This midwife-led project describes an evidence-based approach to the resuscitation of the low-risk, term infant, at elective lower segment Caesarean section under regional anaesthesia.  

Using a SMART assessment tool specific objectives were identified: 

• Implement patient-centred, holistic, evidence-based care
• Provide training on neonatal resuscitation to support midwifery-led resuscitation for the multidisciplinary team
• Develop a guideline with clearly defined roles and responsibilities for the midwifery and nursing team. 

Implementation, tactics and strategy

Drivers for the implementation of this project included the desire for ‘de-medicalisation’ of childbirth and enhancement of maternal satisfaction in keeping with evidence-based, holistic, safe practice. A broader understanding and efficient utilisation of paediatric SHO resource between the maternity and paediatric departments was essential while maintaining high quality, patient-centred care as previously recommended by the paediatric clinical care programme.  

A clinical audit of paediatric SHO activity at elective sections confirmed there was no requirement for the attendance of a paediatric SHO in the presence of a skilled competent midwife trained through an active neonatal resuscitation programme (NRP). Provision for these factors was fundamental to building a culture of efficient team work and a shared philosophy of care and mutual respect.  

With this in mind PESTLE analysis (political, economic, social, technical, legal, and environmental) was chosen as the strategic tool to interpret and understand the detail of the change from a macro-environmental perspective.

I co-ordinated and implemented the change using the HSE change model as a guiding tool. The model was chosen for its people-centred approach and flexibility, underpinned by evidence-based organisational practice. 

In the initiation phase a strong business case was supported by positive feedback from SWOT (strengths, weaknesses, opportunities and threats) analyses, stakeholder and readiness – assessment analysis within the maternity and paediatric accident and emergency department.

Strategy in the planning phase involved explorative information and feedback meetings for the multidisciplinary team to gain buy-in for this project. This was achieved through effective leadership at all levels of the organisation. The strength of this project was in its focus on effective communication supported by a robust neonatal resuscitation educational package with commitment from senior management and medical personnel.

Outcome

The philosophy of midwifery practice has been unearthed and revisited in the provision of holistic, woman-centred, evidence-based care through this change project. Midwives became authentic practitioners in line with their scope of practice. This was demonstrated through a four-month clinical audit of elective caesarean section under regional anaesthesia, which confirmed a 100% compliance with midwife-led resuscitation.   

Eleven of the 57 babies scheduled for elective caesarean section did not meet the criteria due to risk factors identified antenatally. These babies required a paediatric SHO in attendance at caesarean section. Clinical audit also confirmed no babies were admitted to the special care baby unit as a consequence of this change initiative.

Clinical audit of the level of compliance with the NRP educational programme confirmed 100% conformity among the multidisciplinary team. This was necessary to validate best practice. It was achieved through the NRP educational resuscitation programme providing skilled midwives and nurses at the resuscitaire in the operating theatre with competence in initiating resuscitation.

Initially the multidisciplinary team wanted a guideline to support this change project, however through critical analyses of midwifery and nursing scope of practice it has been accepted that a guideline is not necessary to support this change.  

This change involved eliminating duplication and facilitating midwives and nurses to achieve their scope of practice. Therefore, it was recognised by an autonomous midwifery team and their managers that a specific guideline developed for this change project would represent another layer of duplication. The current guideline determined by the NRP for all levels of risk is appropriate.  

Feedback from the paediatric department acknowledged enhancement of paediatric SHO attendance in the accident and emergency department. Clinical audit of the paediatric SHO reported “hours saved“ through the established midwife-led resuscitation and determined that  over the course of 105 days, attending to 45 babies, there was a minimum time-saving capacity of 22 hours and 30 minutes.  

This change project has the potential to be replicated as innovative quality evidence-based initiative in similar organisations.

This project was awarded the CJ Coleman Research Award at the 2013 Irish Nurses and Midwives Organisation Annual Delegate Conference.