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1 Quality, Safety & Experience Sub Committee Item QS15/28 Date of meeting To improve health and provide excellent care Date of Paper Title: Author: Responsible Director: Summary of Key Issues: Welsh Risk Pool Services (WRPS) Risk Management Arrangements within Midwifery Led Units Across Wales Isobel Smith WRPS Assessor/Adviser Mrs Angela Hopkins Executive Director of Nursing and Midwifery 1) PURPOSE 1.1) The enclosed report, produced by the Welsh Risk Pool Services (WRPS) in association with the Heads of Midwifery Advisory Group (HOMAG) in Wales, provides an update and conclusion of the work undertaken in respect of the governance arrangements within Midwifery Led Units in Wales. 2) BACKGROUND 2.1) The Welsh Health Minister s announcement on the siting of the Level 2 Neonatal Unit in Hywel Dda, resulted in a reconfiguration of maternity services with an introduction of a Freestanding Midwifery Led Unit (FMU) on a former Obstetric Unit (OU) at Withybush Hospital, Haverfordwest. 2.2) At a Welsh Risk Pool Committee meeting, held on the 16 th July 2014, the elected Royal College of Obstetricians and Gynaecologists (RCOG) Council Representative for Wales, advised the committee that there was considerable anxiety among his colleagues across Wales about the change to Midwifery Led Units in the same location as what had previously been an Obstetric Unit. 2.3) The RCOG in Wales called for appropriate risk assessments and strict admission criteria and protocols in all Health Boards where Obstetric Units are to become Midwifery Led Units to ensure patient safety as part of a risk management process. 2.4) A letter, seeking these assurances, was issued to all Health Boards by Welsh Risk Pool Services on the 2 nd October

2 2.5) In response to this request to Health Boards, a workshop was facilitated by the Heads of Midwifery Advisory Group (HOMAG) on the 28 th November 2014, in partnership with Consultant Midwives, to provide assurances on the governance arrangements for all Midwifery Led Units in Wales. A WRPS representative was invited to the proceedings to receive written and oral evidence. 3) ASSESSMENT 3.1) The WRPS Committee received the enclosed report at their meeting held on the 23 rd January 2015 and was asked to accept its findings as assurance of the governance arrangements for midwifery led birth settings in Wales and note the recommendations made. 4) CONCLUSION 4.1) The WRPS Committee reviewed the evidence presented and concluded that they were satisfied that a robust clinical governance assurance framework exists for all Midwifery Led Units in Wales. The Committee commended the work undertaken by the Heads of Midwifery Advisory Group (HOMAG) in summarising the evidence and requested to be sighted on the development of the All Wales Midwifery Led Unit outcome measures/data set once agreed. 4.2) There were a total of 7,039 births in North Wales in 2014, of which 1,141 were in the two Alongside Midwifery Led Units (AMUs) and a further 157 in the community. 4.3) The Women s CPG can confirm that the Health Board is fully compliant with all aspects of the All Wales Clinical Governance Assurance Framework for all Midwifery Units in North Wales. 5) RECOMMENDATION The Quality, Safety and Experience Sub Committee is requested to accept the WRPS deliberation and endorse their conclusion. Action Required By Sub Committee: To: (please tick all that apply) Note Endorse Ratify Approve 2

3 (Please provide a short summary against all that apply) Corporate To ensure robust governance arrangements are Objective in place for Midwifery Led Units in Wales. Key Impacts: Finance Quality Impact Assessment Standards for Health Services in Wales Equalities, Diversity & Human Rights Risk & Assurance Reducing possible future claims by ensuring a robust clinical governance framework for this model of care. A QIA has not been undertaken Standard 1 Governance and Accountability Framework Standard 2 Equality, Diversity and Human Rights Standard 6 Participating in quality improvement activities Standard 7 Safe and Clinically Effective Practice Standard 8 Care planning and provision Standard 22 Managining Risk and Health and Safety Standard 24 Workforce Planning Standard 26 Training and OD Not undertaken as part of the process Current Governance Framework for MLUs in Wales Endorsed by WRPS Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Committee Coversheet 7.0 October

4 CIRCULATION WRPS Committee DATE 23 rd January 2015 PREPARED BY CONSULTATION Isobel Smith WRPS Assessor/Advisor Heads of Midwifery Maternity Lead Welsh Government TITLE OF REPORT Welsh Risk Pool Services Risk management arrangements within Midwifery Led Units across Wales following reconfiguration of Maternity Services in Hywel Dda Health Board. PURPOSE OF REPORT The purpose of this report is to provide an update and conclusion of the work undertaken in respect of the governance arrangements within Midwifery Led Units in Wales. 1.0 INTRODUCTION Following a query raised at the WRP Committee in July 2014, a workshop was held by the Heads of Midwifery Advisory Group on the 28 th November 2014 to provide assurance on the governance arrangements for Midwifery Led Units in Wales. The aim of the workshop was to: Ensure a standardised approach to low risk care across Wales To promote evidence based practice Review the criteria and tools used for the systematic assessment of both maternal and fetal wellbeing 2.0 BACKGROUND On the 21 st January 2014 the Welsh Health Minister confirmed that a Level 2 Neonatal Unit was to be created at Glangwilli Hospital, Carmarthen, paving the way for the closure of the Special Care Baby Unit at Withybush Hospital, Haverfordwest. Obstetric and maternity services at Withybush hospital will become midwifery led. At the Welsh Risk Pool Committee meeting held on the 16 th July 2014, Mr Christopher Roseblade, Consultant Obstetrician and Gynaecologist at Betsi Cadwaladr University Health Board and the elected Royal College of Obstetricians and Gynaecologists Council 1

