Incident reporting at Birmingham Women's Foundation NHS Trust identified an increase in the numbers of babies born before the arrival (or attendance) (BBA) of a midwife in both an unplanned or planned environment. An increase in workload following BBA within the midwife-led birth centre was also recognised. Supervisors of midwives (SOMs) recognised this and an audit to review BBAs in detail was undertaken.
The Trust is a large inner-city tertiary referral hospital serving over 8000 births with a multi-cultural population. Located centrally, most women live within a 10 mile radius of the hospital.
Regionally, because of shortages in midwifery resources, ambulance services are called to all BBAs and have been for several years (Local Supervising Authority (LSA), 2013). Consequently, all women who experience BBA are routinely transferred to hospital via ambulance. Although providing an ambulance solution to midwifery shortages, ‘transferring all women to hospital’ will inevitably have an impact on the women's choice, experience, and the care of women needing hospitalisation because it is clinically required.
Locally, it was becoming evident that many women seen at the birth centre following their BBA often required very little actual midwifery care. However, delays often occured for these women while other women at the birth centre received one-to-one care in labour. These delays included perineal inspection and suturing, if required, and depending on the time of day, availability of the neonatal physical examination (NIPE), which affected the women's overall length of stay.
It has been suggested that failure to maintain body temperature poses a significant risk to the baby following BBA (Loughney et al, 2006). It is already recognised that skin-to-skin contact for babies is considered optimal and assists to maintain temperature (Christensson et al, 1998). Evidence of skin-to-skin contact for BBAs during this audit was poorly documented, suggesting it might not have been done. Furthermore, it has been found that following BBA, a number of women experience retained placenta requiring manual removal and increased blood loss (Loughney et al, 2006).
Aim
The audit aim was prompted by the apparent increased number of BBAs and the fact that a BBA audit had not been undertaken locally before. There are no national predetermined standards or guidelines by which to measure practice. A gap in the literature highlighted that women's journey following BBA had not been described following hospital admission previously. Table 1 illustrates what the audit proforma was designed to capture.
| If the women were clinically ‘low or high risk’ of complication in labour |
| Identify any contacts with midwives prior to the baby being born before arrival (BBA) of a midwife |
| The physical condition of the woman and baby around the time of birth |
| Time of day the BBA occurred |
| What happened to the woman and baby following admission to hospital in detail |
| Clinical indications for the hospital stay |
| Broad demographic details including: gestation, parity, body mass index |
Methods
This retrospective audit for a 6 month period included all the women who experienced a BBA. In addition, all homebirth records were reviewed to capture any women booked for a homebirth who did not have a midwife in attendance.
Records were obtained via the local informatics department. The local audit method was followed (Table 2).
| The audit was registered with the clinical governance team |
| The numbers of babies born before arrival (BBA) of a midwife were identified from electronic data provided by the informatics department |
| A literature review was undertaken |
| A proforma was developed and piloted to capture details following a woman's journey from labour onset until going home from hospital following BBA |
| The audit was undertaken by the two authors to ensure consistency and the following case notes were reviewed: |
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| Details from the proforma were input onto an Excel database for analysis |
| The audit data was analysed and an audit report prepared. The findings were presented to supervisors of midwives as well as to a multi-disciplinary team |
Results
Sixty case notes were reviewed initially, which included planned homebirths.
The reason homebirths were included was to capture women who had a planned homebirths without a midwife in attendance. Those found to have a midwife were then excluded. In addition, some cases reviewed did not fit the predetermined definition of BBA, so were also excluded, such as a birth on the antenatal ward and these were reported back to informatics.
Thirty-nine BBAs were included in the analysis. All of the women lived within the Trust catchment area and ethnicity, language, age and body mass index were all found to be generalisable to the local population group. The majority of women who experienced a BBA were multiparous (n=35; 90%). The gestation was mainly between 39–41 weeks; with three (8%) less than 37 weeks. Two women (6%) were ‘in transit’ when they gave birth. All 39 women were noted to have been ‘booked’ and had received care during pregnancy and admitted to hospital by ambulance.
Labour
The antenatal case notes were reviewed to determine any risk factors for labour:
The ‘high risk’ reasons included: Group B Streptococcus (GBS), significant mental health issues, diabetes, late booking, domestic violence history and previous preterm birth. In addition, one woman had a child protection concern history with a common assessment framework in place.
