com

men

ce IO

L.

All

staf

f fe

el c

onfid

ent

to d

iscu

ss E

CV

incl

udin

g th

e be

nefit

s an

d ris

ks.

Each

wom

an r

ecei

ves

writ

ten

info

rmat

ion.

Ther

e is

a h

igh

upta

ke o

f EC

V.

We

do n

ot o

ffer

CS

for

mat

erna

l cho

ice.

We

have

a

varie

ty o

f pa

thw

ays

for

addr

essi

ng t

he in

divi

dual

need

s of

wom

en w

ith f

ears

of c

hild

birt

h in

clud

ing

appr

opria

te f

ollo

w u

p.

Hom

ebirt

h is

off

ered

with

ful

ldi

scus

sion

of

risks

and

bene

fits.

Ant

enat

al e

duca

tion

isac

cess

ible

to

all w

omen

in a

varie

ty o

f se

ttin

gs. C

lass

esex

plor

e a

full

rang

e of

cop

ing

stra

tegi

es. S

essi

ons

are

run

bya

core

of

mid

wiv

es.

NSF

impl

emen

tatio

n is

wel

les

tabl

ished

and

nor

mal

birt

h is

visib

ly p

rom

oted

acr

oss

the

serv

ice.

For

exa

mpl

e, N

CT

post

ers

on p

ositi

ons

for

birt

hing

on

view

for w

omen

;in

form

atio

n bo

ards

with

bes

tpr

actic

e re

com

men

datio

ns

for s

taff

.

A s

tret

ch a

nd s

wee

p is

offe

red.

IOL

book

ed f

or

41+

3 on

war

ds. T

he c

linic

ian

deci

des

to in

duce

or

wai

tde

pend

ing

on t

he c

linic

alfin

ding

s.

All

wom

en a

re g

iven

info

rmat

ion

abou

t th

e ris

ksan

d be

nefit

s of

EC

V u

nles

scl

inic

ally

con

trai

ndic

ated

.

Ther

e is

a d

efin

ed p

athw

ay

to s

uppo

rt w

omen

with

unde

rlyin

g fe

ars

and

conc

erns

.

Hom

ebirt

h is

off

ered

as

rout

ine

but

with

litt

ledi

scus

sion

. The

re is

a

low

upt

ake.

Ant

enat

al e

duca

tion

isac

cess

ible

to

all w

omen

in a

varie

ty o

f se

ttin

gs. C

lass

este

nd t

o fo

llow

a r

igid

for

mat

with

em

phas

is o

n th

e‘m

edic

al p

ain

relie

f m

odel

.’

Ther

e is

rec

ogni

tion

of

the

need

to

wor

k to

war

ds

the

key

goal

s id

entif

ied

in

the

NSF

.

A s

tret

ch a

nd s

wee

p is

offe

red

and

an IO

L bo

oked

for

41+

3.

All

wom

en a

re o

ffer

ed E

CV

but

ther

e is

a lo

w u

ptak

e.

Whe

n w

omen

ask

for

a C

Sw

e tr

y to

fin

d ou

t w

hat

isbe

hind

the

req

uest

.

The

maj

ority

of

mid

wiv

es d

ono

t di

scus

s ho

me

birt

h bu

tso

me

of t

he m

idw

ives

are

very

‘pro

’ hom

e bi

rth

and

are

happ

y to

off

er it

.

Ant

enat

al e

duca

tion

isof

fere

d to

all

wom

en. T

here

isa

low

upt

ake

with

man

yw

omen

cho

osin

g to

mak

eth

eir

own

arra

ngem

ents

.

Som

e ef

fort

has

bee

n m

ade

to a

sses

s cu

rren

t se

rvic

epr

ovis

ion

in li

ne w

ith t

he N

SF.

Ther

e is

a v

arie

ty o

f pr

actic

esde

pend

ing

on t

he c

linic

ian.

Som

e cl

inic

ians

off

er E

CV.

Mat

erna

l req

uest

for

C

S is

agr

eed

only

aft

er

a se

cond

opi

nion

.

It is

ass

umed

tha

t w

omen

will

deliv

er in

the

hos

pita

l. H

ome

conf

inem

ent

is n

ot d

iscu

ssed

or r

outin

ely

offe

red.

Ant

enat

al e

duca

tion

is n

ot a

high

prio

rity

with

in t

here

sour

ces

avai

labl

e.

Ther

e is

no

focu

s on

norm

ality

with

in t

he u

nit.

Wom

en a

re in

duce

d be

fore

41+

3 fo

r un

com

plic

ated

pos

tda

tes.

Wom

en w

ith a

bre

ech

are

not

rout

inel

y of

fere

d EC

V.

If a

wom

an a

sks

for

a C

S in

her

first

pre

gnan

cy w

e ag

ree,

it’s

her

choi

ce.

Wo

men

are

info

rmed

abo

ut

the

op

tio

ns

for

pla

ce o

f b

irth

We

wo

rk w

ith

wo

men

to

ensu

re t

hey

hav

e a

real

isti

cex

pec

tati

on

of

lab

ou

r,b

irth

an

d p

aren

tho

od

We

focu

s o

n k

eep

ing

pre

gn

ancy

an

d b

irth

no

rmal

Ther

e ar

e n

o s

oci

alin

du

ctio

ns

Wo

men

wit

h a

bre

ech

pre

sen

tati

on

are

off

ered

exte

rnal

cep

hal

ic v

ersi

on

(EC

V)

by

a sk

illed

pro

fess

ion

al

We

man

age

wo

men

’sex

pec

tati

on

s, w

e p

rep

are

them

fo

r th

e re

alit

y o

fla

bo

ur

78 Focus on normal birth and reducing Caesarean section rates

Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 78

Page 81: Pathways to success focus on normal birth

Lab

ou

r an

d B

irth

Ther

e is

a h

omel

yen

viro

nmen

t in

all

of t

hero

oms

incl

udin

g hi

ghde

pend

ency

, whe

re c

linic

aleq

uipm

ent

is o

ut o

f si

ght.

The

bed

is n

ot t

he m

ain

focu

s.

All

room

s eq

uipp

ed w

ithbi

rthi

ng b

alls

, gym

mat

s w

all

bars

etc

to

prom

ote

activ

ela

bour

. Sta

ff a

re c

onfid

ent

inof

ferin

g w

ater

birt

h.

All

staf

f be

lieve

in a

nd h

ave

the

skill

s to

sup

port

the

norm

al p

hysi

olog

y of

child

birt

h. W

omen

are

ac

tive

and

mob

ile.

Mid

wiv

es a

re s

kille

d in

no

n-in

vasi

ve ‘p

ain

relie

f’te

chni

ques

, vis

ualis

atio

n,m

assa

ge a

nd b

reat

hing

tech

niqu

es.

Wom

en r

ecei

ve 1

:1 c

are

inla

bour

by

a m

idw

ife. T

he s

kill

mix

is u

sed

inno

vativ

ely

toen

able

mid

wiv

es t

o do

thi

s.

The

mid

wife

rec

ogni

ses

the

valu

e of

oth

er s

uppo

rter

s an

d w

orks

with

the

m.

Labo

ur w

ard

is k

ept

free

for

labo

urin

g w

omen

. Wom

enar

e as

sess

ed p

rior

to a

rriv

ing

on t

he la

bour

war

d ei

ther

at

hom

e or

thr

ough

a

tria

ge s

yste

m.

Ther

e is

a h

omel

yen

viro

nmen

t in

mos

t ro

oms

with

som

e lim

itatio

ns.

The

posi

tion

of t

he b

ed is

depe

ndan

t on

the

mid

wife

.

Room

s ar

e eq

uipp

ed w

ithbi

rthi

ng b

alls

, gym

mat

s w

all

bars

etc

to

prom

ote

activ

ela

bour

. Wat

erbi

rth

is a

vaila

ble.

Wom

en a

re e

ncou

rage

d to

be

mob

ile w

ithin

the

iren

viro

nmen

t. A

ll m

idw

ives

enco

urag

e an

‘act

ive’

birt

hra

ther

tha

n a

relia

nce

on

the

bed.

Mid

wiv

es a

im t

o gi

ve 1

:1

care

to

wom

en b

ut t

his

is

not

alw

ays

poss

ible

the

refo

reot

her

mem

bers

of

staf

f ar

e tr

aine

d to

pro

vide

1:

1 su

ppor

t.

Ther

e is

a 2

4 hr

tria

ge a

rea

sepa

rate

fro

m la

bour

war

dw

here

wom

en in

ear

ly la

bour

or w

ith a

nten

atal

pro

blem

sar

e as

sess

ed.

Equi

pmen

t is

hid

den

away

in

bot

h th

e w

ard

area

s an

dro

oms

but

the

bed

rem

ains

in

the

mid

dle

of t

he r

oom

.

Birt

hing

aid

s ar

e av

aila

ble

to w

omen

on

requ

est.

Wom

en a

re f

ree

to m

ove

arou

nd t

he r

oom

. Som

e st

aff

are

conf

iden

t to

sup

port

wom

en w

ith n

on-in

vasi

vete

chni

ques

but

man

y ar

e no

t.

Mid

wiv

es a

re c

linic

ally

focu

ssed

on

carin

g fo

rw

omen

in n

orm

al la

bour

but

they

are

sho

rt s

taff

ed a

ndm

ay h

ave

to lo

ok a

fter

tw

ow

omen

at

the

sam

e tim

e.

We

have

a s

epar

ate

asse

ssm

ent

cent

re w

hich

oper

ates

9-5

. Dur

ing

the

nigh

t as

sess

men

t is

mad

e on

the

labo

ur w

ard.

Som

e im

prov

emen

ts h

ave

been

mad

e to

the

déc

or

but

it is

stil

l clin

ical

.

Wom

en a

re a

ble

to b

ring

in a

nd u

se t

heir

own

birt

hing

aid

s.

The

maj

ority

of

wom

ensp

end

part

of

thei

r la

bour

on

the

bed

.

1:1

care

is p

riorit

ised

for

hi

gh r

isk

wom

en. T

his

is

at t

he e

xpen

se o

f w

omen

in

nor

mal

labo

ur.

Wom

en w

ho a

re n

ot in

labo

ur r

emai

n on

labo

urw

ard

for

a lo

ng t

ime.

The

yar

e re

gard

ed a

s lo

w p

riorit

y.

The

labo

ur w

ard

and

room

sar

e cl

inic

al w

ith t

he b

ed a

sth

e m

ain

focu

s of

the

roo

m.

The

desi

gn a

nd e

quip

men

t in

the

labo

ur r

oom

s is

gov

erne

d by

the

re

quire

men

ts o

f th

e st

aff.

The

maj

ority

of

wom

enla

bour

on

the

bed.

Ther

e is

a r

elia

nce

on

phar

mac

olog

ical

pai

n re

lief.

1:1

care

in la

bour

is r

arel

ypo

ssib

le. M

idw

ives

spe

nd

a lo

t of

tim

e do

ing

non

mid

wife

ry t

asks

.

All

wom

en p

rese

ntin

g w

ithpr

egna

ncy

prob

lem

s ar

e ad

mitt

ed t

o la

bour

war

d fo

r as

sess

men

t.

The

dec

ora

tio

n o

f th

e b

irth

ro

om

s is

ho

mel

y w

ith

clin

ical

eq

uip

men

t o

ut

of

sig

ht

Bir

th r

oo

ms

are

equ

ipp

ed w

ith

aid

s to

fac

ilita

te a

ctiv

e b

irth

Wo

men

are

dis

cou

rag

edfr

om

lyin

g o

n t

he

bed

1:1

sup

po

rt is

pro

vid

edd

uri

ng

lab

ou

r b

y a

trai

ned

car

er

The

lab

ou

r w

ard

is

res

erve

d f

or

lab

ou

rin

g w

om

en

Focus on normal birth and reducing Caesarean section rates 79

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Page 82: Pathways to success focus on normal birth

Evid

ence

-bas

ed g

uide

lines

ar

e re

gula

rly r

evie

wed

an

d up

date

d.

Wom

en a

re g

iven

cle

arin

form

atio

n ab

out

the

bene

fits

and

risks

. Var

iatio

nsin

pra

ctic

e ar

e ex

plor

ed.

All

wom

en a

re o

ffer

edin

term

itten

t au

scul

tatio

n in

line

with

NIC

E gu

idan

ce.

Elec

tron

ic f

etal

mon

itorin

g is

onl

y us

ed w

hen

ther

e is

a

clin

ical

indi

catio

n.

Con

sulta

nts

prov

ide

hand

s on

trai

ning

and

sup

port

day

and

nigh

t fo

r di

ffic

ult

inst

rum

enta

lde

liver

ies,

EC

V, v

agin

albr

eech

es e

tc.

All

staf

f fe

el e

nabl

ed t

odi

scus

s an

d de

bate

car

e w

ithth

e co

-ord

inat

ing

mid

wife

and

the

cons

ulta

ntob

stet

ricia

n.

