Download Focus on: Caesarean Section

Delivering Quality and Value
Focus on: Caesarean Section
Introduction
This document aims to help local health communities and organisations
improve the quality and value of care for promoting normal outcomes in
maternity care and reducing Caesarean section rates to a safe minimum. It is
one of a series of documents produced by the Delivering Quality and Value
team at the NHS Institute for Innovation and Improvement as part of the high
volume Healthcare Resource Groups (HRG) programme.
Figure 1
Healthcare Resource Groups (HRGs)
Cumulative % FCEs by HRG for England (2003/04)
100
HRGs are groups of
clinically similar
activities for which a
similar quantity of
resources is needed.
They are also the basis
for the NHS Payment
by Results system.
90
80
70
60
% 50
40
30
20
10
0
HRG
Source Hospital Episode Statistics
50 HRGs account for 50% of all bed days. 50 different HRGs (however, there is overlap)
account for 50% of all finished consultant episodes (FCEs). As the graph shows, a relatively
small number of HRGs account for a large proportion of NHS resources.
The programme is based on the
concept that by focusing on a
limited range of HRGs (or related
care groups), the NHS Institute
can help the NHS make the
maximum impact in improving
the quality and value of care for
NHS patients.
The series of HRGs chosen were:
• acute admissions in adult
mental health
• acute stroke
• Caesarean section
• fractured neck of femur
• cholecystectomy
The initial series of HRGs (or
related patient groupings) were
chosen on the basis that they
were high volume, and hence
high resource consumers, and also
represented a range of clinical
areas.
• short stay emergency care
(length of stay two days or less)
• urinary tract infections (as a
tracker condition for frail
elderly patients)
• primary hip and knee
replacement.
The document covers:
• the Delivering Quality and
Value team’s approach
• the key characteristics of
organisations providing high
quality care and value for
money
• measures for improvement
• further information.
01
The approach
A literature review was
undertaken of the recognised
evidence in delivering optimised
care for women having a baby.
The ‘Further information’ section
gives further detail of the
documentary evidence.
A thorough data analysis was
undertaken using nationally
available data from Hospital
Episode Statistics (HES) as an
indicator to rank and identify
organisations using Caesarean
section rates and average length
of stay.
The initial statistics were then
adjusted for age and deprivation
levels, mortality rate and
readmission rates.
Verifying the selection of organisations
02
Having identified the local health
and social care communities, we
then approached the
organisations to allow us to visit
them and observe how they
manage this group of patients.
The ‘Acknowledgements’ section
lists the organisations we visited.
The information contained within
this pathway was only possible
because health and social care
communities allowed us to see
their practice.
We then undertook site visits,
ensuring that at least 50% of our
time was spent observing,
watching, listening and looking
at the flow and processes of care.
We also explored the use of
information to aid clinical and
non-clinical decision making. The
remaining time was spent
conducting a series of semistructured interviews with key
members of staff across the
pathway of care (including
obstetric medical staff, midwives,
healthcare assistants,
anaesthetists, paediatricians,
information analysts, and middle
and senior managers, including
chief executives), and with
patients. In total we interviewed
or observed over 140 people for
this pathway, and spoke to many
others informally through our
observations.
1 Co-production with the NHS, involving all sites visited and national bodies and experts relevant to the pathway
The knowledge we gained from
these visits and the co-production
events1 was then consolidated,
and the optimised pathways of
care illustrated later in the
document were identified.
We worked in partnership with
the NHS throughout this project
to validate the pathway and the
knowledge gained from the site
visits, and to identify measures
for improvement that would be
helpful indicators for evaluating
the impact of change.
03
How to use this document
This document provides the
opportunity to share what we
have learned from the trusts we
worked with. Each NHS maternity
service is at a different stage on
the journey towards providing
optimal care. For most, the
debate is not about what
constitutes best practice, but
about how to make the changes
necessary in order to achieve it,
with all the pressures and
constraints that day-to-day
working brings.
Our aim is to provide useful
examples of how some trusts
have made developments and
changes that have contributed to
their aspirations to promote safe
maternity care with reductions in
intervention rates. Some of these
practices will already be
widespread and others will be
irrelevant in the context of
individual services, but we hope
that there are success stories here
that will be helpful in
strengthening practice or provide
ideas for improving it further.
This document identifies the
characteristics of organisations
whose maternity services are high
performers in minimising
Caesarean section (CS) rates. We
have referred to these as
‘overarching characteristics’.
The document then describes
three key pathways that can
contribute to the reduction of CS
rates in the context of providing
optimal quality and value for
money in maternity care:
• the management of women in
their first pregnancy and labour
• the management of women
with one previous CS to
promote vaginal birth after
Caesarean (VBAC)
• the management of women
undergoing an elective CS.
For each of these pathways, we
have identified the key
characteristics, what might
prevent a trust from moving
towards these, examples of good
practice and suggested measures
for improvement. Each pathway is
illustrated with case studies and
quotations from service providers.
Caesarean section pathway
Context
In the past 15 years, the
proportion of CS births has been
increasing steadily in England. In
1989/90, CS accounted for 12% of
all births, while in 2005/06 the
rate had risen to 24%. (The
proportion of vaginal
instrumental deliveries remained
unchanged over the same
period.) This increase in operative
births has not been accompanied
by a measurable improvement in
the outcome for the baby, and
has been shown to carry an
increased risk to the mother of
morbidity and mortality over
normal delivery.
Figure 2
Caesarean sections (with and without complications)
as a percentage of all births
Caesarean sections
now account for
24.1% of all births.
England 1996–2006
30
04
25
% of all births
20
15
10
5
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
There is wide variation in the CS
rate from one maternity unit to
another. These differences cannot
be readily explained by factors
related to size, complexity of
clinical work or demographic
variations, but variation in clinical
practice does contribute to the CS
rate. This might be influenced by
cultural and organisational
factors.
In 2004/05, 36 of the 186
maternity units in England had CS
rates below 20% and 26 had CS
rates above 27% (Figure 3).
Figure 3
The Caesarean
section rate varies
from 12.5% to
34.6%.
