Homebirth Team Standard Operating Protocol (CG520)

Homebirth Team Standard Operating Protocol (CG520) Approval and Authorisation Approved by Job Title Date Maternity & Children s Services Chair, Maternity Clinical 3 rd March 2017 Clinical Governance Committee Governance Committee Change History Version Date Author Reason 1.0 November Annette Weavers Trust requirement 2014 Kate Clements 2.0 April 2016 Annette Weavers Kate Clements Re-write as per action plan from SI investigation 3.0 January 2017 Natasha Schultz (Homebirth Team Lead) Christine Harding (Consultant Midwife) Re-write following formulation of Homebirth Team 3.1 June 2018 S Mozley (HB Team MW) Pg 22 - Clarification of skill mix so that Band 6 MW should be in attendance with Band 5 MW irrespective of 1 st or 2 nd status Job Title: Homebirth Team Lead & Consultant Midwife Review Date: March 2019 This document is valid only on date last printed Page 1 of 22

Contents 1.0 Introduction 2.0 Purpose 3.0 Function 4.0 Definitions 5.0 Roles and Responsibilities 6.0 Training for Midwives 7.0 Equipment for Home birth 8.0 Planning home birth 8.1 Antenatal: 8.2 Intrapartum Care 8.3 Postnatal Care: 9.0 Recording of home birth 9.1 Unplanned Homebirth or Born before Attendance of midwifery care (BBA) 10.0 Suspension of Home Birth Service 11.0 Monitoring Home Birth Service 12.0 Dissemination/Circulation 13.0 Equality Impact Assessment Toolkit 14.0 References Appendix 1: Out of Hours Access to Home Birth Equipment from the Two Community Areas Appendix 2 Community Equipment Appendix 3: Community Emergency Equipment Checklist Appendix 4: How to record a Home Birth using EPR and CMIS Appendix 5: Medical Gas Cylinder Order Form for Community Midwife Use Appendix 6 (written by Emma Matthews Community midwife lead) This document is valid only on date last printed Page 2 of 22

1.0 Introduction In the RBHFT, our philosophy is to offer women a choice of place of birth. Women should receive clear unbiased advice and be able to choose where they would like their baby to be born (Maternity Matters DH, 2007). One of those options should be birth at home (NHS England, 2016). The Birthplace study findings (NPEU, 2011) demonstrate that birth at home confers benefits to low risk women in that they are more likely to experience normal birth with less intervention. For multiparous women there were no significant differences in adverse perinatal outcomes between planned home birth or midwifery units and planned birth in obstetric units. For nulliparous women there is a statistically significant increase in perinatal morbidity for birth at home although the overall rate remains low. Home birth is therefore a viable option for low risk women. In order to facilitate choice of place of birth the RBHFT has commissioned a specialist Homebirth Team from April 2017. This team is responsible for providing a homebirth service 24 hours a day, seven days per week, for all women planning a homebirth. These women will be provided with a total case loading model of midwifery care (Brintworth and Sandall, 2012) from the team during the antenatal, intrapartum and postnatal periods. 2.0 Purpose The purpose of this standard operating procedure is to outline standards for the Homebirth team in order to maintain the homebirth service. 3.0 Function This standard operating procedure is applicable to midwives working in both the Homebirth Team and the Community Midwifery Team. 4.0 Definitions Term/word Planned home birth Unplanned home birth BBA NIPE The midwife Definition Woman makes decision in consultation with her midwife in antenatal period and/or early labour and midwife provides intrapartum care Midwife provides intrapartum care to a woman who had not chosen home birth (for example precipitate labour) Born before attendance of midwifery care Newborn and Infant physical examination On call Community Midwife for home births This document is valid only on date last printed Page 3 of 22

RBFT EPR CMIS The home birth specialist team midwife Royal Berkshire NHS Foundation Trust Electronic Patient Record Circonia Maternity Information System 5.0 Roles and Responsibilities 5.1 Clinical Director and Director of Midwifery have responsibility for the strategic provision of the home birth service and provide support as needed. 5.2 The Matron for Community Services has the responsibility to facilitate the effective implementation of this protocol by ensuring facilities, equipment and staffing are in place and provides support as needed. 5.3 Homebirth Team Midwives have the role responsibility of providing a 24 hour homebirth service model and to provide a case loading model of midwifery care to all women in their caseload during the antenatal, intrapartum and postnatal periods. 5.4 Community Midwives have the role of supporting the homebirth team by providing the second midwife to Planned homebirths. Their role also includes providing care to all women having unplanned homebirths or births before attendance of midwifery care (BBA). All homebirth team and community midwives participating in the home birth service must hold a full drivers licence and have business insurance car use. For further advice on role of first and second midwives at home birth see Appendix 6. 5.5 Maternity Support Workers have the role to support all midwives in the community in providing information to women and where possible the transport of home birth equipment to the woman s home. Where Maternity Support Workers are deemed competent to support midwives for home birth (competencies for maternity support workers), the attending midwife can request her as the second person at the home birth instead of a midwifery colleague if appropriate. 5.6 Community Coordinator has the role of coordinating all services in community during daytime hours and is therefore to provide senior midwifery This document is valid only on date last printed Page 4 of 22

