Apr 052019

Midwifery is renowned for being one of the most rewarding professions there is; however as so many midwives will testify it is also at times one of the most challenging. It is however incredibly rare to be given the opportunity to take part in quality improvement projects which not only see almost immediate benefits to the women we care for; but which also shape the profession and wider clinical practice. OBS Cymru – the Obstetric Bleeding Strategy for Wales- has been one such project. OBS Cymru is the result of research which began in Cardiff over 10 years ago, and developed over time into an evidence based, highly effective strategy for managing Postpartum Haemorrhage. This approach has now been rolled out to every health board in Wales and has significantly changed practice, seemingly overnight (no mean feat as I’m sure you’ll agree).

Each Consultant Led Unit’s (CLU) OBS Cymru Champion Team have overseen the implementation of the project. I have had the honour of being one of the Champion Midwives in Ysbyty Glan Clwyd in North Wales and I can honestly say it has been more rewarding and equally more influential to my practice than anything I’ve been a part of previously. Simple evidence based interventions with an emphasis on early recognition of PPH through Risk Assessment and measuring blood loss rather than estimating it. This was a major change in practice but one which was adopted by all staff and with remarkable results. Change is inevitable in Maternity care but it is not always so easily achieved!

As Champion Midwives we have encouraged truly multidisciplinary team working and training, generating remarkable and undeniable results for women in our care. The success for OBS Cymru in our unit has been largely due to the engagement of the support workers and midwives. They led the change to measuring blood loss and instigating early recognition and management of PPH.

OBS Cymru as a QI project has now drawn to a close. However, I don’t see this as signifying the end of the OBS Cymru work. Rather, primarily it is an opportunity to reflect on just how far we have come as a nation that is leading the way in effective management of PPH. But in addition it is an opportunity to look to the future and plan our own strategies for ensuring this invaluable work continues and embeds even further into everyday practice.

I feel fortunate to have worked with such an enthusiastic, motivated and knowledgeable team who will help this work continue and who will drive forward change to achieve the best for the women in our care. For us OBS Cymru is here to stay!

Apr 052019

Caiff bydwreigiaeth ei gydnabod fel un o’r meysydd proffesiynol mwyaf gwobrwyol sy’n bodoli. Fodd bynnag, fel mae cymaint o fydwragedd yn tystio, mae’n faes hynod heriol hefyd. Prin yw’r cyfleoedd i gyfrannu at brosiectau gwella ansawdd sydd o fudd uniongyrchol i’r menywod yn ein gofal ac sydd hefyd yn siapio’r maes proffesiynol ac arferion clinigol ehangach. Mae Strategaeth Gwaedu Obstetreg i Gymru (OBS Cymru) yn brosiect o’r fath. Eginodd OBS Cymru o ganlyniad i waith ymchwil a ddechreuodd yng Nghaerdydd dros ddeg mlynedd yn ôl, gan ddatblygu dros amser yn strategaeth seiliedig ar dystiolaeth hynod effeithiol ar gyfer rheoli gwaedu ôl-enedigol. Bellach, mae’r dull wedi cael ei gyflwyno ym mhob bwrdd iechyd yng Nghymru, gan newid arferion yn sylweddol, a hynny dros nos i bob golwg.

Mae pob Tîm Hyrwyddo OBS Cymru sy’n rhan o Uned o dan Arweiniad Ymgynghorydd wedi goruchwylio cyflwyniad y prosiect. Rydw i wedi cael y fraint o fod yn Hyrwyddwr Bydwragedd yn Ysbyty Glan Clwyd yng ngogledd Cymru, a gallaf ddatgan yn gwbl ddiffuant bod y profiad wedi bod yn hynod wobrwyol a’i fod wedi cael mwy o ddylanwad ar fy arferion nag unrhyw beth rydw i wedi bod yn rhan ohono yn y gorffennol. Ymyriadau syml, seiliedig ar dystiolaeth, gyda phwyslais ar adnabod gwaedu ôl-enedigol yn gynnar trwy asesiadau risg a mesur colledion gwaed, yn hytrach nag amcangyfrifo. Mabwysiadwyd y newid arfer mawr hwn gan bob aelod staff gan arwain at ganlyniadau nodedig. Mae newidiadau yn anochel ym maes bydwreigiaeth, er nad yw’n cael ei gyflawni mor hawdd fel arfer!

