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Safe midwifery staffing for maternity settings

About

What is covered

This pathway covers safe midwifery staffing requirements for maternity settings, based on the best available evidence. It does not cover national or regional level workforce planning or recruitment, although its content may inform these areas.
In this pathway, the terms midwife and midwifery refer to registered midwives only. Maternity support workers or other staff working alongside midwives are not included in this definition.
The recommendations in this pathway cover all aspects of care provided by a midwife employed to provide NHS-funded maternity care in:
  • all maternity services (for example, clinics, home visits, maternity units)
  • all settings where maternity care is provided (for example, home, community, free-standing and alongside midwifery-led units, hospitals including obstetric units, day assessment units, and fetal and maternal medicine services)
  • the whole maternity pathway (pre-conception, antenatal, intrapartum and postnatal).
Recommendations in organisational requirements focus on the responsibilities that organisations have and the actions they should take to support safe midwifery staffing requirements in all maternity settings.
The recommendations in set the midwifery staffing establishment describe the process and the factors to consider when setting midwifery staffing establishments. The process could also be used as the specification for a toolkit for setting the midwifery staffing establishment.
Recommendations in assess differences in midwives needed and available are about ensuring that maternity services can respond to increased demand for midwifery staff and to differences between the number of midwives needed and the numbers available.
Recommendations in monitor and evaluate midwifery staffing requirements and red flags are about monitoring whether safe midwifery staffing requirements are being met. This includes recommendations to review midwifery staffing establishments and adjust them if necessary.

Updates

Updates to this pathway

9 December 2015 Intrapartum care (NICE quality standard 105) added to the pathway.
23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on safe midwifery staffing requirements for maternity settings in an interactive flowchart

What is covered

This pathway covers safe midwifery staffing requirements for maternity settings, based on the best available evidence. It does not cover national or regional level workforce planning or recruitment, although its content may inform these areas.
In this pathway, the terms midwife and midwifery refer to registered midwives only. Maternity support workers or other staff working alongside midwives are not included in this definition.
The recommendations in this pathway cover all aspects of care provided by a midwife employed to provide NHS-funded maternity care in:
  • all maternity services (for example, clinics, home visits, maternity units)
  • all settings where maternity care is provided (for example, home, community, free-standing and alongside midwifery-led units, hospitals including obstetric units, day assessment units, and fetal and maternal medicine services)
  • the whole maternity pathway (pre-conception, antenatal, intrapartum and postnatal).
Recommendations in organisational requirements focus on the responsibilities that organisations have and the actions they should take to support safe midwifery staffing requirements in all maternity settings.
The recommendations in set the midwifery staffing establishment describe the process and the factors to consider when setting midwifery staffing establishments. The process could also be used as the specification for a toolkit for setting the midwifery staffing establishment.
Recommendations in assess differences in midwives needed and available are about ensuring that maternity services can respond to increased demand for midwifery staff and to differences between the number of midwives needed and the numbers available.
Recommendations in monitor and evaluate midwifery staffing requirements and red flags are about monitoring whether safe midwifery staffing requirements are being met. This includes recommendations to review midwifery staffing establishments and adjust them if necessary.

Updates

Updates to this pathway

9 December 2015 Intrapartum care (NICE quality standard 105) added to the pathway.
23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Intrapartum care (2015) NICE quality standard 105

Quality standards

Intrapartum care

These quality statements are taken from the intrapartum care quality standard. The quality standard defines clinical best practice for intrapartum care and should be read in full.

Quality statements

Choosing birth setting

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.

Rationale

Women at low risk of complications during labour and birth need information that is specific to their local or neighbouring area about safety and outcomes for women and babies in the different birth settings. This information will help women to make informed choices about where to have their baby.