Ther

e is

a m

ultid

isci

plin

ary

revi

ew o

f ca

re d

aily,

all

emer

genc

y C

S as

wel

l as

birt

hs w

ith a

pos

itive

outc

ome

are

disc

usse

d.

Ther

e is

an

open

and

ho

nest

‘no

blam

e’ c

ultu

re.

All

staf

f ar

e in

volv

ed in

freq

uent

impr

ompt

u sk

ill d

rills

follo

wed

by

a de

brie

f. T

hese

are

view

ed p

ositi

vely

by

staf

f.

Evid

ence

-bas

ed g

uide

lines

ar

e us

ed b

y al

l sta

ff.

Varia

tions

in p

ract

ice

are

reco

rded

and

exp

lain

ed.

The

maj

ority

of

staf

f ar

eha

ppy

with

per

form

ing

inte

rmitt

ent

ausc

ulta

tion.

Con

sulta

nt o

bste

tric

ians

are

pres

ent

on t

he la

bour

war

ddu

ring

the

day.

The

y at

tend

at n

ight

for

em

erge

ncie

s on

ly. T

he c

onsu

ltant

obst

etric

ian

and

co-o

rdin

atin

gm

idw

ife a

re in

volv

ed in

the

deci

sion

mak

ing

proc

ess

of a

ll po

tent

ial c

aesa

rean

sect

ions

. The

re a

re o

pen

com

mun

icat

ion

chan

nels

.

Ther

e is

a m

onth

ly r

evie

w

of in

tere

stin

g ca

ses.

Sta

ffm

embe

rs a

re e

ncou

rage

d to

atte

nd w

hene

ver

poss

ible

.W

e pr

ovid

e pr

otec

ted

time

for

staf

f to

att

end

at le

ast

one

revi

ew a

yea

r.

All

staf

f at

tend

a y

early

upda

te in

ski

lls d

rills

. Th

is is

mul

tidis

cipl

inar

y.

Staf

f us

e a

com

bina

tion

ofev

iden

ce-b

ased

gui

delin

esan

d pr

actit

ione

r pr

efer

ence

.

The

maj

ority

of

staf

f pr

efer

to

do

an a

dmis

sion

CTG

-

just

in c

ase.

The

cons

ulta

nt o

bste

tric

ian

and

co-o

rdin

atin

g m

idw

ifear

e in

volv

ed in

the

dec

isio

nm

akin

g pr

oces

s of

all

pote

ntia

l cae

sare

an s

ectio

ns.

Ther

e ar

e lim

ited

chan

nels

of

com

mun

icat

ion.

We

have

sch

edul

ed r

egul

ardi

scus

sion

for

ums

to e

nabl

ere

flect

ive

prac

tice.

It is

diff

icul

t fo

r st

aff

to f

ind

time

to a

tten

d.

Ther

e ar

e re

gula

r sk

ills

drill

sse

ssio

ns b

ut t

hey

are

not

mul

tidis

cipl

inar

y.

Ther

e ar

e ev

iden

ce-b

ased

guid

elin

es b

ut m

ost

staf

f te

nd t

o re

ly o

n th

eir

expe

rienc

e / p

refe

renc

es.

Our

gui

delin

es s

ay w

e do

an

adm

issi

on C

TG.

Con

sulta

nt o

bste

tric

ians

ar

e pr

esen

t on

labo

ur w

ard

for

less

tha

n 40

hou

rs p

erw

eek.

The

y ar

e al

way

s m

ade

awar

e of

any

em

erge

ncy

CS

occu

rrin

g.

We

have

ad

hoc

disc

ussi

ons

whe

n th

ere

is t

ime.

We

have

ad

hoc

skill

s dr

ills

whe

n th

ere

is t

ime.

Sta

ff

find

them

thr

eate

ning

.

Staf

f te

nd t

o re

ly o

n th

eir

expe

rienc

e al

one.

We

use

cont

inuo

usm

onito

ring

as a

rou

tine.

Con

sulta

nt o

bste

tric

ians

are

only

pre

sent

in a

n em

erge

ncy

and

are

rare

ly in

volv

ed in

the

deci

sion

mak

ing

proc

ess

for

emer

genc

y ca

esar

ean

sect

ions

.

Dec

isio

ns a

re o

ften

crit

icis

edbe

hind

peo

ples

bac

ks. T

here

is n

o fo

rum

for

ope

ndi

scus

sion

and

deb

ate.

Ther

e is

no

mul

tidis

cipl

inar

yle

arni

ng.

Lab

ou

r is

man

aged

u

sin

g e

vid

ence

-bas

edg

uid

elin

es

The

con

sult

ant

ob

stet

rici

anan

d c

o-o

rdin

atin

g m

idw

ife

pro

vid

e st

ron

g v

isib

lele

ader

ship

Ther

e is

an

op

en c

ult

ure

inw

hic

h s

taff

are

su

pp

ort

edan

d c

hal

len

ged

in t

hei

rd

ecis

ion

mak

ing

Ou

r sk

ills

dri

lls a

reg

enu

inel

y m

ult

idis

cip

linar

yA B

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Page 83: Pathways to success focus on normal birth

Doc

tors

are

not

info

rmed

of

deta

ils o

f lo

w r

isk

wom

en.

Doc

tors

onl

y en

ter

a ro

omw

hen

aske

d to

rev

iew

by

am

idw

ife.

Ther

e is

a c

lear

ly d

efin

edin

trap

artu

m p

lan

of c

are

for

all h

igh

risk

wom

en. T

his

iste

am b

ased

invo

lvin

g th

em

idw

ife, o

bste

tric

ian,

paed

iatr

icia

n an

d th

ew

oman

. All

staf

f re

spec

t th

eim

port

ance

of

atta

inin

g a

norm

al o

utco

me

for

thes

ew

omen

whe

re e

ver

poss

ible

.Fo

r ex

ampl

e, m

obili

ty a

ndup

right

pos

ition

s.

Doc

tors

and

mid

wiv

es s

hare

info

rmat

ion

at t

heir

form

alha

ndov

ers

ther

e is

a b

oard

roun

d no

t a

war

d ro

und.

Info

rmat

ion

is u

pdat

ed o

n a

boar

d in

rea

l tim

e fo

r al

lcl

inic

ians

to

see.

Ther

e is

a c

lear

ly d

efin

edin

trap

artu

m p

lan

care

for

all

high

ris

k w

omen

. Thi

s is

tea

mba

sed

invo

lvin

g th

e m

idw

ife,

obst

etric

ian,

pae

diat

ricia

n an

d th

e w

oman

.

Doc

tors

are

info

rmed

of

the

prog

ress

of

all w

omen

but

only

rev

iew

wom

en w

hen

requ

este

d by

a m

idw

ife.

A w

ritte

n in

trap

artu

m p

lan

of c

are

incl

udin

g th

e ro

le

of t

he m

idw

ife is

cle

arly

docu

men

ted

by t

heco

nsul

tant

obs

tetr

icia

n.

This

is a

dher

ed t

o by

al

l sta

ff.

Ther

e is

a w

ard

roun

d of

al

l wom

en. D

octo

rs d

o no

t m

eet

low

ris

k w

omen

.

Obs

tetr

icia

ns d

ecid

e th

e pl

an o

f ca

re f

or h

igh-

risk

wom

en. T

here

is o

ften

a

lack

of

clea

r w

ritte

n gu

idan

ceas

to

how

the

mid

wife

sh

ould

be

invo

lved

.

Ther

e is

a f

orm

al w

ard

roun

d of

all

wom

en o

n th

ela

bour

war

d. D

octo

rs m

eet

all w

omen

.

Ther

e is

no

team

wor

king

an

d a

lack

of

guid

ance

for

high

ris

k w

omen

.

They

may

not

get

to

see

thei

r co

mm

unity

mid

wife

.

Do

cto

rs e

nte

r th

e ro

om

s o

f la

bo

uri

ng

w

om

en b

y in

vita

tio

n

on

ly

Hig

h r

isk

wo

men

rec

eive

team

-bas

ed c

are

too

pti

mis

e th

e p

ote

nti

al

for

no

rmal

ou

tco

mes

.

Focus on normal birth and reducing Caesarean section rates 81

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Page 84: Pathways to success focus on normal birth

82 Focus on normal birth and reducing Caesarean section rates

Pre-

pre

gn

ancy

Bo

oki

ng

The

hea

lth

an

d s

oci

al c

are

com

mu

nit

ies

wo

rk in

par

tner

ship

to

pro

mo

teth

e co

nce

pt

of

no

rmal

pre

gn

ancy

an

d c

hild

bir

th

All

wo

men

are

ab

le t

oac

cess

a m

idw

ife

dir

ectl

y

Mid

wiv

es d

eter

min

e th

e ap

pro

pri

ate

pat

hw

ayat

bo

oki

ng

First pregnancy and labour – Individual Record Sheet

An

ten

atal

An

ten

atal

car

e is

off

ered

in

con

ven

ien

t an

dap

pro

pri

ate

sett

ing

s

Wo

men

are

info

rmed

abo

ut

the

op

tio

ns

for

pla

ce o

f b

irth

We

wo

rk w

ith

wo

men

to

ensu

re t

hey

hav

e a

real

isti

cex

pec

tati

on

of

lab

ou

r,b

irth

an

d p

aren

tho

od

We

focu

s o

n k

eep

ing

pre

gn

ancy

an

d b

irth

no

rmal

Ther

e ar

e n

o s

oci

alin

du

ctio

ns

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Page 85: Pathways to success focus on normal birth

Focus on normal birth and reducing Caesarean section rates 83

An

ten

atal

co

nti

nu

ed

Wo

men

wit

h a

bre

ech

pre

sen

tati

on

are

off

ered

exte

rnal

cep

hal

ic v

ersi

on

(EC

V)

by

a sk

illed

pro

fess

ion

al

We

man

age

wo

men

’sex

pec

tati

on

s, w

e p

rep

are

them

fo

r th

e re

alit

y o

f la

bo

ur

Lab

ou

r an

d B

irth

The

dec

ora

tio

n o

f th

e b

irth

ro

om

s is

ho

mel

y w

ith

clin

ical

eq

uip

men

to

ut

of

sig

ht

Bir

th r

oo

ms

are

equ

ipp

edw

ith

aid

s to

fac

ilita

teac

tive

bir

th

Wo

men

are

dis

cou

rag

edfr

om

lyin

g o

n t

he

bed

1:1

sup

po

rt is

pro

vid

edd

uri

ng

lab

ou

r b

y a

trai

ned

care

r

The

lab

ou

r w

ard

isre

serv

ed f

or

lab

ou

rin

gw

om

en

Lab

ou

r is

man

aged

u

sin

g e

vid

ence

-bas

edg

uid

elin

es

A B

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Page 86: Pathways to success focus on normal birth

Lab

ou

r an

d B

irth

co

nti

nu

ed

The

con

sult

ant

ob

stet

rici

anan

d c

o-o

rdin

atin

g m

idw

ife

pro

vid

e st

ron

g v

isib

lele

ader

ship

Ther

e is

an

op

en c

ult

ure

inw

hic

h s

taff

are

su

pp

ort

edan

d c

hal

len

ged

in t

hei

rd

ecis

ion

mak

ing

Ou

r sk

ills

dri

lls a

reg

enu

inel

y m

ult

idis

cip

linar

y

Do

cto

rs e

nte

r th

e ro

om

s o

f la

bo

uri

ng

wo

men

by

invi

tati

on

on

ly

Hig

h r

isk

wo

men

rec

eive

team

bas

ed c

are

too

pti

mis

e th

e p

ote

nti

al

for

no

rmal

ou

tco

mes

.

