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Audit of Care Provided and Outcomes Achieved by Community Maternity Units in Scotland 2005
Final Report February 2007 Report Authors: Margaret Hogg: Project Midwife Gillian Penney: SPCERH Director Jane Carmichael: SPCERH Administrator
RCOG
RCM UK Board for
Scotland
RCOGRCOG
RCM UK Board for
Scotland
RCM UK Board for
Scotland
2929
Audit of Care Provided and Outcomes Achieved by
Community Maternity Units in Scotland 2005
Final Report
Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH)
2929
3
SPCERH is funded by NHS Quality Improvement Scotland Further copies of this report are available from: SPCERH, Room 66, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, AB25 2ZD Telephone 01224 554476 Fax 01224 550553 Email [email protected] The text is also available as a pdf on our website - www.abdn.ac.uk/spcerh ISBN 1-902076-29-X © SPCERH First published February 2007
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Contents Summary..................................................................................................................................................... 5
Recommendations ...................................................................................................................................... 7
Principal participants ................................................................................................................................... 8
Community Maternity Unit Identifiers .......................................................................................................... 9
Background to the audit ............................................................................................................................ 10
Audit methods ........................................................................................................................................... 11
Community Maternity Units included in the audit ................................................................................. 11 Women included in the audit ................................................................................................................ 12 Data collection ...................................................................................................................................... 12 Data analysis ........................................................................................................................................ 12
Results ...................................................................................................................................................... 13
Utilisation of Community Maternity Units in Scotland........................................................................... 13 Models of midwifery care.................................................................................................................. 13 Workload and workforce................................................................................................................... 13
Opening hours.............................................................................................................................. 13 Bookings and births...................................................................................................................... 14 Staffing Complement.................................................................................................................... 16 Bed complement .......................................................................................................................... 18
Pre-booking and early pregnancy care ............................................................................................ 19 Antenatal booking services............................................................................................................... 20 Ultrasound scanning services .......................................................................................................... 20 ‘Low risk’ antenatal care ................................................................................................................... 20 ‘High risk’ antenatal care .................................................................................................................. 20 Intrapartum care ............................................................................................................................... 21 Postnatal care................................................................................................................................... 21 Parent education .............................................................................................................................. 22 Allied Health Professionals............................................................................................................... 22 Clinical Risk Management ................................................................................................................ 22
Appropriateness of selection of women for delivery in CMUs.............................................................. 23 Risk assessment and EGAMS eligibility criteria............................................................................... 23 Risk assessment - more limited exclusion criteria ........................................................................... 24
Outcomes of labours managed in Community Maternity Units ............................................................ 27 Intrapartum transfers to a consultant-led unit................................................................................... 27 Mode of delivery ............................................................................................................................... 28 Gestation and birthweight................................................................................................................. 31 Duration of labour ............................................................................................................................. 32 Analgesia.......................................................................................................................................... 34 Perineal trauma ................................................................................................................................ 34 Blood loss and postpartum haemorrhage. ....................................................................................... 34 Breastfeeding ................................................................................................................................... 35 Perinatal morbidity and mortality ...................................................................................................... 35 Transfers beyond one hour .............................................................................................................. 35 Risk assessment and the outcome of labour ................................................................................... 36 Outcomes among primigravid women.............................................................................................. 36 Outcomes among parous women with previous forceps/ventouse deliveries ................................. 38 Intrapartum transfer times ................................................................................................................ 38
Illustrative Cases: decision making and transfer arrangements .................................................. 41 Report References .................................................................................................................................... 43
Bibliography .............................................................................................................................................. 43
Appendices ............................................................................................................................................... 44
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Summary Background and methods 1. At the request of NHS Quality Improvement Scotland (NHS QIS) and the Scottish Executive Health
Department (SEHD), we conducted an audit of activity during 2005 in Scotland’s 22 stand-alone Community Maternity Units (CMUs). The 22 CMUs serve over a third of the geographical area of Scotland and sit within nine different NHS Boards.
2. The aims of the audit were: to describe the utilisation of CMUs in Scotland; to assess the appropriateness of selection of mothers for delivery in CMUs; and to describe the outcomes of labours managed within CMUs.
3. Data on CMU utilisation were collected using a Unit Profile Questionnaire completed by each CMU in late 2006. Data on women labouring in CMUs (appropriateness of selection and outcomes) were collected retrospectively using individual Case Note Review Proformas completed for each woman by reference to her original case records.
Utilisation of CMUs 4. 1442 women gave birth in a CMU in 2005 (3% of all births in Scotland). Births in individual CMUs
ranged from 192 (Perth) to two (Bowmore). CMU midwives also managed 68 home births. 5. 5646 women were booked for antenatal care by CMU midwives (10% of all bookings in Scotland). 6. In addition to managing births and bookings, CMU teams made the following contributions to
maternity care: • 4696 pre-booking and early pregnancy clinical episodes • 18,134 pregnancy scans • 53,225 routine antenatal care contacts • 1310 ante- and postnatal inpatient episodes • 29,228 community postnatal visits to mother and baby • 13,000 contacts with women for parent education • 10,537 antenatal emergency and day-care attendances and escorted transfers
7. There was a close relationship between staffing complement and clinical activity. Appropriateness of selection for CMU birth 8. All CMUs provided local eligibility criteria for CMU birth. These were generally based on the national
criteria published in the Overview Report of the Expert Group on Acute Maternity Services (EGAMS) 2002. Some of the EGAMS risk factors (eg moderately elevated BMI) are of doubtful significance for the management of labour, and some recorded risk factors may resolve prior to admission in labour.
9. 1686 women were admitted in labour to a CMU, including 261 women admitted to the CMUs in Kirkwall and Lerwick which are served by general practitioners, surgeons and anaesthetists able to undertake some obstetric interventions.
10. After excluding: risk factors of little significance in labour; women admitted to CMUs in advanced labour (precluding transfer); women making an explicit choice of CMU birth despite recognised risk factors; and women under medical care in Kirkwall or Lerwick, less than 10% of women admitted in labour to a CMU had a documented risk factor.
Outcomes of labour Transfers to consultant-led units 11. Of all 1686 women admitted in labour to a CMU, 295 (17%) were transferred off-site during labour or
within one hour of delivery (‘intrapartum transfers’). The main reasons for transfer were: failure to progress in the 1st or 2nd stage of labour; meconium staining of liquor; and request for epidural analgesia.
12. Of the 295 intrapartum transfers, 60 occurred in the 2nd stage of labour.
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Mode of delivery and duration of labour 13. Of all 1686 women admitted in labour, 88% had spontaneous vertex deliveries (SVD). 14. Of the 1425 women admitted to CMUs other than those with on-site medical staff (Kirkwall and
Lerwick), 90% had SVD. Of parous women, 98% had SVD, as did 77% of primigravidae. 15. Among all 295 women with intrapartum transfers, 50% had SVD as did 17% of women transferred in
the 2nd stage. 16. Mean gestation at delivery was 39 weeks and mean birthweight was 3.5kg. 17. Women with intrapartum transfers had significantly longer durations of all three stages of labour
compared to women who delivered in a CMU. Neonatal outcomes 18. Among 1686 babies, 5% were admitted to a neonatal unit. The rate of neonatal unit admission was
higher among babies born following intrapartum transfer (12%). 19. Among all 1686 births, there were no stillbirths and three early neonatal deaths. Relationship between risk status and outcomes 20. The designated risk status of the women was unrelated to their likelihood of intrapartum transfer or
to the likelihood of their babies requiring neonatal unit admission. 21. It must be remembered however that these women are a highly selected group, having been
accepted for CMU birth following a dynamic risk assessment process. Our findings of similar outcomes among all women accepted for CMU birth suggest that, in practice, risk assessment by the multi-professional team functioned well: women with multiple or major risk factors had already planned to have consultant-led intrapartum care.
22. Of all 1686 women, 37% were primigravid. Over two thirds of primigravidae who began their labour
in a CMU gave birth there. First-time mothers were at increased risk of intrapartum transfer (31%) compared to parous women (9%) and were also at increased risk of transfer in the 2nd stage (7% vs.1%).
23. Parous women with any previous forceps/ventouse delivery were at increased risk of intrapartum transfer (15%) compared to other parous women (8%) and of transfer in the 2nd stage (5% vs.1%).
Transfer times 24. Among all 295 intrapartum transfers, the mean time from the decision to transfer until the woman or
baby was medically assessed within the consultant-led unit was 2.6 hrs. 25. Among the 60 transfers in the 2nd stage, the mean time from the decision to transfer until the
woman or baby was medically assessed within the consultant-led unit was 1.6 hrs.
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Recommendations
1. CMUs currently make an enormous contribution to maternity care in Scotland. This contribution could be increased by further extending the core skills of midwives to include greater involvement in ultrasound scanning, prescribing, and routine examination of the newborn. Telehealth technology should be used to support midwives in these extended roles.
2. National and local eligibility criteria for intrapartum care within CMUs (EGAMS Level 1 intrapartum care) should be reviewed and simplified.
3. Routine data collection at national and local levels should permit ongoing surveillance of the outcomes of midwife-managed labours, in both stand-alone CMUs and alongside midwife-led areas within consultant-led units.
4. NHS Boards should develop formal protocols, jointly agreed by clinical and ambulance staff, for the safe transfer of women in labour. These protocols should address all stages of transfer, from decision-making to eventual clinical assessment within the transfer unit, in order to eliminate avoidable delays.
5. Standard national information on the likely outcomes of labour within CMUs and within consultant-led units should be developed (based on all currently available evidence) to assist women in reaching their decisions about place for delivery.
6. There are large variations among CMUs in intrapartum transfer rates (both overall and specifically for primigravid women). Mechanisms should be established for the sharing of good practice between CMUs, possibly under the auspices of the Keeping Childbirth Natural and Dynamic (KCND) programme.
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Principal participants The audit was undertaken at the request of NHS Quality Improvement Scotland and the Scottish Executive Health Department and was carried out by the Scottish Programme for Clinical Effectiveness in Reproductive Health. A short-life Steering Committee was established to provide support and advice. Steering group members
Dr Laura Cassidy Scottish Committee RCOG Dr Jim Chalmers ISD Mr Robert Colburn Scottish Ambulance Service Dr Ian Bashford SEHD Dr Catriona MacDonald Public Health Dr Gillian Penney SPCERH Programme Director (Chair) Ms Beatrice Cant NHS QIS Mhairi Harvey Lay representative Margaret Hogg SPCERH Project Midwife Dr John McClure Royal College of Anaesthetists Dr Margaret McGuire SEHD Mrs Patricia Purton RCM UK Board for Scotland Dr Janet Tucker Dugald Baird Centre Dr Graham Stewart Scottish Neonatal Consultants’ Group Shona Pert Midwife, Montrose Community Maternity Unit Frances Wright Midwife, Stranraer Community Maternity Unit
The following midwives acted as data collectors for their Community Maternity Units and referral Consultant-led Units
Catherine Olsson Aboyne Hospital Betty Adair Vale of Leven, Alexandria Kate Weir Arbroath Infirmary Fiona Hamilton Isle of Arran War Memorial Hospital, Lamlash Eleanor Brown Chalmers Hospital, Banff Katie MacLellan Islay Hospital, Bowmore Rhona Scott Dr MacKinnon Hospital, Broadford, Skye Catriona Dreghorn Campbeltown Hospital Anne Cruickshank Dunoon and District Hospital, Dunoon Mhairi Milne Belford Hospital, Fort William Maretta Chalmers Fraserburgh Hospital Frances Cassidy Inverclyde Hospital, Greenock Jo Scobie Inverclyde Hospital, Greenock Sheena Leith Balfour Hospital, Kirkwall Edith Evans Gilbert Bain Memorial Hospital, Lerwick Joanne Thorpe Mid Argyll Hospital, Lochgilphead Shona Pert Montrose Infirmary Eileen Clarke Lorne and Islands District General Hospital, Oban Linda Thorne Perth Royal Infirmary Ann Ellington Peterhead Cottage Hospital Fiona Hood Victoria Hospital, Rothesay Frances Wright Dalrymple Hospital, Stranraer Margaret Morrison Uist and Barra Hospital, Benbecula Marie Warren Aberdeen Maternity Hospital Dorothy Finlay Royal Alexandria Hospital, Paisley Alison Alexander Dr Gray’s Hospital, Elgin
Jane Carmichael provided administrative support including data management. Gillian Penney and Margaret Hogg analysed the data and wrote the report.
