Toolkit Reduces Caesarean Rates

Delivering Quality and Value
Pathways to Success:
a self-improvement toolkit
Focus on normal birth and reducing
Caesarean section rates
DeliveringQualityandValue
PathwaystoSuccess:aself-improvementtoolkit
FocusonnormalbirthandreducingCaesareansectionrates
For further information please visit www.institute.nhs.uk
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NHS Institute for Innovation and Improvement
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University of Warwick Campus
Coventry
CV4 7AL
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and quote code NHSIDQVToolkit-C-Section
Version 1 - 2006, Version 2 - 2010
ISBN: 978-1-907045-93-6
NHS Institute product code: NHSIDQVToolkit-C-Section
Copyright © NHS Institute for Innovation and Improvement 2010
All rights reserved
Caesarean_FrontCover:Layout 2 10/6/10 17:02 Page 1

© Copyright NHS Institute for Innovation
and Improvement 2010
Caesarean section rates is published by
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Improvement, Coventry House, University
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ISBN: 978-1-907045-93-6
Caesarean_FrontCover:Layout 2 10/6/10 17:02 Page 2

1
Introduction
01-16
Practical advice on
using the toolkit
17-32
Running workshops:
facilitators guidance
33-54
Top Ten
55-62
Organisational Characteristics
63-74
First Pregnancy and Labour
75-90
Vaginal Birth after Caesarean
91-104
Planned Caesarean Section
105-118
Acknowledgements, References
and Glossary
119-126
Introduction
Focus_On_Caesarean_16April10:Layout 1 10/6/10 16:34 Page 1

02 Focus on normal birth and reducing Caesarean section rates

Introduction
‘This is a great toolkit that should really help
staff and user representatives in NHS trusts
to think about what affects their unit’s
Caesarean rate and work together on a
range of related actions to facilitate normal
birth and prevent unnecessary surgery’
Mary Newburn, Head of Policy Research,
National Childbirth Trust & Honorary Professor,
Thames Valley University
Focus on normal birth and reducing Caesarean section rates 03

Pathways to Success:
Caesarean section rates to a safe minimum
Caesarean section (CS) has an important role in ensuring safe maternity care. How can we make
sure that every Caesarean is appropriate, effective and efficient?
The NHS Institute for Innovation and Improvement is working with NHS clinical staff to promote
best practice in achieving low CS rates while maintaining safe outcomes for mothers and babies.
This toolkit is designed to help maternity services review and assess their current practice in
promoting normal birth and reducing CS rates. The toolkit also provides practical techniques
to support sustainable changes in maternity services.
The NHS Institute for Innovation and Improvement
The NHS Institute for Innovation and Improvement (NHS Institute) was formed in 2005.
It supports the NHS to improve health outcomes and raise the quality of care by speeding
up the introduction of proven new ideas and improvements in healthcare delivery models
and processes, medical products and devices, and healthcare leadership.
The High Volume Care Project1 part of the Delivering Quality and Value Programme at
the NHS Institute, aims to discover how top performing healthcare organisations in the
NHS and elsewhere deliver the highest quality care with the best resource utilisation,
and to find effective ways of spreading that successful practice to other services.
The NHS Institute produced the ‘Focus on: Caesarean Section’2 document as one of a series
in the High Volume Care programme. This initial series of care pathways were chosen on
the basis that they occurred in large numbers and hence consumed high levels of resources.
There was also marked variation across England in the performance of individual services.

Why do Caesarean section rates matter?
• In 2005-2006, over 135,000 CS operations were carried out in England3
• In 1990, the national average CS rate was 12%, in 2006 the average CS rate was 24%4
• In 2005-2006, the CS rate for individual services varied from about 16% to well over 30%3
• Following CS, the average length of post-natal stay varies from 3.5 days to 7 days.3
This increase in Caesareans has not been accompanied by a measurable improvement in the
outcome for the baby.5
What should the Caesarean section rate be?
Many reasons have been put forward to explain the year on year rise in numbers of CS births.6
For instance, reduced working hours of trainee obstetricians may have limited their
opportunities to develop practical skills,7
the move to birth in a hospital setting8
and the
increased use of technology9,10 may have affected midwives’ confidence in managing normal
labour and birth. Fear of litigation is often cited as a major driver for increased intervention
rates in pregnancy and labour.11
Changes in evidence-based clinical practice, for example in
the management of women with breech presentations12
or women who are HIV positive,13
have led to an increase in the number of planned Caesarean sections recommended.
Consumer demand or women exercising choice and requesting CS in the absence of
any clear medical indication may also have played a part.14
No two maternity services are the same. However, variations in CS rates cannot be readily
explained by differences in size, complexity of caseload or demography.15,16
Maternity service professionals have a strong history of identifying evidence-based care.
For most, the debate is not about what constitutes best practice but about how to make
the changes necessary in order to achieve it.
When we worked with services achieving low CS rates, there were clear common themes
in their aims and approaches to delivering maternity care. They have shown that applying
evidence-based good practice and innovative models of care lead to lower CS rates and
a better experience for women when a CS is appropriate. There was a general belief
amongst clinicians involved in this project that maternity units applying best practice to the
management of pregnancy, labour and birth will achieve a CS rate consistently below 20%
and will have aspirations to reduce that rate to 15%.

Benefits of promoting normal birth and reducing
Caesarean section rates to a safe minimum
To women:
• No interventions without benefit to mother or baby
• Birth is seen as a positive experience
• Women receive support from staff to optimise the chance of normal birth
• Women in labour receive one-to-one professional support
• Women feel empowered in making decisions with support from staff
• Mortality and morbidity rates improve
• Women are able to return home more quickly to their families.
To staff:
• Staff derive a high level of satisfaction from providing high quality care and enabling
women to achieve the outcomes they want
• There is a sense of pride in units
• Working in a well-functioning team aids staff retention
• Midwives spend less time on non-clinical tasks
• Reduction in pressure of work on medical staff
• There is a greater opportunity to acquire and maintain a portfolio of skills.
To the organisation:
• Enhanced reputation attracts women to use the service
• Recruitment and retention improves through increased staff satisfaction
• Reduction in post-operative bed days gives opportunity for financial savings
• Enhanced risk management reduces litigation.
To the commissioner:
• Public money is spent according to clinical need
• Savings made on CS can be redirected into improving maternity services
• Savings from achieving optimal value for money in maternity services can be redirected
into other areas of need, e.g. children’s services, care of the elderly
• Improvements in the long-term health of mothers and babies reduces the chronic
care burden.

How was Focus on: Caesarean Section developed?
The NHS Institute worked in partnership with NHS colleagues to identify maternity services that had
succeeded in reducing or maintaining low Caesarean rates, and services that had high rates but had
recognised a need to reduce them. Our small team visited a number of these units, held formal and
informal interviews with a wide range of staff and users, and spent time observing the processes of
care. We identified with trusts those features that they believed have contributed to their success in
maintaining low CS rates.
The findings from the visits were validated in a co-production workshop where representatives of the
trusts met to discuss and prioritise the results. They identified three clinical pathways and a pathway
of organisational characteristics where changes in culture and practice might have the greatest
benefit in reducing CS rates. The pathways are:
• First pregnancy and labour
• Vaginal birth after Caesarean (VBAC)
• Planned Caesarean section
• Organisational Characteristics.
Each pathway describes a woman’s journey through maternity services, identifying the principles
of care at each stage. They illustrate the behaviours and practices that trusts believe have
contributed to their success. From these pathways we extracted the Top Ten Characteristics,
to provide an overview of the principles that were considered highly important to success.

Top Ten Characteristics of services aspiring to
optimal care
‘We focus on keeping pregnancy and birth normal’
‘We are a real team – we understand and respect
roles and expertise’
‘Our leaders are visible and vocal’
‘Our guidelines are evidence-based and up to date’
‘We all practise to the same guidelines – no opting out’
‘We manage women’s expectations and prepare them
for the reality of labour’
‘We are proactive about VBAC, giving accurate information
about risks and benefits’
‘If a Caesarean section is planned, the process is efficient
and effective’
‘We get accurate, timely and relevant information on
our performance’
‘We work closely with our users and stakeholders’
The draft pathways were then circulated to other maternity units, professional representative
bodies, academic institutions and user representative groups for their comments before the
findings were published in Focus on: Caesarean Section.

