Definitions used in the second organisational survey

Maternity unit types

For consistency with current research and national guidance, we are following the unit type definitions as described in the Birthplace in England Research Programme, quoted below.

We do acknowledge that not all maternity units fit these definitions exactly, for example some Scottish community maternity units; we have tried to accommodate this in our survey set up and will take this into account in our analysis. If you find that you are unable to adequately describe the arrangements at your unit, please contact us as soon as possible via nmpa@rcog.org.uk.

  • In an obstetric unit (OU), care is provided by a team of midwives and doctors. Midwives provide care to all women in an obstetric unit, whether or not they are considered at high or low risk, and take primary responsibility for women with straightforward pregnancies during labour and birth. Obstetricians have primary professional responsibility for women at high risk of complications and for women who develop complications during labour and birth. Obstetric units are always situated in hospitals where diagnostic and medical treatment services - including obstetric, neonatal and anaesthetic care - are available on site. Obstetric units provide care to low and higher risk women. ‘Higher risk’ women - those who have health problems and/or less straightforward pregnancies - should normally be advised to give birth in an obstetric unit.

  • In midwifery units, midwives take the primary professional responsibility for labour care. This is sometimes described as midwife-led care. Midwifery units offer care to women with straighforward pregnancies

    • Alongside midwifery units (AMUs) are situated in the same hospital or on the same site as an obstetric unit so have access to obstetric, neonatal or anaesthetic care on site, although women may need to be physically transferred to the obstetric unit if they need obstetric care. 
    • Freestanding midwifery units (FMUs) are not situated in a hospital or site with an obstetric unit or neonatal unit. This means that if the woman needs obstetric or anaesthetic care or the baby requires neonatal care they need to be transferred - typically by ambulance or car - to another hospital where these services are provided. 

Based on: NPEU (2011) The Birthplace in England Research Programme

 

Continuity of carer and midwifery care models

Measuring Continuity of Carer - A monitoring and evaluation framework (Sandall/NHS England/RCM 2018) outlines that continuity of carer means each woman has:
  • Consistency in the midwife or clinical team that provides hands on care for her and her baby throughout pregnancy, labour and the postnatal period.
  • A named midwife who takes on responsibility for coordinating her care, and for ensuring all her needs and those of her baby are met, at the right time and in the right place, throughout the antenatal, intrapartum and postnatal periods.
  • A midwife she knows at the birth.

Continuity of carer is recommended by Better Births (NHS England 2016). Similarly, The Best Start (Scottish Government 2017) recommends that every woman has continuity of carer from a primary midwife who will provide the majority of their antenatal, intrapartum and postnatal care, and the ambition for continuity of carer is included in A Strategic Vision for Maternity Services in Wales (Welsh Government 2011).

Continuity of carer models are based on the above principles and can take the form of midwives carrying a caseload, or midwifery teams organised to facilitate continuity of carer:

  • Full caseloading continuity of carer model: where a midwife is allocated a certain number of women (the caseload) and antenatal, intrapartum and postnatal care is personally provided by this named lead midwife, with or without a buddy midwife as back up. I.e. there is an expectation of continuity of carer by the lead midwife across all three care periods (antenatal, intrapartum and postnatal).
  • Team continuity of carer model: midwifery teams providing antenatal, intrapartum and postnatal care, in which the woman is allocated a named lead midwife within the team who is responsible for coordinating and personally providing most of her midwifery care, with the other midwives in the team as backup. This can be with or without a buddy midwife within the team as first choice to provide back up.

Terms used in continuity models:

  • Lead midwife: the named midwife assigned to each pregnant woman. It is expected that the lead midwife will know the pregnant woman the best and will have met her the most times. This midwife may be called ‘lead’, ‘named’ or ‘primary’ midwife - the important thing is that this midwife personally provides most of the woman's care.
  • Buddy midwife: pairs of midwives working together to provide backup for each other. If a woman’s lead midwife is unavailable the buddy is the first choice for replacement.
  • Team midwife: this refers to a team of midwives that each woman has been assigned to. If the lead/buddy midwife is not available, then a team midwife is assigned. It is presumed that women will have met all team midwives prior to going into labour. 