Fel Hyrwyddwyr Bydwragedd, rydym ni wedi annog gwaith tîm a hyfforddiant amlddisgyblaethol go iawn, sydd wedi arwain at ganlyniadau nodedig ac anwadadwy i’r menywod yn ein gofal. Mae llwyddiant OBS Cymru yn ein huned yn seiliedig ar ymgysylltu â’r gweithwyr cynorthwyol a’r bydwragedd. Nhw arweiniodd y newid i fesur colledion gwaed a chydnabod a rheoli gwaedu ôl-enedigol yn gynnar.

Fel prosiect QI, mae OBS Cymru wedi dod i ben. Fodd bynnag, nid dyma ddiwedd gwaith OBS Cymru. Yn hytrach, dyma gyfle i fyfyrio ar ba mor bell rydym wedi dod fel cenedl sy’n arwain y ffordd o ran rheoli gwaedu ôl-enedigol yn effeithiol. Yn ogystal, dyma gyfle i ni edrych tua’r dyfodol a chynllunio strategaethau er mwyn sicrhau bod y gwaith amhrisiadwy hwn yn parhau ac yn dod yn rhan annatod o arferion bob dydd.

Teimlaf yn ffodus o fod wedi cael cyfle i weithio gyda thîm mor frwdfrydig, gwybodus a llawn cymhelliant, a fydd yn sicrhau bod y gwaith yn parhau ac yn gyrru newidiadau er lles y menywod yn ein gofal. I ni, mae OBS Cymru yma i aros!

Jul 092018

OBS Cymru, the all-Wales collaborative quality improvement project aiming to reduce harm from postpartum haemorrhage, has been shortlisted for two awards this year at the Patient Safety Awards and NHS Wales Awards.

We’ve been getting an update on the project from its two national lead midwives, Elinore Macgillivray and Kathryn Greaves.


For anyone who hasn’t heard of OBS Cymru, can you start by giving an overview?

Elinore: Postpartum haemorrhage (excessive bleeding after childbirth) is the second leading cause of direct maternal death in the UK, and accounts for 80% of maternal morbidity.1 in 20 women will experience a postnatal blood loss in excess of 1 litre, and for 1 in 200 life threatening bleeding will occur, leading to a number of adverse physical and emotional consequences. Rarely (around once every 3 years in Wales) postpartum haemorrhage (PPH) will result in a baby that goes home without its mother. This being so, there was a clear need for quality improvement in the management of PPH, with all the Health Boards in Wales agreeing to take part in the project.

Kathy: PPH is in the top five quality and safety risks identified for every maternity unit in Wales. OBS Cymru – the Obstetric Bleeding Strategy for Wales is a three year national quality improvement project, now in its second year, aiming to reduce harm from PPH. The primary aim of the project is to reduce the number of women suffering a massive obstetric haemorrhage.

How is the project meeting its aims?

Elinore:  Since the project was first launched in November 2016 a number of interventions have been put in place across all Obstetric led labour wards in Wales, and having positive results:

  • Risk Assessment for PPH is now becoming a routine part of the admission process in obstetric led birth settings, leading to increased awareness of and early planning for PPH detection, prevention and management.
  • Early identification by means of Measuring Blood Loss is quickly becoming embedded in practice, with over 90% of women having their postnatal blood loss measured.
  • Multidisciplinary Team Working is improving as a result of the training provided by OBS Cymru teams. Clinicians including Midwives, HCAs, anaesthetists, obstetricians, ODPs, and students working in maternity settings have received OBS Cymru training, and have embraced the 4 stage approach to PPH management.
  • ROTEM point of care testing machines have been installed in every labour ward in Wales to allow access to rapid coagulation results and guide blood product management. Early data suggests this is leading to a decrease in the administration of blood products for the reason of PPH.

Kathy:   These interventions are supported by a robust system of data collection by local OBS Cymru champion teams, we have a dedicated team in every obstetric led labour ward in Wales.  Local teams utilise this data collection to analysis and establish areas for improvement within their own health boards.  The Champion teams attend national meetings in which clinical examples presented show how the OBS Cymru principles supported resolution and improved outcomes for women.  In addition the Midwives from each of the health boards meet annually to review and share learning and take this back to their health boards to disseminate good practice.

Are you seeing any changes since the project was first launch in May 2016?