% rate
Caesarean section rate (percentage) by trust of all births
(with and without complications)
England 2005/06
05
There is wide professional unease
at the continuing increase in CS
rates - especially as this trend
remains inadequately explained.
The majority of senior
obstetricians and midwives
believe that rates could and
should be lower. Some units have
actively engaged in strategies to
reduce the number of CS births
and have made significant
improvements or prevented the
rise in rates observed in other
places. However, even these high
performers recognise that more
could be achieved.
The maternity services we worked
with were diverse in size - from
2,200 births annually to over
8,000 - in demography - from
rural shire to inner-city multiethnicity - and in terms of case
complexity - from standalone
birthing unit to tertiary referral
centre. Nevertheless, there were
strong common themes in their
aims and approaches to
managing Caesarean sections.
There was a general belief that
maternity units applying best
practice to the management of
pregnancy, labour and delivery
will achieve a CS rate that is
consistently below 20% and will
have aspirations to reduce that
rate to 15%.
Delivering quality and value and achieving optimal care
Maternity care has been at the
forefront of the development of
evidence-based guidance on best
practice. This has been driven by
the desire of doctors and
midwives to improve the quality
of their service, by women’s own
demands for reliable information
and choice, and by the
recognition of the burden placed
on society by poor maternity
outcomes.
06
Midwives and obstetricians have a
tradition of openness through
documents such as the
confidential enquiries into
maternal mortality and, more
recently, into perinatal deaths.
They have long recognised the
value of multidisciplinary working
and mutual learning. Evidencebased guidelines have been
produced by individual
professional bodies and, recently,
by the National Collaborating
Centre for Women’s and
Children’s Health, funded by the
National Institute for Health and
Clinical Excellence (NICE). This
group has produced extensive
guidance on Caesarean sections,
and is also due to publish
guidance on intrapartum care.
Midwives, doctors and maternity
service managers are generally
well informed about the
existence of these guidelines and
their content. However, in the
context of their busy jobs and the
conflicting pressures placed on
them, it is difficult for them to
make the changes necessary to
achieve optimal care. Staff are
well aware of their goal - the
problem is identifying how to get
there. This document brings
together examples of practice
that individual maternity services
believe have helped them to
move towards optimal care.
Data quality within maternity
services varies a great deal; many
services still do not fully
understand what needs to be in
the case notes in order for the
correct HRG to be attributed to a
patient’s spell. Much of the
Hospital Episode Statistics data
relating to the delivery HRGs is in
fact inaccurate, but the
introduction of the latest revision
of the HRG classification, HRG 4
(in 2008), will solve some of these
difficulties.
During 2005/06, maternity
services represented £1.87 billion
- 2.6% of total NHS spending for
that period. ‘Normal delivery
without complications’ (HRG code
N7) is the HRG with the largest
number of spells coded to it, with
348,579 spells during 2005/06.
Of the babies born in England
during 2005/06, 24% were
delivered by CS, but these births
actually represented 40.3% of all
spending on delivery HRGs. If the
national CS rate were to drop
below 20%, it is estimated that
£37.7 million would be saved
(based on an average of the
actual payment per delivery
during 2005/06).
At the level of the health
economy there is clearly a
financial case as well as a clinical
one to reduce the CS rate, yet it is
apparent from our observations
that Payment by Results (PbR)
actually creates a perverse
incentive for trusts to undertake
elective Caesarean sections, as
they create a greater profit
margin against the tariff than
normal deliveries do (Figure 4).
Figure 4
Baseline tariff payments (2006/07) and activity for Caesarean section and normal delivery
Without
complications
Annual volume2
With
complications
Annual volume2
Normal delivery
£735
348,579
£1,097
24,277
Caesarean section
£1,370
115,579
£1,879
21,643
There is great potential for local health systems to release resources by managing Caesarean section rates.
Trusts would be able to make
financial savings through a
reduction in bed stock if there
were fewer Caesarean sections.
The typical length of stay for a CS
is three to four days, while it is
just one to two days for a normal
delivery: if more women
delivered normally, the number
of bed days would drop. This
would create surplus bed
capacity.
Figure 5
Average length of stay for Caesarean sections (with and without complications)
England 2005/06
8
Average length of stay (days)
7
6
5
4
3
2
1
0
Trusts
2 Based on Hospital Episode Statistics, 2005/06
There is variation
of more than two
days in length of
stay between
trusts.
07
Identifying the pathways
With the help of the trusts we talked to, we mapped out the key milestones and decision points within a
woman’s pregnancy and birth experience. These are illustrated in Figure 6.
Figure 6
Pre/Inter
pregnancy
Booking
Low-risk
pregnancy
care
No
Yes
Mode of
delivery, eg Csection
Preassessment
Vaginal
delivery
Labour and birth
Normal
Progression
of Labour
No
Admission
C-section
Intervention
eg Syntocinon
or
Unsuccessful
instrumental
delivery
Successful
Location,
eg birthing
unit
Antenatal
Midwifery
-led
Consultant
-led
08
Discharge
from
midwifery
services
Transfer of
care to
community
teams
Postnatal
Education
and debriefing
Recovery
We have identified three pathways of care that particularly influence CS rates. These are shown in Figures
7, 8 and 9.
Figure 7
The management of women in their first pregnancy and labour
Pre-pregnancy
Booking
Antenatal care
Labour and birth
Trusts told us that women in their
first pregnancy and labour
offered the greatest opportunity
to reduce CS rates in the long
term. Women who experience a
normal delivery in their first
pregnancy are highly likely to do
the same in subsequent
pregnancies. These women have
an important lifetime advantage
over women who undergo a
Caesarean section, and they
confer a significant cumulative
benefit on the health economy.
even before conception. Women
are exposed to messages about
pregnancy and childbirth through
family and friends, through the
media and through existing
contact with health and social
care professionals. Maternity
services have limited
opportunities to influence the
national media, but they do have
a role to play in ensuring that all
professionals within the health
economy act as informed
advocates for normality.