84 Focus on normal birth and reducing Caesarean section rates

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First pregnancy and labour - Self-improvement Action Plan

The decoration of the labour rooms is homely with clinical equipment out of sight

Where are we now?• Unnecessary equipment cluttering up rooms, rooms tend to look high tech e.g. nowhere else

to store CTG machines, IVAC’s etc• Walls are bare - no ‘cute’ pictures on the walls. Some rooms have breastfeeding posters• There are no dimmer switches in rooms• Bed is in the middle of the room made up ready for an admission - suggesting to women

they must get on it

Where do we want to get to?• A more homely environment focused around needs of women - not around the needs of the unit• Equipment out of sight in at least 75% of rooms if not all• Subdued lighting for all rooms• Reposition the bed and have one room with no bed• Staff who are confident in supporting women in upright positions

What do we need to change?• Space to store equipment - could reorganise current store cupboards i.e. empty our paper

cupboard and place in one of receptionist’s cupboards, empty paper store to store IVAC’s • Obtain pictures for the walls, and some posters on positions in labour rooms - (NCT posters are good)• Explore with estates department regarding possibility and cost of painting rooms, also dimmer

switches for all rooms (may need to ask the League of Friends for funds)• Explore ways of moving the bed from the centre of the room - fold down or to the side of the room• Will need to address training with staff regarding upright births - to be incorporated into mandatory

study day plus Jill Thomas to do ad hoc training on labour ward regarding upright birth postures• Review birthing aids available e.g. Balls, bean bags - do we have enough? • Discuss with school of midwifery regarding teaching for students

Who will do (and lead) the work?• Labour ward lead• Midwife (experience of working in birth centre) (lead)• Practice Development Midwife• Estates dept

When will we complete this?• July 2007

What tools will we use?• NCT birth environment toolkit• Good practice examples from hospitals

How will we measure success?• Audit of birth positions, including maternal satisfaction• Birth outcomes related to birth posture

What will be the impact? (quality and value, reduction in CS rate)• Women will be more relaxed and feel enabled to be mobile during labour and

birth - increasing maternal satisfaction and leading to more normal outcomes• Midwives will feel more confident in promoting the benefits of mobility / upright positions• Upright birth postures associated with reduction in operative delivery

Worked example

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Principle Measures

Antenatal care is offered in convenient andappropriate settings

• Audit of antenatal visits

Women are informed about the options for place of birth

• Audit of home birth rates

We focus on keeping pregnancy and birth normal

• Percentage of spontaneous vaginal deliveries (target >70%)

• Percentage of vaginal deliveries (target >80%)

• Percentage of normal labour and normaldeliveries (target >50%)

Women with breech presentation areoffered an external cephalic version (ECV) by a skilled professional

• Audit of uptake and outcomes of ECV

We manage women’s expectations, we prepare them for the reality of labour

• Audit of provision of and attendance atantenatal education classes

The decoration of the birth rooms is homelywith clinical equipment out of sight

• Audit of patient experience of the labourward environment

1:1 support is provided during labour by a trained carer

• Percentage of women receiving one-to-one care from a midwife (target:100%)

• Percentage of one-to-one professionalsupport provided in labour (target:100%)

• Percentage reduction in midwife timespent on non-midwifery tasks (target>50%)

Labour is managed using evidence-based guidelines

• Audit of compliance with clinical guidelines

• Audit of appropriate transfers from theplanned place of birth to hospital

The consultant obstetrician and co-ordinating midwife provide strong visible leadership

• Hours of consultant presence on labour ward (against the RCOG recommendations). Audit of co-ordinatorpresence on labour ward (target:100%)

First pregnancy and labour - Measures for Improvement

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Case Study: Midwife-led ECV ClinicAt Nottingham City Hospital, the consultant midwife had set up a midwife led ECV clinic. This involved setting up a training package, leading to a competency based assessment. Outcomes from the midwife-led EVC clinic have been audited and demonstrated an improvedsuccess rate associated with this procedure.

Things to consider in setting up a midwife-led EVC clinic:

• Multidisciplinary support

• Involvement of risk management team /midwife

• Information for women

• PGD for tocolytics

• Skills in ultra-sonography.

For details of how to train for ECV including a shortened USS course and how to set up amidwife led ECV service contact Carol McCormack, Midwife, Nottingham City Hospital

Case Study: Alternative labour pain strategiesOxford Radcliffe Hospital NHS Trust

Following a feasibility study involving 35 couples using a massage programme to help copewith pain during labour, a RCT was completed covering 90 participants. Couples were taughtthe massage programme during the last month of pregnancy. The result has been a steadyincrease in the normal birth rate and the use of baby/mother skin contact immediately after birth. Anne Haines (Associate Midwifery Manager) and Linda Kimber (Research Midwife), Oxford Radcliffe Hospital NHS Trust & RCM award winner 2006

Case Study: Setting up antenatal clinics in Sainsbury’sEast Kent Hospital NHS Trust

As a result of a nine month project, antenatal clinics have been provided in a Sainsburys supermarket. The scheme has been recognised nationally as the first of its kind and receivedextensive publicity. The clinic is run by community midwives once a week in the health room at the supermarket from 8am to 10pm with each appointment lasting 20 minutes. Women attending the clinic can make use of a free bus service and appreciate the easy access,comfortable environment and work-friendly hours.Susan Eve (Community Midwife Manager) and Carol Kenning (Community Midwife), East Kent Hospitals NHS Trust & RCM award winner 2006

Focus on normal birth and reducing Caesarean section rates 87

First pregnancy and labourExample Tools

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Case Study: Stand and deliver - promoting upright postures in birthNHS Lanarkshire

Midwives at Lanarkshire produced posters and leaflets using Davina McCall’s photograph with theslogan ‘Stand and deliver’ to help promote mobility during labour. These were distributed inhealthcare and leisure facilities and also in supermarkets; local and national press and radio have alsotaken up the campaign. They ran a second stage study day for over 200 doctors, midwives, healtheducationalists and physiotherapist which facilitated multi-disciplinary discussion about achievingnormality.Maureen McSherry & Elizabeth Walsh, Midwives, NHS Lanarkshire & RCM award winners 2006

Case Study: Removing the bed as the main focus of the labour room (creating the right environment for birth) One of the biggest problems with our labour rooms is that they are designed to have the bedpositioned in the middle of the room. We felt strongly that women needed to be ‘allowed’ to movefreely in labour because as Gould (2000) states, movement is a core attribute of physiological labour.The advantages of this in terms of increasing pelvic diameters, shorter second stage and reduction in operative delivery are well documented (Michel et al 2002; Gardosi et al 1989; Gupta & Hofmeyr2005). There is also the need for women to feel in control, confident to behave and move accordingto their body’s need, rather than be passive recipients of care restricted to the bed. Midwives willargue that the woman chooses the bed and in many instances this may be true however studies have shown that it is the midwife who is the principle determiner of posture in labour (De Jonge et al 2004).

Attempts to move the bed to the side of the rooms resulted in health and safety issues being raisedand considerable resistance from staff. Eventually it was agreed that the beds stay in the middle ofthe room but they are pumped up high and left in the ‘closed down’ position (the portion of bedwhich folds away for lithotomy procedures is left under the bed). This gives women much more room to mobilise and ensures women are encouraged to adopt upright positions for birth. Jane Kania, Supervisor of midwives, Lincoln County Hospital

Case Study: Setting up a triage service The successful implementation of a maternity triage at West Middlesex University Hospital

The Problem

We had a projected 1500 increase in our annual births with no extra delivery rooms or antenatalbeds. Women were attending labour ward very early in labour or with a variety of non-labourcomplaints. This led to inappropriate antenatal admissions or blocked labour ward rooms. Staff were diverted from care of labouring women and occasionally had to close the unit. We already had a Day Assessment Unit for monitoring high risk pregnancies from 9 to 5, Monday to Friday.

The Solution

Conversion of a four bed room situated between Labour ward and the antenatal ward to a midwife-run triage area. This was staffed and equipped from existing resources. It opened in January 2006 and for a three week pilot was run 9 to 5 Monday to Friday by the TriageCoordinator in order to establish access criteria and to overcome initial staff reluctance.

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Focus on normal birth and reducing Caesarean section rates 89

After the pilot, triage was opened for 24 hours seven days per week. The service is staffed bythe coordinator or an experienced labour ward midwife on every shift. All new staff, junior orstudent midwives and medical students have the opportunity to work in triage alongside asenior colleague. If obstetric involvement is required, the duty SHO or SpR is available close by.

Who uses the service?

Women self-refer, usually by walking in. Referrals also come through GPs, communitymidwives and labour ward staff following telephone calls. Ambulance admissions and womenwith serious problems, e.g. heavy bleeding, go straight to Labour ward.

Outcomes

• Activity, casemix and outcome were audited at six and twelve months.

• Daily attendance is between 20 and 30 women

• 60% - 75% attendees returned home.

• Many antenatal admissions were safely avoided

• Marked reduction in numbers of non-labouring women on labour ward.

• No unit closures through inappropriate bed occupancy

• Triage sometimes too busy for a single midwife

• Perceived good service causing inappropriate referrals from GPs or women inappropriately bypassing GPs.

Secrets of Success

• Location adjacent to but separate from Labour Ward

• Separate from but working closely with Day Assessment Unit

• Staffing by experienced labour ward midwives

• Labour ward coordinators closely involved

• Management team that is supportive

• Receptionists are part of the team

• Obstetric team appreciate the well-equipped single location with experienced midwife presence.

Carrie Whitehurst, Triage Co-ordinator, West Middlesex University Hospital

User information • The Royal College of Midwives, Campaign for Normal Birth,(http://www.rcmnormalbirth.org.uk/)

• NCT Birth Position Posters (www.nct.org.uk)

• NCT Info centre (http://www.nct.org.uk/info/)

• MIDIRS Informed Choice, (www.infochoice.org/). Contains useful leaflets on:

• Positions in labour and delivery

• Breech presentation - options for care

• Place of birth

• The use of water during childbirth

• Prolonged pregnancy

• Non-epidural strategies for pain relief during labour

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Vaginal Birth after Caesarean

7

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 91

Page 94: Pathways to success focus on normal birth

Vaginal Birth after Caesarean (VBAC)

‘If a woman has a traumatic birth, it doesn't automaticallymean she wants a Caesarean next time. With the correctmodels of care in place, a woman should be able to make an informed choice, supported by her healthcareprofessionals. For some women, this choice could form a major part of the healing process.’Julie Orford,Chair of the Birth Trauma Association

This pathway begins as soon as a woman has had her Caesarean section. The planning for the next pregnancy begins in the postnatal period.

These pathways reflect the practices and behaviours we have seen and heard. Moving fromleft to right, the process supports lower Caesarean section rates.

You may not agree with all these statements - you will need to decide what changes are right for your organisation.

Postnatal care

Inter-pregnancy

Antenatal care

Labour and birth

92 Focus on normal birth and reducing Caesarean section rates

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Page 95: Pathways to success focus on normal birth

Vaginal Birth after Caesarean (VBAC)

Post

nat

al P

erio

d F

ollo

win

g t

he

Cae

sare

an B

irth

Doc

tors

and

mid

wiv

esdi

scus

s th

e bi

rth

even

tsw

ith e

ach

wom

an a

nddo

cum

ent

the

disc

ussi

onan

d ou

tcom

es in

the

reco

rd.

Wom

en r

ecei

ve w

ritte

nin

form

atio

n ab

out

the

reas

ons

for

thei

r C

S.Th

is is

cop

ied

to t

he G

Pan

d co

mm

unity

mid

wife

.

Leng

th o

f st

ay is

con

firm

edor

adj

uste

d in

the

ligh

t of

birt

h ev

ents

. Wom

en a

ndfa

mili

es a

re in

volv

ed in

leng

th o

f st

ay d

iscu

ssio

n.N

ear

patie

nt d

ispe

nsin

g of

disc

harg

e m

edic

atio

n.

Inte

r-p

reg

nan

cy

Ther

e is

a c

lear

ly d

efin

edpr

oces

s fo

r pr

ovid

ing

supp

ort

and

info

rmat

ion.

All

wom

en a

re g

iven

cont

act

info

rmat

ion

for

a ra

nge

of a

genc

ies.

Ther

e ar

e fo

rmal

and

info

rmal

rou

tes

for

user

invo

lvem

ent

thro

ugho

utth

e se

rvic

e.

Doc

tors

and

mid

wiv

es d

iscu

ssth

e bi

rth

even

ts w

ith e

ach

wom

an a

nd d

ocum

ent

the

disc

ussi

on a

nd o

utco

mes

inth

e re

cord

. The

info

rmat

ion

isno

t in

clud

ed in

the

dis

char

gesu

mm

ary.

Ther

e is

a g

ood

disc

harg

epr

oces

s w

ithin

the

uni

t bu

tde

lays

occ

ur w

ith p

harm

acy,

port

erin

g et

c.

Leaf

lets

pro

vidi

ng in

form

atio

nab

out

VBA

C a

nd o

btai

ning

supp

ort

are

wid

ely

avai

labl

efr

om C

hild

ren’

s C

entr

es e

tc.

Use

r re

pres

enta

tion

refle

cts

the

loca

l com

mun

ity.

An

info

rmal

dis

cuss

ion

take

spl

ace

with

eac

h w

oman

but

isno

t do

cum

ente

d an

d no

pla

nfo

r th

e fu

ture

is m

ade.

Mid

wiv

es a

re n

ot a

llow

ed t

odi

scha

rge

wom

en p

ost

CS.

Com

mun

ity m

idw

ives

are

relu

ctan

t to

tak

e ov

er c

are.

Ther

e is

no

dedi

cate

d fo

llow

-up

serv

ice

that

can

be

acc

esse

d by

all

wom

enw

ith c

once

rns

abou

t bi

rth.

Ther

e is

som

e us

erre

pres

enta

tion

in t

he

serv

ice

(e.g

. MSL

C).