support for the homebirth team or community midwives conducting intrapartum care within the community. 5.7 Delivery Suite Coordinator has the role to facilitate handover of care from the homebirth midwife to a unit midwife when women transfer from home to hospital as soon as possible to enable her to fulfil her role in providing a case loading model of care for women planning a homebirth. 5.8 Unit Coordinator and Manager On-Call has the role of maintaining the safety of the day to day running of maternity services including homebirths. 6.0 Training for Midwives Training for dealing with emergency situations in the home is provided for all community midwives. As a minimum, midwives attending home birth are required to attend the PROMPT training study day and; the Phone 999 study day (which is a multidisciplinary study day alongside the ambulance service covering obstetric emergencies within the community) or equivalent training These should be attended on an annual/biannual basis as per the training needs analysis, to enable staff to maintain their skills. The homebirth team will annually attend a homebirth team update covering obstetric emergencies in a live community setting. Each midwife is able to access practice education or their team lead for further support with skills or learning if a need is identified. All midwives attending home birth have to be competent or working towards their competencies in perineal repair, IV cannulation, intermittent auscultation of the fetal heart rate and water birth. 7.0 Equipment for Home birth Equipment for home birth includes as a minimum: delivery pack, oxytocic drugs, gloves and is routinely carried by the midwife along with the other equipment outlined in Appendix 2. Additional home birth equipment (Appendix 3) is kept at RBHFT and West Berks hospital and can be accessed 24 hours a day (Appendix 1) When transporting labour gases, a TREM sign must be displayed on the window of your car. As a minimum standard, the home birth equipment at the above locations is checked/cleaned on a daily basis and documented accordingly (Checking Maternity This document is valid only on date last printed Page 5 of 22

Emergency Equipment (CG482). The daily Community Co-ordinator is responsible for ensuring this happens in each of the areas. The midwife using the equipment at the homebirth is responsible for cleaning and restocking it following the homebirth in preparation for the next home birth. Medical gas cylinders must be ordered by completing the 'Medical Gas Cylinder Order Form for Community Midwife Use' (appendix 5) which can be found in the wooden box outside the maternity call centre room. The completed form should be left in the wooden box and the order should be phoned through to the porters help desk on ext. 8300. 8.0 Planning home birth 8.1 Antenatal: 8.1.1 Information giving about place of birth will begin at the booking appointment by the community midwife. If they community midwife is aware the woman is requesting homebirth prior to booking then the homebirth team will commence case loading care from booking. As a minimum, all women will be given the leaflet: Planning place of birth. Subsequent information regarding home birth will be discussed later in pregnancy on an individual basis. All women should also be given a leaflet advertising the homebirth team at booking. CMIS must be amended to reflect planned place of birth. For women booked for intrapartum care at neighbouring NHS Trusts who then choose home birth, complete RBHFT booking forms for recording on CMIS indicating the preference for home birth. 8.1.2 If a woman expresses an interest for a homebirth at any gestation then she can be referred to the homebirth team. The community midwife should complete the referral form (See Maternity Stationary) and sent it to: rbft.homebirthteam@nhs.net. This form will then be triaged and allocated to a named midwife within the homebirth team. That midwife will then provide a case loading model of care for the woman and her family within their home. On the first meeting the named midwife will discuss the case loading model and the anticipated standards of care will be outlined in the Homebirth Team Charter (See Maternity Stationary). If the named midwife is unable to fulfil any of the required appointments (e.g. if on This document is valid only on date last printed Page 6 of 22