Quality measures

Structure
a) Evidence of local arrangements to provide women at low risk of complications with a choice of all 4 birth settings.
Data source: Local data collection.
b) Evidence of local arrangements to provide women at low risk of complications with local information about birth outcomes.
Data source: Local data collection.
Process
a) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Data source: Local data collection.
b) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Outcome
Maternal experience and satisfaction with place of birth.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (community, primary and secondary care services) raise awareness of maternity pathways and ensure that systems and tools are in place to offer women at low risk of complications a choice of all 4 birth settings and local information about birth outcomes to support them to make informed decisions about where to have their baby.
Healthcare professionals provide women at low risk of complications with local information about birth outcomes and rates of transfer to an obstetric unit for all birth settings, and support them to make informed decisions about where to have their baby. Healthcare professionals can adapt and use NICE's choosing place of birth resource for midwives to do this.
Commissioners (clinical commissioning groups) commission maternity services to ensure that all 4 birth settings are available in the local or a neighbouring area to women at low risk of complications. Commissioners also ensure that services provide local information about outcomes for women and babies and rates of transfer to an obstetric unit for all birth settings to support women to make informed decisions about where to have their baby. Commissioners coordinate collection of outcome data in local and neighbouring areas to help service providers and healthcare professionals giving information to women. Commissioners can refer to the costing statement for the guideline on intrapartum care for healthy women and babies for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

Women at low risk of having problems during labour and birth have a choice of 4 places where they can have their baby – at home, in a midwife-led unit that is either next to a hospital obstetric unit or in a different place, or in an obstetric unit (‘labour ward’). To help women make an informed choice, they are given information by their midwife about birth outcomes and rates of transfer to an obstetric unit for their local or neighbouring area. Birth outcomes are things like the chances of needing a ventouse or forceps birth, caesarean section or episiotomy, and the risk of serious medical problems for the baby.

Source guidance

Definitions of terms used in this quality statement

4 birth settings
The 4 settings where a woman at low risk of complications may choose to have her baby are: at home, in a freestanding midwifery unit, in an alongside midwifery unit and in an obstetric unit.
[Intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.1.2]
Birth outcomes
Outcomes for women for each planned place of birth include rates of spontaneous vaginal birth, transfer to obstetric unit, obstetric intervention and delivering a baby with or without serious medical problems.
[Adapted from intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.1.3]

One-to-one care

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women in established labour have one-to-one care and support from an assigned midwife.

Rationale

One-to-one care will increase the likelihood of the woman having a ‘normal’ vaginal birth without interventions, and will contribute to reducing both the length of labour and the number of operative deliveries. Care will not necessarily be given by the same midwife for the whole labour.

Quality measures

Structure
Evidence of midwifery staff available to provide one-to-one care to women in established labour in each birth setting.
Data source: Local data collection.
Process
Midwifery staffing levels as in the NICE guideline on safe midwifery staffing for maternity settings.
Numerator – The number of women in the denominator who receive one-to-one care from an assigned midwife during established labour.
Denominator – The number of women in established labour in a time period.
Data source: Local data collection.
Outcome
a) Neonatal morbidity.
Data source: Local data collection.
b) Maternal morbidity.
Data source: Local data collection.
c) Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) ensure that recommended midwifery staffing ratios are maintained so that women in established labour have one-to-one care and support from an assigned midwife.
Healthcare professionals (assigned midwives) give one-to-one care to each woman in established labour and are solely dedicated to the care of that woman.
Commissioners (clinical commissioning groups) commission services that have systems in place to maintain recommended midwifery staffing ratios, so that women in established labour have one-to-one care and support from an assigned midwife. Commissioners can refer to the costing statement for the guideline on intrapartum care for healthy women and babies for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

A woman in labour is cared for by a midwife who is looking after just her – this is called ‘one-to-one care’. She might not have the same midwife for the whole of labour. One-to-one care aims to ensure that the woman has a good experience of care and reduces the likelihood of problems for her and her baby.

Source guidance

Definitions of terms used in this quality statement

Established labour
Labour is established when:
  • there are regular painful contractions and
  • there is progressive cervical dilatation from 4 cm.
[Intrapartum care for healthy women and babies (NICE guideline CG190) recommendation 1.3.1]

Cardiotocography and the initial assessment of a woman in labour

This statement has been removed. For more details see update information in the intrapartum care quality standard.