The

duty

doc

tor

sees

the

wom

an f

or a

pos

tnat

alm

edic

al r

evie

w a

nd a

nsw

ers

any

ques

tions

she

may

rai

se.

Wom

en a

re t

old

on t

he d

ayth

at t

hey

will

be

disc

harg

edbu

t pl

ans

may

be

disr

upte

d by

othe

r in

fluen

ces

e.g.

bed

shor

tage

s.

If w

e th

ink

wom

en w

ill n

eed

follo

w-u

p or

sup

port

we

give

them

a m

ater

nity

con

tact

num

ber

but

ther

e is

no

orga

nise

d pr

oces

s if

they

do

rin

g.

We

reac

t to

com

plai

nts

and

patie

nt s

atis

fact

ion

surv

eys.

Wom

en a

re g

iven

info

rmat

ion

only

if t

hey

ask.

Usu

ally,

it is

the

post

nata

l mid

wife

who

isle

ft t

o an

swer

any

que

stio

ns.

Ther

e is

no

form

al r

ecor

d of

plan

s fo

r ne

xt p

regn

ancy

.

Wom

en d

o no

t kn

ow w

hen

they

are

exp

ecte

d to

go

hom

e.D

elay

s in

dis

char

ge p

roce

ss a

reca

used

by

lack

of

plan

ning

(e.g

. dru

g de

lays

).

Onc

e w

e di

scha

rge

wom

enpo

stna

tally

we

are

not

resp

onsi

ble

for

them

any

mor

e. If

the

y w

ant

advi

ce o

rhe

lp t

hey

shou

ld g

o to

the

irow

n G

P.

Use

r re

pres

enta

tion

is a

nuis

ance

- w

e do

it t

o tic

k th

e bo

x.

Wo

men

wh

o h

ave

had

a

CS

or

a tr

aum

atic

b

irth

exp

erie

nce

rec

eive

info

rmat

ion

ab

ou

tm

ater

nit

y ev

ents

to

allo

wth

em t

o m

ake

info

rmed

cho

ices

ab

ou

t ca

re in

afu

ture

pre

gn

ancy

Ther

e is

a c

lear

ly d

efin

edd

isch

arg

e p

roce

ss

Wo

men

hav

e ac

cess

to

su

pp

ort

, ad

vice

an

din

form

atio

n a

bo

ut

pas

tan

d f

utu

re p

reg

nan

cies

Use

rs’ e

xper

ien

ces

and

feed

bac

k in

form

ser

vice

dev

elo

pm

ent

Thes

e p

ath

way

s re

flec

t th

e p

ract

ices

an

d b

ehav

iou

rs w

e h

ave

seen

an

d h

eard

. Mo

vin

g f

rom

left

to

rig

ht,

th

e p

roce

ss s

up

po

rts

low

er C

aesa

rean

sec

tio

n r

ates

. Yo

u m

ay n

ot

agre

e w

ith

all

thes

e st

atem

ents

– y

ou

will

nee

d t

o d

ecid

e w

hat

ch

ang

es a

re r

igh

t fo

r yo

ur

org

anis

atio

n.

Focus on normal birth and reducing Caesarean section rates 93

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Page 96: Pathways to success focus on normal birth

An

ten

atal

Wom

en a

nd p

rofe

ssio

nals

are

wel

l inf

orm

ed a

bout

VBA

C.

Wom

en a

rriv

e at

the

irbo

okin

g ap

poin

tmen

tco

nfid

ent

abou

t V

BAC

.C

hoic

es a

re c

onfir

med

early

in p

regn

ancy

.

All

mid

wiv

es a

re a

ble

to d

iscu

ss a

nd a

gree

m

ode

of b

irth

and

offe

rm

idw

ifery

-led

care

with

out

med

ical

invo

lvem

ent.

All

staf

f ar

e ab

le t

o di

scus

s th

e be

nefit

s of

VBA

C. T

he p

ossi

bilit

y of

VBA

C is

exp

lore

d w

ith

all w

omen

.

Wom

en w

ho h

ave

had

a pr

evio

us C

S re

ceiv

em

idw

ife-le

d an

tena

tal c

are.

The

refe

rral

crit

eria

are

iden

tical

with

tho

se f

orot

her

preg

nant

wom

en.

Ther

e is

a d

esig

nate

dap

poin

tmen

t in

ear

lypr

egna

ncy

to d

iscu

ss V

BAC

.

Oth

er p

rofe

ssio

nals

res

pect

th

e de

cisi

on m

ade.

All

mid

wiv

es a

re a

ble

todi

scus

s an

d ag

ree

mod

e of

birt

h w

ith w

omen

. Wom

en

are

care

d fo

r by

mid

wiv

es

but

have

a n

amed

con

sulta

nt.

Ded

icat

ed m

ultid

isci

plin

ary

VBA

C c

linic

pro

vide

sin

form

atio

n an

d su

ppor

t to

tho

se u

ndec

ided

abo

utm

ode

of b

irth.

Wom

en r

ecei

ve m

idw

ife-le

dca

re b

ut a

re r

outin

ely

offe

red

an a

ppoi

ntm

ent

with

the

obst

etric

ian

durin

g th

eir

preg

nanc

y.

Clin

icia

n’s

supp

ort

VBA

C in

som

e ca

ses

but

deci

sion

sm

ust

be m

ade

by a

sen

ior

doct

or, w

omen

are

not

see

nun

til 3

6 w

eeks

in c

ase

othe

rpr

oble

ms

occu

r af

fect

ing

deliv

ery

plan

s.

Mid

wiv

es a

re a

ble

to d

iscu

ssm

ode

of b

irth

with

wom

enbu

t th

e de

cisi

on f

or V

BAC

can

only

be

mad

e af

ter

disc

ussi

on w

ith c

onsu

ltant

mid

wife

or

obst

etric

ian.

If w

omen

ask

for

CS

with

no

cle

ar in

dica

tion

we

goth

roug

h th

e m

otio

ns o

fas

king

for

a s

econ

d op

inio

nbe

fore

we

say

yes.

All

wom

en w

ith p

revi

ous

CS

mus

t be

see

n at

leas

t on

ce

by t

he o

bste

tric

ian

to c

onfir

mm

ode

of d

eliv

ery.

Ther

e is

diff

eren

ce o

f op

inio

nbe

twee

n cl

inic

ians

. Mid

wiv

esan

d w

omen

are

con

fuse

dab

out

plan

s of

car

e.

Mid

wiv

es f

eel e

mpo

wer

ed t

odi

scus

s m

ode

of d

eliv

ery

but

are

not

allo

wed

to

mak

e th

efin

al d

ecis

ion.

If a

wom

an a

sks

for

CS

we

acce

pt h

er c

hoic

e af

ter

telli

nghe

r ab

out

the

rela

tive

risks

and

bene

fits

of C

S an

d V

BAC

.

Thes

e w

omen

may

be

atgr

eate

r an

tena

tal r

isk

sosh

ould

be

seen

in h

ospi

tal

as w

ell a

s in

the

com

mun

ity.

“Onc

e a

sect

ion

alw

ays

ase

ctio

n –t

he w

oman

exp

ects

an o

pera

tion.

Mid

wiv

es la

ck c

onfid

ence

an

d ex

perie

nce

in V

BAC

.

Mid

wiv

es a

ctiv

ely

avoi

ddi

scus

sing

mod

e of

del

iver

yaf

ter

prev

ious

sec

tion.

Wom

en h

ave

alre

ady

mad

eth

eir

min

ds u

p w

hen

they

book

. If

they

ask

for

CS

we

acce

pt t

heir

choi

ce. S

taff

avo

iddi

scus

sing

mod

e of

del

iver

y in

ear

ly p

regn

ancy

.

Follo

win

g C

S, t

his

isau

tom

atic

ally

a h

igh

risk

preg

nanc

y an

d is

man

aged

by

obs

tetr

icia

ns.

Wo

men

ch

oo

se V

BA

Cw

hen

clin

ical

ly a

pp

rop

riat

e

Mid

wiv

es a

re s

kille

d

in r

isk

asse

ssm

ent

and

con

fid

ent

in a

dvi

sin

gw

om

en a

bo

ut

VB

AC

We

are

com

mit

ted

to

th

e p

hilo

sop

hy

of

faci

litat

ing

a n

orm

al

bir

th w

ith

wo

men

wh

oh

ave

exp

erie

nce

d a

CS

An

ten

atal

car

e is

un

affe

cted

b

y p

revi

ou

s C

S

94 Focus on normal birth and reducing Caesarean section rates

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Page 97: Pathways to success focus on normal birth

Lab

ou

r an

d B

irth

Staf

f re

ceiv

e re

gula

rst

atis

tics

deta

iling

the

C

S ra

te a

nd t

he V

BAC

rate

. Wom

en a

lso

rece

ive

info

rmat

ion.

All

staf

f fo

llow

agr

eed

good

pra

ctic

e gu

idel

ines

.W

omen

rec

eive

writ

ten

info

rmat

ion

abou

t th

egu

idel

ines

for

VBA

C.

Indu

ctio

n is

off

ered

at

42 w

eeks

if c

onse

rvat

ive

man

agem

ent

not

appr

opria

te.

The

guid

elin

es f

or

IOL

are

iden

tical

for

al

l wom

en.

We

appl

y th

e sa

me

rule

s fo

r au

gmen

tatio

nto

all

wom

en in

labo

ur.

Info

rmat

ion

abou

t V

BAC

rat

esis

dis

play

ed o

n no

tice

boar

ds.

We

have

writ

ten

guid

elin

es

but

not

all t

he c

linic

ians

us

e th

em in

pra

ctic

e.

If no

t in

labo

ur b

y 42

wee

ksw

e w

ould

do

a C

S.

ARM

and

syn

toci

non

is u

sed

rega

rdle

ss o

f w

heth

er t

hece

rvix

is f

avou

rabl

e.Pr

osta

glan

dins

are

not

use

d fo

r IO

L.

We

use

the

stan

dard

synt

ocin

on r

egim

en b

ut

allo

w le

ss t

ime

for

it to

w

ork

befo

re d

oing

a C

S.

We

can

get

info

rmat

ion

on V

BAC

rat

es if

we

ask.

Indi

vidu

al c

linic

ians

var

y in

the

ir ap

proa

ch. E

ach

wom

an h

as a

diff

eren

tm

anag

emen

t pl

an.

If no

t in

labo

ur b

y 41

wee

ksw

e w

ould

do

an p

lann

ed C

S.

We

use

ARM

and

syn

toci

non

if th

e ce

rvix

is f

avou

rabl

e.

We

use

synt

ocin

on b

ut m

odify

the

dosa

ge r

egim

en if

the

re is

a sc

ar o

n th

e ut

erus

.

The

maj

ority

of

staf

f do

not

know

wha

t ou

r V

BAC

rat

e is

.

Thes

e w

omen

are

cle

arly

m

ore

at r

isk.

If la

bour

slo

ws

dow

n fo

r an

y re

ason

it is

an

indi

catio

n fo

r C

S.

If la

bour

has

n’t

star

ted

spon

tane

ousl

y by

the

due

dat

ew

e w

ould

do

an p

lann

ed C

S.

We

wou

ld c

onsi

der

ARM

if

cerv

ix f

avou

rabl

e.

We

are

caut

ious

abo

utsy

ntoc

inon

use

– if

labo

ur

is n

ot p

rogr

essi

ng n

orm

ally

it

is a

n in

dica

tion

for

CS.

We

don’

t ro

utin

ely

colle

ct a

nyfig

ures

on

VBA

C r

ates

.

Wom

en a

re t

reat

ed a

s hi

gh r

isk

obst

etric

cas

es –

con

tinuo

usm

onito

ring,

ear

ly e

pidu

ral ‘

just

in c

ase.

The

baby

mus

t be

del

iver

edw

ithin

six

hou

rs.

VBA

C m

ay b

e co

nsid

ered

ifla

bour

beg

ins

befo

re p

lann

edC

S da

te a

t 39

wee

ks.

Wom

en w

ith p

revi

ous

CS

are

neve

r in

duce

d.

We

do n

ot u

se s

ynto

cino

n fo

rau

gmen

tatio

n –

it is

dan

gero

us.