The pathway for women in their
first pregnancy and labour starts
The birth outcome is influenced
throughout the process of formal
maternity care. Midwives are the
key health professionals, offering
a continuous and consistent
message prior to labour. This
pathway ends with labour and
birth, where a normal outcome is
achieved through genuine
multidisciplinary teamwork. If an
emergency CS is required, the
second pathway - the
management of women who
have had one previous CS immediately becomes relevant to
the outcome of the next
pregnancy.
09
Figure 8
The management of women to promote vaginal birth after Caesarean (VBAC)
Postnatal care
Inter-pregnancy
Antenatal care
Labour and birth
10
Trusts identified the care of
women who have had one
previous CS as a critical area for
reducing the overall CS rate. The
‘once a section, always a section’
belief is increasingly questioned
in the light of accumulating
evidence, and vaginal birth after
Caesarean section (VBAC) is now
considered to be a safe option for
most women. However, women
themselves often think that
history will repeat itself and that
another CS is inevitable or
preferable to their previous
experience.
Women need accurate
information about events and
their significance for the future,
including the possibility of VBAC,
as soon as possible. Therefore the
pathway for this group of
patients starts in the postnatal
period of one pregnancy and
finishes with the management of
the next labour and birth.
11
Figure 9
The elective Caesarean section process
Antenatal care
Labour and birth
Postnatal care
In those women where the need
for delivery by CS is agreed
during the antenatal period, the
care process should be as efficient
as possible. It is for this group of
women that trusts have the
greatest potential to deliver care
below tariff. As shown in Figure 9,
the elective CS process runs from
the antenatal to the postnatal
period.
What are the characteristics of services aspiring to optimal care?
‘We focus on keeping pregnancy and birth normal.’
‘We are a real team – we understand and respect roles and expertise.’
‘Our leaders are visible and vocal.’
‘Our guidelines are evidence-based and up to date.’
‘We all practise to the same guidelines – no opting out.’
‘We manage women’s expectations and prepare them for the reality of labour.’
‘We give accurate information about risks and benefits, but with a positive spin.’
‘If a Caesarean section is planned, the process is efficient and effective.’
‘We get accurate, timely and relevant information on our performance.’
12
‘We are involved with our users and stakeholders.’
The key characteristics of
organisations providing high
quality care and value for
money
The following characteristics
have been found to be the key
features for delivering quality
and value for promoting normal
outcomes in maternity care and
reducing Caesarean section rates
to a safe minimum. These are
followed by suggested measures
for improvement. The suggested
measures for improvement are
those that we judge to be of
value to organisations to enable
them to benchmark current
practice against the
characteristics described and to
further improve it.
Overarching characteristics
Women are empowered to make informed choices about
their maternity care.
• Staff recognise and respect women’s views.
• Women contribute to decisions about their care plan.
• Women are supported and educated in normal birth throughout
their pregnancy care.
Staff share a common ethos and aspirations for high
quality care.
• Emphasis is placed on achieving normality rather than thinking in
terms of reducing intervention.
• Recruitment criteria include a commitment to promoting normality.
13
‘We only employ people who share our belief in normal birth.’
Divisional manager, Women’s Services
Maternity care is delivered by a multidisciplinary team,
with a high level of mutual trust and respect between
professions.
• There is an open and inclusive communication structure.
• Strong clinical leadership is visible to all staff.
• Staff feel empowered to challenge each other constructively.
‘We support our midwives to challenge doctors when they see
them doing things that are outside our agreed guidelines.’
Consultant obstetrician
There is a robust clinical governance structure
throughout the trust.
• The trust board champions an open and just culture.
• Preparation for Clinical Negligence Scheme for Trusts (CNST)
assessments is properly resourced.
• Learning from adverse incidents is systematically spread through
the organisation.
There is an embedded and sustainable model of good
clinical practice.
• Evidence-based care is adopted wherever available.
• Clinical guidelines are regularly updated.
• Everyone is committed to the use of agreed clinical guidelines.
Maternity services provide value for money.
14
• A consistent costing model is applied to maternity services.
• The directorate finance officer attends and contributes to all
business meetings.
• Finance staff understand clinical issues.
• There is a thorough understanding of PbR.
Effective communication and use of information enhance
decision making.
• Staff receive timely feedback on clinical outcomes:
• individual case review and feedback within 24 hours
• weekly multidisciplinary review of CS or abnormalities in labour
• monthly statistical information includes CS and VBAC rates, as
well as length of stay.
‘At handover each morning, every emergency CS undertaken over
the previous 24 hours is reviewed by the multidisciplinary team.
This provides team members with the opportunity to receive early
review of decisions by all members of the team. Midwives
challenge doctors and vice versa.’
Consultant obstetrician
• Maternity information systems are designed to benefit users, saving
work and producing clinically relevant information:
• paperwork is replaced by an output from the information system
so there is no duplication.
• Statistical information is interesting and meaningful:
• run charts show change with time
• statistical process control charts are used.
Several trusts that we visited displayed their monthly data in run
charts and left them on the labour ward notice board for both
staff and patients. One trust provided information for each
consultant.
Accurate and comprehensive clinical coding is used to
ensure the correct HRG.
• There is regular communication between clinicians and coders.
• There is a clear, robust coding process, agreed by all.
• There is a common knowledge and understanding of what
constitutes a ‘complication’.
• Maternity information systems are programmed to support
accurate coding.
One trust in the South West has made inroads into improving the
quality of information in the case notes by running workshops for
midwives to improve their understanding of what coders require.
Measures for improvement
• Percentage of women who
contribute to their birth plan
(target should be 100%).
• Multidisciplinary attendance
at clinical review meetings.
• Maternal and perinatal
mortality and morbidity rates.
• Percentage of guidelines that
are referenced to best
practice and reviewed
annually (target should be
90%).
• Percentage of clinical staff
who are aware of monthly CS
rates and trends (target
should be 90%).
• Accuracy of HRG attributions.
• Depth of coding in upper
quartile.
15
Characteristics of the management of
women in their first pregnancy and
labour
Pre-pregnancy
Booking
Antenatal care
Labour and birth
16
Pre-pregnancy
The health and social care communities work in
partnership to promote the concept of normal pregnancy
and childbirth.
What could prevent you from achieving this?
Women receive conflicting information from different agencies.
