Improving quality outcomes and satisfaction for women: VBAC outside of Delivery Unit Jan Butler Consultant Midwife 2017
Introduction In the context of healthcare service improvement, improving quality outcomes and satisfaction for women. • Process • Information Governance • Midwife-led labour care pathway • Outcomes measures; 11.2014 – 2017 • What went well • Where are we now
Process • Leading Change as a Process (Martin, 2003): • Awareness: KH 09/2013: learn from this experience • Developing vision: MDT approach, shared and agreed with RL, CD. • Developing Direction : agreed strategy for women requesting VBAC outside of Delivery Unit; RBC/Home. • Inspiring Action: formulation of Governance; discussion/care plan and labour care pathway. Ready to go 11.2014 • Reviewing, Revising and Reflecting • Other models: RAPSIES framework for effective change management Gopee and Galloway(2009)
Outcomes 11.2014 – 06.2015 • 39 women in total: Discussion care plan. • > 06. 2015 = 13 women in total : 10 successful VBAC; = 76% • RBC: 4 (all 3 rd babies) • 1 home • Delivery Unit: 5 • 1 started on RBC • 1 VBAC Breech, 3 instrumental) • 2 ELSCS 15% ( Breech ) • 2 EM LSCS 15% ( cat2),(transferred from RBC; slow progress, fetal concerns )
Outcome measures: What went well for women SATISFACTION Scale 1 - 5 5 4 3 2 1 0 All 13 women scored 5 High satisfaction from Consultant Midwife Clinic, being listened to, information given was detailed , understood risks, but felt able to make informed decision, very pleased that I was fully supported .
Outcome measures: What went well for women Quality Experience 5 4 3 2 1 0 7 women 2 women 1 woman Unable to contact High quality experience regardless of mode of birth; given opportunity to have a very different experience , less traumatic, abled to labour spontaneously in a calm, low intervention area.
Outcomes 07/2015 - 12/2015 26 Discussions and plan of care: • 17 successful VBAC = 65% • RBC – 7 • Home – 3 planned • Delivery Unit – 7 • IoL VBAC – 2 • VBAC – 5 (3 transferred from RBC) • 5 ELSCS 19 % (post dates T+12, declined IOL, breech x2 , fetal anomaly) • 4 EMLSCS 15% (slow progress x2 on RBC, DU reduced FM’s, opted for DU) All cases reviewed, governance followed, and transfer appropriate and timely
Outcomes 2016 -2017 • 37 Discussions and plan of care: • 30 successful VBAC = 78% • RBC - 43% (13) • HB – 10% (3) • DU - 46% (14) • 50% transferred from RBC • 3 ELLSCS 8.1% (breech x2, post dates declined IOL) • 4 EMLSCS 10.8% (transferred from RBC slow progress, Iol fetal heart rate concerns, malposition declined IOL- DU)
Example of a quality experience I will always be grateful for your hard work and expertise, which enabled me to have the birth experience I had been keen to have . As you are aware, this was my third delivery. My first ended up being a planned Caesarean, my second was a very quick (6 minute) VBAC delivery on the delivery suite as per the royal college guidelines . I had always wanted a midwife led minimal intervention delivery but was worried I would automatically be sent to the delivery unit. When I expressed this to the midwife in the VBAC clinic, she referred me to yourself and I am so glad she did. As expected, the delivery was very quick again. The midwives were wonderful , supportive and encouraging and I managed to deliver with minimal pain relief (tens machine and paracetamol taken about 5 minutes before my boy was delivered). I was able to hold my little boy immediately (something I had been unable to do with my other children). Following the delivery I felt unrushed, and I was encouraged to relax and enjoy those precious early moments. I am so grateful that I managed to have my desired delivery and this would never have happened without the pathway you had put into place to allow me to labour on the midwife led unit. An eternally thankful
Outcome measures: what went well for staff Staff feedback : High support for midwives • Unanimous; ‘ individual plans are a good thing ’ • Midwives, especially junior staff appreciated the documentation supported practice, ie identifying signs of scar rupture, was to do, ‘ thorough and informative .’ • Midwives liked that there is ‘still room to risk assess’ supporting the Midwife-Led philosophy. • Everyone believes that they are providing excellent service; women and their families were very happy with the care they received.
What can we do differently? Feedback from Women: • ‘become an accepted pathway for women who especially have had a previous VBAC’ • ‘Continue to listen and give support’ Feedback from Staff : • Feel more confident with well established governance and individual plans of care • Can we extend this service to other groups of women?
Where are we now? • Referral pathway and Governance working well for women who wish to birth outside Delivery Unit. • Numbers increasing: 6 more women seen and plan made for RBC/home. • Review women who have had successful VBAC for routine RBC? Continue to support women in making informed decisions, improve quality and satisfaction.
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