We

take

pri

de

in

ou

r V

BA

C r

ate

Lab

ou

r is

man

aged

to

op

tim

ise

a n

orm

alo

utc

om

e

Inte

rven

tio

ns

are

min

imis

ed t

o o

pti

mis

eV

BA

C o

utc

om

es

Man

agem

ent

of

ind

uct

ion

of

lab

ou

r

Man

agem

ent

of

aug

men

tati

on

of

lab

ou

r

Focus on normal birth and reducing Caesarean section rates 95

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Page 98: Pathways to success focus on normal birth

96 Focus on normal birth and reducing Caesarean section rates

Post

nat

al P

erio

d F

ollo

win

g t

he

Cae

sare

an B

irth

Inte

r-p

reg

nan

cy

Wo

men

wh

o h

ave

had

aC

S o

r a

trau

mat

ic b

irth

exp

erie

nce

rec

eive

info

rmat

ion

ab

ou

tm

ater

nit

y ev

ents

to

allo

wth

em t

o m

ake

info

rmed

cho

ices

ab

ou

t ca

re in

afu

ture

pre

gn

ancy

Ther

e is

a c

lear

ly d

efin

edd

isch

arg

e p

roce

ss

Wo

men

hav

e ac

cess

to

sup

po

rt, a

dvi

ce a

nd

info

rmat

ion

ab

ou

t p

ast

and

fu

ture

pre

gn

anci

es

Use

rs’ e

xper

ien

ces

and

feed

bac

k in

form

ser

vice

dev

elo

pm

ent

An

ten

atal

Wo

men

ch

oo

se V

BA

Cw

hen

clin

ical

ly a

pp

rop

riat

e

Mid

wiv

es a

re s

kille

d in

ris

kas

sess

men

t an

d c

on

fid

ent

in a

dvi

sin

g w

om

en a

bo

ut

VB

AC

We

are

com

mit

ted

to

th

ep

hilo

sop

hy

of

faci

litat

ing

an

orm

al b

irth

wit

h w

om

enw

ho

hav

e ex

per

ien

ced

a C

S

An

ten

atal

car

e is

un

affe

cted

by

pre

vio

us

CS

Vaginal Birth after Caesarean (VBAC) – Individual Record Sheet

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Lab

ou

r an

d B

irth

We

take

pri

de

in o

ur

VB

AC

rat

e

Lab

ou

r is

man

aged

to

op

tim

isea

no

rmal

ou

tco

me

Inte

rven

tio

ns

are

min

imis

edto

op

tim

ise

VB

AC

ou

tco

mes

Man

agem

ent

of

ind

uct

ion

of

lab

ou

r

Man

agem

ent

of

aug

men

tati

on

of

lab

ou

r

Focus on normal birth and reducing Caesarean section rates 97

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Vaginal birth after Caesarean - Self-improvement Action Plan

Women who have had a CS or a traumatic birth experience receive information about maternity events to allow them to make informed

choices about care in a future pregnancy

Where are we now?• The midwife who has been with the woman during her caesarean section usually takes time to do an informal

debrief to check that the woman knows why she has had a CS and that she is OK. This isn’t formallydocumented. The midwife that has gone to theatre with the woman isn’t always the midwife who has done themajority of the labour care. The obstetrician who performed the CS will usually catch up with the woman and/ or her partner and will explain their theatre findings. This discussion isn’t formally documented

• The obstetricians will review all women on the first day post CS and inform them as to why they had the CS.Generic information is given about VBAC and the woman is informed that decisions regarding this can bemade in the next pregnancy

Where do we want to get to?• All doctors and midwives feel they have the skills to discuss birth events• Each woman will have the opportunity to discuss their birth events very soon after their CS and this

discussion will be recorded in the woman’s notes. The implications for the next pregnancy will also be documented and each woman will know if she is likely to have a good chance of VBAC next time

• Each woman will be given a letter which is personal to her and captures this information. A copy will be sent to her community midwife and GP

What do we need to change?• Set up workshop regarding giving information on labour events and identifying women who need

formal debriefing• Develop a guideline for staff to use to give information on labour events • Explore pathway for women who require formal debriefing• Set up question on IT system to collect incidence of these discussions• Design letter for women

Who will do (and lead) the work?• Training and guideline - Practice Development Midwife• Debriefing pathway - Head of Midwifery and Clinical Director (lead)• Letter to women - Labour Ward lead and Labour Ward Forum• IT question - IT Midwife

When will we complete this?• Training - within 6 months• Guideline - within 3 months• Debriefing pathway - within 6 months• Letter to woman - next LWF meeting (1 month)• IT - 1 month

What tools will we use?• Guideline on Clinical debriefing• Case Studies - setting up workshops on Birth Trauma• ‘Why don’t you’ scenario on designing a letter for women

How will we measure success?• Audit from IT system of explanation of birth events• Random sample notes audit of topics of discussion of birth events against guideline• Community Midwives audit of letters received by women (at postnatal check)

What will be the impact? (quality and value, reduction in CS rate)• Women are likely to feel clear about their birth events and confident about what is possible next time

Less feelings of inadequacy through discussion of events• Early discussion of birth events will identify women who may need formal debriefing and may prevent

some women from needing formal debriefing• All staff will be skilled in providing information on birth events and able to identify women who have

experienced a traumatic birth. Specialist services can be targeted

Worked example

98 Focus on normal birth and reducing Caesarean section rates

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Principle Measures

Women who have had a CS or a traumatic birth experience receive information about maternity events to allow them to make informed choices about care in a future pregnancy

• Percentage of women with delivery problems or CS receiving a verbal debriefing (target:100%)

• Percentage of women with delivery problems or CS receiving written information (target:100%)

There is a clearly defined discharge process • Audit of delays against discharge plan

Users’ experiences and feedback inform service development

• Audit of women following first CS - satisfaction, quality of information and intentions for next birth

Women choose VBAC when clinically appropriate

• Percentage of women opting for VBAC (target >80%)

• Audit of reasons for women opting for a CS

Midwives are skilled in risk assessment and confident in advising women about VBAC

We are committed to the philosophy of facilitating a normal birth with women whohave experienced a CS

• Percentage of women receiving VBAC advice before the 16th week of pregnancy(target >75%)

• Percentage of health records of women with a previous CS that are available at the booking appointment (target >100%)

We take pride in our VBAC rate • Percentage of clinical staff aware of unit’s figures and trends in VBAC

Labour is managed to optimise a normal outcome

• Percentage of women choosing VBAC who go on to have a vaginal delivery (target >80%)

• Audit of practice against VBAC guidelines

Vaginal birth after Caesarean - Measures for Improvement

Focus on normal birth and reducing Caesarean section rates 99

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VBAC Example Tools

Why don’t you…Design a letter for women

Talk to women after their CS and design a letter to give to them before they go home.

We asked a focus group of women what information they would like to receive after CS that would prepare them for their next pregnancy and birth.

They said:

‘Being debriefed on the first one’We suggested that they could have letter detailing the reasons for their CS and implications for their next birth.

They said:

‘A copy of the letter should also go to the Community Midwife and GP.’We asked them what they would want to be included in this letter.

They said:

‘What went wrong / why it happened like it did? ‘What are the chances of it happening again?’What can I do to try to avoid it? ‘Need to address that women feel it was their fault’’Most women don’t know that they can request to see their notes’‘It would be good for women to know that they can come back at any time to access information’With thanks to the Women’s Focus Group, East Sussex Hospitals NHS Trust

Scenario: Nicola - planning pregnancy careNicola had her first baby three years ago. The pregnancy went well. After an unsuccessful attempt at ECV she had a Caesarean section at 39 weeks for a persistent breech presentation.The operation was straightforward and she recovered well. Overall, once she had accepted the advice that CS was safer for her baby she found her experience a positive one.

She is now booking in her second pregnancy. She wants to discuss her antenatal care and birth.

You are the first point of contact for Nicola. What will you discuss with her and how will you plan her care?

Is this what happens in your maternity service?

What might be different? And why?

If Nicola opts for VBAC, what are her chances of success in your service?

In high-performing units?

What would we need to change here to achieve a ‘best practice’ VBAC rate?

100 Focus on normal birth and reducing Caesarean section rates

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Focus on normal birth and reducing Caesarean section rates 101

Template: Post CS Audit tool

Telephone Questionnaire: Post-natal satisfaction survey following emergency caesarean section andviews on mode of future birth

Name

Hospital number

Date of delivery

Date of interview

Reason for emergency CS

Breech Failure to progress

Distressed baby Failed instrumental delivery

Unknown

Other: (specify)

Satisfaction with birth experience

Below expectations Met expectations

Above expectations Satisfaction with service provided

Below expectations Met expectations

Above expectations

Have you had a previous vaginal delivery? Yes / No

Were you told clearly why a CS was recommended? Yes / No

Do you agree with the following statements:

• During my labour I felt cared for by the staff Yes / No

• During my labour my personal wishes were listened to Yes / No

• I got clear information on the health of my baby and myself Yes / No

• I am happy with my experience of labour Yes / No

• I got the pain relief I wanted in labour Yes / No

• Doctors explained why I needed CS Yes / No

• Midwives explained why I needed CS Yes / No

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What aspects did you not like about your birth?

• Loss of control over what was happening Yes / No

• Unable to achieve birth plan Yes / No

• Having an operation Yes / No

• Poor communication with staff Yes / No

• Separation from your baby Yes / No

When would you like to discuss your next birth?

• Before leaving hospital? Yes / No

• Six weeks after the CS? Yes / No

• Six months after CS? Yes / No

• At your booking in your next pregnancy? Yes / No

• At 36 weeks in your next pregnancy Yes / No

• Other: please specify

In your next pregnancy would you like…..

An elective Caesarean

A vaginal birth

Don’t know

What would help you decide on your type of birth?

Appointment with an obstetrician

Leaflets

Antenatal counseling

What factor would be most likely to make you consider VBAC?

• Good antenatal preparation

• Chance to experience a vaginal birth

• Opportunity to choose type of birth

• Good pain control in labour

• Fewer maternal complications

102 Focus on normal birth and reducing Caesarean section rates

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Focus on normal birth and reducing Caesarean section rates 103

What factor would be most likely to make you consider CS?

• Worry about risks (scar rupture)

• Need for continuous monitoring in labour

• Concerns about pain in labour

• Might go through labour and still need a CS

• CS would give certainty about the birth

• Fewer complications for the baby

About the risks of VBAC, do you know that…

Scar rupture in spontaneous labour happens to fewer than 1:200 women Yes / No

Scar rupture with Prostaglandin induction happens to about 1:45 women Yes / No

About 20% women who plan VBAC will actually have a CS Yes / No

Is there anything else you would like to tell us about your experience or your thoughts for the future?

Catherine Mammen, Michelle Wu, West Middlesex University Hospital NHS Trust

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104 Focus on normal birth and reducing Caesarean section rates

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Planned CaesareanSection

8

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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Planned Caesarean section

‘Reducing length of stay after CS is not really about making women go home when they don’t want to, it’s about making sure the system works properly so they get home when they do want to. We often hidebehind issues of patient choice instead of confronting our own inefficiencies.’Janet Baldwin,Clinical Lead, Caesarean Section team

This pathway is for women who are going to have a planned Caesarean section. It looks atstreamlining the process rather than reducing the number of Caesarean sections performed.

These pathways reflect the practices and behaviours we have seen and heard. Moving fromleft to right, the process supports lower Caesarean section rates.

You may not agree with all these statements - you will need to decide what changes are rightfor your organisation.

Antenatal care

Birth

Postnatal care

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An

ten

atal

All

wom

en h

avin

g an

plan

ned

CS

are

seen

by

a m

idw

ife t

wo

or t

hree

days

bef

ore

surg

ery.

The

mid

wife

doe

s th

ew

hole

pre

-ass

essm

ent

acco

rdin

g to

agr

eed

guid

elin

es a

nd c

alls

the

anae

sthe

tists

or

surg

eon

only

if a

pro

blem

isid

entif

ied.

The

cons

ent

path

way

is

initi

ated

in t

hean

tena

tal c

linic

and

th

e de

cisi

on is

con

firm

edby

the

sur

geon

on

day

of o

pera

tion.

In o

ther

wis

eun

com

plic

ated

preg

nanc

ies

all w

omen

are

give

n a

date

for

CS

for

whe

n th

ey a

re 3

9w

eeks

pre

gnan

t.

All

wom

en h

ave

a pr

e-as

sess

men

t vi

sit.

Pre-

oper

ativ

e as

sess

men

t is

pro

vide

d by

am

ultid

isci

plin

ary

team

in

the

Day

Ass

essm

ent

Uni

t.

Wom

en r

ecei

ve f

ull w

ritte

n an

d ve

rbal

info

rmat

ion

on

risks

and

ben

efits

ant

enat

ally.

The

cons

ent

proc

ess

is n

otfo

rmal

ly in

itiat

ed p

rior

toad

mis

sion

.

Mos

t w

omen

are

boo

ked

for

oper

atio

n at

39

wee

ks b

utth

ere

is v

aria

tion

betw

een

obst

etric

ians

.

The

maj

ority

of

wom

en h

ave

a pr

eope

rativ

e as

sess

men

t.

Pre-

oper

ativ

e as

sess

men

t is

doc

tor-

led.

Dis

cuss

ion

of r

isks

and

bene

fits

take

s pl

ace

ante

nata

lly b

ut is

not

docu

men

ted

form

ally.

In o

ther

wis

e un

com

plic

ated

preg

nanc

ies

wom

en a

re g

iven

a da

te f

or C

S fr

om 3

8 w

eeks

.

