Objective: To explore implementation of two intrapartum trials with compelling findings: BUMPES (position in second stage of labour in nulliparous women with epidural), and RESPITE (remifentanil intravenous patient-controlled analgesia). Design: Qualitative interview study. Setting: UK NHS Trusts and Universities. Sample: Purposively sampled investigators from RESPITE and BUMPES trials and clinicians providing intrapartum care: midwives, anaesthetists and obstetricians recruited using existing networks and snowball sampling. Methods: Semi-structured virtual interviews. Thematic analysis was underpinned by Capability Opportunity Motivation Behaviour Change Framework. Results: Twenty-nine interview participants across 19 maternity units: 11 clinical academics, 10 midwives, 4 obstetricians, 4 anaesthetists. Most (25/29) were aware of one or both trials. BUMPES had been implemented in 4/19 units (one original trial site) and RESPITE in 3/19 units (two trial sites). Access to sufficient resources, training, exposure to interventions, support from leaders, and post-trial dissemination and implementation activities all facilitated uptake of interventions. Some clinicians were opposed to the intervention or disagreed with trial conclusions. However competing priorities in terms of staff time and a plethora of initiatives in maternity care, emerged as key barrier to implementation. Conclusions: Compelling trial findings were not implemented widely, and numerous barriers and facilitators were identified. Large-scale improvement programmes and evidence-based national guidelines may mean single trials have limited potential to change practice. There is a need to examine how intervention implementation is prioritised to optimise safety outcomes in the context of workforce restrictions, limited resources and large arrays of competing priorities including statutory requirements, that have increased in maternity care.

Background: Effective clinical escalation on recognition of maternal or fetal deterioration is a crucial component of maintaining safety in intrapartum settings. Objective: To overview systematic reviews on interventions for escalating care around birth. Search strategy: Reviews published 2015 to 2021. Sources searched included eight databases. Selection criteria Reviews involving randomised controlled trials on the clinical impact on mothers and neonates, process outcomes, and/or qualitative evidence on stakeholders’ perspectives on intervention. Where gaps were found other types of review evidence were considered. Data collection and analysis Cochrane approaches applied including in evaluating evidence quality. Results Seven systematic reviews and one scoping review were relevant for in-depth review: six were on clinical impact, and two on perspectives (studies from 16 countries, over 909,027 pregnancies/births of undefined risk). In comparison with no intervention, early warning systems trigger tools and team training in obstetric emergencies were evaluated. Various measures of clinical impact were used, only one on time-to-treat. We found that most evidence was of low to very-low quality because of study limitations and imprecision as outcomes are rare, and overall failed to find a clinical improvement favouring early warning systems trigger tools or training. Qualitative studies captured challenges in implementing trigger tools. Reviews of women’s perspectives or other types of care escalation were searched but not identified. This is not to suggest studies don’t exist. Conclusions Conclusions cannot be made on clinical effect of interventions to escalate care around birth as review evidence is limited. Evaluations need to consider use of proxy outcomes.