For Healthy Women who are at low risk of complications in pregnancy and childbirth. The Free Standing Midwifery Unit at Ysbyty Glan Clwyd Is it a safe option?

Evidence Birth Place Study (BPS 2011) Answer questions about the risks and benefits for healthy women with a low risk of complications in childbirth and pregnancy giving birth in 4 different settings Home Free standing midwifery unit(FMU), Alongside midwifery unit(AMU) Obstetric unit (OU) The BPS collected data on over 64,000 mothers and babies of which 11,500 were in a FMU.

Safety for the baby was measure by adverse outcomes Stillbirth , Death of the baby in the first week after birth. Neonatal encephalopathy (disordered brain function caused by oxygen deprivation before or during birth) Meconium aspiration syndrome Physical birth injuries, brachial plexus injury, bone fractures. These outcomes were chosen because differences in how often these events occurred might reflect differences in the quality of care received during the birth.

Safety for the mother was assessed Poor medical outcomes eg: serious perineal tears, need for a blood transfusion, Woman who received obstetric interventions eg: emergency caesarean section, forceps/ventouse delivery. Positive outcomes for mothers were measured Normal birth without intervention Breast feeding at least once

What did the study show about safety of planning birth in different settings? Giving birth is generally very safe. For ‘low risk’ women the incidence of adverse perinatal outcomes was low 4.3 events per 1000 births Midwifery units appear to be safe for the baby and offer benefits for the mother.

For women who planned to have their first babies in a FMU There were no significant differences in adverse perinatal outcomes compared with a planned birth in an OU. However the women had significantly fewer interventions, including substantially fewer intrapartum caesarean sections, and more ‘normal births’ than women who planned birth in an OU. For women who planned a second or subsequent baby in a FMU

Are midwifery unit births as safe as births in a hospital obstetric unit? Babies BPS found that the proportions of babies with an adverse outcome were similar in births planned in midwifery units compared with births planned in obstetric units. 3.1 per 1000 births - OU 3.2 per 1000 births - FMU 3.4 per 1000 births - AMU Mothers Midwifery units were also safe for the mother. 75% of women achieved a normal birth at home or MLU’s compared to 58% in an OU.

Were the outcomes worse for women who are transferred? Women are transferred for many reasons during labour, The majority are appropriate - long labour, delay in labour, additional analgesia. Rowe et al (2013) reviewed the transfer times from home births and FMU births in the BPS. They concluded that emergency transfers and adverse out comes were rare Rowe et al (2013) also stated that BPS evaluated the safety of planned births in FMU. Any risks associated with transfers were taken into account. There were no differences in the number of perinatal adverse outcomes

National Institute For Health and Care Excellence (NICE) Intrapartum care: Care of healthy women and their babies during childbirth (December 2014)

Women having their first, second or subsequent babies may choose to give birth in any of the four settings. Commissioners and providers should ensure that all 4 birth settings are available to all women Home FMU AMU OU

Clinical Governance (All birth settings NICE 2014) Timely access to an OU if there is a need to transfer Robust protocols in place for transfer Clear local pathways for continued care Multidisciplinary clinical governance structure in place

Clinical Governance Arrangements for the FMU at Ysbyty Glan Clwyd All Wales Midwifery Led Guidelines (AWML 2013) based on evidence and NICE guidance All Wales Clinical Pathway for Normal labour AWCPNL 2012) based on evidence standardises decisions to transfer care AWCPNL a robust risk assessment for mother and baby – beginning of the care episode Transport details for transfer are included in the AWMLG Robust selection criteria – AWMLG - NICE (2007/14)

Education and Training of Midwives and Health care support workers. Once identified all will attend workshops Discuss the evidence and guidelines General discussion regarding care in FMU Decision making regarding transfers How to arrange a transfer etc Emergency skills and drills scenarios in the FMU. All midwives are NLS trained

Data collection Data will be collected separately for nulliparous and parous women Number births, analgesia uses, perineal trauma etc. Number of transfers Total time of transfer Reason for transfers Birth outcomes after transfer Any adverse outcomes using the BPS criteria

Discussion regarding women’s care who are transferred All transfers cases will be reviewed on a monthly basis Monthly meetings to discuss transfers and reflect on care given. If there is an obstetric emergency all the staff involved will be asked to a ‘debrief meeting’ Monthly scenarios will continue - obstetric emergencies

Patient and Public Involvement Women will continue to receive robust information based on available evidence Women will be informed of the average transfer times Audits will be undertaken re satisfaction levels of women FMU Transferred North Wales midwives ‘facebook’ page Maternity services liaison committee

Conclusion The FMU proposed at Ysbyty Glan Clwyd is as safe for healthy women who are at low risk of complications in pregnancy and childbirth compared with the same cohort of women giving birth in the OU (BPS 2011). NICE (2014) have stated that providers should offer all 4 birth settings. In accordance with NICE robust clinical governance arrangements will be in place.

Midwifery care in Wales is already standardised through existing documents Data collection will be the same as other established FMU in Wales Statistics will be compared to the BPS criteria and other FMU in Wales Women will be encouraged to be an active participant in not only their care but the development of the FMU

Thank You Maggie Davies Consultant Midwife Maggie.e.davies@wales.nhs.uk