Escalation Guideline for Community Midwives attending Home Births:- Staff Safety, Fatigue & Illness.

1 Risk Assessment

A risk assessment must be undertaken:

• Prior to attendance - completed antenatally when a decision is made for a Home Birth
  
  
• On arrival and continuously throughout care

This should include:

Environmental Factors

• Safe entry and exit to the property
  
  
• Adequate lighting and safe parking arrangements
  
  
• Presence of animals (appropriately secured)
  
  
• Household dynamics, including any known risks
  
  
• Access to communication (mobile signal/landline)

Clinical Factors

• Maternal and fetal risk profile (Appendix 1)
  
  
• Progress of labour and any deviation from normal
  
  
•  Geographical distance from the hospital, including travel time, rural access considerations (e.g. road conditions), and the availability and response times of Scottish Ambulance Service (SAS) in the event of transfer

2 Identification of Rest Area

As part of the initial assessment, midwives must:

• Identify an appropriate area within the home where midwives can rest if required, ensuring a second midwife remains in attendance, and that basic needs such as access to water and a safe, suitable rest environment are available.

• Ensure the area is:
  
  
• Safe, clean, and private
  
  
• Free from interruption where possible
  
  
• Confirm with the family that use of this space is acceptable. (discuss during antenatal assessment).
  
  
• If a suitable rest environment is not available at the time of care, this should be recognised as a potential safety concern, and escalation or alternative arrangements should be considered to support safe care delivery:

• Escalate to Labour Ward Coordinator
  
  
• Consider:
  
  
• Additional Midwifery support
  
  
• Earlier review of ongoing suitability for Home Birth

1 Recognition of Fatigue

Safe Working Limits

• Continuous working time, including any prior shift, call-out, clinical care, and travel, should not exceed 16 hours.

• Absolute maximum: 18 hours (exceptional circumstances only)

• A minimum of 11 hours uninterrupted rest must be achieved, in line with Agenda for Change (AfC) compensatory rest guidance for staff undertaking on-call duties. (Appendix 2)

• 48-hour weekly average applies

Recognition of Fatigue -

Midwives should self-monitor fatigue and consider using the Home Birth Self Check as a tool if required (Appendix 3) for:

• Reduced concentration

• Physical exhaustion
  
  
• Prolonged attendance
  
  
• Lack of rest prior to or during shift

Immediate Actions

• Where a second midwife is present and the clinical situation is stable, limited rest periods may be taken. These should be considered as managed rest rather than formal breaks, with the midwife remaining clinically responsible and able to respond without delay.

Escalation Thresholds (Rural)

Prolonged continuous attendance (e.g. approaching or exceeding 8 hours) should prompt review of staff fatigue, clinical circumstances, travel considerations, and service capacity.

Escalation should occur immediately where:

• The situation is assessed as unsafe
  
  
• Fatigue is impacting, or is likely to impact, clinical judgement or safety
  
  
• Labour becomes more complex or requires increased vigilance

All escalation decisions should be guided by real-time assessment, staffing availability, and professional judgement, rather than fixed time limits alone.

 Post-Call Recovery

• Minimum 11 hours rest
  
  
• Staff should not return to duty if they remain fatigued to a level that may impact safe practice. A minimum of 11 hours compensatory rest should be achieved in line with AfC guidance; however, fitness to return should be based on individual assessment, with discussion and agreement with the line manager where required.

 Travel Safety

• Do not drive if fatigued
  
  
• Assess risk prior to travel >60 minutes

2  Fatigue Escalation Procedure (SOP )

Declaration of Fatigue

• A midwife who declares themselves unfit to work due to fatigue must be supported and their concerns taken seriously
  
  
• The declaration should be acknowledged without challenge, and prompt escalation through real-time staffing processes should occur to ensure safe service provision
  
  
• Decisions should be made collaboratively, using professional judgement, with priority given to staff wellbeing and patient safety

 Escalation Steps  – see flowchart  

• Immediate contact with Labour Ward Coordinator / Senior Midwife (Band 7)
  
  
• The Labour Ward Coordinator will liaise with Site & Capacity as required and initiate escalation to the Hospital On Call Manager where concerns cannot be resolved
  
  
• Further escalation to the On Call Executive should be undertaken via Site & Capacity/On Call Manager if risk persists

Agreed Mitigation Options

May include:

• Relief midwife deployment:
  
  If a Home Birth call-out occurs later in the day, consider contacting on-duty staff to assess availability for additional on-call support, providing flexible back-up and reducing pressure on the core team.
  
  
• Transfer of woman to hospital (BGH) following clinical discussion
  
  
• Safe transport for midwife (taxi or alternative)

 A fatigued midwife must not drive.

Legal Position

• A woman with capacity has the right to decline transfer, even where risk increases

Required Actions

• Confirm capacity
  
  
• Provide clear explanation of risks, benefits and alternatives
  
  
• Ensure shared decision-making without coercion

Escalation and Responsibility

• Inform Labour Ward Coordinator
  
  
• Seek Consultant Obstetrician input where required
  
  
• Escalation must continue in line with fatigue/safety concerns

Documentation

Must include:

• Recommendation and rationale
  
  
• Information provided
  
  
• Capacity assessment
  
  
• Woman’s decision
  
  
• Senior staff involvement
  
  
• Agreed care plan

1 Immediate Actions

If a Midwife becomes unwell: 

• Ensure safety of woman and baby
  
  
• Inform Labour Ward Coordinator
  
  
• Provide SBAR handover
  
  
• Withdraw if unsafe to continue

2 Infection Prevention and Control

Where illness may be infectious:

• Withdraw from care immediately
  
  
• Follow NHS Borders infection control guidance if required
  
  
• Report absence in line with sickness absence polic

1 Escalation Triggers

Immediate escalation is required if:

• The Midwife feels unsafe at any point
• There is evidence of:
  
  
• Aggression or threatening behaviour
  
  
• Substance misuse
  
  
• Unsafe or deteriorating environment

2 Actions

• Leave the environment if necessary
  
  
• Contact: On call Manager via switchboard (01896 826000)

• Emergency services 999 (if required)
  
  
• Complete an InPhase

Midwives must:

• Document all risk assessments
  
  
• Record fatigue, illness and escalation
  
  
• Document refusal of transfer discussions
  
  
• Complete incident reporting (InPhase)

Community Midwife:

• Monitor fatigue
  
  
• Undertake risk assessment
  
  
• Escalate concerns
  
  
• Document decisions
  
  
• Prioritise personal wellbeing and safety

Labour Ward Coordinator:

• Lead escalation response
  
  
• Coordinate staffing and support

Site & Capacity / On Call Manager:

• Provide operational support
  
  
• Enable escalation and mitigation

On Call Executive / Head of Midwifery:

• Provide senior decision-making support where risks cannot be mitigated locally

Compliance will be monitored via:

• Incident reporting (InPhase)
  
  
• Clinical review and audit
  
  
• Feedback from staff and service users

• Supportive debrief offered
  
  
• No punitive action for fatigue escalation
  
  
• All learning will be managed in accordance with the Patient Safety Incident Response Framework (PSIRF), supporting a systems-based approach to incident review and continuous improvement.

Declaring fatigue, escalating concerns, and stepping away from unsafe practice are recognised patient safety actions and are fully supported by NHS Borders.

Home Birth Flowchart

Community Midwifery & Home Birth Risk Assessment Tool

Compensatory Rest For Agenda For Change Staff Undertaking On-Call Duties

NHS Borders – Home Birth Fatigue Self‑Check