Stopping cardiotocography

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

Rationale

Cardiotocography is offered to women if intermittent auscultation indicates possible fetal heart rate abnormalities. However, cardiotocography that is started for this reason should be stopped if the trace is normal for 20 minutes, because it restricts the woman’s movement and can cause labour to slow down. This can lead to a cascade of interventions that may result in adverse birth outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications having cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Data source: Local data collection.
Process
Proportion of women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Numerator – The number in the denominator who have the cardiotocograph removed.
Denominator – The number of women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation and who have a normal trace for 20 minutes.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners.

Service providers (for freestanding midwifery units, alongside midwifery units and obstetric units) have evidence of local arrangements to ensure that protocols are in place so that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Healthcare professionals (midwives and obstetricians) remove the cardiotocograph if the trace is normal for 20 minutes for women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

What the quality statement means for women and their companions

Women who are at low risk of problems during labour, but who have electronic monitoring because of possible concerns about the baby's heartbeat, are taken off the monitor if the baby’s heartbeat is normal for 20 minutes.

Source guidance

Definitions of terms used in this quality statement

Normal cardiotocograph trace
A normal trace has the following normal/reassuring features:
  • baseline fetal heart rate of 100 to 160 beats per minute and
  • baseline variability of 5 beats per minute or more and
  • no or early decelerations.
[Intrapartum care for healthy women and babies (NICE guideline CG190) table 10]

Interventions during labour

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women at low risk of complications are not offered amniotomy or oxytocin if labour is progressing normally.

Rationale

For women at low risk of complications, amniotomy and oxytocin do not reduce the incidence of caesarean section, increase the incidence of spontaneous vaginal births or contribute to improved neonatal outcomes. They are therefore unnecessary for women at low risk of complications if labour is progressing normally.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications who are in labour that is progressing normally do not have amniotomy or oxytocin.
Data source: Local data collection.
Process
Proportion of women at low risk of complications whose labour is progressing normally who do not have amniotomy or oxytocin.
Numerator – The number in the denominator who do not have amniotomy or oxytocin.
Denominator – The number of women at low risk of complications whose labour is progressing normally.
Data source: Local data collection.
Outcome
a) The number of women in labour that is progressing normally having amniotomy or oxytocin.
Data source: Local data collection.
b) Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.
Healthcare professionals (midwives and obstetricians) do not offer amniotomy or oxytocin to women at low risk of complications whose labour is progressing normally.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.

What the quality statement means for women and their companions

Women who are at low risk of having problems and whose labour is progressing normally are not offered amniotomy (having their waters broken) or oxytocin (a medicine given through a drip that speeds up labour).

Source guidance

Definitions of terms used in this quality statement

Normal labour and normal progression of labour
The NICE full guideline on intrapartum care for healthy women and babies adopts the World Health Organization definition of a normal labour: ‘labour is normal when it is spontaneous in onset, low risk at the start and remaining so throughout labour and birth. The baby is born spontaneously and in the vertex position between 37–42 completed weeks of pregnancy. After birth woman and baby are in good condition’.

Delayed cord clamping

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women do not have the cord clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.

Rationale

The benefits of delayed cord clamping include higher haemoglobin concentrations, a decreased risk of iron deficiency and greater vascular stability in babies. If they wish, women can ask healthcare professionals to wait longer to clamp the cord.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians do not clamp the cord earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Process
a) Proportion of cords clamped earlier than 1 minute after the birth where there is not a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped after 1 minute after the birth.
Denominator – The number of babies born where there is no concern about cord integrity or the baby’s heartbeat.
b) Proportion of cords clamped earlier than 1 minute where there is a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped earlier than 1 minute after the birth.
Denominator – the number of babies born where there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Healthcare professionals (midwives and obstetricians) do not clamp the cord earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.

