RCM Annual Conference




Event Timeslots (5)


Chair: Michelle Beacock, board member, RCM

Early pregnancy assessment suite (EPAS): an outpatient management care bundle to improve care and experience for women suffering with hyperemesis gravidarum
Elaine Pirrie, senior charge midwife, Ayrshire & Arran Health Board

The aim of the project was to introduce a standardised regime and outpatient management care bundle to support women suffering with hyperemesis gravidarum (HG), with early access to EPAS for accurate assessment, diagnosis and treatment; reduce HG symptoms; reduce the number of women requiring an overnight stay; promote women-centred care by provision of accurate and appropriate information on discharge from EPAS. We developed a telephone triage flowchart; provided EPAS staff with effective triage training, including community midwives and the maternity outpatient department; and developed clear guidelines for outpatient management of women with HG. An innovative and revolutionary outpatient service has been set up, dramatically improving care. A hyperemesis team has been formed to ensure guidelines are followed; we text message women weekly for ongoing support; women are connected with a support group; and all GPs have been emailed information about the outpatient care bundle and treatment. There has been a significant reduction of women requiring an overnight stay, and standardised practice for treatment of HG as an outpatient has ensured women receive high-quality care without requiring hospital admission, improving patient experience and psychological wellbeing. We saw a 70% reduction in inpatient stays, improving bed availability.

A mixed methods exploration of the experiences of women living with inflammatory bowel disease during pregnancy
Helen Janiszewski, midwife researcher, Coventry University & Nottingham University Hospitals

Inflammatory bowel disease (IBD) is a chronic condition affecting the gastrointestinal system and is an umbrella term for ulcerative colitis and Crohn’s disease, affecting one in 250 people. Management of IBD prior to and during pregnancy is key, with active IBD disease activity increasing the risk of maternal gestational diabetes, preterm birth and low birthweight (Getahun et al, 2014). Literature about IBD and pregnancy is dominated by medicinal safety, with few articles centred on women. The aim of this study was to gain insight into the experiences of women with IBD during pregnancy. An anonymous survey, using closed-ended questions, open-ended questions and agreement scales, was distributed on Crohn’s & Colitis UK’s website and social media platforms. Women self-selected as fulfilling the eligibility criteria, and the potential number of eligible women was calculated using the fertility rate and number of female members of childbearing age. The quantitative data was analysed using descriptive statistics, and template analysis was used for the qualitative data. The survey is closed and final analysis is under way. Findings will offer an opportunity to hear the voices of women with IBD and to interpret their views into further maternity care planning.

Outpatient induction of labour using a cervical ripening balloon project: review and co-design care with women and their families to improve experience and outcomes
Elita Mazzocchi, quality improvement and assurance midwife, Barking,Havering & Redbridge University Hospital Trust

In September 2017, we decided to work on improving women’s experience of induction of labour (IOL) by reviewing and co-designing existing outpatient arrangements. The service at the time involved administration of prostaglandins, which restricted birth location as well as affecting the workload and costing of inpatient services. The aim was to increase the outpatient IOL rate to 5%. The project involved an extensive training programme, which allowed the IOL service to be midwife-led, expanding the midwifery scope of practice and the outpatient IOL criteria to include women requiring low- to intermediate-risk care. This enabled women to have the full induction process at home, and meant they could now deliver at a birth centre. It also allowed staff to provide high-risk care for women without ‘distractions’ in inpatient settings. The project also involved a review of literature available and development of guidelines and a competency pack, information leaflets, etc. The results of the project are excellent: higher vaginal delivery rate (>80%) compared to previously used medical agents for induction (65%), significant reduction in length of stay resulting in 50% cost reduction (saving of >£12,000 per month), increased utilisation of birth centres (>20%), good maternal and neonatal outcomes.


Chair: Julie Richards, chair, RCM board

Factors influencing the utilisation of freestanding and alongside midwifery units in England: a mixed methods research study
Denis Walsh, retired associate professor in midwifery, University of Nottingham

Midwifery units (MUs) are recommended for low-risk births by NICE because they lower rates for CS and other interventions, while maintaining outcomes comparable with obstetric units (OUs). However, they are not available in a quarter of trusts in England and are used by only a minority of low-risk women. This study explores why, using mixed methods to map MU access and utilisation; undertaking case studies in six sites to explore barriers and facilitators; and developing interventions to address these. Ethical approval was gained for the case study component. We found that births in MUs have nearly tripled since 2011 to 15% of all births. However, this increase is almost exclusively in alongside units, whose numbers have doubled. Births in freestanding units have stayed the same, and these are susceptible to closure. Most trust managers, midwifery managers and obstetricians do not regard MU provision as being as important as OU provision, so it does not get embedded as an equal component. Provision and utilisation is influenced by a complex range of factors, including medicalisation, financial constraints and institutional norms, and strategies are required at commissioner and provider level to install MU provision as an essential component of English maternity services.