Women get a distorted view of pregnancy and birth via the media.
Examples of best practice:
• Children’s Centre staff offer information about healthy pregnancy
and normal birth.
‘We are moving midwives out of GP surgeries and into the new
Children’s Centres.’
Community midwife
• Maternity services support other specialist clinical departments to
ensure good pre-pregnancy advice and care.
• Professionals work with representatives of hard-to-reach groups to
improve access to services.
One trust is improving access to maternity services for asylumseekers by employing a midwife within the community specifically
for this group of women.
‘Understanding your population helps … it breeds cooperation …
we are sensitive to the needs of all our women - not just those
from ethnic minorities.’
Head of midwifery
17
Booking
All pregnancies are treated as normal until proven
otherwise.
What could prevent you from achieving this?
A perception of clinical risk results in the medicalisation of
pregnancy.
Healthcare professionals lack the skills to promote normality.
Examples of best practice:
• All women are able to access a midwife directly to book pregnancy
care.
• The midwife is the lead healthcare professional throughout; for
normal pregnancies, no named obstetrician is required.
• There is a choice of time and location for booking, including home
and workplace.
18
• Risk factors are identified using agreed criteria.
• If risks are identified, midwives have the skills and knowledge to
optimise the potential for normal care.
‘Consultants used to review all booking notes and umpire the care
pathway. This is now done by the ANC - antenatal clinic midwife
team - avoiding inappropriate medical involvement.’
Lead antenatal midwife
One trust has introduced a triage system at the booking stage that
has successfully halved the number of women requiring a
consultant appointment. This has freed up consultant obstetrician
time, so that women now receive up to 45 minutes to discuss their
concerns and issues with a consultant. The triage midwife streams
women in red, amber and green pathways, with only those on the
red pathway needing to see an obstetrician.
Antenatal care
Women receive information that allows them to make
informed choices about their plan of care.
What could prevent you from achieving this?
Health professionals do not use information appropriately to meet
the needs of women.
Examples of best practice:
• Antenatal care is offered in convenient and appropriate settings,
eg in Children’s Centres or community centres.
• Patient information leaflets are evidence-based.
• Women are given consistent and balanced information on the risks
and benefits of all modes of delivery, taking individual
circumstances into account.
• Women are informed about the options for place of birth.
• Staff work with women to ensure that they have realistic
expectations of labour, birth and parenthood.
• The expected length of postnatal stay is agreed during the
antenatal period.
• Women are educated in active birth techniques.
One maternity service has worked hard to ensure that its belief in
normality becomes a reality for the women that it serves by
establishing links with voluntary organisations and providing
active birth teachers.
• Women are offered appropriate professional support to address
their concerns and fears about childbirth.
• Women with a breech presentation are offered external cephalic
version (ECV) by a skilled professional, in accordance with best
practice guidelines.
It is important to recognise that women with physical, learning or
mental disabilities have the potential to have a normal delivery.
One trust in the north of England employs a specialist midwife for
disabled women. The philosophy of the service for women is that
of ‘normality with specific needs’. The focus is very much on what
is normal, rather than on the problems that these women have.
19
Case study
East Kent Hospitals NHS Trust birth centres
The maternity services currently
offered by the East Kent
Hospitals NHS Trust include two
birth centres, one in Dover and
the other in Canterbury. In 2005,
just over 800 women delivered
their babies in these centres. As
well as helping women through
labour and birth, the centres
offer a variety of other
maternity services.
20
The midwives working at the
birth centres are community
midwives who provide antenatal
care for all women in Dover and
Canterbury (not just those who
have their babies there), many
of whom attend midwife-led
antenatal clinics at the birth
centre. The midwives also
provide postnatal care in the
birth centre and in the
community for all local women.
The birth centre acts as a base
for all of the midwives working
in the Dover and Canterbury
area, as well as a centre for
women to access easily.
Breastfeeding support
Women who have their babies
at one of the birth centres (as
well as those women who
transfer from the consultant-led
units for postnatal care) are well
supported with breastfeeding.
The centres have had the
highest breastfeeding rate on
discharge from hospital of all
East Kent maternity sites for the
past two years.
Day care
Day care is another important
service provided for all women
at the birth centres. It is offered
24/7 for women to undergo
routine treatments and
investigations - eg
administration of prophylactic
anti-D, blood tests, glucose
tolerance tests - as well as
emergency treatment and
assessment - eg not feeling the
baby move, pre-labour rupture
of the membranes, etc. The
community midwives provide
the day care service. Without it,
women would have to travel to
one of the acute sites such as
William Harvey Hospital or
Queen Elizabeth The Queen
Mother Hospital.
Antenatal education
Midwives offer regular
workshops and classes at the
birth centres to prepare women
for the physical and emotional
dimensions of birth and
parenthood. These are well
attended.
Consultant-led clinics
Weekly consultant-led antenatal
clinics are also held at the birth
centres. Women would
otherwise have to travel to the
William Harvey Hospital or the
Queen Elizabeth The Queen
Mother Hospital. Routine
ultrasound scans are also
available at the birth centres.
The small scale of the birth
centres and their integration
into the local community makes
it possible for them to achieve
many of the aims of modern
maternity care that are so
difficult to realise in larger,
busier and more impersonal
maternity units.
Women in a high-risk pregnancy receive care that
optimises their opportunities for a normal birth.
What could prevent us you from achieving this?
Women are denied the opportunity for normal birth for irrelevant
reasons.
Professionals do not recognise the value of working together to
support high-risk women.
Examples of best practice:
• High-risk women receive team-based care from both obstetrician
and midwife to optimise the potential for normal care and
outcomes.
• Midwives have direct and immediate access to a consultant
obstetrician for advice.
• There are clear guidelines for the management of women who
experience variations from the norm in order to avoid
inappropriate interventions.
21
Labour and birth
One-to-one support is provided during labour by a
trained carer, reducing interventions and improving
outcomes for both mother and baby.
What could prevent you from achieving this?
Because of budget constraints or recruiting difficulties, staffing
levels are inadequate for achieving one-to-one care.
Examples of best practice:
• The labour ward is reserved for labouring women.
