Thousands of women are having induction of labour delayed because of a shortage of staff, raising concerns about the safety of them and their babies, HSJ has found.
The issue has been highlighted at seven hospitals in Care Quality Commission reports over the past six months, and HSJ has identified a further three trusts declaring they are concerned about it in their own board papers over the same period.
At University Hospitals of Leicester Trust, more than 1,300 “red flags” were raised in a five-month period due to delays in the induction of labour, linked to staffing levels, the CQC said earlier this month. Most were dealys in continuing inductions, and a smaller number were delays between admission and beginning an induction. UHL indicated it had set its own “red flag” bar locally, so all the delays did not represent a national alert.
Carolyn Jenkinson, CQC deputy director of secondary and specialist healthcare, told HSJ: “At some maternity services we’ve found women having to wait long periods of time to be induced or for transfer to a labour ward once the induction process has started, and in some cases a lack of effective monitoring during periods of delay.
“Where we have found concerns about delayed treatment – including induction of labour – we have made clear to those trusts that effective oversight of the issue is vital and that all action possible should be taken to mitigate any risk and keep people using the service safe.”
In June, the CQC found eight high-risk women at Blackpool Victoria Hospital were waiting up to five days for induction amid severe shortages of midwives. Blackpool Teaching Hospitals Foundation Trust maternity services were rated “inadequate” for safety.
And after an April inspection, University Hospitals of Morecambe Bay FT was told it must ensure there was a clear protocol for identifying women for priority induction, with a sixth of inductions being delayed, largely due to staffing. It is looking at whether it can transfer women to nearby hospitals to speed them up.
The CQC found similar issues in March at County Durham and Darlington FT; and at North Manchester Hospital and Wythenshawe Hospital. At Wythenshawe, nearly a third of those induced in February had not been transferred to the delivery suite within 48 hours, inspectors said.
In the past few weeks, several trusts have reported problems in their own board papers. This month Medway FT’s board was told its maternity unit was currently unable to meet induction of labour demand because of staffing issues, with delays being rated high on its risk register.
Hull University Hospitals Trust reported maternity leave and welfare issues were causing delays to inductions, while Liverpool Women’s FT reported 17 cases of delays “due to the high acuity and occupancy in maternity services”. It is planning to create a specific induction of labour lounge.
The Ockenden review, published last year, called for safe pathways for induction if delays occurred due to high activity or short staffing.
Induction is the inducing of labour by artificial means. It is often used for women who are past their due date with no sign of labour starting naturally, who have complications, such as hypertension or where the baby’s movements have reduced.
The percentage of births nationally which are induced has risen from 22 per cent in 2011-12 to 33 per cent in 2021-22, according to NHS Digital data. The figure may have risen more recently because in late 2021 the National Institute for Health and Care Excellence recommended all women with uncomplicated, singleton pregnancies should be offered induction at 41 weeks because of increased risks of stillbirth and neonatal deaths.
But inductions can put additional strain on maternity units and the Healthcare Safety Investigation Branch warned this year that some maternity units had insufficient capacity to accommodate the number of women planned for induction. Some women – including those at high risk of complications – were not having their individual risks assessed when offered a date for induction, it added, and others had “limited clinical oversight” while undergoing induction.
Royal College of Midwives executive director midwife Birte Harlev-Lam said: “Safety is paramount, so midwives should only induce labour when there is a midwife available to support the woman and a bed on the labour ward. Inevitably, with the well-known staffing and resource issues in maternity services, there may sometimes be a delay, which is why effective monitoring by midwives is so important.”
What the trusts say
University Hospitals Leicester said: “We have adopted a set of locally defined red flags… in addition to those defined by NICE and National Quality Board’s Improvement Resource for Maternity.
“This gives us better oversight of elective activity and demand across our maternity services.”
Manchester University FT said that since the inspection in March it had made significant improvements, including further investment in maternity services, which had reduced waiting times for the women who require induction of labour.
Medway FT CEO Jayne Black said: “We risk assess each person individually to reduce risk and mitigate against the delays.
“We understand that delays to induction of labour can be upsetting. We recognise there has been an increase in the number of delayed inductions of labour and our maternity team is working hard to address the issue. This includes the introduction of a dedicated induction of labour team, improvements to how the pathway is organised and managed, plus an active midwifery recruitment programme.”
County Durham and Darlington FT said: “Most inductions are planned, with the process only starting once one to one care is in place. The decision to start induction is taken whilst ensuring the safety, care and experience of all those in the care of the maternity team at the time. Whilst a short wait does not pose a clinical risk we are in the process of recruiting to new roles dedicated to supporting women requiring induction, to improve their experience.”
UHMBT chief nurse Tabetha Darmon said: “The CQC said they were assured that good clinical practice was taking place across Morecambe Bay. There was evidence that changes had been made as a result of feedback, for example, any delays in induction of labour of more than four hours were reviewed by a senior clinician.
“Since the CQC inspection, we have also launched our Induction of Labour Escalation ‘Pathway’ for delays of inductions. This pathway ensures that women whose care is delayed are clinically reviewed at two hours, eight hours, 12 hours, 18 hours and 24 hours to ensure any evolving risks are identified and reviewed by our maternity team.
“The pathway includes liaising with neighbouring NHS trusts within the local maternity and neonatal system as part of our mutual aid agreement. Delays in induction of labour are all reported, and all cases are reviewed to ensure the pathway is followed.”
Liverpool Women’s did not want to comment further.