IDEAS & RESOURCES FOR IMPROVING INDUCTION OF LABOUR PRACTICE

Group facilitators: Sharon Morad (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham), Sarah Roberton (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: Chineze Otigbah (Barking, Havering and Redbridge NHS Trust), Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Barking, Havering and Redbridge NHS Trust has a maternity unit at Queens Hospital, Romford, which has 7,100 births annually and an IOL rate of 27%. They have a Delivery Suite, a Birth Centre Midwifery unit (for low-risk women) and offer a home birth service. There is a Fetal Medicine Unit and a Level 2 Neonatal Unit. They care for a population with high levels of deprivation and a large migrant population.

The problem: 

Multiple issues were identified: 

· Saving babies lives and implementation of Gap Grow resulted in an increase in induction rates from 28% to between 34-39% on occasion, with no change in capacity and staffing. This also dovetailed with the retirement of senior midwives in 2019-2020 and recruitment and retention issues.

· On some days as many as 10 inductions were booked on one day. On busy days, inductions had to be deferred. In order to ‘safety net’ the women and their babies, they then had to be assessed and sent home to `wait' until they could be called. On occasions they had to return daily for fetal assessment until there was a space. 

· The number of complaints increased, and midwives and doctors were dealing with angry women and their partners. The day unit was inundated with returning women who could not be induced. 

· This resulted in women who really needed inductions not having them in a timely manner, whilst those that complained the loudest were being given priority.

· Those on the antenatal ward were waiting up to 5 days due to the lack of LW capacity, with backlogs causing further complaints. Often there were no antenatal beds to facilitate admissions of other women such as those with PET, antepartum haemorrhage (APH), premature rupture of membranes (PPROM) resulting in the need to discharge women earlier than normal to create bed capacity.

· In March 2020 there was lockdown. All the strands of triaging, creating and offering intermediate risk IOLs as outpatients all had to come together to maintain a safe service, thus became the basis for the clinic. 

The project: 

Involved several components. Supervision of IOL process is overseen by a consultant with specialist interest: 

· Setting up a midwifery run IOL clinic in the Obstetric Assessment Unit where midwives triage the women using the RAG rating tool (to be described), conduct full assessments (using computerised cardiotocography scans as needed), provide cervical sweeps and information about IOL. They also identify women who may not need to be induced. 

· The Queen’s Hospital RAG rating tool was developed by using an agreed list of conditions based on current guidance for women undergoing IOL. It enabled identification and prioritisation of women with risk factors based on the RAG rating matrix, to stratify those with the highest risk as red meaning induction within 24 hours of the date given and not to be deferred. Those rated amber to be booked between 24-48 hours of the date given and possible deferral of up to 48hrs with reassessment of the patient before deferral if a red rated induction is required. Similarly, with green; to be booked between 48-72 hours of the date given, and the option of deferral if necessary for up to 72hrs, again after reassessment of the patient. 

· The tool therefore informed on the timing of the booking of the induction in the antenatal clinic and the triaging at the time of booking as well as re-organising the admissions according to risk and bed availability thus avoiding the issues described above

· The RAG rating is also used to warn women in the amber and green category that their inductions might be delayed at least once after careful assessment to provide for more urgent cases thus pre-warning them.

Evidence for the RAG rating:

All the conditions listed have some type of guidance in terms timing of delivery, and what effect the maternal condition may have on the fetus. For example:

· In women with gestational diabetes (GDM) on diet, if well controlled, NICE guidance recommends delivery any time between 39+6 and 40+6 weeks. This provides flexibility making the women suitable for the low-risk green category and outpatient IOL.

· Women with intrahepatic cholestasis (ICP) with bile acids of >100, abnormal Dopplers, poorly controlled diabetes and moderate/severe pre-eclampsia (PET) have an increased risk of unexpected stillbirth and /or maternal compromise. They are therefore graded red with a recommendation for urgent delivery (Green Top guideline, RCOG) and no deferrals.

· In ICP bile acids of 40-99, the RCOG Green Top Guideline recommends delivery between 38-39 weeks, so suited for amber/ red RAG rating depending on the level of bile acid.

· With mild pregnancy induced hypertension (PIH), there is no consensus of timing of delivery but if well controlled, can be deferred for between 2-3 days of decision made for IOL. We consider, however, that an amber RAG rate is appropriate as it may affect both mother and fetus.