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CMU Identifiers Because of space constraints and to improve clarity, in the graphs and charts included in this report individual CMUs are identified by a number, rather than by name. The identifier numbers used throughout are as follows:
CMU identifier CMU location 1 Perth
2 Montrose
3 Kirkwall
4 Lerwick
5 Greenock
6 Peterhead
7 Arbroath
8 Stranraer
9 Aboyne
10 Fraserburgh
11 Alexandria
12 Banff
13 Fort William
14 Dunoon
15 Oban
16 Broadford
17 Rothesay
18 Campbeltown
19 Lochgilphead
20 Lamlash
21 Benbecula
22 Bowmore
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Background to the audit Over the last decade, planning of maternity services in Scotland has been strongly influenced by the need to meet the distinctive health care requirements of urban, rural, and remote communities. In addition, the service must provide women with the opportunity to make informed choices about pregnancy and childbirth. Fundamental to maternity care is the necessity to sustain a safe and clinically effective service. Service planning must take cognisance of advances in medical and social science and technology as well as the views of women using the service. The SEHD Framework for Maternity Services in Scotland (2001), and the subsequent publication from the Expert Group on Acute Maternity Services (EGAMS) (2002) set out a tiered model for maternity care: ranging from community care (Level 1 - midwife-managed normal birth) when pregnancy is straightforward, to Level 111 (consultant obstetrician-managed birth) when pregnancy is complicated. The concept of the managed clinical network is central to the EGAMS tiered model of maternity care. Midwives providing care within CMUs are supported by colleagues within the multi-professional managed clinical network. At each stage of her pregnancy and delivery, each woman receives her maternity care from the most appropriate person, in the most appropriate setting, according to her individual circumstances and preferences. In 2005, over 55,000 women give birth in Scotland. Pregnancy care for approximately 5600 of these women (10%) was provided, totally or in part, by midwife-managed CMUs; and 1442 (3%) of the total births in Scotland took place in a CMU. Scotland’s 22 CMUs contribute to services for over one-third of the geographical area of Scotland. To date, comprehensive data have not been collected to demonstrate the extent of the contribution CMUs make to maternity care in Scotland; nor have the outcomes of CMU intrapartum care for both mothers and babies been reviewed on a Scotland-wide basis. Against this background, NHS QIS and the SEHD requested that SPCERH undertake a retrospective audit in 2006. The aims were: to describe the utilisation of CMUs in Scotland; to assess the appropriateness of selection of mothers for delivery in CMUs; and to describe the outcomes of labours managed within CMUs.
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Audit methods Community Maternity Units included in the audit There is no standard definition of a ‘Community Maternity Unit’ (CMU). Such units are sometimes referred to as ‘birth centres’ or ‘midwife units’. For the purpose of this audit, a CMU is defined as ‘a hospital that undertakes deliveries and is not staffed by consultant obstetricians’. Midwife-led, ‘low risk’ units located on the same site as a consultant-led maternity unit were excluded. Using this definition, in 2005 Scotland was served by 22 CMUs and by 18 consultant obstetrician-led maternity units (Appendix 1). According to the EGAMS ‘levels of care’, the CMUs included in our audit are Level 1b - ‘Stand alone midwife-led community maternity units’, and Level 1c - ‘midwife-led community maternity units adjacent to a non-obstetric hospital where there are medical staff (surgeon/general practitioner) appropriately trained to perform emergency caesarean section’. (In practice, such medical staff undertake both elective and emergency caesarean sections, forceps/ventouse deliveries, and induction of labour for prolonged pregnancy.) All 22 CMUs participated in the audit as detailed in Table 1. Table 1 Scotland’s 22 stand-alone Community Maternity Units (2005)
NHS Board Hospital with stand alone CMU Location
A&C Vale of Leven District General Hospital * Alexandria Islay Hospital** Bowmore Campbeltown Hospital** Campbeltown Dunoon and District General Hospital** Dunoon Inverclyde Royal Hospital * Greenock Mid Argyll Hospital** Lochgilphead Lorne and Islands District General Hospital** Oban Victoria Hospital** Rothesay
A&A Isle of Arran War Memorial Hospital Lamlash
D&G Dalrymple Hospital Stranraer
Grampian Aboyne Hospital Aboyne Chalmers Hospital Banff Fraserburgh Hospital Fraserburgh Peterhead Cottage Hospital Peterhead
Highland Mackinnon Memorial Hospital Skye Broadford Belford Hospital Fort William
Orkney Balfour Hospital Kirkwall
Shetland Gilbert Bain Memorial Hospital Lerwick
Tayside Arbroath Infirmary Arbroath Montrose Royal Infirmary Montrose Perth Royal Infirmary Perth
W. Isles Uist and Barra Hospital Benbecula Explanatory notes: The units in Orkney and Shetland undertake general practitioner-managed births as well as midwife-managed births (EGAMS Level 1c) In April 2006, Argyll & Clyde NHS Board merged with Greater Glasgow and Highland NHS Boards * CMUs now part of Greater Glasgow and Clyde NHS Board ** CMUs now part of Highland and Argyll NHS Board
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Women included in the audit All women who were admitted in labour to a CMU during 2005 were included. Case Note Review Proformas were completed for all these women; both those who gave birth within the CMU and those who were transferred during labour to a consultant-led unit. Planned and unplanned (‘Born Before Arrival’) home births managed by CMU midwives were excluded from the audit. All women who laboured in Orkney and Shetland CMUs (including those electively managed by general practitioners) were included. We acknowledge that the model of care provided in the CMUs in Orkney and Shetland is very different from that provided in the other 20 CMUs. The involvement of non-obstetric medical staff allows a wider range of interventions (including induction of labour, assisted vaginal delivery, and elective and emergency caesarean section) to be undertaken. (Indeed, for part of the audit period a locum consultant obstetrician was in post in Lerwick.) Because of these differences, women cared for in these CMUs were excluded from some of the analyses. Data collection A Unit Profile Questionnaire was designed to obtain information relating to the model of care provided in each CMU and to describe the utilisation and workload of each CMU during 2005. The questionnaire elicited data which described all elements of maternity services offered to women within the CMU building and also midwifery services provided by the CMU team in community settings. An audit midwife in each CMU completed this questionnaire at the beginning of the data collection period (late 2006). Information was retrieved from local data collection systems. To assess the appropriateness of selection of mothers for delivery in a CMU, local protocols for eligibility were collected from each CMU. The eligibility criteria described in each protocol were compared with the characteristics and circumstances of individual mothers to identify whether or not selection for CMU birth was appropriate. Due to time constraints, data analysis relating to appropriateness of mothers for CMU birth focused mainly on the eligibility criteria detailed in the EGAMS report, rather than those detailed in individual unit protocols. In practice, most local protocols were similar to the EGAMS criteria (Appendix 2). Outcome measures for labours managed in CMUs were agreed by the project steering group and included: mode of delivery; place of delivery; condition of the baby; complications including postpartum haemorrhage and third degree tear; and neonatal unit admission of the baby. For women who eventually delivered in consultant-led units, data were collected on the timing and circumstances of transfer. Data on each woman admitted in labour to a CMU were collected by extracting information from her original case records onto an individual Case Note Review Proforma. The Case Note Review Proformas were completed by the CMU audit midwife or in some instances (where women were transferred to a consultant-led unit) by an audit midwife in the transfer unit. Data analysis Data from the completed Unit Profile Questionnaires and from the Case Note Review Proformas were entered into SPSS databases. Descriptive statistics were derived.
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Results Utilisation of Community Maternity Units in Scotland Data collected through the Unit Profile Questionnaires provided details of local service organisation and of care provided in, and from, CMUs during 2005. The findings demonstrate the extent of the role of the midwife in the provision of maternity services within the CMU model of care. There was great variation in the models of care provided by different CMUs; no two CMUs provided the same model of care. These differences can be attributed to local factors, clinical case-load, and to innovative midwifery practices in different settings (Appendices 3 and 4). These fundamental differences in the models of care mean that great caution is needed in drawing comparisons. Models of midwifery care In the majority of CMUs (18), the CMU team of midwives provides all components of maternity care for their local population, both within the CMU building and in community settings. Three CMUs (Oban, Kirkwall and Lerwick) serve particularly remote and rural populations; hence, CMU midwives provide all maternity care within the CMU building plus community midwifery services for the nearby population, with a separate team of midwives (including double and triple duty nurse-midwives) providing community midwifery services for more distant areas. The CMUs at Kirkwall and Lerwick have support from obstetric general practitioners, general surgeons, and anaesthetists for the management of obstetric emergencies. In both these units, elective caesarean sections at term are performed by a general surgeon. Within the Lerwick CMU, induction of labour for prolonged pregnancy is also undertaken. Thus, CMUs in Orkney and Shetland have mechanisms for non-obstetric medical care as well as for midwife-led care. In one CMU (Perth), CMU midwives provide all maternity care within the CMU building and also community midwifery services; but a separate, dedicated team of midwives provides early pregnancy assessment services. Workload and workforce Opening hours Opening hours for the majority of CMUs correlated with the number of births and with overall clinical activity. Twelve CMUs provide a 24-hours/7-days a week service. Of these, seven had between 100 and 200 births in 2005, four had between 50 and 100 births and one (Oban) had 30 births. (Towards the end of 2005, the CMU in Oban changed to a limited opening hours service with a 24-hours/7-days a week midwifery on-call system.) The remaining 10 CMUs had limited opening hours (covering between three and seven days a week) with a 24-hours/7-days a week midwifery on-call system. Two of these limited-hours CMUs had 50 or more births in 2005 (Fort William, 50 births and Aboyne, 60 births) and eight had between two and 37 births. On Islay, the weekend and overnight on-call maternity service is provided by general practitioners.
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Bookings and births In total, 5646 women (over 10% of women who gave birth in Scotland during 2005) were booked for pregnancy care by CMU midwives. (All these women had their booking assessment undertaken by a member of the CMU team. However, not all of these women were booked with a view to CMU delivery. In a proportion, delivery in a consultant-led unit was planned from the outset and in others, the most appropriate setting for delivery was agreed as the pregnancy progressed.) In CMUs in 2005, there were 1384 midwife-managed births plus 58 general practitioner-managed births in Lerwick and Kirkwall, and 68 planned or unplanned home births managed by midwives from CMU teams (Table 2). The ratio of CMU midwife-managed births to bookings (Figure 1) is 24% (which increases to 26% with the inclusion of the 58 general practitioner-managed births, 40 planned home births and 28 unplanned home births). The highest ratio of births to bookings was achieved in Kirkwall (65%) followed by Montrose (62%). The remaining 20 units had a births to bookings ratio of 8% (Bowmore) to 58% (Lerwick). In 2005, the CMU with the minimum number of births (2) was Bowmore; and with the maximum (192), Perth. Most CMUs (15) had fewer than 75 births, while seven had between 100 and 200 births (Figure 2). Planned home births were uncommon, with the majority of units (20) providing midwifery care for fewer than four home births. The highest number of home births took place in and around Stranraer (5) and Perth (12). Table 2: Summary of births in 2005 managed within Community Maternity Unit buildings or by midwives in the community
Setting for birth
Total
Maximum
Minimum
Average
CMU births* 1442 192 2 63
Home births (planned) 40 12 0 2
Home births (unplanned) 28 8 0 1
Total births 1510
Note: Two units’ total births (131 and 127) include ‘higher risk’ mothers (58) whose care involved non-obstetric medical staff (general practitioners, surgeons, and anaesthetists).
