Group facilitators: Charlotte Barry (NHS Birmingham and Solihull Clinical Commissioning Group), Jude Field (Royal College of Midwives) and Jane Whitehurst (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: Linda Stewart (NHS Grampian), Mairead Black (University of Aberdeen), Jack Hamer (Birmingham Women’s and Children’s NHS Foundation Trust), Sara Kenyon (University of Birmingham)
The setting:
Aberdeen Maternity Hospital is part of NHS Grampian and serves the area of Grampian within Scotland. There is on average 5000 births a year, with an IOL rate of 32% in 2022. NHS Grampian has one tertiary unit in Aberdeen which consists of an obstetric led and alongside midwifery led unit (MLU), and there are two community maternity units located in Inverurie and Peterhead and a District General hospital, Dr Gray’s in Elgin which is currently providing midwife led intrapartum care. In 2022, 17% of births occurred within the midwifery led setting, with 1.8% consisting of home births. Aberdeen Maternity Hospital encompasses a diverse range of women, with many situated within rural areas.
The problem:
It was noted by maternity staff that the current IOL process, whereby women undergo the initial phases within a multi bedded bay within the maternity unit which may be some distance from home, may not be the ideal method to optimise women’s satisfaction and ensure personalised patient care plans are achieved. Increasing dissatisfaction from women and their families aided the decision for change.
The project:
Aberdeen Maternity Hospital trialled the large-scale implementation of outpatient cervical ripening prior to induction. This was commenced by switching from their primary pharmacological cervical ripening agent (Propess) to a mechanical cervical ripening balloon (see link).
Women who were deemed low risk and recommended for IOL due to post maturity were included. Additionally, women needed to have access to a telephone, have a good understanding of English or someone who is able to interpret with them at all times, have someone who will be at home with them and have ready access to transport.
Initially women were able to have the balloon inserted by an appropriately trained midwife within Aberdeen Maternity Hospital. The balloon remained in situ for a maximum of 24 hours before removal. Consequently, women could manage the initial phases of the IOL within their own home, allowing for improved experience. An initial survey of 86 women within 2018 who initially undertook the new outpatient IOL pathway demonstrated a 100% satisfaction rate with the process and no reported adverse events.
The impact:
From the initial findings, the implementation of outpatient IOL was widened to the entirety of the trust’s catchment area for the same group of women, with cervical ripening routinely taking place on MLU. This has allowed for a reduction in patient commuting time and associated travel cost. At project inception, balloon insertion was performed by two appropriately trained midwives, with one inserting the balloon and another assisting. However, increased staff training has facilitated healthcare support staff to assist midwives with balloon insertion. This has ensured a greater number of community midwives are available to perform balloon insertions.
Unfortunately, the local electronic patient record does not have the functionality to provide the percentage of women treated as outpatient during the IOL process. However, anecdotally, numbers are high with the majority of women of low-risk women being commenced on the IOL pathway within the outpatient setting at Aberdeen Maternity Hospital. However, all women receive an individualised care plan prior to commencing their IOL, with women requesting inpatient IOL care also able to opt out of initial outpatient management.
Criteria for outpatient IOL have widened over time and example contexts where women currently have the option of commencing their IOL on the outpatient pathway include where the only indication for IOL is being 41-42 weeks gestation; those having had reduced fetal movements and a normal scan after 39 weeks where movements have return to normal; gestational diabetes; reduced fetal growth with normal liquor volume and doppler on scan and normal fetal movements; large for gestational age fetus; social indications; and musculo-skeletal pain-related indications.
The Trust IOL guideline (see link) includes outpatient IOL. Additionally, further scoping work is planned in partnership with both women with lived experience of IOL and the multidisciplinary team to consider future service improvements that could be made to increase patient satisfaction.
