Assisted birth practitioner (ABP) midwives are experienced midwives who have undertaken additional training through a recognised course such as the Assisted Birth Programme run by the University of Bradford, and in-house training. They have extended their scope of practice to include fetal blood sampling, instrumental vaginal birth, medical diagnostic assessments and advanced clinical decision making. This is seen as an important extension of women's care that allows valuable continuity, and can also be a rewarding career development for the individual midwife.
Changes in middle-grade medical practitioner training has created a service pressure at this level and the ABP midwife role offers a way of continuing safe service provision. Ongoing staffing pressure makes it likely that more midwives may pursue this training opportunity, and Health Boards and Trusts may seek to encourage this role extension. Service users and employees are likely to look for reassurance that such a service development is safe and effective. This article represents the interim findings of the first 6 months of a study of the first 12 months of such a service in Scotland.
Previous authors have already explored whether instrumental vaginal births performed by trained midwives are safe (Awala et al, 2006; Black et al, 2013), but this is, to the authors' knowledge, the first time the initiation of such a service has been specifically analysed. It is also the first study to explore the views of service users about the changing role.
Aims
The aim of this study was to identify any differences in neonatal and maternal outcomes and levels of maternal satisfaction following instrumental vaginal births by ABP midwives in comparison to births by medical practitioners.
Methods
A retrospective cohort study was performed in the Borders General Hospital, Scottish Borders. This is a district general hospital with approximately 1200 births per year and an instrumental birth rate of 13.2% over the study period. For the year ending 31 December 2012, the instrumental birth rate in the unit was 13% (Birthchoice UK, 2013). The study population comprised all women who had undergone an instrumental vaginal birth in the labour ward during the study period of August 2013–January 2014. The time frame was chosen because it represented the start of the ABP midwives role as a permanent feature on the middle grade on-call rota.
The criteria used for instrumental births by the ABP midwives are summarised in Table 1, and the Advanced Life Support Group in Obstetrics (ALSO, 2000) acronym (A–J pneumonic) was also used to guide safe practice. Only births on the labour ward were included in the audit as it was felt that those births in theatre, which were performed by medical practitioners, were unlikely to match the criteria of those performed by ABP midwives.
| Maternal indications | Maternal contraindications |
|---|---|
| Prolonged second stage Maternal exhaustion/distress |
Vertex 1/5th palpable abdominally or more |
| Criteria | Fetal contraindications |
| Cephalic presentation |
Less than 34 weeks gestation (Ventouse) |
| Fetal indications | |
| Suspected fetal compromise Abnormal fetal pH scalp readings |
A retrospective case note review was carried out to record maternal age, gestation, parity, date of delivery, mode of delivery, body mass index (BMI) and birth weight. Maternal and neonatal outcomes were audited in-line with the auditable standards identified in the Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 26a Operative VaginaI Delivery (RCOG, 2011): third and forth degree tears; postpartum haemorrhage; maternal debrief; documentation; rates of urinary retention; post-birth void timing and volume passed. Neonatal outcomes used were: Apgar scores; arterial and venous cord blood gases; admission to special care baby unit (i.e brachial plexus injury/fractures/nerve palsy). Although Apgar scores are recognised to have little long-term predictive value, they were included as a surrogate marker of the birth as our numbers were too small to achieve a meaningful statistic for neonatal encephalopathy.
The instrumental vaginal birth performed by ABP midwives formed the exposed cohort with those delivered by medical practitioners the control cohort. Maternal experience feedback was received from both groups in the form of a retrospective experience feedback questionnaire. This was sent to mothers and returned anonymously to the labour ward. Women were asked to consent to participation in the study by returning the completed questionnaire. The questions asked were ‘Did you understand why you had an assisted birth?’, ‘Do you think your type of birth was explained well enough?’, ‘Did you have enough pain relief?’, ‘Were you given the chance to ask questions or tell someone about any concerns after the birth?’, ‘Was your birth companion included as much as you wanted?’, and ‘Were you given enough privacy?’ (Appendix).
| Our records show that your baby's birth was helped either by forceps or suction cup. We would welcome your feedback as it will help us to continually improve our service. We are not asking you to complete your name on the form as it will remain anonymous. Please return the completed form in the envelope provided. | ||
| Q1. Do you understand why you had an assisted birth? | Yes | No |
| Q2. Do you think your type of birth was explained well enough? | Yes | No |
| Q3. Did you have enough pain relief? | Yes | No |
| Q4. Were you given the chance to ask questions or tell someone about any concerns after the birth? | Yes | No |
| Q5. Was your birth companion included as much as you wanted? | Yes | No |
| Q6. Were you given enough privacy? | Yes | No |
| What do you think we did well? | ||
| What do you think we did not so well? | ||
| What do you think we could have done better? | ||
| Thank you for taking the time to complete this feedback form your comments are valued. | ||
Data analysis
Data analysis was performed using the statistical package for Social Scientists (SPSS) version 17.0. Baseline descriptive values between the two groups were calculated and compared statistically. Those outcomes which were normally distributed were compared using the independent t-test with the P-value set at 0.05. Non-parametrically distributed variables were compared using the Mann-Whitney U-test and the chi-square test was used for non-nominal data.