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Figure 1 Ratio of births to bookings in Community Maternity Units (2005)
0
200
400
600
800
1000
1200
1 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 19 20 21 22CMU identifier
num
ber
births bookings
Figure 2 Number of births in each Community Maternity Unit (2005)
22212019181716151413121110987654321
CMU identifier
200
150
100
50
0
Num
ber o
f birt
hs in
CM
U (2
005)
268
141520
24
3737
5050
58586064
104
114116
127131
155
192
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Staffing Complement Overall, there was a weak correlation between the whole time equivalent (wte) staffing establishment and the number of births in the CMU (Figure 3). However, there was a strong correlation between staffing establishment (support staff and midwives) and births + bookings as a measure of workload (Figures 4 and 5). The CMU with the highest number of midwifery staff (Perth, 30.8 wte) had 192 births and 1,105 bookings; whereas the CMU with the lowest staffing complement (Bowmore, 0.6 wte) had two births and 24 bookings. Fourteen CMUs’ workforce (Appendix 3) included health care assistants, ward assistants and/or nursery nurses (Table 3). The units with the highest ratio of support staff to midwives were Peterhead (5.3 wte support staff: 7.7 wte midwives), Fraserburgh (4.7: 7 wte), and Kirkwall (5.2: 8.2 wte). Table 3 Summary of relationship between workforce and workload in Scottish Community Maternity Units (2005)
Number of Units Total workforce (wte) (range)
Births (range) Bookings (range)
3 28.6-35.6 58-192 716-1105
10 10.4-18.0 37-155 165-301
9 0.6-7.8 2-37 24-190
Figure 3 Relationship between CMU total staffing complement and births in the CMU
200150100500
Births in CMU (2005)
40.00
20.00
0.00
tota
l sta
ffing
wte
(200
5)
22
2120
19
18 17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
R Sq Linear = 0.485
17
Figure 4 Relationship between CMU total staffing complement and births + bookings
1250.001000.00750.00500.00250.000.00
births and bookings (2005)
40.00
20.00
0.00
tota
l sta
ff w
te (2
005)
22
21
20
19
1817
16
15
1413
12
11
10
9
8
7
6
5
43
2
1
R Sq Linear = 0.909
__ Figure 5: Relationship between CMU midwifery staffing complement and births + bookings
1250.001000.00750.00500.00250.000.00
births and bookings (2005)
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
mid
wife
ry s
taffi
ng e
stab
lishm
ent 2
005
22
2120
19
1817
16
15
14
13
12
11
109
8
7
6
5
4
3
2
1
R Sq Linear = 0.909
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Bed complement We collected data on three key measures of accommodation (Table 4): the number of birthing rooms, the number of inpatient beds, and birthing pool facility. Nineteen CMUs had a maternity inpatient facility plus birthing rooms, while three CMUs had birthing rooms only. Nine CMUs provided inpatient antenatal care (109 episodes of care in 2005) and five CMUs provided an inpatient neonatal ‘step down’ facility (35 babies in 2005). Women who gave birth in a consultant-led unit could transfer to a CMU for inpatient postnatal care (791 episodes of care in 14 CMUs). The criteria for assessing the clinical need for a woman to transfer to a CMU, rather than being discharged home for community midwifery postnatal care, are variable [Appendix 4] (as reflected in the unit ratios of bookings to postnatal admissions). The utilisation of the inpatient antenatal facility was low (106 episodes of care); the majority of these care episodes were attributed to the management of women with hyperemesis gravidarum. NHS QIS Maternity Services Clinical Standards (2005) states that access to a birthing pool is an essential requirement for childbirth and the management of pain. Over 50% of units (12) did not have a birthing pool. There was some correlation between the total number of beds available (birthing rooms + inpatient beds) and inpatient episodes; however, five CMUs with between five and eight beds appeared to have poor bed utilisation compared to other CMUs (Figure 6). A number of these CMUs have reviewed, or are currently reviewing, their bed complement. There was variation among CMUs in the average length of stay following birth. Women who gave birth in CMUs with no inpatient beds tended to go home two to six hours following birth. Across all CMUs, the median length of stay was two days and 95% of women had a length of stay of five days or fewer. Of the 1391 women who were not transferred in labour, 230 (16%) went home on the day they gave birth, 406 (29%) on the day after they gave birth and 314 (22%) two days after giving birth; very few women remained as an inpatient for over five days.
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Table 4 Summary of bed complement in Scottish Community Maternity Units (2005)
Accommodation Number of beds
Number of births
Postnatal transfers
Birthing rooms + inpatient beds (19 CMUs) Range 6 - 9 37 -192 0 - 420
Range 2 - 5 6 - 116 0 - 95
Birthing rooms only (three CMUs) Range 1 - 3 2 - 64 0
Figure 6: Relationship between inpatient bed complement and inpatient workload (births + antenatal admissions + postnatal transfers from other units + postnatal admissions for neonatal ‘step down’ care) (2005)
700.00600.00500.00400.00300.00200.00100.000.00
inpatient workload (births + antenatal + postnatal)
10.00
8.00
6.00
4.00
2.00
0.00
tota
l bed
s (b
irthi
ng +
oth
er in
patie
nt b
eds)
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
R Sq Linear = 0.579
Pre-booking and early pregnancy care Seventy-two percent of CMUs provide a pre-booking and/or pregnancy testing service. Such services accounted for 981 episodes of care during 2005. Three CMUs (all of which had previously been consultant-led units) operate an on-site early pregnancy assessment service for women with threatened miscarriage and related early pregnancy problems. These are generally open 9am to 5pm Monday to Friday. The early pregnancy assessment services had a high level of clinical activity; with 3887 episodes of care (equivalent to more than one episode of care for each woman [2556] booked in these CMUs for pregnancy care). Another 12 CMUs provide midwife assessment of early pregnancy bleeding, including ultrasound scanning (809 episodes of care; 25% of total bookings). The provision of this type of service is dependent on availability of midwives who have undergone first level ultrasound training. It is acknowledged, given the nature of this service, that the clinical activity was not always recorded.
20
In the areas covered by the remaining seven CMUs, women with early pregnancy problems are either assessed by general practitioners and/or referred directly to a consultant-led unit. Antenatal booking services Eleven CMUs (50%) offer booking services organised so that referrals can be made via a general practitioner or midwife. In seven CMUs, referrals are always made via a general practitioner. Conversely, the remaining four CMUs (Campbeltown, Stranraer, Lochgilphead, and Benbecula) have a midwife-only referral system. In all CMUs, a midwife undertakes each woman’s booking assessment, although general practitioners have some involvement in Orkney. Ultrasound scanning services Early pregnancy dating scans are undertaken in 21 of the 22 CMUs. In the remaining CMU (Aboyne), this service is provided by referral to the consultant-led unit in Aberdeen. Only nine CMUs perform 20 week anomaly and late pregnancy scans. Midwives undertook 50% of early pregnancy scans; while ultrasonographers or obstetricians performed 82% of scans undertaken from 20 weeks onwards (Table 5). In Kirkwall, Banff and Greenock, a proportion of second and third trimester scans are undertaken by midwives. Given that women have to travel significant distances by road, boat, and/or plane to have fetal anomaly scanning, it might be feasible to offer this service in more CMUs with a supporting telemedicine facility. Table 5 Provision of pregnancy ultrasound scans in Scottish Community Maternity Units (2005) Total number of ultrasound scans undertaken = 18,134
Early pregnancy dating scans 20 week anomaly scans
No. of CMUs providing the service 21 9
Professional groups involved in scanning service
Midwife Ultrasonographer Radiologist Obstetrician General Practitioner
11 8 1 6 4
3 6 1
‘Low risk’ antenatal care The routine pattern of antenatal care for pregnant women should be no more than nine visits for a primigravida and eight visits for a multigravida (Maternity Services Clinical Standard 3c3 2005). The number of recorded routine antenatal care contacts by CMU team members was 53,225 in 2005 (an average of 9-10 contacts for each woman). During 16% of these contacts, women were reviewed by an obstetrician. The units with the highest input from obstetricians were Alexandria, Greenock and Perth. Twelve CMUs indicated that antenatal care for ‘low risk’ women was usually provided by midwives. Eight CMUs indicated that midwives and general practitioners shared responsibility for antenatal care of ‘low risk’ women. In Arran, midwives, general practitioners and obstetricians were all involved in ‘low risk’ antenatal care, while in Uist, midwives and obstetricians were involved. ‘High risk’ antenatal care A full range of ‘high risk’ clinics are held in the three CMUs which were recently operating as consultant-led units (Perth, Greenock, and Alexandria) with 14 further CMUs providing ‘high risk’ clinics every two or four weeks. Four CMUs do not provide any ‘high risk’ antenatal services. It is recognised at least 30% of women have ‘complicated’ pregnancies (Tucker 1999) and require additional antenatal assessments of feto-maternal wellbeing. The three CMUs that were recently
21
consultant-led units provide a dedicated maternity day care assessment service. The majority of other CMUs (15) offer a limited day care service, with telephone advice available from an obstetrician. The remaining five CMUs provide follow-up assessments based on clinical need. Over 12,000 antenatal ‘day care-type’ assessments were undertaken; 16% of these involved the woman seeing an obstetrician. All CMUs which were particularly remote from a consultant-led unit (12 CMUs) provide an emergency antenatal assessment services. CMU midwives undertake initial assessment in order to determine whether or not the woman requires to be escorted to a consultant-led unit. In the remaining CMUs, those women who are planning to deliver in a consultant-led unit and who develop complications of pregnancy are normally advised to contact that unit directly. In 2005, 638 women with antenatal complications were transferred directly from a CMU (and 54 from home) for emergency assessment in a consultant-led unit. Of these women, 272 were escorted by a CMU midwife. Intrapartum care Some CMUs (particularly those which are very remote from a consultant-led unit) offer a ‘confirmation of labour’ service for women who have ‘high risk’ pregnancies and are booked to deliver in a consultant-led unit. At least 2060 clinical assessments of women were undertaken in CMUs to confirm the onset of labour. In 2005, 1686 women were admitted to CMUs in labour. The admissions included women who planned to deliver in the CMU and others who had planned to deliver in a consultant-led unit, but presented to a CMU for emergency delivery, as birth was imminent. Of the women who were admitted, 1437 (85%) gave birth (two twin deliveries) in the CMU and 249 (15%) were transferred to a consultant-led unit prior to the birth of their baby. (Both women with twin pregnancies were planning to deliver in a consultant-led unit but were admitted to a CMU in advanced labour precluding transfer.) The total number of cases where a decision was taken to transfer a woman during labour or up to one hour following birth was 281. In addition, on 14 occasions the decision was taken to transfer a baby to a neonatal unit within an hour of birth. (All of these 295 transfers for maternal, fetal, or neonatal indications during labour or within an hour of birth are considered as ‘intrapartum transfers’ in this report.) Beyond one hour following birth, a further 65 mothers or babies developed complications that necessitated their transfer to a consultant-led unit. The outcomes of labour and birth are detailed later in the report. Postnatal care Midwifery postnatal care is provided for a minimum of 10 days following birth but, dependent on clinical need, can be for a longer period. (Midwives Rules and Standards. Nursing and Midwifery Council 2004). There was a consistent pattern of community postnatal visiting in the majority of areas served by the CMUs, with mothers receiving between three and five home visits. The total number of actual home visits from all the CMUs was 29,327 in addition to at least 390 (1%) wasted visits. Newborn hearing screening was fully implemented in 2005. A range of health care professionals have been trained to undertake this test and it appears that the service has evolved in response to local circumstances. In half the CMUs, screening is undertaken in the CMU by a midwife, nursery nurse, health care assistant, or newborn hearing screener. For the remaining CMUs, a health visitor usually performs the screening in the baby’s home. Standards for routine examination of the newborn were implemented in 2004 (NHS Quality Improvement Scotland - Routine Examination of the Newborn Best Practice Statement) and in 2005 a number of CMU midwives undertook the first Scottish course in preparation for this extended role. Nine CMUs indicated that midwives were undertaking all or some of these examinations (837) in 2005. More CMU midwives completed the course during 2006, although nine units (six with >50 births) have indicated that there are currently no plans for midwives to access this course.
