Every woman should have at least one registered midwife present during established labour to ensure a safe experience of birth, according to draft guidelines on staffing in maternity settings.
Any occasion when one midwife is not able to provide continuous 1:1 support to women during established labour should be considered a “red flag”, which requires immediate action, said the draft guidance from the National Institute for Health and Care Excellence.
The draft guidance, published today for consultation, is the second in a series on safe staffing levels developed by the NICE in response to the Francis report into care failings at Mid Staffordshire NHS Foundation Trust.
The first set of guidance was published in July and covered safe staffing for nursing in adult inpatient wards in acute hospitals. Similar staffing guidelines are also planned for other settings including community and mental health.
“The care that a woman receives, throughout her pregnancy and after she has given birth has a huge impact on her physical and emotional wellbeing, as well as the health of her baby”
NICE said its new draft guideline provided “advice on how to make the right decisions about safe midwife staffing levels for women and their babies, wherever they choose to receive care”.
It sets out the process that registered midwives should use to determine whether there are sufficient staff to provide for the needs of women and babies, and the red flags that warn when immediate action is required (see box below).
It also highlights the responsibilities of hospital managers and actions that organisations should consider as part of their midwife staff planning.
The draft guideline calls for hospital boards and senior management to plan for all midwife care to be delivered by registered midwives and includes step-by-step guidance on determining the number of midwives required and how to be flexible to unplanned variations.
The draft guideline also proposes that, as a minimum, the number and skill mix of midwives needed should be determined by the midwife in charge at the start of every shift or service. But this should be done more frequently in maternity services where needs change quickly, such as birthing units.
Local factors such as the individual needs of each woman and baby and the availability of other staff or departments should also be considered, it said.
To ensure that a woman has a safe experience of giving birth, the draft guideline stresses that every woman should have at least one registered midwife present during established labour – when there are regular and painful contractions, and there is progressive cervical dilatation from 4cm.
The draft document also called for “appropriate escalation plans” to be put in place, as a contingency, to guide responses to unplanned changes in the number of midwives available.
In addition, the draft recommends how management should best work alongside senior midwives when making staffing decisions, and calls for establishments to be developed in advance by a registered midwife specifically trained to do this.
Professor Gillian Leng, NICE’s deputy chief executive and director of health and social care, said: “The Department of Health and NHS England have asked NICE to produce evidence-based guidelines advising the NHS on how to ensure levels of midwife staffing is safe in all maternity settings, be it at home, in the community or in hospital.
“We are now actively seeking feedback from midwives, hospital trusts, doctors, nurses and other healthcare professionals, as well as members of the public, to ensure the views of all relevant stakeholders are reflected in the final guideline,” she added.
The draft guideline is open for consultation until 13 November. The final version is expected to be published in February 2015.
Sean O’Sullivan, head of policy at the Royal College of Midwives, said the timing of the guidance was “particularly apposite, given current concerns about staffing shortages”.
He said the RCM beleived 3,200 more midwives were needed in England to ensure that all women received care that is both safe and of good quality.
“It is our hope that the guidance that emerges following this consultation will make a significant contribution to the elimination of this shortage, once and for all,” he said.
Midwife red flags
Occurrence of a midwife red flag should prompt an immediate response by the person in charge
- Delayed or cancelled time-critical activity because of midwife staffing issues (for example, identifying pre-eclampsia, or malposition, screening appointments)
- Midwife unavailable to make timely referral to other services (for example, services for ectopic pregnancy or miscarriage, referral to mental health services)
- Missed or delayed care because of midwife staffing issues (for example, delay in triage, delay in washing and suturing)
- Missed or delayed medication because of midwife staffing issues (for example, delay in prescription of gestational diabetes medication, pain relief not given when clinically appropriate,)
- Any occasion when one midwife is not able to provide continuous 1:1 support to women during established labour
- Incidence of birth trauma (for example, 3rd and 4th degree tears)
- Safeguarding cases inappropriately discharged home
- Other red flags may be agreed locally