For further information contact:
Linda Stewart Community midwifery manager or Mairead Black Consultant Obstetrician
Email: linda.stewart2@nhs.scot or mairead.black@abdn.ac.uk
Authors: Louise Clarke (University Hospitals Coventry and Warwickshire NHS Trust), Jack Hamer (Birmingham Women’s and Children’s NHS Foundation Trust), Sara Kenyon (University of Birmingham)
The setting:
University Hospitals Coventry and Warwickshire NHS Trust maternity unit is a level 3 tertiary unit with approximately 6,000 deliveries per annum. The unit covers areas of both Coventry and Warwickshire and is located alongside 2 smaller NHS trusts to form a local midwifery and neonatal system (LMNS). The IOL rate averages between 32-39% per month and include a multi-diverse patient demographic with small areas of deprivation.
The problem:
Clinical staff within the unit noted that the communication with women at the initial phases of the IOL process were problematic. A thematic evaluation of complaints identified similar concerns with women’s experience, whereby women felt their expectations of the IOL pathway had not been sufficiently met. An initial audit of the electronic IOL booking diary and the electronic patient records of women booked for IOL was performed by the consultant midwife over a 4-week period which identified key areas of concern around IOL discussion and delays. A third of women (32%) contacted prior to their booked IOL did not feel they had the full procedure explained clearly enough, nor were they informed the length of time the IOL may take, including the potential for delays. These results prompted the unit to implement quality improvement changes aiming to improve patient experience.
The project:
1. A pre-IOL clinic was set up by the consultant midwife which occurred 2 afternoons per week. All women booked for an IOL are called 7-10 days prior to their booked IOL date. They are offered to come to the clinic for a discussion about IOL and for a stretch and sweep. Most women appreciate the additional information given over the telephone or in person although some decline attending the clinic as they have a stretch and sweep already booked with their CMW. The aim of the clinic was to ensure women felt well informed about the whole IOL pathway, optimise experience, and manage expectations, including if delays were to arise. Women could also be risk triaged to ensure appropriate setting for commencing the IOL is achieved.
2. Managing expectations regarding starting time for IOL. Women were given particular booked days to attend for their IOL, rather than set times and were informed that they would receive a phone call between 7 and 10am to inform them of the time to attend the antenatal ward to commence the IOL. This change resulted in a reduction in complaints.
The impact:
A re-audit has demonstrated positive qualitative feedback from women engaging with the pre-IOL clinics held by the consultant midwife. Women have a greater understanding of the IOL pathway and feel fully informed, with realistic expectations of the process. A reduction in complaints from women arriving to the hospital to begin the IOL process has been noted.
For further information contact:
Louise Clarke: Consultant midwife Email: Louise.Clarke@uhcw.nhs.uk
Authors: Kate Eadie (Oxford University Hospitals NHS Foundation Trust), Jack Hamer (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)
The setting:
The John Radcliffe Hospital in the Oxford University Hospitals NHS Foundation Trust has approximately 7,500 births per year and is the main maternity unit in Oxfordshire, with alongside the Midwifery Led Units at Horton, Chipping Norton, Wantage and Wallingford. They have a fetal medicine unit and are a Level three neonatal unit. The IOL rate is approximately 25%. The population served is predominantly White British with 23% ethnic minority people. There are small pockets of deprivation.
The problem:
There were obvious delays in the IOL process and staff had raised concerns regarding IOL. This together with negative feedback from Maternity Voices Partnership (MVP) which we receive monthly and quarterly raised this as an issue. Key issues raised were delays in IOL process followed by separation from partners, lack of support and information regarding IOL process.
The project:
Quality Improvement Project to help improve workflow and care provision in relation to the IOL (IOL) process.
We have utilised the MVP feedback to apply for funding from a few different sources (including unit/ward specific charitable funds, League of Friends, local clubs) to be able to improve our IOL spaces and capacity. This has been used to facilitate partners staying overnight (where clinically appropriate) in side-rooms with pull-down beds. It has enabled us to plan a ‘Patient Wellbeing’ room with sofa, fridge (so that women can store their own food if required), things to do such as puzzles and colouring books and with ambient lighting to create a relaxed space during the IOL process. We have also begun to rearrange IOL space on the antenatal ward where a 4-bedded bay will become a 2 bedded dedicated IOL space, which will contain birthing balls and mat.