· In women with Type 1-2 Diabetes, NICE recommends birth to be between 37 and 38+6 weeks, so amber or red RAG rating depending on fetal and maternal wellbeing.

· IOL for maternal age, in vitro fertilisation (IVF), symphyseal pelvis dysfunction (SPD), previous stillbirth (non-recurring cause) are all without consensus, other than delivery at/by 40 weeks. 72 hours variance would therefore be acceptable, hence a green RAG rating. 

· Usually, only amber and green RAG rating can be deferred, and all women will need review if their IOL is deferred.

This method has increased the numbers of women being offered outpatient induction. We use osmotic methods (Dilapan®) for cervical ripening, inserted by the trained midwives, for women assessed to have a low or intermediate (green or amber) risk. This allows for higher risk women to be prioritised for admission and result in increased capacity. 

The impact:

Overall, there have been substantial improvements, demonstrated by a prospective data collected by the midwives and presented yearly.

The midwife led IOL clinic has resulted in:

· More cervical sweeps so that more women come in labour and thereby avoid IOL (8-10% fewer IOL with no increase in maternal or neonatal morbidity). 

· Annual audits with results indicating an improvement in all parameters, including length of time to admission, need to defer, length of time waiting to be transferred to delivery suite. 

· Complaints from women and their partners regarding delays in beginning the process have all but stopped.

· The RAG rating system has enabled the more urgent women to be prioritised. These 2–3-day difference of admission for IOL has improved the flow through the unit, facilitated safe outpatient induction, and enable prioritisation. This has been presented to the Northeast London Maternity and Neonatal Network and is supported by the network.

· Training midwives to undertake induction in the clinic has resulted in an increase in the number able to have outpatient IOL by 30%. More women are therefore at home during the early stages of IOL and fewer are waiting for ARM in the hospital, or occupying the antenatal ward.

· Women are more informed about the process and have time to ask questions. They are informed about potential delay so they are prepared if their induction is deferred and as long as they have been assessed, are safe to remain at home. Audit shows a marked reduction in complaints and increase in compliments for the midwives.

· These changes have significantly reduced the incidence of women having their IOL cancelled or postponed at short notice and improved the flow of inductions as it removed the extreme peaks and troughs which challenged the system. 

For more information contact:

Chineze Otigbah, Consultant Obstetrician 

Email: chineze.otigbah@nhs.net

Authors: Nicky Farmer (Birmingham Women’s and Children’s NHS Foundation Trust), Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Sharon Morad (Birmingham Women’s and Children’s NHS Foundation Trust) 

The setting:

Birmingham Women’s and Children’s NHS Foundation Trust has a larger tertiary maternity unit with a level 3 neonatal unit. They are a quaternary referral centre for fetal medicine and the maternal medicine network hub. The birth rate is approximately 8,000 per year with 30% of women undergoing IOL. The population is largely urban and highly multicultural with a disproportionately high level of women with deprivation. Women at higher risk of complications (e.g. Fetal Growth Restriction or scarred uterus) are induced in the Induction Suite, a 5-bedded bay on delivery suite, whereas women at lower risk start their induction on the antenatal ward on the floor above.

The problem:
Delays during the IOL were identified as a source of poor experience from women through frequent PALS and formal complaints and as a source of harm in adverse events reported through Datix® and SIRI investigations. A deep dive analysis comprising an audit of all the inductions in September 2020 and a process map of the induction pathway was undertaken by a midwife supported by the trust’s transformation team. This analysis confirmed that large numbers of women were exposed to significant delays throughout the IOL process with 56% of women delayed on - admission and delays after completion of cervical priming with 45% waiting over 24 hours for transfer to delivery suite for ARM / oxytocin infusion (and of these 59% waited over 48 hours for transfer). It also identified that increasing length of delay was associated with increased risks of adverse maternal and neonatal outcomes and caesarean birth, and a reduction in spontaneous vaginal birth. A process map of the entire IOL pathway was constructed and data collected on how many women experienced delays and where in the pathway their delays were likely to occur. A root cause analysis identified the following four problems:

1. Although the mean number of beds required for IOL each day did not differ significantly from the mean capacity there was a day-to-day mismatch between demand and capacity because of the wide variation in the number of women booked to begin their IOL on any given day with frequent overbooking of IOL beds and poor clinical prioritisation.

