IDEAS & RESOURCES FOR IMPROVING INDUCTION OF LABOUR PRACTICE

Group facilitators: Louisa Davidson (Birmingham Women’s and Children’s NHS Foundation Trust Hospital), Nicola Farmer (Birmingham Women’s and Children’s NHS Foundation Trust), Mike Peart (Public Contributor)

If you are intending to use any of these materials, please can you acknowledge the Trust who have developed the original by stating ‘This work was originally undertaken by XXXX Trust/Health Board’ 

Authors: Sarah Pitts (Betsi Cadwaladr University Health Board), Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Betsi Cadwaladr University (BCU) Health Board comprises 3 acute hospitals across North Wales: Ysbyty Gwynedd (Bangor), Glan Clwyd (near Rhyl) and Wrecsam Maelor (Wrexham). Each has an alongside midwifery led and a consultant led unit, plus an ICU. Neonatal services have a central level 2 unit, which accepts babies from 26 weeks gestation, plus two level 3 units. There are 5,900 births across the Health Board, a 1% home birth rate and a 39% IOL rate. The catchment includes large rural areas. 90% of the population are covered by the 3 acute sites within a 60 minute drive. There are significant pockets of poverty, and levels of obesity above the national average. Bilingualism is important; this is the largest population in UK where Welsh is the first language.

The problem:

Women felt they were ill informed and unprepared for the IOL process. Many, in hindsight, thought they might not have accepted the recommendation to be induced if they understood it better. This dissatisfaction was captured in Birth Stories where women and their families co-created a narrative of their experience for staff feedback. This service is provided through Birth Afterthoughts, a listening service coordinated by the consultant midwife, which is available to any woman and their partner who have given birth in BCU. These stories were widely shared through WhatsApp midwifery groups, local and Board-wide forums. Concerns were also reflected in formal complaints. 

Audit data demonstrated half of category 3 caesarean births were in women who had already started their IOL.

The project:

Our Maternity Voices group brings together those with recent experience of maternity services with healthcare professionals to improve maternity services. The group designed a process centred on the BRAIN framework with the consultant midwife co-chair (see link). The aim was to embed this decision tool into our counselling processes, particularly surrounding IOL, to aid shared decision making. BRAIN (or MAGGU in Welsh) stands for:

      Benefits – What are the benefits of doing this?

      Risks – What are the risks involved?

      Alternatives – Are there any alternatives?

      Intuition – What is my gut feeling?

      Nothing or next – What if we did nothing or waited a while?

The consultant midwife gave in-person training in the BRAIN tool to all Community midwives. Doctors and hospital midwives were informed of the tool through staff briefings, ward launches, and discussion in forums. 

The BRAIN acronym is published on the front of the IOL patient leaflet as a prompt for its use during consultations. The CMW staple a BRAIN business card to the hard cover of the All Wales Antenatal Handheld Notes. BRAIN stickers are displayed waiting rooms and on the back of patient toilet doors in key areas: scan, CMW hubs, ANC and day assessment units.

The information shared continues to be clinician-dependent; there is no agreed written information about risks and benefits for the various indications for IOL.

The impact:

Systematic data on the use of BRAIN has not been collected, and the current IOL booking system does not reflect usage of the tool.

      · Women’s satisfaction: Although no systematic collection of patient satisfaction data has taken place, individual and informal feedback has been positive, especially from women with a previous poor experience who report feeling more empowered. The rate of complaints related to IOL has not fallen, but as the rate of induction over this period increased, the static rate of complaints may reflect overall improvement in satisfaction. 

      · Staff engagement: The Community Midwives and Day Assessment Unit staff now routinely use the acronym. Written reference to the tool is seen both in the Antenatal Handheld Notes from the CMW and in birth plans from the Perinatal Mental Health Team. When an IOL is booked, (student) midwives go through the BRAIN tool when providing the information leaflet, to help improve women’s understanding as to why it is recommended. 

      · Informal staff feedback raises lack of privacy for conversation and lack of time or staff for adequate discussion due to high clinical acuity. Information sharing in ANC and Day Assessment Unit remains time-pressured. Awareness and training in rotational and new-starting doctors has been lacking. Plans have been made to add the BRAIN tool to doctors’ induction information to help address this. 

For further information contact:

Sarah Pitts, Labour Ward Lead West or Emma Adamson, Consultant Midwife BCUHB

Email: Sarah.Pitts@wales.nhs.uk, Emma.Adamson@wales.nhs.uk

Authors: Tiziana Drago (Kings College Hospital NHS Foundation Trust), Octavia Wiseman (Kings College Hospital NHS Foundation Trust), Ana Lagarto (Kings College Hospital NHS Foundation Trust), , Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Kings College Hospital NHS Foundation Trust comprises King’s College Hospital, Denmark Hill, based in a diverse area of South London, and Princess Royal University Hospital (PRUH), Orpington with 7,600 births across both sites both with Neonatal Units: level 3 at Kings College and level 1 at Princess Royal University. There is an induction rate of 35% across both sites (8% of which commence as outpatient IOL). This urban trust is culturally and ethnically diverse (including 33% white British, 26% white other, 18% black, 9% Asian, 5% mixed ethnic background, 5% other), and serves both deprived and affluent communities. 

