What’s new in the world of maternity in the UK? In England? New for those of us who got involved in family and Christmas preparations in December are the Quality Standards for care during labour and birth – or Intrapartum Care NICE Quality Standard [QS105] – for healthy women with a straightforward pregnancy.
These are based on the NICE Intrapartum Care ‘clinical guideline’ that was published a year ago.
Seven key ‘quality statements’ are highlighted
Seven key ‘quality statements’ are highlighted. These are auditable. Commissioners, managers, and advisory forums where service users get to have a say in what goes on in local services, can use these to audit how services are being run.
If you are are a midwife or a student, on a maternity group, such as an MSLC (https://www.nct.org.uk/professional/mslcs ) or a labour ward forum, these statements might just help you in your work. Are local services complying with these quality statements? If not why not? Is the reason a good one? What are the consequences? Do management know? Do local people in the community know? How does your local service compare with neighbouring services, or services 200 miles away?
The statements are roughly split between positive approaches to care that need to be promoted as they are not mainstream yet (things that should be done), and practices that are commonplace but are not supported by evidence (things that should not be done). In effect, things that need to be undone. Read on (or you can go to : http://www.chimat.org.uk/resource/view.aspx?RID=269485&src=KU )
There are four positive activities to do:
Do – Women receiving care who are unlikely to have complications during labour or birth should be given the choice of planning their birth in any one of four places: in a midwifery unit (birth centre) freestanding in the local community or alongside a hospital, at home, or in a hospital unit run by obstetricians and midwives.
Statement 1. Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.
Do – Women need practical and psychological support in labour, not just task-oriented clinical care. NICE says midwives should provide both care and support, enabled by being allocated on a one-to-one ratio, rather than caring for several women at once or focusing on record keeping at the expense of women’s needs.
Statement 2. Women in established labour have one‑to‑one care and support from an assigned midwife.
Do – Get the woman off the electronic fetal heartrate monitor when the trace is reassuring, if it is used at any stage because of uncertainty about wellbeing. This is important because leaving women on this kind of monitoring equipment can cause harm, e.g. by reducing comfort and mobility and increasing use of other interventions, unnecessarily.
Statement 4. Women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Do – Make it easy, and gently encourage women, to hold their baby next to their skin without clothing in between them, so they have intimate loving contact in the hours and days after birth. This is great for forging loving bonds, helping the baby to feel secure, regulation of baby’s temperature, colonisation of the baby’s skin with mother’s microbiome (healthy bacteria), and establishing breastfeeding.
Statement 7. Women have skin‑to‑skin contact with their babies after the birth.
And the don’ts
Some developments that have become common practice aren’t necessary, and may do harm. Three of these kinds of practices are highlighted as indicators for quality:
Don’t do – Avoid continuous electronic fetal monitoring in women who are healthy and have no known complications of labour. In practice this can lead to false positives (concern when the baby’s heartbeat is normal), and continuous monitoring being continued which can restrict movement, the opportunity to use a birth pool, more need for pain relief and the impact of epidural /opioid drugs for the labour and the baby.
Statement 3. Women at low risk of complications do not have cardiotocography as part of the initial assessment of labour.
Don’t do – Cutting the umbilical cord immediately after birth does more harm than good. It deprives the baby of blood that will circulate from the placenta if the cord is left intact until it stops pulsating.
Statement 6. Women do not have the cord clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Don’t do – Avoid intervening in the biopsychosocial symphony of labour and birth when labour is progressing within the normal range. Surgical interventions, including ‘breaking the waters’ can have an unwelcome impact, including more pain for the woman, leading to other interventions. Giving synthetic hormones interrupts the flow of hormones produced by the women and the development of her labour. Unless there is a reason to intervene, leave well alone.
Statement 5. Women at low risk of complications are not offered amniotomy or oxytocin if labour is progressing normally.
Already well known in the UK
The NICE Intrapartum Care Guideline was made public knowledge when it was distributed for consultation, before the final version was published. There were press and TV stories and social media discussions.So the recommendations are already widely discussed and familiar to many midwives, doctors and women. In the UK, in England, Wales and Northern Ireland NICE the recommendations are generally considered seriously by commissioners and managers. Scotland makes its own clinical recommendations.
Are these standards a reality in your area?
The development of quality standards is designed to promote implementation across NHS services and enable monitoring of practice to improve care and make it more consistent.
Are these standards a reality in your local service – or in your country? If you are doing anything to improve these aspects of care, share your successes. We want to hear all your good news stories.
What can you do to make a difference?
Last July, I organised a conference with NCT and Dr Sara Kenyon of Birmingham University and the West Midland CLARHC to share evidence and good practice on midwifery-led care and choice of place of birth. Sara, Richard and I (see above) contributed to the chairing and discussion. Speakers included:
- Tracey Johnston, Consultant Obstetrician, Birmingham Women’s NHS Foundation Trust
- Tracey Cooper, Consultant Midwife, Normal Midwifery at Lancashire Teaching Hospitals NHS Trust and member of the NICE Intrapartum care guideline development group
- Cathy Shneerson, Reasearch Fellow, University of Birmingham
- Paula Clarke, Consultant Midwife, Birmingham Women’s Hospital
- Sarah Noble, Consultant Midwife, Birmingham Women’s Hospital
- Kirstie Coxon, Senior Lecturer, Florence Nightingale Faculty of Nursing and Midwifery, Kings College, London
- Diane Reeves,Chief Accountable Officer, Birmingham South Central Clinical Commissioning Group
- Kathryn Gutteridge,Consultant Midwife, Serenity and Halcyon Birth Centres
- Soo Downe, Professor in Midwifery Studies, University of Central Lancashire
To be informed and inspired on this topic, see the speakers’ presentations available at https://www.nct.org.uk/professional/events Just scroll down the page and look for the PDFs in ‘related documents’.
Why not hold your own local event on one or all aspects of the quality standards? Get local women involved to tell their stories. Get midwives, obstetricians, a local commissioner and public health lead to present. good luck!