Keeping first pregnancy and labour normal
Women who experience a normal birth in their first pregnancy are highly likely to do the same in
subsequent pregnancies. This pathway starts even before conception. Women are exposed to
messages about childbirth through family and friends, through the media and through existing
contact with health and social care professionals. Although it is difficult to influence the media, there
is an opportunity for all professionals within the health economy to promote and sustain practices
that are likely to lead to normal outcomes in pregnancy and labour.
The birth outcome is influenced throughout the process and provision of maternity care. Midwives
are ideally placed to offer a continuous and consistent message in preparing women for labour.
Although care for a normal birth is usually provided by midwives, optimising the chance for this to
occur requires genuine multidisciplinary teamwork.
This pathways ends with increasing the chance of normal birth for women who have risk factors.
Improving opportunities for vaginal birth after
Caesarean (VBAC)
Maternity units identified the management of women who have had one previous Caesarean as
critical to reducing overall CS rates. There is accumulating evidence to support VBAC as a safe option
for most women. However, many professionals feel apprehensive about managing VBAC and women
often believe another Caesarean is inevitable or preferable to their previous experience.
Women need accurate information about the events of their labour and birth and how these
may affect their future births (including the possibility of VBAC), as soon as possible after the CS.
This pathway begins in the postnatal period of the CS and finishes with the management of the
next labour and birth. It focuses on optimising opportunities to give accurate information and
empowering clinicians to use their skills to support these women to increase the likelihood of
a vaginal birth.
The Pathways

Women having a planned Caesarean section
If a decision is made in the antenatal period that CS is the appropriate means of birth, the
process should be as efficient as possible to ensure optimal use of resources and to enhance
the experience for the woman and her family.
A planned CS has many requirements in common with other operations. There are important
opportunities to learn from best practice in pre-assessment, skill mix of theatre staff, early
mobilisation, pain relief and discharge planning derived from work in other specialties.
Length of post-operative stay is often used as an indicator for the efficient use of resources.
In CS, the picture is more complex as the service continues to deliver care regardless of the
setting. This pathway ends with transfer home.
Maternity services delivering high quality care that provides value for money cannot
sustain an existence in isolation. They must be supported by an organisational infrastructure
that provides accurate and relevant information, has effective communication pathways
upwards and downwards throughout the trust and fosters an open and just culture in
clinical governance.
High performing maternity services often provide positive role models within their trust for
adoption of evidence-based care, multidisciplinary team-working and involving their users
in evaluating and developing their service.

Developing Pathways to Success:
The NHS Institute is committed to identifying successful health care practices and supporting
their rapid spread throughout the NHS.
Having identified the behaviours and practices that maternity services with low CS rates
believed were important in achieving this outcome, our team then addressed the task of
disseminating this information to other trusts across the country.
The team worked directly with maternity units offering a wide range of service configurations,
demographic characteristics and current CS rates to develop and test a tool that would assist
them to understand how their service works and to provide support in making sustainable
changes aimed at promoting normal birth and reducing CS rates to a safe minimum.
With their help, and advice from a number of other sources, we developed the Pathways to
Success: self-improvement toolkit that contains:
• A self-assessment tool for each pathway and the Top Ten Characteristics
• Self-improvement Action Plans
• Tools for improvement
• Measures for improvement
• Facilitator’s guidance.

Pathways to Success: self-assessment tool
Focus on: Caesarean Section identified four pathways that were important in achieving
low CS rates:
• First pregnancy and labour
• Vaginal birth after Caesarean (VBAC)
• Planned Caesarean section
• Organisational Characteristics.
Each pathway lists principles of care and examples of the behaviours and processes that trusts believe
have contributed to their success.
The self-improvement toolkit is based on the same pathways. In each of these ‘self-assessment
pathways’ the rows address individual principles and describe a range of behaviours and processes,
progressing from those associated with high CS rates on the left to those associated with low CS
rates on the right. Each pathway reflects the wide range of behaviours and processes that we have
seen or have been reported to us during our observations.
This does not mean that all the boxes on the right side are automatically ‘best practice’ or indeed
that it is possible to provide a sound evidence base, but that these units believed they made an
important contribution to their success in maintaining low CS rates.
The pathways tool is designed to assist units in defining their own current service and identifying
the characteristics of the service they aspire to. This will not necessarily be at the extreme of the
spectrum. Each trust should define its own targets, taking into consideration its service configuration,
priorities, resources etc.
When high performing maternity units reviewed the pathways we had described, they identified key
principles from each pathway that they considered to be of overarching importance in achieving
success. We have presented these Top Ten Characteristics in a similar self-assessment format.
“The pathways tell us what units saw as an important part of keeping the CS rate
low, not what is right or wrong.”
Cathy Walton,
Consultant Midwife, Kings College Hospital

Self-improvement Action Plans
This template leads participants through the process of developing an action plan for each of
the pathways. Working in small multidisciplinary groups the action plan enables colleagues to
plan systematic changes to their service provision. It encourages participants to assess the gap
between their current position and their aspiration, focusing clearly on what must change and
how this can be achieved.
These plans can then be prioritised and co-ordinated to form the basis of a longer term action
plan for the service.
Tools for Improvement
This section describes a number of tools to support and assist services in making changes.
It includes examples of service improvement tools, scenarios, case studies reflecting successful
practice and of documents that can be adapted to specific needs.
Measures for Improvement
As part of any service development, it is important to know if the changes made have resulted
in real improvements. This section provides useful information on choosing suitable measures
with examples applied to specific pathways.
Running Workshops: Facilitator’s Guidance
The self-improvement toolkit has been developed for use in the context of multidisciplinary
workshops (see ‘field testing’ section). This section provides guidance useful to units wishing
to use the pathways in their own workshops. It contains:
• Guide for Facilitators
• Guide for Team members
• Suggested agenda and description of activities
• Do you know the answers? (a series of questions designed to help you kick start your
workshop and explore how much is known about your services)
• Frequently asked questions
• Additional resources are available in the Resource Pack.

Field testing the toolkit
The self-assessment workshop
At each stage of the development of the tool we asked people to comment and contribute to
its contents. Once the self-assessment pathways were completed in prototype we engaged
with a first wave of six trusts that were enthusiastic to review their practice and reduce their
CS rates. With each trust we carried out a workshop where groups of staff from all disciplines
and at all levels in the maternity service could come together to explore what their service was
really like and how it compared with the culture and practices in trusts that had low CS rates.
“We found it a great afternoon and a very useful discussion that continued
in the unit afterwards.”
Liz Ross,
Clinical Midwifery Manager, York Hospitals NHS Trust
Guidance for Facilitators
Our experience in conducting the first wave of testing provided us with the material to
develop a facilitator’s guide for staff to be able to run their own workshops unsupported.
The facilitator’s guide has been widely circulated to groups of maternity staff, educators,
managers, commissioners and lay representatives who have provided feedback on its content
and reviewed how they might use it in their own organisations. Several trusts successfully
hosted their own self-assessment workshop using the facilitator’s guidance. They have
provided feedback on the experience and in some cases the workshop has been directly
observed by a member of our team.
“I particularly liked the clear layout, in a ‘what to do and how to do it’ format.
The ’Frequently asked questions’ were particularly helpful.”
Susie Weekes,
Practice Development Midwife, Gloucester Hospitals NHS Trust

The self-improvement workshop
We further developed this process in a second wave of workshops, designed to support
services that have carried out the self-assessment process or have already identified a
priority area that they wish to address. This process combines individual preparation with
a multidisciplinary workshop to help staff and users define the gap between their current
service and the position on the pathway spectrum that they aspire to. Using the action
planning sheets and supporting tools, small groups of participants were able to work through
an action plan for one or two principles within an hour during the course of a workshop.
“It was a very positive experience. By the end of the session we had a clear
idea of what we had to do and some quick wins that we could get on with.”
Fiona Ghulastians,
Midwife Facilitator, West Middlesex University Hospital NHS Trust
Validation by high performers
We also tested the self-assessment pathways tool with high performing trusts that had not
participated in the development of Focus on: Caesarean Section. They were able to confirm
that their spectrum of behaviours and processes corresponded well with those on the right
side of the pathways. However, each trust was able to identify new ideas or possible changes
that would be of benefit to their service.
“We take ideas from anywhere, we are not always top-down. We are willing
to be different – we are very much a ‘can do’ trust”
Alison Whitham,
Midwifery and Gynaecology Manager, King’s Mill Hospital,
Sherwood Forest Hospitals NHS Foundation Trust

Practical advice on
using the toolkit 2
Introduction
01-16
Practical advice on
using the toolkit
17-32
Running workshops:
33-54
Top Ten
55-62
63-74
75-90
91-104
105-118
and Glossary
119-126

How can you use Pathways to Success?
Practical advice on using the
self-improvement toolkit
To use this toolkit effectively, please consider the following points carefully.
Sustainable service change needs real commitment. Form a core team with:
• Multidisciplinary membership
• Clinical leaders
• Appropriate expert knowledge and support
• Clear reporting and communication pathways
Outcomes can be improved by preparation in advance:
• Decide what you aim to do
• Consider who should participate
• Decide what they should be briefed about in advance
• Do you need to appoint leaders and scribes ahead of the workshop?
The toolkit was designed to be used in a workshop environment. It can be used in other
ways but the best results come from:
• Multidisciplinary groups
• Representation from all levels of staff
• Input from all parts of your service (e.g. community, separate birth centres)
• User involvement
• Protected time
Remember; in your service, everyone knows and can contribute something,
no-one knows everything.