Why can’t we all just get along? A critical realist review of how to facilitate positive intraprofessional relationships between alongside midwifery units and obstetric units
Alison Corr, teaching associate, University of Nottingham

Alongside midwifery units (AMUs) provide midwife-led care to low-risk women and are situated next to consultant-led obstetric units (OUs). Research indicates a significant problem with intraprofessional, cross-boundary relationships between AMU and OU midwives (McCourt et al, 2016; 2014), resulting in damaging working environments and affecting women transferring between units. A critical realist review was undertaken to explore evidence and uncover macro causal mechanisms relevant to a wide frame of reference. Relevant papers were identified by searching electronic databases. Included papers were read and continuously compared to extract reoccurring results, identified as codes. Similarities and differences between the codes were developed into overarching themes. These were explored using different schools of thought to identify potential causal mechanisms that facilitate or hinder AMU/OU partnerships. Eleven peer-reviewed, primary research articles were included in the review. Themes extracted included: midwives’ identity, medical dominance and surveillance of midwives. Recommendations for practice include identifying and valuing the importance of AMU midwifery skills; rotating midwives between all intrapartum care settings to develop an understanding of each unit’s/midwife’s role; ensuring that all intrapartum care settings are appropriately resourced so that maternity care professionals do not develop a defensive need to protect resources.

Development of a programme for the prevention of post-traumatic stress disorder in midwifery: preliminary effectiveness and feasibility learning
Helen Spiby, professor in midwifery, University of Nottingham and Professor Pauline Slade, professor of clinical psychology, University of Liverpool

Midwives can experience events they perceive as traumatic when providing care and develop post-traumatic stress disorder (PTSD). A national survey with the RCM estimated that at least one in 20 experience clinical levels of PTSD (Sheen et al, 2015). PTSD is distressing and potentially enduring without appropriate psychological intervention. It may also affect quality of care. Strategies to prevent PTSD and support midwives are required. We developed a stepped programme of resources, including universal prevention in the form of a workshop, a peer support system with specifically trained midwives, and access to a clinical psychologist. The programme was implemented to identify feasibility, acceptability and potential utility. Questionnaires measuring trauma exposure, knowledge and confidence of managing trauma responses, professional impacts, PTSD symptoms, burnout and job satisfaction were completed prior to training and approximately six months later. After implementation, midwives’ confidence in recognising and managing early responses to trauma in themselves and colleagues significantly increased. Potential improvements to mental health were detected via reduction in sub-diagnostic levels of PTSD. Significantly higher levels of job satisfaction were reported, with lower levels of depersonalisation and positive implications for the quality of care. There was also reduced service disruption.


Chair: Helene Marshall, board member, RCM

‘I thought they were going to handle me like a queen but they didn\'t’: the impact of supportive leadership on the quality of care that women receive and midwives provide at the time of birth
Jaki Lambert, head of midwifery/consultant midwife, NHS Highland

‘Technically competent care’ is not enough to improve the quality of care for women giving birth (de Souza et al, 2014). But the relationships and culture central to care provision are often given less priority as they are harder to monitor and therefore more challenging to improve (Bohren et al, 2015; Freedman and Kruk, 2014). We explored the maternity care experience to inform how quality of care from the woman and care provider’s perspectives can be monitored and improved by identifying key barriers and facilitators. A descriptive phenomenological approach was used, with a total of 63 interviews including in-depth interviews, focus group discussions and key informant interviews with women who had given birth in the preceding 12 weeks, healthcare providers, managers and policymakers. Following verbatim transcription, thematic framework analysis was used to describe lived experience. Ethical approval was granted. The strongest theme identified was that both women and healthcare providers largely felt alone and unsupported. Visible supportive clinical leadership and a companion whenever women wanted one were the strongest mitigating factors. This was triangulated between women, midwives and key informants. We concluded that supportive visible clinical leadership had the greatest impact on the culture and behaviours in a maternity hospital.

Your birth, we care: women tell us what we know, so what are we going to do about it?
Sarah Fox, consultant midwife, Abertawe Bro Morgannwg University Health Board and Abi Holmes, consultant midwife, Cardiff and Vale University Health Board.

