All Wales Birth Centre Guidelines

Rev
/
Date
/ Purpose of Issue/Description of Change / Planned Review Date
MAT 030 / Jan 2009 / All Wales Birth Centre Guidelines. To be implemented by all Welsh Birth centres.
Reviewed and updated with NICE antenatal care guidelines 2008 and NICE intrapartum care guidelines 2007 / Jan 2012
Responsible Officer / Approved by / Date
Practice Development Midwife /
Women and Children’s Directorate meeting
Senior Nurses
Clinical Governance & HCS Committee / 29/01/09
18/02/09
March 2009

All Wales Birth Centre Guidelines

Developed by the All Wales Birth Centre Group with support from Welsh Assembly Government

Updated with NICE 2008 January 2009

All Wales Birth Centre Guidelines

Contents: PAGE

Forward 3

Background 3

Clinical Governance structures for birth centres 4

Assessment for choosing place of birth 7

Multi-disciplinary planning of pregnancy and place

of birth for women with additional risk factors 11

Pre-labour rupture of membranes 13

Meconium stained liquor 13

Normal labour and birth 13

Criteria for midwifery-led care in labour 13

Transfer for additional care in labour 14

All Wales midwifery transfer record 18

Management of obstetric emergencies in birth centres 19

Management of an unexpected intrauterine or neonatal death 30

When a woman declines treatment or refuses to be

transferred to a main obstetric unit 31

Home or birth centre birth against midwifery or medical advice 32

Use of birthing pool in labour 33

Data collection tool 35

References 36

Forward

These guidelines have been developed by an all-Wales multi-disciplinary working group to provide guidance on midwifery practice at birth centres across Wales. Birth centres are specifically designated facilities where midwives as lead professionals care for women and babies during labour, birth and the postnatal period. The birth centre may be stand-alone or situated alongside an obstetric unit. These guidelines are compatible with the recommendations made by NICE (NICE, 2007).

The aim of this guideline is to provide a component of a sound clinical governance framework to support midwives in their practice and enhance the care of women, babies and their families. Although these guidelines were written specifically for birth centres, they are equally applicable in the provision of midwife-led intrapartum care regardless of the place of birth. In recognising the individuality of women, these guidelines are not meant to replace the knowledge and skills of experienced health professionals.

Women and their families are equal partners with health professionals in the choices they make regarding place of birth. These guidelines are written for professionals but women must have access to clear, accurate information and the opportunity to discuss their choices with a midwife. An accompanying information leaflet for women can aid this discussion.

Background

Over the last decade there has been expansion in the number of birth centre facilities across Wales. Birth centres follow the overarching principles of health care strategy in Wales as outlined in Designed for Life (WAG, 2005). Independent enquiries have recognised the need for structured and robust clinical governance structures within birth centres. It is anticipated that further birth centres will open across Wales in line with service reviews, and with a clear drive from clinicians, it was timely to develop an all-Wales approach to operational standards for birth centres.

The need for a national surveillance scheme, which allows appropriate comparisons, including safety and cost effectiveness, of all places of birth has been recognized and we would recommend that this be established to address the poor quality and lack of coverage of current data.

Women should have access to information in order to make an informed choice about their preferred place of birth and should be supported in their choice appropriate to the level of clinical risk (WAG, 2004: NSF).

Clinical Governance structures for birth centres

These are the points of clinical governance, which are expected to be implemented in every birth centre. This document will consider clinical risk management and audit processes, although local arrangements should be in place to address the other pillars of governance: education and training needs, involvement of consumers, health and safety and reporting structures.

Clinical governance structures should be implemented in all places of birth (NICE, 2008 guidance).

·  Multidisciplinary governance structures should be in place to enable the oversight of all places of birth. The clinical governance group should include, as a minimum: representative from midwifery; representative from obstetric, anesthetics and pediatrics team (where they form part of the local service); supervisor of midwives; representative from local maternity services users forum and neonatal expertise. This should be worked out on a local level as appropriate.

·  There should be agreed criteria for women planning to give birth in each setting.

·  Information should be available to all women regarding local maternity services.

·  Clear referral systems must be in place for midwives who wish to seek advice on the care of women whom they consider may have risk factors, but who wish to labour outside a consultant unit. A senior member of the midwifery team, ideally a consultant midwife or supervisor of midwives, should be identified to fulfill this role, and clear referral paths need to be established.

·  If a woman has a risk factor (listed in ‘Assessment for choosing place of birth’) and wishes to give birth outside a consultant unit, a supervisor of midwives, consultant midwife or midwifery manager should be involved.

·  Should a woman choose to give birth outside of a consultant unit against midwifery and / or medical advice, the head of midwifery needs to be made aware

·  If an obstetric opinion is deemed necessary, this should be obtained from a consultant or an obstetrician with appropriate experience.

·  All healthcare professionals should document discussions with women about their chosen place of birth in the hand-held maternity record.

