Third trimester scan demand across the UK grew by 27.9% between 2016 and 2018, (Widdows et al, 2018). Reflecting this national trend, the Kingston Hospital NHS Trust maternity unit saw a 32% increase from 2015-2018 (Figure 1). The likely reason for this rise in third trimester scan demand relates to the recommendations of the Saving Babies' Lives care bundle, version 1 (NHS England, 2016). This was produced in response to the UK stillbirth rate being higher than other comparable European nations, at 4.7 per thousand births (Office for National Statistics, 2014). The report's recommendations arose from the NHS England Mandate Objective to halve the stillbirth rate by 2030 (NHS England, 2014) by focusing on four key elements of maternity care. Two of these had a direct impact on the demand for third trimester scans: increased fetal surveillance for fetal growth restriction and increased awareness of reduced fetal movements.
At the Kingston maternity unit, the demand for unscheduled scans grew from 1–3 daily to 5–20 every day and the existing ultrasound service was often overwhelmed. The sonographers struggled to triage appropriately, were squeezing scans into already full scan lists and increasing the numbers of referrals to day assessment unit, triage and the antenatal clinic for post-scan management. Simultaneously, the unit had trained its first midwife-sonographers in 2013 and 2016, the authors of this article. Both had worked in the day assessment unit for several years previously and were familiar with high-risk pregnancies. After qualifying as midwife-sonographers, both continued to work one shift a week in the day assessment unit and the rest of their shifts in ultrasound.
Initially, the midwife-sonographers practised in the same way as the sonographers, performing the usual mix of routine screening scans and third trimester scans. However, as the demand for unscheduled scans rose, they increasingly found themselves managing the daily triaging of scan requests. With their combined knowledge of obstetric and ultrasound guidelines, the midwife-sonographers could triage the daily extra scan requests quickly and effectively. However, ultrasound capacity remained a problem and the increasing volume of scan requests presented huge challenges to safe and effective timing of scans and appropriate post-scan management. The potential risk that was incurred by the sheer volume of scan requests crystallised the idea that the midwife-sonographers could not only be useful in triaging the scan requests, but could also perform the scans in a ring-fenced scheduled list on a daily basis.
Summary
In January 2019, a midwife scan clinic was started at Kingston Hospital maternity unit. The unit delivers approximately 5000 babies annually in an obstetric-led delivery suite, a midwife-led birth unit and in a well-established homebirth service (NHS Digital, 2021). The midwife scan clinic has been running four afternoons a week since it was established to provide unscheduled third trimester scans.
This clinic is distinct from a routine scan list in that the appointments are ring-fenced for unscheduled third trimester scans and post-scan management occurs simultaneously. Three midwife-sonographers triage all scan requests, perform the scans and provide post-scan management directly after the scan.
Evaluation of the first 12 months found that the clinic had performed 1578 scans for the full range of third trimester indications (Figure 2) and 292 post-scan appointments were avoided as a result of women being seen by midwife-sonographers at the service. The women experienced a more streamlined service with a reduction in multiple appointments. Those who required serial growth scans were likely to see the same midwife-sonographer, ensuring continuity of care. The increasingly central role that ultrasound plays in fetal surveillance, means that the combined skills of midwives who scan, can be harnessed to improve safety and efficiency as well as reducing costs.
This article explores the establishment of this midwife scan clinic at Kingston Hospital NHS Trust, which was introduced to manage the increased demand for third trimester scans. The statistics used to inform this article are derived from local data collected, stored and analysed during 2019 by the midwife-sonographers. This quality improvement project was overseen by Radiology and Maternity management.
Setting up the midwife scan clinic
A proposal document was submitted to Maternity and Radiology management, both of whom were supportive of the idea. It was decided to identify one scan room on four afternoons a week for the clinic, providing 32 slots weekly. Both midwife-sonographers arranged their working pattern so that the lists were slightly longer than a standard list to accommodate as many unscheduled third trimester scans as possible. The slots are scheduled at 30 minutes to allow time for the scan and post-scan management. All scheduled third trimester scans remain on routine lists, such as those for gestational diabetes, placental site at 32 weeks, maternal medical history. At the start of each shift, one of the midwife-sonographers triages all scan requests and allocates slots according to clinical guidance. Furthermore, the relationship between the day assessment unit and the midwife scan clinic is flexible and supportive; if the unit require an urgent scan, it can often be arranged within an hour or two and when the midwife-sonographers need to refer a woman to the unit following a scan, their request is accommodated without delay. Having midwife-sonographers who also work in the day assessment unit has enhanced the safety and effectiveness of the clinic because of their familiarity with guidelines relating to high-risk pregnancy. A third midwife-sonographer qualified in 2019 and joined the team.
