1. How to use the
Intrapartum scorecard

2. Contents
Background
Tools
Data
Analysis

3. Background Intrapartum scorecard project
CMO Annual Report – intrapartum related stillbirths
Daily or more regular monitor of safety on the labour ward
Complement the “dashboard”

4. CMO Annual Report – intrapartum related stillbirths
Background
CMO Annual Report – intrapartum related stillbirths
In his 2006 Annual Report1, the Chief Medical Officer highlighted the issues concerning intrapartum stillbirths. Childbirth is often the first time that women and their partners encounter the healthcare system. Whatever the exact mode of delivery chosen, be it a home birth attended by a midwife or a hospital delivery with a doctor present, people put their trust in the system to be as safe as it can be and to minimise harm. Today, the expectation is for a healthy baby.
Yet every year, 7,000 babies die during or shortly after birth. Much more is known today about the reasons why babies die and the actions necessary to prevent such deaths. However, there is one group of babies, those that start labour apparently healthy but then die – so-called intrapartum-related infant deaths – whose numbers have remained constant in recent years, and the causes of death for many of them remains a mystery.
Recommendation Four of the chapter “Intrapartum-Related Deaths: 500 Missed Opportunities” calls for:
The use of a maternity ‘dashboard’ to assess and improve standards of care in maternity units should be piloted at sites nationwide.

5. Intrapartum scorecard project
Background
Intrapartum scorecard project
12 month project
Project group
3 month pilot
Intrapartum scorecard project
12 month project – commenced September 2008
Project group – composed of midwives, obstetricians, representatives from the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and Department of Health
3 month pilot – 11 sites across England and Wales piloted the intrapartum scorecard for up to 3 months.

6. Complement the “dashboard”
Background
Complement the “dashboard”
The Royal College of Obstetricians and Gynaecologists (RCOG) Good Practice Guide Number Seven2, issued in January 2008, serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground. This may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure woman-centred, high-quality, safe maternity care. This is a high level document intended for use by Trust Boards to monitor maternity unit clinical governance performance on a monthly basis.
The intrapartum scorecard is designed to complement the RCOG dashboard.

7. Daily or more regular monitor of safety on the labour ward
Background
Daily or more regular monitor of safety on the labour ward
The purpose of this project is to have an overview of the work being undertaken by the RCOG to automate the ‘dashboard’ and to develop an intrapartum scorecard that can be used on a daily, or more regular, basis to monitor the safety of the maternity unit at any particular time. It is imperative that this data is easily obtainable and if possible available transparently to reduce the affect on the workload of the units.

8. Intrapartum scorecard
Tools
Intrapartum scorecard
Paper version
Excel spreadsheet
“How to” Guide
Available for reference
The intrapartum scorecard is designed to be used as an Excel spreadsheet to document the 4 hourly assessment of patient safety on labour suite.
It has also been designed so that the data entry sheet can be printed off and used daily, if preferred.
A “How to” Guide is available for reference if required.

9. Data
Implementation
Collection
Saving
Use

10. Implementation Implementation
Week 1
Fill in scorecard once each day (i.e just at 08:00)
Week 2
Fill in scorecard twice each day (i.e at 08:00 and 20:00)
Week 3, etc
Continue to increase the amount of times the scorecard is being filled in until it is being completed every 4 hours
Implementation
Small tests of change until the scorecard is being completed every four hours, every day.
To implement and sustain the use of the intrapartum scorecard, it is vital to ensure that all staff have received information and/or training on how to use the intrapartum scorecard and feel confident in how to use the data that are produced. The accompanying PowerPoint presentation, frequently asked questions and “webinar” have been developed for this purpose.
The intrapartum scorecard should be completed by the labour ward coordinator, and it may be necessary to involve the organisation’s Information Technology department to ensure that the intrapartum scorecard can be accessed on labour ward.
To commence using the intrapartum scorecard, we suggest starting with a small scale test and gradually increase the number of times the intrapartum scorecard is used, until data are being recorded every 4 hours, each day.

11. Data entry sheet Midwives Women Staffing Activity Action taken
Local measures
4 hourly assessment
The intrapartum scorecard is divided into sections for midwifery staffing, the women being cared for on labour ward, other staffing categories and labour suite activity. These are followed by a section to document any action taken as a result of any of the items “triggering” a response.
There is also the opportunity to include 3 local measures if required.
The intrapartum scorecard is designed to be used on a 4 hourly basis starting at XX:00hrs (start time to be decided upon and entered onto the set up page of the excel spreadsheet.)
We will now go through each of the sections in turn, explaining what is being measured.

