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High impact actions

The high impact actions for nursing and midwifery 7: promoting normal birth

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Over the past 20 years, more and more babies have been born by C-section. We need to eliminate unnecessary procedures and increase normal birth rates


Liz Ward, RGN, is associate, high impact team, NHS Institute for Innovation and Improvement; Katherine Fenton, MA, RCNT, RM, RGN, is chief nurse and director of clinical standards and workforce, NHS South Central; Lynne Maher, DProf, MBA, RGN, is interim director for innovation, NHS Institute for Innovation and Improvement.


Ward L et al (2010) The high impact actions for nursing and midwifery 7: promoting normal birth. Nursing Times; 106; 33, early online publication.

There is significant variation in rates of Caesarean section between maternity units. Higher rates appear to be associated with older mothers and women from certain ethnic groups. However, taking these and other demographic factors into account does not explain the differences between trusts.

This eighth article in this series on the high impact actions for nursing and midwifery looks at how midwives and nurses can help to avoid unnecessary Caesarean sections.

Keywords High impact actions, midwifery, childbirth


Compared with Caesarean sections, normal births have shorter (or zero) hospital stays, fewer adverse incidents and admissions to neonatal units, and better health outcomes for mothers. There is also a link between normal birth, successful breastfeeding and a more positive birth experience.

However, the rate of C-sections in England rose from 12% in 1990 to 24.6% in 2008-09. It varies significantly between maternity units, ranging from 12.5% to 34.6% (NHS Institute for Innovation and Improvement, 2007).

Higher rates of C-section appear to be linked to age and ethnicity, but taking these and other demographic factors into account does not explain the differences between trusts (Healthcare Commission, 2008). There is evidence that the difference in C-section rates is also influenced by cultural and organisational factors within organisations (NHSIII, 2007).

Clinicians in services with low C-section rates believe maternity units applying best practice to pregnancy, labour and birth management can achieve rates that are consistently below 20% (NHSIII, 2006).

In addition to benefiting women and their babies, fewer C-sections mean midwives are able to spend less time on non-clinical tasks and more on supporting and caring for women and their babies.

There is a particular need to increase the number of vaginal births after C-section (VBAC). The Royal College of Obstetricians and Gynaecologists (2008) suggested three quarters of women should be able to have a VBAC but, among trusts able to supply figures on VBAC rates, the average was 32% with a range of 10% to over 60%.

The savings to be made by reducing C-sections are significant. Depending on complications, a C-section costs £1,370-£1,879 and has a typical stay of 3-4 days; in contrast, a normal delivery costs £735-£1,097. An unpublished cost study by NHSIII calculated that £65.5m could potentially be saved by reducing the national C-section rate by 4% and cutting the length of stay for a Caesarean without complications from four to 2.5 days. This equates to a saving of £510,000 per trust.

What can midwives and maternity service nurses do?

Focusing on VBAC can have a huge impact on C-section rates. Nurses and midwives have a role to play in giving women accurate information on the benefits of VBAC in the postnatal period following a C-section and during a future pregnancy.

RCOG’s (2007) recent consensus statement suggested 60% was a realistic objective for normal births – that is, births without interventions such as epidurals or episiotomies. All women should be able to benefit from the philosophy of normal birth and receive midwife led care, even in an obstetric unit.

The Essential Collection (NHS III, 2010) includes four case studies, in different settings, each of which demonstrates success in increasing the number and the profile of normal birth in its organisation.

Case study 1: massive organisational change

Blackpool, Fylde and Wyre Hospitals Foundation Trust had the highest C-section rate in the north west (28%). As part of a trustwide organisational change, it introduced projects to improve the care and support of women through natural birth:

  • Developing a formalised handover using the situation, background, assessment, recommendation (SBAR) model for communicating critical information;
  • Introducing a weekly incident review meeting facilitated by the clinical governance lead, which is open to anyone and relaxed and informal in its approach;
  • Disseminating learning at all levels;
  • Open and accessible appraisals and training for staff, with a two way system that enables junior members to comment on the performance of senior staff;
  • Learning about practice elsewhere, such as the use of aromatherapy during labour.

Impact of the initiative

The trust has reduced its rate of C-sections by a fifth, from 28% to 22%, and increased VBAC rates from 50% to 65%. The estimated cost saving is £194,724.

Mothers now receive the support and information they need to make informed choices about the place and method of birth.

Multidisciplinary training includes normal birth study days, where staff are put into multiprofessional teams and asked to re-enact emergencies. New processes ensure a faster response to incidents, involving the entire team. The new two way appraisal system has increased teamworking and removed a culture of mistrust.