Evaluation of the first year
Review of the clinic's data at 6 months was encouraging. Data collection continued for a full 12 months, including indication for scan, scan results and post-scan management. During 2019, of the 1578 scans performed in the clinic, the majority were for reduced fetal movement and small for gestational age, reflecting the increase in scan demand as a result of the recommendations of Saving Babies' Lives (NHS England, 2016; 2019). Other indications for scans can be seen in Figure 2.
Reduced fetal movements
The link with reduced fetal movement and stillbirth is long established (Confidential Enquiry into Stillbirths and Deaths in Infancy, 1997) and the need for ultrasound assessment as part of a package of fetal surveillance is emphasised by Saving Babies' Lives (NHS England, 2016; 2019). All requests for reduced fetal movement were given a scan slot within the 48 hour timeframe required by the local reduced fetal movement guideline. A standard growth scan was performed, including umbilical and middle cerebral artery Dopplers. If scan findings were normal, the midwife-sonographer would then review the previous cardiotocograph, the woman's notes and recent admissions to the day assessment unit/triage and discuss the current situation with the baby's movements and document a plan. This resulted in 65% of women being scanned for reduced fetal movement going home directly from the scan room, rather than being referred to the day assessment unit, triage or antenatal clinic (Figure 3). This represents a significant reduction in multiple appointments and a more streamlined service for women. Furthermore, multiple episodes of reduced fetal movement in late pregnancy are associated with a further increase in the risk of stillbirth (Scala et al, 2015). The midwife scan clinic performed repeat scans on many women with ongoing reduced fetal movement, providing the added reassurance of continuity of care (NHS England, 2017). Over a third (34%) were referred for cardiotocograph and review because of ongoing reduced fetal movements and/or other findings.
Small for gestational age
Small for gestational age was the most common indication for referral to the midwife scan clinic and a likely reflection of the guidance from Saving Babies' Lives, which recommends increased and more robust use of symphysis fundal height charts at routine antenatal appointments (NHS England, 2016; 2019) and referral for a scan where symphysis fundal height plots below the 10th centile. A growth scan with fetal Dopplers was performed and 66% of women were discharged back to routine care. This did not impact on multiple appointment numbers, as sonographers have always been able to send women home if scan findings are normal after a scan for small for gestational age. However, midwife-sonographers are well placed to recognise the distinction between small for gestational age and fetal growth restriction, which aids appropriate post-scan management. There is a growing body of evidence that suggests fetal growth restriction may be the most significant risk factor for stillbirth, (Blencowe et al, 2016) and the Saving Babies' Lives recommendations reflect this (NHS England, 2016; 2019). Furthermore, 11% of women were booked for repeat scans. The reasons for this varied, but most commonly, a woman had been assessed as having a constitutionally small baby at a fetal medicine scan and she was referred back to the midwife scan clinic. Repeat scans were booked directly into the midwife scan clinic, ensuring continuity of care. Continuity of sonographer for serial growth scans is considered to assist in more accurate assessment of growth velocity, by removing inter-operator discrepancy (Dyer and Chudleigh, 2020). For the 23% of women where fetal growth restriction and/or abnormal Dopplers were identified and referral was required, the midwife-sonographers were able to explain the implications of the findings before referral. If there were likely to be delays being seen in the day assessment unit or triage, the midwife-sonographer would perform blood pressure measurement, urinanalysis, take bloods and admit directly to the antenatal ward if indicated. These data are shown in Figure 4.
Large for gestational age and/or polyhydramnios
Two thirds (66%) of women referred for large for gestational age had normal findings. As with small for gestational age referrals, sonographers have always been able to refer these cases back to routine care without midwife input, so no impact was noted in terms of reduction of appointments. However, 34% required referral either for blood sugar monitoring to the diabetic clinic or for a fetal medicine scan. When macrosomia or polyhydramnios was identified, the necessary serial growth scans were booked into the midwife scan clinic, ensuring continuity of care (NHS England, 2017). These data are displayed in Figure 5.