12. Midwives
Midwives
The first section of the intrapartum scorecard deals with staffing and case mix. It is based on the recommended ratios of midwives to labouring women published in “Safer Childbirth” (2007), as adapted from Ball (2006). The underpinning principle of midwifery care in labour is that labouring women receive one-to-one individual care by midwives throughout established labour. The midwife-to-woman standard ratios (Table 2) relate to intrapartum care provision and are derived from recognised evaluation data which reflect the increased activities associated with complex cases.
The basic principles of risk management accept that ‘to err is human’. Staffing is key to delivering safe maternity services, as shortness of time increases the risk of error tenfold. Problems associated with this were highlighted in the Healthcare Commission Report into an excess of maternal deaths at North West London NHS Trust. The Safer Childbirth document produced recommendations on minimum standards of staffing in intrapartum areas. The scorecard uses these, in conjunction with activity, to assess the appropriateness of staffing levels for key groups off staff. It also records agency and bank staff in order to draw attention to increase risks associated with unfamiliarity.
Local standard for MW staffing
Staffing levels should be based on an evidence-based workforce planning tool as described by the RCOG in Changing Childbirth .This section is for the LW coordinator to document if there are sufficient midwives available on labour ward.
Number of midwives on LS (inc. shift lead)
This is the number of midwives that are on the labour ward at the time of the assessment. Depending on the unit, this may include midwives staffing an assessment unit, or attending labour suite with women in their caseload. This does not include midwives redeployed to other tasks. The graph “Comparison of local standard for midwifery staffing with the number of midwives on labour ward” shows the total number of midwives rostered for labour ward.
Labour suite shift lead supernumerary
If the labour ward coordinator is rostered to take a caseload on labour ward then they are potentially not able to undertake the duties of a labour ward coordinator. This category should be used to state whether or not the labour ward coordinator is supernumerary or not at the time of the assessment and is a yes/no answer.
Number of bank midwives
This is to record the number of midwives that are working a bank shift, even if they are a regular member of staff.
Number of agency midwives
This is to record the number of midwives employed by an agency rather than a regular member of staff.
Nº of midwives redeployed to other tasks (scrubbing, transfers, etc.)
If midwives are taken from labour ward to scrub for caesarean sections or to transfer women out of the unit, this should be entered here.

13. Women Number of labouring women
This is the number of women on labour ward in established labour.
Number of antenatal women
This section should be used to document the number of women that are being cared for on labour ward, but are not in labour. For example, women who are being assessed on labour ward for reduced fetal movements or suspected ruptured membranes.
Number of postnatal women
The number of women who are on labour ward at the time of assessment that are post delivery. For example, they could be waiting for a bed on the postnatal ward, or waiting to go home from labour ward.
Total number of women
This is the total number of women being cared for on labour ward at the time of the assessment.
Nº of women receiving 1:1 care
A woman in established labour receives care from a designated midwife for the whole of that labour, or the midwife’s whole shift whichever is the shorter.  The Midwife will be available to care for the woman 100% of the time.
At the end of the shift, if necessary, care will be handed over to another designated Midwife, who will continue the one to one care of that woman.
Birthrate Plus® Acuity score* (if used)
If the unit is using the Birthrate Plus® Acuity Tool*, the acuity score can be entered here.
*Copyright Ball and Washbrook 1996

14. Staffing Number of maternity support workers required
The recommended number of support workers required for the number of midwives.
Nº of maternity support workers available
This is where it should be noted the number of support workers available on labour ward.
Nº of clerical staff available
This is where it should be noted the number of clerical staff available on labour ward.
Junior medical staff available on LW to local standard
This includes medical staff up to registrar level and whether or not they are available to attend labour ward if required or whether they are undertaking other duties (for example, gynaecology or A&E cover).
Obstetric consultant available on L to local standard
Whether or not the obstetric consultant presence on labour ward conforms with the local standard for the unit, based on recommended staffing levels
Anaesthetists available
This is used to note whether the labour ward anaesthetist is available when required.