Self-assessment workshop
Initial steps for maternity services wishing to explore their current practices related to
Caesarean section rates.
Aims: To make a detailed assessment of current culture, behaviours and processes.
To stimulate ideas and aspirations for your future service.
Other benefits: an opportunity for enhanced multidisciplinary understanding of the
service you provide.
Self-improvement workshop
For services that have carried out an assessment of their current position or that have
identified specific issues on Caesarean section that they wish to address.
Aims: To position your current maternity services against services that are successful
in maintaining low CS rates.
To agree what your service should aspire to.
To agree priorities for change.
To develop a detailed action plan.
Other benefits: an opportunity to benefit from exchanging examples of successful
practice and using service development tools.
There are different ways of using the workshops. Choose your agenda. Decide which
workshop or which elements of the process have most relevance for you.

Decide with the core team which pathway to study. Your particular service or priorities may
point to specific pathways.
Whatever your priorities or interests, we recommend that you always carry out a Top Ten
Characteristics assessment. This tool has been used in a number of valuable ways:
• As an introduction to the process
• As an eye-opener to reveal your current position
• To provide a ‘helicopter view’ of the whole service
• To act as a barometer of progress by repeating this assessment at key points
in your journey.
“It helped us see how we vary in perceiving the same service.”
Manager,
The Princess Alexandra Hospital NHS Trust
Put participants at their ease:
• This can be an interesting and enjoyable experience
• Everyone’s contribution is valued
• Individual contributions in the workshops will be confidential and everyone owns
the final outputs.
Be clear about what the pathways are and are not:
• They describe practice seen or reported in a range of maternity services even when
there is no evidence base to support it
• The boxes on the right side reflect the position of units with low CS rates
• The pathways do not dictate how individual services should function.

Manage the expectations of participants:
• Share with participants the aims and priorities of the core team
• Be realistic about what can and cannot be achieved at a single session
• Be open about timescales and resources available to support their proposals.
At the end of each session:
• Identify some quick wins
• Celebrate the progress you have made
• Explain how the work will be taken forward
• Clarify how progress will be communicated to everyone.
The toolkit can:
• Share what has been learned from other trusts
• Facilitate reflection on the culture and care pathways of your organisation or team
• Stimulate discussion about the strengths and weaknesses of your service
• Show up any differences in perception between staff groups, managers or users
• Help you to understand the complexities of your organisation and how they contribute
to care
• Help you to understand how a service with a more progressive approach might look
• Identify practices or behaviours you would like to change
• Provide you with tools and case studies to share good practice and resources
• Question some of your current practices.
The toolkit is not intended:
• To be imposed for external audit or performance management (although it may
provide material to support these)
• To apportion blame when results show that an organisation or team would benefit
from development.
“The feedback from the session was extremely positive, they wanted more!”
Jacqueline Dunkley-Bent,
Head of Midwifery & Women’s Services, Consultant Midwife,
Guy’s and St Thomas’ Hospitals

Self-improvement
Action Plan Template:
Pathway:
Principle:
Where are we now?
Where do we want to get to?
What do we need to change?
Who will do (and lead) the work?
When will we complete this?
What tools will we use?
How will we measure success?
What will be the impact? (Quality and value, reduction in CS rate)
This template leads participants through the process of developing an action plan.

Tools for Improvement
Once you have agreed where you want to get to it is important that you identify the right
solutions for your service. A selection of tools and ideas to help you make changes are
highlighted in this Toolkit. They provide evidence of success that you may be able to adapt
to your needs. Examples from each pathway are shown in the relevant pathway sections.
A more comprehensive range is available in the Resource Pack.
Scenarios
These stories are illustrations of behaviours and processes in maternity care.
They are pathway specific but often address more than one principle within a pathway.
Scenarios can be used to:
• Gain the engagement of participants at the start of a workshop or meeting
• Act as examples for the self-assessment process
• Provide a ‘safe’ platform for discussion of difficult topics where participants are unwilling
to discuss their own services initially
• Raise questions that you should answer in your self-improvement plans.
Example of scenario: VBAC
“Melanie had her first baby by emergency Caesarean section. She had a long labour but
did not progress beyond 8cm dilatation. The epidural sited for analgesia was not adequate
for the operation so she had a general anaesthetic.
After delivery she was tired and in pain. Her attempts to breastfeed left her with cracked
nipples so she abandoned this.
She is now booking with you at twelve weeks in her second pregnancy. She is adamant
that she does not wish to go through a similar experience of labour and delivery again.
Unless you can promise her a straightforward normal birth she wants a Caesarean section
and she certainly isn’t interested in breastfeeding.

What can you, as the midwife, offer her to increase her chances of a normal birth?
As the obstetrician or midwife, what information would you give her about the risks
and chances of success of VBAC?
How can you address her views on breastfeeding?”
Service improvement tools
Every single person is enabled, encouraged and capable to work with others to improve their
part in the service (Discipline of Improvement in Health and Social Care)
These tools draw on experience in a variety of areas including business and industry and have
already been applied successfully to other areas of healthcare.
They focus on processes and behaviours that are relevant to all the pathways but some techniques
have relevance to specific areas.
Service improvement tools can be used to:
• Identify what changes are needed
• Understand the processes needed to achieve change
• Ensure engagement of staff and users
• Demonstrate, celebrate and sustain success.
Case studies
The case studies are examples of practice in maternity services that we have seen or been
told about.
Most describe improvement journeys related to specific points in a pathway but the
underlying principles are relevant to many areas.
Case studies can be used to:
• Reflect on your practice
• Provide material for group discussion
• Identify key features and interventions that are relevant to your service.

Example of Case study: ‘Walking the floor’
“We meet regularly with our Maternity Services Liaison Committee and value the opportunity to
work with our users and stakeholders. Prior to our meeting we take the members of the MSLC to
our postnatal ward and invite them to ‘walk the floor’. Here they have the opportunity to talk
directly with women who have just had their babies using our services. These discussions with
women then form the basis for our meeting with the MSLC members”.
Jacqueline Dunkley-Bent, Head of Midwifery,
Guys and St Thomas Hospital Foundation Trust
Why don’t you?
These are examples of innovations you could try in your organisation. They are often unstructured
examples of what you could do but with little detail. They are designed to provoke thoughts of what
might be possible rather than giving you a definitive message about what you should do. They
should help you to think ‘outside the box.’
Example of Why don’t you? Letter
Why don’t you …
... talk to women after their CS and design a letter to give to them before they go home.
We asked a focus group of women what information they would like to receive after
CS that would prepare them for their next pregnancy and birth. They said:
‘Being debriefed on the first one’
We suggested that they could have a letter detailing the reasons for their CS and implications
for their next birth. They said:
‘A copy of the letter should also go to the Community Midwife and GP.’
We asked them what they would want to be included in this letter. They said:
‘What went wrong / why it happened like it did?
‘What are the chances of it happening again?’
‘What can I could do to try to avoid it?’
‘Need to address that women feel it was their fault’
’Most women don’t know that they can request to see their notes’
‘It would be good for women to know that they can come back at any time to
access information’.
With thanks to the Women’s Focus Group,
East Sussex Hospitals NHS Trust

Examples of key documentation
These are documents that direct, support, challenge or inform current maternity care. They will
be useful as reference tools for standard setting or for ‘positioning’ your organisation within the
wider context.
Sources of information for users
These examples of user information demonstrate good practice in communication with and
involvement of users. They may be appropriate for direct use in your service or provide a
structure for your own local information.
Examples of information
MIDIRS Informed Choice
National Childbirth Trust: NCT Info centre
Understanding NICE guidance: Information for pregnant women, their families
and the public
Royal College of Obstetricians and Gynaecologists: Information for patients
Templates
Templates can be used to save you time in preparing documents. Most are already being
used somewhere within a maternity service but have been provided in a format so that
you can adapt them for your own use.
Topic
Text Description
We will:
Insert your commitment
to your users
It would help us if you could:
Insert what the users could
/ should do themselves
Thank you for your support and co-operation

Measures for Improvement
As you work on the pathways it is important to know if the changes you have made have
resulted in real improvements. This section provides some useful tips and examples of
measures to help you along your improvement journey.
All improvements involve a change, but not all changes are improvements
(Goldratt)
Key Steps to Measurement
Follow these simple steps for a successful measurement plan:
It is important that you collect a mixture of both quantitative and qualitative data
to really understand your current services.
1. What is our aim?
As a team you need to decide what you want to improve (i.e. which principle?).
Example: Mothers and babies return home as soon as clinically safe and appropriate.
2. What do we want to focus on?
Once you have decided what your aim is you then need to decide which particular
aspect you wish to focus on.
Example: The length of stay for women undergoing a planned Caesarean section.
3. What are the appropriate measures?
Use the SMART technique when starting to think about developing measures
- make sure you apply these principles to your measures
S - Specific
M - Measurable
A - Attainable
R - Realistic
T - Timely
Example: Percentage of women discharged within 56 hours of a planned
Caesarean section.