annual leave or off sick) then another member of the team will conduct the required care. The earlier the referral to the team in the pregnancy, the more the family are likely to benefit from the case loading model of care. 8.1.3 The named midwife will complete a homebirth risk assessment (See Maternity Stationary) at the woman s home between 33-37 weeks of pregnancy. The purpose of this meeting is to evaluate the home for risks e.g. fire safety and to further discuss the benefits/counter benefits of birth at home to enable the woman to make an informed choice for her birth. A copy of this completed risk assessment should be filed in the home birth folder in Rushey triage office. 8.1.4 Suitability for a homebirth would be assessed using a risk assessment process involving the woman s medical, social, obstetric history and current circumstances. If the woman is suitable for GP/Midwife led care, then they are suitable for homebirth. If woman choses a homebirth but her history or circumstances indicate the most appropriate place for birth to be the main obstetric unit then a multidisciplinary approach would be taken to support the woman in facilitating her choice. Care would be shared between the named homebirth team midwife, Consultant Midwife and a named Obstetrician to make a plan with the woman and her family that reflects her wishes and the safety of her and her baby. 8.1.5 If a woman s circumstances change within her pregnancy due to complexity or complication and a hospital birth is indicated and agreed, her care would be transferred back to the generic community midwifery team. 8.1.7 All women should be made aware that their choice for place of birth will be revisited during the pregnancy if there are changing clinical indications and there is a chance that their choice of place of birth may not be possible due to adverse weather conditions or in the unlikely event that the service is unable to facilitate the birth e.g. a shortfall in staffing levels. This document is valid only on date last printed Page 7 of 22

8.2 Intrapartum Care: 8.2.1 See Homebirth Guideline (CG520) for information on the management of intrapartum care for women in the home environment. 8.2.2 The care of the woman in labour should be documented in the Trusts labour care pathway. 8.2.3 It is the responsibility of the midwife finishing their shift to handover the care to the next home birth midwife coming on duty. The midwife coming on duty must also ensure she is updated on any pending home birth/labour assessments. 8.2.4 When handing over care of a woman in established labour/early postnatal period, use of the SBAR tool is recommended in the records. 8.3 Postnatal Care: 8.3.1 The midwife should stay with the mother and baby for a minimum of 2 hours following completion of the third stage to ensure safety and wellbeing. 8.3.2 The placenta should be placed in a yellow placenta bag and placed in a placenta pot for transport to the unit. For women wishing to keep their own placenta follow guidance on the tissue release form available via stationary section of unit guidelines. 8.3.3 Document all postnatal care within the Postnatal booklet. The woman should be given her baby s red child health record and information leaflets including bounty pack. 8.3.4 When the midwife leaves she should ensure the family have appropriate contact telephone number 0118 3227319 (Marsh Ward) and 0118 3228059 (Reading Community Office) and advise when contact should be made. 8.3.5 A subsequent postnatal visit should be made either later on the day of birth or the following whichever is the sooner. This document is valid only on date last printed Page 8 of 22

8.3.6 Ensure the Newborn and Infant Physical Examination (NIPE) is arranged within 72 hours, where possible a NIPE midwife will carry this out in the community, if this is not possible, refer to the woman s GP. 8.3.7 Ensure the BCG vaccination is offered to women who answer yes to the screening questions at booking. Mothers will be invited to the RBH BCG clinic. 8.3.8 Return the antenatal hand held records and intrapartum records to RBFT filing them in the maternity case notes; complete EPR and CMIS information systems ensuring the birth registration document is returned to the woman at her next postnatal visit 8.3.9 Ensure any other items are returned to the maternity unit and disposed of correctly. Items on the equipment list should be checked re-stocked and signed. 8.3.10 On-going postnatal care should then be provided by the team within the home in line with the Trust s postnatal guidelines. 9.0 Recording of home birth See Appendix 4 on how to record a home birth delivery using EPR and CMIS To ensure accurate data collection for statistical purposes, ensure the following boxes on CMIS are correctly filled out: Ensure planned place of birth is Homebirth. Under DELIVERY and FURTHER LABOUR INFORMATION ensure both the boxes TRANSFER IN LABOUR and REASON if transferred is completed in all cases. If no transfer occurred click on not transferred in both boxes. If no transfer, under PLACE of DELIVERY, click on HOME. If REASON FOR CHANGE box comes up click on either PREGNANCY clinical reasons or LABOUR clinical reasons to indicate a planned home birth. This document is valid only on date last printed Page 9 of 22