Elinore – Early data is showing that now over 90% of women are having their blood loss measured, which empowers clinicians to provide the right treatment to the right women at the right time. Blood product usage due to PPH is also beginning to decrease.

Kathy: OBS Cymru is a live quality improvement project and there are daily conversations about good practice happening in the health boards and about it’s impact on practice.  One health board has incorporated the risk assessment as part of their multidisciplinary handover when reviewing the women in labour so that as a team they know and are aware of any potential risks and make appropriate preparations as a team prior to delivery.  Others have noted a potential risk when using drapes during delivery and the hidden blood loss which is collected.  A simple solution of using the suction tubing during a procedure placed in the drape has fixed this potential to miss the slow steady bleed which goes unrecognised.  These gems of learning are being shared across Wales so that others can benefit from practice examples and our Champion teams are integral to the dissemination of this.  We are absolutely thrilled that the project has been recognised in the Patient Safety and NHS Wales Awards.  We are privileged to have been shortlisted and recognise that we are fortunate to be representing all of Wales maternity services and that this award is for them and their hard work and commitment to the project.

What makes you both so passionate about this project?

Kathy:  It’s always humbling to see the growth in confidence of myself as a practitioner and my midwifery colleagues as a profession and their integral role in managing PPH.  The 4 stage paper work has given midwives an indicative tool that is diagnostic of PPH and that it has formalised defined trigger points for action that supports the team’s situational awareness when managing obstetric bleeding. Everyday midwifery teams go to work intent on doing a good job, this is one tool in their armoury to achieve this day in day out, from Bangor in the North to Carmarthen in the West and Cardiff in the South, once for Wales.

Elinore: It’s a privilege to be involved in a project that is not only improving outcomes for women, but also empowering teams to use the skills they have acquired to have the confidence to provide the right treatment to the right women at the right time. Measured blood loss is becoming a powerful tool for communication during postpartum haemorrhage, improving team working.  An important part of the project is the women’s experience. Our patient survey shows that although PPH can be a frightening experience, women and their birth partners feel confident that they are receiving a high standard of care, which is very pleasing.

Two years into a three year project, what does the future hold for OBS Cymru?

Elinore:  Although we have made great inroads towards improving care during a PPH, we will continue to work on sustaining these changes beyond the lifespan of the project. The OBS Cymru approach to PPH management has now been incorporated into All Wales PROMPT as an integral part of sustaining the principles of risk assessment, measuring blood loss, early MDT involvement, and ROTEM POCT testing. We are also keen to see how the data reflects these changes.

Find out more about OBS Cymru here and follow the conversation on Twitter #OBSCymru

Jul 092018

Mae OBS Cymru, prosiect gwella ansawdd cydweithredol Cymru gyfan sydd â’r nod o leihau niwed yn sgil gwaedlif ôl-enedigol, wedi cyrraedd y rhestr fer ar gyfer dwy wobr eleni yn y Gwobrau Diogelwch Cleifion a Gwobrau GIG Cymru.

Rydym ni wedi bod yn cael diweddariad ar y prosiect gan ei ddwy fydwraig arweiniol genedlaethol, Elinore Macgillivray a Kathryn Greaves.


Ar gyfer unrhyw un sydd heb glywed am OBS Cymru, allwch chi ddechrau trwy roi trosolwg?

Elinore: Gwaedlif ôl-enedigol (gwaedlif gormodol ar ôl geni plentyn) yw’r ail achos mwyaf o farwolaethau mamol uniongyrchol yn y DU, ac mae’n cyfrif am  80% o farwolaethau mamol. Bydd 1 o bob 20 menyw yn colli dros 1 litr o waed ôl-enedigol, ac ar gyfer 1 o bob 200, bydd gwaedu sy’n bygwth bywyd yn digwydd, sy’n arwain at nifer o ganlyniadau corfforol ac emosiynol niweidiol. Mewn achosion prin (oddeutu unwaith bob 3 blynedd yng Nghymru), bydd gwaedlif ôl-enedigol (PPH) yn arwain at faban yn mynd adref heb ei fam. Gan ystyried hyn, roedd angen amlwg i wella ansawdd rheoli gwaedlif ôl-enedigol, a chytunodd yr holl Fyrddau Iechyd yng Nghymru i gymryd rhan yn y prosiect.