22
To provide a seamless service, consideration should be given to supporting midwives who provide care in CMUs to become proficient in the routine examination of the newborn. Parent education Parent education services are an integral part of maternity care. They should be comprehensive, flexible, woman- and family-centred, with an emphasis on promoting good health and providing clear information about childbirth and the transition to parenthood. All CMUs provide parent education sessions either in the unit, at another location in the community, or in the woman’s home. Data were collected on women’s attendance at parent education sessions including breastfeeding workshops. There were just under 9000 attendances in the CMU and just over 4000 attendances in the community for parent education (either at a one-to-one or group session). This equates to at least two separate parent education contacts for each woman who booked for pregnancy care, in addition to their routine antenatal visits. Several CMUs in remote rural settings reported that they normally undertook parent education in the home during an antenatal care visit. These contacts were not included in the above figures. Allied Health Professionals Women occasionally require to be referred to a physiotherapist during pregnancy or, more often, in the postnatal period following an instrumental delivery or caesarean section. Each CMU has access to an on-site physiotherapy service with midwives normally making arrangements for women to be referred. Physiotherapists provide some input into parent education classes organised by CMU midwives in nine CMUs. The need to refer women during pregnancy to a dietician is becoming more prevalent. However, this service is not so accessible, as only 11 CMUs have an on-site dietician service. Two CMUs reported that a dental nurse provides advice at one of the parent education sessions. CMUs also provide a broad range of services including ‘Special Needs in Pregnancy’, baby massage, and aquanatal exercises. Clinical Risk Management A robust risk management system is crucial to minimising the likelihood of adverse outcomes during childbirth. The system should ensure that all critical incidents are reported, investigated, and analysed, resulting in changes in practice, where necessary (Maternity Services Clinical Standards 1b.1). One CMU (Kirkwall) did not have a formal risk management system at the time of the audit; however a system was implemented in 2006. A limitation of this part of the audit was, that given the range and volume of clinical activity undertaken in the CMUs, the figures probably slightly under-represent the number of face-to-face contacts midwives had with women.
23
Appropriateness of selection of women for delivery in CMUs Assessing the appropriateness of place of birth for women is based on a complex decision-making process that involves dynamic risk assessment throughout pregnancy and labour. Selection is based on the best available unbiased information and takes into consideration non-clinical risk factors such as geography, weather conditions, and anticipated transfer time. Risk assessment in early pregnancy aims to determine the most appropriate setting and carer for an individual woman’s antenatal care. Risk assessment in later pregnancy aims to determine the most appropriate setting and carer for intrapartum care. Risk assessment is updated at each antenatal contact, on admission in labour, and during labour. A woman’s risk status may fluctuate during pregnancy and labour, meaning that plans for antenatal care and birth may change several times during the total journey of care. Because of the dynamic nature of risk assessment, and the retrospective design of this audit, accurate determination of each woman’s risk status at the onset of labour was problematic. We acknowledge that some of the risk factors recorded may have had relevance for antenatal care, but less relevance for the management of labour or may have resolved prior to the onset of labour. These factors mean that we may have over-estimated the number of ‘higher risk’ women admitted to CMUs in labour. An extensive literature review was undertaken by EGAMS in 2002 and led to the development of a comprehensive template for pregnancy risk assessment based on entry and exit criteria for different levels of maternity care. This risk assessment template has been used locally to develop guidelines and referral pathways for any mother or baby who gives cause for concern. The EGAMS eligibility criteria for Level 1 intrapartum care were used to assess the appropriateness of women giving birth in CMUs. In addition, local CMU policies were audited and women’s preferences recorded to identify possible reasons for any non-compliance with the EGAMS risk assessment template (Appendix 2). The EGAMS eligibility criteria (Reference Report 2002, page 52) for Level 1a -1d intrapartum care are, in brief:
• ‘low risk’, healthy woman • Singleton pregnancy • Cephalic presentation • Spontaneous labour between 37 weeks gestation and 40 weeks + 10 days • Primigravida or multigravida <5
Risk assessment and EGAMS eligibility criteria In 2005, 1686 women were admitted to CMUs in labour who either:
• planned to give birth within the CMU • were assessed on admission as suitable to give birth within the CMU • had one or more risk factors but could not be transferred to a consultant-led unit as the
birth was imminent We initially used EGAMS eligibility criteria to identify the number of women with risk factors. Applying this method to the data obtained from the case note audit, 31% (526) of the 1686 women had one or more risk factors at some stage in their pregnancy, which designated them as EGAMS ‘higher risk’. At the time of delivery, the mean age of the women was 28.9 years (range 16.5 to 44.5 years); 23 women were aged 41 years or over. Six hundred and twenty seven (37%) of the 1686 women were primigravidae, 1051 women (62%) were multigravidae 1-4, and the remaining eight women (1%) had ≥5 previous deliveries. Information on Body Mass Index (BMI) was recorded for 1568 women. Of these, 124 had a BMI of 20 kg/m2 or less (and two of these had a BMI of 15 kg/m2 or less). One hundred and fifteen women had a BMI of 32 kg/m2 or more (45 of these had a BMI of 35 kg/m2 or more, and nine had a BMI of 40 kg/m2 or more). From the women’s medical and surgical history, a total of 174 risk factors were identified. The most prevalent condition was a history of ‘major’ psychiatric illness (71 women), followed by asthma requiring oral or intravenous steroids (44 women). (The number of women with severe asthma may be an over-estimate as we have become aware that in some cases, no distinction was made between inhaled and
24
oral steroids.) The remaining risk factors (59) were associated with a wide range of medical conditions, the commonest being essential hypertension (eight women), and the least common diabetes (two women). Examination of women’s previous obstetric and gynaecological history led to the identification of 263 risk factors. Among the 1059 parous women, 145 (14%) had a previous forceps or ventouse delivery, and eight had a history of shoulder dystocia. Thirty women had a previous caesarean section; 24 of these women were from Shetland or Orkney. The other risk factors associated with the mother and her previous labours were retained placenta (eight women), post partum haemorrhage of >1000mls (seven women), previous 3rd or 4th degree tear (six women), and other major problems (eight women). Just under 20% (51) of the risk factors related to the baby. Seventeen women had a past obstetric history of Group B streptococcal infection; the birth weight of 22 babies at term was <2.5kg; and 12 women had a previous baby at <34 weeks gestation. In the current pregnancy history, women had a total of 73 risk factors. The majority of these (32) were categorised as ‘other significant problems’. The remaining risk factors were diastolic hypertension (13 women), ultrasound scan diagnosis of growth restriction (11 women), substance misuse (seven women), blood group antibodies (seven women), twins (two women), and hepatitis carrier (one woman). Risk assessment - more limited exclusion criteria Because of the limited significance to the management of labour of some of the EGAMS criteria, we subsequently applied more limited exclusion criteria. These were developed primarily from the CMU local eligibility protocols and led to the identification of 280 (17%) women who did not meet these criteria. We excluded from our ‘higher risk’ category women with the following:
• BMI less than 20 kg/m2 but greater than 15 kg/m2, or BMI over 32 kg/m2 but less than 35 kg/m2 (228 women)
• A history of ‘major’ psychiatric illness (71 women) As summarised in Table 6, we found marked differences among CMUs in the percentage of women with risk factors admitted in labour. However it is recognised that risk factors should be considered in the context of feto-maternal wellbeing in the current pregnancy before a decision can be made about the best place for the woman to give birth. This decision-making process is dynamic and involves clinical assessment of the woman by both midwives and obstetricians and in some instances general practitioners. We reviewed these ‘higher risk’ cases to find out if there was a reason documented to explain why these women gave birth within a CMU. In 114 cases, we found justification for the decision, as one or more of the following was documented: the woman explicitly chose to give birth locally (41); the woman was admitted in advanced labour (47); the woman was referred to on-site, non-obstetric medical care (26). The remaining 166 (10%) women had a well-defined risk factor that a midwife and/or obstetrician should have discussed with them prior to the woman making a decision to give birth in a CMU. It may be that such a discussion did take place but was not documented in such a way as to be captured by a retrospective audit. Each of these 166 women was documented as having only one risk factor. The most common category of risk factor (57 women) was an adverse event in the woman’s past obstetric history (eg retained placenta, small-for-dates infant, Group B streptococcal infection). Asthma requiring oral or intravenous steroids was documented in 29 women. (As mentioned previously, the number of women with severe asthma may be an over-estimate as we have become aware that in some cases, no distinction was made between inhaled and oral steroids.) Thirty four women had documented risk factors relating to the current pregnancy: we acknowledge that some of these (eg diastolic blood pressure sustained at >90mmHg; scan diagnosis of fetal growth restriction) may have resolved by the time of the woman’s admission in labour. The proportions of women with various categories of risk factors are summarised in Figure 7.