2. The peaks and troughs of women awaiting transfer was further exacerbated by a a wide variation in the length of potential cervical ripening regime times. At the beginning of the project there were 5 different regimes with lengths of time ranging from 0 hours (for women have IOL following a previous caesarean birth who had prelabour rupture of membranes at term) to a maximum of 74 hours for nulliparous women. This resulted in a large variation in the number of women that complete their cervical ripening phase on a day-to-day basis which caused delays in transferring patients to Delivery Suite for ARM.

3. The long cervical ripening regimes also resulted in women spending many days occupying IOL beds, which increased bed demand. As a result of this, bed demand was always 100% of capacity. This caused bottlenecks during IOL admission as the unit was unable to admit new women for IOL until transfers to delivery suite had been made. On occasion this resulted in unacceptable delays in admission for women with urgent need for induction because an IOL bed was already occupied by those with less pressing clinical indications.

4. Lack of oversight of women undergoing IOL throughout the trust. Women could be booked in for IOL by any clinician with no immediate mechanism to ensure that the IOL complied with local guidance. The IOL process began in one of two different areas of the trust (the antenatal ward or the IOL suite) which did not always communicate effectively together.

The project:

1. Changes in the IOL pathway:

a. IOL Safe Gestational Ranges were implemented. (The details of this change are discussed in Chapter 5)

b. Reducing the length of time for cervical ripening for nulliparous women. At the beginning of this project, the cervical ripening regime for nulliparous women could take up to 74 hours, this was reduced to a maximum of 30 hours by changing the cervical priming agent.

c. Change in the pathway for women with pre-labour rupture of membranes at term, including offering women a choice of immediate IOL, IOL after 24 hours, or expectant management if IOL is declined; and where prostaglandins were offered for cervical ripening, reducing the regime length from 24 hours (using Propess®) to 6 hours (using Prostin®).

2. Creation of a new role, the Flow and Capacity Midwife (see link for job description and business case). This role, initially as a trial period, is now substantive and covered by two midwives, 7 days a week. 

a. In normal working hours, all booked inductions go through the Flow and Capacity Midwife, who ensures correct indication and appropriate gestational range are recorded and the correct location to commence IOL is identified. Where there are periods of high demand, the capacity midwife will suggest that a woman should be scheduled to begin her induction on a different day within the safe gestational range. 

b. As the midwives in this role are senior and very well informed regarding the guidance regarding indications and timing of IOL, they can respectfully challenge a clinician who requests induction outside of guidance. Sometimes a second opinion from a senior doctor is sought until an agreement is reached. When inductions have been appropriately booked, it becomes more objective and straightforward to prioritise admissions.

c. Each morning, the Flow and Capacity Midwife reviews all women due to be admitted that day, prioritises the order of admission and potentially postpones some women if acuity of the unit is high. Women are only postponed to another date within their safe gestational range. Importantly, she also updates the Delivery Suite Shift Leader and relays any concerns or breaches.

d. The Flow and Capacity Midwife has developed and maintains the IOL of labour spreadsheet (see Chapter 6 for details) which is displayed on a large screen in the delivery suite handover room, providing continuous real time data of all women undergoing IOL within the trust at any point in their IOL journey. This ensures that complete oversight of all women can be maintained with up-to-date information for risk assessment and prioritization.

The impact:

1. Reduction in admission delays (Delay = anyone admitted for IOL outside of their Safe Gestational Range):

· Average of all IOL admission = 07:05 hour delay (Sept 2020) to 0:13 min delay (Aug 2022)

· Average delay of those classified as delayed = 39:42 hours (Sept 2020) to 12:54 hours (Aug 2022).

· Percentage of mothers with a delayed IOL = 17% (Sept 2020) to 4% (Aug 2022).

2. Reduction in the time waiting for transfer to delivery for ARM / Oxytocin

· The percentage of women being transferred to Delivery Suite for ARM / oxytocin infusion within 6 hours has increased from 43% (Sept 2020) to 57% (Aug 2022)

· The percentage of women waiting over 24 hours for transfer to Delivery Suite for ARM / oxytocin infusion has decreased from 32% (Sept 2022) to 13% (Jan 2023).

