Maternity care pathways

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In developing this pathway, we aim to provide maternity

services commissioners with valuable guidance so that they

may safely and effectively meet the demands of their local

population.

The pathway also describes what women can expect on

their maternity journey.

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Maternity best practice

Go to pre-pregnancy Go to antenatal care Go to intrapartum care Go to postnatal care

1 Maternity best practice

Quick info:

Scope:

•t his pathway provides a broad overview of the key steps in maternity, including: •p re-pregnancy care

• antenatal care

•c are during labour and delivery • postnatal care

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1 Pre-pregnancy care

Pre-pregnancy Contact with healthcare professional

Is the woman planning pregnancy?

No

Access to healthcare

Yes

Newly identified medical, mental health and social needs

Health and lifestyle advice to woman and partner

Once pregnant, refer for antenatal care

Eating habits (Body Mass Index) Screening

-information and advice Pre-existing medical, surgical and/or psychiatric conditions Go to antenatal care Pre-existing medical, surgical and/or psychiatric conditions

Consider all of the following

Nutritional advice, vitamins, prescriptions and over-the-counter medicines

The Pregnancy Care Planner and the Pregnancy Book

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1 Pre-pregnancy care

1 Pre-pregnancy

Quick info:

Scope:

•t his pathway gives an overview of what to expect when planning pregnancy. The pathway is based on UK National Health Service policies and schedules.

Associated maternity standards:

• standard 1: looking forward to pregnancy

• standard 2: pre-pregnancy care for women with existing medical conditions or significant family or obstetric history • standard 3: access to maternity care

• standard 6: pre-existing medical conditions in pregnancy

• standard 8: pre-existing and developing mental health conditions in pregnancy • standard 7: women with social needs

• standard 21: choice and appropriate care • standard 22: communication

• standard 23: training and professional competence • standard 24: documentation and confidentiality • standard 25: clinical governance

2 The Pregnancy Care Planner and the Pregnancy Book

Quick info:

•The Pregnancy Care Planner is the NHS guide to having a baby

•t he Department of Health Pregnancy Book contains information for women on what to do, how to cope and how to get the most from pregnancy and the new baby

3 Contact with healthcare professional

Quick info:

•f or example GP, practice nurse, family planning clinic, midwife etc

4 Is the woman planning pregnancy?

Quick info:

•a sk the woman if she has had previous pregnancies and if so, what was the experience and what was the outcome •o ffer information on place of birth and vaginal birth after caesarean (VBAC)

• if previous pregnancy problem(s) are identified, offer advice and refer according to individual need, ensuring woman continues on maternity pathway

5 No

Quick info:

• if woman is not planning pregnancy, consider the next two stages

6 Yes

Quick info:

•f or women planning pregnancy

7 Access to healthcare

Quick info:

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1 Pre-pregnancy care

•p rovide advice on choice of and how to access a healthcare professional and pregnancy advice in the future •p rovide contraception advice as appropriate and refer to NHS Direct for information

•o ffer general good health advice on smoking, alcohol, BMI and substance misuse •p rovide pre-pregnancy leaflet

8 Consider all of the following

Quick info:

If woman is planning pregnancy, consider the following steps

9 Pre-existing medical, surgical and/or psychiatric conditions

Quick info:

Pre-existing medical, surgical and/or psychiatric disorders:

•o ffer advice on pre-existing conditions which could impact on pregnancy outcome

•o ffer advice on risk of pre-existing condition to pregnancy and risk of pregnancy to condition •r eview medication(s) and advise of its risks and benefits in pregnancy

•c onsider specialist advice

•c onsider additional information, care and treatment, and refer according to individual need • if healthcare professional or woman has significant concerns, refer to GP for further assessment

•a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman, couple and/or family •f or further information refer to the NICE mental health guidance

10 Newly identified medical, mental health and social needs

Quick info:

•a ssess medical needs and refer as appropriate, ensuring woman continues on maternity pathway •a ssess mental health (current, new onset and/or past incidence):

• if mental health needs are identified refer to ‘Pre-existing physical and/or psychiatric disorders’ •f or further information refer to the NICE mental health guidance

•a ssess social needs and refer according to individual need, ensuring woman continues on maternity pathway •o ffer advice on risk of condition to pregnancy and risk of pregnancy to condition

