The role of the Royal College of Midwives

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Developing guidelines for midwife-led care

• The role of the Royal College of Midwives
• in
• leading practice
• Frances Day-Stirk
• Royal College of Midwives
• Director Learning Research Practice Development
• International Office

Rio de Janeiro 4 November 2009
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The voice of midwifery in the United Kingdom

• Professional organisation and trade union for
  midwives led by midwives for midwives
• The vast majority of the midwifery profession are
  members. 
• represents the interests of midwives in all four
  UK countries individually and collectively. 
• promote excellence, innovation and leadership in
  the care of childbearing women, the newborn and
  their families, nationally and internationally. 
•  

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Strategic intentions

• As part of the strategy to promote the
  midwifery profession and support midwifery
  practice, the Royal College of Midwives (RCM)
  developed several of approaches
• Aim to improve midwifery practice and encourage
  a national standard of practice, by producing
  quality reference (d) documents for local use

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Key initiatives

• RCM Evidence Based Midwifery peer-reviewed
  research journal launched 2003
• promotes the dissemination,
• implementation and
• evaluation of midwifery evidence
• locally, nationally and internationally.
• publishes papers - qualitative or quantitative
  research studies, philosophical analyses and
  systematic reviews. 

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• Midwife-led care has an underpinning philosophy
  of labour as a normal physiological process. It
  also recognises that, for the woman, labour is
  not just normal but actually extraordinary as
  a good or bad experience it has great
  implications for her psychological well-being and
  her relationships with her family
• Wiklund et al 2008 Lemola et al 2007
  Waldenstrom et al 2004 Simkin 1992

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• Hands-on guidance for midwives doing home
  birth (2003)
• Common concerns when developing home birth
  practice
• Guidance on practical information
• Antenatal preparation, labour and postnatal care
  in the home environment

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Evidence-based midwifery led care in labour

• First two editions- developed for use in one NHS
  Trust, UK
• (Helen Spiby Jane Munro)
• Third edition- commissioned by the Royal College
  of Midwives
• intrapartum care in midwifery-led environments,
  midwifery-led schemes

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Guiding principles

• Process for developing and evaluating guidelines
  should focus on outcomes valued by users
• The guidelines should be based on best available
  evidence and include a statement about the
  strength of evidence
• A sound method of critical analysis should be
  adopted
• The guidelines should be flexible and adaptable
• There is evidence of user involvement and other
  appropriate professionals

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The Process

• Suitability screen
• Scope
• Literature search
• Grading of recommendations
• Audit
• Peer Review
• Declaration of interests
• Support
• Disclaimer

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Context and philosophy

• Evidence base to midwifery care
• Clinical practice guidelines
• Midwifery-led approaches to care
• Information and involvement in decision-making

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Identifying topics for inclusion

• Preparatory survey
• usefulness acceptability to midwives
• Identification of topics via stakeholders
• Midwives - Evidence Based Midwifery Network
  Royal College of Midwives
• Women - via User Groups at national level

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Literature review

• prospective randomised controlled trials
• midwives research and reviews exploring
  womens views
• professional bodies (RCM RCOG) and
  government policy directives
• expert opinion

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Search strategy
Search of electronic databases Cochrane, Medline, CINAHL, MIDIRS Guideline databases and collections Hand searching of six key journals English language papers or abstracts Publication period Separate search strategy each topic MeSH headings and keyword terms
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Formulation of recommendations

• Critical appraisal
• Research conducted in settings contexts
  relevant to midwifery-led care
• Two authors peer reviewed each section
• Presented as a narrative and in bullet points
• No grading of evidence

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Evaluation

• Peer review
• Use of the AGREE tool
• Midwifery guideline experts
• Service users/representatives

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Guideline titles

• Birth Environment
• Latent Phase
• Supporting Women in Labour
• Supporting and Involving Womens Birth
  Companions
• The Use of Water for Labour and Birth
• Pharmacological Pain Relief
• Fetal Heart Rate Monitoring
• Assessing Progress in Labour
• Rupturing Membranes
• Positions for Labour and Birth
• Persistent lateral and posterior fetal positions
  at the onset of labour
• Second Stage of Labour
• Care of the Perineum
• Third Stage of Labour
• Suturing the Perineum
• Immediate Care of the Newborn
• Early Breastfeeding

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Birth Environment Practice Points

• Go to website
• http//www.rcm.org.uk/college/standards-and-practi
  ce/practice-guidelines/

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Evidence based midwife-led care clinical
governance

• Working in
• in an environment that is open and
  participative, where ideas and good practice is
  shared, where education and research is valued
• Scally Donaldson 1998
• Can mean learning how to start stopping

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The environment

• Hospital is an alienating environment for most
  women, in which institutionalised routines and
  lack of privacy can contribute to feelings of
  loss of control and disempowerment
• Lock and Gibb 2004 Steele 1995
• Control, or lack of it, has been found to be
  important to womens experience of labour and
  their subsequent emotional well-being
• Green et al 1990 Simkin 1992
• The home-like environment is associated with
  lower rates of analgesia, augmentation and
  operative delivery, as well as greater
  satisfaction with care
• Hodnett et al 2005

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Fetal heart rate monitoring

• Because of the high level of intervention
  associated with electronic fetal monitoring,
  intermittent auscultation with a hand held
  instrument is the recommended method for the
  woman who is healthy and has had an uncomplicated
  pregnancy
• NICE 2007 MIDIRS 2005 RCOG 1993

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• Current evidence does not support the use of the
  admission CTG in low risk pregnancy. It should
  not be used routinely
• NICE 2007 MIDIRS 2005 Blix et al 2004 Impey et
  al 2003 Mires et al 2001

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• Midwife-led care has been found to have as good
  outcomes as medical-led and shared care, met with
  greater satisfaction from the women and reduced
  obstetrical intervention rates
• Hatel et al 2009 Campbell et al 1999 McVicar
  et al 1993 Shields et al 1998 Turnbull et al
  1996 Hundley et al 1994 McVicar et al 1993

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• Obrigado

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• www.rcm.org.uk
• http//www.rcm.org.uk/ebm/
• http//www.rcm.org.uk/college/standards-and-pract
  ice/practice-guidelines/
• Acknowledgements
• Jane Munro Mervi Jokinen