From MIDWIFERY MATTERS, Issue No.116 - Spring 2008
Sarah Montagu and Margaret Jowitt
Key Priorities for Implementation
Communication
All women in labour should be treated with respect and should be in control of and involved in what is happening to them, and the way in which care is given is key to this. To facilitate this, healthcare professionals and other caregivers should establish a rapport with the labouring woman, asking her about her wants and expectations for labour, being aware of the importance of tone and demeanour, and of the actual words they use.
Support in Labour
A woman in established labour should receive supportive one-to-one care.
A woman in established labour should not be left on her own except for short periods or at the woman’s request.
Normal labour
Clinical intervention should not be offered or advised where labour is progressing normally and the woman and baby are well.
Planning place of birth
Women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit.
These words from page 4 of the quick reference guide to the NICE guidelines on intrapartum care could almost have been written by an ARM working party; radical midwifery has at last become mainstream. The establishment now accepts that enabling women to have a normal birth requires respect for the woman, support in labour and minimal intervention. There is even an acceptance that low risk women should be offered the option of home birth – in fact they are to be offered a choice between home, midwife-led unit and an obstetric unit and this will be audited. We might have some qualms about the definition of ‘low risk’; there do seem to be rather a lot of exclusions. The audit criteria document lists the following:
“... healthy women who are in labour at term (37–42 weeks), not those with suspected or confirmed preterm labour. The audit should not include women with an intrauterine fetal death, women with coexisting severe morbidities such as pre-eclampsia or diabetes, women who have multiple pregnancies, women with intrauterine growth retardation of the unborn baby, women whose delivery is covered by other NICE clinical guidelines such as ‘Caesarean section’, women who undergo an operative delivery, or women who need additional care for known or suspected infectious comorbidities such as group B streptococcus, HIV or genital herpes virus.”
We are pleased to see the acknowledgment of the association between birth experience and both short-term and long-term psychosocial consequences, and it was particularly good to note the listing of the Birth Trauma Association website on the women’s leaflet. Acceptance of the long-term consequences of women’s experience of birth has been a long time coming.
The guidance on place of birth is to be welcomed. The draft version had been far more guarded, the guideline development group (GDG) had attached much more weight to various overseas studies (with more adverse outcomes) than to UK research which was equivocal. There was an outcry from stakeholders and the GDG commissioned a re-analysis of existing statistics to try and tease out more reliable figures for the UK. It then reissued that chapter. Press coverage at the time of reissue was somewhat negative about home birth but the guideline as now published seems reasonable enough – allowing for jitters by some members of the GDG and firmly entrenched beliefs!
We do find ourselves wondering whether guidance about the intricacies of drugs and dosages of epidural anaesthesia should be included in the intrapartum care guideline for normal birth, and continue to be flummoxed by the GDG’s intransigent use of the term ‘epidural analgesia’. They use this term only for professionals, describing it more accurately as anaesthesia for the women’s leaflets! We would have thought that obstetric epidural anaesthesia, as a self-contained medical technology, deserved a guideline to itself.
We welcome the reference to the latent phase of labour in the guideline but would welcome more explanation in the women’s leaflet, women do get very distressed at being told they are not in labour when they are experiencing regular painful contractions. NICE may underestimate women’s distress at being advised to return home once they have made the effort to get themselves into hospital. Is there not a case for women being advised to contact their community midwife to check progress of labour at home before going into hospital?
The use of the words ‘chance’ and ‘risk’ in the women’s leaflet are rather revealing, ‘chance’ is used when talking about epidurals and the accompanying increased possibility of forceps or Ventouse in second stage but ‘risk’ is used when talking about the likelihood of postpartum haemorrhage after a physiological third stage. ‘Chance’ is a far more positive word that ‘risk’ – my chance of winning the lottery feels very different from my risk of winning the lottery! The subtle use of language reveals NICE’s preferences! Moreover, in the light of recent interest in the adverse effects of early cord clamping, we hope that NICE will pay more attention to third stage management when the guideline is revised.
Also in the woman’s leaflet the advice on support in labour is somewhat ambiguous, women are advised to bring someone to support them in labour. A full reading of the guideline shows that the maternity services are expected to provide one-to-one care in labour but women may still be worried that they need to bring support in with them. The audit criteria state: “One-to-one care is defined as continuous presence and support by midwives or other employed support persons” (our italics). However, we very much hope that NICE isn’t giving a green light for the NHS to employ a new category of labour support worker instead of midwives. ARM favours one-to-one midwifery care in labour. This is what midwives are; this is what midwives do.
