Group facilitators: Andrew Weeks (British Intrapartum Care Society), Asma Khalil (Royal College of Obstetricians Gynaecologists), Magda Skrybrant (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: Sophie Mackenzie (Royal Berkshire NHS Foundation Trust), Sami Saba (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 Labour Ward (LW) to continue their care.
The problem:
This unit found that the recent increase in their numbers of women requiring IOL led to delays whilst awaiting transfer to LW and management of patients' expectations became difficult.
Two audits were undertaken in 2021 to explore the average length of time women had to wait to be transferred to LW once they were deemed suitable (for ARM or augmentation post-Prostin®):
1. Aug-Sept 2021 (from 25 randomly selected samples from the EPR) showed an average wait time of 19 hours 48 minutes (maximum 73 hours).
2. Sept-Dec 2021 (from 40 samples) showed an average wait time of 14 hours 09 minutes (maximum 83 hours).
There had also been an increase in negative feedback from women about the delays in waiting to be transferred to LW.
The project:
Creation of the Royal Berkshire IOL RAG rating system by the IOL manager and consultant midwife:
· The IOL RAG system is a visual aid for the Obstetric & Maternity Teams to visualise the delays in the patients waiting to be transferred from IOL to LW and create an individualised action plan based on it.
· Each woman is categorised on the length of time they have been waiting from the moment they become suitable for LW (the moment that ARM becomes possible, irrespective of whether preceded by mechanical induction or by membrane sweep).
· For those requiring Prostaglandins (Prostin®) due to Premature Rupture of Membranes (PROM), categorisation was determined by the length of time following the Prostaglandin when transfer to DS was deemed appropriate (Trust guideline target is 6-8 hours).
The categories for the RAG system are as follow:
· RED – > 24 hours waiting for ARM/transfer to intrapartum area or 8 hours post Prostin® administration. Actions: Prioritise transfer to LW if able to do so. Women are escalated to the Consultant Obstetrician and Maternity Coordinator for an Obstetric review. An incident report is completed.
· AMBER – Between 12- 24 hours of being suitable for ARM/transfer to intrapartum area or 6 hours post Prostin® administration. Transfer to LW when capacity allows. Actions: Inform Delivery Suite Midwife in Charge and Maternity Coordinator.
· GREEN - Between 0-12 hours of being suitable for ARM/transfer to LW. Transfer to LW when capacity allows, no further action required.
The impact:
In June 2022, the IOL RAG system was implemented. To assess if the RAG system was having an impact, audits were conducted all using 40 data samples randomly selected from EPR:
· At 2 months - 1st June-1st Aug 22 – average wait time was 11 hours 11 minutes (longest wait was 64 hours)
· At 4 months - 15th Aug-15th Nov 2022 - average wait time was 10 hours 30 minutes (longest wait was 48 hours)
· At 8 months – 15thNov 2022-15th February - average wait time was 10 hours 15mins (longest wait was 32 hours)
· A further audit is planned at 1 year
The introduction of the IOL RAG system has seen a positive impact on reducing the time for women waiting to be transferred to LW for IOL. It has now been incorporated into our Trust IOL Guidelines (see link) and used by the Senior Team for the Daily Maternity Operations Meetings. It has been proposed to continue to use the IOL RAG system. The next review is June 2023.
Informal feedback from women reported more clarity about IOL and decisions about delays during the process at the trust. The Maternity Voice Partnership also reported a reduction in negative feedback concerning IOL.
For more information:
Sophie Mackenzie IOL lead and senior midwife sophie.mackenzie@royalberkshire.nhs.uk
Authors: Nicky Farmer (Birmingham Women and Children’s NHS Foundation Trust), Sharon Morad (Birmingham Women and Children’s NHS Foundation Trust), Sami Saba (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. FGR 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:
Thematic review of clinical incidents identified delay in commencing induction in high-risk pregnancies as a safety risk. A deep dive investigation including process mapping the IOL pathway, a detailed quantitative audit of all inductions in September 2020 and qualitative interviews with midwives working in the induction bay, delivery suite shift leaders and obstetric consultants identified two key issues. First, there was wide variation in the number of women booked to commence their induction each day (range 2 to 12) with no mechanism to identify which women could safely be deferred if the unit could not safely accommodate them. Secondly, there was no facility to maintain oversight of all women including those who had begun IOL and those due to come in. A different Midwife Coordinator and Consultant each shift would decide which woman to invite in next, sometimes without a fair representation of the individual risks of all women in the queue.
