IDEAS & RESOURCES FOR IMPROVING INDUCTION OF LABOUR PRACTICE

Facilitators: Susie Al Samarrai (Sherwood Forest Hospitals NHS Foundation Trust), Nimarta Dharni (University of Birmingham), Sam Russell (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: Victoria Wenlock (Belfast Health and Social Care Trust), Sami Saba (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Belfast Health and Social Care Trust’s Royal – Jubilee Maternity Service is a medium sized Trust with approximately 5000 births a year. It is a tertiary referral service for Northern Ireland. The neonatal unit is level 3. Greater than 50% of the population it serves are social class 5, demonstrating the highest level of social deprivation. There currently is an IOL rate of between 40-50%.

The problem:

A number of problems were identified through Serious Adverse Incidents and complaints that were recurrent concerning the entire IOL process. It was noted that there was little information given to women regarding the IOL process such as information about why it was needed, the benefit and risks, time of admission as well as poor continuity of IOL care provision.

The project:

In April 2019 the following technology tools to streamline IOL services were implemented: 

· E-referrals from community midwives or antenatal clinic for an IOL to be arranged

· Text messages were sent from the IOL team, once the telephone number has been confirmed to: 

• confirm booking at pre-induction assessment clinic 
• inform women of their planned date for IOL to be commenced

This intervention was part of a group of IOL interventions which included the following initiatives:

· An IOL team was appointed consisting of 1 x Band 7, 2 x Band 6 and 2 x Band 3 MSW

· A Pre-Induction Assessment Clinic was commenced to discuss IOL expectations, consent and offer a membrane sweep

· The main agent for cervical ripening was changed from prostaglandin (Propess®) to mechanical method (Foley catheter) that the midwives were trained to insert

· The IOL service was relocated to a previously disused ward area outside delivery suite

· An outpatient IOL service was introduced

In March 2020 the service expanded to provide links to YouTube videos (see IOL - YouTube) via text message to enable women to visualise the IOL ward and the staff involved, as well as inform about options for cervical sweeps and IOL processes. These were developed by the IOL team with help from the Trust communication team and in partnership with the local Maternity Liaison Committee. 

The impact:

In 2019, before and after 60 days of implementing the IOL team and clinic, e-referrals and initial text messages a telephone survey was conducted of women who had used the service. There were 100 responses, which showed large increases in women’s satisfaction with IOL: 

1. How well did you feel prepared for your induction?

     Prior to IOL Team: 44% reported feeling fully prepared

     Post IOL team: 87% reported feeling fully prepared

2. Difference to change of IOL agent?

      80% rated experience excellent or good with Propess® IOL

      100% rated experience excellent or good with Foley IOL

3. How would you rate the IOL experience?

      Prior to IOL Team: 42% good or excellent

      Post IOL Team: 93% good or excellent

Additionally, the following data was obtained from 30 women:

1. Hyperstimulation experienced

      With Propess® - 27%

      With Foley - 0%

2. Tachysystole

      Required Propess® to be removed– 47% 

      Required Foley to be removed - 2%

3. Required terbutaline for hyperstimulation

      With Propess® IOL – 11%

      With Foley IOL - 0%

The compliments increased and complaints around IOL reduced. By creating a team providing IOL care, women were able to access more information during decision-making as well as continuity and support throughout the IOL process. 

An unexpected outcome was a reduction in the number of women attending for IOL and the spontaneous onset of labour increasing, thought to be as a result of the dedicated clinic offering sweeps. 

For more information contact:

Victoria Wenlock IOL Team Project Lead Sister (Victoria.Wenlock@belfasttrust.hscni.net) or Helen Goodall (Helen.goodall@belfasttrust.hscni.net) 

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 is 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:

1. Documentation regarding IOL for individual women: The maternity unit transferred record keeping to an Electronic Patient Record (EPR) some time ago. However, within this record there was no dedicated area/section in which to document IOL discussions, bookings or the IOL process. All documentation was free text which meant information was only stored in chronological order rather than within a central area for IOL. This made it difficult to follow a woman’s pathway through her IOL journey while an inpatient and auditing IOL processes was time-consuming and often inaccurate.