Hig

h ris

k w

omen

hav

e a

pre-

asse

ssm

ent

visi

t.

This

is d

octo

r-le

d an

d ca

rrie

dou

t in

the

ant

enat

al c

linic

.

Risk

s an

d be

nefit

s ar

eex

plai

ned

whe

n co

nsen

t is

obta

ined

by

an a

ppro

pria

tely

expe

rienc

ed h

ealth

car

epr

ofes

sion

al o

n da

y of

oper

atio

n.

Wom

en r

ecei

ve n

o w

ritte

nin

form

atio

n an

tena

tally

.

Wom

en a

re n

ot a

sses

sed

prio

r to

adm

issi

on.

Wom

en a

re a

sked

for

con

sent

on d

ay o

f op

erat

ion

by a

juni

ordo

ctor

with

min

imal

dis

cuss

ion

of r

isks

and

ben

efits

.

Wom

en r

ecei

ve n

o w

ritte

nin

form

atio

n an

tena

tally

.

In o

ther

wis

e un

com

plic

ated

preg

nanc

ies

wom

en a

re g

iven

a da

te f

or C

S fr

om 3

7 w

eeks

onw

ards

.

Fully

info

rmed

wo

men

ar

e ac

tive

par

tner

s in

th

e d

ecis

ion

to

hav

e C

S

Info

rmat

ion

lead

ing

to

co

nse

nt

is a

n

on

go

ing

pro

cess

The

pla

nn

ed c

aesa

rean

is

bo

oke

d f

or

a g

esta

tio

nth

at m

inim

ises

ris

ks f

or

mo

ther

an

d b

aby

Planned Caesarean SectionTh

ese

pat

hw

ays

refl

ect

the

pra

ctic

es a

nd

beh

avio

urs

we

hav

e se

en a

nd

hea

rd. M

ovi

ng

fro

m le

ft t

o r

igh

t, t

he

pro

cess

su

pp

ort

s lo

wer

Cae

sare

an s

ecti

on

rat

es.

You

may

no

t ag

ree

wit

h a

ll th

ese

stat

emen

ts –

yo

u w

ill n

eed

to

dec

ide

wh

at c

han

ges

are

rig

ht

for

you

r o

rgan

isat

ion

.

A B

Focus on normal birth and reducing Caesarean section rates 107

Pre-

asse

ssm

ent

take

sp

lace

fo

r al

l wo

men

.Th

is is

mid

wif

e-le

dac

cord

ing

to

an

ag

reed

pro

toco

l.

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Bir

th

Prot

ecte

d fa

cilit

ies

are

prov

ided

for

pla

nned

CS

inth

e m

ost

appr

opria

te p

lace

.Li

sts

are

not

disr

upte

d by

emer

genc

y w

ork.

Wom

en a

re a

dmitt

ed o

n th

e da

y of

the

ope

ratio

n to

the

rec

over

y ar

ea o

r a

post

nata

l war

d.

The

obst

etric

tea

m is

se

para

te f

rom

the

sta

ff

on la

bour

war

d.M

ater

nity

car

e as

sist

ants

are

trai

ned

for

role

s in

the

atre

(run

ning

, scr

ubbi

ng, a

ssis

ting

etc)

. The

atre

nur

ses

scru

bra

ther

tha

n m

idw

ives

. The

reis

an

oper

atin

g de

part

men

tas

sist

ant

dedi

cate

d to

mat

erni

ty.

Follo

win

g th

e op

erat

ion

wom

en r

emai

n in

a s

ingl

elo

catio

n on

the

pos

tnat

alw

ard.

The

mid

wife

adm

its t

hew

oman

and

acc

ompa

nies

he

r th

roug

h th

e op

erat

ion

and

to t

he p

ostn

atal

war

d.

We

regu

larly

aud

it in

fect

ion

rate

s, a

ntib

iotic

an

d th

rom

bopr

ophy

laxi

s;

resu

lts a

re f

ed b

ack

prom

ptly

to

the

staf

f.

Ther

e ar

e de

dica

ted

plan

ned

lists

. Lab

our

war

d or

mai

nth

eatr

es a

re u

sed.

Wom

en a

re a

dmitt

ed o

n th

e da

y of

the

ope

ratio

n to

the

pos

tnat

al w

ard.

A t

heat

re n

urse

scr

ubs

for

plan

ned

CS.

Mat

erni

ty c

are

assi

stan

ts h

ave

take

n on

ext

ende

d ro

les.

Follo

win

g th

e op

erat

ion

wom

en r

emai

n in

a s

ingl

elo

catio

n on

the

pos

tnat

alw

ard.

The

pos

tnat

al m

idw

ifere

cove

rs t

he w

oman

pos

t-op

erat

ivel

y an

d co

ntin

ues

her

care

on

the

post

nata

l war

d.

We

high

light

sig

nific

ant

com

plic

atio

ns a

s th

ey o

ccur

and

disc

uss

them

in o

urla

bour

war

d fo

rum

.

Ther

e ar

e de

dica

ted

plan

ned

lists

.

Wom

en a

re a

dmitt

ed o

n th

e da

y of

the

ope

ratio

n to

the

labo

ur w

ard.

A t

heat

re n

urse

scr

ubs

for

plan

ned

CS.

Mid

wiv

es h

ave

take

n on

exte

nded

rol

es.

The

mid

wife

adm

ittin

g th

ew

oman

acc

ompa

nies

her

thro

ugh

the

oper

atio

n.

Our

doc

tors

do

perio

dic

audi

ts a

s pa

rt o

f ou

r au

dit

prog

ram

me.

Labo

ur w

ard

thea

tres

are

used

for

pla

nned

CS.

Wom

en a

re a

dmitt

ed o

n th

eda

y of

the

ope

ratio

n to

the

ante

nata

l war

d.

A s

epar

ate

CS

team

isso

met

imes

ava

ilabl

e.

Serio

us c

ompl

icat

ions

are

pick

ed u

p th

roug

h ou

r ris

km

anag

emen

t pr

oces

ses.

The

man

agem

ent

of

plan

ned

proc

edur

es is

se

en a

s lo

w p

riorit

y.

Wom

en a

re a

dmitt

ed b

efor

eth

e da

y of

the

ope

ratio

n to

the

ante

nata

l war

d.

The

CS

team

is n

ot s

epar

ate

from

the

Lab

our

War

d te

am.

Ther

e is

res

ista

nce

toch

angi

ng t

he t

radi

tiona

l ro

les

of h

ealth

care

sta

ff.

Dur

ing

thei

r st

ay w

omen

are

tran

sfer

red

to a

ser

ies

ofdi

ffer

ent

loca

tions

with

no

con

tinui

ty o

f st

aff.

We

don’

t au

dit

our

com

plic

atio

ns.

Plan

ned

CS

is o

rgan

ised

effi

cien

tly

to m

inim

ise

del

ays

and

clin

ical

ris

k

Wo

men

are

ad

mit

ted

on

the

day

of

the

op

erat

ion

The

per

son

nel

an

d s

kill

mix

in o

per

atin

g t

hea

tres

is o

pti

mis

ed t

o r

edu

ceim

pac

t o

n t

he

man

agem

ent

of

lab

ou

rin

g w

om

en

Du

rin

g t

he

adm

issi

on

,tr

ansf

ers

of

care

are

min

imis

ed t

o a

void

del

ays,

risk

s an

d c

om

mu

nic

atio

np

rob

lem

s

Co

mp

licat

ion

s ar

e ke

pt

to a

min

imu

m

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Post

nat

al

Plan

ning

for

dis

char

gest

arts

pre

-adm

issi

on.

The

expe

cted

dat

e of

disc

harg

e is

agr

eed

atth

e pr

e-as

sess

men

t vi

sit.

Post

CS

stay

is n

otex

pect

ed t

o be

long

erth

an 5

6 ho

urs.

Doc

tors

see

wom

en w

hoha

ve h

ad a

CS

on d

ayon

e. M

idw

ives

dis

char

geth

em o

n da

y tw

o or

thre

e ac

cord

ing

toag

reed

pro

toco

l.

Ther

e is

cle

arin

form

atio

n ab

out

any

impl

icat

ions

for

a f

utur

epr

egna

ncy.

Iden

tical

info

rmat

ion

isco

mm

unic

ated

to

the

wom

an a

nd h

er G

P an

dco

mm

unity

mid

wife

inw

ritin

g.

Ther

e ar

e sp

ecifi

cgu

idel

ines

for

pos

t-C

San

alge

sia.

Patie

nt G

roup

Dire

ctiv

es(P

GD

) are

set

up

tore

duce

the

tim

e w

aitin

gfo

r di

scha

rge

med

icat

ions

.

Pre-

pack

ed d

isch

arge

med

icat

ion

isst

anda

rdis

ed a

ndav

aila

ble

on t

he w

ard.

The

expe

cted

dat

e of

dis

char

geis

dis

cuss

ed a

t pr

e-as

sess

men

tan

d co

nfirm

ed t

he d

ay b

efor

edi

scha

rge.

Doc

tors

see

wom

en w

ho h

ave

had

a C

S on

day

one

. Mid

wiv

esm

ay d

isch

arge

wom

en w

hoha

ve h

ad a

n un

even

tful

reco

very

; the

re is

no

form

alpr

otoc

ol in

pla

ce.

The

wom

an is

giv

en v

erba

lin

form

atio

n ab

out

her

CS

and

the

poss

ible

impl

icat

ions

for

the

next

pre

gnan

cy.

Ther

e is

gen

eral

gui

danc

e fo

rpo

st-C

S an

alge

sia

and

thes

ear

e ro

utin

ely

pres

crib

ed a

ndad

min

iste

red.

Ther

e is

gui

danc

e on

med

icat

ions

to

take

hom

e.Th

ey a

re p

resc

ribed

by

doct

ors.

Pre-

pack

ed d

isch

arge

med

icat

ion

is s

tand

ardi

sed

and

avai

labl

e at

a s

ingl

e lo

catio

nw

ithin

the

mat

erni

ty u

nit.

The

expe

cted

dat

e of

disc

harg

e is

dis

cuss

ed a

t pr

e-as

sess

men

t bu

t no

t ag

reed

or

conf

irmed

unt

il th

e da

y of

disc

harg

e.

Mid

wiv

es m

ay d

isch

arge

wom

en w

ho h

ave

had

anun

even

tful

rec

over

y fo

llow

ing

disc

ussi

on w

ith t

he o

n-ca

llob

stet

ricia

n.

Det

aile

d no

tes

abou

t th

e C

Sca

n be

fou

nd in

the

wom

an’s

reco

rds.

The

y in

clud

eim

plic

atio

ns f

or t

he n

ext

preg

nanc

y.

Ana

lges

ia p

resc

ribed

ac

cord

ing

to t

he g

uida

nce

isno

t ro

utin

ely

adm

inis

tere

d.

Ther

e is

no

spec

ific

guid

ance

for

med

icat

ions

to

take

hom

e.D

octo

rs m

ake

indi

vidu

alch

oice

s.

Som

e pr

e-pa

ckag

ed m

edic

ines

are

avai

labl

e bu

t th

ey d

o no

tco

ver

the

wid

e ra

nge

ofm

edic

atio

ns p

resc

ribed

.

Wom

en a

re g

iven

info

rmat

ion

abou

t ex

pect

ed le

ngth

of

stay

follo

win

g a

CS

at p

aren

ted

ucat

ion

sess

ions

.

Med

ical

sta

ff m

ust

revi

eww

omen

on

the

day

ofdi

scha

rge

befo

re t

hey

are

allo

wed

hom

e.

Det

aile

d no

tes

abou

t th

e C

Sca

n be

fou

nd in

the

wom

an’s

reco

rds.

Ana

lges

ia is

not

rou

tinel

ypr

escr

ibed

acc

ordi

ng t

o th

egu

idan

ce.

Dis

char

ge m

edic

atio

n is

obta

ined

fro

m p

harm

acy

the

day

befo

re d

isch

arge

.

No

spec

ific

info

rmat

ion

is g

iven

abou

t ex

pect

ed le

ngth

of

stay

.

Med

ical

sta

ff r

evie

w a

ll w

omen

on a

dai

ly b

asis

.

Ther

e is

no

info

rmat

ion

abou

tan

y im

plic

atio

ns f

or f

utur

epr

egna

ncie

s.

Ther

e ar

e no

gui

delin

es f

oran

alge

sia

follo

win

g pl

anne

d C

S.

All

med

icat

ions

are

pre

scrib

edon

an

indi

vidu

al b

asis

and

are

obta

ined

fro

m p

harm

acy

on t

heda

y of

dis

char

ge.