What the quality statement means for women and their companions

Women who have just given birth do not have the cord clamped for at least 1 minute after the birth unless there are concerns about the baby. This is to allow more blood to reach the baby and may help to prevent anaemia.

Source guidance

Definitions of terms used in this quality statement

Cord integrity
Concerns would arise over cord integrity if the cord was damaged in any way, if it had snapped during delivery or if there was bleeding to the cord. Definitions of cord integrity are not limited to those stated here.
[Expert opinion]
Concern about the baby’s heartbeat
Concern would arise if, after delivery, the baby has a heartbeat below 60 beats/minute that is not getting faster.
[Adapted from Intrapartum care for healthy women and babies (NICE guideline CG190), recommendation 1.14.14]

Skin-to-skin contact

This quality statement is taken from the intrapartum care quality standard. The quality standard defines clinical best practice in intrapartum care and should be read in full.

Quality statement

Women have skin-to-skin contact with their babies after the birth.

Rationale

Skin-to-skin contact with babies soon after birth has been shown to promote the initiation of breastfeeding and protect against the negative effects of mother–baby separation.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians encourage women to have skin-to-skin contact with their babies after the birth.
Data source: Local data collection.
Process
Proportion of women with a record of having skin-to-skin contact with their babies after the birthIt is important that this happens as soon as possible, but timescales should be determined locally, depending on the setting and whether the baby and mother are stable..
Numerator – The number in the denominator where there is a record of the woman having skin-to-skin contact with the baby.
Denominator – The number of babies born.
Data source: Local data collection.
Outcome
Women’s satisfaction with the support received to have skin-to-skin contact with their babies after the birth.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (for all 4 birth settings) have protocols in place for midwives and obstetricians to encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Healthcare professionals (midwives and obstetricians) encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

What the quality statement means for women and their companions

Women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Consider risk, acuity and dependency of each woman and baby when assessing maternity care needs

Risk

  • Age
  • Cardiovascular
  • Complications (previous)
  • Current pregnancy
  • Disabilities
  • Endocrinological
  • Fetal
  • Gastrointestinal
  • Gynaecological
  • Haematological
  • Immunological
  • Infective
  • Learning difficulties
  • Neurological
  • Obesity
  • Psychiatric
  • Renal
  • Respiratory
  • Skeletal
  • Substance use

Antenatal acuity/dependency

  • No significant intervention required
  • Induction of labour
  • Requires specialised care
  • Requires treatment

Intrapartum acuity/dependency

  • Apgar score
  • Birth trauma
  • Birth weight
  • Caesarean section
  • Death
  • Duration of labour
  • Gestation
  • Operative vaginal delivery
  • Post-delivery emergency

Postnatal acuity/dependency

  • Moderate dependency
  • Readmission
  • Straight forward
  • Transfer out

Examples of environmental factors to consider when assessing maternity care needs

Local service configuration or models of care, for example:

  • Consultant-led care
  • Midwife-led care
  • Shared care

Unit/department layout, for example:

  • Number of beds, units, bays (and distance between them)

Availability of and proximity to related services, for example:

  • Breastfeeding clinics
  • Fetal medicine department
  • Maternal medicine department
  • Other specialist centres

Local geography and availability of neighbouring maternity services, for example:

  • Travel time between services

Examples of staffing factors to consider when assessing maternity care needs

Availability of non-midwifery staff, for example:

  • Allied health professionals (e.g. sonographers)
  • Clerical staff and data inputters
  • GPs
  • Maternity support workers
  • Medical consultants
  • Nursery nurses
  • Registered nurses
  • Temporary staff

