Transfer of Women to an Alternative GGC Maternity Unit (Divert, PCB, IOL), SOP

Maternity & Gynaecology Guidelines
NHS GGC

Women may on occasion be asked to attend an alternative NHSGGC maternity site for their ongoing care. This may occur proactively—for example, to facilitate planned Caesarean birth or Induction of Labour—or reactively during periods of high acuity, reduced capacity, or safety concerns that trigger divert arrangements. All decisions are person-centred, undertaken with individualised risk assessment and clear cross-site communication..

This process is guided by the GGC Site Activity Escalation and Potential Divert Process for Maternity (Guideline 407) as well as the Safe to Start, Cross-Site Huddles SOP, and associated escalation and documentation requirements.

1. Identifying Capacity and Triggering Consideration of Transfer

Capacity concerns are first identified through real-time staffing and workload assessments, including Safe to Start ratings (Green/Grey/Amber/Red). These are completed up to four times within each 24hour period and feed directly into local and cross-site awareness of safe operating levels.

A divert or alternative site plan may be considered when:‑

  • Acuity/workload exceeds staffing/skill mix levels
  • Bed occupancy blocks flow despite usual mitigations
  • Safe 1:1 intrapartum care cannot be assured
  • High-risk or time dependent care (e.g., planned Caesarean birth list) is compromised.

The Site Coordinator or Senior Charge Midwife initiates the local safety brief, ensuring RAG rated assessment is documented

2. Cross-Site Senior (Charge Midwife/Coordinator) Huddle

Daily Senior Cross Site Huddles take place Monday to Friday at 0900.

Where internal mitigations are exhausted—and particularly if a unit is rated Red, transferring women across site may be considered. In addition, a cross-site huddle is also triggered out of hours.
This structured discussion occurs according to the Cross-Site Huddles SOP, which applies across Princess Royal Maternity, QEUH, and RAH.
Key features:

  • Triggered when a site declares Red after mitigation
  • The Red site notifies others (typically by 20:30–21:00)
  • Charge Midwives (or trained deputies) attend
  • Sites share staffing, activity, acuity, and capacity status
  • A consistent and respectful approach is expected

Huddle outputs include identification of available capacity, particularly for:

  • Planned Caesarean lists
  • Induction of Labour workload
  • Augmentation and intrapartum care requirements

This process allows units to proactively offer women the option of attending an alternative site, particularly for planned activity where appropriate.

3. Individualised Clinical Risk Assessment

Any proposal to transfer a woman across sites must be based on individualised clinical risk assessment, undertaken jointly by:

  • The Unit Coordinator/SCM
  • The on-call Obstetric Consultant

Risk assessment considers:

  • Clinical condition, obstetric history, risk factors
  • Gestation and urgency
  • Fetal/neonatal needs
  • Level of monitoring/interventions expected
  • Whether PCB/IOL is time critical
  • Transport safety and feasibility

The approach is person centred, aligned with GGC’s commitment to Safe, Effective, Person-Centred Maternity Care.

If safe and appropriate, the receiving unit’s capacity is confirmed via:

  • Dialogue between Unit Coordinators
  • Confirmation by the on-call obstetric team

4. Partnership with Women: Person Centred Communication Centred Communication

Women are approached sensitively and collaboratively, with clear, honest explanation of:

  • The reason for suggesting transfer
  • The assessment of risks and benefits
  • What care will look like at the receiving site
  • How the decision supports safe, timely care

This aligns with professional responsibilities to involve and empower women in personalised decision-making. 

Women are offered choice wherever clinically appropriate—particularly for planned care (e.g., PCB/IOL) during times of predicted high activity.

5. Formalising the Divert or Planned Transfer

When a divert is agreed, documentation follows the SBAR for Divert process:

  • Unit requesting divert
  • Unit receiving divert
  • Consultant obstetrician agreeing plan
  • Internal mitigations actioned
  • Time commenced, review time, and updates on Cross-site huddle
  • Recording on the General Teams Channel
  • Summary entry once divert has been lifted

6. Documentation Requirements

a) BadgerNet

BadgerNet must contain:

  • The individualised risk assessment
  • Details of the discussion with the woman
  • Decisions made, including rationale and chosen site
  • Who was involved in agreeing the plan (Coordinator/Consultant)

(This requirement is reflected in multiple SOPs where risk assessment, decision making, and communication must be clearly recorded.)

b) Daily Safety Brief / Safe to Start Brief

Safety briefs must reflect:

  • RAG status
  • Key activity, acuity and capacity issues
  • Any active diverts and outcomes

c) Cross-Site Channels

The relevant Teams channels record:

  • Active diverts
  • Reviews/updates
  • Closing summaries

7. Proactive System-Wide Workload Management Wide Workload Management

Daily reviews of workload across GGC aim to reduce unplanned diverts by identifying opportunities to redistribute planned work, especially:

  • PCB lists
  • IOL workload
  • Induction pathways, including outpatient approaches

This ensures:

  • Maintenance of safe staffing
  • Better bed utilisation
  • Improved flow for labour ward access and postnatal care
  • Enhanced equity across QEUH, PRM and RAH

Summary

Women may be asked to attend an alternative NHSGGC maternity unit for planned or emergency reasons, but only after structured, multi‑layered checks including:

  1. Capacity review and Safe to Start assessment
  2. Cross-site huddle consultation
  3. Individual risk assessment by Coordinator + Consultant
  4. Person centred discussion and shared decision making with the woman
  5. Formal SBAR and safety brief documentation
  6. Recording in BadgerNet and cross-site communication channels

This process is rooted in the GGC Escalation and Divert Guideline (407) and the Cross-Site Huddle / Safe to Start SOPs, ensuring safe, consistent, transparent and person-centred practice across NHSGGC.

Editorial Information

Last reviewed: 24/02/2026

Next review date: 31/12/2028

Author(s): Gaynor Bird.

Approved By: Maternity Clinical Governance Group