5 Representative for Wales, advised the Committee that there is considerable anxiety among his colleagues across Wales about the change to Freestanding Midwifery Led Units (MLU) in the same location as former Obstetric Units. The concerns raised at the WRP Committee focussed on the risks associated with introducing a freestanding Midwifery Led Unit on the site of the former Obstetric Unit. In particular, it was felt that Obstetricians working in clinics on site may be asked to attend and review patients in the midwifery led setting outside the new clinic protocols. The expectations placed on staff to provide support need to be clearly outlined especially in relation to emergency scenarios such as a pregnant woman presenting in the Emergency Department with active bleeding. The concern was that unless there was absolute clarity about roles, responsibilities and expectations there was potential for adverse outcomes and potential GMC referrals. Therefore appropriate risk assessments and strict admission criteria and protocols must be in place in all Health Boards when Maternity services reconfigure to provide midwifery services as opposed to Obstetric services, to ensure patient safety is paramount as part of the risk management process. 3.0 WORK UNDERTAKEN Consultant Midwives and Heads of Midwifery considered the Birthplace study report 2011 which informed the revised NICE Intrapartum Guidance (2014), supporting the evidence that low risk women birthing in midwifery led units have better outcomes than women birthing in Obstetric Units during a normal delivery, with fewer interventions. 4.0 EVIDENCE BASED FINDINGS The key findings from the evidence are that: All women should be risk assessed at booking to determine appropriate lead professional and place of birth and any specific needs or risks identified and documented in the women s Antenatal hand-held record. Women appropriately risk assessed should be recommended midwife-led care and a midwife led setting for birth (NPEU 2014; NICE 2008). 4.1 Uncomplicated pregnancies For women without risk factors (low-risk women) the appropriate lead professional is the midwife. Antenatal care for low-risk women should be provided in accordance with NICE guidelines for routine antenatal care. NICE [2010] 2

6 In planning place of birth women should be informed that research suggests positive outcomes for women who choose to birth their babies in midwife-led environments:- low-risk women planning birth in a midwifery-led unit and low-risk multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes.[npeu 2011] Low-risk primiparous women have a greater chance of requiring intrapartum transfer than low-risk multiparous women. [NPEU 2011] Low-risk women who birth in a birth centre type environment report higher levels of satisfaction with their birth experience as they report feeling informed, listened to and supported in their decision-making [Overgaard et al 2012] Clinical Governance Arrangements: The workshop confirmed the following clinical governance arrangements: Information should be available to all women regarding local maternity services. Clear referral systems should 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 led unit. A senior member of the midwifery team, a consultant midwife or supervisor of midwives, should be identified to fulfil this role, and clear referral pathways need to be established. 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 continuous assessment. Clear pathways and local agreements on 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. Monthly figures of numbers of women booked, admitted to, being transferred from and giving birth in each place of birth should be audited. This should include maternal and neonatal outcomes. There should be continuous audit of the appropriateness of the reason for and speed of transfer (Transfer form included in the All Wales Clinical Pathway for 3

7 normal labour 2013). 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. There should be locally agreed robust systems in place for incident reporting, investigating and identifying key lessons to be learnt. Themes and trends identified through this process should be acted upon promptly and effectively through midwifery management, midwifery supervision, training and service evaluation. The clinical governance group within each Health Board should be responsible for detailed root-cause analysis of any serious maternal or neonatal outcomes (for example, intrapartum related perinatal death or seizures in the neonatal period) and consider any near misses identified through risk management systems. 5.0 TRAINING IN EMERGENCY PROCEDURES IN MIDWIFERY LED UNITS The workshop confirmed that training in the following emergency procedures should be in place within midwifery led units. Cord prolaspe Shoulder Dystocia Major haemorrhage Breech Birth Uterine inversion Newborn life support Sepsis Meconium Stained Liquor (NICE 2007) Retained Placenta (NICE 2007) Criteria for referral to medical staff in the postnatal period 6.0 CONCLUSION The All Wales Documentation to support Midwifery Led Care and Birth Centres was reviewed in 2012/2013 and is consistent with the relevant guidance including NICE inclusion criteria as is the Normal Labour Pathway. This documentation provides the clinical governance framework for managing risks appropriately in Midwifery Led Units in Wales. Further review of these strategic documents is planned in light of the publication of the revised NICE Intrapartum Guidance which was issued on the 3 rd December Agreement was reached that the Governance around the development and Revision of All Wales Documentation e.g. Normal Labour Pathway and the All Wales Birth Centre Guidelines will be a Maternity Network function in the future. The evidence presented at 4

8 the Workshop provided a sound assurance framework for the governance arrangements for Midwifery Led Units in Wales. 7.0 RECOMMENDATIONS The Committee is asked to accept this report as assurance of the governance arrangements for Midwifery Led Units in Wales and note that the following recommendations were made following the workshop: 1) A Midwifery representative to sit on the WRPS Committee 2) Heads of Midwifery to raise the profile of the Birthplace Study and the new NICE recommendations through the National Specialist Advisory Group (NSAG) and the Maternity Network 3) Frequently Asked Questions (FAQ) leaflet for Professionals and Women to be developed to include transfer times from stand alone midwifery units based on the Birthplace Study findings 4) Data set/outcome measures for all Freestanding Midwifery Units and Alongside Midwifery Units (AMU) to be developed 5) All Health Boards to consider appointing a Consultant Midwife to focus on the governance of promoting Normal Birth within their area of responsibility 5

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