Ethical approval
The study was assessed by the local clinical audit team as service evaluation using anonymised data, and formal ethics approval was therefore not required.
Results
In the study period, there were 57 instrumental vaginal births, 14 of which were performed by ABP midwives (25%) and 43 performed by medical practitioners (75%). Baseline demographic characteristics were similar between the two groups (Table 2).
| Baseline characteristic | ABP midwife births | Medical practitioner deliveries | P value |
|---|---|---|---|
| Age, mean in years (SD) | 29 (4.2) | 28 (5.6) | 0.94 |
| Body mass index (kg/m2) (SD) | 25.3 (4.67) | 23.8 (4.0) | 0.25 |
| Primiparous |
12 (86%) |
35 (81%) |
0.71 |
| Birthweight mean (g) (SD) | 3269 (393.9) | 3504 (553.8) | 0.15 |
| Term (>37 weeks) Preterm | 13 (93%) |
41 (95%) |
0.71 |
| Birthweight (≥4 kg) | 1 (7%) | 4 (29%) | 0.80 |
There were no significant differences between maternal and neonatal outcomes of instrumental birth at the Borders General Hospital in the study period between ABP midwives and medical practitioner births. Key results included no significant differences in rates of third degree tears, postpartum haemorrhage, apgar score, cord pHs or admission to the special care baby unit. The full results are presented in Table 3.
| Outcome | ABP midwife births | Medical practitioner deliveries | P value |
|---|---|---|---|
| Delivery Indication | |||
| Delay in second stage | 6 (43%) | 17 (40%) | 0.83 |
| Maternal exhaustion | 1 (7%) | n/a | |
| Fetal distress | 7 (50%) | 26 (60%) | 0.49 |
| Delivery details | |||
| Decision to delivery (mins) | 12.9 (7.9 SD) | 18 (11.7 SD) | 0.13 |
| Shoulder dystocia | 1 | 3 | 0.39 |
| Consultant present | 0 | 3 | 0.31 |
| Analgesia | |||
| Pudendal | 6 (40%) | 13 (30%) | 0.38 |
| Epidural | 8 (57%) | 22 (70%) | 0.69 |
| Instrument used | |||
| Mid-cavity forceps | 6 (40%) | 26 (60%) | 0.25 |
| Kiwi | 8 (57%) | 13 (30%) | 0.07 |
| Keilland's forceps | n/a | 1 (2%) | |
| Wrigleys forceps | n/a | 3 (7%) | |
| Multiple instrument | 1 (2%) | 3 (7%) | 0.98 |
| Neonatal outcomes | |||
| Apgar 1 min | 8.7 | 8.6 | 0.88 |
| Apgar 5 min | 8.9 | 9.0 | 0.31 |
| Mean arterial cord pH | 7.234 (0.03 SD) | 7.26 (0.08 SD) | 0.23 |
| Mean venous cord pH | 7.362 (0.03 SD) | 7.343 (0.05 SD) | 0.28 |
| Admission to special care baby unit | 0 | 0 | 0.00 |
| Maternal outcomes | |||
| Episiotomy | 14 (100%) | 41 (95%) | 0.41 |
| 3rd or 4th degree tears | 1 | 1 | 0.39 |
| Estimated blood loss | 507 (291.5 SD) | 535 (368.5 SD) | 0.87 |
| Postpartum haemmorhage | 7 (50%) | 17 (40%) | 0.49 |
| Lowest Hb | 98 (19.4 SD) | 109 (23.32 SD) | 0.16 (15 values missing) |
| Transfusion | 1 (7%) | 4 (9%) | 0.80 |
| Debrief | 8 (57%) | 13 (30%) | 0.07 |
| Indwelling catheter placed | 4 | 15 | 0.66 |
| First void volume | 277 | 310 | 0.76 (40 values missing) |
| Urinary retention | 0 | 1 | 0.56 |
| Discharge day | 1.64 (0.5 SD) | 1.67 (0.9 SD) | 0.4 |
Patient feedback
Of the 57 instrumental vaginal births there were 20 feedback forms returned, 5 from the ABP midwife (42%) births and 20 (47%) from the medical practitioner births. For the majority of the questions, the feedback for both groups was very positive, and the results are presented in Table 4.
