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Guideline for admission to midwife-led units in Northern Ireland and Northern Ireland Normal labour and birth care pathway

  • This Guidelines for Nurses summary has been adapted from the original guidance to focus specifically on the needs of the midwife, please refer to the original guideline for more information: www.rqia.org.uk/RQIA/files/3a/3a7a37bb-d601-4daf-a902-6b60e5fa58c2.pdf

  • It is the editorial policy of Guidelines for Nurses not to use proprietary drug names, however, an exception has been made for this summary to prevent any confusion relating to drug combinations and drug delivery systems recommended 

Planning place of birth

  • This guideline predominantly relates to women with a straightforward singleton pregnancy(*) at the point of labour(†)

  • It is important to note that at each point of maternity care, all women should be assessed to ensure that they are receiving care from the most appropriate professional, which may involve:(‡)

    • continuing with midwife-led care (MLC)
    • being transferred to consultant-led care or
    • being transferred back to MLC, in particular, women who have been referred for investigation(s) or treatment which has been resolved
  • If there is any uncertainty, multidisciplinary discussion is necessary, with appropriate documentation
  • Further clarification with regard to place of birth can be facilitated by a senior midwife

Planning births within midwife-led units (MLUs)

  • The following leaflet can be brought to the attention of women and their partner/significant other to aid their decision making and to plan to birth in a MLU: www.rqia.org.uk/RQIA/files/71/71cffe60-dd2d-405d-bd86-5728f5623fab.pdf

  • Specific criteria for planning birth within MLUs is detailed below—Box 1 relates to freestanding midwifery units (FMUs) and alongside midwifery units (AMUs) and Box 2 relates to AMUs only(§)

Box 1: Criteria for planned birth in any midwife-led unit (freestanding midwifery units and alongside midwifery units)

  • Maternal Age ≥16 years and ≤40 years
  • Body mass index at booking ≥18 kg/m2 and ≤35 kg/m2(l)
  • Last recorded Hb≥100g/l
  • No more than four previous births
  • Assisted conception with clomifene or similar
  • Spontaneous rupture of membranes ≤ 24hours and no sign of infection
  • Women on Tier 1 of the South Eastern Health and Social Care Trust Integrated perinatal mental health care pathway(¶a)
  • Threatened miscarriage, now resolved
  • Threatened preterm labour, now resolved
  • Suspected low lying placenta, now resolved
  • Medical condition that is not impacting on the pregnancy or the woman’s health
  • Women who have required social services input and there is no related impact on the pregnancy or the woman’s health
  • Previous congenital abnormality, with no evidence of reoccurrence
  • Non-significant (light) meconium in the absence of any other risk(¶b)
  • Uncomplicated third degree tear
  • Serum antibodies of no clinical significance
  • Women who have had previous cervical treatment, now term

Box 2: Criteria for planned birth in alongside midwifery units only

  • Maternal age <16 years or >40 years(¶c)
  • Body mass index at booking ≥35 kg/m2 and ≤40 kg/m2 with good mobility
  • Last recorded Hb >85g/l(¶d)
  • No more than five previous births(¶e)
  • In vitro fertilisation pregnancy at term (excluding ovum donation and maternal age >40 years)
  • Spontaneous rupture of membranes >24 hours, in established labour and no sign of infection
  • Women on Tier 2 of the South Eastern Health and Social Care Trust Integrated perinatal mental health care pathway, following individual assessment(¶f)
  • Previous postpartum haemorrhage, not requiring blood transfusion or surgical intervention
  • Previous extensive vaginal, cervical, or third degree perineal trauma following individual assessment
  • Prostaglandin induction (administered in accordance with relevant summaries of product characteristics) resulting in the onset of labour(¶g)
  • Group B Streptococcus positive in this pregnancy with no signs of infection(¶h)

Notes relating to planning place of birth

(*) Straightforward singleton pregnancy, is one in which the woman does not have any pre-existing condition impacting on her pregnancy, a recurrent complication of pregnancy, or a complication in this pregnancy which would require on-going consultant input, has reached 37 weeks gestation and ≤ term +15

(†) The Northern Ireland Normal labour and birth care pathway provides an evidence-based framework for normal labour and birth

(‡) It is the responsibility of the professional undertaking the assessment to document in the maternity care record the reasons for change of lead-maternity care professional

(§) FMU—freestanding midwife-led unit; AMU—alongside midwife-led unit (i.e. adjacent to consultant-led unit)

(l) Women with a body mass index of 16–18 kg/m2 require medical review to assess suitability of birthing in a MLU

Additional supporting midwifery practice recommendations

(¶a) South Eastern Health and Social Care Trust (SEHSCT, 2013) Integrated perinatal mental health care pathway Northern Ireland:

’Tier 1—women with mild depressive illness, anxiety, adjustment disorders, and other more minor mental illnesses associated with pregnancy or the postnatal period are unlikely to require referral to psychiatric services. In general, they can be managed within the primary care team, by their own GP, health visitors, and practice-based counsellors if required. Social factors should always be considered and social support offered. Most of these women will not require medication’ (page 3)

(¶b) Definition of Significant Meconium (NICE. Intrapartum care for healthy women and babies. NICE Clinical Guideline 190. NICE, 2014. Available from: nice.org.uk/cg190):

dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing lumps of meconium’ (page 32)

(¶c) Women who are aged >40 years and ≤43 years and wish to give birth in an AMU should be no more than 40 weeks gestation. Primigravid women who are >40 years of age and women who are 44 years and older also require individual assessment with a consultant obstetrician. In the case of a pregnant teenager who is under 16 requiring intravenous fluids in labour, the paediatric fluid protocol must be followed, and care transferred to a consultant-led unit