2. Process of booking women for IOL and tracking their process through the IOL pathway: Women requiring IOL were booked into two paper diaries (one for lower-risk women that could be induced on the antenatal ward and one for the IOL Suite where high-risk patients are induced). While inpatient, women’s details were maintained on ward handover sheets and updated on the computer twice daily. Those awaiting transfer to delivery suite for ARM or oxytocin infusion were transcribed onto a separate paper list which was reviewed at least twice daily and the priority set by the obstetric consultant. The paper diaries and lists risk having incorrect information inputted or transcribed, with a loss of paper lists and the lack of an audit trail if information went missing. All this together meant there was little oversight of women that were booked to come in and those who were in the hospital undergoing IOL including women awaiting transfer to delivery suite for ARM or oxytocin infusion.

The project:

Clinical midwives and medical staff worked collaboratively with the EPR designers to develop the following features within the EPR.

· Electronic IOL Booking Form 

§ Completed by the clinician booking IOL

§ Documentation includes the following:

      · Clinical indications for IOL

      · Appropriate gestational range in which the IOL may be commenced

      · Planned date and location of admission

      · Planned method of IOL is documented

      · VE findings and cervical sweep (if offered)

      · Details regarding the conversation with the woman including indication for IOL and the process and risks of IOL

· IOL tab and enclosed Induction details pages

§ Completed by midwives caring for women undergoing IOL

§ Progress through the IOL pathway is recorded in these pages, including the following:

      · Maternal observations and examinations (e.g. Bishop’s score)

      · Fetal monitoring

      · Induction agents used 

      · Medications administered (e.g. prostaglandin’s, analgesia) 

      · Clinical change (e.g. SROM, contractions, bleeding)

      · Time ready for transfer to DS for ARM/oxytocin

· Electronic Ready for Delivery Suite list and prioritisation 

§ This is a live electronic list of all women currently undergoing IOL (including both the antenatal ward and the IOL suite) with the ability to select women awaiting transfer to Delivery Suite for ARM or augmentation. It proved impossible to develop the functionality for this dashboard within the EPR, and therefore the clinical team have developed an excel spreadsheet which can be accessed and edited by all members of the IOL team, includes an audit trail for governance purposes and is backed up on the trust servers.

§ This active dashboard will include important details including the following:

      · Name and location of woman

      · Indication for IOL and gestation

      · Comorbidities and other risk factors

      · Critical times including: commencement of IOL, SROM, ready for transfer

      · Prioritization order for women requiring transfer

§ The medical staff and delivery suite shift leaders are then able to view this list taking all factors into account and electronically prioritise which women require transfer to Delivery Suite first depending on their individual circumstances.

The impact:

Development of the individual elements of the EPR (i.e. the Electronic IOL Booking Form and the IOL tab with the enclosed Induction details pages) has been straightforward both to design and implement. Completion of the IOL booking form was formally assessed during the implementation phase until completion rates of >90% were consistently found. Completion of the IOL tab is well embedded in practice, particularly for examinations and interventions while some other fields (e.g. ready for delivery suite) are less reliably completed.

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: Leanne Rutkowski (Sheffield Teaching Hospitals NHS Foundation Trust), Sami Saba (Birmingham Women’s and Children’s NHS Foundation Trust), Sara Kenyon (University of Birmingham), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Sheffield Teaching Hospitals NHS Foundation Trust – The Jessop Wing is a tertiary Fetal and Maternal Medicine Centre, has a level 3 Neonatal Unit and accommodates approximately 6500 births per year. It serves an ethnically diverse area, including both rural and urban populations and significant levels of deprivation. The IOL rate is between 26-29%. Cervical ripening takes place on the antenatal ward with Propess or is undertaken on an outpatient basis with an intracervical balloon. Once ready for ARM, women are moved to the Labour Ward.

The problem:

The maternity unit recognised safety concerns regarding the prioritisation of women awaiting transfer to the Labour Ward (LW) for ARM. Patient complaints, clinical incidents, Datix® reporting, staff concerns and a recent CQC report all highlighted the need for a robust prioritisation process that was easy to view and readily auditable. 