·  In all places of birth, the processes of risk assessment in the antenatal period and when labour commences should be subjected to audit.

·  Clear pathways and guidelines on the indications for, and the process of transfer to, a consultant-led unit should be established, including the continued care of women and their babies. There should be no barriers to rapid transfer when required in an emergency.

·  These pathways should include arrangements for when the nearest consultant obstetric or neonatal unit is closed to admissions.

·  If the emergency is such that transfer is not immediately possible, assistance should be sought from any appropriately trained staff available.

·  There should be continuous audit of the appropriateness of the reason for and speed of transfer (use All Wales Midwifery Transfer Form). This audit needs also to consider whether women who gave birth in the midwifery-led unit had indications for transfer and why that did not occur. Audit should also include time taken to see a specialist obstetrician and time from admission to birth once transferred.

·  Monthly figures of numbers of women booked, being admitted to, being transferred from and giving birth in each place of birth should be audited. This must include maternal and neonatal outcomes.

·  Any serious maternal or neonatal adverse outcome should be subject to detailed root cause analysis.

At all times it must be clear who is the lead professional co-ordinating a woman’s care (WRP 2004). Following any referral for additional care, the lead professional should document the management care plan in the woman’s hand held records. When the deviation from norm has resolved and no further additional care is required the woman should be referred back to her midwife who will resume responsibility as the lead professional.

The lead professional should ensure that all aspects of care have been discussed with the woman and that discussions have been documented with clear guidance on the action required. If a woman decides not to accept the offer of referral for additional care, the midwife will continue to provide midwifery care. The midwife should discuss the case with her supervisor of midwives and ensure that documentation of the woman’s decision is clear.

Inter-Professional Working

It would not be anticipated that medical staff would be called to attend a woman or baby in a birth centre but rather, in the event of a deviation from normal progress, the woman and /or baby would be transferred to a hospital consultant–led delivery suite as soon as physically possible. However, in the event of an emergency arising in a birth centre geographically close to the main delivery unit, arrangements should be established locally depending on each woman’s situation. Medical staff and other relevant personnel would normally be expected to provide emergency assistance for the unit.

The aim of management in an emergency situation arising in a birth centre is to sufficiently stabilise the condition of the mother or baby to facilitate safe transfer to the delivery suite or neonatal unit. It would normally be expected that any professional groups who may be called upon in an emergency situation would be consulted in the planning and equipping of the birth centre.

.Statistics

All birth centres should keep detailed records including outcomes for women transferred to obstetric care during labour (see Audit form). It would be expected that details are kept of women transferred from midwifery-led care during the antenatal, intrapartum and postnatal periods.

Documentation

Documentation of all transfers should comply with the requirements of the NMC (NMC, 2004). It is recommended that all units use the ‘All Wales Birth Centre’ transfer form or a local variant containing the same minimal data set to record the details of mother transferred during labour or for babies requiring additional care

Assessment for choosing place of birth

The following criteria are recommended to be used by the midwife to assess suitability for the woman’s preferred place of birth (NICE, 2008). This list is not exhaustive and midwives should utilise their clinical judgment.

1.  Conditions where the expected lead professional would be a consultant obstetrician for antenatal and intrapartum care:

Medical conditions / Additional information
Cardiovascular / ·  Cardiac disease requiring antibiotics in labour
·  Currently on treatment or considering treatment
·  Hypertensive disorders
·  Previous open heart surgery
Respiratory / ·  Asthma requiring an increase in treatment or hospital treatment
·  Cystic fibrosis
Haematological / ·  Atypical antibodies which carry a risk of haemolytic disease of the newborn
·  Beta-thalassaemia major
·  Bleeding disorder in mother or fetus
·  Haemoglobinopathies – sickle cell disease
·  History of thrombo-embolic disorders
·  Immune thrombocytopenia purpura or other platelet disorder.
·  Platelet count blow 100. [Updated NICE 2007]
·  Rhesus disease
·  Von Willebrand’s disease
Infective / ·  Carrier/infection of Human Immunodeficiency Virus
·  Current active infection of chickenpox / rubella / genital herpes in women or babies
·  Hepatitis B/C with abnormal liver function tests
·  Risk factors associated with group B streptococcus such that advice is given to treat woman with antibiotics in this labour
·  Toxoplasmosis – mother receiving treatment
·  Tuberculosis on treatment
Immune / ·  Scleroderma
·  Systemic Lupus Erythematosus
Endocrine / ·  Diabetes
·  Thyroid dysfunction requiring neonatal assessment.
Renal / ·  Renal disease
·  Abnormal renal function [Updated NICE 2007]
Neurological / ·  Epilepsy
·  Myasthenia Gravis
·  Previous cerebrovascular accident [NICE 2007]
Gastro-Intestinal / ·  Liver disease associated with current abnormal liver function tests
Psychiatric / ·  Psychiatric disorder requiring current in patient care. [Updated NICE 2007]
Obstetric history / Additional information
Previous Complications / ·  Caesarean section
·  Eclampsia
·  Pre-eclampsia requiring preterm birth
·  Previous baby with neonatal encephalopathy
·  Primary postpartum haemorrhage (more than 1000mls or any amount that adversely affects woman’s condition or requiring blood transfusion).
·  Shoulder dystocia
·  Stillbirth/neonatal death or previous death related to intrapartum difficulty
·  Uterine rupture
·  Previous retained placenta requiring manual removal [updated NICE 2007]
·  Placental abruption with adverse outcome. [Updated NICE 2007]
·  Previous history of puerperal psychosis. [Updated NICE 2008]
Current pregnancy / ·  Anaemia haemoglobin less than 8.5g/dl or woman symptomatic at onset of labour [Updated NICE 2007]
·  Alcohol or drug dependency requiring assessment or treatment
·  Body Mass Index at booking of >35 or <18
·  Confirmed intrauterine death
·  Induction of labour
·  Multiple birth
·  Onset of gestational diabetes
·  Persistent malpresentation – breech or transverse lie after 36 weeks pregnancy.
·  Placental abruption
·  Placenta praevia
·  Pre-eclampsia or pregnancy induced hypertension
·  Preterm labour or preterm pre-labour rupture of membranes
·  Notbooked in this pregnancy
·  Significant blood group antibodies [Updated NICE 2008]
Fetal indications / ·  Abnormal fetal heart rate/Doppler studies
·  Clinically large baby with ultrasound measurements over 97th centile
·  Oligo/poly-hydramnios on ultrasound
·  Small for Gestational Age fetus (less than 5th centile or reduced growth velocity on ultrasound) [Updated NICE 2007]
Previous gynae. history / ·  Hysterotomy
·  Myomectomy

2.  In isolation, the factors listed below would be an indication for the woman to be offered an obstetric opinion in the antenatal period.

An individual clinical management plan should be devised between the obstetrician, woman and midwife for the intrapartum care.

Medical conditions / Additional information
Cardiovascular / ·  Conditions that have not required treatment (insignificant murmur, no antibiotic cover required for labour)
Haematological / ·  Anaemia haemoglobin 8.5-10.5g/dl at onset of labour [Updated NICE 2007]
·  Atypical antibodies where baby is not at risk of haemolytic disease
·  Blood results outside the range of normality for pregnancy
·  Idiopathic thrombocytopaenia (cut off of 100 for platelets)
·  Sickle cell or sickle cell trait, Thaliseamia trait. [Updated NICE 2007]
Infective / ·  Hepatitis B/C with normal liver function tests (Immunoglobulin for baby will have to be arranged).
Immune / ·  Non specific connective tissue disorders
Endocrine / ·  All should be assessed.
Skeletal/Neurological / ·  Neurological defects
·  Previous fractured pelvis
·  Spinal abnormalities
Gastro-Intestinal / ·  Crohns disease
·  Liver disease without currently abnormal liver function
·  Ulcerative colitis
Obstetric history / Additional information
Previous complications / ·  Extensive vaginal, cervical or 3rd or 4th degree perineal trauma
·  History of previous baby >4.5kg or below 2.5kg [updated NICE 2008]
·  Infant below 5th centile or above the 95th centile. [Updated NICE 2008]
·  Placental abruption
·  Pre-eclampsia developing at term
·  Stillbirth/neonatal death with a known non recurrent cause
·  Recurrent miscarriage 3 or more. Or mid Trimester loss. [Updated NICE 2008]
·  Previous history of antepartum Heamorrage on two occasions. [Updated NICE 2008]
·  Previous baby with structural or chromosomal abnormality.
·  Previous baby with jaundice requiring exchange transfusion.[ Updated NICE 2007]
Current pregnancy / ·  Abdominal pain
·  Antepartum bleeding after 24 weeks on one occasion
·  Asymptomatic bacteriuria
·  Blood pressure of 140 mm Hg systolic or above; or 90 mm Hg diastolic on 2 occasions
·  Concern over maternal mental health
·  Clinically small or large for gestational age baby
·  GBS detected in pregnancy
·  Late booking: after 18weeks.
·  Para 6 or more [Updated NICE 2007]
·  Recreational drug use or substance misuse
·  Recurrent urinary tract infection
·  Reported reduced fetal movements
·  Suspected malpresentation at 36 weeks
·  Women complaining of persistent pruritis
·  Age over 40yrs at booking [updated NICE 2007]
Fetal indications / ·  Fetal abnormality
Previous Gynaecological history / ·  Cone biopsy or LLETZ (large loop excision of the
·  transformation zone)
·  Fibroids
·  Major gynaecological surgery

Multi-disciplinary care-planning of pregnancy and place of birth for women with additional risk factors