The midwife-led birthing unit (MLBU) at Norfolk and Norwich University NHS Foundation Trust provides care for approximately 1000 healthy, low-risk women annually. Evidence has indicated that these women were more likely to experience normal birth with fewer interventions in a MLBU rather than in a consultant-led unit, with no changes as to the safety of mothers or babies (Brocklehurst et al, 2011). A risk assessment tool (Appendix 1), based on the best available evidence, is applied on admission to identify women as low-risk and to ensure that choices can be supported.
The MLBU philosophy is to support women's birth choices, focusing on normal physiological processes and avoiding unnecessary medical interventions. In 2012, 41% of women who gave birth at an MLBU experienced a physiological third stage of labour. The third stage lasts from the birth of the baby to the expulsion of the placenta and membranes (National Institute for Health and Care Excellence (NICE), 2014). ‘Physiological management’ awaits spontaneous separation and expulsion of the placenta: no drugs are routinely administered, the umbilical cord is not clamped or cut before the placenta has separated from the uterus and the placenta is birthed by maternal effort (NICE, 2014). Embracing physiology avoids disturbing initial mother-infant interactions important in bonding (Buckley, 2011) and allows physiological transfusion of blood to the neonate, reducing neonatal anaemia caused by under-transfusion (Harris, 2001; Mercer, 2001; Fry 2007, Andersson et al, 2012).
The traditional medical model is reflected in local and national guidance, which recommends active management of the third stage to prevent postpartum haemorrage (PPH) (NICE, 2014). Active management comprises three components: administration of prophylactic uterotonic drugs, the practice of delayed cord practice of clamping, and controlled cord traction (NICE, 2014). Evidence of adverse effects on the neonate prompted a change in recommendations, from the traditional early cord clamping, to delayed cord clamping in active management (NICE, 2014). Although NICE (2014), recommends active management of the third stage, it supports physiological management when chosen by women at a low risk of PPH. The importance of providing and documenting accurate information on the increased risk of haemorrhage, the increased need for blood transfusion and longer third stage is also highlighted.
| Audit standard | Evidence |
|---|---|
| Uterine atony requires uterine massage and clot expulsion. The bladder should be catheterised with a self retaining catheter | Uterine massage and clot expulsion stimulates uterine tone |
| Bleeding continuing or estimated blood loss (EBL) >500mL requires intravenous (IV) access and bloods | Minor postpartum haemorrhage 500–1000mL requires monitoring IV access, crystalloids and bloods (group, crossmatch and clotting) |
| EBL >500mL or symptomatic requires vital signs recording every 15min | Monitoring of vital signs aids recognition of compromise to ensure prompt resuscitation and treatment to prevent deterioration (15 minute blood pressure, pulse, Respirations in minor postpartum haemorrhage (PPH) 500–1000mL) |
| Excessive bleeding requires uterotonics within 10 minutes | Oxytocics initially moving to ergometrine (in absence of hypertension) |
| Woman symptomatic of hypovolaemia resuscitation or EBL >1000mL, transfer to obstetrician within 15 minutes | Major PPH >1000mL requires full protocol of measures |
| If initial treatment fails to arrest bleeding or clinical condition deteriorates, an emergency call should be made to summon assistance | Major PPH >1000mL requires full protocol of measures |
Postpartum haemorrhage
PPH is a recognised complication of childbirth, traditionally defined as estimated blood loss >500mL or any amount sufficient to cause maternal compromise, (Lalonde and International Federation of Gynecology and Obstetrics, 2012; World Health Organization (WHO), 2012). However, WHO (1996) suggests that blood loss ≤1000mL may be considered physiological in healthy women, as the majority will remain well with this estimated volume of blood loss. This audit focused on estimated blood loss >1000mL because of its clinical significance (Griffiths and Howell, 2003; Bais et al, 2004; Cameron and Robson, 2006; Mavrides et al, 2016).