25
Figure 7 Risk factors present at some stage of pregnancy among women admitted in labour to CMUs
7a Proportion of women with risk factors according to EGAMS risk assessment template 7b Proportion of women with risk factors according to more limited criteria 7c Types of risk factor present in 166 women with documented risk factors but no documented reason for the decision to labour within a CMU
1160, 69%
526, 31%
EGAMS low risk EGAMS higher risk
47, 3%
41, 2%
26, 2%
166, 10%1406, 83% 280, 17%
Low risk Advanced labourMaternal choice on-site medical careHigher risk, unexplained
asthma, 29
age, 14
POH, 57
BMI, 10
misc. medical, 20
current preg, 34
parity, 1
height, 1
26
Table 6 Risk status of women admitted to CMUs in labour based on documentation of risk factors at any stage in pregnancy
CMU identifier and location
Women admitted in labour
‘higher risk’ women according to EGAMS
criteria*
‘higher risk’ women according to more limited criteria**
‘higher risk’ women: no documented reason for CMU
labour No. No. % No. % No. %
1. Perth 243 44 18 22 9 14 6
2. Montrose 169 54 32 30 18 21 12
3. Kirkwall 134 62 46 43 32 9 7
4. Lerwick 127 31 24 20 16 10 8
5. Greenock 154 26 17 3 2 2 1
6. Peterhead 124 39 31 18 14 14 11
7. Arbroath 137 80 58 49 36 40 29
8. Stranraer 69 24 35 14 20 7 10
9. Aboyne 77 22 28 8 10 6 8
10. Fraserburgh 78 26 33 13 17 8 10
11. Alexandria 78 17 22 7 9 5 6
12. Banff 61 15 47 6 10 6 10
13 Fort William 55 26 47 18 33 9 16
14. Dunoon 39 9 23 3 8 1 3
15. Oban 43 17 39 8 19 3 7
16. Broadford 24 13 54 8 33 6 25
17. Rothesay 21 9 43 5 24 2 10
18. Campbeltown 20 5 25 4 20 3 15
19. Lochgilphead 17 6 35 1 6 0 0
20. Lamlash 8 1 12 0 0 0 0
21. Benbecula 6 0 0 0 0 0 0
22. Bowmore 2 0 0 0 0 0 0
TOTAL 1686 526 31 280 17 166 10
*Women were designated ‘higher risk’ according to EGAMS criteria if they had any of the following: Age at delivery ≤16 years or ≥41 years; ≥5 previous deliveries; height <150cms; BMI ≤20 or ≥32; diabetes, essential hypertension, cardiac disease, renal disease, epilepsy, asthma requiring steroids, haematology problems, major psychiatric illness, or other major health problems; previous perinatal death, baby weighing <2.5kg at term, delivery at <34 weeks, caesarean section, mid cavity instrumental delivery, estimated blood loss >1000mls (EGAMS specifies blood loss >500mls but our audit proforma captured only >1000mls), 3rd or 4th degree tear, shoulder dystocia, retained placenta, Group B strep, or other major obstetric or gynaecological problem; or in the current pregnancy: twins, blood group antibodies, hepatitis carrier, Group B strep, substance misuse, diastolic hypertension, scan diagnosis of growth restriction, significant APH, or other significant obstetric problem. **Women were designated ‘higher risk’ according to our more limited criteria if they had any of the following: Age at delivery ≤16 years or ≥41 years; BMI ≤15 or ≥35; diabetes, essential hypertension, cardiac disease, renal disease, epilepsy, asthma requiring steroids, haematology problems, or other major health problems; previous perinatal death, baby weighing <2.5kg at term, delivery at <34 weeks, caesarean section, estimated blood loss >1000mls, 3rd or 4th degree tear, shoulder dystocia, retained placenta, Group B strep, or other major obstetric or gynaecological problem; or in the current pregnancy: twins, blood group antibodies, hepatitis carrier, Group B strep, substance misuse, diastolic hypertension, scan diagnosis of growth restriction, significant APH, or other significant obstetric problem.
27
Outcomes of labours managed in Community Maternity Units For 2005, we have data on 1686 women who were admitted in labour to a CMU, 63% (1059) were multigravidae and 37% (627) primigravidae. There were two twin deliveries; the outcomes data described relate to twin 1 for each of these deliveries. (Both twin deliveries occurred in women with a plan to deliver in a consultant-led unit but were admitted in advanced labour to a CMU and transfer prior to delivery was not feasible.) Intrapartum transfers to a consultant-led unit Of the 1686 women who began their labour in a CMU, 295 (17%) were transferred off-site to a consultant-led maternity unit during labour or within one hour of delivery (ie the decision to transfer was made within one hour of delivery). For the purposes of the audit, all these 295 transfers are designated as ‘intrapartum transfers’. Of the intrapartum transfers, 60 (20% of all transfers and 3% of all CMU labours) occurred during the second stage of labour. Rates of transfer by individual CMU are summarised in Table 7. Low transfer rates in Lerwick (0%) and Kirkwall (4%) were achieved largely because of the availability of non-obstetric medical care on site. We acknowledge that the model of care provided in the CMUs in Lerwick and Kirkwall is fundamentally different from that provided in the other CMUs. Thus, we have also analysed outcomes data for the remaining 20 CMUs separately. A total of 1425 women began their labours in CMUs other than those in Orkney and Shetland. Of these 1425 women, 290 (20%) had off-site intrapartum transfers. Table 7 Summary of transfers from a CMU to a consultant-led unit in labour or within one hour of
delivery CMU identifier and
location Women
admitted in labour
Transfers to a consultant-led unit in labour or within one hour
of delivery Transfers to a consultant-led unit
in the 2nd stage of labour
No. No. % No. % 1. Perth 243 58 24 9 4 2. Montrose 169 15 9 9 5 3. Kirkwall 134 5 4 0 0 4. Lerwick 127 0 0 0 0 5. Greenock 154 45 29 3 2 6. Peterhead 124 11 9 4 3 7. Arbroath 137 36 26 12 9 8. Stranraer 69 10 14 2 3 9. Aboyne 77 21 27 6 8 10. Fraserburgh 78 22 28 5 6 11. Alexandria 78 26 33 4 5 12. Banff 61 13 21 2 3 13. Fort William 55 9 16 2 4 14. Dunoon 39 3 8 0 0 15. Oban 43 9 21 0 0 16. Broadford 24 1 4 0 0 17. Rothesay 21 2 9 0 0 18. Campbeltown 20 6 30 1 5 19. Lochgilphead 17 3 18 1 6 20. Lamlash 8 0 0 0 0 21. Benbecula 6 0 0 0 0 22. Bowmore 2 0 0 0 0 TOTAL 1686 295 17 60 3
28
Of the 295 intrapartum transfers (during labour or within one hour of delivery), 14 were for neonatal indications only. The remaining 281 cases each had one or more obstetric indications for transfer (231 women had only one documented reason; 42 had two; seven had three; and one had four). The commonest reason described for transfer was ‘failure to progress in the 1st stage of labour’ (84 women). ‘Request for epidural’ was reported as a reason for transfer in 30 women and was the only reported reason in 18 women (6%). The reasons reported for transfer to a consultant-led unit are summarised in Figure 8. Figure 8 Reasons for transfers of women from a CMU to a consultant-led unit in labour or within one hour of delivery (n=295)
84
58
46
3025 23
1914
9 7 6 4 3 2 1
914
0
10
20
30
40
50
60
70
80
90
Failure
to pr
ogres
s (1s
t stag
e)
Failure
to pr
ogres
s (2n
d stag
e)
Mecon
ium st
aining
Epidura
l requ
est
Fetal d
istres
s (1s
t stag
e)
Retaine
d plac
enta
Malpos
ition
Hypert
ensio
n
Antepa
rtum ha
emorr
hage
Fetal d
istres
s (2n
d stag
e)
Malpres
entat
ion
Postpa
rtum ha
emorr
hage
Pyrexia
3rd/4t
h deg
ree pe
rinea
l tear
Eclamps
ia
Misc. m
aterna
l indic
ation
s
Neona
tal in
dicati
ons o
nly
No.
Mode of delivery Data on mode of delivery were recorded for 1685 of the 1686 women who were admitted in labour to a CMU. Overall, 1479 women (88%) had spontaneous vertex deliveries. Among the 1425 women who commenced their labour in CMUs other than Lerwick and Kirkwall, 1281 (90%) had spontaneous vertex deliveries, 88 (6.2%) had forceps/ventouse deliveries, three (0.2%) had vaginal breech deliveries and the remaining 52 (3.6%) had an emergency caesarean section. Just under two-thirds (64%) of these women (1425) were multigravidae and just over one-third were primigravidae (36%). Data on modes of delivery are summarised in Figure 9. Table 8 summarises data on mode of delivery for all 22 CMUs.
29
Figure 9 Modes of delivery by parity for all women who were admitted in labour to a CMU **
90
6.2 3.6 0.2
97
1 1 0.2
77
148
0.20
20
40
60
80
100
SVD Forceps/ventouse Emergency CS Vaginal breech
%CMU labours** Multigravidae Primigravidae
**Cases exclude women admitted to the CMUs in Kirkwall and Lerwick. n= 1425 Table 8 Modes of delivery of women admitted in labour to each CMU (includes women transferred in labour)
CMU identifier and location
Women admitted in
labour Spontaneous
vertex delivery Forceps/ ventouse
Emergency caesarean
section
Elective caesarean
section No. % % % %
1. Perth 243 89 6 4 0 2. Montrose 169 92 4 4 0 3. Kirkwall 134 69 4 13 13 4. Lerwick 127 83 3 15 0 5. Greenock 154 85 9 6 0 6. Peterhead 124 95 5 0 0 7. Arbroath 137 89 9 2 0 8. Stranraer 69 94 3 3 0 9. Aboyne 77 86 9 5 0 10. Fraserburgh 78 85 10 5 0 11. Alexandria 78 86 8 6 0 12. Banff 61 89 8 3 0 13. Fort William 55 95 4 2 0 14. Dunoon 39 97 0 3 0 15. Oban 43 88 5 5 0 16. Broadford 24 100 0 0 0 17. Rothesay 21 100 0 0 0 18. Campbeltown 20 80 0 20 0 19. Lochgilphead 17 88 12 0 0 20. Lamlash 8 100 0 0 0 21. Benbecula 6 100 0 0 0 22. Bowmore 2 100 0 0 0 TOTAL 1686 88 6 5 1
Percentages for individual CMUs may not total 100% because of rounding or because of breech delivery (three cases).
30
Among the 295 women with intrapartum transfers to a consultant-led unit, 149 (50%) had a spontaneous vertex delivery; 30%, forceps/ventouse; and 19%, a caesarean section. Among the 60 women transferred in the second stage, 10 (17%) had a spontaneous vertex delivery. Data on modes of delivery for all women and for transferred women are summarised in Figure 10. Figure 10 Modes of delivery in different groups of women who were admitted in labour to a CMU
88
6 5 1 0.2
50
3019
0 0.717
68
150 0
0
20
40
60
80
100
SVD Forceps /ventouse
Emergency CS *Elective CS Vaginal breech
%
All CMU labours All transfers to a CLU Transfers in 2nd stage
*Cases include 18 women admitted for elective caesarean section under non-obstetric medical care in the CMUs in Kirkwall and Lerwick. Of the 1686 women admitted in labour to a CMU, 1391 remained in the CMU throughout labour, delivery, and for the first hour postpartum. Of this ‘non-transferred’ group, 1330 (96%) had a spontaneous vertex delivery. The remaining non-transferred women delivered in the CMUs in Kirkwall or Lerwick and were delivered by emergency caesarean section (33 women), elective caesarean section (18 women), or forceps/ventouse (nine women) under the care of non-obstetric medical staff. Of the 1330 spontaneous vertex deliveries managed entirely within CMUs, 174 (13%) were conducted as water births. Twelve CMUs had one or more water births, the majority of these births taking place in the Montrose unit (91 of the 151 births); the Perth unit (30 of the 193 births) and the Fort William unit (11 of the 51 births). In the nine remaining units there were between one and nine births conducted in water.
31
Gestation and birthweight Among all 1686 deliveries, mean gestation at delivery was 39 weeks (range 27-42 weeks) (Figure 11); and the mean birthweight of the infants was 3.5 kg (range 1.1-5.3 kg) (Figure 12). Figure 11 Gestation at delivery among 1686 women with labours managed (in full or in part) in a Community Maternity Unit Figure 12 Birthweight of 1686 infants following labours managed (in full or in part) in a Community Maternity Unit There was no significant difference in mean gestation at delivery between deliveries managed in full within a CMU (mean 39.6, std. dev 1.21 weeks) and those where intrapartum transfer occurred (mean 39.6, std. dev 1.46 weeks), nor was there any significant difference in mean birthweight between births managed in full within a CMU (mean 3.49, std. dev 0.47kg) and those where intrapartum transfer occurred (mean 3.47, std. dev 0.46kg).
