Supported and Active in Labour (SAIL) · A learning session for midwives and student midwives on helping women through labour This session was developed by Dr Mary Ross-Davie as Educational

Quality Education for a Healthier Scotland

Supported and Active in Labour

(SAIL)A learning session for midwives and student midwives on

helping women through labour

This session was developed by Dr Mary Ross-Davie as

Educational Project Manager for maternal health at NES. The

presentation was used in workshops in NHS GGC and

Lothian from May – September 2016.

The adapted slides are now available to be used by any

midwives wishing to run workshops or work through the

material.


Supported and Active in Labour

SAIL

• Helping women sail

through labour

• Even if it’s not plain

sailing, these approaches

can help you tack to reach

the shore, changing

direction to respond to

changing conditions


Learning Outcomes

By the end of this session you will be able to:

• Describe how maternity services in Scotland and in your local area are evaluated

by service users – particularly in relation to how supported women felt and how active and upright women were able to be during labour and childbirth.

• Describe the evidence for the impact of continuous support in labour on outcomes

• Define high quality labour support

• Describe why support may have a positive impact on outcomes

• Describe the evidence for the impact of upright positions in labour on outcomes

• Describe the benefits of upright positions on the labour process

• Demonstrate upright positions for labour and birth and the use of equipment to

support women being active in labour

• Plan your next steps to improve the support and activity for women you work with


How do women feel we are doing?

Care during labour and birth

• 74% of women rated the care they received in labour as excellent

• 59% said they always had enough help to enable them to cope with

their pain during labour

• 73% of women were able to move around and choose a position that

made them most comfortable during labour, only 32% give birth in an upright position.

• 84% of women said that if they raised concerns during labour these

were always taken seriously and 77% of women who called for

assistance during labour said that they always received it within a reasonable time.

• (Having a baby in Scotland, 2015, Scottish Government)


What women say about care in labour…

• 83% of women said that all staff introduced themselves

• 77% of women said that they were always involved enough in decisions

about their care and 95% that their birth partner was always involved in their care as much as they wanted

• 92% of women said that they had a period of skin to skin contact with

their baby following birth

Women’s comments indicated that they valued the support of skilled,

supportive and confident staff who listened to their concerns, took time

to give them explanations and involved them and their birth

companions in decisions. Women were disappointed by staff who were

dismissive of their concerns, in particular relating to uncertainty about whether labour had started.

(Cheyne et al, 2015)


Are we comfortable with these results?

• Overall in Scotland 1 in 4 women rate their care in labour as less than

excellent

• Nearly 1 in 2 women saying they didn’t have enough help to cope with the pain during labour

• 2 in 3 women gave birth in recumbant or semi-recumbant position

• 1 in 3 women describe giving birth with their legs in stirrups

• 1 in 5 women saying they didn’t always receive help in a timely manner

when they asked for it

• 1 in 5 women saying they didn’t feel they were involved enough in decisions about their care


Understanding women’s experiences in your

health board

• Do you know the results of the national service user survey for your health

board area? You can see individual board reports here:

• How does your board compare to the national picture for feeling well

supported during labour, being left alone during labour, giving birth in an

upright position or in lithotomy?

• What other methods do you currently have in your board for gathering

women’s views about their care in labour and about labour and birth

positions?

• Do you (& all labour ward staff) know your local results in terms of key outcomes: epidural rates, operative birth rates, % of babies with an Apgar

lower than 7 or admitted to SCBU, Caesarean section rates? How do

these compare with other health boards and the overall Scottish rates:


Practice change point

In your birth centre or labour ward do you have the following visible or easily

available for staff to see,

Do you feel it would be helpful to have these visible – could you choose a particular statistic to focus on in different months?

• The month by month operative delivery rates in your unit

• The annual rates for the last 5 years of premature births, stillbirths, neonatal deaths, admissions to

SCBU

• The number of complaints about labour care

• The number of positive comments about labour care (with examples of what was said)

• The % of women giving birth in the pool/using water in labour each month

• The % of women being induced and the reasons

• The % of women having syntocinon

• The % of women having an epidural

• The % of women giving birth in upright positions/in lithotomy each month

• If we don’t have these visible how will staff know if anything is improving or

worsening?