•f or further information on diabetes, refer to Diabetes UK advice on preconception care for women with diabetes and to NICE diabetes in pregnancy guidance

•c onsider additional information, care and treatment and refer to primary or specialist services according to individual need, ensuring woman continues on maternity pathway

11 Pre-existing medical, surgical and/or psychiatric conditions

Quick info:

Diabetes:

•o ffer interim contraception until optimal control is achieved • educate women and partners in glycaemic control as appropriate

• review medication(s) and inform of its risks and benefits in pregnancy consider specialist advice •c heck date of last review and repeat comprehensive review as appropriate

•o ffer enhanced medical surveillance until glycaemic control is achieved •o ffer advice on folic acid and appropriate dose

• once pregnant, refer back to antenatal pathway with all relevant medical and maternity information

•f or further information, refer to Diabetes UK advice on preconception care for women with diabetes and to NICE diabetes in pregnancy guidance

Other pre-existing medical, surgical and/or psychiatric disorders:

•o ffer advice on folic acid and appropriate dose •c onsider specialist advice

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1 Pre-pregnancy care

•c onsider additional information, care and treatment, and refer according to individual need, ensuring woman continues on maternity pathway

• if healthcare professional or woman has significant concerns, refer to GP for further assessment •a ssess mental health (current, new onset or past incidence)

•a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman/couple and/or family • if severe mental illness (e.g. bipolar disorder or schizophrenia) is suspected, refer to specialist mental health service,

including, if appropriate, specialist perinatal mental health service: •t his should be discussed with woman and preferably with her GP

•i nform GP in all cases if a possible current mental disorder or history of significant mental disorder is detected, even if no further assessment or referral is made

•f or further information refer to the NICE mental health guidance

12 Screening - information and advice

Quick info:

•o ffer advice and information on screening, and offer choice, which could include: • Down's syndrome

•i nfectious diseases

• sickle cell and thalassaemia

•f etal anomaly ultrasound 18 - 20 weeks + 6 days •click here for screening publications

•o ffer screening for sickle cell disease

•c onsider serum screening and screening for infectious diseases and sexually transmitted infections: •o ffer vaccinations according to individual need, including rubella

•c onsider screening for inherited disorders as appropriate

•e xplore alcohol, tobacco and other substance misuse in woman and partner

13 Eating habits (Body Mass Index)

Quick info:

•c alculate BMI and offer advice if too high or too low:

•r efer according to individual need and culturally appropriate BMI • if BMI is greater than 30, screen to exclude diabetes

• if test is positive for diabetes, refer to the diabetes in pregnancy pathway • if test is negative for diabetes, refer to obesity pathway

• if BMI is too low, refer to eating disorder service according to individual need, ensuring woman continues on maternity pathway

14 Nutritional advice, vitamins, prescriptions and over-the-counter medicines

Quick info:

•o ffer folic acid advice according to individual need

•o ffer dietary advice regarding healthy eating and what foods to avoid (harmful dietary substances) •o ffer advice on nutritional supplements

•o ffer advice on vitamins (including importance of vitamin D) as appropriate, and advice on which vitamins to avoid •o ffer advice on over-the-counter medicine and advice on what to avoid

•o ffer painkiller advice and what to avoid

• advise to use as few prescription medicines as possible and only where the benefit outweighs the risk •f or further information refer to the Foods Standards Agency website

15 Health and lifestyle advice to woman and partner

Quick info:

•o ffer early pregnancy information leaflet if appropriate

• where woman has no GP, refer to primary care to arrange registration

•o ffer advice to partner (where applicable) on alcohol consumption, smoking and substance misuse as appropriate •o ffer information to both woman and partner (if applicable) on antenatal classes for couples and fathers

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1 Pre-pregnancy care

16 Once pregnant, refer for antenatal care

Quick info:

• advise woman how to access maternity services and inform of choice of booking method (referral/self-referral) • once pregnant refer to antenatal provider at earliest opportunity, with all relevant medical information

•o ffer information on screening. For further information, refer to screening guidance

• if severe/complex mental illness is identified refer to specialist perinatal mental health team • ensure compliance with national guidelines

•e xplain importance of booking early (within first 10 weeks) and advise how to obtain booking form

•f or women considering termination of pregnancy, offer advice and refer as appropriate, ensuring woman is returned to maternity pathway when appropriate

•f or further information, refer to the termination of pregnancy pathway and to NHS London abortion guidance

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Evidence summary for Pre-pregnancy

This pathway gives an overview of what to expect when planning pregnancy. The pathway is based on UK National Health Service policies and schedules.