(¶d) A woman presenting with last recorded Hb <100g/l requires a repeat full blood count at point of admission. If rechecked Hb is <100g/l, secure intravenous (IV) access, take blood, and send to laboratory for group and hold. Then follow the Northern Ireland Normal Labour and Birth Care Pathway for active management of third stage (available from: www.rqia.org.uk/RQIA/files/0b/0b9d5aee-0f80-47e6-8967-0c34216200af.pdf)

(¶e) A woman with more than five previous births should normally have IV access secured (on admission), blood taken and sent to laboratory for Group and Hold, and follow the Northern Ireland Normal Labour and Birth Care Pathway for active management of third stage (available from: www.rqia.org.uk/RQIA/files/0b/0b9d5aee-0f80-47e6-8967-0c34216200af.pdf)

(¶f) South Eastern Health and Social Care Trust (SEHSCT, 2013)Integrated perinatal mental health care pathway Northern Ireland:

Tier 2—these are women with more significant illness who may require medication as well as some form of psychological intervention. In [some Trusts] women may be referred to antenatal perinatal mental health clinic. However, some women may be managed by their own GP, midwife/health visitor. If a significant illness develops and if GPs have concerns about prescribing in pregnancy or in the postnatal period, they should be referred to Mental Health Services via the Mental Health Assessment Centre. The referral will then be seen as a priority, triaged, and forwarded to the relevant team depending on a woman’s past mental health history, current mental health service input, and severity of illness. At this level most of the referrals will be assessed by the assessment centre staff, which can include assessment by a psychiatrist if it is deemed appropriate. Medication may be started or a brief focused psychological intervention may be offered. In this event those women who are within midwife-led services will be referred to a consultant obstetrician due to the medical management needed of their mental health condition’ (page 3)

(¶g) A woman who has gone into labour following induction with either one Propress® or two Prostin® only

(¶h)  Women that are Group B Streptococcus positive in current pregnancy require IV antibiotics in labour as per NICE Clinical Guideline 149 Neonatal infection (early onset): antibiotics for prevention and treatment  (available from nice.org.uk/cg149). In the absence of a midwife prescriber, the doctor on call should be consulted to prescribe antibiotics as per guideline

In utero transfer

  • When transferring a woman and/or baby from MLU to a consultant-led unit, document the evidence, rationale, and collaborative communication held with colleagues

  • In addition, complete the Regional In Utero Transfer Proforma (available at www.rqia.org.uk/RQIA/files/b8/b8d90f30-8fa0-4a83-aef7-6e0c1d52d6c5.pdf); document the time of decision, time of transfer, and measures taken in the event of delay (MLU version January 2016)

Northern Ireland Normal Labour and Birth Care Pathway*

Topics for discussion and initial assessment

Woman/partner/significant other Information

  • Following discussion with the woman/and her partner/significant other, a normal labour and birth care pathway will be designed that fits the woman’s needs and values

  • There will be ongoing discussion with the woman and her partner/significant other during the woman’s admission, labour, and birth

  • If as an individual, the woman’s health requirements vary from those outlined in this pathway, members of the maternity care team should discuss this with the woman and other members of the team (if appropriate) and adapt the care given accordingly

  • The woman will be involved in all discussions and decision-making surrounding her care 

Staff Information

  • This Pathway aims to provide a structured, evidence based framework for normal labour and birth. It is not intended to be prescriptive but should act as a guide and encourages clinical judgment to be used and documented in partnership with the woman/and her partner/significant other

  • Each step of the pathway must be signed off as care is provided. Anyone completing any part of the document must ensure that it is secured within the regional maternity handheld records and sign the signature sheet

  • Remember to complete venous thromboembolism assessment and review the woman’s Group B Streptococcus status

Active phase of labour—first stage

Figure 1: Active phase of labour—first stage

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Second stage of labour

Figure 2: Expected progress in second stage

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Third stage of labour

  • Third stage of labour may be managed actively or physiologically based on individual risk assessment and maternal choice.

  • Physiological measures to aid expulsion of placenta include:

    • ensuring the bladder is empty

    • encouraging the mother to breastfeed her baby to aid expulsion of placenta

    • encouraging maternal effort to expel the placenta

    • encouraging the mother to adopt an upright position

  • If there are no midwifery concerns and physiological management is planned it can proceed for up to 1-hour duration without the need for active intervention. However, if physiological management is planned or commenced and intervention is needed, the third stage of labour must be managed actively 

Figure 3: Expected progress—third stage of labour

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*Based on the SE Trust, Belfast Trust, and Welsh Integrated care pathway for normal labour© Northern Ireland Normal Labour and Birth Care Pathway

full guideline available from…

www.rqia.org.uk/RQIA/files/3a/3a7a37bb-d601-4daf-a902-6b60e5fa58c2.pdf

Guidelines and Audit Implementation Network. Guideline for admission to midwife-led units in Northern Ireland and Northern Ireland normal labour and birth care pathway. January 2016.

For more information please contact: Dr Maria Healy, Chair, Project lead and Main author, Lecturer in Midwifery (Education), Queen’s University Belfast, maria.healy@qub.ac.uk; Dr Patricia Gillen, Project Lead and Main author, Head of Research and Development for Nurses, Midwives and AHPs Southern HSC Trust/ Lecturer, Ulster University, patricia.gillen@southerntrust.hscni.net

 

First included: September 2017.