4. What is the definition of the measure?
Is the data you need already collected through existing systems? Ensure you develop a clear
definition of what you want to measure. Failure to develop a clear definition can lead to
confusion and misunderstanding.
Example: Start of process: time and date of admission for a planned Caesarean section
(as recorded on information system).
End of process: time and date of discharge following a planned Caesarean section
(as recorded on information system).
5. What is our baseline?
It is important to understand how you are currently performing.
Example: 65% of women are discharged within 56 hours.
Just establishing your baselines and targets can really motivate and excite your teams.
6. What is our target?
Agree as a team what you want to achieve. Make sure your timescales are realistic.
You may want to consider incremental targets.
Example: 75% of women are discharged within 56 hours (short term goal).
90% of women are discharged within 56 hours (long term goal).
7. Over what period will we collect the data?
Ensure you collect a sufficient amount of data over a period of time to allow you to see
the changes.
Example: We want to look at 100 planned Caesarean births, we do 400 planned
Caesarean births a year and therefore will look at a three month period
(1st February to 30th April).
8. How will we collect the data?
Will you collect the data manually or from an existing information system? Is the data collected
routinely? Be careful to check that any data from an information system is what you really need.
Does it fit with your definition?
Example: Local maternity information system.
Remember, crude measures of the right things are better than precise measures of the
wrong things.

LengthofStay(hours)
Week
0
10
20
30
40
50
60
70
80
Target - 56 hours
9. How often will we collect it?
Example: Weekly.
10. Who will collect the data?
Designate someone to be responsible for the collection and collation of your data.
Example: Information lead.
11. How will I present the data?
How do you turn your data into useful information? A picture tells a thousand words and is
much easier to read than a table of numbers. Simple line graphs (or run charts) are easy to
produce and are very powerful.
Example: Run chart.
You may decide to undertake a simple audit of women who stayed longer than
56 hours to understand and categorise the reasons why this has happened.
For further information on how to develop measures and how to present your data please
refer to the Improvement Leader’s Guide on ‘Measures for Improvement’. This can be found at:
www.institute.nhs.uk

Measurement Plan Template
Principle
What is our aim?
Measure
Definition
Baseline
Target
Over what period will we collect the data?
How will we collect the data?
How often will we collect the data?
Who will collect the data?
How will we present the data?

Celebrating Success
It is important that you celebrate and share your successes - this will give an incredible boost
for further improvements.
How can we celebrate and share our successes?
Identify five things that you do really well
These may be from a clinical pathway or from the Top Ten or Organisational Characteristics.
• Which principles did staff identify you did well during the self assessment?
• What have you done that is different?
• Can you explain your success?
Next, think about who you can tell about your successes!
Share your successes with colleagues, users, stakeholders, networks, forums and other
maternity units.
• How about presenting your work at an event or writing an article?
• Explain the work that has been done, what has been achieved and what is hoped
to be achieved in the future.
Sharing your successes is a vital method of helping other maternity units learn from
you and ultimately, achieve results. Each NHS maternity service is at a different stage
on the journey towards providing optimal care. For most, the debate is not about
what constitutes best practice, but about how to make the changes necessary in order
to achieve it, with all the pressures and constraints that day-to-day working brings.
Sharing your success story will help strengthen practice and provide ideas for improving
it further.

Running workshops:
3
Introduction
01-16
Practical advice on
using the toolkit
17-32
Running workshops:
33-54
Top Ten
55-62
63-74
75-90
91-104
105-118
and Glossary
119-126

Workshop Facilitators Notes
Running workshops - facilitators guidance
The self-improvement toolkit is designed to help you assess where your maternity service
currently is on a spectrum of processes and behaviours associated with achieving a low
Caesarean section rate.
It will allow you to debate how your unit could aspire to work in the future and what you
would have to change to achieve that. It also offers tools to assist you in developing your
services. These workshops are the first step on this journey.
The toolkit is constructed on the ‘Top Ten’ Characteristics and the four pathways developed
in Focus on: Caesarean section, published in October 2006.
The first part of the toolkit is a self-assessment tool. It is intended to be used within maternity
services at a multidisciplinary workshop, where each member of the team has the chance to
contribute equally. This pack contains the information you need to run your own workshops;
you may wish to adapt it for your own particular service.
The self-improvement workshop is the second step in the process, designed to help services
develop an action plan that is based on current position and a mutually owned vision of
the future.

Initial steps for maternity services wishing to explore their current practices related to
Caesarean section rates.
Aims:
• To make a detailed assessment of current culture, behaviours and processes.
• To identify aspirations for your future service.
Other benefits: An opportunity for enhanced multidisciplinary understanding of the
service you provide.
For services that have carried out an assessment of their current position or that have
identified specific issues on Caesarean section that they wish to address.
Aims:
• To position your current maternity services against services that are successful
• To agree what your service should aspire to.
• To agree priorities for change.
• To develop a detailed action plan.
Other benefits: An opportunity to benefit from exchanging examples of successful
practice and using service development tools.
Who will own the process?
Each maternity service should identify a small core team of committed professionals
who are prepared to lead and guide the process. As a minimum this team should
include a midwife leader, an obstetrician leader and a manager. Additional members
might include an educator or an information analyst. As facilitator, you may be part
of this team or will be working closely with it to ensure you share common goals.

What are we aiming for?
The core team should decide which pathway to discuss during the workshop. This may be influenced
by the configuration of your service, any existing priorities, or the mix of staff who will attend.
We recommend that you should always include the Top Ten Characteristics assessment.
How far down the improvement road can you reasonably expect to go? We suggest that in the first
workshop you should be able to achieve a detailed assessment of where you are now and to begin
to identify aspirations for your future service.
The core team should also identify how the work will proceed after the workshop and be prepared
to commit to next steps at the end of the sessions.
How do I organise a workshop?
The process works best with a diverse range of staff disciplines and grades.
• Identify the people that you think should attend (see below)
• Make sure they have enough notice to be able to do so
• Give them information on the aims of the workshop.
Think about your regular meetings, could you arrange the workshop as part of one?
Who should attend?
Think about all the people who contribute to your service. Make sure that all groups who deliver
first-hand care are invited:
• Clinical staff from all disciplines: midwives, nurses, maternity support workers,
obstetricians, anaesthetists, etc.
• Support staff: clerical, IT
• Managers
• Service users
It is helpful to involve trainees and staff who rotate between maternity units.
We have piloted this process with up to 40 people at a time.
How long will the process take?
Allow at least two hours. Participants have told us how much they valued the opportunity for
discussion. The toolkit contains a suggested timetable.

Sample background slides
• The pathways identify a range of behaviours
• The last column identifies practice witnessed
in trusts with a low CS rate
• Each trust must decide which changes
(if any) are right for its organisation
Why look at Caesarean section?
• Average LOS after CS varies from 3.5 to 7 days
• CS rate has doubled in 15 years
- from 12% to >24%
• In England variation in CS rate between
units of <15% to >30%
• No associated improvement in
outcomes for babies
• Uncertain impact on long term
health of mothers
Getting started on the day
Step 1 - Do you know the answers?
As people arrive for the workshop, use the Do you know the answers exercise (on page 44)
as an ice breaker. Ask them to discuss the 8 questions with their neighbours. This will help to
start debate and raise individual awareness of gaps in knowledge.
It will allow you to get started and engage your audience while the latecomers are arriving.
Step 2 - Background to the pathways and the
At the start of the workshop make sure you allow time to explain the background to the
toolkit and introduce the pathways. See example slides below.

Step 3 - Explaining the process
To get the maximum benefit from the workshop it is essential that all the participants feel
comfortable with the process. Please explain clearly that:
• Everyone is a valuable contributor
• There are no right and wrong answers
• It does not matter if part of the pathway is unfamiliar to individuals
• The workshop is a protected environment and comments from individuals will not be repeated
outside of the workshop.
Show the audience an example of a pathway. Explain that the white boxes look at individual
principles of care associated with the woman’s journey in that particular pathway. The shaded boxes
in each row show behaviours and processes from those associated with high CS rates on the left to
those associated with low CS rates on the right. This does not mean that all the boxes on the right
side are automatically ‘best practice’, simply that units believed they were important to their success
Explain again that the aim of the workshop is to establish where your organisation currently sits on
the pathways and to identify where you would like to be in the future.
The tool is not designed to dictate patterns of care to units, it is for each individual
organisation to decide what practice it should aim for and what changes should and
could be delivered to achieve this.
Finally, ensure everyone is aware of the time available for each task. See the Suggested Agenda
for timings.

Step 4 - Getting down to work
Ask your audience to work through the Top Ten Characteristics, deciding as individuals which
statements best describe their service. Ask them each to fill in a record sheet. At the end of the
allocated time, collect these up and collate this information into a picture of your organisation
to feed back to everyone at the end of the workshop. In the Resource Pack there is a
spreadsheet to present this information for you.
Example of Record Tool in Resource Pack
We focus on keeping pregnancy and birth normal
We are a real team - we understand each others roles and expertise
Our leaders are visible and vocal
Our guidelines are evidence-based and up to date

Then ask your participants to divide into small groups, we recommend groups of four to
eight people.
You may want to consider in advance who should be in each group to ensure a good
mixture of skills and experience and to manage any difference in expectations.
Give each group a copy of the ‘How to use the tool - a guide for team members’ (found on
page 45) and each member a copy of the chosen pathway.
Ask each group to identify a leader who will ensure everyone has an opportunity to contribute
and a scribe to make notes of their discussions.
When the groups are settled, ask each member to spend ten minutes looking individually at
the pathway and to make an assessment of where the service is currently. Then, as a group, to
look at each of the principles in turn, exploring the individual assessments and trying to reach
a consensus. Ask the groups to think specifically about any areas of difference or difficulty in
understanding. Why did they think this occurred?
The groups should then try to look at the behaviours and processes to the right of their current
position and debate where they would aim to move their service to.
As facilitator,
• try to keep an eye on how the discussions are going
• be prepared to prompt or question assumptions
• check that the group leaders are ensuring all participants have an opportunity to speak
• ensure that they are sticking to the task.
There will be different views; constructive challenge is part of mature organisational behaviour,
however, if this is hindering progress:
• encourage the group to look for areas where they can agree
• suggest that they move on to another area and return to the topic later
• recommend a separate meeting outside the workshop to address areas of concern.