What is the evidence about what helps keep

things as normal as possible in labour?

• In the hierarchy of evidence to

inform practice, the highest level of

evidence is provided by systematic

reviews – Cochrane reviews are a

great example

• If you search the Cochrane

database for which intrapartum

interventions or behaviours have a

positive impact on outcomes, two

interventions come out most

strongly:

• Continuous positive high quality

support

• Upright positions and active labour

and birth


Continuous support v intermittent support

• Hodnett et al’s Cochrane systematic review examined 21 Randomised

controlled trials (RCTs) with over 15,000 women.

• The studies were carried out in many different countries across the world.

• The intervention group had a trained support person (in addition to the

woman’s birth partner) in the room for more than 80% of the woman’s active

labour.

• The support person was, depending on the setting, either a midwife, an

obstetric nurse or a doula.

• The support person was advised to provide the woman with emotional and

physical support and to stay in the room.

• The control group had ‘usual care’ – where caregivers came in and out of

the labour room, without focussing their efforts particularly on providing

emotional and physical support.


The impact of continuous support on

outcomes was clearWomen who received continuous rather than intermittent support during labour

were:

• More likely to have a spontaneous vaginal delivery (18 trials, n= 14,005, RR (relative ratio) 1.08),

• Less likely to have intrapartum analgesia or anaesthesia(13 trials, n=12,169, RR 0.90),

• Less likely to report negative feelings about their childbirth experience (11 trials, n=11,133, RR0.69),

• More likely to have a shorter labour length (11 trials, n=5269, mean difference -0.58 hours),

• Less likely to have an instrumental birth (18 trials, n=14,004, RR0.9),

• Less likely to have a caesarean birth (21 trials, n=15,061, RR0.79)

• Less likely to have a baby that received a low Apgar score at 5 minutes after birth (12 trials, n=12,401, RR0.7)

More than 15,000 women ,

21 RCTs, Cochrane Systematic Reviews, Hodnettet al 2015).


How does RR translate into %?

• RR .90 = 10% less likely to have an epidural (so if you were looking at

10 births instead of having 6 women with an epidural there would be 5)

• RR .69 = 31% less likely to have negative feelings about birth (so if you are looking at 100 births, instead of having 10 women with negative

feelings about the birth there would be 7)

• 21% less likely to have emergency caesareans ( if your emergency cs

rate is 12%, then out of 100 births, instead of 12 CS you would have 8

or 9)

• 30% less likely to have low Apgar

How would it feel to see those data on a graph?


Definitions of intrapartum support


Examples of support behaviours

Emotional Tangible Informational Partner Advocacy

Smiling Eye contact Coaching

breathing

Involving partner Shared

decision

making

Nodding Staying close Relaxation Giving partner: Informing

others of:

Reassuring Hand holding Explaining: - A break - Woman’s

views

Praising Cool compress - Next steps - Food or drink - Care

preferences

Reflecting back Back massage - Next

sensations

- Reassurance Individualise

care

Humour Giving drink - Procedures - Information

Chatting Position

change

Describing: Asking partner’s

view

Empathising Help to toilet - Progress Listening to

partner


Women’s Definitions of support

• Presence of nurse/midwife

• Enabled to feel in control

• Caregiver presents a positive, calm, friendly attitude

• Feeling cared for as an individual

• Praise, reassurance and encouragement

• Help with breathing and relaxation

• Being treated with respect

• Being kept informed

• Being involved in decisions

• Ensuring partner feels supported and involved

• Physical support such as touch and help with position

changes

Lesser and Keane 1956

Shields 1978Field 1987Kintz 1987

Bryanton 1994 & 2008Tarkka and Paunonen 1996

Holroyd 1997Watkins 1998Lavender 1998 &9

Powell-Kennedy 2000Miltner 2000

Tumblin 2001 Bowers 2002, Hodnett 1996, 2002 & 2006,

Matthew and Callister 2003Goodman et al 2004

Lundgren 2005Newburn and Singh 2005Larkin and Begley 2009

‘Intrapartum support: What do women want?’

