pathways to success focus on normal birth
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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.TRANSCRIPT
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.
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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
Focus on normal birth and reducing Caesarean section rates 51
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 51
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
52 Focus on normal birth and reducing Caesarean section rates
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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
Focus on normal birth and reducing Caesarean section rates 53
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 53
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.
54 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 55
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.
56 Focus on normal birth and reducing Caesarean section rates
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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
.
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 57
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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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 59
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
60 Focus on normal birth and reducing Caesarean section rates
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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.
62 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 63
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.
64 Focus on normal birth and reducing Caesarean section rates
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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.
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 65
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
)
66 Focus on normal birth and reducing Caesarean section rates
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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)
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 67
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
Focus on normal birth and reducing Caesarean section rates 69
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 71
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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74 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 75
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
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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
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 79
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
80 Focus on normal birth and reducing Caesarean section rates
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 80
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:35 Page 81
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 82
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 83
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 84
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
Focus on normal birth and reducing Caesarean section rates 85
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 85
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
86 Focus on normal birth and reducing Caesarean section rates
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 86
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 87
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.
88 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 89
90 Focus on normal birth and reducing Caesarean section rates
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 90
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
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
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Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 92
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 93
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 94
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 95
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 96
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 97
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 99
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 100
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 101
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
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 103
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 105
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.
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 107
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
108 Focus on normal birth and reducing Caesarean section rates
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 108
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
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 110
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 111
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
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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 113
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
114 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 115
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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118 Focus on normal birth and reducing Caesarean section rates
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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
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:36 Page 120
Focus on normal birth and reducing Caesarean section rates 121
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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122 Focus on normal birth and reducing Caesarean section rates
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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Focus on normal birth and reducing Caesarean section rates 123
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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124 Focus on normal birth and reducing Caesarean section rates
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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