| Question | ABP feedback maternal satisfaction | Doctor feedback maternal satisfaction |
|---|---|---|
| Do you understand why you had an assisted birth? | 100% | 100% |
| Do you think your type of birth was explained well enough? | 100% | 100% |
| Did you have enough pain relief? | 60% | 90% |
| Were you given the chance to ask questions or tell someone about any concerns after the birth? | 100% | 80% |
| Was your birth companion included as much as you wanted? | 100% | 100% |
| Were you given enough privacy? | 100% | 100% |
In one of the feedback forms from an ABP birth, analgesia had been offered in the form of an epidural top-up but the woman declined. The woman later said that she had insufficient pain relief. As the numbers in this study are low, this made a significant impact on the results. The questionnaires included a mix of open and closed questions and the results are represented as a percentage of the total questions asked. The free text sections encouraged women to comment on their experience choosing their own words. This feedback was useful to the practitioners as it helped develop a sense of the woman's understanding of the situation.
Some of the positive feedback from the ABP midwife births include:
‘Communication from the midwife was excellent.’
‘My husband was very involved by the team, excellent debrief by the midwife practitioner after the forceps and we felt that was really helpful.’
‘I appreciated the midwife who carried out the procedure visiting the following day to explain why they chose to assist the delivery.’
There was some negative feedback relating to debriefing the woman and her family following an assisted birth. Examples of negative feedback include:
‘I don't know why I needed forceps- I almost felt like I asked for help too much and that's why.’
‘I felt the midwives explained everything better than the consultants.’
‘Looking back now, however, I felt it may have been good to speak about what happened and why, once I had come round from the drugs/shock’
‘No follow up consultation after the birth.’
‘I did not get enough pain relief.’
Discussion
Since the introduction of the APB midwives on the medical rota there has been no change in maternal or neonatal morbidity rates when instrumental vaginal birth is performed by ABP midwives compared to medical practitioners. The percentage of ABP debriefing was almost double that of the obstetric births (57 vs 30%), although this did not quite reach statistical significance (P=0.07). There was also a trend towards shorter decision to birth intervals (12.9 mins vs 18 mins) for the ABP midwives group, perhaps reflecting the fact that the midwife was more available on the labour ward rather than having to await the arrival of an obstetrician, although again this did not reach statistical significance.
The choice of instrument used for the assisted birth was similar between the two groups. There was no difference in the need for senior supervision in either of the groups suggesting that trained ABP midwives practice at an independent level similar to that of medical practitioners when performing instrumental vaginal birth.
The study benefitted from inclusion of the qualitative data extracted from the maternal experience feedback forms. Since the creation of the ABP midwife role, the feedback from women has been positive. It has been valuable in building the confidence of the ABP midwives and aiding staff recognition of their new role in the labour ward.
The feedback has also been used for both medical practitioners and ABP midwives to improve practice, especially in relation to debriefing.
The audit form has now been changed following this interim analysis to include the type of analgesia and there is a separate section for documented debrief. Although there is no evidence linking adverse outcomes if debriefing is not performed, debrief is frequently mentioned as a positive thing in the patient's feedback forms.
The interim findings of our study demonstrate that there is no difference in maternal and neonatal outcomes where an instrumental birth is performed by appropriately trained midwife practitioners compared to medical practitioners. A review of the literature found two previous similar studies. The retrospective case review by Awala et al (2006) of 1673 midwife Ventouse births concluded that midwives who were appropriately trained and skilled offered a safe and effective service. Black et al (2013) undertook a retrospective cohort study of 2540 deliveries, concluding that instrumental vaginal births performed by trained midwives were associated with equivalent maternal morbidity to those performed by doctors.
Limitations
It is recognised that the small sample size limits the findings of this study, but the audit is ongoing and will continue to collect data and to compare outcomes.
Conclusion
The results from this interim study show that maternal and neonatal outcomes for instrumental births are similar between ABP midwives and medical practitioners. The qualitative component of our study suggests that patient satisfaction rates of birth performed by ABP midwives are high, especially in relation to post-delivery debriefing.
These results provide reassurance to both service users and those planning service delivery, that ABP midwives are able to offer a valuable and safe extended role through instrumental birth.