Step 5 - Sharing the results
Give each group a chance to feed back to the whole workshop. Ask them about their
experience of working together on this task as well as the conclusions they came to.
Ask for the notes taken by the scribes so that you can review all the outputs later and
ensure nothing important was missed.
Step 6 - Agreeing next steps
Ask the members of your core team to speak for five minutes about how the work will be
taken forward. This should include agreeing the way forward, offering an opportunity for staff
and users to contribute to the work; and making a commitment to a timetable for progress.
Step 7 - Feedback of Top Ten profile

Suggested Agenda -
Description of Activities
Self-assessment Workshop
2 hour workshop
Participants: maternity services staff from all disciplines: midwives, obstetric doctors, maternity support
workers, administrative support staff, service managers, risk managers, students and
user representatives.
Recommended group size: 15 - 40 (for larger groups consider having two facilitators)
1. Do you know the answers? Informal discussion with neighbours before formal work begins.
10 minutes
2. Presentation: description of the pathways, brief background to the ‘Focus on’ methodology
and explanation of how the toolkit was made (what it is and what it isn’t).
10 minutes
3. All participants look at the Top Ten Characteristics individually and identify where on the pathway
they think their service is now. Collect up the assessment sheets and collate during step 5 below.
15 minutes
4. Divide into small groups (4-8 people), ensuring an appropriate multidisciplinary mix.
Each team appoints a leader and a scribe / raporteur.
5 minutes
5. Each small group chooses a single clinical pathway (or Organisational Characteristics
if desired). Individual members read through the pathway and make an assessment of
current position. The group then discusses and makes a group decision on their position.
30 minutes
6. The group looks at the pathway to decide where they would like their service to be.
Why have they made that choice? If not at far right column, why not? Prepare feedback.
20 minutes
7. Feedback from groups:
• What did we learn?
• Where are we now?
• Where would we like to be?
• Were there any surprises?
• Did the group reach consensus?
• What was good / not so good about the experience?
20 minutes
8. Next steps
5 minutes
9. Feeding back the results of the Top Ten Characteristics assessment
5 minutes
Any additional time available for the workshop should be allocated to steps 5, 6 & 7.

AGENDA - Self-assessment Workshop
Pathways to Success: Focus on normal birth and
reducing Caesarean section rates
(Trust name, department etc)
(Date and Place)
(Time from/to)
1. Do you know the answers?
2. Background to the pathways and how to use the
3. The Top Ten Characteristics. How does your service compare?
4. Group work: the pathways - where are we and where do we
want to be?
5. Feedback from the groups
6. Next steps
7. The Top Ten Characteristics - your answers

Do you know the answers?
1. The national average Caesarean section rate is 25%
Do you know what your CS rate is?
2. What percentage of your clients try for a VBAC and are
actually successful?
3. Do your facilities provide the right environment to support
normal labour and birth? Is medical equipment out of sight?
4. The labour ward should be used for women in labour only.
How many women on your labour ward last month were
not in labour?
5. How much time do your midwives spend on non-clinical tasks?
6. What percentage of clinical staff are aware of monthly CS rates
and trends?
7. Organising planned Caesarean sections efficiently minimises
delays and clinical risks.
Do you have a clearly defined process for managing planned
Caesarean sections?
8. Women should be able to make an informed choice about their
mode of birth.
Can you provide accurate facts and figures about risks and
benefits to support their decision?
Focus on: Normal birth and reducing
Caesarean sections

Each pathway has six columns. On each row, the first box states principles on which top
performing organisations base their care, allowing them to maintain low CS rates. The
corresponding boxes show a range of behaviours occurring in maternity units.
As you read across the rows you will see that there is a progression of ideas and practices.
The column on the far right represents behaviours adopted by trusts that are ‘high performers’
in keeping their CS rates low while achieving good outcomes.
Individual assessment
Each member of the group should start by making an individual assessment for each principle
in the pathway. Choose the description of behaviours you think best fits your organisation or
team. Do this on your own without discussion. This is your opinion of your service. If you can’t
decide between two of the descriptions tick both. This will give you an indication of the
current CS profile for your organisation.
Group assessment
Choose one of your group to lead the discussion and make sure that everyone has the
opportunity to contribute, and choose a scribe to make notes of your discussions. Look at
each principle in turn, explore the individual assessments and then try to reach a group
consensus. Once you have identified where you are compared to these ‘high performers’, start
discussing where you as an organisation want to be. Ask yourselves what can realistically be
taken forward and improved within your service? There are tools and case studies that can
help you achieve your goals and move towards those behaviours.
We do not expect that as an individual or a team you will agree with all the suggested
‘successful practice’ shown in column five. It is important that you discuss why these
behaviours are not appropriate to your service when you decide where your unit wants to go
and how you can get there.
The objective is to stimulate debate and enable you to focus on areas you would like to
change. The toolkit is not designed to dictate how you should run your own unit.
Be prepared to share your comments and views with the wider audience.
How to use the toolkit
- a guide for team members

This step follows on from the self-assessment workshop where groups of staff and users had the
opportunity to assess their present service against the behaviours and processes of a number of
maternity services with a range of CS rates.
That process may have helped you to agree priorities for service change.
You may have identified specific areas for improvement through other channels.
This workshop will help you achieve the next steps.
Before starting, take time to review your present situation. Have you got a core team (see page 35)
that is committed to driving this process and owning its outputs? Do you have good communication
channels for reporting the work you are doing?
The self-assessment process used the Top Ten Characteristics to help you produce an overview
of your service. A similar process looking at your chosen pathway will have given you information
about the variety of perceptions about your clinical behaviours and processes and offered your
staff examples of a wide range of practices reported or observed in other organisations to help
you decide on the service you aspire to.
What are we aiming for?
• To share an accurate overview of your service (Top Ten Characteristics)
• To describe your current service against each of the principles in the chosen pathway
• To determine where your service could and should aspire to move, using the processes
and behaviours described in the pathways
• To identify the barriers to success; what has to change?
• To agree an outline action plan that has tasks, timescales, named responsibilities and
outcome measures.
Identifying quick wins can be very motivating for getting the work started.
How do I organise this workshop?
In addition to the principles of multidisciplinary involvement and breadth of experience outlined
above, there may be key individuals whose involvement is critical to the process you wish to focus on.
For example, anaesthetic expertise is vital to the Planned Caesarean pathway. Consider where and
how you can engage users in your discussions.
Think carefully about numbers of people involved in any one pathway. The self-assessment process is
about broadening horizons and stimulating debate, this process is now about focusing on specific
objectives and tasks.
It is important that everyone leaves the workshop with a clear understanding
about the way forward and their role in it.

How long will the process take?
Working through a complete pathway to the production of an outline action plan will take
between two and six hours depending on the pathway chosen, the tools you look at and
the degree of detailed discussion. Realistically, you may decide to tackle only part of a
pathway or part of the process in one session. Alternatively you can divide the work up
amongst the small groups of participants as long as you allow ample time for feedback and
discussion in the whole group.
Preparation before the day
To make the best use of time together we recommend that your participants do some work
individually before the day of the workshop. Send each participant a copy of; ‘How to use the
toolkit - a guide for team members’, the Top Ten Characteristics, and the specific pathway you
plan to discuss in that particular group.
Ask everyone to make their own personal assessment of the current position of the service
and to start thinking about where on the pathway they aspire to be.
Decide, in discussion with the core team, who should lead the groups in the workshop.
Brief these people in advance about the aims of the workshop and the process you are
planning (see next section).

Step 1 - Introduce the workshop
• Present the aims for the workshop that have been agreed by the core team
• Ensure that all participants understand the aims
• Outline the stages in the process and the timetable for the session.
To get the maximum benefit from the workshop it is essential that all the participants feel
comfortable with the process. Please explain clearly that:
• Everyone is a valuable contributor
• There are no right and wrong answers
• It does not matter if part of the pathway is unfamiliar to individuals
• Participants are free to express themselves within the workshop but at the end of the
process must take responsibility for areas of the agreed action plan under their name.
Step 2 - Explaining the process
There may be people in the workshop who did not attend the self assessment workshop. It is
important that you provide a background to the work and explain how the pathways work.
This will also help as a refresher. See “Explaining the process” on page 38 for further information.
Also, if you have previously run a self assessment workshop you will already have a Top Ten profile
which you can share with participants and will help with explaining the background to the work.
Step 3 - Getting down to work
In the group, discuss together where your service currently sits in the spectrum of behaviours
illustrated. When you have reached agreement, use your own words to describe your service
in the Where are we now? boxes on the action plan. Then consider where you think the service
should aspire to move to and fill in the Where do we want to get to? boxes.
Step 4 - Setting priorities
If the core team has already determined some priority work streams to be taken forward in
the action planning, share these with the participants now. These are the ‘must do’s’.
Ask them to return to their small groups and assign all the priority areas amongst the groups
(depending on the time available). Ask them to work through the action planning sheet for each
priority area.