In a survey of 4583 women who gave birth in 2017, four key messages emerged: Models of care – women wanted to understand which professional was responsible for their care but frequently did not. They perceived a lack of birthplace choice, and half were not aware of all four options. Most women wanted to birth outside an obstetric unit (OU), but more birthed in an OU than planned. Antenatal information – clinic appointments were a missed opportunity to discuss birth options, rushed appointments affected ability to build up a relationship with the midwife, but NHS antenatal classes were useful. Information around birth was considered leading. Continuity of carer – respondents linked continuity of carer with good-quality care. Having a ‘good or bad’ midwife had a direct impact on decision-making and choice. Enabling choice – women occasionally had their choice to birth in a midwife-led unit taken away when acuity was high. Respondents believed the OU was the default option for birth. Women valued the opportunity for a birthplace discussion and believed it could contribute to reducing unnecessary intervention. Women’s voices from this survey will provide the backbone of future maternity strategy and ensure the safest care that can meet the needs of women.

Supporting and developing midwifery leaders: a challenge and an opportunity for the profession
Dr Bernie Divall, lecturer in leadership and management, Northumbria University

There has been recognition of the central role for clinical leaders in the NHS and the importance of developing clinicians into formal leadership roles. However, many clinicians do not aspire to such roles. Within midwifery, leadership has been identified as a key priority in the implementation of maternity care policy. There is rising concern about the ageing senior workforce, and recognition of the importance of developing the next generation of leaders has led to a number of initiatives. This study explored the challenge of addressing concerns around leadership and management roles. A qualitative, exploratory design was used, involving narrative interviews with midwifery leaders and internet-mediated discussion with clinical midwives. Topics related to career narratives, clinical leadership roles and career aspirations. While the career narratives of midwifery leaders described their desire to make a difference and demonstrated a clear understanding of the hybrid nature of their role, clinical midwives painted a far more negative picture of leadership. Clinical leaders were perceived as \\\'managers\\\', and there was a lack of attraction to midwifery roles considered as managerial. The findings demonstrate the importance of developing a clear understanding of the many clinical leadership roles available if midwives are to influence maternity care policy.


Chair: Birte Harlev-Lam, board member, RCM

Baby skincare – sharing evidence with new parents to ensure safe and effective best practice
Alison Cooke, lecturer in midwifery, The University of Manchester

There is a rising prevalence of childhood atopic eczema in the UK (Flohr and Mann, 2014), and a number of factors may be contributing to this, including lack of guidance about best baby skincare owing to misunderstandings about evidence and uncertainties about effective and safe baby skincare practices. To develop appropriate, evidence-based guidance, a mixed methods study using concurrent triangulation was undertaken. The study comprised a quantitative survey of 42 lead midwives for education (LMEs), a UK survey of 96 parents, and an exploratory qualitative study using focus groups and interviews with 10 parents, 13 health professionals, five LMEs and four student midwives. A stakeholder group was convened to monitor and inform progress. A lack of awareness among all audiences of the evidence on baby skincare was clear; health professionals who were aware of some of the evidence did not share it with parents in case it violated their professional code; many health professionals adhered to NICE guidance (2015), which doesn’t reflect the current evidence base; parents felt they received conflicting advice; and participants felt that where there was no evidence then the best expert opinion should be given. A clear and simple consistent message on current evidence is needed.

Quantitative fibronectin to help decision-making in women with symptoms of preterm labour: determining decisional requirements (QUIDS qualitative)
Helen White, lecturer/researcher, The University of Manchester

Reducing the detrimental impact of preterm birth relies on timely interventions. However, for those who do not have a preterm birth, interventions are not necessarily benign. Accurate prediction of preterm birth is a challenging clinical priority. The QUIDS study aims to develop a decision-support tool to be used with fetal fibronectin testing. This was a qualitative study, with data collected via focus groups, face-to-face or telephone interviews. Nine clinicians experienced in threatened preterm labour and 12 women with personal experience of, or risk factors for, preterm birth were recruited from three NHS tertiary-referral centres. Interviews were audio recorded, transcribed verbatim and analysed by three researchers, using a framework approach. Ethical approval was granted. Analysis revealed four themes: decision-making, communication, accessing and negotiating care, and impact. Women and clinicians welcomed the ability to predict preterm birth accurately, using fetal fibronectin testing and the decision-support tool. Women wanted to be involved in decision-making to varying extents. Some felt they could make wrong decisions owing to their vulnerability and competing family priorities. Where women trusted clinicians to keep their babies safe, they handed over control. High-quality communication can positively influence women’s experiences of care and trust.