Based on: Sandall/NHS England/RCM (2018) Measuring Continuity of Carer - A monitoring and evaluation framework

 

Adult critical care levels

  • Level 0 care: requiring hospitalisation/normal ward care, e.g. 4 hourly observations.
  • Level 1 care: requiring additional input/monitoring/critical care outreach, or recently discharged from a higher level of care. E.g. continuous insulin infusion or requiring bolus drugs through central venous catheter.
  • Level 2 care: requiring single organ support (unless advanced respiratory support). E.g. use of central venous or arterial line to monitor pressures, acute renal replacement (e.g. dialysis) or use of a single intravenous vasoactive drug to control pressures.
  • Level 3 care: requiring support of two or more organs OR requiring advanced respiratory support (ventilation). E.g. requiring both dialysis and cardiovascular support, requiring mechanical ventilation, or requiring pressure ventilation through a laryngeal mask or tracheostomy.

Based on: Intensive Care Society (2013) Core Standards for Intensive Care Units

 

Neonatal unit designations

Neonatal units are designated nationally as special care baby units (SCBU), local neonatal units (LNU) and neonatal intensive care units (NICU). The Department of Health Toolkit for High Quality Neonatal Services defines these as follows:

  • Special care baby units (SCBU/SCU) provide special care for their own local population. Depending on arrangements within their neonatal network, they may also provide some high dependency services. In addition, SCBUs provide a stabilisation facility for babies who need to be transferred to a NICU for intensive or high dependency care, and they also receive transfers from other network units for continuing special care.
  • Local neonatal units (LNU) provide neonatal care for their own catchment population, except for the sickest babies. They provide all categories of neonatal care, but they transfer babies who require complex or longer-term intensive care to a NICU, as they are not staffed to provide longer-term intensive care. The majority of babies over 27 weeks of gestation will usually receive their full care, including short periods of intensive care, within their LNU. Some networks have agreed variations on this policy, due to local requirements. Some LNUs provide high dependency care and short periods of intensive care for their network population. LNUs may receive transfers from other neonatal services in the network, if these fall within their agreed work pattern.
  • Neonatal intensive care units (NICU) are sited alongside specialist obstetric and feto-maternal medicine services, and provide the whole range of medical neonatal care for their local population, along with additional care for babies and their families referred from the neonatal network. Some NICUs are co-located with neonatal surgery services and other specialised services. Medical staff in a NICU should have no clinical responsibilities outside the neonatal and maternity services.

Based on: Department of Health (2009) Toolkit for High Quality Neonatal Services

Neonatal categories/levels of care

  • Intensive care: care provided for babies who are the most unwell or unstable and have the greatest needs in relation to staff skills and staff to patient ratios. An intensive care day is defined as a day where a baby receives any of the following: any form of mechanical respiratory support via a tracheal tube; both non-invasive ventilation and parenteral nutrition; the day of surgery; the day of death; or a day receiving any of a number of interventions as described in the British Association of Perinatal Medicine (BAPM 2011) Categories of care.
  • High dependency care: care provided for babies who require highly skilled staff but where the ratio of nurse to patient is less than intensive care. A high dependency care day is defined as a day where a baby does not fulfil the criteria for intensive care and where the baby receives any of the following: any form of non-invasive respiratory support; parenteral nutrition; or has any of a number of interventions as described in BAPM 2011.
  • Special care: care provided for babies who require additional care delivered by the neonatal service but do not require either intensive or high dependency care. A special care day is defined as a day where a baby does not fulfil the criteria for intensive or high dependency care and where the baby receives any of the following: oxygen by nasal cannula; feeding by nasogastric tube, jejunal tube or gastrostomy; has an intravenous cannula; or has any of a number of interventions as described in BAPM 2011.
  • Transitional care: neonatal transitional care (NTC) is care additional to normal infant care, provided in a postnatal clinical environment by the mother or an alternative resident carer, supported by appropriately trained healthcare professionals. NTC can be delivered under several different service models, including within a dedicated transitional care ward and on a postnatal ward, but the primary carer must be resident with the baby and providing care. Whatever the location, NTC should be considered a service, rather than a place in which care is delivered. Additional support for the mother in caring for her baby should be provided by a midwife and/or healthcare professional trained in delivering elements of neonatal special care but not necessarily with a specialist neonatal qualification. Maternity care for newly delivered women must be provided by a midwife.
  • Normal care: normal newborn care is delivered by a mother with the support and guidance of her midwife, either on a labour ward, a postnatal ward or at home. Normal newborn care includes immediate review of the baby after birth to detect major physical abnormality, establishment of feeding and ongoing assessment of infant well-being, including observation of vital signs. The newborn initial physical examination (or routine examination of the newborn) may be undertaken by the midwife, who will also normally facilitate newborn blood spot screening. None of these tasks should involve separation of mother and baby.

Based on: British Association of Perinatal Medicine (2011) Categories of care and British Association of Perinatal Medicine (2017) A Framework for Neonatal Transitional Care