Breech presentation after 36 weeks
An unanticipated outcome of the midwife scan clinic was the improvement for women with breech presentation at term. Traditionally, this group of women would have multiple appointments around the time of diagnosis of breech presentation. When a breech presentation was suspected at a routine appointment, the woman was referred to the day assessment unit for a presentation scan, (most day assessment unit midwives at Kingston are trained in basic presentation scanning). She would then have a growth scan a few days later, following which she would be referred back to the unit or to the antenatal clinic, either on the day or a day or two later, to discuss ongoing management. After establishment of the midwife scan clinic, a woman with a confirmed breech at term is referred directly to the midwife scan clinic, often on the same day. The midwife-sonographer explains the scan findings, implications and options for delivery as well as booking an appointment for external cephalic version, if appropriate, all at the same time as the scan. During 2019, 53 women with breech presentation were seen in the midwife scan clinic, most of whom were referred directly to the breech clinic, saving 39 appointments and providing a more streamlined service for the women (Figure 6).
Scans requested by the safeguarding team
Another unexpected outcome of the midwife scan clinic was that a relationship was soon established with the safeguarding midwives. A proportion of women under the care of safeguarding teams have an erratic uptake of antenatal care and routine scans are sometimes missed (Downe et al, 2009). Because the midwife scan lists, by their nature, are filled at the last minute, it was possible for the safeguarding midwives to request a scan on the day, when a woman happened to turn up at the maternity unit. To some extent, this accounts for the higher than expected number of routine 12 and 20 week scans that were performed in the midwife scan clinic. Figure 2 shows that 305 routine scans were performed in the clinic during 2019 and this includes many 12 and 20 week scans for women who had missed their scheduled scan, booked late or transferred from elsewhere, many of whom were being cared for by the safeguarding team. Although this was not a function of the midwife scan clinic that was planned or anticipated, it has become an effective way of ensuring scans that otherwise might be missed are performed in this group of women. Furthermore, vulnerable women who benefit from continuity of care were also able to have continuity of sonographer by booking all their scans in the midwife scan clinic.
Scans for inpatients
The flexible nature of the midwife scan clinic has streamlined access to urgent ultrasound for inpatients. Approximately 70 scans were done in the midwife scan clinic during 2019 on inpatients for a variety of indications, most commonly new onset severe pre-eclampsia, significant vaginal bleeding, premature rupture of membranes and maternal illness (this category grew significantly during the COVID-19 pandemic in 2020/21). Other requests included the need for an estimated fetal weight to decide on the need for in utero transfer in cases of threatened preterm labour and dating and placental site in unbooked women. Direct communication from delivery suite staff to the midwife sonographers was easy and the scan added to a list on the day of request.
Scans for women who decline induction
The midwife scan clinic is largely concerned with high-risk pregnancies, but also plays a role in lower risk pregnancies. A proportion of women who are recommended induction of labour for post maturity, raised uterine artery Dopplers or maternal age, but who have otherwise low-risk pregnancies, are reluctant to be induced. These women will have seen an obstetric doctor and have a plan of care that includes a scan (National Institute for Health and Care Excellence, 2008). If seen in the clinic, the scan is followed by further discussion of their options, sometimes a ‘sweep’ and if a clearly documented plan has already been made, they can go home without referral to the day assessment unit, triage or the antenatal clinic. Numbers were small during 2019; however, the growing success of the unit's homebirth service (particularly during the pandemic) has seen an increase in women wanting to delay induction of labour in the hopes of giving birth at home or in the midwife-led birth unit. Direct communication between homebirth midwives, the obstetric consultant with the homebirth team and the midwife-sonographers has streamlined this process and improved timely access to scans.
Cost implications
There were no cost implications to setting up the midwife scan clinic as it utilises existing staff, clinic space and equipment. Approximately 292 appointments were avoided during the first year as a result of the midwife-sonographers providing this clinic and this represents a financial saving. However, in order to maintain the service, a commitment to training midwives in ultrasound is necessary. It is widely known that most midwives who train in ultrasound do not maintain their midwifery practice because of pay differentials and they practice solely as sonographers. Enlightened maternity management at Kingston matched the ultrasound pay scale for the midwife-sonographers for their midwife shifts, (in return for some band 7 operational management in the day assessment unit) allowing them to practice effectively as midwife-sonographers. Maintaining the midwife scan service into the future will incur the cost of training midwives to scan and pay-band matching for midwifery shifts. However, this is likely to be offset by the financial saving incurred by reduction in appointments that results from a midwife scan clinic.