Evidence Based Midwifery, June 2014

http://issuu.com/redactive/docs/ebm_june_2014


The SMILI study of support in labour

The study was part of the PhD of Mary Ross-Davie at Stirling university

• The aim of the study was to identify whether it was possible to find links

between the quantity and quality of the support provided by the midwife and labour outcomes

• In 2010-2011 the SMILI (Supportive Midwifery in Labour Instrument)

study was undertaken in 4 maternity units in Scotland.

• Four midwives were trained to use the SMILI (a computer based

observation instrument)

• The SMILI allows an observer sitting in the labour room to note down

all of the behaviours of the midwife – particularly focussing on the support behaviours

• 105 hours of observation were undertaken of 45 women in active

labour

• The women were primips and multips, high and low risk

• The midwives were only looking after one woman in active labour


Development of a new systematic observation

instrument:

Testing of the instrument of validity and reliability

• Ethical approval for study provided by University of Stirling and NHS Tayside’s ethics committee

• Clinical testing: Data collection December 2010 – April 2011

• Four maternity units in Scotland, two consultant led units, one consultant led unit with alongside midwife led unit and one midwife led unit

• Information leaflets about study distributed to women and midwives four weeks prior to start and then throughout study

• Consent sought from woman and partner when admitted in early labour or for induction

• Systematic non-participant observation using ‘SMILI’ computer based instrument , observer sitting in corner of the room

• Outcomes data collected – usability, validity, birth outcomes (type of birth, analgesia, medical interventions); women’s views using the Support and Control in Birth (SCIB) questionnaire (Ford and Ayers 2009)



What kind of support is provided? Did the SMILI measure it?

Midwife Behaviours0.7%7.8%

19%

27.6%

34.4%

46%

108%

Emotional Support

Informational Support

Indirect Care

Assessment

Tangible support

Partner support

Advocacy


Do NHS midwives in Scotland provide continuous one to one care to women in

active labour?

Yes. In room on average 90.7% of observation. 25% (n=12) in room >98%; 57% (n=28) present >90%, just 8% (n=4) out of room for >20%

The Answers to the key research questions of the

SMILI study


Quantitative descriptive results:

Quantity of emotional support behaviours


Continuous presence most effective

Statistically significant

correlations:

• The proportion of time

the midwife was out of

the room and the type of

birth

• The longer the midwife

was out of the room the

more likely the woman

was to have an

operative delivery

SVD CSForceps/Ven

touse

Proportion out of room 7.4 13 12

0

2

4

6

8

10

12

14

% of observation

midwife out of

room

Proportion midwife out of room and type of birth

SVD CS Forceps/Ventouse


High quantities of emotional support

most effective

Statistically significant

correlations:

• The more emotional

support given by the

midwife the more likely

the woman was to have

a vaginal birth

• Where emotional

support was recorded

less than the study

average, women 2x as

likely to have a forceps

or ventouse SVD LSCSForceps/Ven

tous

Verbal support 92.1 14.6 52.9

0

10

20

30

40

50

60

70

80

90

100

% Seen in observation

Typeof birth

Amount of verbal support by the midwife and type of birth


And women noticed!

We asked women within 48 hours of the

birth about how supported they felt

in labour by their midwife,

We used a validated questionnaire

called the SCIB – Support and

Control in Birth (Ayers et al, 2009)

The top ‘score’ that a woman could give

to a midwife was 5/5

Women were generally very very

positive about the support they

received

But you can see from the graph there

was some variability with a handful

of women giving some lower scores


Relationship between women’s views and SMILI data

Variable Low scoring

midwives

(n=7) %

Overall study

mean (n=49)

%

High scoring

midwives

(n=32) %

Proportion midwife of room 13.0 9.3 7.5

Neutral professional

demeanour

49.9 37.7 29.8

Lack of attentiveness 36.3 26.2 19.9

Negative behaviours 17.2 11.6 5.0

Emotional Support 280.1 395.5 422

Rapport building 15.4 36.0 42.9

Informational support 30.1 38.9 42.5

Physical support 13.1 18.8 21.4

Partner support 2.3 7.5 8.7

Non-support direct care 3.1 2.9 2.9

Assessment 23.2 27.7 29.1


Summary of the Evidence about support

• Continuous intrapartum support is where the

midwife stays in the room for >80% of the

woman’s labour.