3. Total length of IOL

· The total mean length of time from admission for IOL to birth has reduced from 57:33 hours to 41:28 hours 

For more information contact:

Nicky Farmer (IOL Flow and Capacity Coordinator) nicola.farmer1@nhs.net or Sharon Morad (Lead Obstetrician for Delivery Suite) sharon.morad@nhs.net

Authors: Mary Goodin (East and North Hertfordshire NHS Trust), Katie Lang (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

East and North Hertfordshire NHS Trust has a maternity unit at the Lister Hospital in Stevenage. The unit has 5,100 births annually and a Consultant led Delivery Suite as well as a Midwife led unit. The IOL rate is between 30-33%. Induction is usually started on the antenatal ward, unless there are maternal or fetal concerns. There is a fetal medicine service and a Level 2 Neonatal Service which includes Intensive, High Dependency and a Special Care service. The population consists of a mix of rural and urban populations: 91% of women spoke English as their first language, 14% of women were from ethnic minorities, 2.7% of women were from the most deprived category as defined in the 2020 MBRRACE report.

The problem:

When NICE updated its IOL guidance in May 2021, concerns grew that the unit’s capacity for to carry out a potentially increased number of inductions was inadequate. Delays in the pathway have also previously been highlight in Serious Incidents and by the risk management team. This resulted in:

·  A month-long audit into the flow of every patient undergoing IOL– looking at numbers being induced, the indications for induction and any delays that occurred. We found the biggest delay was waiting for a transfer to labour ward for an ARM. 

· Conducting staff & patient surveys to have a wider review of the service. 

      - Key findings from women were a desire for better quality information about the process of IOL and better communication regarding delays. 

      - The staff survey findings recommended the introduction of a booking sticker or proforma to ensure all the options were discussed with women prior to admission for their IOL and indications and timing of the IOL were clear to staff carrying out inductions plus an introduction of a RAG rating system to help prioritise IOLs. 

· Liaising with other units looking for ideas and set up a group containing a lead consultant, antenatal ward manager, matron and consultant midwife to work on a variety of improvements.

In addition to concerns about unacceptable delays because of higher numbers of IOL, there was no effective method of tracking and appropriately prioritising women who were waiting for transfer to labour ward, with the potential risk for women to be missed. It also featured in the Ockendon report about a “culture of delays” in transferring women having IOL to Delivery Suite.

The project:

Introduction of an IOL Oversight Board, situated on Labour Ward. It currently gets updated twice a day and discussed at the sitrep meeting, where the manager of the day, LW coordinator, matron and consultant on-call run through the unit’s activity and staffing and any concerns escalated. The board is maintained by the coordinating midwife on labour ward and includes:

· Women’s names

· Indication for induction

· Any additional risk factors 

· Length of time waiting for ARM

The consultant undertaking the ward round of antenatal women is then in a position to bring updates to the labour ward IOL board and assist with prioritising women who are not known by the labour ward team, due to their location on the antenatal ward.

The oversight board aims to ensure these women remain in the forefront of the labour ward teams minds and the future workload is visible. It has raised the profile of women undergoing IOL, to those waiting for a category 3 caesarean section. It is also a useful tool at the midday situational report (‘sitrep’) meeting. One of the routine questions at this meeting is “do we need to ask for mutual aid?” This is where we ask other units (firstly within our LMNS) if they can take any women if there are significant delays and we are unlikely to facilitate their ongoing induction in a timely fashion. We do have a SOP for this as part of our ‘escalation policy’ (see link).

A Red, Amber, Green (RAG) rating system developed by Queen’s Hospital at Barking, Havering and Redbridge NHS Trust (featured in Chapter xx) is also used to assist prioritisation decisions, bringing a clear colour-coded visual aid to highlight women in the highest risk categories.

To publicise all the aspects of the QI work on the IOL pathway, a 9-minute video tutorial was created and shared with all medical and midwifery staff, updating them with the changes, which was effective. This was so successful that we repeated it when BSOTS was introduced to our unit. 

An IOL booking checklist sticker has been developed and is currently placed on women’s notes to standardise discussions and signpost to an information leaflet for women (see link). 

The impact:

Due to the recent launch of the IOL Oversight Board, its impact is yet to be formally evaluated but positive comments have been received, in particular from the ward staff, reflecting that the women they are caring for report being more informed and understanding the reasons they may need to wait longer. A new team has been set up to work on the “IOL next steps” project which will focus on working further on the delays in the pathway and improving our outpatient IOL rate. 

For more information contact: 

Mary Goodin Consultant Obstetrician Mary.goodin1@nhs.net