Case study 2: top to bottom cultural change

A C-section rate that peaked at 31% in April 2009 was a wake-up call for Luton and Dunstable Hospital’s maternity unit. Having a level 3 neonatal unit had created a perception among staff that it was a place suitable for high risk births. To counteract this, the hospital made a commitment to normalise birth through top to bottom cultural change.

The trust introduced a midwife lead for normality to champion normal birth with staff and pregnant women, and developed a birth options clinic for women who had previously had a Caesarean. A daily multidisciplinary review meeting was introduced to look at all the deliveries in the previous 24 hours; here, staff at every level are encouraged to speak out and even challenge senior staff if they need to.

The philosophy on normalising birth extends to staff at every level. Normality study days have been developed for community midwives, as they are crucial in promoting normality; study days are held on Saturdays to improve access. A new skills book for maternity care assistants details training and competencies; when they join the trust, they receive information cards explaining terminology and a list of key contacts.

Impact of the initiative

Feedback from mothers has been extremely positive. They now have a range of options and more information to make the choice that is right for them. Of those who attended the birth options clinic, 80% tried a VBAC; around half were successful. A prebirth clinic is now being planned to advise women on early labour and to encourage self care.

Case study 3: support for women after previous caesarean

Stockport Foundation Trust has a tradition of promoting normality in childbirth. In 2008, it focused on reducing C-sections by supporting women who had had one before. It was chosen as a pilot site for NHSIII’s Focus on Normal Birth and Reducing Caesarean Section Rates toolkit.

Stockport established its first service users’ forum to involve parents in developing services. These developments include:

  • A weekly VBAC clinic post 20 week scan;
  • VBAC workshops where women talk about their experience and answer questions;
  • A postnatal debrief in response to feedback;
  • Choices, a DVD of delivery options for women, now available on the trust’s website;
  • Facilitated “time out” sessions for delivery suite coordinators;
  • Using everyday language to help women understand complex information.

The trust also has a weekly Caesarean audit and a daily review of emergency Caesareans to monitor what is happening in real time.

Impact of the initiative

Stockport has two birth centres and a delivery suite for higher risk deliveries. It was aiming for 20% of births to occur outside the delivery suite (that is, in the birth centres or at home) by March 2010. Women find attending the VBAC clinic a powerful experience and feel better able to talk about their last pregnancy.

The clinic is being evaluated and audited by a local data resource company and users are being asked for feedback. Staff morale has risen and the trust is confident C-section rates will fall below their current 24%.

Case study 4: a wide ranging programme to normalise birth

Western Sussex Hospitals Trust has increased its VBAC rate by more than 300% and continues to reduce its overall C-section rate through a programme to normalise birth. The trust was an early adopter site for NHSIII’s Focus on Normal Birth and Reducing Caesarean Section Rates toolkit.

It identified VBAC as its priority pathway, which led to the introduction of a VBAC lead and midwife counsellor.

All women who have a C-section are given a letter that explains the reasons for the intervention and outlines their choices for next time. The birth afterthought service gives women a telephone number for support from the midwife counsellor.

The trust also invites women onto its ward rounds so staff can hear about their experience firsthand. In addition, a new weight management in pregnancy clinic has been developed for women with a raised body mass index.

A new birth centre in Chichester was developed in consultation with service users. It has two birthing pools and is designed to encourage normal birth. The trust recently reported its first successful VBAC in the pool.

The competency pathway has recently been revised, focusing on normalising birth. A band 5 midwives “club” ensures staff have protected time for study days.

Impact of the initiative

The trust increased its rate of successful VBAC from 26% in 2006 to 84% in 2009. Water births now account for 5% of all births and C-section rates have reduced by 2% and are still falling. A 2% reduction equates to a yearly saving of £96,285. There is a far greater emphasis on normal birth, particularly following a C-section, and women can choose from a greater range of birth environments. The midwife counsellor provides debriefing and support following a traumatic birth experience. “Comments on our services” cards have been redesigned to ensure staff get more useful feedback. l

The Essential Collection

The Essential Collection, plus literature reviews for each high impact action, can be downloaded from the NHS Institute website. This also contains an opportunity estimator so that you can calculate potential savings, and a range of tools and resources.

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Readers' comments (1)

  • I`ve recently been appointed Antenatal Clinical Lead in a Stand Alone Midwife Led Unit and am hoping to set up a VBAC/ Debriefing Service. I`m extremely heartened to read the different Case Studies and would really like to make contact with the key people responsible. I found West Sussex Hospitals Case Study particularly inspiring and would love to learn more about the VBAC Lead and Midwife Counsellor.

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