9.1 Unplanned Homebirth or Born before Attendance of midwifery care (BBA) See Homebirth Guideline (CG520) for information on the management of intrapartum care for women in the home environment. To ensure accurate data collection for statistical purposes make sure the following boxes on CMIS are correctly filled out: Under PLACE OF DELIVERY, click on HOME and under REASON for CHANGE, click BBA unintentionally in labour 10.0 Suspension of Home Birth Service The maternity service aims to provide a home birth service 24hrs a day, 7 days a week. The suspension of the service should only be in extreme circumstances as outlined in the Home Birth Guideline (CG520) and the Unit Diversion and Escalation protocol CG483. All decisions to suspend the home birth service should be taken in collaboration with the Community Coordinator, Unit Coordinator or Maternity manger On-Call. 11.0 Monitoring Home Birth Service On a monthly basis the following information will be collected and reported on the departmental dashboard and separately to the Director of Midwifery: Number of homebirths planned (data source: CMIS) Number of home births (data source: CMIS and CMW statistics) Number of BBA (data source: CMIS) Number of women transferred in from intended home to DS including reason for transfer (data source CMIS) Number of times home birth service suspended (data source: triage excel spread sheet) Number of women unable to access choice of home birth (data source: triage excel spread sheet) This document is valid only on date last printed Page 10 of 22

DATIX incident reporting should occur in the following situations: suspension of home birth service, BBA, transfer of woman in the intrapartum period 12.0 Dissemination/Circulation The ratified document will be placed on the Trust Intranet Site under the Maternity Department. Additionally the following midwives will be sent the document: Community Midwives The Home birth team 13.0 References 1. Brintworth K & Sandall J (2013) What makes a successful home birth service: An examination of the influential elements by review of one service. Midwifery 29 713-721 2. Davey et al (2013) Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial). Birth http://dx.doi.org/10.1016/j.midw.2013.05.014 3. Lundgren et al (2013) Care seeking during the latent phase of labour Frequencies and birth outcomes in two delivery wards in Sweden. Sexual & Reproductive Healthcare 4 (4) 141-146 4. NHS England (2016) National Maternity Review (Better Births) [PDF] available on-line at: https://www.england.nhs.uk/wpcontent/uploads/2016/02/national-maternity-review-report.pdf. This document is valid only on date last printed Page 11 of 22

Appendix 1: Out of Hours Access to Home Birth Equipment from the Two Community Areas Reading Equipment stored in the maternity community office, Royal Berkshire Hospital, Craven road, RG1 5AN. Please park on ramp, if no spaces available, park on ramp and inform security that you are collecting the homebirth emergency equipment. A Trust ID card is needed to gain access to the corridor. The door code to where the homebirth equipment is stored is C1235. The home birth equipment is already in a trolley and can be easily wheeled out to the car. Please check gasses are OFF before transporting and a Transport Emergency (TREM) card displayed in the car. Please return trolley to the office after use. Newbury West Berkshire Community Hospital, London Road, Benham Hill, Thatcham RG18 3AF. The community hospital is situated between Thatcham and Newbury. Please telephone main reception on (01635) 273300 before arriving. Please park on the yellow shaded area at the front of the main hospital entrance. Prior to midnight a WESTCALL receptionist will assist you, after this time, the night porter will let you in and accompany you to the clean utility room where the home birth equipment is stored. The door code is: C0X2013. Syntometrine and Ergometrine are kept in the fridge in the same room. The equipment can be easily wheeled out to the car. Please check gasses are OFF before transporting and a Transport Emergency (TREM) card displayed in the car. A Trust ID card required. This document is valid only on date last printed Page 12 of 22

Appendix 2 Community Equipment Item Day to Day Bag MW Homebirth Bag Day to Day Bag MSW 1 Spare at RBH for hospital midwives (xnot required for hospital midwife bag) Sonicaid, sonicaid gel and spare battery Pinard Sphygmomter with normal and large size cuff Stethoscope Thermometer Adult mask One way valve and filter Neonatal mask size 1 Grey guedel size 0 and tongue depressor Clinical tape Delivery pack Disposable measuring tapes x10 Small sharps box Charcoal swabs x2 Stitch cutter x Staple remover x MSU Bottles and syringes x2 Uristicks Path forms x2 Chlamydia and x gonorrhoea specimen collection pot Neonatal blood spot x (x10) cards x5 Lancets x10 x (x20) Cotton wool (half path bag) Clinnel wipes (with scales). I separate bag with scales. 1 set of scales available to unit staff Blood bottles (x2 pink, This document is valid only on date last printed Page 13 of 22

x2 purples, x1 blue, x1 red, x1 grey) Cannula, chlor prep, dressings, red dots x2 of all x2 needles, x2 Vacutainer X2 tourniquet Red drawing up needles x2 Green and orange needles x3 10 and 20 mls syringe Vacutainer adaptors Normal saline x2 5mls Non-sterile gloves (path bag full) Sterile gloves x3 Aqua gel x2 sachets Lansinoh sachets x5 X 2mls oral syringes x5 (x10) Drugs pot x Syntometrine, Oxytocin, ergometrine, vitamin k Hat Speculum x1 Actiprom x1 Suture pack Sterile gloves Sutures x2 Lidocaine 10+10mls Voltarol x1 Large swabs x1 Eyewear Apron x2 Inco x 6 Catheter, catheter bag, Instillagel Wound care pack Octenalin Amnihooks x2 Placenta bags x2 Placenta pot and lid This document is valid only on date last printed Page 14 of 22

