Published: 22/08/2002, Volume II2, No. 5819 Page 24 25
Demand on beds at one delivery suite was so acute that women in labour had to sit on chairs in the corridor. Sue Dennett and Fay Baillie describe a scheme which eased the pressure
How can women in labour be assured appropriate care when the demands on delivery units are so intense? And how should maternity services provide for women who are not in labour but in need of advice or investigations?
Modernising the NHS is not necessarily about funding, it is also about looking at what is happening and finding better ways of working. Birmingham Heartlands and Solihull trust was faced with a problem in its maternity service which had to be solved relatively quickly to prevent increasing dissatisfaction among users and frustration among the staff. An increase in admissions to the delivery suite at Heartlands Hospital among women who were not actually in labour was noticed. It was not unusual to find women in labour sitting on chairs in the corridor, waiting for rooms to be vacated.Yet the capacity of the delivery suite could not be expanded without major investment. And an increase in the number of midwives or support staff would not solve the problem.
The delivery suite, which has approximately 4,500 births a year, consists of eight rooms and one fourbed bay. The hospital has two maternity wards - one with 26 beds and the other with 23. There are a total of 89 midwives working on the delivery suite and the wards.
In large delivery suites, midwives are often expected to care for more than one woman at a time.
Prioritisation is often weighted by how complicated the case is; with the danger of women in 'normal labour' being deprived of the support they need.Not only does this cause dissatisfaction all round, those women may then actually develop complications that could have been prevented with the appropriate care.And with the highest litigation bill in the NHS resting with maternity services, delivery suites are extremely stressful places to work. The pressure to provide sensitive, 'woman-centred' care in this acute setting compounds the stress.
If the facilities could not be expanded to meet the increasing demand, were there ways of improving capacity and changing working patterns? The first task was to assess what the throughput was in the delivery suite and how women accessed the service.
A maternity project was launched in 1999.
What was happening?
Most women arriving at the delivery suite were selfreferrals. Only a small number were referred from primary care providers or antenatal clinics. During the antenatal period, the pregnant woman receives information about how to contact the delivery suite by telephone and is encouraged to ring if she has a concern; in many cases reassurance and advice can be offered and admission prevented. But many simply arrive without telephoning.
Calls to the delivery suite were reviewed and it was found that only a quarter were directly related to labour. Seventeen per cent were queries from friends or relatives and 15 per cent were administrative questions.
Midwives on the delivery suite and a clinical manager then conducted a 24-hour snapshot study of activity on the unit, which was followed up by a further study lasting a month.
The 24-hour study revealed that only 57 per cent of activity was with women who were in labour or in the early post-natal period. The remainder of women were either undergoing induction, had come in with a problem or were waiting to be reviewed by a doctor.
The month-long study broadly confirmed these findings. It showed that 41 per cent of women on the unit were not in labour and did not require high-dependency care.Most of these women were there because they had a problem with their pregnancy or because they had delivered but were still waiting for a bed on the maternity wards (see figure).
The mapping exercise produced the following findings:
Between 43 per cent and 57 per cent of women on the delivery suite were not in labour or the early postnatal period.
Thirty-five per cent of women who came to the delivery suite had not telephoned beforehand.
Many of the telephone calls to the unit were not related to labour.
It was clear that systems should be established to divert these women and the telephone enquiries away from the acute delivery suite area.
A midwifery triage service was launched in July 2001. It consists of a 24-hour telephone helpline staffed by midwives, a two-bed assessment room and a small, child-friendly waiting room. It is situated at the entrance to the delivery suite to act as a reception area for incoming women while being close enough to the delivery suite to access acute services if necessary. It is separated from the main clinical area by double doors.
Set-up costs of£15,000 came from a successful bid for re-engineering money from the Department of Health. This paid for some minor building work and provided essential equipment such as fetal heart monitors and a computer.
The triage team is made up of a small number of midwives taken from the delivery suite establishment, supported by healthcare assistants.
They have developed guidelines and protocols in partnership with colleagues in obstetrics and anaesthetics. These allow the midwives to work autonomously and facilitate the midwife-led discharge of most clinical situations. Senior obstetricians are always available for advice or referral of women with complications.
Women are now encouraged to contact the service by telephone initially.Many queries are dealt with without necessitating the journey to hospital.
The objectives of the service are:
to provide an assessment facility for women with symptoms;
to refer women with obstetric complications;
to offer reassurance and advice;
to reduce the demand on acute delivery suite resources;
to provide an out-of-hours pre-arranged assessment service;
to provide a pre-operative service.
The service has now been established for almost a year. It deals with around 250-300 women per month. Staff have experienced major benefits since it opened.Those who work within it feel they have increased job satisfaction and enjoy the autonomy, which helps develop their decision-making skills.
The delivery staff have also noticed the difference and believe the reduction in pressure allows them to concentrate on providing a high standard of care to women in labour or those with high dependency.
It is believed the scheme has reduced unnecessary admissions, though this has yet to be evaluated, and midwives appear to have grown in confidence about their ability to make safe decisions.Certainly, they report that working in this team has given them more chance to reflect on their practice. The consultant obstetricians have been very supportive.
Purists may criticise the centralisation of the midwifery facility and argue that it should be offered in the community - either in, or close to, the woman's home.Community resources are currently stretched to the limit and there may be the danger of duplication, with the mother being referred to the hospital anyway.Domiciliary visits out of hours could leave midwives vulnerable to attack, so these tend to be kept to the minimum, in emergencies only.
Over the next few months, the outcomes will be analysed, together with views from staff and the women who use the service.A further rethink of other activities that occur on delivery is needed to ensure that women in labour get the one-on-one midwifery care they need. l Key points lA review of activity in a delivery suite in an acute hospital found that many women were there for reasons unconnected to labour, or because a bed could not be found in the hospital's maternity wards.
Midwives have established a two-bed assessment room next to the suite and set up a 24-hour telephone helpline.
Women are encouraged to telephone for advice rather than turn up at the unit when they have problems with their pregnancy.
These innovations, which have been in operation for a year, are believed to have reduced pressure on the delivery unit.
Sue Dennett is consultant midwife and Fay Baillie is directorate manager, midwifery, obstetrics, gynaecology and paediatrics, Birmingham Heartlands and Solihull trust.