Quality assurance improvement- reducing the avoidable repeat newborn blood spot screening rates- NBSS
Rachel McLean, neonatal screening specialist midwife, University Hospitals of Derby and Burton

In 2015, national guidelines changed on standards for accepting good-quality newborn blood spot samples (NBSSs). Subsequently, our trust had a significant rise in ‘avoidable’ repeat NBSSs (10.8%). But with intervention from the neonatal screening midwife and management support, there has been a steady decline in rejected NBSSs. Staff have received direct individual support from the neonatal screening midwife, and, through collaborative working with line managers, the trust is now considered an example of good practice. The neonatal screening midwife and managers organised ‘fresh eyes’ exercises once a month for four months to quality control NBSSs. Members of staff who had more than three avoidable NBSSs per quarter were given one-to-one training in obtaining good-quality samples. Staff also visited the hospital where the samples are analysed to gain a better understanding of why good-quality NBSSs are important and the potential devastating effects if treatment for the nine serious metabolic conditions is delayed. Since last year, the trust has introduced daily ‘fresh eyes’ in the hospital and community, which has had a significant effect on reducing the number of errors. For the last three quarters of 2017-18, we have achieved NHS England targets and have been asked to showcase our hard work.


Chair: Kate Evans, board member, RCM board

One giant leap for NQMs! Does it have to be?
Nerys Kirtley, midwifery mentorship facilitator, Cardiff and Vale University Health Board

NQMs struggle when they start employment without the support of mentors (Hughes and Fraser, 2011), and resilience and retention is low (DH, 2010). Data collected through anonymous questionnaires showed our NQMs did not feel supported to fulfil their roles and morale was low, leading to a preceptorship programme, called ‘Prep for Practice’, whereby a team of midwives committed to supporting NQMs. Members were allocated as link midwives to give NQMs access to senior midwives in clinical areas. NQMs’ first clinical areas in employment were matched to their final placements, and placement mentors then became their preceptors. Third-year students shadowed our Band 7 coordinators on delivery suite, developing teamworking, caseloading and prioritising skills but also strengthening relationships. We also created learning opportunities for identified gaps in the curriculum, such as recordkeeping. The programme offered support and guidance through WhatsApp groups, meet, greet and orientation days, supernumerary status and development of a manual, allowing our new midwives to feel part of the team and develop their competencies to gain a Band 6. Results have been fantastic so far. When asked ‘Were you supported during the preceptorship programme?’, 100% either strongly agreed or agreed, compared with 45% last year.

Implementing a succession planning programme to assist midwives to develop their own career pathway within maternity services
Brigid McKeown, lead midwife for community midwifery and public health, NHSCT

The State of maternity services report (RCM, 2016) reveals that two in every five midwives (40%) in this region are aged over 50. More worrying, 53.57% of Band 7 midwives are aged over 50 years. Concern is growing about the impact of such a large proportion of our midwifery workforce approaching retirement age. We recognise the need to motivate, enthuse and nurture future midwifery leaders, but fully understand the barriers for midwives with busy lives when contemplating more senior roles. Within our trust, midwifery leaders have worked together to introduce a new and exciting way to inspire and develop Band 6 and 7 midwives. The aim of the succession-planning programme is to assist midwives to develop their own career pathway within the maternity services. This innovative programme is offered to any midwives who meet the set criteria. We were delighted with the response, as almost 20 midwives self-nominated with support from their line managers to participate. The programme covers networking, shadowing and masterclasses and runs over 10 months, with pre/post questionnaires and regular evaluation. It will enable midwives to develop coping and resilience skills, communicate more effectively, build useful networks, motivate teams, plan projects and work collaboratively.

Pressure area care in maternity
Alison Jones, midwife, Cardiff and Vale University Health Board

Pressure ulcers or bedsores occur when an area is placed under pressure, reducing bloodflow and risking the skin breaking down and injury occurring. Following a number of pressure ulcers being sustained by women during a 12-month period, we reviewed midwifery practice. Two main themes were identified: risk assessments for intrapartum pressure area care were not being completed, and appropriate care plans were not being put in place for epidural anaesthesia. We needed a programme of collective learning to improve practice, but a literature review found few maternity-specific documents. Advice was sought from the tissue viability team within the health board and a workbook tailored to midwifery practice was developed. This has been used as part of a presentation for student midwives in their first year of training and the session is now part of the curriculum. Lunch-and-learn sessions have been provided using the workbook, and it is also accessible on the health board clinical portal. Midwives are now able to demonstrate knowledge, skills and competence relevant to their role in caring for those at risk of pressure ulcers, including identification and referral to specialist services, and to promote best practices in the prevention and management of pressure ulcers.