Aqua gel x4 Tiger bags x2 Torch Bowl to measure 1 st void Hat for the baby Slide Sheet IV Fluids Giving set Epi pen x2 Oxygen transfer card and compressed gas sign Oxygen Adult mask and tubing Emergency calls in maternity 500mls ambu bag and mask size 1 Guedel airways 0,00 Laryngoscope with large and small blade (HB Team MW to carry) Entonox cylinders Suction unit with yankauer sucker Consider BOC bag Separate Paperwork X 2 continuation sheets Emergency and transfer proforma Labour care pathway MOWS Chart Adult name band PN Book Allergy band Neonatal notes Neonatal band Drug chart SBAR Sticker SP, EM, JC, LA, DP, KC April 2016 Updated Dec 2016 SP, NS This document is valid only on date last printed Page 15 of 22

Appendix 3: Community Emergency Equipment Checklist This document is valid only on date last printed Page 16 of 22

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Appendix 4: How to record a Home Birth using EPR and CMIS Access and log in to EPR from RBH homepage Application section right side/click for more select EPR Select PMR Office If problem logging in to EPR application (forgotten password etc.) out of hours call helpdesk on x7411 or 3563 Open Conversation workgroup Select Homebirth Delivery conversation Search for correct woman Add encounter Amend/update any inaccurate demographic data i.e. last name, GP, home address, add temporary address if required Complete VISIT tab Lead clinician = midwife Date and time = arrival at woman s home Click OK Open CMIS Click CHECK EPR button, this will bring across any updates to woman s record Add antenatal information Do you need to check admission info before able to continue? Add Delivery and Discharge data EPR Discharge conversation Search for correct woman Select HOMEBIRTH encounter lower pane Click OK Date and time will be time left woman s home This document is valid only on date last printed Page 20 of 22

Appendix 5: Medical Gas Cylinder Order Form for Community Midwife Use Medical gas cylinders must be ordered by completing this form and telephoning the order through to the porter s help-desk on ext. No 8300. Please complete if lending cylinders to another ward ** ------------------------------------------------------------------------------------------------------- 1) RETURNED Cylinders Gas type Oxygen Entonox Size CD or other? Quantity ORDER FULL /EMPTY? FROM? RBH/Newbury/Wokingham 2) Stock Required for: RBH / Newbury / Wokingham (ring as appropriate) Ordered by:..... Date Time Grade: MEDICAL GAS REQUIRED (please print) i.e. Oxygen or Entonox SIZE Delete CD if another size required CD CD CD QUANTITY Required DELIVERED BY:.. Date delivered: Time CHECKED / RECEIVED and PUT IN STOCK ROOM BY Grade:... Date Time **If lent to another ward; ** Lent to;-.. Nurse supplying cylinder to sign "Delivered by" Nurse receiving cylinder must sign "Checked and Received by" This document is valid only on date last printed Page 21 of 22

Appendix 6 Role of Homebirth Midwives To ensure the correct skill mix, there should always be a Band 6 or above Midwife in attendance with a Band 5 Midwife, irrespective of first or second status. Two Band 5 Midwives should not attend any homebirths together. First Midwife Usually first attender to homebirth Provides initial clinical assessment Lead midwife for clinical care unless by agreement with second midwife and clearly documented in notes Provide routine care as per normal care pathway and NICE guidelines Detecting deviation from norm and escalating as required Documentation of care Setting up and checking of homebirth emergency equipment To remain in home for at least two hours following birth to ensure mother and baby clinically well Goes with mother or baby to hospital (delivery suite for mother and A&E for baby) if transfer is required unless agreed for second midwife to go (SBAR should be used) Second Midwife Works as support for first midwife whilst caring for woman Attends usually at commencement or signs of second stage May be present prior to second stage for extra support to women and/or midwife Use of second midwife is at discretion of first midwife or community coordinator/unit coordinator Could take over documentation at request of first midwife whilst first midwife focuses on clinical care Initiates escalation if deviation from norm Bring equipment if not already there Check emergency equipment if not already checked Can return to hospital/other duties after delivery as per clinical picture and can take back notes and equipment Remains with mother or baby who remains at home in event of transfer unless agreed with first midwife to go on transfer This document is valid only on date last printed Page 22 of 22