The project:

A multi-disciplinary team (consisting of an obstetrician, midwives and IT systems specialist) developed a RAG prioritisation system which classifies urgency of women ready for ARM as Red, Amber or Green. The system also displays relevant clinical information, length of time waiting and allows clinicians to prioritise in numerical order. The prioritisation system was developed using clinical expertise and incorporates national guidance. The system was piloted, amended and then rolled out on 1stMarch 2022. [Link to rag rating score]

Once the woman is suitable for ARM and ready for transfer to LW she is added to the digital board. The obstetric consultant on call, in conjunction with the LW coordinator, reviews the clinical information and classifies the woman as red, amber or green urgency. The list is reviewed at least twice a day on the Ockenden ward round. If a women is rated as a ‘Red’ indication the aim is admit to LW and perform ARM within 24 hours. If the women is rated as ‘Amber’ ARM should take place within 48 hours and for less urgent ‘Green’ indications ARM should take place within 5 days. 

The electronic Board on LW shows the number of women awaiting ARM, their reason for induction, relevant clinical details, category of urgency and allows women to be prioritised in numerical order. The electronic board is visible remotely to the Maternity Leadership Team and trust on-call manager allowing improved oversight regarding the number of women waiting for ARM and their risk profiles, ensuring an accurate assessment of the unit acuity level. 

The impact:

The Trust data systems did not enable a robust assessment of impact. However, an audit for the month of September 2022 highlighted 136 women on the ARM list with an average waiting time of 50 hours. Approximately 73% of these women received an individual risk assessment with an average wait time of:

· High risk (Red) 26 hours (birth targeted to be within 24 hours)

· Medium risk (Amber) 43 hours (birth targeted to be within 48 hours)

· Low risk (Green) 64 hours (birth targeted to be within 5 days)

This demonstrated that most clinicians were using the RAG prioritisation system and that ARM was being undertaken within an acceptable timeframe for the majority of women. There was a reduction in complaints and Datix’s® and an improvement in staff morale was noted; this was attributed to the system feeling safer and being more transparent to both staff and women. 

Changes to the IOL Maternity Information System have improved visibility of the number of women booked for IOL in the future, as well as providing information on current induction activity (number of women undergoing cervical ripening, number of women awaiting ARM/acceleration of labour and number of induction women in active labour). This has the ability to increase bookable slots when urgent IOL need to be booked to ensure complete oversight, removing the need of a paper diary. The consultant undertaking the daily antenatal ward round can also view the ARM list and communicate any concerns or changes in women’s clinical condition with the on-call team. The system is useful for communicating realistic timeframes with women and managing expectations.

Since rollout, the IOL RAG rating has been an extremely useful tool for communicating risk and acuity levels within the trust and within the wider LMNS. It has been utilised in discussions about escalation processes and transfer of women to other units if ARM is likely to be delayed. The LMNS is in the process of adopting the IOL RAG rating so that there is a local common language at regional escalation meetings. The RAG rating assessment has enabled us to assess how many women across all urgency categories are awaiting ARM in the region, ensuring that the highest risk women are prioritised for the next available LW beds.

For more information:

Tessa Bonnett – Consultant Obstetrician  - tessa.bonnett1@nhs.net

Leanne Rutkowski – Intrapartum Services Matron - leanne.rutkowski@nhs.net

Sarah Stuchbury – Inpatient Services Matron – sarah.stuchbury@nhs.net

Authors: Katie Philpott (Dudley Group NHS Foundation Trust), Sami Saba (Birmingham Women’s and Children’s NHS Foundation Trust), Fiona Cross-Sudworth (University of Birmingham)

The setting:

Russells Hall Hospital of the Dudley Group NHS Foundation Trust in Dudley is a district general hospital serving a small geographical area with 4,100 births at a single site and a level 2 NICU. The population is primarily white British, English-speaking, and urban, with deprivation levels that are roughly median for England. The IOL rate is currently 34% having increased from 26% in 2021. The delivery suite has 8 IOL beds (4 x 2 bedded rooms), and the remaining IOL inpatients are managed on the maternity ward adjacent to delivery suite. 

The problem: 

Following cervical priming women were waiting in the IOL area of delivery suite and the also on the antenatal ward for transfer to delivery suite for ARM or oxytocin. This was often significantly delayed due to staffing and capacity issues. Within the previous 12 months there had been 18 formal complaints and a vast number of PALS complaints from women where delays or IOL processes were stated as a concern. 