PPH is often unpredictable (Al-Zirqi et al, 2008). Excessive bleeding must be recognised and treated; however, studies repeatedly demonstrate inaccuracy in visual estimation (Bose et al, 2006; Buckland et al, 2006; Karavolos, 2007; Maslovitz, 2008; Yoong et al, 2010). Bose et al (2006) produced images of blood loss to assist estimation but their effectiveness has not been rigorously evaluated. Collection-based methods may also be subject to inaccuracy due to body fluid contamination (Schorn, 2010), although Lilley et al (2015) showed a correlation between weight of blood soaked swabs and fall in haemoglobin, which may assist estimation in land births. Approximately half of births at the MLBU are waterbirths and some linked these anecdotally to the high incidence of PPH. Estimated blood loss is obviously challenging in waterbirths, as midwives must recognise PPH with changes in water opacity (Harper, 2000). Otigbah et al (2000) suggested that waterbirth was associated with increased risk of PPH, but Damodaran et al (2010) reported a major PPH in only 1.3% of waterbirths.
Rationale
The incidence and severity of clinically significant PPH (>1000mL) among low-risk women at the MLBU was an issue. Individual cases were discussed in multidisciplinary forums, where concern was expressed about the management of the third stage of labour and midwives' management of excess bleeding. Concern was also expressed about whether midwives gained informed consent for third stage management. It was therefore important to explore whether midwives undertook physiological management based on guidance, and whether excess bleeding was promptly recognised and treated to reduce the severity of PPH (Draycott et al, 2008; NICE, 2014).
MLBU midwives will understand the tension that exists between the competing philosophies of medical and midwifery care, which can lead to an ‘us and them’ culture, characterised by criticism and negativity (Kirkham, 2003). The challenge for the author, the MBLU team leader, was to robustly defend the philosophy and practice of midwifery-led care using appropriate evidence, while also being open to the possibility that criticisms might be justified.
The incidence of clinically significant PPH (>1000mL) (WHO, 1996; Mavrides et al, 2016) at the MLBU in 2012 was 5%, with 1% >2000mL. This is significantly higher than the 1% reported in a similar UK MLBU cohort (Burns et al, 2012), or among low risk populations of Australian and Dutch women, where rates were reported at 2% and 4% respectively (Dahlen et al, 2013; Bais et al, 2004). The UK incidence of major PPH is 3.7% (Norman, 2011); however, this varies considerably, in part due to a lack of standardised definitions (Brace, 2007). Physiological third stage management was common on the MLBU. Begley et al's systematic review (2011) indicated that for women at low risk of PPH, active management at the time of birth did not reduce the likelihood of significant PPH (>1000ml) compared to physiological management. Although this suggests that women at a low risk of haemorrhage should be able to safely choose physiological management, the high incidence of significant PPH among low-risk women warranted further investigation to confirm both the adequacy of informed consent for third stage management and safe standards of midwifery practice.
Aim
To explore the third stage of labour and initial management of excess bleeding in women giving birth at the Norfolk and Norwich University Hospital MLBU.
Method
Clinical audit was selected as a quality improvement process to enable systematic appraisal of care against explicit criteria, so that changes could be made and further monitored to confirm improvement (NICE, 2002). A retrospective audit of health records was undertaken to determine the incidence and severity of PPH and any relationship between third stage management and PPH in a sample of 524 women who gave birth at the MLBU between January and June 2013. The audit was registered and approved by the Trust audit department. The audit reviewed records of women who experienced PPH to determine whether risk factors were evident at the time of birth, to allow comparison with Begley's systematic review (2011). The audit also considered the type of birth because of the criticisms that implicated waterbirth.
A literature review was conducted in 2012 to define good practice for the prevention and treatment of excess bleeding in low-risk women, and to develop evidence-based standards to enable audit of practice. The standards used reflected local and national recommendations (NICE, 2014; Mavrides, 2016). These were reviewed before the 2015 re-audit to reflect the updated NICE 2014 guidelines, but no amendments to the standards were required. Audit standards and the underpinning evidence are detailed in Figure 1. The audit was undertaken using a standardised audit proforma.
Results
Incidence
The incidence and severity of PPH is displayed in Figure 2. PPH >1000mL occurred for 21 women (4%). Of these, 6 women (1%) had estimated blood loss ≥2000mL. The reported UK incidence of major PPH is 3.7% (Norman, 2011), with lower rates reported for other low risk populations (Burns et al, 2012; Dahlen et al, 2012).