The proof of the pudding will be in the implementation. The NICE website has all sorts of goodies on it to help with implementation but unfortunately some of the web technology didn’t work (the section on costings, for example) and there were several ‘loops’ so that it became extremely irritating trying to navigate around the site. On the other hand I (MJ) went on a journey to far flung reaches of the NHS, to such places as the National Patient Safety Agency (NPSA) and its Seven Steps to Patient Safety, which has many lessons to share for the maternity services – particularly regarding the elimination of the blame culture. It starts by exploding two myths – the perfection myth and the punishment myth. Taken together these imply that perfect care is possible and that if care is imperfect some one can be blamed and punished.
The seven steps dates from 2004 and is worth inserting here as some of the lessons don't yet seem to have been learnt:
1. Build a safety culture
2. Lead and support your staff, listen to all of them, there should be a culture of respect for staff.
3. Integrate risk management activity into everyday work.
4. Promote reporting both locally and nationally.
5. Involve and communicate with patients and the public.
6. Learn and share safety lessons using root cause analysis rather than perpetuating the blame culture
7. Implement solutions to prevent harm.
This safety model originated in the aviation industry where it is applied as much to near misses as to actual adverse events. In the NHS the first reaction to an adverse event has usually been to identify and blame a member of staff and then to suspend them, while leaving in place the systems that allowed the event to happen in the first place. The Intrapartum Care implementation plan is calling for root cause analysis of any serious maternal or infant adverse outcome; it is also calling for reporting of incidents where care is transferred from one setting to another – at present this is in terms of place of intended birth but it would be good if it could be extended to mean a change in the planned mode of birth so that root cause analysis of reasons for emergency caesarean section became the norm. It is a pity that the implementation plans do not mention the excellent toolkit produced by the NHS Institute for Innovation and Improvement, Pathways to success: a self improvement toolkit - focus on normal birth and reducing Caesarean section rates, which Catherine Gulati reviewed for us in summer 2007 (issue 113, p 32). NICE does seem to be reinforcing an ideological/logistical split between the expectation of normal birth and high risk birth whereas in reality there is a continuum both in terms of risk and in terms of outcome. Undoubtedly, some women receiving care under these new NICE guidelines will end up with a surgical birth – and some of these will have been preventable.
We were unhappy with NICE’s assumption that baths could be considered under the heading of labouring in water. While there is a great deal of evidence about labouring in birthing pools there is far less evidence of the efficacy of bathtubs in labour. We wonder whether this is a cost and availability issue, most units will have more bathtubs while birth pools will still come under the heading of optional extras. However, the auditing guidance includes questions about whether women were offered the chance to labour in water. At present there simply won’t be enough birth pools to offer this option to most women.
In the current climate with such a shortage of midwives implementing the NICE intrapartum care guidelines must be little but a dream for many places. How can one-to-one care be offered when midwives are so thinly spread? How can trusts enable midwives to offer a homebirth service and tie up two midwives with one woman at home when the local obstetric unit struggles to fill vacant posts? How can women be offered care in a midwife-led unit if no such place exists locally, or if it peroidically closed to release midwives to cover shortages in the main obstetric unit?
Perhaps it doesn’t matter that the costing guidelines are [still] not up on the website. Forgetting about capital costs for new birth pool rooms and so on, the main cost will be in employing more midwives and there are already formulae for determining how many midwives are needed per thousand births and employment costs are well known. Will more midwives be employed? Can midwives be encouraged to return? If the NICE guidelines are implemented perhaps midwives will come back. If it is true that midwives have left the NHS because they are unable to practise the midwifery they were taught, will these guidelines be enough to convince them that the tide is turning back again? Time will tell.
These guidelines need a hard sell, to the media, to the medical profession, to woman and their families and to midwives who have given up on the profession. Why is is that NICE recommendations that advocate not doing something (I wonder how many units are not putting the majority of women who walk through their doors on to continuous monitoring?) are so slow to become accepted, when any recommendation that involves doing something, especially if the something involves a nice shiny new bit of technology, spreads seemingly within weeks across the whole NHS? We are also still waiting for the media response to the more measured tone of the chapter on place of birth – when the draft was released, the media response was instantaneous and the headlines screamed that NICE was saying home birth would be unsafe. Now that the actual guidance has been published, the response has been muted to say the least. However, so long as the impulse to find exclusions for more and more women can be resisted, so that the majority still come under the rubric of ‘normality’, these guidelines can be used as a tool to promote women-centred and women- focused care.
Sarah Montagu & Margaret Jowitt
This article was originally published in Midwifery Matters ISSUE 116 - Spring 2008
AH updated 16 October 2008