The project:
The use of Appropriate Gestational Range for induction was introduced to formalise a safe range of dates during which a woman could be admitted to start induction. The quality improvement was conducted through a Plan – Do – Study – Act (PDSA) cycle.
a. Plan: The ranges were proposed by the consultant obstetrician and midwife who authored the IOL guideline after a literature review including any local and national guidance. They were approved by specialty leads and the clinical improvement group. When applied in practice for a specific woman the gestational ranges took into account the woman’s individualised risks and circumstances. For example, if a woman’s only indication for induction was only for diet controlled gestational diabetes, with no other risk factors, her safe gestational range during which IOL should be commenced might be recorded as 40+0 to 40+2, with a view towards achieving birth by 40+6 weeks gestation. If, however, a woman’s indication for IOL was more urgent (e.g. reduced fetal movements in a growth restricted baby), the beginning and end of the safe gestational range would be identical, and the expectation is that they would be admitted directly with IOL commenced as soon as possible. In order accommodate an urgent induction, women with a broader safe gestational range might find their admission deferred to a later date within their gestational range.
b. Do:
i. The concept of appropriate gestational ranges was disseminated to the medical and midwifery teams through team meetings, formal teaching sessions, e-mail and social media. The midwife recording the induction into the ward diary was instructed to ask the booking clinician for the safe gestational range and this was recorded in the ward diary.
ii. If the unit was unable to admit a woman to commence her IOL on the scheduled day, the Delivery Suite Shift leader and Obstetric consultant on-call would be able to recognise at a glance which women could safely have their IOL commencement deferred compared to women who would be at higher risk from delay. Women with a short gestational range are higher priority for admission compared with those with a longer range, as their induction start date can be safely postponed.
iii. At the time of booking the IOL the clinician informs the woman of the date range that would be appropriate for commencing the IOL and of the possibility that their admission might be deferred, but only to another date within the safe gestational range.
c. Study: In order to book an IOL, a clinician needed to call the relevant clinical space (either the AN ward or the IOL suite) where a midwife would document the woman’s details in the IOL paper diary. A new space was created in the IOL diary for the midwife to record the ‘safe gestational range’ along with the other mandatory information. The midwife recording the IOL was asked to prompt the clinician booking the IOL by asking for the safe gestational range if it was not automatically provided. A weekly rolling audit identified what proportion of women booked for IOL had a gestational range recorded in the IOL diaries. This was communicated back to the team every week in an e-mail displaying with the associated run chart which demonstrated a steady increase in the documentation of gestational ranges as the team grew increasingly familiar with the idea. Individual cases where a gestational range had not been identified were scrutinized to see if a gestational range had been documented in the notes but not recorded in the IOL diary. Where no documentation of a gestational range could be found, clinicians were contacted individually by the audit lead in order to better understand their concerns. The most common responses received included either that the midwife recording the induction in the diary had failed to ask for the gestational range, or the clinician booking the IOL was uncertain as to what should be the safe gestational range.
d. Act: The electronic patient record IOL booking page was amended to include a mandatory field for appropriate gestational range. A list of safe gestational ranges for the most common indications for IOL was printed onto small laminated cards that could be carried in the same holder as a clinician’s hospital ID badge and therefore could be accessed for easy reference when booking IOL. This is provided to all new clinicians who come to the trust who have responsibility for booking IOL.
The impact:
· Women’s perceptions: Most women understand that there needs to be some flexibility in when their induction begins in order to ensure that more urgent inductions can be accommodated. They are reassured that although inconvenient, this is safe for them and their babies as long as the new date is still within the gestational range that is safe for them. We have therefore seen a reduction in PALS, formal complaints and concerns expressed in the Birth Afterthoughts service regarding delays in the commencement of IOL.
· Staff perceptions: Qualitative interviews with clinicians report increasing confidence that a standardised approach to booking inductions within safe gestational ranges provides an objective method prioritisation and has meant that the women at highest risk of complications are admitted before women who can safely wait.