Booked for homebirth without a midwife
It was documented that there was no midwife available for two women (6%) booked for a homebirth. Although both had been advised to attend the birth centre for midwifery care (as per local guidance for staffing problems), both women laboured quickly and gave birth at home without a midwife.
Labour-related contacts with a midwife
The majority of women (n=25; 64%) made no contact with a midwife prior to the birth. This suggested that these were unavoidable BBAs.
Fourteen women (36%) made contact and the details were reviewed. Of these women, four (10%) made contact within 30 minutes immediately before the birth and were also considered to have been an unavoidable BBA.
Five women had already telephoned before the final call with an imminent BBA. On review of the documentation regarding the initial advice given, the women described signs of early labour. The advice provided by the midwife appeared to be in accordance with acceptable early labour advice.
For five women (13%), there was at least 30 minutes from the call until the BBA occurred. One woman was described as experiencing six contractions in every 10 minutes, and advised to come in but gave birth around 30 minutes later at home. With the benefit of hindsight, there might have been time for a midwife to attend these five women had a midwife been available to attend imminent births or BBAs.
Time of day
The majority of the BBAs occurred ‘out of hours’ (Table 3).
| Time | n | % | |
|---|---|---|---|
| Weekday: daytime | 09:00 – 17:00 | 6 | 16 |
| Weekday: night | 17:01 – 08:59 | 22 | 56 |
| Weekend: daytime | 09:00 – 17:00 | 2 | 5 |
| Weekend: night | 17:01 – 08:59 | 9 | 23 |
| Total | 39 | 100 | |
Initiation of skin-to-skin contact
Skin-to-skin contact was only documented for 15 (39%) babies and it remains unclear if it was initiated for 24 babies (61%). Subsequent hypothermia was found in two babies (6%) with temperatures of 35.8°C and 34.4°C once in hospital. Both babies were also noted to be ‘small’ for gestational age as well as premature (born at 34 and 35 weeks).
Length of stay in hospital
Women
Following assessment, the women were all found to be physically well. Only seven (18%) required a second degree tear to be sutured, 32 (82%) had either an intact perineum or first degree tear that did not need suturing. All 39 women (100%) had an estimated blood loss of less than 500 ml. There was nothing found in the records available to suggest a reason for the hospital stay other than those highlighted for the baby.
Babies
The main issues highlighted that had an impact on length of stay involved the baby. On initial assessment, five babies (13%) would have been immediately identifiable from the outset as requiring hospital care and/or admission: two preterm with low birthweight; two prolonged rupture of membranes (PROM) beyond 24 hours/meconium/liquor, maternal GBS (requiring a minimum of 12 hour observation (National Institute for Health and Care Excellence (NICE), 2007) and one small for gestational age.
The majority of babies (n=34; 87%) would not have required hospital admission from the outset. However, five (13%) later required additional care: three (8%) for sepsis requiring antibiotics identified during the PROM observations and two heart murmurs following NIPE (National Screening Committee (NSC), 2008). Although 10 babies required additional care (either from the outset or later), 29 (74%) women and babies did not.
The overall length of hospital stay is shown in Table 4.
| Length of stay | n | % |
|---|---|---|
| Less than 12 hours | 15 | 39 |
| 12–36 hours | 11 | 28 |
| 36 hours–3.1 days | 13 | 33 |
| Total | 39 | 100 |
Discussion
When the audit commenced there were no preconceived ideas or plans for what would be found or how the audit findings might be used.
It is recognised that there is an apparent increase in the number of BBAs both locally, regionally (Kuypers, 2013) and nationally (Ford and Pett, 2008). A national agreement on the definition of BBA is required and would be beneficial so that accurate information can be captured. Because this is a SOM-led audit, it is envisaged that the Local Supervising Authority Midwifery Officers (LSAMOs) will assist to establish consistency in the reporting of BBAs for the future.
Nothing remarkable was identified from the demographic details and multiparous women more likely to experience BBA, these findings were described by others (Loughney et al, 2006; Ford and Pett, 2008).
The majority of women either made no contact with a midwife prior to the BBA (n=25; 64%) or did so with less than 30 minutes before the birth (n=4; 10%) and were therefore considered to have been unavoidable BBAs.