It was noted that the number of IOLs booked for each day was inconsistent and this caused a backlog within the system. The standard model for number of inductions to be booked per day is 4 per day. However, when 1 month was audited there were between 2 and 8 women booked daily. This inconsistency led to more dissatisfaction for both women and staff. There were long waiting times for women who were booked on a high workload day, and staff felt that they were unable to manage or standardise their workload. There is capacity for only 8 ongoing IOL patients, leading to some high risk IOLs taking place on the antenatal ward adjacent to delivery suite. 

In a recent survey of staff and women the overall score for having a positive experience during the IOL process was only 3.2 out of 10. The staff score for being able to give the care they wished was 5.2 out of 10.

Staff of all professions caring for the IOLs were asked for their feedback at the end of the shift, whilst women undergoing induction were asked at the point of ARM or starting the oxytocin infusion. The surveys were available to staff and patients via a QR code, using Microsoft Forms.

The project:

In 2022, the Trust carried out a week-long improvement event designed to look at IOL as a whole. Service users were not present at the event, though women’s voices had been heard through surveys and through other forms of feedback such as PALS and complaints. A consistent theme coming through women’s feedback was that where possible and safe, they preferred to be at home during the cervical ripening phase of IOL rather than in hospital. The improvement event took place off-site event and was attended by 30 members of the multi-professional team of all grades (obstetrics, anaesthetics, assistant directorate manager, paediatrics, theatres, and the senior leadership). The team was taught LEAN principles of improvement theory[i] and was given opportunities to apply it to their area of practice. During the event, the current state was mapped, problems were identified and the opportunities for improvement noted. A video of the report out can be seen here. By the end of the week the following aim for IOL was set:  

“By 30th September 2023 we will improve patient and staff satisfaction by reducing delays by 20% whilst implementing individualised care pathways for IOL in Maternity. We will ensure that all women who enter the pathway are fully informed and correctly prepared for IOL.”

Two changes to the IOL pathway have been introduced since the improvement event:

1) Introduction of Dilapan® for outpatient induction of labour (see link). This expands the number of women who could be eligible for induction of labour, which increases maternal choice (see link) and has the potential to accrue cost savings for the unit. During a 2-month audit, 22 patients could potentially have been eligible for outpatient induction (see link) with Dilapan® instead of inpatient induction with Propess® or Prostin® Gel. The move to outpatient cervical ripening had the potential to result in annual (?) savings of up to £11,749 (see table below). 

Propess (1 application) - £33.00 

Prostin Gel (1 application) - £13.28 

Overnight Stay (24hrs) - £313.00 

Dilapan (4 Rods + equipment) - £35.99 

2) Introduction of an IOL virtual ward. Women were able to be at home during the IOL process, undergoing an outpatient IOL with the safety of knowing they are being monitored on a virtual ward (see link). The women go home with a tablet that asks them questions and gives advice every 6 hours, it also allows video consultation with the Midwife caring for the inpatient IOL women (see link). If the woman identifies a problem, it will also automatically prompt her to call the Maternity unit for advice. At the point in time that the woman can be accommodated for her ARM she can be contacted via the telephone or via the tablet device and asked to attend delivery suite. The information from her virtual ward stay is then uploaded into her electronic patient record and is available as part of her Maternity notes, this includes any triggers, alerts or messages.

The impact:

The number of women eligible with the current guidance is approximately 5 per week which works out between 15-20% of the induction workload. 

Women who are accessing the virtual ward have reported high satisfaction and the feeling of being safe whilst also enjoying their home comforts. The tablet has a built-in survey that the women can completed at any time. 

The following balanced metrics for IOL will be collected as part of the Dudley Improvement Practice project.

· Delivery- Number of women undergoing outpatient IOL 

· Quality- Number of hours waiting for ARM 

· Cost- Bed stay cost saved per patient 

· Morale- Staff and Patient survey

For more information contact:

Katie Philpott - Matron for Maternity Inpatients katie.philpott@nhs.net

[i] https://theleanway.net/The-Five-Principles-of-Lean#:~:text=The%20five%20principles%20are%20considered,%2C%20and%205)%20pursuing%20perfection.(accessed 12.06.2023)