· Quantitative results:
- No clinical incidents resulting from women having the commencement of their IOL delayed has been reported during the course of this project.
- The percentage of women who had a delay in commencing their IOL fell from 17% to 4%. Of those women who are delayed, the mean length of delay has also reduced from 39 hours 42 minutes in September 2020 to 12 hours 54 minutes in August 2022.
- As a result of spreading out the number of women admitted for IOL throughout their safe gestational ranges, the peaks and troughs of demand for transfer to delivery suite for ARM has also reduced with 35% of women waiting >24 hours for transfer in July 2022 to 13% in January 2023.
Further information is contained within the Trust IOL Guideline (see link).
For further 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: Summia Zaher (Cardiff and Vale University Health Board), Lauren Day (Cardiff and Vale University Health Board), Sami Saba (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)
The setting:
Cardiff and Vale University Health Board provide maternity services at the University Hospital of Wales, Cardiff. There are approximately 5,500 deliveries per annum and a IOL rate of 35-38% along with a Tertiary level Neonatal Intensive Care Unit with space for 30 cots. The population served is urban with an ethnically diverse population and a mix of socio-economic backgrounds.
The problem:
An increased demand for IOL, which is causing delays. Delay and interruption to IOL is on our risk register as a red rating (from 1/4/22 to 1/8/22 there were 35 adverse events concerning delays recorded on our Datix® Risk Management Information System). Women who have IOL are cared for on the obstetric unit, even if considered low risk, which is reducing their choice of place of birth.
The project:
Our low-risk induction pathway was launched September 2022. An IOL development working group with members represented by stakeholders from all areas of service provision was created and input sought in developing an IOL care pathway for low-risk women.
We aimed to formally evaluate the safety and acceptability of a midwifery led care model for IOL, where mothers with an uncomplicated pregnancy can continue to experience midwifery led care during IOL and birth. This will be in line with the Wales maternity vision (2019) to ensure that maternity care is family centred allowing women choice and involvement in decision-making regarding place of birth. This study allows us to determine the suitability of implementing this pathway into practice and if so dissemination of results will take place across the NHS to other maternity units.
The MLU IOL pathway (see link)
Inclusion Criteria for women to be considered for labour and birth on the MLU (indication for IOL includes any ONE of the below):
Women who are in their first cycle of induction agents (maximum 1 round of Dilapan® and 1-2 Prostin® OR 1 Propess® and 1-2 Prostin®) being induced for the following:
· Post-dates offered from T+10 weeks
· Maternal request from 39+0 weeks
· Symphysis pubis dysfunction from 39+0 weeks
· Pelvic Girdle Pain from 39+0 weeks
· Maternal anxiety from 39+0 weeks
· Large for gestational age where estimated fetal weight 97th centile in the absence of diabetes
· Low PAPP A (pregnancy associated plasma protein A) with normal serial growth scans
· Raised BMI with normal serial growth scans (BMI 39.9 kg/m2 and assessment in healthy pregnancy clinic)
· Previous pregnancy with small for gestational age (SGA) baby with normal serial growth scans in current pregnancy.
· Smoker with normal serial growth scans
· Women with less than 5 previous vaginal deliveries
· Gestation between 37+0 and 41+6 at time of ARM or onset of labour
MLU pathway
Women undergo either inpatient or outpatient IOL as per policy:
· Following one cycle of IOL agent (see above) a 20-minute CTG is performed to confirm fetal wellbeing and assess uterine activity.
· If the CTG is normal, a cervical assessment is offered by the IOL midwife to determine if the woman is suitable for artificial rupture of membranes (ARM).
· If the woman is suitable for ARM, the midwife contacts the delivery suite coordinator to determine acuity on maternity unit. If agreed, an ARM can then be performed on the IOL ward by the IOL midwife.
· A CTG is then be continued for 30 minutes to confirm fetal wellbeing. If the CTG is normal and there are no signs of meconium or blood- stained liquor, transfer to the MLU is arranged.
· A review, including fetal wellbeing assessment is carried out after 4 hours to ensure the woman remains suitable for midwife-led care, is documented. In the absence of contractions, a vaginal examination should not be performed.*
· If labour has established and the IOL remains uncomplicated, the woman remains on the MLU to continue the All Wales Clinical Pathway for Normal Labour. This includes intermittent auscultation through labour.