We have adjusted the IOL midwifery staffing to provide consistent cover throughout a 24-hour period (3 midwives per shift). This has meant we have been able to invite women to attend for the start of their IOL at any time between 6.30am to 10pm. We are also in the process of changing the way that IOL is administrated to simplify and make processes more effective, including Maternity Support Workers being involved in booking and updating women about their IOL and using Microsoft Teams for documentation. We have also introduced Outpatient IOL using Dilapan® for low-risk multiparous women.
The impact:
Staff are happier with the overall changes so far as identified in feedback (via survey monkey). The unit considers that there are fewer IOL delays. We have an ongoing audit and will be happy to provide this data once this has occurred. We have created a bespoke IOL feedback QR code which is on the new patient information leaflet, and we should start gathering this data soon.
The staffs raised concerns regarding a lack of IOL training. – We are now in the process of creating a training package for all midwives to increase confidence in caring for women having IOL.
For further information contact:
Kate Eadie Antenatal Ward Manager and IOL lead midwifeKate.Eadie@ouh.nhs.uk
Authors: Sophie Mackenzie (Royal Berkshire NHS Foundation Trust), Jack Hamer (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)
The setting:
The Royal Berkshire NHS Foundation Trust maternity unit serves the area of Reading and West Berkshire, offering a comprehensive maternity service where almost 5,000 babies are born every year. There is a level 2 Neonatal Unit.The Trust covers both urban and rural communities with a diverse population. The current IOL rate is 38%. The women remain on the IOL unit until their cervix is favourable for artificial rupture of membranes (ARM) or they spontaneously go into labour. At this point, they are transferred to the LW to continue their care.
The problem:
Due to the rising rate of women undergoing IOL, the trust had increasing difficulties in managing women’s expectations, particularly when providing specific dates and times for women to commence their personalised IOL. Difficulties were primarily identified either through formal complaints received through the Patient Advice and Liaison Service (PALS) and/or from verbal feedback that staff had received from the women.
The project:
1. IOL core team: The maternity unit has constructed a permanent IOL team comprising of a core group of five band 6 midwives, who are led by a band 7 ward manager (see link). The team was launched in February 2017 and work within an IOL suite, located on the antenatal ward, with support provided by the obstetric multidisciplinary team.
2. Booking IOL: All IOL appointments are requested by the community midwife or obstetrician by using the electronic patient record (Cerner) system and scheduled by the IOL midwifery team, with support from admin staff. Women are offered an appointment day to commence their IOL, but without a specific time, thus aiming to widen women’s expectation of when their IOL will take place.
3. Communication with women prior to admission: Women are sent a personalised email, from the dedicated IOL email account, detailing information about their IOL at the Trust (see link). They receive an information leaflet (see link) containing key items about the process of IOL, including contact details if they decide to decline IOL. This aims to improve clarity and involvement of women in their own care, whilst upholding autonomy. If women do not hear from the IOL Midwife by 8pm on the day of their appointment, they are informed within the email to call the team on the dedicated phone line number provided to receive an update. The women are informed that they can be contacted at any time on their appointment date and that the appointment can also be subject to change depending on the capacity of the unit. The IOL midwife will aim to call all the women to give them regular updates on the time to come in, ideally during the morning of their appointment if they have not already been contacted. The women are also given information about the Labour Suite and what to expect (see link).
The impact:
The majority of feedback from women has been positive, with women citing a greater understanding of the IOL process including potential uncertainties, more personalised communication, and the opportunity to be at home while awaiting the start of their IOL, rather than waiting in hospital. Clinical staff also report an improvement in women’s overall expectation and familiarity of the IOL process, whilst able to maintain effective communication with women and manage the workload more efficiently. On occasion women have reported negative feedback about their expectations of the IOL, however, this has been mainly attributed to the overall length of the full IOL process.
Future scope includes the possibility of a formal audit looking at the women’s perspective with the current IOL pathway.
For further information contact:
Sophie Mackenzie: IOL lead and senior midwife
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