The role of the Royal College of Midwives in in leading practice Frances Day-Stirk Royal College of Midwives Director Learning Research & Practice Development International Office Developing guidelines for midwife-led care Rio de Janeiro 4 November 2009

The voice of midwifery in the United Kingdom  Professional organisation and trade union for midwives led by midwives for midwives  The vast majority of the midwifery profession are members.  represents the interests of midwives in all four UK countries individually and collectively.  promote excellence, innovation and leadership in the care of childbearing women, the newborn and their families, nationally and internationally.

Strategic intentions As part of the strategy to promote the midwifery profession and support midwifery practice, the Royal College of Midwives (RCM) developed several of approaches Aim: to improve midwifery practice and encourage a national standard of practice, by producing quality reference (d) documents for local use

Key initiatives RCM Evidence Based Midwifery peer-reviewed research journal – launched 2003 promotes the dissemination, implementation and evaluation of midwifery evidence locally, nationally and internationally. publishes papers - qualitative or quantitative research studies, philosophical analyses and systematic reviews.

Midwife-led care has an underpinning philosophy of labour as a normal physiological process. It also recognises that, for the woman, labour is not ‘just normal’ but actually extraordinary: as a ‘good’ or ‘bad’ experience it has great implications for her psychological well-being and her relationships with her family Wiklund et al 2008; Lemola et al 2007; Waldenstrom et al 2004; Simkin 1992

‘Hands-on’ guidance for midwives doing home birth (2003) Common concerns when developing home birth practice Guidance on practical information – Antenatal preparation, labour and postnatal care in the home environment

Evidence-based midwifery led care in labour o First two editions- developed for use in one NHS Trust, UK (Helen Spiby & Jane Munro) o Third edition- commissioned by the Royal College of Midwives intrapartum care in midwifery-led environments, midwifery-led schemes

Guiding principles o Process for developing and evaluating guidelines should focus on outcomes valued by users o The guidelines should be based on best available evidence and include a statement about the strength of evidence o A sound method of critical analysis should be adopted o The guidelines should be flexible and adaptable o There is evidence of user involvement and other appropriate professionals

The Process o Suitability screen o Scope o Literature search o Grading of recommendations o Audit o Peer Review o Declaration of interests o Support o Disclaimer

Context and philosophy o Evidence base to midwifery care o Clinical practice guidelines o Midwifery-led approaches to care o Information and involvement in decision-making

Identifying topics for inclusion o Preparatory survey usefulness & acceptability to midwives o Identification of topics via stakeholders Midwives - Evidence Based Midwifery Network & Royal College of Midwives Women - via User Groups at national level

Literature review o prospective randomised controlled trials o midwives’ research and reviews exploring women’s views o professional bodies (RCM & RCOG) and government policy directives o expert opinion

Search strategy o Search of electronic databases o Cochrane, Medline, CINAHL, MIDIRS o Guideline databases and collections o Hand searching of six key journals o English language papers or abstracts o Publication period o Separate search strategy each topic o MeSH headings and keyword terms

Formulation of recommendations o Critical appraisal o Research conducted in settings & contexts relevant to midwifery-led care o Two authors peer reviewed each section o Presented as a narrative and in bullet points o No grading of evidence

Evaluation o Peer review o Use of the AGREE tool o Midwifery guideline experts o Service users/representatives

Guideline titles o Birth Environment o Latent Phase o Supporting Women in Labour o Supporting and Involving Women’s Birth Companions o The Use of Water for Labour and Birth o Pharmacological Pain Relief o Fetal Heart Rate Monitoring o Assessing Progress in Labour o Rupturing Membranes o Positions for Labour and Birth o Persistent lateral and posterior fetal positions at the onset of labour o Second Stage of Labour o Care of the Perineum o Third Stage of Labour o Suturing the Perineum o Immediate Care of the Newborn o Early Breastfeeding

Birth Environment Practice Points Go to website

Working in ‘in an environment that is open and participative, where ideas and good practice is shared, where education and research is valued’ Scally & Donaldson 1998 Can mean learning how to ‘start stopping’ Evidence based midwife-led care & clinical governance

Hospital is an alienating environment for most women, in which institutionalised routines and lack of privacy can contribute to feelings of loss of control and disempowerment Lock and Gibb 2004; Steele 1995 Control, or lack of it, has been found to be important to women’s experience of labour and their subsequent emotional well- being Green et al 1990; Simkin 1992 The home-like environment is associated with lower rates of analgesia, augmentation and operative delivery, as well as greater satisfaction with care Hodnett et al 2005 The environment

Because of the high level of intervention associated with electronic fetal monitoring, intermittent auscultation with a hand held instrument is the recommended method for the woman who is healthy and has had an uncomplicated pregnancy NICE 2007; MIDIRS 2005; RCOG 1993 Fetal heart rate monitoring

Current evidence does not support the use of the admission CTG in low risk pregnancy. It should not be used routinely NICE 2007; MIDIRS 2005; Blix et al 2004; Impey et al 2003; Mires et al 2001

Midwife-led care has been found to have as good outcomes as medical-led and shared care, met with greater satisfaction from the women and reduced obstetrical intervention rates Hatel et al 2009; Campbell et al 1999; McVicar et al 1993; Shields et al 1998; Turnbull et al 1996; Hundley et al 1994; McVicar et al 1993

Obrigado

practice/practice-guidelines/ Acknowledgements Jane Munro & Mervi Jokinen