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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Breech Delivery Vaginal Breech (378)

Please report any inaccuracies or issues with this guideline using our online form

The incidence of breech presentation is 25% at 28 weeks, 16% at 32 weeks and 3-4% at term. The authors of the term breech trial recommended “the best method of delivering a complete or frank breech singleton at term is by planned lower segment caesarean section”. Nevertheless there are women with a breech presentation at term who will make an informed choice to have a trial of vaginal breech delivery.  There is no good evidence to support that caesarean section is the safest mode of delivery for the preterm breech.  There are also women who will present in advanced labour with an undiagnosed breech presentation, for whom caesarean section may not be an option.

IT IS THERFORE IMPORTANT THAT CLINICIANS ARE FAMILIAR WITH TECHNIQUES FOR ACHIEVING SUCCESSFUL VAGINAL BREECH DELIVERY

The same manipulations are employed when delivering a breech or a Caesarean section. Master them when doing CS for Breech presentations.

Management of Vaginal Breech Delivery: In women who decline or are unsuitable for Caesarean section Types of Breech

There are four types of breech presentation. They are determined by the way in which the fetal legs are flexed or extended, and these have implications for the birth

  • Complete or Flexed Breech: The flexed breech occurs more commonly in the multigravid woman. Flexed breech is when the fetus sits with the thighs and knees flexed with the feet close to the buttocks. (see Diagram A)
  • Frank or Extended Breech: This is the commonest type of breech presentation and occurs most frequently in the primigravid woman towards term: the fetal thighs are flexed, but the legs are extended at the knees and lie alongside the trunk, the feet being near the fetal head. (see Diagram B)
  • Footling presentation: This type of breech is more likely to occur when the fetus is preterm, but is relatively rare. Footling breech is when one or both feet present below the fetal buttocks, with hips and knees extended. There is increased risk of cord prolapse.
  • Knee presentation: This is the least common. This occurs when one or both knees present below the fetal buttocks, with one or both hips extended and the knees flexed.

Management of First Stage of labour

On admission

  • Confirm breech presentation.
  • Clinical assessment of the fetal size
  • Assess whether pelvis seems to be adequate.
  • Ultrasound by a competent practitioner is useful to:
    • assess the type of breech
    • Locate the placenta,
    • Assess size of the fetus (unless AC performed within last 14 days)
    • Determine the attitude of the fetal head.
    • Fetal heart activity
    • Amniotic fluid volume
    • Whether neck is extended or not

N.B There should be no hyperextension of the fetal head. If present: explain to woman what this means. This is a contra-indication to attempting vaginal birth.

Following above assessment:

  • Discuss management options and confirm that the mother still wishes to have a vaginal breech delivery.
  • Obtain written consent including options of emergency interventions (Breech extraction and CS)
  • Inform the consultant obstetrician on call
  • Inform on-call anaesthetist / paediatric staff
  • Obtain IV access: 14g cannula
  • Offer epidural anaesthesia (not essential but helpful)
  • If membranes  rupture  spontaneously,  vaginal  examination  is  required  to  exclude umbilical cord prolapse.
  • If membranes are still intact then amniotomy should only be performed  for usual indications.
  • Continuous fetal monitoring should be used.
  • Fetal blood sampling can be performed from the fetal buttocks. The indications,  technique  and interpretation used should be the same as for cephalic presentations.
  • Oxytocin may be used with caution; after discussion with senior obstetrician; usual regime depending on parity.

Management of Second Stage:

Ideally a consultant obstetrician with experience of vaginal breech delivery should be present for the management of the second stage if time allows.

Basic principles:

  • A scrubbed assistant should be present if possible
  • Avoid handling the breech as it descends until leg manipulation required
  • Ensure good maternal effort
  • Do not touch the cord
  • Keep the sacrum anterior
  • Empty bladder
  • Begin active pushing when breech has descended to the pelvic floor.
  • Delay Lithotomy position until anus is visible over the fourchette.
  • Consider episiotomy at this time.
  • Allow spontaneous rotation to sacrum anterior position.
  • If legs extended, deliver legs by applying pressure in the popliteal fossa to flex the legs at the knee joint.

  • As the trunk descends with maternal effort, the tip of the scapula of the anterior shoulder becomes visible. The anterior arm should be delivered by splinting the humerus between 2 fingers. The other shoulder should rotate spontaneously to allow similar delivery of the other arm.
  • If the arms are extended or a nuchal arm is diagnosed Lovsett’s manoeuvre should be used Apply gentle traction using a femero-pelvic grip and deliver one arm by clockwise rotation to the oblique, followed by counter clockwise rotation to the oblique to deliver the other arm.

 

N.B Lovsett is not a routine part of a vaginal breech delivery

  • Support the baby as the head engages.
  • Use Mauriceau-Smellie-Veit (MSV) manoeuvre to complete delivery. The MSV manoeuvre encourages flexion of the fetal head. Place one hand above the fetus with one finger on the fetal occiput and one finger on each of the fetal shoulders. The other hand should be placed below the fetus and 2 fingers should be placed on the maxillae (not in the mouth). Some practitioners use their 2nd and 4th fingers for this and place their middle finger under the chin for triangular stability. The fetal body is raised upward in an arc completing delivery

 

Application of Forceps to After Coming Head

In up to 20% of cases forceps may be required to deliver the fetal head.

This is not as difficult as it might appear. Practise on a manikin is advised to become familiar with the technique.

  • Do not panic
  • The head is generally direct OA or no more than 15° left or right.
  • Assistant should gently lift and support the baby without undue traction. Its body can be wrapped in a towel to keep it warm
  • Select Mid Cavity forceps, such as Simpsons. Do Not use Wrigley’s.
  • Apply Forceps using a standard approach. Once the first blade is applied any lateral deviation can usually be corrected to DOA.
  • Once the forceps are applied, check application and lock as next contraction commences
  • Gentle downward traction
  • Start upward traction once chin on perineum (evaluate for episiotomy if not already done; usual care and angulation)
  • Controlled and slow delivery of head
  • Transfer baby to waiting paediatric team
  • Take a cord PH
  • Deliver placenta and repair perineum
  • Record Comprehensive note

Editorial Information

Last reviewed: 30/04/2015

Next review date: 31/12/2022

Author(s): Julie Murphy.

Version: 3

Approved By: Obstetrics Clinical Governance Group

Document Id: 378

References

Images From:

www.manbit.com/images/f14-2a.gif

www.who.int/reproductive-health/impac/procerdures/breech

Seeds JW. Malpresentations. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 2nd ed. New York: Churchill Livingstone, 1991:5 3 9-72.

Baskett TF. Essential management of obstetric emergencies. 2nd ed. Bristol: Clinical Press, 1991:126-3 5.

Emergencies Around Childbirth, A handbook for midwives. Edited by Maureen Boyle: Radcliffe medical Press, 2002.