• Triage is used to prevent inappropriate admissions to the labour
ward.
• Women are assessed at home to avoid admission before labour is
established.
22
• There is a designated high-dependency area for antenatal and
postnatal women to allow midwives to care for more than one
woman.
‘Those midwives [in triage] are experienced midwives – they can
send women home. We [consultants] respect their clinical
expertise.’
Consultant obstetrician
• The skill mix is developed and innovative roles are created to allow
time for midwives to provide care to women in labour.
• Additional training is provided to enhance the role of maternity
support workers.
• Labour ward coordinators are supernumerary, to allow flexibility.
• Advanced midwifery (and neonatal) practitioners are developed.
• Theatre and recovery nurses support CS.
• Operating department practitioners have wider roles.
• Data inputting is performed by administrative staff.
Case study
Diana, Princess of Wales Hospital Maternity Unit
Skill mix on the
maternity wards
The problem
The maternity unit was housed
in outdated, conventionally
designed buildings. The split
site required a large number of
senior house officers (SHOs) to
cover both sites and their
working pattern did not meet
the requirements of the New
Deal on junior doctors’ hours.
In 2003, the maternity unit
moved into a new building,
designed on the Labour,
Delivery, Recovery, Postnatal
(LDRP) model. This offered a
high quality environment for
women, but provided a
challenge to midwifery and
medical staff caring for women
in labour in the four separate
ward areas.
assessments and interventions,
including ventouse deliveries.
The role of the labour ward
coordinator has been enhanced
to ensure that support can be
provided to staff across the
whole unit. Communication
between the coordinator and
midwives caring for women in
labour is by cordless phone, so
midwives do not have to leave
the individual room. Although
several coordinators are also
AMPs, the roles are kept
separate and are never
performed together.
The benefits
For women:
• improved environment for
birth and the postnatal
period
• one-to-one midwifery care.
What we did
A full shift was introduced for
the SHOs to comply with New
Deal and European Working
Time Directive. Savings made by
reducing the number of SHOs,
and rebanding the post funded
an additional middle grade
doctor and the training of five
senior midwives as advanced
midwifery practitioners (AMPs).
They undertook a specially
adapted academic programme
supported in-house by the lead
consultant for the labour ward.
For staff:
• increased career
opportunities for practising
midwives
The AMPs participate in the
SHO daytime rota, carrying out
• costs savings.
• stable, experienced staffing
on the first tier ‘medical’ rota.
For the Trust:
• CNST requirements met
• consultant presence and oneto-one midwife care
contribute to low CS rate
• improved recruitment and
retention of staff
23
• Processes are in place to ensure that the philosophy of midwiferyled care in labour is maintained.
• Midwifery-led care does not depend on physical boundaries; it
can be made to work in separate locations, designated areas or
adjacent rooms.
• Community midwives follow women into the labour ward to
provide continuity of care.
‘We do handover as a board round not a ward round … a doctor
will only enter a room if requested to do so by a midwife.‘
Midwife coordinator
Appropriate management of labour reduces the number
of Caesarean sections.
What could prevent you from achieving this?
24
Constraints are imposed by the design and layout of existing
buildings.
There are traditional patterns of hospital care.
Examples of best practice:
• The appropriate environment for labour is provided.
• Labour rooms are equipped with aids to active labour, eg mats,
birth balls, wall bars, water pools, etc.
• Women are discouraged from lying in bed during labour.
• The decoration of labour rooms is home-like and nonthreatening, with clinical equipment stored behind curtains or in
cupboards.
• LDRP rooms minimise patient movement and optimise continuity
of care.
• There are agreed protocols for the transfer of labouring women
from home or the standalone birthing unit to the hospital
maternity unit.
One trust designed single LDRP rooms so that women remain in
their own room for the duration of their stay, rather than being
moved within the maternity unit. All medical equipment is kept
out of sight.
• The labour ward is managed by a multidisciplinary team.
• Doctors and midwives trust and respect each other’s skills,
knowledge and opinions.
• The consultant obstetrician and coordinating midwife provide
strong, visible leadership. All staff have direct access to their
advice and help.
• There is a ‘virtual ward round’ communication system that
ensures that all staff are aware of activity on the labour ward.
• When women arrive in labour, the midwife makes an assessment
to decide whether the labour is high- or low-risk.
• Doctors enter the rooms of labouring women by invitation only.
• The labour ward consultant obstetrician is involved in decision
making about every CS. There is an open culture in which staff
are supported and challenged in their decision making.
• A multidisciplinary review of all labour ward events is held daily.
• Impromptu emergency simulations are carried out unannounced
on labour wards.
‘Our skills drills are genuinely multidisciplinary. How do you know
what your own role is if you don’t know what everyone else is
doing? We make emergency simulations fun and give out prizes.’
Labour ward consultant midwife
• Midwives are skilled in maximising the potential for normal birth.
• All women, however high-risk, have the support of a skilled
midwife during labour to optimise the outcome for them and for
their baby.
• Midwives are trained in non-invasive pain relief techniques, eg
water, relaxation and breathing techniques, massage etc.
• Midwives have the confidence to empower women to use selfhelp strategies.
• Student midwives in training rotate through high- and low-risk
practice to develop a range of skills.
• Newly qualified midwives have the opportunity to consolidate
their skills in caring for low-risk women in normal labour.
25
• Doctors acquire and maintain practical skills on labour wards.
• Consultants are present on labour wards to provide support and
hands-on training.
• Consultants and trainees compare vaginal examination findings
at full dilatation to optimise the potential for an assisted vaginal
delivery.
• If a woman with a breech presentation is admitted in labour, an
individual risk assessment is carried out.
• Labour is managed using evidence-based guidelines and protocols
that are regularly reviewed and updated.
• The augmentation of labour is timely and effective.
• The significance of cardiotocograph abnormalities is assessed with
fetal blood sampling.
• There is the potential for STAN® automatic real-time analysis of
fetal electrocardiography to enhance the accuracy of the
diagnosis of fetal distress.
• Induction of labour for the indication of post-dates alone takes
place according to NICE guidelines and there are no ‘social’
inductions.
