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A Framework for maternity services in Scotland

Childbirth

This section outlines the care requirements and service planning needed to ensure that women's expectations of a positive birth experience are met.

Local Action

• Women must be given information in a suitable format to allow them to understand that equal access to services cannot always be guaranteed because geographical factors can impact on the services available in their locality. Women must have information to allow them to make informed decisions by balancing risks;
• When planning the location for childbirth the following levels of care model should be considered in the local context: These are developed further in Table 20.

Table 20 Levels of care by location, childbirth

• Regardless of the location of birth, there should be clearly established mechanisms and guidelines for seeking specialist advice. These should include agreed emergency transfer guidelines to a linked secondary or tertiary unit;
• All maternity services should be in a clear and explicit network that identifies the transition of care from different levels and locations;
• The skills of the midwife in the management of normal delivery must be balanced with the specialist expertise which is required for women who may need operative delivery or high dependency care;
• For home births, the lead professional should be identified, who will normally be the midwife;
• There should be a minimum of two professionals present at a planned home birth. One of them should be trained in maternal and neonatal resuscitation;
• An individual action plan, agreed with the supervisor of midwives, must be in place for each home birth. It should outline emergency procedures, including avenues of professional support and emergency transfer;
• Where there is a geographical imperative, community maternity units may be considered for low risk women with a normal pregnancy. In particular, this may provide a model of care for remote and rural areas, offering a local service choice for women in the absence of other options of care, and following discussions with them, on risk and contingency plans for referral if required;
• Every community maternity unit should have a clearly established link - support, advice and transfer - to a consultant-led maternity and neonatal unit. Evidence-based referral and transfer guidelines must be developed, implemented and audited;
• Small consultant-led maternity units should develop and maintain close links with a specified neonatal and larger maternity unit;
• In the absence of specialist neonatal and anaesthetic support, immediate neonatal care in small consultant led maternity units should be provided by appropriately trained professionals. Midwives, nurses and doctors providing a neonatal resuscitation service must be appropriately trained and supported by a programme of regular updates to facilitate the maintenance of skills;
• NHS Trusts should offer key professionals in Acute and Primary Care settings the opportunity to undertake courses such as Advanced Life Support in Obstetrics (ALSO), Paediatric Advanced Life Support (PALS) and Neonatal Advanced Life Support (NALS);
• Consultant-led maternity units without on-site neonatal services (<1,000 births) must make sure that professionals are competent to provide temporary high dependency care and stabilisation before transferring mother and baby. They must also make sure that a local strategy and evidence-based guidelines are in place to support the service;
• Consultant-led maternity units with on site neonatal services (<1,000 births) should care for women with low risk pregnancies and the majority of women with higher risk pregnancies. There should be short-term intensive care facilities available before transferring women to a specialist maternity unit;
• Consultant-led maternity units providing a full range of services appropriate to women with high risk pregnancies should have the following services available (1,000-3,000 births):
  • obstetric;
  • anaesthetic services and access to adult intensive care;
  • neonatal resuscitation, stabilisation and access pathways to neonatal intensive care;
  • midwifery
  • radiology and Imaging;
  • laboratory;
  • blood transfusion.
• Specialist maternity units should care for women with complex pregnancies where expert maternal, fetal, neonatal, anaesthetic and intensive care facilities are based. Specialist maternity units should be equipped with the highest standards of diagnostic imaging and have specialist laboratory support;
• In some instances, a tertiary maternity unit will be the most local and convenient location for the care of women with low risk pregnancies and the environment of care should be tailored accordingly;
• Direct consultant input in the management of high risk pregnancies is required;
• The labour ward must have medical leadership and experience available to provide an agreed standard of care over the 24 hour period;
• All labour wards should have a lead consultant obstetrician and clinical midwife manager;
• A named consultant obstetric anaesthetist should have responsibility for the organisation and management of the obstetric anaesthetic service;
• A named consultant paediatrician with an interest in neonates should have responsibility for the organisation and management of neonatal services;
• Labour ward rounds for women with a high risk pregnancy should be undertaken by the on-call consultant obstetrician at least twice during the day, with a physical or telephone round during the evening;
• All maternity units should have a multi-disciplinary labour ward forum to formalise systems of care appropriate to women's needs;
• Regular multi-disciplinary in-service training sessions on the management of high risk labours including cardiotocograph interpretation should be attended by all professionals involved in delivering care during childbirth;
• NHS Trusts should carry out regular audit to make sure there is maintenance and ongoing improvement of services;
• NHS Boards in remote and rural areas should make sure that adequate and appropriate accommodation is provided for women, and their partners, who need to transfer from home for the birth or in the neonatal period;

Views

What mattered most during my care without a doubt was the emotional care and support. We cannot speak highly enough of them. They went the extra mile for us. It is thanks to them that the baby is here and I am healthy. I can't think of anything they could have done to make things better. They welcomed the whole family. I am sure that the care that I got here prevented postnatal problems of depression. (Lay Interview)

Though I received excellent care throughout I had some concerns in the beginning about not having anaesthetic and paediatric services "on demand", however, I required both for delivery and both were present very quickly. (Lay Interview)

Local Action

• NHS Trusts should use existing workforce planning tools for labour ward staffing and implement the results (MATS and Birthrate Plus); small units should devise their own workforce planning tools;
• NHS Trusts should consider flexible work rotas to facilitate continuity of carer taking into account family/employee friendly policies;
• The needs of the baby must always be considered separately from the needs of the mother;
• All professionals directly involved with care during childbirth should be given appropriate neonatal resuscitation and immediate care training;
• Professionals should give consideration to women's choice in using complementary therapies to alleviate pain and have due regard to the evidence base.

Local Action

• NHS Trusts should promote effective partnership between women and professionals to make sure that care providers do not exert undue influence to direct the pathway of care;
• NHS Trusts should ensure that comprehensive written and oral information is given to, and discussed with, all women and their families which should include an assessment of the advantages and risks to allow them to make an informed choice regarding the location of birth;
• Where women choose to be cared for by an independent midwife, contact should be made with the supervisor of midwives and an "Intention to Practice" form completed. A link should be established with a consultant-led maternity unit at an early stage of the pregnancy;
• In the interests of women, NHS Boards should consider providing honorary contracts to independent midwives to support continuity of care and carer in the event of a woman booked for home delivery being transferred to hospital;
• NHS Trusts should make sure that each woman is given full information about the choices of location available for the birth of her baby should she choose epidural anaesthesia for pain relief during childbirth.

Views

I wasn't offered a choice of where to have my baby. The doctor just said "Where are we having the baby?" and before I could reply, she wrote down and said, "the hospital". (Lay Interview)

I was over my expected date of delivery and I was kept in hospital. I didn't want to be in hospital but felt that everything around the reasons for that decision were explained well. So in the end I felt happy with the decision. But the next day I was told I was going to the labour ward to be induced. I felt that was decided very suddenly and I was quite shocked and not really involved in the choice. (Lay Interview)

Further Work to be undertaken

• A review of the Transport of Critically Ill Neonates is currently being carried out by a sub-group of the Acute Services Review and should inform whether there is a need for a Scotland-wide framework for neonatal transfers;
• A Multi-Professional Working Group led by the Scottish Executive Health Department, should address the emergency transfer needs of mothers, their babies and their partners;
• An Expert Advisory Group on Caesarean Section will report in early 2001 and account should be taken of its findings and recommendations.

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