Risk factors
Although all women met the MLBU admission criteria, risk factors for PPH evident at the time of birth and in the early postnatal period were frequently overlooked. Risk factors identified are highlighted in Figures 3 and 4. Retained placenta was noted in 4 (66%) of the women who experienced PPH ≥2000mL.
Standards of care
Deficiencies in care were identified in 56% of records. The main deficiencies are detailed in Figure 5 and could be summarised as: inadequate monitoring of women (35%), failure to treat promptly with a primary uterotonic (15%), and delayed transfer (59%) of women. When the unit opened in 2011, an arbitrary transfer standard of 15 minutes was established. This standard was used to identify delay.
Third stage management
The risks and benefits of both active and physiological management should be discussed (Royal College of Midwives, 2012). Midwives often overlooked risk factors when planning third stage management and frequently failed to record informed consent, which was only evidenced in 49% women who experienced PPH. This was a particularly important finding, as significant PPH >1000mL was more common following physiological management of the third stage between January and June 2013. PPH by third stage management is detailed in Figure 6.
Recommendations
Audit findings and recommendations were shared with the MLBU team, who were encouraged to generate realistic, practice-based solutions. The following areas were highlighted:
Recommendations for third stage of labour
Responses to recommendations
Holding case discussions, highlighting risk factors and reviewing care facilitated debate and learning. Some of the team questioned whether there might be reluctance from some midwives to recognise and treat excess bleeding promptly, suggesting that some midwives may hope that it would settle. This arose from a faith in physiology and fear of disturbing the mother-infant dyad. It was important therefore to highlight how this might inadvertently lead to unsafe practice among the team.
Agreeing a standardised pathway with the MLBU team helped to clarify immediate management of excess bleeding (Figure 7). Midwifery practices associated with both active and physiological management of the third stage of labour were reviewed, and literature was displayed to promote discussion and debate. PPH boxes (Figure 8) were developed to contain all that was required to ensure prompt and safe treatment of excess bleeding.
Re-audit in 2015
After allowing time for new practices to be embedded, the same audit tool and methodology were used to review significant PPH >1000mL over 6 months between January and June 2015 (Figure 9). On this occasion, the sample focused only on PPH >1000mL because of its clinical significance.
Third stage management
Between January and June 2015, 492 women gave birth at the MLBU. There was a shift to management of the third stage, with a marked improvement in documentation of informed discussions of third stage management options, from 49% in 2013 to 78% in 2015 (Figure 10). Trends in third stage management had also changed, with 27% of women opting for physiological management and 73% for active management (Figure 11).
Incidence following 2015 audit
The incidence of PPH >1000mL was 14 women (2.8%), of whom 3 women (0.6%) bled ≥2000mL. PPH >1000mL occurred after physiological third stage for 4 women (3%) and for 10 women (2.8%) following active third stage. Trends in PPH during the audit are displayed by third stage management in Figure 12.
Review of adherence to audit standards in 2015
Improvements were identified following review in 2015. Midwives were recognising risk factors and considering them in discussions about third stage management. Although compliance with undertaking appropriate vital signs had deteriorated in the re-audit, this was not reflected in the overall quality of PPH treatment, where improvements were apparent in IV cannulation, administration of uterotonics and speed of transfers to obstetric care when appropriate. Awareness of risk factors may have contributed to these improvements. Although Figure 13 appears to demonstrate a reduction in the administration of secondary uterotonics, this may have reflected clinical decisions to administer ergometrine as a secondary uterotonic in response to initial excess bleeding.
Conclusion
Audit was used to identify deficiencies in midwifery care surrounding risk assessment, third stage management and the recognition and treatment of excess bleeding. Engaging the whole team when reviewing the findings resulted in ownership of the results and the generation of creative solutions that were readily adopted. Re-audit suggested that changes were associated with improved outcomes for women, such as a reduction in the incidence of PPH >1000mL. It was satisfying to see similar outcomes to the literature in relation to risk of significant PPH (Begley et al, 2011), following the initial audit. Raising awareness of risk factors in the MLBU population, and using this information to inform third stage management is likely to have been significant in achieving this improvement, demonstrating the importance of carefully reviewing practice to ensure that criteria match those of research in order to anticipate the same results. Re-audit is now recommended to ensure sustained improvement particularly as rotation means that the MLBU workforce has changed.