Mo

ther

s an

d b

abie

s re

turn

ho

me

as s

oo

n

as c

linic

ally

ind

icat

ed

Mid

wiv

es le

ad t

he

dis

char

ge

pro

cess

acc

ord

ing

to a

n a

gre

ed p

roto

col

Ther

e is

cle

ar in

form

atio

nab

ou

t an

y im

plic

atio

ns

for

a fu

ture

pre

gn

ancy

Effe

ctiv

e an

alg

esia

gu

idel

ines

are

pro

vid

ed t

op

rom

ote

ear

ly m

ob

ilisa

tio

n

Ther

e is

a n

ear

pat

ien

tsu

pp

ly o

f d

isch

arg

em

edic

atio

n in

th

em

ater

nit

y u

nit

Focus on normal birth and reducing Caesarean section rates 109

Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 109

Page 112: Pathways to success focus on normal birth

Ther

e ar

e cl

ear

chan

nels

of

com

mun

icat

ion

betw

een

the

inpa

tient

uni

t an

dco

mm

unity

car

e.

Each

wom

an, h

erm

idw

ife a

nd h

er G

Pha

ve id

entic

alin

form

atio

n.W

omen

kno

w h

ow t

oco

ntac

t th

eir

com

mun

ity m

idw

ifeat

all

times

.

Com

mun

ity s

taff

are

proa

ctiv

e in

iden

tifyi

ng w

omen

for

early

post

oper

ativ

e ca

re a

tho

me.

The

y ar

esk

illed

at

optim

isin

gbr

east

feed

ing

outc

omes

.

Ther

e is

goo

d co

mm

unic

atio

nbe

twee

n w

ard

and

com

mun

ityst

aff

at a

ll tim

es. W

omen

kn

ow h

ow t

o co

ntac

t th

eir

mid

wife

.The

GP

cont

ribut

esap

prop

riate

ly t

o po

stna

tal c

are.

Com

mun

ity s

taff

acc

ept

wom

en f

or e

arly

dis

char

ge.

They

are

tra

ined

to

man

age

post

-CS

care

.

Ther

e is

goo

d co

mm

unic

atio

nbe

twee

n th

e in

patie

nt u

nit

and

com

mun

ity c

are.

Out

of

hour

s ad

vice

is v

ia D

eliv

ery

Suite

. All

wom

en w

ithpr

oble

ms

retu

rn t

o th

em

ater

nity

uni

t.

Mem

bers

of

the

com

mun

ityte

am v

ary

in t

heir

will

ingn

ess

to a

ccep

t w

omen

for

ear

lydi

scha

rge.

Adv

ice

to p

ost-

CS

wom

en is

inco

nsis

tent

. The

reis

an

expe

ctat

ion

that

brea

stfe

edin

g m

ay f

ail.

Whe

n a

wom

an g

oes

hom

e,ou

t of

hou

rs a

dvic

e is

via

Del

iver

y Su

ite, n

ot b

y th

eco

mm

unity

mid

wiv

es.

The

GP

does

not

con

trib

ute

to p

ostn

atal

car

e.

Com

mun

ity s

taff

are

rel

ucta

ntto

acc

ept

wom

en f

or e

arly

disc

harg

e. T

here

is a

ver

y lo

wth

resh

old

to r

eadm

it w

omen

from

the

com

mun

ity.

Ther

e is

no

defin

ed p

roce

ss

of c

omm

unic

atio

n be

twee

n th

e in

patie

nt u

nit

and

com

mun

ity c

are.

Com

mun

ity m

idw

ifery

sta

ff a

reun

skill

ed in

pos

tope

rativ

e ca

rean

d do

not

see

it a

s pa

rt o

fth

eir

role

.

Co

mm

un

ity

care

is

co

-ord

inat

edA B

110 Focus on normal birth and reducing Caesarean section rates

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Page 113: Pathways to success focus on normal birth

An

ten

atal

Bir

th

Pre-

asse

ssm

ent

take

s p

lace

fo

r al

l wo

men

. Th

ese

are

mid

wif

e-le

dac

cord

ing

to

an

ag

reed

pro

toco

l

Fully

info

rmed

wo

men

ar

e ac

tive

par

tner

s in

th

ed

ecis

ion

to

hav

e C

SIn

form

atio

n le

adin

g t

oco

nse

nt

is a

n o

ng

oin

gp

roce

ss

The

pla

nn

ed c

aesa

rean

isb

oo

ked

fo

r a

ges

tati

on

that

min

imis

es r

isks

fo

ro

ther

an

d b

aby

Plan

ned

CS

is o

rgan

ised

effi

cien

tly

to m

inim

ise

del

ays

and

clin

ical

ris

k

Wo

men

are

ad

mit

ted

on

the

day

of

the

op

erat

ion

The

per

son

nel

an

d s

kill

mix

in o

per

atin

g t

hea

tres

iso

pti

mis

ed t

o r

edu

ce im

pac

to

n t

he

man

agem

ent

of

lab

ou

rin

g w

om

en

Du

rin

g t

he

adm

issi

on

,tr

ansf

ers

of

care

are

min

imis

ed t

o a

void

del

ays,

ris

ks a

nd

com

mu

nic

atio

n p

rob

lem

s

Co

mp

licat

ion

s ar

e ke

pt

toa

min

imu

m

Planned Caesarean Section – Individual Record Sheet

Focus on normal birth and reducing Caesarean section rates 111

A B

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Page 114: Pathways to success focus on normal birth

112 Focus on normal birth and reducing Caesarean section rates

Post

nat

al

Mo

ther

s an

d b

abie

s ar

ere

turn

ed h

om

e as

so

on

as

clin

ical

ly in

dic

ated

Mid

wiv

es le

ad t

he

dis

char

ge

pro

cess

acco

rdin

g t

o a

n

agre

ed p

roto

col

Ther

e is

cle

ar in

form

atio

nab

ou

t an

y im

plic

atio

ns

for

a fu

ture

pre

gn

ancy

Effe

ctiv

e an

alg

esia

gu

idel

ines

are

pro

vid

ed

to p

rom

ote

ear

lym

ob

ilisa

tio

n

Ther

e is

a n

ear

pat

ien

tsu

pp

ly o

f d

isch

arg

em

edic

atio

n in

th

em

ater

nit

y u

nit

Co

mm

un

ity

care

is

co-o

rdin

ated

A B

Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 112

Page 115: Pathways to success focus on normal birth

Focus on normal birth and reducing Caesarean section rates 113

Planned Caesarean Section - Self-improvement Action Plan

There is pre-assessment for all women This is midwife-led according to a protocol

Where are we now?• Women with risk factors for anaesthetics are sent to the Labour ward to speak to an anaesthetist• Healthy women come up to the antenatal clinic a few days before their CS. The duty midwife

takes blood tests and gives them a supply of Ranitidine. This is an extra visit with no antenatalcheck. The midwife doesn’t work on Labour ward and can’t deal with any queries. She calls a doctor to answer a woman’s questions

Where do we want to get to?• There is an anaesthetic advice clinic to which women can be referred antenatally according to guideline• The pre-assessment visit combines a normal antenatal check with preparation for CS• The professional seeing the woman for pre-assessment can answer her questions about the operation,

its risks and benefits, the postnatal effects and implications for the future• The expected date of discharge is discussed and agreed, subject to clinical considerations• Each woman receives written information covering all these issues

What do we need to change?• Set up a specialist anaesthetic referral antenatal clinic for women with anaesthetic risk factors• Develop a protocol for a midwife-led visit to combine antenatal check with preparation for CS• Decide on appropriate environment and midwife staffing for CS preparation visit• Consider need for multi-site use of the protocol• Ensure that all staff members involved use and are comfortable with the same factual information

Who will do (and lead) the work?• Obstetric anaesthetist • Day Assessment midwife (lead)• Labour ward midwife• Obstetric doctor

When will we complete this?• October 2007

What tools will we use?• Obstetric Anaesthetists Association guidelines• NICE guidance on antenatal care• Mapping the patient’s journey (NHS Modernisation Agency)

How will we measure success?• Audit of delays on admission for CS

What will be the impact? (quality and value, reduction in CS rate)• Reduction in variation of length of stay through planning discharge with each woman• Increase in satisfaction with service through greater involvement in planning• Consistent information to women • Avoidance of delays through early identification of risk factors• Possible minor reduction of CS rates through giving information on risks and benefits without

the pressure of decision-making

Worked example

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Principle Measures

Pre-assessment takes place for all women • Percentage of women who have a pre-assessment visit within one week of operation date (target:100%)

Planned CS is organised efficiently to minimisedelays and clinical risk

• Audit of gestation at date of operation

• Audit of delays in planned operations

Women are admitted on the day of theoperation

• Percentage of women who are admitted onthe day of the operation (target:100%)

Complications are kept to a minimum • Audit of post-operative infection rates

• Audit of compliance with thromboprophylaxisguidelines

Mothers and babies are returned home as soon as clinically indicated

• Percentage of women who have agreed a discharge date prior to admission (target:100%)

Midwives lead the discharge process accordingto an agreed protocol

• Percentage of women who are discharged on the planned date (target >90%)

Planned Caesarean Section - Measures for Improvement

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Planned Caesarean Section Example Tools

Scenario: Jane - pre-assessmentAfter an uneventful second pregnancy Jane is having an elective CS for a breech presentation.It is booked for 38 weeks gestation.

She has a supply of ranitidine prescribed by her GP ready at home.

On the afternoon before the operation she attends the Antenatal ward for pre-assessment.Labour ward is busy and the duty SHO and anaesthetist are delayed. The midwife takes bloodfor Group and save and full blood count. When he arrives the anaesthetist confirms that Janeis fit for operation and recommends an epidural anaesthetic.

Jane’s partner has to go home to look after their child. When the SHO arrives at 20.00 henotes that Jane’s blood pressure is up (for the first time). He requests further blood tests forpre-eclampsia and blood clotting. Jane asks what sort of stitches will be used and the doctortells her it will depend on who is doing the operation. He asks her to sign a consent form.

It is now late and Jane has no transport. She has to stay the night. The midwife is annoyed theJane has left her ranitidine at home. There s a further delay waiting for the doctor to prescribeit on the ward. At 02.30 Jane is woken to take the tablet ‘because a general anaesthetic willbe dangerous without it’.

Jane is transferred to the labour ward at 08.30 and is prepared for theatre by the midwife.Theatre is busy so they chat to the midwife until 11.00 when the anaesthetic registrar andobstetric registrar arrive to speak to her. Jane says she is confused about the sort of anaestheticshe will be having. The doctors tell her that it’s her choice but if she has a general anaestheticher partner will not be allowed into the operating theatre.

• Could this pathway have been more effective?

• Could any of these things have happened in you service?

• What were Jane’s expectations and were they met?

• How could communications be improved?

Service improvement tools

Mapping the woman’s journey

As a multidisciplinary team, map out the stages that women go through in your service from the time of decision for planned CS is made to a woman returning home after the birth.Think about where each stage happens and which different members of staff a woman meets.

Ask yourselves:

• Does this process flow (are the steps in a logical order)?

• Is the process consistent (does it happen this way every time)?

• Are there bottlenecks (where do delays occur and why)?

• Does every stage in the journey add value to the woman or to the staff (could you miss steps out or combine steps)?

Focus on normal birth and reducing Caesarean section rates 115

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Try mapping the Jane’s case scenario above and compare it with your own.

• Lean

• NHS Institute for Innovation and Improvement (2006), Going Lean in the NHS (available at: www.institute.nhs.uk)

Case study: Maternity Care Assistants assisting at CSSince I have been in post (December 2006) I have been working with the MCAs to facilitate theirextending their skills to assist the obstetricians at CS operations. They are supported by a consultantobstetrician and by me until they are competent to perform this extended skill.

The MCSAs who perform this role either volunteered for the programme or were appointed to thescheme. They are very keen, willing and conscientious in this role. Most of them gained competencywithin 6 to 12 weeks.Jenny Burton, Clinical Skills Facilitator, East Sussex Hospitals NHS Trust

Why don’t you………

Form a partnership with women having planned CS? Preparation for your Caesarean Birth

We will:

Do everything we can to carry out your operation on the day and time planned.

Provide you with clear information about…………

Agree an expected date to return home before you come into hospital………etc.

You can help by:

Being patient if an emergency delays the time of your operation.

Reading the information we provide and thinking about any questions…………….

Making sure you have prepared to go home on the expected day………….etc

When we make a commitment to a shared responsibility, there is more likelihood that these thingswill happen.