26
‘When new doctors arrive, we say to them, “you’ve seen things
done in different ways in different places. Here we all do things
the same way”.’
Lead obstetrician, labour ward
Measures for improvement
• Percentage of women
receiving one-to-one care
from a midwife (target
should be 100%).
• Percentage of one-to-one
professional support provided
in labour (target should be
100%).
• Percentage reduction in
midwife time spent on nonmidwifery tasks (target
should be 50% reduction).
• Percentage of spontaneous
vaginal deliveries (target
should be greater than 70%).
• Percentage of normal labour
and normal deliveries (target
should be greater than 50%).
• Hours of consultant presence
on labour ward (against the
RCOG target).
• Audit of patient experience
of the labour ward
environment.
• Audit of appropriate transfers
from the planned place of
birth to hospital.
• Audit of compliance with
clinical guidelines.
• Percentage of vaginal
deliveries (target should be
greater than 80%).
27
Characteristics of the management of
women to promote vaginal birth after
Caesarean (VBAC)
Postnatal care
Inter-pregnancy
Antenatal care
Labour and birth
28
Postnatal care
There is a clearly defined discharge process.
What could prevent you from achieving this?
Women’s expectations may differ from practice.
Examples of best practice:
• Length of stay is discussed as soon as possible after delivery to
reconfirm the antenatal decision or to adjust for any problems that
occurred during labour and birth.
• Women without complications have a midwifery-led discharge.
• Community midwives are willing to take on postoperative care at
home.
Women who have had a CS or a traumatic birth
experience receive information about maternity events
to allow them to make informed choices about care in a
future pregnancy.
What could prevent you from achieving this?
Staff have insufficient time or information to brief women
adequately.
Examples of best practice:
• Doctors and midwives discuss pregnancy and labour events with
women, and document their discussion in the clinical record.
‘Our doctors record in the case notes the recommended mode of
delivery for any future pregnancy.’
Divisional manager
• The discussion covers the implications for any future pregnancy.
• Each woman is provided with written information about the
reasons for her CS.
• Discharge communications to GPs and community midwives reflect
the information given to the woman.
• Postnatal follow-up visits to hospital are offered selectively.
‘Community midwife workers come into the unit every day. We
communicate with the staff who have provided care, so that when
women raise concerns with us at home, we have all the facts.’
Community team midwife
29
Inter-pregnancy
Women have access to support, advice and information
about past and future pregnancies.
What could prevent you from achieving this?
The traditional demarcation of inter-agency responsibilities leaves a
vacuum in care.
Examples of best practice:
• Trusts offer channels for women to access help and information
from maternity services.
• Women receive information about independent support groups.
• Children’s Centres disseminate information to women between
pregnancies.
• Pathways are established for users to feed their experiences back in
order to inform service development.
30
One trust offers a midwife-run Reflections Clinic, where women
can contact the midwife directly to discuss any concerns about
their experiences or about the birth.
Antenatal care
Women who have already had a CS are managed to
optimise their chances of a normal delivery.
What could prevent you from achieving this?
Women and staff have inaccurate perceptions of pregnancy after a
previous CS.
Examples of best practice:
• The maternity service has a standard approach for providing
information about VBAC.
• Women are given the best available information on the benefits
and risks of VBAC.
• Written information on VBAC is readily available.
• Dedicated VBAC clinics are staffed by obstetricians and midwives
with a special interest in this care.
A hospital in the Midlands set up a separate clinic for the
management of VBAC patients. Since its introduction, a VBAC rate
of 80% has been achieved.
• Women have an opportunity early in pregnancy to discuss mode of
delivery.
• Women are offered an appointment with a senior obstetrician or
midwife.
• Staff are able to access accurate information on the reasons for
the previous CS before the discussion.
• Women are given the time and encouragement to discuss their
own feelings about delivery, so that any specific concerns can be
addressed. Possible outcomes include:
• VBAC agreed - no further medical involvement until 41 weeks
• Elective CS agreed - midwifery care until planned admission at
39 weeks
• Undecided - further appointment made for discussion at 36
weeks.
31
32
• A woman’s request for a CS in the absence of any clear medical
indication is managed according to best practice guidance.
• The reasons, concerns and fears underlying the woman’s request
are explored, discussed and recorded.
• A second opinion is sought where there is a lack of agreement
about the appropriate mode of delivery.
• The reason for performing a CS is clearly stated on the consent
form.
• A previous CS does not render a pregnancy high-risk - the majority
of women appropriately receive midwifery-led antenatal care.
‘We don’t have women who are “too posh to push” - there is
nearly always an underlying reason. If we uncover the real reasons
and address them, women usually accept our advice.’
Consultant obstetrician
Labour and birth
Labour is managed to optimise a normal outcome.
What could prevent you from achieving this?
Health professionals lack experience in managing VBAC.
Examples of best practice:
• The multidisciplinary team is skilled and confident in the
management of VBAC.
• One-to-one care is provided by a midwife experienced in
supporting VBAC.
• Units ensure that all student and newly qualified midwives gain
experience in VBAC from senior colleagues.
• There are agreed roles for both medical and midwifery staff in
the management of VBAC.
• Multidisciplinary reviews of outcomes of intended VBAC are
carried out regularly.
33
‘Our local population is very keen on vaginal delivery, so there is a
big demand for VBAC. We have developed our skills to meet the
requirements, and that has fuelled the confidence of all staff - a
sort of virtuous spiral.’
Consultant obstetrician
• VBAC is managed according to best practice guidelines.
• Agreed guidelines are followed by all staff to ensure consistency
of support and messaging to women in labour.
• Women receive written information about the guidelines for
VBAC.
• Interventions are timely and appropriate.
• If the pregnancy is progressing normally, induction is planned for
term +14 days to maximise the opportunity for the spontaneous
onset of labour.
• Guidelines for the use of Syntocinon in VBAC are identical to the
guidelines for its use with any other labour.
• VBAC is not regarded as a contra-indication to epidural analgesia,
but epidurals are discouraged before labour is established.
‘We do not regard a previous Caesarean section as a risk factor in
labour - our management is the same for VBAC women as it is for
any woman in labour.’