Kathy: Mae gwaedlif ôl-enedigol yn un o’r pum prif risg ansawdd a diogelwch a amlygwyd ar gyfer pob uned famolaeth yng Nghymru. Mae OBS Cymru – Strategaeth Gwaedu Obstetrig i Gymru yn brosiect gwella ansawdd tair blynedd cenedlaethol, bellach yn ei ail flwyddyn, sy’n ceisio lleihau niwed yn sgil gwaedlif ôl-enedigol. Prif nod y prosiect yw lleihau nifer y menywod sy’n dioddef gwaedlif obstetrig enfawr.

Sut mae’r prosiect yn cyflawni ei nodau?

Elinore:  Ers lansio’r prosiect ym mis Tachwedd 2016, mae nifer o ymyriadau wedi cael eu rhoi ar waith ar draws wardiau geni dan arweiniad obstetrig yng Nghymru, gan arwain at ganlyniadau cadarnhaol:

  • Mae asesu risg ar gyfer gwaedlif ôl-enedigol nawr yn dod yn rhan arferol o’r broses dderbyn mewn lleoliadau geni dan arweiniad obstetrig, sydd wedi arwain at ymwybyddiaeth gynyddol o ganfod, atal a rheoli gwaedlif ôl-enedigol a chynllunio’n gynnar ar gyfer hynny.
  • Mae amlygu cynnar trwy fesur colli gwaed yn cael ei ymsefydlu mewn ymarfer, a chaiff faint o waed ôl-enedigol a gollir gan dros 90% o fenywod ei fesur.
  • Mae gwaith tîm amlddisgyblaethol yn gwella o ganlyniad i’r hyfforddiant a ddarparwyd gan dimau OBS Cymru. Mae clinigwyr, gan gynnwys bydwragedd, cynorthwywyr gofal iechyd, anesthetyddion, obstetryddion, ymarferwyr yr adran lawdriniaethau, a myfyrwyr sy’n gweithio mewn lleoliadau mamolaeth, wedi derbyn hyfforddiant OBS Cymru, ac maent wedi defnyddio’r ymagwedd 4 cam i reoli gwaedlif ôl-enedigol.
  • Mae peiriannau profi pwynt gofal ROTEM wedi cael eu gosod ym mhob ward geni yng Nghymru i ganiatáu mynediad at ganlyniadau tolchi cyflym ac arwain rheoli cynhyrchion gwaed. Mae data cynnar yn awgrymu bod hyn yn arwain at ostyngiad mewn rhoi cynhyrchion gwaed yn sgil gwaedlif ôl-enedigol.

Kathy:   Caiff yr ymyriadau hyn eu cefnogi gan system gadarn o gasglu data gan dimau hyrwyddo OBS Cymru lleol, ac mae gennym ni dîm pwrpasol ym mhob ward geni dan arweiniad obstetrig yng Nghymru. Mae timau lleol yn defnyddio’r data a gesglir i ddadansoddi a sefydlu meysydd i’w gwella o fewn eu byrddau iechyd eu hunain. Mae’r timau hyrwyddo yn mynychu cyfarfodydd cenedlaethol lle mae enghreifftiau clinigol a gyflwynir yn dangos sut mae egwyddorion OBS Cymru wedi cefnogi penderfyniadau a chanlyniadau gwell i fenywod.  Yn ogystal â hyn, mae bydwragedd o bob bwrdd iechyd yn cyfarfod yn flynyddol i adolygu a rhannu dysgu, a chyflwyno hyn i’w byrddau iechyd i ledaenu arfer da.

Ydych chi wedi gweld unrhyw newidiadau ers lansio’r prosiect ym mis Mai 2016?

Elinore – Mae data cynnar yn dangos bod faint o waed a gollir gan dros 90% o fenywod yn cael ei fesur, sy’n grymuso clinigwyr i roi’r driniaeth gywir i’r menywod cywir, ar yr adeg gywir. Mae’r defnydd o gynhyrchion gwaed yn sgil gwaedlif ôl-enedigol hefyd yn dechrau gostwng.