4540353025
Gestation
600
400
200
0
Freq
uenc
y
Mean =39.6�Std. Dev. =1.26�
N =1,682
600040002000
Birthweight (Grammes)
200
150
100
50
0
Freq
uenc
y
Mean =3490.63�Std. Dev. =472.265�
N =1,680
32
Duration of labour Durations of the first, second and third stages of labour were documented for the vast majority of women (over 90% for each stage). Among women who completed their intrapartum care within a CMU (‘non-transferred’ women), the mean duration of the first stage was 6hrs 15mins (range 17mins to 39 hours); of the second stage, 32mins (range 1min to 5hrs 52mins) and of the third stage, 12mins (range 0mins to 3hrs 15mins). As would be expected, the 295 women who underwent ‘intrapartum’ transfer had significantly longer mean durations of each stage of labour compared to women who completed their intrapartum care within a CMU. The 60 women who were transferred in the second stage of labour had longer durations of the second stage. It is noteworthy that the mean duration of the second stage in these women was four hours, with a maximum of 7hrs 49mins. Data on duration of labour are summarised in Table 9 and in Figure 13. Interpretation of data on duration of labour is difficult in the absence of comparative data for all births in Scotland. Table 9 Duration of first, second, and third stages of labour (hours:minutes) in different groups of
women admitted in labour to a CMU
‘Non-transferred’ women*
All ‘intrapartum’ transfers* 2nd stage transfers Comparison*
Mean Range Mean Range Mean Range
1st stage 6:15 0:17-39:0 8:51 0:30-36:50 8:23 0:30-34:35 P=0.000
2nd stage 0:32 0:01-5:52 1:51 0:01-7:49 4:00 0:48-7:49 P=0.000
3rd stage 0:12 0:00-3:15 0:31 0:00-8:25 0:09 0:01-2:53 P=0.000
33
Figure 13 Duration of second stage of labour in different groups of women admitted in labour to a CMU
06:00:0005:00:0004:00:0003:00:0002:00:0001:00:0000:00:00
Duration of 2nd stage (hrs)
500
400
300
200
100
0
Freq
uenc
y
Mean =1,884�Std. Dev. =2,469�
N =1,327
Duration of 2nd stage: non-transferred women
08:00:0007:00:0006:00:0005:00:0004:00:0003:00:0002:00:0001:00:0000:00:00
Duration of 2nd stage (hrs)
80
60
40
20
0
Freq
uenc
y
Mean =6,629�Std. Dev. =6,112�
N =249
Duration of 2nd stage: all intrapartum transfers
09:00:00
08:00:00
07:00:00
06:00:00
05:00:00
04:00:00
03:00:00
02:00:00
01:00:00
00:00:00
14
12
10
8
6
4
2
0
Freq
uenc
y
Mean =11,530�Std. Dev. =5,024�
N =56
Duration of 2nd stage: transfers in 2nd stage
34
Analgesia The majority of women received one or more types of analgesia during labour. As expected, women who were transferred in labour received more pharmacological pain relief. The most frequently used forms of pain relief were equanox (1344 women) and hydrotherapy (non-pharmacological analgesia), which was used by just under a third of women (497). Details of the analgesia used are summarised in Table 10. Table 10 Analgesia used in labour for all women admitted to a CMU* in labour
Analgesia All women n = 1686
Non- transferred women n = 1391
Intrapartum transfers n = 295
No % No % No % Hydrotherapy 497 29 389 28 108 37 Equanox 1344 80 1090 78 254 86 Diamorphine 336 20 221 16 115 39 Pethidine 205 12 136 10 69 23 Epidural 73 4 1 <1 72 24 Spinal 111 7 43 3 68 23 TENS 246 15 191 14 55 19
*Cases include women admitted to CMUs in Kirkwall and Lerwick. Some women in these CMUs had general anaesthesia (not included in this table) Perineal trauma Table 11 summarises the rates of perineal trauma for all women admitted in labour to a CMU. The rate of episiotomy in the non-transfer group was 4%. Five hundred and eighty four women (42%) in this group had a first or second degree tear. We did not collect data on the number of women who had a second degree tear sutured. Sixteen women (1%) had third or fourth degree tears, nine of these women gave birth in a consultant unit and the remaining seven women gave birth in a CMU. All women who had a third or fourth degree perineal tear had the tear sutured in a consultant-led unit. Table 11 Rates of perineal trauma for all women admitted to a CMU in labour All women (n=1686) All prims (n=627) Non-transferred
women (n=1391) Intrapartum
Transfers (n=295) No % No % No % No % Episiotomy 129 8 105 17 51 4 78 26
1st/2nd degree tear 666 39 253 40 584 42 82 28
3rd/4th degree tear 16 1 14 2 5 <1 11* 4*
*Intrapartum transfers includes all women where the decision to transfer was made up to one hour after delivery. For two of these women, 3rd/4th degree tear was the reason for transfer. Blood loss and postpartum haemorrhage. The mean blood loss for all women (1686) was 250mls (range 10-7500mls). Thirty women had a blood loss of >1000mls (28 of 295 women who had intrapartum transfers and two of 1391 non-transferred women). Five women (all transferred intrapartum) had a blood loss of >3000mls. In most cases where the blood loss was >1000mls the woman had either an emergency caesarean section or a manual removal of placenta. In the non-transfer group (1391 women), 9.6% (133) had a physiological third stage of labour. Most of these women gave birth in Montrose (51), Greenock (24), Perth (24), or Fort William (11).
35
Breastfeeding Breastfeeding rates varied among CMUs. The figures were consistent with the Guthrie Data for 2005. Following the birth of their baby, just under two-thirds of women (1077 of 1686; 64%) commenced breastfeeding. By day 10, the rate had fallen to 53% (890 women). Among units where over 100 women commenced their labour, the highest breastfeeding rates on day 10 were in Kirkwall, 73% (93 women) and Perth, 66% (154 women). In units where between 50 and 100 women commenced their labour, the highest breastfeeding rates on day 10 were in Aboyne, 77% (57 women) and Fort William, 66% (35 women). Units where fewer than 50 women commenced their labour achieved breast feeding rates of 40-100%. Perinatal morbidity and mortality Of the 1686 babies born following (all or part of) intrapartum care in a CMU, 78 (5%) were admitted to a neonatal unit; of these, 37 (2%) were admitted for >48 hours. Of the 295 babies born following intrapartum transfer to a consultant-led unit, 37 (12%) were admitted to a neonatal unit, 18 of these (6%) for >48 hours. Of the 60 babies born following 2nd stage transfer to a consultant-led unit, six (10%) were admitted to a neonatal unit, two of these (3%) for >48 hours. The difference in the rate of neonatal unit admission between the babies of ‘transferred’ and ‘non-transferred’ mothers is statistically significant (p<0.001). Fifteen babies had an Apgar score of ≤6 at 5 minutes. Ten of these babies were born in a CMU; five required intermittent positive pressure ventilation (IPPV) by bag and mask, and three required IPPV and drugs. Four of the 10 babies were subsequently admitted to a neonatal unit and two died. Among all 1686 births, there were no stillbirths and three early neonatal deaths (the two mentioned above and one who died prior to admission to a neonatal unit). All three occurred in term births to ‘lower risk’ women. One death occurred following intrapartum transfer and was due to a major complex cardiac anomaly. The remaining two deaths occurred following delivery within a CMU; both were related to intrapartum asphyxial events. Transfers beyond one hour There were 65 transfers of mothers and babies where the decision to transfer was made beyond one hour after birth. Of these, 11 were for maternal indications (eg retained placenta, haemorrhage, pyrexia and hypertension). The remaining 54 transfers were because of problems in the infant. Forty one of these 'late transfers' resulted in the baby being admitted to a neonatal unit. The remaining 13 babies, although transferred to a consultant-led maternity unit, were not admitted to a neonatal unit; their problems included jaundice, 'irritability' and positive Coomb's test.
36
Risk assessment and the outcome of labour Many women who had risk factors recorded at some stage in pregnancy were admitted to a CMU in labour. Were these women or their babies more likely to be transferred? We found that of the 526 (31%) women identified as ‘higher risk’ using the EGAMs criteria, 86 (16%) were transferred, and of the 1160 ‘low risk’ women, 209 (18%) were transferred (no significant difference; p=0.404). We had 280 women who were ‘higher risk’ at outset of labour by our more limited criteria. Were they more likely to be transferred? We found that 47 (17%) of these 280 ‘higher risk’ women were transferred compared to 248 (18%) of the 1406 ‘low risk’ women (Table 12). We identified a group of 166 women who were ‘higher risk’ at outset of labour by our more limited criteria and for whom there was no documented reason (maternal choice, imminent delivery, or under medical care in Orkney or Shetland) to explain why they had been admitted in labour to a CMU. Thirty four (20%) of these women were transferred compared to 261 (17%) of the remaining 1520 women (p=0.283). Using admission to a neonatal unit as the outcome (78 admissions), and applying the EGAMS risk criteria, 27 of the 526 babies (5.1%) whose mothers were ‘higher risk’ were admitted compared to 51 of the 1160 babies (4.4%) whose mothers were ‘low risk’ (p=0.53). When we related our more limited eligibility criteria to neonatal admissions, there were slightly more babies whose mothers were ‘higher risk’ (19 of 280; 6.8%) admitted versus 59 of 1406 (4.2%) babies whose mothers were ‘low risk’ (p = 0.085). Among the babies of the 166 women who were ‘higher risk’ and for whom there was no documented reason to explain why they had been admitted in labour to a CMU, seven (4%) were admitted to a neonatal unit compared to 71 (5%) of the remaining 1520 women (p=1.00). Our audit data show that among these women admitted to CMUs in labour, designated risk status is not related to outcome. It must be remembered however that these women are a highly selected group, having been accepted for CMU birth following a dynamic risk assessment process. In our audit, the vast majority of those ‘higher risk’ women accepted in labour had only one risk factor, some of limited relevance to the management of labour. Our findings of similar outcomes among all women accepted for CMU birth suggest that, in practice, risk assessment by the multi-professional team functioned well: women with multiple or major risk factors had already planned to have consultant-led intrapartum care. Table 12 Risk assessment of women and transfers to a consultant-led unit
Women Total women N =1686
EGAMS ‘higher risk’
N =526
EGAMS ‘low risk’
N = 1160
Our more limited criteria
‘higher risk’ N = 280
Our more limited criteria ‘low risk’
N = 1406
Not transferred 1391 440 951 248 1359
Transferred 295 (17%) 86 (16%) 209 (18%) 47(17%) 248 (18%)
Outcomes among primigravid women EGAMS eligibility criteria do not exclude primigravid women from delivering in a CMU and we found that over two-thirds of primigravidae admitted to a CMU in labour gave birth there. However, primigravid women were at increased risk of intrapartum transfer compared to parous women (197 of 627 [31%] vs. 98 of 1059 [9%]; p=0.000). We also found that primigravid women were at increased risk of transfer in the 2nd stage (46 of 627 [7%] vs. 14 of 1059 [1%]; p=0.000). These figures are comparable to those found by Mahmood (2003) in Evaluation of an experimental midwife-led unit in Scotland (intrapartum transfer rate for nulliparous women, 27% and for multiparous women, 10%).