• Continuous support, when compared to

intermittent, improves a whole range of

outcomes.

• Observational research in Scotland (SMILI) found that midwives that provided higher quantities of

support, particularly emotional support, had

higher ratings from women and higher SVD rates

than midwives who were out of the room more

and gave less support when they were in it.

• Rapport building, encouragement and non verbal

friendly presence highly effective in improving

outcomes, including women’s experience


Positions for labour and childbirth

https://www.youtube.com/watch?v=0J5xlBmJHTI

https://www.youtube.com/watch?v=0J5xlBmJHTI


Today’s normal

https://youtu.be/MSmkT

LqHR3M

better births presentation mrd.pptx


Hierarchy of evidence

Let’s have a look at the

evidence again.

• There are several

systematic Cochrane

reviews

• There are also a range

of other studies, further

down the the hierarchy


25 methodologically

variable studies

5218 women


Lawrence et al 2013

Upright v Recumbent(standing, sitting, kneeling, walking) (supine, semi-recumbent and lateral)

• Upright intervention group 1st Stage – 1 hour 22 minutes shorter

• Less Likely to have a Caesarean – RR 0.71 (29% lower)

• Less Likely to have an Epidural – RR 0.81 (19% lower)

• Babies less likely to be admitted to SCBU – RR 0.20 (but just one

study, 200 women)


They conclude…

There is clear and important evidence that walking and

upright positions in the first stage of labour reduces

the duration of labour, the risk of caesarean birth, the

need for epidural and does not seem to be

associated with increased intervention or negative

effects on mothers’ and babies’ well being.

Based on the current findings, we recommend that

women in low-risk labour should be informed of the

benefits of upright positions, and encouraged and

assisted to assume whatever position they choose


Gupta et al 2012

‘Position in 2nd stage of labour for women without

an epidural’

• 22 Trials, variable quality

• 7280 women

• Upright positions v recumbent

• Significant reduction in operative deliveries (RR0.78)

• Significant reduction in episiotomies (RR 0.79)

• Fewer abnormal fetal heart rates (RR 0.46)

• Non-significant reduction in duration of 2nd stage (-

3.71 min)

• Increased 2nd degree tears and blood loss >500ml

(but this was around 60ml)


Kemp et al, 2013

‘Position in 2nd stage for women with an epidural’

• 5 RCTs

• 879 women

• Non-significant difference in operative

deliveries RR 0.97

• Reduction in length of 2nd stage -22.98

mins

• But no difference in perineal trauma and

fetal distress, low cord ph or admission

to SCBU


NICE Intrapartum Care guideline 2014

‘ Encourage and help

the woman to move

and adopt whatever

positions she finds

most comfortable

throughout labour’


RCM Evidence Based

Guidelines 2010

Mobility and upright positions are recommended for:

Physiological Benefits

Effect of gravity on the fetus in utero

Reduced risk of aorto-caval compression

Better alignment of the fetus

Increased efficiency of contractions

Increased pelvic outlet

Psychological Benefits

Enables woman to feel more in control

Reduces severity of pain


Literature Review: Romano and Lothian 2008,

‘Promoting, protecting and supporting normal

birth, A look at the evidence’ 6 key practices

Avoid unnecessary Induction of

labour

Nonsupine spontaneous

pushing

Continuous labour support

Freedom of movement

Avoid routine interventions

and restrictions

Keep mothers and babies

together


Observational study: Reitter et al, 2014, ‘Does

pregnancy and or shifting positions create more

room in a woman’ pelvis?’