Search date: Jun-2009

Evidence grades:

Intervention node supported by level 1 guidelines or systematic reviews Intervention node supported by level 2 guidelines

Intervention node based on expert clinical opinion Non-intervention node, not graded

Evidence grading:

Graded node titles that appear on this page Evidence grade Reference IDs

Is the woman planning pregnancy? 9, 8, 7

Access to healthcare 9

Newly identified medical, mental health and social needs 1, 9, 8, 6

Health and lifestyle advice to woman and partner 9, 8

Once pregnant, refer for antenatal care 1, 9, 8

Eating habits (Body Mass Index) 9

Screening - information and advice 9

Pre-existing medical, surgical and/or psychiatric conditions 1, 9, 8, 6, 7

Pre-existing medical, surgical and/or psychiatric conditions 9

Nutritional advice, vitamins, prescriptions and over-the-counter

medicines 9

References

This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice ID Reference

1 Department of Health. National Service Framework for Children, Young People and Maternity Services: Maternity services. London: 2004.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4089101

2 Department of Health. National service framework for children, young people and maternity services. 2004.

http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111

3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.

4 National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal care of women and their babies (NICE Clinical Guideline 37). London: 2006.

http://www.nice.org.uk/CG37

5 National Collaborating Centre for Women's and Children's Health. Intrapartum care: management and delivery of care to women in labour (NICE Clinical Guideline 55). London: 2007.

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ID Reference

6 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical management and service guidance (NICE Clinical Guideline 45). London: 2007.

http://www.nice.org.uk/guidance/CG45

7 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63). London: 2008.

8 National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the healthy pregnant woman (NICE Clinical Guideline 62). London: 2009.

9 NHS Choices. Health A-Z: Preconception. 2007.

http://www.nhs.uk/conditions/Preconception/Pages/Introduction.aspx

10 NHS Choices. The pregnancy care planner. 2009.

http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx

11 NHS Choices. The pregnancy care planner: Bereavement. 2009.

http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Bereavement.aspx

12 Royal College of Nursing. Abortion care: RCN guidance for nurses, midwives and specialist community public health nurses. London: 2008.

http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177

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2 Commissioning antenatal care

Antenatal (once pregnant) Principles of antenatal care Provide antenatal information Booking appointment (ideally by 10 weeks) 16 weeks appointment 18 20 weeks appointment 25 weeks appointment 28 weeks appointment 31 weeks appointment 34 weeks appointment 36 weeks appointment 38 weeks appointment 40 weeks appointment 41 weeks appointment Consider all of the following 42 weeks appointment Go to intrapartum care First contact with healthcare professional Pre-existing medical, surgical and/or psychiatric conditions Newly-identified

medical, mental health and social needs

The Pregnancy Care Planner and the Pregnancy Book

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2 Commissioning antenatal care

1 Antenatal (once pregnant)

Quick info:

This pathway is based on UK National Health Service policies and schedules and gives an overview of what to expect in the antenatal period:

• antenatal care should be provided by a small group of carers with whom the woman feels comfortable •t here should be continuity of care throughout the antenatal period

•a system of clear referral paths should be established so that pregnant women who require additional care are managed and treated by the appropriate specialist teams when problems are identified

•t he purpose and choice of screening should be explained to the woman Associated maternity standards:

• standard 3: access to maternity care • standard 4: early pregnancy services

• standard 5: maternity booking and planning of care • standard 6: pre-existing medical conditions in pregnancy • standard 7: women with social needs

• standard 8: pre-existing and developing mental health conditions in pregnancy • standard 9: antenatal screening

• standard 10: routine antenatal care • standard 11: pregnancy-related conditions

• standard 20: supporting families who experience bereavement, pregnancy loss, stillbirth or early neonatal death • standard 21: choice and appropriate care

• standard 22: communication

• standard 26: development, implementation and review of local maternity services strategy • standard 27: maternity and neonatal networks

• standard 29: infection prevention and control • standard 30: staffing

2 The Pregnancy Care Planner and the Pregnancy Book

Quick info:

3 First contact with healthcare professional

Quick info:

• once pregnant refer to antenatal provider at earliest opportunity, with all relevant medical information

• if self-referred to antenatal provider, ensure primary care is informed and provide woman with telephone number and contact details of midwife

•i nform woman how to access maternity services and of choice of booking method (referral/self-referral) •e xplain importance of booking early (within first 10 weeks) and inform of booking form

• screen and refer according to individual need, ensuring woman continues on maternity pathway • if severe/complex mental illness is identified refer to specialist perinatal mental health team •o ffer information on screening

•f or further information, refer to screening guidance •o ffer blood tests as appropriate

• structured hand-held maternity records should be used for antenatal care

• undertake health, social and psychological needs assessment within first 10 weeks

• where woman is a late booker, provide information, screen as appropriate, and refer to antenatal provider at earliest opportunity •g ive information (supported by written information and antenatal classes), with an opportunity to discuss issues and ask

questions

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2 Commissioning antenatal care

•f or women considering termination of pregnancy, offer advice and refer as appropriate

• be alert to any factors clinical, psychological, cultural and/or social that may affect the health of the woman and baby

4 Consider all of the following

Quick info:

Consider the following steps

5 Provide antenatal information

Quick info:

Provide information and advice within first 10 weeks on: • where the woman will be seen and by whom

•t he likely number, timing and content of antenatal appointments, participant-led antenatal classes and breastfeeding workshops •t he right to accept or decline a test

•t aking as few prescription medicines as possible, and only where the benefit outweighs the risk •o ffer over-the-counter medicines advice and what to avoid

•o ffer choice of place of birth as appropriate, explaining what to expect with each option available •v aginal birth after caesarean (VBAC)

•f olic acid supplements

•f ood hygiene and how to reduce risk of food-acquired infection

• lifestyle, including smoking cessation, substance misuse and alcohol consumption - refer according to individual need, ensuring woman continues on maternity pathway

•a ll antenatal screening, risks, benefits and limitations - refer to Screening tests for you and your baby for information •r efer to Department of Health Standards to support the UK antenatal screening programme and to and the NSC Green

Book for information

• be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby

6 Principles of antenatal care

Quick info:

•m idwives and GPs should care for women with an uncomplicated pregnancy, providing continuous care throughout the pregnancy:

• obstetricians and specialist teams should be involved where additional care is needed

• antenatal appointments should take place in a location women can easily access and at convenient times: •t he location should be appropriate to the needs of women and their community

• maternity records should be structured, standardised, national maternity records, held by the woman

•t here should be 10 appointments for first-time mothers and a minimum of seven appointments for all other women • each antenatal appointment should have a structure and a focus

• appointments early in pregnancy should be longer to allow time to discuss screening so women can make informed decisions • if possible, incorporate routine tests into the appointments to minimise inconvenience to women

• be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby •f or further information on substance misuse and other problems, refer to NICE guidance

• be alert to the symptoms and signs of domestic abuse:

•f or further information, refer to the Department of Health Domestic Abuse Handbook and to the CEMACH Saving Mothers Lives report

7 Newly-identified medical, mental health and social needs

Quick info:

•a ssess medical needs and refer as appropriate, ensuring woman continues on maternity pathway •a ssess mental health (current, new onset and/or past incidence):

• if mental health needs are identified refer to ‘Pre-existing physical and/or psychiatric disorders’ •f or further information refer to the NICE mental health guidance

•a ssess social needs and refer according to individual need, ensuring woman continues on maternity pathway •o ffer advice on risk of condition to pregnancy and risk of pregnancy to condition

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2 Commissioning antenatal care

•c onsider additional information, care and treatment and refer to primary or specialist services according to individual need, ensuring woman continues on maternity pathway

8 Pre-existing medical, surgical and/or psychiatric conditions

Quick info:

Pre-existing medical, surgical and/or psychiatric disorders:

•c onsider specialist advice

•c onsider additional information, care and treatment, and refer according to individual need, ensuring woman continues on maternity pathway

• if healthcare professional or woman has significant concerns, refer to GP for further assessment •a ssess mental health (current, new onset or past incidence):

•a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman/couple and/or family • if severe mental illness (e.g. bipolar disorder or schizophrenia) is suspected, refer to specialist mental health service,

including, if appropriate, specialist perinatal mental health service: •t his should be discussed with woman and preferably with her GP