Examples of maternity care activities that affect midwifery staffing

Antenatal
Intrapartum
Postnatal
All stages of care
Part A: Examples of routine care activities
Booking appointment
Routine intrapartum care including assessment, support, monitoring, management
Routine postnatal care including observations, hygiene, discharge planning
Routine administration including care planning, case notes, referrals
Antenatal appointment including assessment, education, lifestyle advice and fetal monitoring
One-to-one care during established labour
Newborn assessment/examination/screening/vaccination (e.g. heel prick, hearing, vitamin K administration)
Checking/ordering/chasing (e.g. preparing medication, checking specialist equipment, checking blood results)
Antenatal screening and tests (e.g. fetal heart auscultation/scan)
Postnatal appointment including assessment, education, advice and infant monitoring
Transfers
Part B: Examples of activities that may need additional time
Admission to labour ward or day unit
Additional monitoring/Interventions (e.g. cannula, epidural, fetal monitoring, induction of labour)
Maternal or neonatal death including arrangements after death and support for relatives and carers
Case conferences
Providing additional antenatal screening and tests (e.g. fetal anomaly)
Managing complications (e.g. managing fetal distress, complicated birth)
Managing complications (e.g. postpartum haemorrhage, difficulty establishing infant feeding)
Additional time for the following:
  • Consideration of preferred place of birth (e.g. home birth)
  • Providing care for women needing specialist input (e.g. female genital mutilation)
  • Managing specific clinical conditions (e.g. diabetes)
  • Managing specific social issues (e.g. child protection, safeguarding)
  • Communicating with women and carers/family including those with sensory impairment or language difficulties
  • Providing additional education, training and emotional support (e.g. new medication, equipment or diagnosis in baby/mother)
Providing antenatal vaccinations (e.g. flu)
Specialising/high dependency/intensive care
Coordination of service, or liaison with multidisciplinary team, or other services
Escorts/transitional care
Note: these activities are only a guide and there may be other activities that could also be considered.
For further information please see the relevant NICE pathways:

Midwifery red flag events

A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. If a midwifery red flag event occurs, the midwife in charge of the service should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed.
  • Delayed or cancelled time critical activity.
  • Missed or delayed care (for example, delay of 60 minutes or more in washing and suturing).
  • Missed medication during an admission to hospital or midwifery-led unit (for example, diabetes medication).
  • Delay of more than 30 minutes in providing pain relief.
  • Delay of 30 minutes or more between presentation and triage.
  • Full clinical examination not carried out when presenting in labour.
  • Delay of 2 hours or more between admission for induction and beginning of process.
  • Delayed recognition of and action on abnormal vital signs (for example, sepsis or urine output).
  • Any occasion when 1 midwife is not able to provide continuous one-to-one care and support to a woman during established labour.
Other midwifery red flags may be agreed locally.

Safe midwifery staffing indicators

Indicators are positive and negative events that should be reviewed when reviewing the midwifery staffing establishment, and should be agreed locally.

Outcome measures reported by women in maternity services

Data for the following indicators can be collected using the Maternity Services Survey:
  • Adequacy of communication with the midwifery team.
  • Adequacy of meeting the mother's needs during labour and birth
  • Adequacy of meeting the mother's needs for breastfeeding support.
  • Adequacy of meeting the mother's postnatal needs (postnatal depression and post-traumatic stress disorder) and being seen during the postnatal period by the midwifery team.

Outcome measures

  • Booking appointment within 13 weeks of pregnancy (or sooner): record whether booking appointments take place within 13 weeks of pregnancy (or sooner). If the appointment is after 13 weeks of pregnancy the reason should also be recorded, in accordance with the Maternity Services Data Set.
  • Breastfeeding: local rates of breastfeeding initiation can be collected using NHS England's Maternity and Breastfeeding data return.
  • Antenatal and postnatal admissions, and readmissions within 28 days: record antenatal and postnatal admission and readmission details including discharge date. Data can be collected from the Maternity Services Data Set.
  • Incidence of genital tract trauma during the labour and delivery episode, including tears and episiotomy. Data can be collected from the Maternity Services Data Set.
  • Birth place of choice: record of birth setting on site code of intended place of delivery, planned versus actual. Data can be collected from the Maternity Services Data Set.

