A national survey of obstetric early warning systems in the United Kingdom: five years on.

The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.

Clinical interventions and outcomes of One-to-One midwifery practice.

BACKGROUND: Changing Childbirth became policy for the maternity services in England in 1994 and remains policy. One-to-One midwifery was implemented to achieve the targets set. It was the first time such a service had been implemented in the Health Service. An evaluation was undertaken to compare its performance with conventional maternity care. METHODS: This was a prospective comparative study of women receiving One-to-One care and women receiving the system of care that One-to-One replaced (conventional care) to compare achievement of continuity of carer and clinical outcomes. The evaluation took place in The Hammersmith Hospitals NHS Trust, the Queen Charlotte's and Hammersmith Hospitals. This was part of a larger study, which included the evaluation of women's responses, cost implications, and clinical standards and staff reactions. The participants were all those receiving One-to-One midwifery practice (728 women), which was confined to two postal districts, and all women receiving care in the system that One-to-One replaced, in two adjacent postal districts (675 women), and expecting to give birth between 15 August 1994 and 14 August 1995. Main outcome measures were achievement of continuity of care, rates of interventions in labour, length of labour, maternal and infant morbidity, and breastfeeding rates. RESULTS: A high degree of continuity was achieved through the whole process of maternity care. One-to-One women saw fewer staff at each stage of their care, knew more of the staff who they did see, and had a high level of constant support in labour. One-to-One practice was associated with a significant reduction in the use of epidural anaesthesia (odds ratio (OR) 95 per cent confidence interval (CI) = 0.59 (0.44, 0.80)), with lower rates of episiotomy and perineal lacerations (OR 95 per cent CI = 0.70 (0.50, 0.98)), and with shorter second stage labour (median 40 min vs 48 min). There were no statistically significant differences in operative and assisted delivery or breastfeeding rates. CONCLUSIONS: This study confirms that One-to-One midwifery practice can provide a high degree of continuity of carer, and is associated with a reduction in the rate of a number of interventions, without compromising safety of care. It should be extended locally and replicated in other services under continuing evaluation.

The use of clinical audit in evaluating maternity services reform: a critical reflection.

The clinical evaluation described here, using a casenote study, was part of a larger study evaluating the changes made to part of the maternity services in one NHS Trust, in response to the recommendations of Changing Childbirth (Department of Health 1993a). Results of the audit showed no evidence of a lowering of clinical standards within the study group and provided reassurance that a radical change in the model of care, with greatly enhanced continuity of career, an emphasis on community-based and midwifery-led care, and some reductions in labour interventions, could be implemented without compromising safety of care. The audit process raised a number of methodological problems which will need to be addressed in developing audit approaches which are able to reflect quality of care. It is important to recognize that the record of care is not a direct mirror of the care provided but a secondary source, kept for different purposes and designed to cover a different set of priorities from those which audit may seek to capture. The audit approach used in this study will be modified in continuing evaluation of the service as it moves from a pilot stage towards providing a mainstream service. Additional methods, including direct observation of care, will be employed in a sample of cases in order to assist in interpretation of audit findings.