116 Focus on normal birth and reducing Caesarean section rates

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Focus on normal birth and reducing Caesarean section rates 117

Key documents

National Collaborating Centre for Women’s and Children’s Health (2004), Caesarean section:Clinical guideline, RCOG Press, London, (www.nice.org.uk)

NHS Employers (2006), Maternity Support Workers: enhancing the work of the maternityteam, NHS Confederation(https://www.nhsemployers.org/restricted/downloads/download.asp?ref=759&hash=80a36fa871b65815d77b0522ee6f37fa)

Ontario Women’s Health Council (2002), Attaining and maintaining best practices in the use ofCaesarean sections, OWHC, Ontario, Canada, (www.womenshealthcouncil.on.ca)

Royal College of Midwives (2002), Understanding the national sentinel Caesarean section auditreport 2001: an RCM topical briefing for midwives, RCM, London

Royal College of Obstetricians and Gynaecologists (2006), Obtaining Consent for CaesareanSection, (http://www.rcog.org.uk/resources/Public/pdf/consent7_csection.pdf)

The Obstetric Anaesthetists Association (2005), Guidelines for Obstetric Anaesthetist Services(revised edition), (http://www.oaa-anaes.ac.uk/pdfs/obstetric-guidelines.pdf).

Thomas, J., and Paranjothy, S., (RCOG clinical effectiveness support unit) (2001), The nationalsentinel Caesarean section audit report, RCOG Press, London(http://www.rcog.org.uk/resources/public/pdf/nscs_audit.pdf

User InformationMIDIRS Informed Choice, (www.infochoice.org/).

Caesarean Section and VBAC (Vaginal birth after Caesarean)

National Childbirth Trust, Leaflets – Caesarean Section, (www.nct.org.uk)

National Collaborating Centre for Women’s and Children’s Health (2004), Understanding NICEguidance. Information for pregnant women, their partners and the public, RCOG Press,London, (http://guidance.nice.org.uk/CG13)

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Acknowledgements, References and Glossary

8

Introduction01-16

Practical advice on using the toolkit

17-32

Running workshops: facilitators guidance

33-54

Top Ten55-62

Organisational Characteristics63-74

First Pregnancy and Labour75-90

Vaginal Birth after Caesarean91-104

Planned Caesarean Section105-118

Acknowledgements, Referencesand Glossary

119-126

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120 Focus on normal birth and reducing Caesarean section rates

Acknowledgments

We wish to thank everyone who has contributed their time to enable us to develop this toolkit,and in particular the frontline staff who took time out from their busy schedules to show ushow they work and for all the information they shared.

We would like to thank the following for their contribution to Focus on: Caesarean Sectionand the Pathways to Success Toolkit:

• Bradford Teaching Hospitals NHS Foundation Trust

• Central Manchester and Manchester Children’s University Hospitals NHS Trust

• East Kent Hospitals NHS Trust

• East Sussex Hospitals NHS Trust

• Gloucestershire Hospitals NHS Foundation Trust

• Guy’s & St Thomas’ NHS Foundation Trust

• King’s College Hospital NHS Foundation Trust

• Kingston Hospital NHS Trust

• Liverpool Women’s NHS Foundation Trust

• Milton Keynes General NHS Trust

• Northern Lincolnshire and Goole Hospitals NHS Trust

• Nottingham University Hospitals NHS Trust

• Royal Devon and Exeter NHS Foundation Trust

• Royal United Hospital Bath NHS Trust

• Salisbury NHS Foundation Trust

• Sherwood Forest Hospitals NHS Foundation Trust

• South Devon Healthcare NHS Foundation Trust

• Tameside and Glossop NHS Trust

• Taunton and Somerset NHS Trust

• The Princess Alexandra Hospital NHS Trust

• The Shrewsbury and Telford Hospital NHS Trust

• United Lincolnshire Hospitals NHS Trust

• University Hospitals of Leicester NHS Trust

• West Middlesex University Hospital NHS Trust

• Worcestershire Acute Hospitals NHS Trust

• Worthing & Southlands Hospitals NHS Trust

• York Hospitals NHS Trust

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We would also like to thank:

• Birth Trauma Association

• Care Services Improvement Partnership

• Eastbourne Women’s Focus Group at East Sussex Hospitals Trust

• Foundation Trust Network

• Heads of Midwifery Network

• Local Supervising Authority Midwifery Officers UK

• Maternity Services External Working Group (Department of Health)

• Maternity Services Liaison Committees

• Midwifery Advisors (Department of Health)

• National Childbirth Trust

• National Institute for Health and Clinical Excellence

• NHS Employers

• North West London Midwifery Strategy Group

• Royal College of Midwives

• Royal College of Obstetricians and Gynaecologists

• Trauma and Birth Stress Charitable Trust (New Zealand)

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References

1. NHS Institute for Innovation and Improvement (2006), Delivering Quality and Value: Focuson: High Volume Care Executive Summary

2. NHS Institute for Innovation and Improvement (2006), Delivering Quality and Value: Focuson: Caesarean section

3. Department of Health (2006), Hospital episode statistics 2005/2006, Department of Health,London

4. Department of Health (2006), NHS Maternity Statistics, England: 2004-2005, Department of Health, London

5. Confidential Enquiry into Maternal and Child Health (2005), Stillbirth, neonatal and post-neonatal mortality 2000-2003: England, Wales and Northern Ireland, RCOG Press, London

6. Thomas, J. and Paranjothy, S. (RCOG clinical effectiveness support unit) (2001), The nationalsentinel Caesarean section audit report, RCOG Press, London

7. RCOG , RCM (1999), Towards safer childbirth: minimum standards for the organisation oflabour wards, RCOG Press, London

8. Hodnett, E. (2000), Caregiver support for women during childbirth, The Cochrane LibraryIssue 1, Oxford

9. Thacker, S., Stroup, D., Chang, M. (2001), Continuous electronic heart rate monitoring forfetal assessment in labour, Cochrane review

10. RCOG (2001), The use of electronic fetal monitoring: the use and interpretation ofcardiotocography in intrapartum fetal monitoring. Evidence-based clinical guidelines, RCOG Press, London

11. Vincent, C., Davy, C., Esmail, A., et al. (2004), Learning from litigation: an analysis of claimsfor clinical negligence, Victoria University, Manchester

12. Hannah, M., Hannah, W., Hewson, S., Hodnett, E., Saigal, S., Willan, A. (2000), Planned caesarean section versus planned vaginal birth for breech presentation at term; a randomised multicentre trial, Lancet 2000; 356: 1375-83

13. European mode of delivery collaboration, Elective caesarean section versus vaginal delivery in prevention of vertical HIV1 transmission: a randomised clinical trial, Lancet 1999;353:1035-9

14. National Collaborating Centre for Women’s and Children’s Health (2004), Caesarean section: Clinical guideline, RCOG Press, London

15. Robson, M., Scudamore, I., Walsh, S. (1996), Using the medical audit cycle to reduce cesarean section rates, Am J Obstet Gynecol 1996; 174: 199-205

16. Paranjothy, S., Frost, C., Thomas, J. (2005), How much variation in CS rates can be explainedby case mix differences, BJOG: An International Journal of Obstetrics and Gynaecology, No. 112, pp. 658–66

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General bibliography

Ball, J.A., Washbrook, M. (1996), Birthrate plus: a framework for workforce planning anddecision-making for maternity services, Books for Midwives, Hale, Cheshire

Confidential Enquiry into Maternal and Child Health (2005), Stillbirth, neonatal and post-neonatal mortality 2000-2003: England, Wales and Northern Ireland, RCOG Press, London

Department for Education and Skills and Department of Health (2004), Joint planning andcommissioning framework for children, young people and maternity services, Department ofHealth, London

Department of Health (2004), National Service Framework for children, young people andmaternity services, Department of Health, London

Department of Health, Hospital episode statistics 2005/2006, Department of Health, London

Department of Health (2006), National Tariff 2005–06, Department of Health, London

Flamm, B., Kabcenell, A., Berwick, D., Roessner, J. (1997), Reducing Cesarean section rates whilemaintaining maternal and infant outcomes, Institute for Healthcare Improvement, CambridgeMA

Lewis, G., Drife, J. (Eds)(2004), Why mothers die 2000-2002: the sixth report of the ConfidentialEnquires into Maternal Deaths in the United Kingdom, GCOG Press, London

National Childbirth Trust conference proceedings (1999), The rising Caesarean rate: a publichealth issue, Royal College of Midwives and RCOG Press, London

National Childbirth Trust conference proceedings (2000), The rising Caesarean rate: causes andeffects for public health, Royal College of Midwives and RCOG Press, London

National Childbirth Trust conference proceedings (2002), The rising Caesarean rate: from auditto action, Royal College of Midwives and RCOG Press, London

National Childbirth Trust conference proceedings (2003), Making normal birth a reality: sharinggood practice and strategies that work, NCT, London.

National Childbirth Trust, The Royal College of Midwives and The Royal College of Obstetriciansand Gynaecologists, Maternity Care Working Party (2006), Modernising Maternity Care – ACommissioning Toolkit for England (2nd ed), NCT and Royal College of Obstetricians andGynaecologists (RCOG) Press, London.

National Collaborating Centre for Women’s and Children’s Health (2004), Caesarean section:Clinical guideline, RCOG Press, London.

National Collaborating Centre for Women’s and Children’s Health (2003), Antenatal care:routine care for the healthy pregnant woman. Clinical guideline, RCOG Press, London

National Institute for Health and Clinical Excellence (2004), Caesarean section: UnderstandingNICE guidance. Information for pregnant women, their partners and the public, NICE, London

Newburn, M., Singh, D. (2003), Creating a better birth environment: women’s views about thedesign and facilities in maternity units; a national survey. An audit toolkit, National ChildbirthTrust, London

NHS Institute for Innovation and Improvement (2006), Delivering quality and value: Focus onCaesarean section.

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Ontario Women’s Health Council (2002), Attaining and maintaining best practices in the use ofCaesarean sections, OWHC, Ontario, Canada

Ontario Women’s Health Council (2002), Caesarean section best practices project: impact andanalysis, OWHC, Ontario, Canada

Paranjothy, S., Frost, C., Thomas, J. (2005), How much variation in CS rates can be explained bycase mix differences, BJOG: An International Journal of Obstetrics and Gynaecology, No. 112,pp. 658–66

Parliamentary Office of Science and Technology (POST) (2002), Caesarean sections, Postnote, No. 184, POST, London (www.parliament.uk/post/pn184.pdf).

Royal College of Midwives (2002), Understanding the national sentinel Caesarean section auditreport 2001: an RCM topical briefing for midwives, RCM, London

RCOG (2001), The use of electronic fetal monitoring: the use and interpretation of cardiotocography in intrapartum fetal monitoring. Evidence-based clinical guidelines, RCOG Press, London

RCOG, RCM (1999), Towards safer childbirth: minimum standards for the organisation of labour wards, RCOG Press, London

Thomas, J. and Paranjothy, S. (RCOG clinical effectiveness support unit) (2001), The national sentinel Caesarean section audit report, RCOG Press, London

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Glossary and list of abbreviations CS toolkitARM: artificial rupture of the membranes performed prior to or during labour

Children’s Centre: locality-based hub for the provision of integrated services to children under 5 years and their families

CNST: Clinical Negligence Scheme for Trusts; a centralised resource pooling to meet clinical negligence claims against the NHS.

Ctg: Cardiotocograph; automated recording of fetal heart rate and maternal uterine contractions.

Admission Ctg: automated recording of fetal heart rate and maternal uterine contraction performed when a woman is admitted to the unit in labour

ECV: external cephalic version; manipulation of the fetus through the maternal abdomen into a cephalic presentation

GP: General Practitioner; a primary care physician

HRG: Health Resource Groups: classifications used by the English NHS to describe healthcare activity. They form the basis of the costing and payment system.

IOL: Induction of Labour; procedure to initiate labour artificially using mechanical or pharmacological agents.

MSLC: Maternity Services Liaison Committee; a forum established by statute in which for maternity services users, providers and commissioners come together to design services that meet the needs of local women.

NCT: National Childbirth Trust; a charitable organisation providing information and support for pregnancy childbirth and early parenthood.

NHS: National Health Service; publicly funded health care for residents of the United Kingdom

NICE: National Institute for Health and Clinical Excellence; an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health

NSF: National Service Framework; Department of Health guidance for a ten year programme of service improvement.

PCT: Primary Care Trust: statutory bodies under the NHS responsible for managing primary care health services and commissioning hospital care for their population

PGD: Patient Group Direction; agreement under which nurses may supply and administer prescription-only medication to patients using their own assessment of patient need without referring to a doctor or pharmacist.

.

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Delivering Quality and Value

Pathways to Success:a self-improvement toolkit

Focus on normal birth and reducingCaesarean section rates

Delivering Q

uality and ValuePathw

ays to Success: a self-improvem

ent toolkitFo

cus o

n n

orm

al birth

and

redu

cing

Caesarean

section

rates

For further information please visit www.institute.nhs.ukor email [email protected]

NHS Institute for Innovation and ImprovementCoventry HouseUniversity of Warwick CampusCoventryCV4 7AL

To order further copies contact [email protected] and quote code NHSIDQVToolkit-C-Section

Version 1 - 2006, Version 2 - 2010ISBN: 978-1-907045-93-6NHS Institute product code: NHSIDQVToolkit-C-SectionCopyright © NHS Institute for Innovation and Improvement 2010 All rights reserved

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