Step 5 - Sharing the results
Give every group a chance to feed back to the whole workshop. Ask them about their
experience of working together on this task as well as the conclusions they came to.
Ask for all the scribes’ notes and the action planning sheets so that you can review all
the information later and ensure that nothing important was missed.
Go back to the spreadsheet of the Top Ten Characteristics and highlight your service’s strengths
and weaknesses. Will the action plans improve your position as a whole service? You can
continue to use this tool following the workshop at key milestones in your action plans to
measure your progress.
Step 6 - Agreeing next steps
Ask the members of your core team to speak for five minutes about how the work will be
taken forward. This should include confirming priorities, ensuring that the most appropriate
people have committed to the plan, and making a commitment to a timetable for progress.
This should include a clear communication plan to everyone who has been involved.

Example of Action Plan for the Planned
Caesarean section pathway
There is pre-assessment for all women.
This is midwife-led according to a protocol.
Where are we now?
Women with risk factors for anaesthetics are sent round to the Labour ward to speak to an anaesthetist.
Healthy women come up to the antenatal clinic a few days before their CS. The duty midwife takes
blood tests and gives them a supply of Ranitidine. This is an extra visit with no antenatal check.
The midwife doesn’t work on Labour ward and can’t deal with any queries. She calls a doctor to
answer a woman’s questions.
There is an anaesthetic advice clinic to which women can be referred antenatally according to guideline.
The pre-assessment visit combines a normal antenatal check with preparation for CS.
The professional seeing the woman for pre-assessment can answer her questions about the operation,
its risks and benefits, the postnatal effects and implications for the future.
The expected date of discharge is discussed and agreed, subject to clinical considerations.
Each woman receives written information covering all these issues.
Set up a specialist anaesthetic referral antenatal clinic for women with anaesthetic risk factors.
Develop a protocol for a midwife-led visit to combine antenatal check with preparation for CS.
Decide on appropriate environment and midwife staffing for CS preparation visit. Day Assessment
Unit (DAU)
Consider need for multi-site use of the protocol.
Ensure that all staff members involved use and are comfortable with the same factual information.
Obstetric anaesthetist
Day Assessment midwife (lead)
Labour ward midwife
Obstetric doctor
October 2007
Obstetric Anaesthetists Association guidelines
NICE guidance on antenatal care
Mapping the patient’s journey (NHS Modernisation Agency)
Percentage of women who have a pre-assessment visit.
Audit of delays on admission for CS.
What will be the impact? (Quality and value, reduction in CS rate)
Reduction in variation of length of stay through planning discharge with each woman.
Increase in satisfaction with service through greater involvement in planning.
Consistent information to women.
Avoidance of delays through early identification of risk factors.
Possible minor reduction of CS rates through freeing midwife time to spend with women in labour.

Suggested Agenda -
Description of Activities
Self-improvement Workshop
2 hours 30 minutes to 4 hours
Participants: Targeted participants appropriate to the pathway you will address. Consider the
possible role of people from every discipline and at all levels in the service to ensure you have
full involvement.
Recommended group size: 10 – 25 (for larger groups consider having two facilitators or a
facilitator for each pathway)
1. Aims of the workshop: what you plan to achieve and how the work will be organised.
Reminder of how the pathways were derived and how they should be used.
10 minutes
2.Individuals record their own Top Ten Characteristics (TTC) assessment and hand it in.
Show previous summary slides of TTC if available or derive new summary slides.
(Discussion of pathway-specific scenario with neighbours).
20 minutes
3. Leaders gather their small groups of 4-8 people, ensuring an appropriate multidisciplinary skill
mix. Each group discusses the designated pathway and identifies where they think their service is
now and where they aspire to move to. They complete the Where are we now? in their own words
and Where do we want to get to? boxes on the action planning sheet.
30 minutes
4. Groups reviewing the same pathway come together to exchange views and reach a consensus
on their position and aspirations. These groups then agree the priority areas within their
pathway and allocate each one to a small group.
30 minutes
5. Small groups reconvene to work though the action planning sheet for each of the
priority areas.
30 to 120 minutes
6. Plenary session with feedback from each group on progress with action planning.
Each group identifies one quick win. Review of gaps in the Top Ten Characteristics
and how this will be addressed.
20 minutes
7. Next steps
10 minutes

AGENDA - Self-improvement Workshop
Pathways to Success: Focus on normal birth and
reducing Caesarean section rates
(Trust name, department etc)
(Date and Place)
(Time from/to)
1. Aims for the workshop
2. What does our service look like? Results of the Top
Ten Characteristics
3. Where are we now and where are we trying to get to?
4. Confirming the common vision: people who have worked on
the same pathway now get together
5. Action planning the priority areas
6. Feedback and review of the Top Ten Characteristics
7. Next steps

Does it matter which staff groups undertake the self-assessment?
The tool is designed to generate discussion and therefore it works best if there is a mix of
staff. This gives you the chance to get other professionals’ points of view and build a more
complete picture of how your service works. Involving a large cross section of staff
(midwives, doctors, managers, support workers, clerical staff and students) is likely to
make your assessment more accurate and give a clearer idea of where you want to be.
How large should each group be?
The tool has worked well when groups of four to eight people have discussed a pathway
in detail then fed back their thoughts and ideas to the whole workshop of up to forty
participants.
Our trust provides maternity services on more than one site, how
should we use the tool?
Many trusts provide a range of services across different geographical sites. The views and
experiences of all staff, whether working in a birthing centre or an acute unit, are
invaluable when looking at promoting normal outcomes for women. Behaviours and
processes on one site may influence outcomes on another. Giving staff prior information
about the aims of the workshop will help them to have a better understanding of how
they fit in and how they can contribute.
We didn’t always feel we could answer all the questions. Why was this?
Not all of the steps in the clinical pathways are relevant to every service but think carefully
before deciding that a statement doesn’t apply to you. It may be that you need a different
mix of people in your group to give you a broader picture of your whole service and how
it all fits together.
Sometimes we couldn’t agree on what the statements meant?
It is really important to take time to read the tool thoroughly as individuals, deciding where
you think you are before discussing it with your group. It is quite likely that individuals will
have different interpretations of the statements - sometimes this relates to different
perceptions from managers and clinicians and from midwives and obstetricians.
Generating discussions about these differences will add value to your conclusions.
We didn’t always feel there was a progression between the statements.
Focus your attention on teasing out what sort of behaviours might lie beneath the
statements and what that sort of service might look like. Even if you believe that there is
some inconsistency of progression you should be able to explore how you could move to
the next level.
What happens if we feel that we are between two columns, or that
more than one column applies?
This may well happen. Try to use similar ideas and language to make your own statement
about where your service is now and what you would like it to look like. The toolkit can
still help you to achieve the changes.
Frequently Asked Questions

We couldn’t always agree where we are. Does this matter?
Sometimes it can be difficult to pinpoint where you are. The tool highlights that you
don’t always know what happens in all areas of your service. It should still increase your
awareness and focus where you want to be.
What is the benefit of having the first boxes in the tool when the
behaviours are likely to be associated with higher CS rates?
The tool describes practices or beliefs that have been seen in maternity units. Most
people have a good idea as to what constitutes best practice but not all people can see
how to move from one set of behaviours to another.
Having a wide spectrum of behaviours to explore can help you identify what happens in
your own service and decide what you need to change to move on.
Is the final column always what we are aiming for?
The tool is not designed to dictate patterns of care to trusts but to share what we have
learned from others. It provides the opportunity for you to debate why the final column
may not be the place for you and to decide what changes are appropriate and feasible.
It should stimulate discussion about the strengths and weaknesses of your organisation
and make you aware of varying practices, as well as give you lots of food for thought.
Do we need to score where we are?
No. Staff using the tool have told us that attaching numbers to the boxes on the
pathways is not helpful. Not all the elements of the pathways are of equal importance
but each contributes to the wider picture.
If we all commit to doing the same thing with no opting out, does
this affect choices for women?
The tool enables you to explore the complexities of your organisation and understand
the care you provide. Consistency of approach doesn’t close down care options but
makes it clearer which options are available. If all your staff are consistently employing
the best practice and giving consistent information the women using your service will
receive good care. They in turn will be able to give you valuable feedback.
The guidance suggests that we can involve users in the assessment.
How do we do this?
Each discussion group would benefit from having an experienced maternity service user
in it. This will broaden discussions even further. It is useful to invite someone who
already has background information on your service such as your user member on your
labour ward forum or a member of your Maternity Services Liaison Committee.
What happens if we don’t have the resources to make changes?
Not all changes cost money. Many of the changes described in the tool do not require
additional funding. Sometimes it is not about changing what you do but when you do
it. Getting a fuller understanding of where your service is now and where you want to
go to will help you prioritise what resources you have. Using the toolkit will save you
time as we are able to share what others have already tried and tested. If other trusts
have made it work there is a good chance you can too.
Can other people audit our service using this tool?
No. The tool should be used to promote discussion and exploration of the way a service
functions by the people that work in it.