Consultant obstetrician
Measures for improvement
• Percentage of women with
delivery problems or CS
receiving an oral debriefing
(target should be 100%).
• Percentage of women with
delivery problems or CS
receiving written information
(target should be 100%).
34
• Percentage of women
receiving VBAC advice before
the 16th week of pregnancy
(target should be 75%).
• Percentage of women opting
for VBAC (target should be
80%).
• Percentage of women
choosing VBAC who actually
go on to have a vaginal
delivery (target should be
80%).
• Percentage of health records
of women with a previous CS
that are available at the
antenatal appointment
(target should be 100%).
• Audit of reasons for women
opting for a CS.
• Audit of practice against
VBAC guidelines.
Characteristics of the management of
women undergoing an elective
Caesarean section
Antenatal care
Labour and birth
Postnatal care
The elective CS pathway has many features in common with other
high-volume elective surgical procedures, and there are important
opportunities to learn from best practice in those areas.
35
Antenatal care
Preoperative care is undertaken by the most appropriate
professional.
What could prevent you from achieving this?
There may be resistance to changing the traditional roles of
healthcare professionals.
Examples of best practice:
• Consent for an elective CS is obtained.
• The risks and benefits are discussed and documented by a
consultant midwife or obstetrician.
• The consent process is initiated in the antenatal clinic by the
obstetrician agreeing to the operation.
• The elective CS is booked for 39 weeks’ gestation.
• Pre-assessment visits take place for all women.
36
• These are midwife-led, according to an agreed protocol.
• They take place within one week of admission.
• It is explained that the stay is not expected to be longer than 56
hours.
• The expected date of discharge is agreed.
‘All women booked for an elective CS are seen by the midwife in
the day assessment unit two or three days before. She does the
whole pre-assessment and calls the anaesthetist or surgeon only if
there’s a problem.’
Head of midwifery
Labour and birth
Elective CS is organised efficiently to minimise delays
and clinical risk.
What could prevent you from achieving this?
The management of elective procedures is seen as a low priority on
labour wards.
Examples of best practice:
• Women are admitted on the day of the operation.
• Hand-offs are minimised.
• Pre-operation, women are admitted to the recovery area or a
postnatal bed.
• The anaesthetic is administered in the theatre.
• Following the operation, women remain in a single location on
the postnatal ward.
37
A Midlands trust admits women on the day of operation direct to
the recovery bay of the obstetric theatre, where they are prepared
for operation by the recovery nurse.
• Protected facilities are provided for elective Caesarean sections.
• There are dedicated elective lists.
• The obstetric team is separate from the staff of the labour ward.
• General theatres are used, rather than theatres on the labour
ward.
• The skill mix in operating theatres is optimised.
• Theatre nurses scrub, rather than midwives.
• There is an operating department practitioner dedicated to
maternity.
• Maternity care assistants are trained for roles in theatre (running,
scrubbing, assisting, etc).
• Complications are kept to a minimum.
• Compliance with infection control, antibiotic and thromboprophylaxis guidelines is audited.
Postnatal care
Mothers and babies return home as soon as clinically
safe and appropriate.
What could prevent you from achieving this?
Women’s expectations of their length of stay are unrealistic.
Community midwifery staff are unskilled in postoperative care.
Examples of best practice:
• The length of stay is less than 56 hours.
• Effective analgesia guidelines are provided, to promote early
mobilisation.
• Women undergo a medical review on the first postoperative day.
• There is clear information about any implications for a
subsequent pregnancy.
38
• Midwives lead the discharge process, according to an agreed
protocol.
• There is a near-patient supply of discharge medication kept in the
maternity unit.
‘For CS, discharge planning starts at pre-admission. Post-delivery
women are seen on day one by the surgical team, and if there are
no problems, women will go home (by midwifery-led discharge)
on day two or three. Problems associated with waiting for
discharge medication have been overcome by setting up Patient
Group Directives and by having pre-packaged drugs on the ward.’
Midwife
• Community midwifery care is coordinated.
• There are clear channels of communication between the inpatient
unit and community care.
• Community staff are proactive in accepting women for early
postoperative care at home.
Case study
Bradford Teaching Hospitals NHS Foundation
Trust
As Ward Sister, it’s my
responsibility to make sure that
my ward runs as efficiently as
possible. As a Trust, we were
under financial pressure and
beds had to be closed. I knew
we had problems with
discharging patients which
would only be exacerbated
with reduced beds - we already
struggled to find enough beds
for women some days. We have
nearly 6,000 births and 58 beds,
so we are very busy.
getting discharge medications
from the pharmacy. So what we
did was to set up Patient Group
Directives (PGDs) and have
stocks on the ward. We have
PGDs for:
• Paracetamol
• codeine phosphate
• Diclofenac
• iron therapy
• Cefradine
• Metronidazole
• Erythromycin
About 18 months ago we did
an audit to identify where the
problems were. Our doctors
were already seeing women
who had undergone CS on day
one. If everything is OK, then
midwives discharge them, but
the problem was around
• Lactulose.
This has reduced the time we
have to wait by 90%, which has
really helped with the beds, but
more importantly the women
get to go home when they
expect to.
39
40
Measures for improvement
• Percentage of women who
have a pre-assessment visit
within one week of operation
date (target should be 100%).
• Audit of delays in planned
operations.
• Percentage of women who
have an agreed discharge
date prior to admission
(target should be 100%).
• Percentage of women who
are discharged on the
planned date (target should
be greater than 90%).
• Percentage of women who
are admitted on the day of
the operation (target should
be 100%).
• Audit of post-operative
infection rates.
Benefits of promoting normality
and reducing Caesarean section
rates to a safe minimum
To women
To staff
There will be no unnecessary
interventions.
Midwives will spend less time on
non-clinical tasks.
Childbirth will be viewed as a
positive experience.
There will be a sense of pride
within units.
They will receive support from
staff to optimise the potential
for normal birth.
Working in a well functioning
team will have a positive effect
on staff retention.
Women in labour will receive
one-to-one professional support.
All professional groups will
derive a high level of
satisfaction from providing high
quality care and enabling
women to achieve the outcomes
they want.