37
The proportion of all women admitted in labour who were primigravid varied greatly among CMUs. These proportions are summarised in Figure 14. Intrapartum transfer rates among primigravid women also varied among CMUs. Data relating to admissions and transfers of prims in labour are summarised in Table 13. Figure 14 Proportion of all women admitted in labour who were primigravid by CMU
39
50
43 43 44
30
40
27
45
3633 33
14
28 26
1214
2529
0 0 0
37
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 All
CMU identifier
%
38
Table 13 Summary of admissions and transfers of primigravid women in labour by CMU
CMU identifier & location
Total women admitted in
labour
Overall intrapartum transfer rate
Prims as % of all women admitted
in labour
Intrapartum transfer rate among prims
No. % % %
1. Perth 243 24 39 45 2. Montrose 169 9 50 15 3. Kirkwall 134 4 43 5 4. Lerwick 127 0 43 0 5. Greenock 154 29 44 47 6. Peterhead 124 9 30 22 7. Arbroath 137 26 40 44 8. Stranraer 69 14 27 21 9. Aboyne 77 27 45 40 10. Fraserburgh 78 28 36 50 11. Alexandria 78 33 33 65 12. Banff 61 21 33 40 13. Fort William 55 16 14 37 14. Dunoon 39 8 28 18 15. Oban 43 21 26 54 16. Broadford 24 4 12 0 17. Rothesay 21 9 14 33 18. Campbeltown 20 30 25 40 19. Lochgilphead 17 18 29 60 20. Lamlash 8 0 09 0 21. Benbecula 6 0 0 0 22. Bowmore 2 0 0 0 TOTAL 1686 17 37 31
Outcomes among parous women with previous forceps/ventouse deliveries The EGAMS eligibility template does not exclude women who have previously had uncomplicated forceps/ventouse deliveries from CMU intrapartum care. In our audit, women with any previous forceps/ventouse delivery were at increased risk of intrapartum transfer compared to other parous women (22 of 145 [15%] vs. 76 of 914 [8%]; p=0.013); and of transfer in the 2nd stage (7 of 145 [5%] vs. 7 of 914 [1%]; p=0.001). Intrapartum transfer times We collected data on the various stages of transfer: from the time the decision was made to transfer either the mother or baby to an off-site consultant-led unit to the time of clinical assessment by an obstetrician or neonatologist. The overall transfer time, from decision to assessment, was recorded in 230 of the 295 transfers (Figure 15). The mean overall transfer time was 2.6 hrs (median 1.9 hrs; range 0.5 to 13.5 hrs). There were variations in overall transfer times among CMUs (Figure 16); these are mainly attributable to differences in use of air ambulances, actual journey times, and the intervals between arrival at a consultant-led unit and documented clinical assessment.
39
Among the 60 transfers in the 2nd stage of labour, the overall transfer time, from decision to assessment, was recorded in 51. The mean overall transfer time was 1.6 hrs (median 1.4 hrs; range 0.85 to 4.33 hrs). Ambulance travel times were recorded for 185 cases (from leaving the CMU to arrival at the consultant-led unit) (Figure 17). The mean ambulance travel time was 0.77 hrs (median 0.58 hrs; range 0.22 hrs -3.00 hrs). The longest recorded ambulance travel time was for a transfer by road from Campbeltown to the Southern General Hospital in Glasgow. Figure 15 Overall transfer times (Interval between decision to transfer and clinical assessment in consultant-led unit)
12.5010.007.505.002.500.00
interval between decision to transfer and assessment in CLU (hrs)
60
50
40
30
20
10
0
Freq
uenc
y
Mean =2.5749�Std. Dev. =2.01513�
N =230
Figure 16 Median and range of interval between decision to transfer and assessment within a consultant-led unit by CMU
0123456789
101112131415
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 ALL
CMU identifier
Hou
rs
40
Figure 17 Ambulance travel time
14.0012.0010.008.006.004.002.000.00
ambulance travel time (hrs)
50
40
30
20
10
0
Freq
uenc
y
Mean =0.7711�Std. Dev. =0.50967�
N =185
Transfer times in excess of four hours Thirty four cases had a recorded overall transfer time of greater than four hours. We scrutinised the data relating to these selected cases in some detail in order to identify where delays occurred. In six cases, there was a delay of over one hour from ordering the ambulance to the ambulance leaving the CMU; these occurred at Campbeltown (three cases with a maximum delay of two hours associated with awaiting arrival of the air ambulance); Alexandria (one case with an ambulance delay of 3hrs 20mins, no explanation given); Oban (one case with a delay of 1hr 20mins, as the ambulance initially despatched was re-routed to another emergency); and Greenock (one case with a delay of 1hr 2mins, no explanation given). In just over 50% of the 34 cases, the first entry in the case notes by an obstetrician was over one hour (and up to 11 hours) after the patient’s arrival in the consultant-led unit. While these women may have been assessed by an obstetrician in collaboration with a midwife on arrival at the consultant-led unit, if the obstetrician did not record this discussion and or assessment in the case notes at that time, long intervals between arrival and clinical assessment were recorded in the audit. We had complete data on all stages of the transfer process for 15 out of the 34 cases. This information is presented in Figure 18.
41
Figure 18 Transfer times for 15 selected cases with complete dataset (all with overall transfer times of >4 hours)
0
2
4
6
8
10
12
14
15 9 15 18 15 18 18 14 6 7 5 5 7 11 5CMU identifier of woman
hrs
decision - ordering ambulance ordering ambulance - leaving CMUambulance travel time arrival at consultant-led unit - clinical assessment
In general, the overall transfer times from the different CMUs to consultant-led units were good. There is however scope for improvement in several aspects of the transfer procedure. First, as there were a significant number of cases where no timings were recorded, or there were omitted timings for various stages of the transfer process, a consistent approach to recording these stages needs to be implemented. Second, women who are transferred to consultant-led units should, as a priority, be assessed on arrival by a member of the obstetric team and the findings recorded promptly, and third, to minimise the potential for delays, cases where transfer times are longer than the average should be reviewed and where necessary action taken to resolve local difficulties. Illustrative Cases: decision making and transfer arrangements Case 1 A 30 year old woman in her third pregnancy was admitted to a CMU at 00:30 hrs in established labour. She had had a straightforward pregnancy and her membranes had ruptured at 22:00 hrs on the previous day. The only thing of note in her past history was that she had a previous forceps delivery. She progressed quickly in labour and commenced active pushing at 03:30 hrs. The fetal head was in the occipito-posterior position. After 1 hr 30 mins in the second stage there was no progress and a decision was made to transfer to a consultant unit. The ambulance arrived at the CMU 45 minutes later. The woman left the CMU in the ambulance at 06:00 hrs and arrived at the consultant unit at 09:00 hrs. Transfer was by road as there was no air ambulance available. The woman was assessed by a member of the obstetric team at 09:20 hrs. She had an emergency caesarean section at 10:16 hrs. The duration of the second stage was 6 hrs 30 mins. The baby weighed 4.02kg and had Apgar scores of 4 at 1 minute and 9 at 5 minutes. The baby was given IPPV by bag and mask. Mother and baby were subsequently transferred to the postnatal ward and were discharged home three days later.
42
Case 2 A 26 year old woman in her first pregnancy was admitted to a CMU at 02:30 hrs. She had been well during pregnancy. On admission she was in early labour. She laboured in the birthing pool and required equanox for pain relief. At 07:00 hrs her blood pressure was 146mmHg (systolic) and 108mmHg (diastolic). She had made slow progress in labour and the decision was taken at 11:00 hrs to transfer her to a consultant-led unit. On requesting an ambulance, staff were advised that one was not immediately available as the two local ambulances were transporting other patients. The woman needed to be transferred and she was using equanox; it was agreed that her partner would take her to the consultant-led unit in his car. At 14:30 hrs she arrived at the consultant-led unit and was assessed by an obstetrician at 16:10 hrs. She was ketotic, had made slow progress in the first stage of labour, and had mild hypertension. She was given diamorphine and an intravenous infusion, and required antihypertensive drugs. She progressed to a normal delivery at 21:00 hrs. The baby weighed 3.04kg and had Apgar scores of 9 at 1 min and 9 at 5 mins. Mother and baby were discharged home four days following birth. Case 3 A 25 year old woman who had three children was admitted, at 04:00 hrs, to a CMU on a Scottish Island in the second stage of labour. She was thought to be 34 weeks pregnant; however, she had not had any pregnancy care. At 04:10 hrs, the decision was taken to advise the neonatal retrieval team that the birth was imminent and the baby would need to be transferred. The woman had a normal birth 30 minutes after admission. The baby weighed 1.85kg and had Apgar scores of 7 at 1 minute and 9 at 5 minutes. The baby did not require any active resuscitation and was nursed in the unit’s incubator prior to the arrival of the neonatal retrieval team six hours later. The baby was in good condition and was transferred to the neonatal unit. She became jaundiced but otherwise had no problems. Mother and baby were discharged home 15 days following the birth.
43
Report References Mahmood TA. Evaluation of an experimental midwife-led unit in Scotland. Journal of Obstetrics and Gynaecology 2003;23(2):121-129 NHS Quality Improvement Scotland (2005). Clinical Standards – March 2005 Maternity Services. Edinburgh: NHS QIS NHS Quality Improvement Scotland – Routine Examination of the Newborn Best Practice Statement (2004). Edinburgh: NHS QIS Nursing and Midwifery Council. Midwifery rules and standards 2004. www.nmc-uk.org Scottish Executive Health Department (2001) A Framework for Maternity Services in Scotland. Edinburgh. Scottish Executive. Scottish Executive Health Department (2002a) Report of the Expert Group on Acute Maternity Services (EGAMS). Implementing a Framework for Maternity Services in Scotland. Edinburgh: Scottish Executive Health Department. Scottish Executive Health Department (2002b) Expert Group on Acute Maternity Services (EGAMS) Reference Report. Edinburgh: Scottish Executive Health Department. Tucker J, Hall M. (1999) Latest views on antenatal care programmes. In: Renfrew M and Marsh G eds. Community-based maternity care. Oxford: Oxford University Press. Bibliography Epidemiology Unit, University of Oxford. Report of a Structured Review of Birth Centre Outcomes December 2004. Mary Stewart, Rona McCandlish, Jane Henderson, Peter Brocklehurst. The Guthrie data. Most recent (Year 2005) Guthrie Data. www.breastfeed.scot.nhs.uk Hodnett ED; Downe S; Edwards N; Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database of Systematic Reviews 4,2006. Hundley VA, Cruickshank FM, Milne JM, Glazner CM, Lang GD, Turner M, et al. Midwife managed delivery unit: a randomised controlled comparison with consultant led care. BMJ 1994; 309:1400-4 Tucker J, Farmer J, Bryers H, Kiger A, van Teijlingen E, Ryan M, Pitchforth E on behalf of the Research Project Team. Final Report. Sustainable Maternity Service Provision in Remote and Rural Scotland: implementing and evaluating maternity care models for remote and rural Scotland. RARARI, Dumfries, 2006.