Kathy: Mae OBS Cymru yn brosiect gwella ansawdd byw a chynhelir sgyrsiau dyddiol yn y byrddau iechyd am arfer da a’i effaith ar arferion. Mae un bwrdd iechyd wedi ymgorffori asesu risg yn rhan o drosglwyddo amlddisgyblaethol wrth adolygu’r menywod sy’n esgor, fel bod y tîm yn ymwybodol o unrhyw risgiau posibl ac yn gwneud paratoadau priodol fel tîm, cyn i’r menywod roi genedigaeth. Mae eraill wedi nodi risg bosibl wrth ddefnyddio gorchuddion yn ystod  esgor, a’r gwaed cudd a gollwyd sy’n cael ei gasglu. Mae ateb syml, sef gosod y tiwb sugno a ddefnyddir yn ystod gweithdrefn yn y gorchudd, wedi datrys y posibilrwydd o fethu gwaedu araf, cyson, na sylwir arno. Mae’r perlau dysgu hyn yn cael eu rhannu ledled Cymru, er mwyn i eraill allu elwa ar enghreifftiau o ymarfer, ac mae ein timau hyrwyddo yn rhan annatod o ledaenu hyn. Rydym ni wrth ein bodd bod y prosiect wedi cael ei gydnabod yn y Gwobrau Diogelwch Cleifion a Gwobrau GIG Cymru. Mae’n fraint cyrraedd y rhestr fer ac rydym ni’n cydnabod ein bod ni’n ffodus i gael cynrychioli holl wasanaethau mamolaeth Cymru, a bod y wobr hon ar eu cyfer nhw, a’u gwaith caled a’u hymrwymiad i’r prosiect.

Beth sy’n eich gwneud chi’ch dwy mor frwdfrydig am y prosiect hwn?

Kathy:  Mae bob amser yn galonogol gweld twf yn fy hyder i fel ymarferwr, a fy nghydweithwyr bydwreigiaeth fel proffesiwn, a’u rôl annatod o ran rheoli gwaedlif ôl-enedigol. Mae’r gwaith papur 4 cam wedi rhoi offeryn dangosol i fydwragedd sy’n mesur gwaedlif ôl-enedigol yn ddiagnostig, ac mae wedi ffurfioli pwyntiau sbardun penodol ar gyfer gweithredu, sy’n ategu ymwybyddiaeth sefyllfaol y tîm wrth reoli gwaedu obstetrig. Bob dydd, mae timau bydwreigiaeth yn mynd i’r gwaith gyda’r bwriad o wneud gwaith da, a dyma un o’r dulliau sydd ganddyn nhw i allu cyflawni hyn bob dydd, o Fangor yn y gogledd, i Gaerfyrddin yn y gorllewin, a Chaerdydd yn y de, unwaith i Gymru.

Elinore: Mae’n fraint bod yn gysylltiedig â phrosiect sydd nid yn unig yn gwella canlyniadau i fenywod, ond hefyd yn grymuso timau i ddefnyddio’r sgiliau y maen nhw wedi’u caffael i gael yr hyder i ddarparu’r driniaeth gywir, i’r menywod cywir, ar yr amser cywir. Mae mesur colli gwaed yn dod yn offeryn pwerus i gyfathrebu yn ystod gwaedlif ôl-enedigol, sy’n gwella gwaith tîm. Rhan bwysig o’r prosiect yw profiad y menywod. Mae ein harolwg cleifion yn dangos, er y gall gwaedlif ôl-enedigol fod yn brofiad brawychus, mae menywod a’u partneriaid geni yn teimlo’n hyderus eu bod nhw’n derbyn gofal o safon uchel, sy’n rhoi boddhad mawr.

Ar ôl dwy flynedd o brosiect tair blynedd, beth yw dyfodol OBS Cymru?

Elinore:  Er ein bod ni wedi cymryd camau breision tuag at wella gofal yn ystod  gwaedlif ôl-enedigol, byddwn ni’n parhau i weithio ar gynnal y newidiadau hyn y tu hwnt i oes y prosiect. Mae ymagwedd OBS Cymru at reoli gwaedlif ôl-enedigol wedi cael ei hymgorffori yn PROMPT Cymru Gyfan, fel rhan annatod o gynnal egwyddorion asesu risg, mesur colli gwaed, ymwneud cynnar gan dîm amlddisgyblaethol, a phrofi pwynt gofal ROTEM. Rydym ni hefyd yn awyddus i weld sut mae’r data’n adlewyrchu’r newidiadau hyn.

Darganfyddwch fwy am OBS Cymru yma a dilynwch y sgwrs ar Twitter #OBSCymru