Top Ten
4
Introduction
01-16
Practical advice on
using the toolkit
17-32
Running workshops:
33-54
Top Ten
55-62
63-74
75-90
91-104
105-118
and Glossary
119-126

Top Ten Characteristics
The Top Ten Characteristics brings together key features from all of the pathways to illustrate
the culture of your whole maternity service.
‘This is a powerful exercise that everyone should do.
It gives a helicopter view of your service and will help
you agree priorities and measure your progress.’
Richard Hallett
Co-chair, Maternity Services Liaison Committee,
East Sussex Hospitals NHS Trust
These pathways reflect the practices and behaviours we have seen and heard. Moving from
left to right, the process supports lower Caesarean section rates.
You may not agree with all these statements - you will need to decide what changes are right
for your organisation.

Althoughuniquetoeach
woman,birthisseenasa
normallifeeventwhich
requiresnointervention
unlessclinicallyprovento
beofbenefit.
Staffcommunicatefreely
andlearntogether.Theytrust
eachotherandcanchallenge
eachotherconstructively
andopenly.
Weareallpotentialleaders.
Wechampionourservice
andallworktomakeit
evenbetter.
Everyonehasanopportunity
tocontributetoguideline
development.
Evidence-basedcareis
adoptedwhereveravailable
andguidelinescoverour
entireservice.
Weallusethesameguidelines
inourpractice.Variationsare
recordedandjustified.Staff
feelempoweredtochallenge
eachother’spractice.
Staffrecognisethatpregnancy
andbirthhavethepotential
tobenormalandareworking
towardsthis.
Staffcommunicatewellwith
eachotherandshareteaching
andtraining.Theygainmutual
respectbyunderstandingeach
other’sroles.
Ourleadersarechampionsfor
ourservice.Wefeelvalued
andareencouragedtodiscuss
andtryoutnewwaysof
working.
Guidelinesareproducedby
agroupofstaff.Somekey
guidelinesareevidence-based
andproducedtoCNST2
standards.
Wehaveevidence-based
guidelinesbutallowstaffto
useotherevidence-based
guidancetheyaremore
familiarwith.Variations
remainunchallenged.
Staffrecognisethatsome
elementsofthemanagement
ofnormalpregnancyand
labourcanenhancethecare
ofhigh-riskwomen.
Clinicalinformationisshared
amongstseniorstaffbutitis
passeddownfrommidwife
tomidwifeordoctorto
doctor.Thereareseparate
trainingsessionsformidwives
anddoctors.
Wehaveidentifiableleaders.
Thereareclearchannelsof
communicationandstaffare
abletoraiseconcerns.
Thereissomeoneincharge
ofproducingandcirculating
allourguidelines.Theyare
regularlyupdated.
Allseniorstaffhavesigned
uptoourguidelinesbut
somedonotchangetheir
personalpractice.
Thereisaprotocolfor
managingnormalpregnancy
andlabour.Onceanydeviation
occurs,womenbecome
high-riskobstetriccases.
“Wearecarefulwhatwesay.
Wedon’tliketoaskquestions
-wefeelwearebeing
troublesome.”
Communicationoccursonly
withinstaffgroups.Incidents
arereportedupwardsbutwe
don’tgetfeedback.
Thoseinchargeneverseem
tobearoundunlessthereis
acrisis.
Neworupdatedguidelines
appearfromtimetotime
–wefindoutbychance.
Ourguidelinesarenot
acceptedbysomeseniorstaff
soareforinformationonly.
Staffbelievethatbirthisonly
normalinretrospect.
Theobstetricstaffareinvolved
ineverylabour.
Staffgroupsdon’tmix.
“Midwiveshidethings
fromus...”
“Doctorsinterferewithour
cases….”
Thereisablameculture.
Sometimeswedon’tknow
whoisincharge.
Wehavesomeguidelines
buttheyarenotreviewed
regularly.
“Thisguidelinewaswritten
forsomeoneelse–itdoesn’t
applytome.”
“Ithinktherearesome
guidelinesbutIhaven’t
actuallyseenthem.”
Wefocusonkeeping
pregnancyandbirthnormal
Wearearealteam–we
understandandrespect
rolesandexpertise
Ourleadersarevisible
andvocal
Ourguidelinesare
evidence-basedand
uptodate
Weallpractisetothesame
guidelines–nooptingout
Top Ten Characteristics
Thesepathwaysreflectthepracticesandbehaviourswehaveseenandheard.Movingfromlefttoright,theprocesssupportslowerCaesareansectionrates.
Youmaynotagreewithallthesestatements–youwillneedtodecidewhatchangesarerightforyourorganisation.

Womenaresupportedto
exploretheirfeelingsfor
labourandbirth.Weknow
thatwomenfeelprepared
andconfidentabouttheir
ownlabour.
Weworkwithwomento
agreepersonalbirthplans
ifthereareconcernsabout
childbirth.
Eachwomaniswellbriefed
postnatallyonthereasons
forherCSandthe
implicationsforthefuture.
Inhernextpregnancy,all
midwivesareabletoleadthe
discussiononVBACatthe
bookingappointment.
Womenandstaffarefully
informedpartnersin
followinganagreedpathway
thatoptimisesqualityofcare
andresourceutilisation.
Therearedailyclinicalcase
reviewsopentoallstaff.
Lessonslearntfromadverse
incidentsinformservice
development.
Monthlyclinicalinformation
ispresentedasStatistical
ProcessControlcharts
showingtrends.Theyare
availableontheintranet.
Midwivessupportwomenin
preparingfornormallabour
followingafixedprogramme.
Thereareformalsupport
servicesforwomenwith
underlyingfearsand
concerns.
Womenarebriefedonthe
reasonsfortheirCSsoon
afterthebirth.
Eachwomandiscussesthe
managementofhernext
birthwithadoctoror
specialistmidwifeearlyinher
nextpregnancy.
Thereisanefficientpathway
howeverdelaysoftenoccur
becauseplannedCSisalow
priorityonlabourward.
Thereareregularmeetings
forthediscussionof
interestingclinicalcases.
Thereisaprocessfor
disseminatinglearning
fromadverseincidents.
Thematernityinformation
systemproducescustomised
monthlyclinicallyrelevant
figuresthatstaffcanaccess
directly.
Pregnancyclassesarereadily
accessiblebutfocusonwhat
mightgowrong.
Whenwomenaskfora
CSwetrytofindoutwhat
isbehindtherequest.
VBACisrepresentedas
ahigh-riskprocessthat
mustbesanctionedby
aconsultantobstetrician.
Allclinicalstaffgive
consistentinformation
andadviceaboutdelivery.
Thereisanagreedpathway
butthisisinefficientfor
thewomanandthestaff.
Forexample,womenare
admittedonthedayof
operationandwaitfortheir
preoperativeinvestigations
beforesurgery.
Clinicalcasereviewsaread
hoc.Wedonothavetime
forregularmeetings.
Wedonotgetinformation
ontrendsinouradverse
incidents.
Monthlyperformance
statisticsarecollectedand
widelypublicised.
Womenintheirfirst
pregnancyareoffered
aclassaboutlabourafter
34weeks.
Maternalrequestfora
CSisagreedonlyafter
asecondopinion.
Intheirsubsequent
pregnancy,womendiscuss
modeofdeliverywitha
consultantlateinpregnancy,
shortlybeforeaCSisbooked.
Theinformationgivenis
inconsistentandthe
subsequentadvicevaries
byclinician.
Individualteamshavecustom
andpracticearrangements
forplannedCS.
PlannedCSisalowpriority
onlabourward.
Seniorstaffdiscuss
problemclinicalcases
behindcloseddoors.
Ifthereisanincidentwe
prefertodealwithit
informallyratherthan
reportingit.
Maternityperformancedata
iscollectedformanagement
purposesonly.
Wedonotprovideany
preparationforlabourfor
womenintheirfirst
pregnancy.
IfawomanasksforaCSin
herfirstpregnancyweagree
–it’sherchoice.
Women,theirmidwivesand
theirobstetriciansexpectthe
nextdeliverytobebyCS.
VBACisonlyconsideredat
theinsistenceofindividual
women.
Thereisnoagreedpathway
forwomenhavinga
plannedCS.
Thereareadhoc
arrangementswithlabour
ward.
Thereisnoformalclinical
casereview.
Adverseincidentreporting
issparse.
Therearenodetailed
performancefigures
formaternity.
Wemanagewomen’s
expectations,we
preparethemfor
therealityoflabour
Weareproactive
inrecommending
VBAC,givingaccurate
informationabout
risksandbenefits
IfaCaesareansectionis
planned,theprocessis
efficientandeffective
Wegetaccurate,
timelyrelevant
informationon
ourperformance
A
B
A
B