The majority of BBAs occurred ‘out of hours’ (n=33; 85%) and similar findings were also highlighted by others (Haloob and Thein, 1992, Scott and Essen, 2005; Loughney et al, 2006; Ford and Pett, 2008).
All 39 women (100%) were automatically transferred to hospital with their baby in line with a local agreement. This audit found all women to be physically well, unlike others which found retained placenta and subsequent haemorrhage (Loughney et al, 2006). It is acknowledged that the audit sample size is small and if larger, might find retained placenta. If a midwife was in attendance a prompt transfer to hospital could then be arranged.
Despite the automatic transfer to hospital the audit found that 34 women and babies (87%) were not clinically required to be in hospital. Five babies required admission to hospital following an initial assessment (13%) shortly following birth. If a midwife assessment had been undertaken at home, the reasons identified would have been evident at the time (i.e prolonged rupture of membranes (PROM) beyond 24 hours; meconium liquor which required 12 hour observation; preterm, cold or small for gestational age) thus prompting appropriate and timely hospital admission and preventing the other women being transferrred to hospital.
Although five (13%) women were required to remain in hospital because of their baby, the length of stay in hospital was high for the other women who had already given birth safely without complication. Twenty-six women (67%) stayed up to 36 hours for no apparent clinical indication. One observation was that if a woman arrived onto the postnatal ward after the baby clinic finished, NIPE was often not undertaken until the following day.
The findings of the audit were both interesting and timely. There were plans already underway to develop a dedicated homebirth team. In addition, it was recognised that the maternity tariff for BBA is the same as for hospital birth (Department of Health, 2012). The audit suggested the majority of women and babies were well, and could have been appropriately ‘assessed’ at home by a midwife. The majority did not require a hospital admission, which occurred regardless of an individualised clinical assessment or choice. The findings also suggested that the service should be for women who experience birth ‘out of hours’ both as a homebirth or BBA. Subsequently, this audit has been instrumental in assisting with plans to improve the local service for women.
Using the audit findings to improve care
The audit has prompted improvement for women. By developing appropriate community services for women who experience a quick birth, anticipated benefits include:
Midwife role in care for women experiencing a BBA
From early 2014, a midwife has attended all women experiencing an imminent birth or BBA. Thus enabling appropriate support and optimal care and avoiding an automatic transfer to hospital. A midwife is well placed to provide immediate care and plan appropriate ongoing care, implicit within the midwife's role (NMC 2008; NMC, 2012b) (Table 5).
| Acknowledgement of the born before the arrival of a midwife (BBA)—often frightening for her and her family |
| Assessment of the physical wellbeing of both woman and baby |
| Prompt initiation of skin to skin contact resulting in a reduction in the likelihood of the baby becoming hypothermic whilst also promoting optimal bonding and likelihood of successful breastfeeding |
| Appropriately manage the third stage of labour and offer perineal suturing as required |
| Confirm the woman and her baby's suitability and choice to remain at home and exclude any safeguarding concerns |
| Plan ongoing midwifery care in community or transfer to hospital via ambulance as required |
Developing services to improve care while avoiding hospital stay
Including BBA in the new ‘24 hours homebirth service bid’ was not only timely, it also enabled us to ensure the availability of a skilled midwife ‘out of hours’. The new homebirth team skills include perineal suturing and NIPE. Funding has subsequently been secured for the homebirth team who are now in post and establishing their service.
Anecdotally, while planning the service improvements and knowing the audit findings, women's views have been sought. Those who experienced BBA were asked if they would have liked a midwife to attend them at home. Overwhelmingly, the women said they would have chosen to remain at home and have a midwife attend them and avoid a hospital admission where possible. There are plans to formally seek the views of women who experience BBA in the future.
Conclusion
The role of the SOM interfacing with clinical risk and responding to an increase in BBA has resulted in significant local improvements in the midwifery service for women and babies. This audit and the findings from others suggest that it would be beneficial to develop a standardised definition for BBA. Supervision is well placed to take this forward and assist with benchmarking nationally in the future.
Community midwifery services are in the best position to support women giving birth unexpectedly quickly by providing women with timely, woman-centred and cost-effective care at the point of need.