44
Appendices 1 Location of Community Maternity Units and Referral Consultant Units in Scotland (2005)................................................................................................................. 45 2 EGAMS and Community Maternity Units exclusion criteria for birth in a Scottish Community Maternity Unit (2005). .................................................................................. 46 3 Overview of services provided by Scottish Community Maternity Units (2005) ............... 49 4 Summary of clinical activity in Scottish Community Maternity Units (2005) ..................... 51 5 Modes of delivery of parous women admitted in labour to each CMU ............................. 52 6 Modes of delivery of primigravidae women admitted in labour to each CMU................... 53
45
Appendix 1 Location of CMUs in Scotland
Community Maternity Units Consultant-led Maternity Referral Units
Appendix 2 EGAMS and Community Maternity Units exclusion criteria for birth in a Scottish Community Maternity Unit (2005) Health Board A&C A&A D&G Grampian Highland Orkney Shetland Tayside W. Isles
Unit code 5,11,14,15,17,18,19,22 20 8 6,9,10,13 12,16 3 4 1,2,7 21
EGAMS EXIT CRITERIA
Primigravida <16 years x x x x
Primigravida >40 years x <16->37 x x x
Multigravida >40 years 18-39 <16->37 16-37 No info
Multigravida >5 1-4 No info Para 1-4 No info
Height <150cms No info No info No info No info No info
BMI of <20 or >32 20-34 Wt <45kg->100kg <20 or >35 <35 <20 or >35 No info <20 or >35
Maternal medical/surgical history
Diabetes (type 1 and 2 )
Gestational diabetes
Essential hypertension
Cardiac disease
Renal Disease
Asthma oral /IV steroids
Coagulopathy/haematology problems
Major psychiatric illness
Other major health problems
- yes in protocol x - excluded no info - no information in protocol
46
Appendix 2 (continued) EGAMS and Community Maternity Units exclusion criteria for birth in a Scottish Community Maternity Unit (2005)
Health Board A&C A&A D&G Grampian Highland Orkney Shetland Tayside W. Isles
Unit code 5,11,14,15,17, 18,19, 22 20 8 6, 9,10,13 12,16 3 4 1, 2, 7 21
Previous obstetric gynaecological problems
Perinatal death Significant perinatal probs
Preterm birth <34wks Prem.labour No info Previous baby <2.5kg IUGR No info Forceps/ventouse Difficult del Difficult del Difficult del Difficult del Difficult del PPH >500mls >500 >1000 >1000 >1000 >1000 >1000 >1000 PPH >1000 3rd or 4th degree perineal tear Shoulder dystocia No info No info No info No info No info Retained placenta No info Group B strep Hysterotomy uterine surgery Other significant obstetric gynaecological problems
Current pregnancy
Multiple pregnancy Blood group antibodies Hepatitis carrier HIV positive Group B strep Diastolic BP sustained >90mgHg Antepartum haemorrhage Fetal growth restriction (scan) Gestation <37wks Hb <10g/dl at 34 - 36 wks Other significant problems
- yes in protocol x - excluded no info - no information in protocol
47
48
Appendix 2 (continued) EGAMS and Community Maternity Units exclusion criteria for birth in a Scottish Community Maternity Unit (2005)
EXCLUSION CRITERIA
During labour normal at outset Neonatal problems normal labour Antepartum haemorrhage Jaundice first 24 hrs Hypertension Hypoglycaemia persisting Eclampsia Hypothermia Pyrexia Respiratory distress Malpresentation Infection Multiple pregnancy Apgar 6 or less at 5 mins Fetal distress 1st stage Congenital malformation Fetal distress 2nd stage Other significant problems Cord prolapse Meconium stained liquor Maternal postnatal problems Failure to progress 1st stage of labour Sepsis Failure to progress 2nd stage of labour Other significant problems Request for epidural Retained placenta 3rd or 4th degree perineal tear Postpartum haemorrhage Other significant problem
Appendix 3 (part 1) Overview of Services provided in CMUs during 2005 (Source of data: Unit Profile Questionnaire)
Location Bookings CMU births
Pre booking services
Early Pregnancy
Assessment Service
Early Pregnancy
Scans
Pregnancy scans over 20 weeks
Antenatal care
midwife
Antenatal high risk clinics
Maternity day care
Labour assessment all women
Postnatal care CLU to CMU
Neonatal care CLU to CMU
Perth 1105 192 clinic m clinic x
Montrose 251 155 m x x
Kirkwall 201 131 x m m
Lerwick 220 127 x x x x
Greenock 716 116 x clinic m m clinic x x x
Peterhead 225 114 x x x
Arbroath 319 104 m x x
Stranraer 224 64 x x m x x x x
Aboyne 190 60 x x x x x x x
Fraserburgh 299 58 x
Alexandria 735 58 clinic m x clinic x x x
Banff 228 50 m m x
Fort William 208 50 x x x
Dunoon 105 37 m x x x
Oban 165 37 x m x
Broadford 112 24 x x x x
Rothesay 49 20 x x
Campbeltown 82 15 m x x x x
Lochgilphead 97 14 m x x x
Lamlash 45 8 x x
Benbecula 46 6 x m x x
Bowmore 24 2 x x x x
Service provided m Service provided by midwife Full range of clinics c Full day care service x Service not provided
49
Appendix 3 (part 2) Overview of Services provided in CMUs during 2005 (Source of data Unit: Profile Questionnaire)
Location Bookings CMU births
CMU staffed 24/7
Wte establishment
midwives
Double /triple duty
nurse midwives
N/N HCA Wd
Assts Total wte
Total beds and
birthing rooms
Birthing rooms only
Birthing pool
Midwife routine examination of the newborn
Modes of transport
Minimum Ambulance
transfer travel time *
Perth 1105 192 30.8 4.8 9 - + paed R 25 mins
Montrose 251 155 9.8 x 1 6 - R 40 mins
Kirkwall 201 131 8.2 x 5.2 7 - x GP R+Air 60 mins
Lerwick 220 127 8.7 4.1 8 - x GP R+Air 180 mins
Greenock 716 116 26.3 x 4.2 3 - paed R 30 mins
Peterhead 225 114 7.7 x 5.3 6 - x GP R 40 mins
Arbroath 319 104 9.9 x 1.1 6 - GP R 30 mins
Stranraer 224 64 13.6 x 4.4 - 2 x R 75 mins
Aboyne 190 60 6.7 x 0 4 - GP R 45 mins
Fraserburgh 299 58 7 x 4.7 7 - x GP R 40 mins
Alexandria 735 57 24.6 x 4 - 3 R 25 mins
Banff 228 50 9.1 x 2.7 5 - x +GP R 60 mins
Fort William 208 50 7.2 x 3.2 3 - R 80 mins
Dunoon 105 37 7.5 x 0.3 5 - +GP R + boat 60 mins
Oban 165 37 x 9.2 1.2 7 - GP R 120 mins
Broadford 112 24 x 6.7 x 0 2 - x GP R 95 mins
Rothesay 49 20 x 2.7 0 4 - x GP R 120 mins
Campbeltown 82 15 x 5 x 0 2 - +GP R +Air 180 mins
Lochgilphead 97 14 x 6 x 0 3 - GP R 120 mins
Lamlash 45 8 x 1 0 3 - x GP R +Boat 60 mins
Benbecula 46 6 x 2 x 0 2 - x GP R +Air 60 mins
Bowmore 24 2 x 0.6 0 - 1 x GP R +Air 90 mins
Service provided x service not provided *Ambulance transfer times exclude time involved in arranging ambulance (air, neonatal transport, boat)
50
Appendix 4 Summary of clinical activity in Scottish Community Maternity Units (2005)
CMU identifier Location
Number of births in
CMU
Pre-booking attendances
(eg for pregnancy
testing)
Early pregnancy
assessment service
attendances
Antenatal bookings by
CMU midwives
Pregnancy scans
undertaken by midwives
Pregnancy scans
undertaken by
obstetricians and other
professions
Routine antenatal care visits (midwife or
obstetrician)
Antenatal education
attendances (CMU or
community settings)
Antenatal day care & emergency
contacts (including escorted transfers)
Community postnatal checks by
CMU midwives
1 Perth 192 167 873 1105 873 4677 7735 1668 2029 6970
2 Montrose 155 6 149 251 307 1 2059 764 1099 1985
3 Kirkwall 131 49 0 201 38 454 1943 692 79 765
4 Lerwick 127 0 0 220 0 0 1253 392 378 1115
5 Greenock 116 0 1069 716 865 3873 6595 1999 970 2962
6 Peterhead 114 57 0 225 0 0 1803 1121 236 1680
7 Arbroath 104 54 385 319 785 8 2757 1035 1307 2037
8 Stranraer 64 0 0 224 379 0 757 351 1500 784
9 Aboyne 60 0 0 190 0 0 1620 618 35 954
10 Fraserburgh 58 25 0 299 0 524 1323 475 55 1572
11 Alexandria 58 0 1072 735 694 831 10659 1438 639 3884
12 Banff 50 77 45 228 520 14 2940 450 89 668
13 Fort William 50 23 0 208 0 320 2774 492 118 649
14 Dunoon 37 309 0 105 12 92 969 174 169 359
15 Oban 37 0 0 165 100 445 1765 287 440 746
16 Broadford 24 0 0 112 0 258 1822 52 15 516
17 Rothesay 20 42 77 61 82 95 1090 118 1030 120
18 Campbeltown 15 120 20 82 151 0 877 178 28 491
19 Lochgilphead 14 50 25 97 157 137 792 724 130 410
20 Lamlash 8 0 0 45 0 78 372 56 19 164
21 Benbecula 6 0 0 46 64 44 46 0 0 208
22 Bowmore 2 2 0 24 0 0 276 80 12 288
51
52
Appendix 5 Modes of delivery of parous women admitted in labour to each CMU (includes women transferred in labour)
CMU identifier and location
Women admitted in
labour
Spontaneous vertex
delivery Forceps/ ventouse
Emergency caesarean
section
Elective caesarean
section No. % % % %
1. Perth 147 97 1 2 0
2. Montrose 84 98 2 0 0
5. Greenock 86 97 3 0 0
6. Peterhead 87 99 1 0 0
7. Arbroath 82 99 1 0 0
8. Stranraer 50 100 0 0 0
9. Aboyne 42 98 0 2 0
10. Fraserburgh 50 94 6 0 0
11. Alexandria 52 96 2 2 0
12. Banff 41 98 2 0 0
13. Fort William 47 98 0 2 0
14. Dunoon 28 100 0 3 0
15. Oban 32 94 0 6 0
16. Broadford 21 100 0 0 0
17. Rothesay 18 100 0 0 0
18. Campbeltown 15 87 0 13 0
19. Lochgilphead 12 100 0 0 0
20. Lamlash 8 100 0 0 0
21. Benbecula 6 100 0 0 0
22. Bowmore 2 100 0 0 0
Sub Total 910 97 1 1 0
3. Kirkwall 76 71 0 7 22 4. Lerwick 72 92 1 7 0
TOTAL 1686 88 6 5 1 Percentages for individual CMUs may not total 100% because of rounding or because of breech delivery (three cases).
53
Appendix 6 Modes of delivery of primigravidae women admitted in labour to each CMU (includes women transferred in labour)
CMU identifier and location
Women admitted in
labour Spontaneous
vertex delivery Forceps/ ventouse
Emergency caesarean
section
Elective caesarean
section No. % % % %
1. Perth 95 78 15 7 0
2. Montrose 85 87 6 7 0
5. Greenock 68 71 16 13 0
6. Peterhead 35 87 13 0 0
7. Arbroath 55 75 20 5 0
8. Stranraer 19 79 10 10 0
9. Aboyne 35 71 20 9 0
10. Fraserburgh 28 68 18 14 0
11. Alexandria 26 65 19 15 0
12. Banff 20 70 20 10 0
13. Fort William 8 75 25 0 0
14. Dunoon 11 91 0 9 0
15. Oban 11 73 18 9 0
16. Broadford 3 100 0 0 0
17. Rothesay 3 100 0 0 0
18. Campbeltown 5 60 0 40 0
19. Lochgilphead 5 60 40 0 0
20. Lamlash 0 0 0 0 0
21. Benbecula 0 0 0 0 0
22. Bowmore 0 0 0 0 0
Sub total 514 77 15 8 0
3. Kirkwall 58 67 9 22 2 4. Lerwick 55 71 4 26 0
TOTAL 627 75 13 11 0 Percentages for individual CMUs may not total 100% because of rounding.