15. Activity Nº of women waiting admission to LW
This constitutes the number of women who are on the antenatal ward waiting transfer to Labour ward when capacity allows.
Nº of available beds for labouring women
This means the total number of labour rooms which are unoccupied at each 4 hourly assessment period.
Nº of emergency cases waiting for theatre
This should be used to record the number of women who are waiting to go to theatre for caesarean section, assisted vaginal delivery, manual removal of placenta, etc. but are having to wait as the theatre is already in use/not available.
Nº of elective LSCS
This is the total number of elective Caesarean sections for the day.
Nº of planned home births/MLU in labour/Assessment Unit
This is the number of women who are in labour at home, in the Community or in a Midwifery Led Unit (MLU) who are in established labour and are booked for Home or MLU births. This reflects the activity in the community and alerts the main Unit to any potential/ possible transfers if needed. This could also apply to any women attending the triage unit or day assessment unit, but only if staffed by midwives from the labour ward.
Multi-disciplinary clinical review and prioritisation in last 4hrs
This constitutes a ward round on Labour Ward by a Consultant or by a Senior Registrar with the labour ward coordinator. The ward round may be a physical ward round, a board round up or a telephone update by one of the above named designations. This item is not intended to imply that all units have to undertake them on a four hourly basis. It is merely a way of recording when the ward rounds are done, therefore the escalation point should be set locally.
Delay in elective LSCS
This means the number of Elective LSCS which are delayed from their actual scheduled time for theatre.
Delay in inductions/augmentations
This means the total number of delays in inductions or augmentations in each 4 hourly period.
Neonatal Unit status (open/restricted/closed/not known)
Whether the unit is open, closed, has restrictions on the type of babies that can be admitted (i.e. only open to babies over 34 weeks or closed to babies from outside the unit) or the status is not known.
Neighbouring maternity units closed
This is the status of neighbouring units, if known, and is a yes/no answer.
Missing/ faulty equipment affecting care
All too often there are times when issues not relating to staffing or the women and their families can have a negative impact on the safety of the labour suite. For example, the blood gas analysis machine not working, missing equipment, inadequate CTG monitors or not enough delivery packs for the labour suite activity.

16. Action taken Action taken
At each 4 hourly interval when the scorecard is completed, the labour ward coordinator needs to decide whether or not any action needs to be taken as a result of any of the items in the scorecard. For example, if there are women waiting to be admitted to the labour ward but there are no rooms available, it would be appropriate to inform the manager of the unit.
Supervisor of Midwives contacted
If any of the categories require escalation to a supervisor of midwives, this should be documented here.
Manager contacted
If any of the categories require escalation to a manager, this should be documented here.
Consultant obstetrician contacted
If any of the categories require escalation to a consultant obstetrician, this should be documented here.
Redeployment of staff
If any staff need to be deployed from other areas to help staff the labour ward, this should be documented here.
Incident form completed
If an incident form has been completed for any of the scorecard items, this should be documented here.
Escalation policy implemented
If the unit escalation policy has been implemented, document this here.
Unit closed
If the unit has to be closed, this should be documented here.
Other
Any other comments about any of the scorecard items should be documented here.
Name
The midwife completing the scorecard should put her/his name into this box at each 4 hourly assessment.

17. Local measures
The intrapartum scorecard may not cover all of the measures that your unit may want to collect and analyse. Therefore, a section of the intrapartum scorecard has been designed to include up to 3 items that can be analysed within the scorecard. The responses can be tailored to be either yes/no or numeric.
The measures and the responses need to be included on the set up sheet of the Excel spreadsheet. This will then populate the intrapartum scorecard thereafter and allow analysis of the data.

18. Charts
Once the intrapartum scorecard Excel sheet has been populated with data, the following charts will be automatically produced for weekly and monthly data:
Comparison of the number of women on the labour ward with the number of midwives on the labour ward – breakdown of the number of postnatal, antenatal and labouring women
Comparison of the number of women on the labour ward and the number of women receiving 1:1 care
Comparison of local standard for midwifery staffing with the number of midwives on LS
Comparison of number of maternity support workers required and actual numbers of support workers and clerical staff on LW
Comparison of 4 hourly acuity scores with the number of midwives on LS (if the Birthrate Plus® Acuity Tool is used)
Using “dummy data” these charts show how the data can look.

19. The Excel spreadsheet will also produce summaries of the weekly data.
Weekly data can be selected for particular times and dates (For example, data for Mondays can be selected in isolation if required).

20. Quarterly summary data can be produced and can be used alongside the “dashboard” information if required.