The midwife scan clinic: a quality improvement initiative
In March 2019, NHS England issued a second version of Saving Babies' Lives (NHS England, 2019) which reiterated the focus on fetal growth restriction and reduced fetal movement in reducing stillbirth rates and placed renewed emphasis on continuity of carer as promoted by the National Maternity Review (NHS England, 2017). In light of this, the launch of the midwife scan clinic seemed a timely method of resolving the issues of unscheduled third trimester scan demand as well as providing continuity of care in higher risk pregnancies.
In January 2020, the results of evaluation of the midwife scan clinic's first year were presented at an ultrasound/fetal medicine multidisciplinary team meeting and there was universal agreement that it should continue. A patient survey took place in November 2020 (delayed by COVID-19) and feedback was very positive (Figure 7). The initial impetus for setting up the clinic arose from the increased ultrasound demand caused by implementation of the Saving Babies' Lives recommendations. Although it is not possible to establish a direct link (Widdows et al, 2018), stillbirth rates have fallen across England since its implementation (Office for National Statistics, 2017) and this is also the case at Kingston. Multiple factors have contributed to this local reduction in perinatal mortality and the clinic has played a small but positive part in a much bigger picture. It has proved to be effective and financially viable, as well as producing unexpected benefits for women with breech presentation, women under the care of the safeguarding team and urgent scans requested for inpatients.
Challenges
The midwife scan clinic does not have the capacity to accommodate all urgent third trimester scans. During 2019, approximately 600 urgent extra scans were added to routine scan lists or to overtime lists. Equally, 300 routine 12 and 20 week scans were performed in the midwife scan clinic. With the exception of routine scans for women under the safeguarding team, this imbalance needs to be rectified. To retain and extend this service, a commitment to training midwives in ultrasound and accommodating them to retain some midwifery practice is required. Furthermore, a midwife scan service will need to be flexible in the face of new developments in fetal surveillance; such as screening at 12 weeks for fetal growth restriction (Rolnik et al, 2017) and the implementation of a universal 36 week scan (Henrichs et al, 2019), both of which may impact on how and when ultrasound is used in the third trimester.
Conclusions
At Kingston, the impact of increased demand for third trimester scans that arose as a result of recommendations of Saving Babies' Lives has been met by setting up a midwife scan clinic. This quality improvement initiative uses the combined knowledge and skillset of midwife-sonographers and has proved a safe and effective way of triaging urgent scan requests, performing the scan and providing post-scan management. It has reduced numbers of appointments, streamlined the service for women and had unexpected benefits in the care of women with breech presentations and vulnerable women.
As the midwife scan clinic is responsive to urgent clinical need, it provides timely ultrasound capacity for high risk inpatients, facilitated by good communication with the day assessment unit, delivery suite and triage staff. In order to retain and expand this service, commitment to training midwives to scan and facilitating them to simultaneously maintain their midwifery practice will present challenges. With ultrasound playing an increasingly central part in fetal surveillance, the role of midwife-sonographer bridges a gap by combining midwifery and ultrasound skills in the safe and effective provision of third trimester scans.
Key points
- The Saving Babies' Lives care bundles have precipitated a significant increase in demand for unscheduled third trimester ultrasound.
- Third trimester ultrasound plays an increasingly central role in fetal surveillance: midwife-sonographers are well placed to manage this workload safely and effectively.
- Midwife scan clinics are responsive to urgent clinical need and therefore provide timely ultrasound capacity for high-risk inpatients and patients under the care of the safeguarding team.
- Provision of an ultrasound appointment with a midwife-sonographer can streamline provision of care where indication for a scan is reduced fetal movement, small for gestational age or breech presentation at term.
- A midwife-sonographer is distinct from a midwife who scans. To achieve the optimum service from a midwife trained in ultrasound, they should be supported to maintain their midwifery practice alongside their ultrasound practice.
- Investment in midwife-sonographers is likely to prove cost effective by reducing the need for multiple appointments.
CPD reflective questions
- How has your maternity unit managed the increase in demand for third trimester scans following the Saving Babies' Lives recommendations?
- When a woman requires a scan following an episode of reduced fetal movements, what timeframe would you expect the scan to occur in? What would you do if a scan was not available in the correct timeframe?
- When you are reviewing a scan report after an episode of reduced fetal movements, which aspects of the scan should you be considering?
- What is the purpose of fetal Doppler studies at a third trimester scan?
- Apart from confirming presentation, what is the rationale for ultrasound assessment in a breech presentation after 36 weeks?