· If labour has not established but fetal wellbeing has been confirmed, the woman can remain on MLU to mobilise.
· If labour has not established within 6 hours of ARM, the woman is transferred to the consultant led unit (CLU) to commence an IV oxytocin infusion. The woman is informed that obstetric-led care and continuous monitoring is then recommended.
· Transfer to the CLU should be arranged sooner if there is maternal or fetal wellbeing concerns, or if delay in labour is suspected.
Virtual learning sessions with staff has provided training on this pathway.
*The use of CTG on an MLU is not supported by the RCM.
The impact:
A three-month pilot study (n=309 women) was undertaken from 1st September to 30th November 2022, to assess the pathway and identify any issues prior to commencing the formal evaluation study. During the pilot 7 (2%) women successfully used the new pathway. A further 53 (17%) women were identified as being suitable for the pathway as per the inclusion criteria but were missed due to reasons including the closure of the MLU for one month (October 2022) and a lack of staff awareness. To address staff awareness, we have implemented a learning session led by the IOL lead midwife, regular email updates & reminders, discussions of the pathway at daily safety briefings and the addition of stickers with 'suitable for MLC pathway’ being made available on the induction ward and in clinic. In addition, the IOL lead midwife daily identifies those on the list of inductions suitable for the pathway. Since then, 39 women have been on the MLC pathway.
The pre-study pilot has been an important exercise in learning valuable lessons, and has enabled us to make informed changes to improve the awareness of, and use of the pathway within the unit.
Patient and Public Involvement and Public Engagement group sent out questionnaire to service users asking ‘If you had an IOL, would the option of delivering on the Midwife Led Unit be important to you’. 34/47 (72%) responded ‘yes’. Focus groups are being planned for those who responded ‘no’ as well as those who have experienced the MLU pathway. Feedback received from the focus groups will be used to revise the pathway. A data analysis on outcomes is currently also underway.
For more information contact:
Dr Summia Zaher - Obstetric Consultant Summia.zaher@wales.nhs.uk
Lauren Day - IOL lead Lauren.Day@wales.nhs.uk
Authors: Ally Clark (Medway Foundation Trust), Sami Saba (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)
The setting:
Medway Foundation Trust has approximately 4,800 births per year with an IOL rate of 22% (April 2022-March 2023). It serves a diverse population in a large area covering both urban and rural communities including many deprived areas. The hospital has a large fetal medicine unit and a level 3 NICU.
The problem:
Recurrent and lengthy delays during the process of induction were identified on a daily basis through staff updates of the Delivery Suite bed state, with increased IOL related red flags and PALS complaints from women. A need was therefore identified to streamline the IOL system and ensure women were as prepared as possible for the induction process.
The project:
A midwifery-run pre-induction clinic for women booked for induction was developed (see link). The women are referred by community midwives, antenatal and scanning clinics at the same time IOL is booked with an initial appointment at the pre-induction clinic approximately one week before their IOL date, although this can be anytime up to the day before admission. The clinic is held in one of the antenatal 4-bedded wards and is run by midwives with a specific IOL role. In the clinic, information is shared with women as to the reason for IOL, risks, benefits, timescales and processes of IOL in a less time pressured environment than antenatal clinic. A cervical assessment and sweep are conducted and a proforma is completed including information about reason for IOL, history and process. Women can return for second and third sweeps if necessary.
The impact:
The outcome of the pre-induction clinic cervical assessment helps to plan the induction process. If women do not require artificial cervical ripening they can be admitted directly to DS for ARM once a bed is available. This means they can stay at home longer as they are not admitted to the AN ward, and do not have to wait for transfer to DS. Informal feedback from women about direct DS admission has been positive. If there is a DS admission delay of 24 hours or longer, fetal monitoring will be conducted in the meantime on the Maternity Care Unit. The Trust have found a reduction in the numbers requiring IOL for postdates, which is thought to be due to conducting more cervical sweeps.
Formal feedback from women or staff about the pre-induction clinic has not yet been sought.
For more information contact:
Ally Clark Delivery Suite Matron
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