• 50 pregnant women, 50 non-pregnant

• MRI to take pelvic measurements:

• Transverse and AP

• Significant increase in Transverse

diameter of 0.9 – 1.9 cm (7-15%) in

kneeling squat for pregnant and non-

pregnant women

• Bispinous diameter in pregnant group

from 12cm in supine to 14.5 cm in

kneeling squat


Some videos to illustrate what is happening

CUB animation:

https://youtube.com/w

atch?v=gVjqStN0y

Q0&feature=youtu.

be

Pelvis Movil

http://linkis.com/www.y

outube.com/PGYUC

https://youtube.com/watch?v=gVjqStN0yQ0&feature=youtu.be

http://linkis.com/www.youtube.com/PGYUC


Expert Opinion: Simkin and Ancheta 2000

To the traditional 3 Ps they added 2 more:

Powers Passenger Pelvis Pain Psyche

Nature’s carefully orchestrated plan for labor and

birth is easily disrupted,

We need to be sure we know how to promote,

protect and support the normal physiological process


Evidence from research about culture

• ‘Culture eats evidence for breakfast’ – whether women are upright is

heavily influenced by their educational level, the philosophy of their

carer and the location of care:

• Dahlen et al 2013, study in Australia: women in midwife led units or

receiving midwife led continuity models of care much more likely to

labour and birth upright (kneeling all fours 48%, waterbirth 13%...)

• Priddis et al 2012, literature review on the facilitators, inhibitors and implications of birth positioning, lack of good research. But very

influenced by health professionals’ philosophy of care.

• De Jonge et al, 2009, study in the Netherlands, found that older women

with higher socio-demographic status were more likely to use upright positions in labour and birth.

• Our role is vital, particularly for women in labour wards with less

education.


Films from betterbirths.rcm.org.uk

15 minute film

introducing different

positions in birth

suite and labour

ward:

http://betterbirths.rcm.

org.uk/resources/intr

oduction-to-

positions-used-in-

labour-and-birth/

Birth ball while on

synto


org.uk/resources/usi

ng-a-birth-ball-for-

labour-and-birth-

when-connected-to-

a-monitor/

Using hospital bed as

chair


http://betterbirths.rcm.org.uk/resources/introduction-to-positions-used-in-labour-and-birth/

http://betterbirths.rcm.org.uk/resources/using-a-birth-ball-for-labour-and-birth-when-connected-to-a-monitor/


Upright positions – does it really matter?

• Upright positions in labour shorten labour significantly,

reduce the need for epidural analgesia, reduce caesarean

sections. Fewer admissions to SCBU/ abnormal FHR/ low

Apgars

• Psychological benefits for women

• No increase in OASIS, reduced episiotomies, more 2nd

degree tears

• Slight increase in blood loss (link to perineal trauma)

• We can improve what we are doing, the key is changing

behaviours by midwives through building motivation,

taking action and prompting positive behaviours.


So What is stopping us doing this every time for

every woman?

What are the things that are

stopping us:

• Being in the room for >80% of the time

• Providing ++ support

• Helping the woman in to different positions – labour

• Helping women give birth off the

bed and upright

What are the

possible solutions to

each of these

problems?


Building motivation among the labour ward

team...

Posters – changed regularly, with key facts and pictures:

‘Did you know upright positions can increase the transverse diameter of the pelvis by 15%?’

Rewards for improvements in numbers of women giving birth in an upright position –individual, shift or team?

Sell benefits of upright positions and activity for midwives’ health and well being


Action

:Audit

before

and after.

RCM

Birth

positions

audit tool

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiIgrG3-JfMAhWCCBoKHcsyASwQjRwIBw&url=http://www.nursingandmidwiferycareersni.hscni.net/employers/&psig=AFQjCNEUsq7UPMpqWTnyNGwDkVy2s6vNQw&ust=1461060441688569


Prompts

• Right thing to do

the easiest thing to

do:

• Laminated pictures

in rooms

• Sessions with

MSWs on setting

up rooms

• Start of shift room

sweep,

• Pre-admission

‘nest building’


Can we make a quality improvement plan today?

• What will your goal be?

• When do we want to reach that

goal?

• When will you start?

• What will be your first 5 actions?

• Is a PDSA cycle possible?

• Does this fit a driver diagram?


Thank you and Good Luck with Setting Sail!

Documents

Supported and Active in Labour (SAIL) · A learning session for midwives and student midwives on helping women through labour This session was developed by Dr Mary Ross-Davie as Educational