Staff-reported measures

  • Missed breaks: record the proportion of expected breaks that were unable to be taken by midwifery staff.
  • Midwife overtime work: record the proportion of midwifery staff working extra hours (both paid and unpaid).
  • Midwifery sickness: record the proportion of midwifery staff's unplanned absence.
  • Staff morale: record the proportion of midwifery staff's job satisfaction. Data can be collected using the NHS staff survey.

Midwifery staff establishment measures

Data can be collected for some of the following indicators from the NHS England and Care Quality Commission joint guidance to NHS trusts on the delivery of the 'Hard Truths' commitments on publishing staffing data regarding nursing, midwifery and care staff levels and more detailed data collection advice since provided by NHS England.
  • Planned, required and available midwifery staff for each shift: record the total midwife hours for each shift that were planned in advance, were deemed to be required on the day of the shift, and that were actually available.
  • The number of women in established labour and the number of midwifery staff available over a specified period, for example 24 hours.
  • High levels and/or ongoing reliance on temporary midwifery staff: record the proportion of midwifery hours provided by bank and agency midwifery staff on maternity wards. (The agreed acceptable levels should be established locally.)
  • Compliance with any mandatory training in accordance with local policy (this is an indicator of the adequacy of the size of the midwifery staff establishment).
Note: other safe midwifery staffing indicators may be agreed locally.

Glossary

refers to the seriousness of a woman or baby's condition, the risk of clinical deterioration and their specific care needs
the period of time after conception and before birth
The balance between time spent providing direct care and indirect care such as attendance at multidisciplinary team meetings, ward rounds and discharge planning. See the NHS England website for further details.
the level to which a woman or baby is dependent on direct care to support their physical and psychological needs and activities of daily living, such as eating and drinking, personal care and hygiene, and mobilisation
established labour is when there are regular and painful contractions, and there is progressive cervical dilatation from 4 cm
In the context of this pathway establishment refers to the number of registered midwives funded to work in an organisation providing maternity care. This includes all midwives in post, as well as unfilled vacancies or vacancies being covered by temporary staff. Midwife establishments are usually expressed in number of whole-time equivalents.
positive or negative signs that can be monitored and used to inform future midwifery staff requirements or prevent negative events related to midwifery staffing levels happening in the future
the period of time from the start of labour to birth of the baby and delivery of the placenta and membranes
Care and treatment provided in relation to pregnancy and delivery of a baby. It is influenced by the physical and psychosocial needs of the woman, the woman's entire family, and the baby. Maternity care is provided by a range of healthcare professionals.
qualified midwives who are registered with the Nursing and Midwifery Council
Red flag events are negative events that are immediate signs that something is wrong and action is needed now to stop the situation getting worse. Action includes escalation to the senior midwife in charge of the service and the response may include allocating additional staff to the ward or unit.
used to describe the number of registered midwives that are needed for the establishment and on each day
Staff who are available to work at short notice during the period of time that they are not rostered to work or off duty. The on-call arrangements should be locally agreed and should not deplete other areas of care.
care provided for the woman throughout labour exclusively by a midwife solely dedicated to her care (not necessarily the same midwife for the whole of labour)
the first 6 weeks after birth
in the context of this pathway, pre-conception refers to care provided by midwives to women before they are pregnant
a period of time when newly qualified midwives are supported by a clinical instructor or preceptor
the daily staffing schedule for each maternity service
the composition of the midwifery team in terms of qualification and experience
Aims to safeguard and enhance the quality of care for childbearing women and their families. Its primary purpose is to protect women and babies by actively promoting safe standards through ensuring that midwives are fit to practice autonomously and by initiating action when a midwife's fitness to practice is impaired.
local bank or agency staff
a practical resource to facilitate the process of calculating midwifery staffing requirements for maternity services. It may be electronic or paper-based
uplift is likely to be set at an organisational level and takes account of annual leave, maternity leave, paternity leave, study leave (including time to give and receive supervision) and sickness absence

Paths in this pathway

Pathway created: February 2015 Last updated: February 2017

© NICE 2017

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