Women feel empowered in
making decisions with support
from staff.
Mortality and morbidity rates
will improve.
Women will be able to return
home more quickly to their
families.
There will be a greater
opportunity to acquire and
maintain a portfolio of skills.
To the organisation
To the taxpayer
An enhanced reputation means
that women will choose the
organisation as the place to
have their baby.
Public money is being spent
appropriately, where there is
clinical need.
A lower CS rate will mean fewer
bed days, resulting in financial
savings.
Recruitment and retention will
be better in a well functioning
team in which staff have high
levels of job satisfaction.
Enhanced risk management will
reduce litigation via the Clinical
Negligence Scheme for Trusts
(CNST).
Saving costs on Caesarean
sections means that money can
be redirected into improvements
for women’s and children’s
services.
Achieving optimal value for
money in maternity services
means that funds can be
redirected towards other
services, such as oncology and
elderly care.
Improvements in the long-term
health of mothers and babies
will reduce the burden of
chronic care on the health
economy.
41
Conclusion
42
The contents of this report are
based on the Delivering Quality
and Value team’s observations of
the practices of NHS organisations
that are judged to be delivering
high quality care and value for
money. Although these
observations have been validated,
it should be recognised that they
may not be the only ways of
delivering high quality care and
value for money, but we believe
that they will give valuable
guidance and direction to those
seeking this goal.
• Understand how your
organisation performs when
compared against the key
measures and benchmarks
suggested.
To improve services, organisations
should follow this guidance and
take the following simple steps:
Further products will be produced
to support implementation of this
guidance and local improvement.
In particular, the Delivering
Quality and Value team expects
• Generate a locally owned
change programme for
improvement.
• Integrate the local change
management programme
within health community
integrated service improvement
programmes (ISIPs) and local
delivery plans (LDPs).
to produce the following to
support the Caesarean section
pathway:
• Pathway to Success - Caesarean
section: A self-assessment tool
(available March 2007): a tool
that will help trusts to assess
their current practice and
capacity, identify potential
improvements and provide
practical support for making
changes.
We would value your
contributions to our future work.
If you would like to be involved,
or have any comments, please
contact the Delivering Quality
and Value team at
[email protected].
Acknowledgements
We wish to thank everyone who has contributed
their time to enable us to carry out this work, and
in particular the frontline staff who took time out
from their busy schedules to show us how they
work and for all the information they shared.
The trusts we visited were:
• Bradford Teaching Hospitals NHS Foundation Trust
We would also like to thank the following for their
contribution:
• Care Services Improvement Partnership
• Maternity Services External Working Group
(Department of Health)
• National Institute for Health and Clinical
Excellence
• Central Manchester and Manchester Children’s
University Hospitals NHS Trust
• National Childbirth Trust
• East Kent Hospitals NHS Trust
• North West London Midwifery Strategy Group
• Liverpool Women’s NHS Foundation Trust
• Nottingham University Hospital
• Northern Lincolnshire and Goole Hospitals NHS
Trust
• Royal College of Midwives
• Royal United Hospital Bath NHS Trust
• The Shrewsbury and Telford Hospital NHS Trust
• University Hospitals of Leicester NHS Trust
• York Hospitals NHS Trust
• NHS Employers
• Royal College of Obstetrics and Gynaecology
• South Devon Healthcare NHS Trust
• Worcestershire Acute Hospitals NHS Trust
43
Further information
Published material
Department for Education and Skills and
Department of Health (2004), National Service
Framework for children, young people and
maternity services, Department of Health, London.
National Institute for Health and Clinical Excellence
(2004), Caesarean section: Understanding NICE
guidance. Information for pregnant women, their
partners and the public, NICE, London.
Department of Health (2006), National Tariff
2005-06, DH, London.
NHS Institute for Innovation and Improvement
(2005), Delivering quality and value: Focus on
Caesarean section, DH, London.
Flamm, B., Kabcenell, A., Berwick, D. and Roessner,
J. (1997), Reducing Caesarean section rates while
maintaining maternal and infant outcomes, Institute
for Healthcare Improvement, Cambridge MA.
Ontario Women’s Health Council (2002), Attaining
and maintaining best practices in the use of
Caesarean sections, OWHC, Ontario, Canada.
National Childbirth Trust conference proceedings
(1999), The rising Caesarean rate: a public health
issue, Royal College of Midwives and RCOG, London.
Ontario Women’s Health Council (2002), Caesarean
section best practices project: impact and analysis,
OWHC, Ontario, Canada.
National Childbirth Trust conference proceedings
(2000), The rising Caesarean rate: causes and effects
for public health, Royal College of Midwives and
RCOG, London.
Paranjothy, S., Frost, C. and Thomas, J. (2005), How
much variation in CS rates can be explained by case
mix differences, BJOG: An International Journal of
Obstetrics and Gynaecology, No. 112, pp. 658-66.
National Childbirth Trust conference proceedings
(2002), The rising Caesarean rate: from audit to
action, Royal College of Midwives and RCOG,
London.
Parliamentary Office of Science and Technology
(POST) (2002), Caesarean sections, Postnote, No. 184,
POST, London (www.parliament.uk/post/pn184.pdf).
44
National Childbirth Trust conference proceedings
(2003), Making normal birth a reality: sharing good
practice and strategies that work, NCT, London.
National Childbirth Trust, The Royal College of
Midwives and The Royal College of Obstetricians
and Gynaecologists, Maternity Care Working Party
(2006), Modernising Maternity Care - A
Commissioning Toolkit for England (2nd ed) NCT
and Royal College of Obstetricians and
Gynaecologists (RCOG) Press, London.
National Collaborating Centre for Women’s and
Children’s Health (2004), Caesarean section: Clinical
guideline, RCOG Press, London.
Royal College of Midwives (2002), Understanding
the national sentinel Caesarean section audit report
2001: an RCM topical briefing for midwives, RCM,
London.
Thomas, J. and Paranjothy, S. (RCOG clinical
effectiveness support unit) (2001), The national
sentinel Caesarean section audit report, RCOG Press,
London.
To find out more about the NHS Institute Email: [email protected] You can also visit our website www.institute.nhs.uk
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