Usersactivelyengage
withtheservicethrough
anumberofdifferent
channelsandhelpto
informservicedevelopment.
Wefacilitateuserstoact
aspeersupporte.g.for
breastfeeding.
Providersandcommissioners
worktogethertoagree
qualityimprovementtargets
fortheservice.
Ourregularusersatisfaction
surveysareusedasabasis
foraserviceimprovement
actionplan.
Userrepresentationonthe
MSLCreflectsourcommunity.
Ourcommissioners
regardthematernity
serviceashighpriority
andsetqualitymeasures.
Wecarryoutpatient
satisfactionsurveys.
Theresultsarefedback
tostaff.
Thereareregular
formaldiscussionswith
commissionersabout
maternityservices.
Thesedonotinclude
qualitymeasures.
Someonecarriesout
occasionalpatient
satisfactionsurveys
butwedon’thear
abouttheresults.
Thereareadhocdiscussions
withcommissionersabout
maternityservices.
Wereplytocomplaints.
Wehavedifficulty
inmaintaininguser
involvementon
ourMSLC.
Ourcommissioners
regardmaternityservices
aslowpriority.
Weworkclosely
withourusers
andstakeholders
A
B

Top Ten Characteristics – Individual Record Sheet
Wefocuson
keepingpregnancy
andbirthnormal
Wearearealteam–we
understandandrespect
rolesandexpertise
Ourleadersarevisible
andvocal
Ourguidelinesare
evidence-basedand
uptodate
Weallpractiseto
thesameguidelines
–nooptingout
Wemanagewomen’s
expectations,we
preparethemfor
therealityoflabour
Weareproactivein
recommendingVBAC,
givingaccurateinformation
aboutrisksandbenefits
IfaCaesareansection
isplanned,theprocess
isefficientandeffective
Wegetaccurate,timely
relevantinformation
onourperformance
Weworkclosely
withourusersand
stakeholders
A
B
A
B
A
B

Top Ten Characteristics - Self-improvement Action Plan
We work closely with our users and stakeholders
Where are we now?
• We do an annual user satisfaction survey and present the results at staff meetings
• Our MSLC (Maternity Services Liaison Committee) meets irregularly
• There is a user representative on the Labour ward forum
• Meetings with the PCT are focused on activity only
• A range of channels for user input. Start a focus group to address specific areas of development
• All information leaflets to have user input
• Increase membership of MSLC to reflect local community
• Discussions with PCT include quality measures and opportunities for women’s choice
• Strategy for involving hard to reach groups of users
• Develop communication chain for publicising user feedback
• Develop quality indicators with PCT
• Head of midwifery (lead)
• Clinical Director
• Maternity risk manager
• Lay chair MSLC
• March 2008
• Maternity services focus group case study and terms of reference
• User involvement audit
• Modernising maternity care - a commissioning toolkit for England
• Charter Mark Standards
• We will / you will poster template
• Audit of complaints
• Audit of MSLC (user involvement audit)
What will be the impact? (quality and value, reduction in CS rate)
• Reduction in complaints
• Improved job satisfaction for staff
• More effective relationship with commissioners
Worked example

For further information on how to develop measures and on how to present your data,
please refer to the Improvement Leaders Guide on ‘Measurement for Improvement.’
This can be found at: www.institute.nhs.uk
Why not revisit the results of the Top Ten Characteristics exercise to see how staff think you
have progressed since your first workshop? This is a very powerful tool to show your progress.
Initial Results
The health and social care communities work in partnership to promote the concept
of normal pregnancy and childbirth.
New Results
The health and social care communities work in partnership to promote the concept
of normal pregnancy and childbirth.

Organisational
Characteristics
5
Introduction
01-16
Practical advice on
using the toolkit
17-32
Running workshops:
33-54
Top Ten
55-62
63-74
75-90
91-104
105-118
and Glossary
119-126

The Organisational Characteristics looks at how your maternity service fits together as a whole
and how it sits within your trust.
‘The pathways support issues that are not often
discussed or even acknowledged within an organisation
- the culture of your organisation is paramount in
reducing Caesarean section rates.’
Alison Whitham
Maternity and Gynaecology Manager, King’s Mill Hospital,
Sherwood Forest Hospitals NHS Foundation Trust (CS rate 14%)
These pathways reflect the practices and behaviours we have seen and heard. Moving from
left to right, the process supports lower Caesarean section rates.
You may not agree with all these statements - you will need to decide what changes are right
for your organisation.

Wehaveconsistent,
evidence-basedinformation
thatallmembersofstaffuse
whendiscussingchoicesin
maternitycare.Womenare
activepartnersindecisions
abouttheircare.
Allstafffromtheclinical
directortothehousekeeping
staffarefocussedon
achievingtheoptimal
outcomesformother
andbaby.Itispartoftheir
jobdescription.
Ourleadersarehighlyvisible.
Welooktothemasrole
models.Stafftrusteachother
andcanchallengeeachother
constructivelyandopenly.
Everyoneisencouragedto
contributetoguideline
development.Guidelines
coverourentireserviceand
areevidence-basedwhere
possible.Theyareavailable
electronicallyandevery
print-outisdated.Variance
fromguidelinesisrecorded
andaudited.
Ourmanagershaveregular
sessionswiththeboard
toreviewourrisks.Wefeel
theyarefullyinformed.
Wecangiveyouexamples
ofimprovementsthathave
comethroughourrisk
reporting.
Wehaveevidence-based
informationavailablebut
notallwomenreceiveit.
Weencouragewomento
writebirthplansandwetry
torespondtotheirrequests.
Ourseniorstaffare
committedtoachieving
optimaloutcomesbut
whennewstaffjointheunit
thingswobbleforawhile.
Staffcommunicatewell
andshareteachingand
training.Wegainmutual
respectbyunderstanding
eachother’sroles.
Guidelinesareconsulted
onbyagroupofstaff.
Theyareregularlyupdated.
CNST2standardsareapplied
tosomeguidelinesonly.
There’sagoodclinical
governancestructurein
maternitybutnochannel
forsharinglearningwith
otherservices.Wehave
rapidaccesstothetrust
boardifsomethinggoes
seriouslywrong.
Werespectwomen’s
viewsbutwehavedifferent
interpretationofrisksand
choices.Theoutcome
dependslargelyonwhich
clinicianyoutalkto.
Wesetclearaimsand
standardsbutwearetoo
busytoreflectontheservice
weareactuallydelivering.
Weknowwhoisincharge
andwheretofindthem.
Intheory,anyonecan
approachtheseniormidwife
ordoctorbutinrealitythere
iscommunicationonlyat
thetop.
Thereisanominatedperson
whoproducesandcirculates
ourguidelines.Someare
availableaspaperformat,
someelectronicformat.
Seniorstaffhavesigned
uptothembutdonot
alwayschangetheir
personalpractice.
Whenthereisaserious
problemandthetrustboard
isinvolveditfeelsveryunfair
onus;we’veoftenbeen
raisingconcernsformonths.
Itisdifficulttoexplainrisks
andmakethemmeaningful
towomen.Itisunkind
tofrightenthemwithall
thedetails,wearethere
toprotectthemandlook
afterthem.
Weexpectallhealth
professionalstoknow
whathighqualitycare
is,wedon’tspellitout
forthem.
“Wearecarefulwhat
wesay.Wedon’tlike
toaskquestions.”
Neworupdatedguidelines
appearfromtimetotime
–wefindoutbychance.
Theyareforinformation
only–noteveryoneagrees
withthecontent.
Ourmanagerssupportusin
identifyingandreportingrisks
butnothingseemstochange
asaresult.
Mostwomendon’treally
wantchoicetheywant
recommendationsfrom
theprofessionals.
Recruitmentandretentionis
difficult–wetakethestaff
wecanget.
Staffgroupsdon’tmix.
“Midwiveshidethings
fromus….”
“Doctorsinterferewith
ourcases….”
Wehavesomeguidelines
buttheyarenotreviewed
regularly.
Manypeopledon’tusethem
orknowwhatisinthem.
Wearereluctanttofill
inincidentforms;there
isstillablameculturein
thistrust.
Womenareempoweredto
makeinformedchoices
abouttheirmaternitycare
Staffshareacommon
ethosandaspirationsfor
highqualitycare
Maternitycareisdelivered
byamultidisciplinaryteam
withhighlevelsofmutual
trustandrespectbetween
professions
Thereisanembedded
andsustainablemodel
ofgoodclinicalpractice
Thereisarobustclinical
governancestructure
throughoutthetrust
Thesepathwaysreflectthepracticesandbehaviourswehaveseenandheard.Movingfromlefttoright,theprocesssupportslowerCaesareansectionrates.
Youmaynotagreewithallthesestatements–youwillneedtodecidewhatchangesarerightforyourorganisation.

Toolkit Reduces Caesarean Rates

Toolkit Reduces Caesarean Rates

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