Background
The failure to diagnose labour and /or subsequent presentation in late labour with a problem or born before arrival (BBA) have been identified as themes in adverse events and contributed to adverse outcomes MNSI/MBBRACE/ESMI). In June 2021, following discussions at LMNS safety and governance meetings, it became clear that inconsistencies in the diagnosis of and management of the latent phase of labour and subsequent delays in the transfer to a labour environment or consultant care if appropriate were resulting in safety concerns for mother and baby within the HIOTV regional network.
One woman’s lived experience
A woman attended a consultant midwifery clinic in 2022 where the initial labour assessment compromised her entire experience. She has given permission to share her experience.
Multip, contracting regularly, vomiting, feeling like her labour was progressing quickly, previously 3 almost 4cm (note admission assessment suggests 2cm).
“I had been contracting at home for six hours and followed my instinct to come to the unit for assessment as I really needed a midwife with me. This was my second baby and the pain intensity so different to the first one. We arrived at 04:20 contracting frequently, found to be 3cm (midwife said almost 4, but not quite). I work in healthcare and understand those metrics can be hard to assess. They suggested I should go home as I was not in labour. I was in disbelief and felt hysterical. After discussion with the midwife, she reluctantly offered me to stay in a side room as they did not feel one-to-one care was appropriate yet.
I really wanted Entonox as struggling with pain, but the midwife said this should not be use in early labour. I was confused because I truly believed my labour was progressing. The team did not listen to me; I felt so alone and let down – why could the team not work around their policy and provide one-to-one care and offer me labour care? Was starting to think my body was letting me down too. I was left in room 12 and had someone checking in hourly, they had finally compromised and given me Entonox. No one attempted to listen to my baby because they did not believe I was in labour.
I was hysterical and did not feel the Entonox was enough any more. I was constantly contracting, so frequent and long. I asked for reassessment, was convinced my labour was progressing, wanted epidural. The team were reluctant as should only do four-hourly, but eventually they agreed. I was found to be 8cm at 06:30. Had to wait for room to be cleaned. Does not feel that anyone was thinking ahead and by the time I was moved to the room, the baby was born. I feel so lucky my son is alive today.”
What did we do?
The HIOTV maternity network convened a multi-professional working group with representation from each of the trusts, Maternity Neonatal Voice Partnerships (MNVP), Maternity and Newborn Safety Investigations (MNSI) obstetric and safety lead and clinical leadership from Professor Lawrence Impey. A framework was developed: ‘The Diagnosis of labour and improving the safety of the latent phase: a framework for best practice’ with extensive collaboration including with members of the MNSI team. This framework aims to aid the diagnosis of labour and prevent adverse outcomes associated with presentation in late labour, specifically to:
- minimise unnecessary maternal intervention
- improve birth experience
- allow most appropriate use of resource/ midwifery workload
The framework is supporting clinicians to consider the bigger picture and provides clarity on what to consider such as clinical findings, history, psychological well-being and the woman’s preferences. It encourages clinicians to make informed and compassionate choices. The framework isn’t saying you must admit all women who attend in early labour.
Guidelines for diagnosis of labour, latent and active phase differ widely between different trusts. It is suggested that this document forms a framework to support best practice and forms part of the teaching of midwifery and medical staff. Agreement of the principles outlined in the framework could lead to their embedding in a local management of labour guideline, emphasising particularly the importance of cervical effacement in nulliparous women and the limited use of cervical dilatation in multiparous ones. These measures alone could have considerable benefit.
Principles in making the diagnosis of labour, video: Diagnosis of labour; Developing our holistic approach by Louise Perkins, Consultant Midwife, Royal Berkshire NHS Foundation Trust (RBH)
What’s happening now in our region?
The diagnosis of labour framework is being implemented in our region at Buckinghamshire Healthcare, RBH and Oxford University Hospitals. It is supported by Eileen Dudley, Senior Programme Lead & MatNeo SIP Lead at HIOTV, with monthly working group meetings with leads from each trust as well as the lead midwives for education from Oxford Brookes and Buckinghamshire New University.