The problem:

Maternity Voice Partnership (MVP) working with the PRUH carried out two surveys on two consecutive years with service users and reported that inadequate antenatal information regarding the evidence for indication, timing and process of IOL as reflected in the 2021 NICE guidance resulted in a decreased opportunity for women to have truly informed consent when planning IOL. 

The project:

A 2-hour online parent education session on IOL was designed and launched February 2022. All women are welcome to attend and can sign up to the course via the Trust Eventbrite page for Parent Education (see link). In addition, women who are recommended IoL or who are more likely to need it are signposted to this course by their midwives and through antenatal clinic, should they want more in-depth information about induction. 

This programme was developed by the Parent Education Team in collaboration with the Guidelines Team and the MVP. The session, which runs twice a month, provides information from up-to-date guidelines and evidence-based risks and benefits of induction. It is facilitated by two midwives, one from King’s College Hospital Denmark Hill, one from PRUH, both of whom have personal experience of induction. The session aims to be interactive and includes a “Myth-busting quiz” (see link) by way of introduction. Both breakout rooms and chat function encourage discussion, questions and participation.

Content includes:

       · Indications for induction

      · Summary of relevant evidence

      · Case studies of:

• Lower risk inductions (including outpatient induction, use of midwife led unit and pools)
• Higher risk inductions (inpatient, obstetric unit, continuous fetal monitoring)

      · Photographs help to illustrate all stages of induction and elective caesarean section is discussed an alternative

      · Tips on improving experience of induction are discussed, along with evidence for various natural methods of inducing labour

The session finishes with strategies for how to make a personalised plan and informed decision about induction and includes advice if considering birth outside of guidance.

A follow up email is sent with an evaluation and links to resources to aid decision-making (see link).

The impact:

400 pregnant people have attended over the 12 months the course has been running. Ten to twenty-six women attend per session, many with their partners. The attendees comprised women for whom induction had been recommended for a wide range of reasons, as well as people who just wanted more information.

The feedback provided through the formal evaluation requested after each session has been overwhelmingly positive. Sample comments include the following:

      · Good use of breakout groups and appreciate the follow up with additional materials to read

      · Please continue conducting these online seminars as they greatly help us moms-to-be, especially first time moms like me to prepare for childbirth. Thank you for patiently answering all our questions!

      · The description of all the different induction types was very clear

      · Informative and questions from the chatbox were entertained and answered for everyone to hear

This course, along with other specialist sessions from the Parent Education Team at this Trust, was shortlisted for an HSJ Communications Award in 2022.

For further information contact:

Octavia Wiseman octavia.wiseman@nhs.net 

Ana Lagarto ana.lagarto_sintra_dos_santos@kcl.ac.uk

Tiziana Drago tiziana.drago@nhs.net

Authors: Louise Nunn (Chelsea and Westminster Hospital NHS Foundation Trust), Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Sara Kenyon (University of Birmingham)

The setting:

Chelsea and Westminster Hospital NHS Foundation Trust comprises of two hospital sites: Chelsea and Westminster Hospital and West Middlesex University Hospital. The Trust provides maternity care for approximately 10,500 women across the two sites in this urban population centre. Chelsea and Westminster Hospital has a Level 3 NICU and is a tertiary referral centre for fetal and maternal medicine e.g. joint cardiac service with the Royal Brompton Hospital. The overall induction rate is 30%. There are differences in the demographics of the women between the two hospital areas, with West Middlesex looking after more women from a low socio-economic population, 60% of whom are South Asian. At the Chelsea and Westminster site 50% of women are over 35 years old.

The problem:

Information from a national survey done of women’s experiences of induction by the Patient Information Forum in 2021 found only 1 in 4 women said they understood why they were being induced. We also had a mixture of informal complaints and post birth debriefs identifying lack of informed choice as an issue. We felt there was a lack of standardised information about risks and benefits of induction available to women and a lack of accessible evidence-based information regarding induction for precautionary reasons, such as post-dates, advanced maternal age and IVF.

The project:

1. IOL decision aid for postdates pregnancy (see link). This evidence-based IOL decision aid was co-produced along with the Maternity Voices Partnership (MVP). It is designed to be used antenatally at the time IOL is offered and includes the following information: 

       · Why induction may be offered

       · Statistics about stillbirth rates from 40 weeks, in pictorial and graphic formats

       · Benefits and risks of induction

       · Mode of birth related to timing of induction

       · Options offered when women decide to decline induction

2. Information booklet (see link). This booklet about methods and types of IOL was also co-produced with the MVP. The leaflet is designed to be part of a woman’s notes and includes the following:

       · Decision making guide

      · IOL checklist

      · Information with pictures about all stages of the process of induction

      · Top Tips for induction

      · Information on analgesia

      · Advice on optimising induction, active birth positions

      · Visualisation colouring sheets

      · Space for women to make their own notes

The impact: 

Both the decision aid and leaflet have been well received but are yet to be formally evaluated. Staff have been delighted with the decision aid, especially community midwives who are obviously speaking to women about IOL. We have a large cohort on the Chelsea site of younger and less experienced midwives (40% are band 5, average age is 25 and the average length of post qualification time is less than 3 years) so they are often anxious about having more detailed conversations with women. Plus 50% of women on that site are over 35, hence the need for a decision aid for IVF and maternal age, which is being developed at the moment.

For more information contact:

Louise Nunn: Consultant Midwife, 

Email: louise.nunn2@nhs.net