•i nform GP in all cases if a possible current mental disorder or history of significant mental disorder is detected, even if no further assessment or referral is made

•f or further information refer to the NICE mental health guidance

9 Booking appointment (ideally by 10 weeks)

Quick info:

•i dentify women who may need additional care and plan pattern of care for the pregnancy

•c alculate BMI and manage and/or refer according to individual need, ensuring woman continues on maternity pathway •a sk recommended questions to identify those at risk of and those with current mental health problems

•r efer women with current or previous severe/complex mental health needs to specialist perinatal mental health services •f or further information refer to the NICE mental health guidance

•o ffer blood tests as appropriate

•o ffer screening as appropriate and refer according to individual need, ensuring woman remains on maternity pathway •f or further information refer to UK National Screening Committee

•o ffer early ultrasound scan for gestational age assessment and ultrasound for structural anomalies

•i dentify women who have had genital mutilation (FGM) and refer according to individual need, ensuring woman continues on maternity pathway

•a sk about woman’s occupation to identify potential risks •g ive specific information on:

•t he pregnancy care pathway

•p lanning place of birth (refer to NICE Intrapartum guidance) •b reastfeeding, including workshops

• participant-led antenatal classes • maternity benefits

•f or women choosing screening, arrange as appropriate: •b lood tests, ideally before 10 weeks

•u rine tests

•u ltrasound scan to determine gestational age • Down’s syndrome screening

•u ltrasound screening for structural anomalies, normally between 18 weeks and 20 weeks 6 days • undertake full health and social needs assessment

10 16 weeks appointment

Quick info:

•r eview, discuss and record the results of screening tests:

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2 Commissioning antenatal care

•r equest permission to inform other healthcare professionals involved in her pregnancy and the Healthcare Protection Unit •o ffer to screen partner and children as appropriate

• screen and refer according to individual need, ensuring woman continues on maternity pathway •g ive specific information on:

•t he routine anomaly scan and refer as appropriate for: • abnormalities related to pregnancy

• abnormalities not related to pregnancy

11 18 20 weeks appointment

Quick info:

• if the woman chooses, an ultrasound scan should be performed between 18 weeks 0 days and 20 weeks 6 days to detect structural anomalies

•o ffer counselling and support as appropriate

•f or a woman whose placenta extends across the internal cervical os, offer another scan at 32 weeks • screen and refer according to individual need, ensuring woman continues on maternity pathway

12 25 weeks appointment

Quick info:

• screen and refer according to individual need, ensuring woman continues on maternity pathway • measure fundal height and refer as appropriate, ensuring woman continues on maternity pathway

13 28 weeks appointment

Quick info:

• screen and refer according to individual need, ensuring woman continues on maternity pathway •o ffer a second screening for anaemia and atypical red-cell alloantibodies, and hepatitis B • obtain maternal consent to give baby vaccinations at birth according to individual need •o ffer anti-D prophylaxis to women who are rhesus D-negative 1

•c heck for reduced fetal movement depending on normality of episodes

•r efer for fetal wellbeing assessment according to individual need, ensuring woman continues on maternity pathway • screen for eclampsia and refer as appropriate, ensuring woman continues on maternity pathway (refer to Action on

Pre-eclampsia website for further information)

14 31 weeks appointment

Quick info:

•r eview, discuss and record the results of screening tests undertaken at 28 weeks

• screen and refer according to individual need, ensuring woman continues on maternity pathway

15 34 weeks appointment

Quick info:

•r eview, discuss and record the results of screening tests undertaken at 28 weeks

• screen and refer according to individual need, ensuring woman continues on maternity pathway •o ffer a second dose of anti-D prophylaxis to women who are rhesus D-negative1

•g ive specific information on:

•p reparation for labour and birth, including the birth plan •t he postnatal period, including the postnatal plan

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2 Commissioning antenatal care

• start planning of postnatal care

16 36 weeks appointment

Quick info:

• screen and refer according to individual need, ensuring woman continues on maternity pathway • measure fundal height and refer as appropriate, ensuring woman continues on maternity pathway •c heck the position of the baby:

• if breech is suspected, offer external cephalic version

•r efer as appropriate, ensuring woman continues on maternity pathway •g ive specific information (at or before 36 weeks) on:

•b reastfeeding technique and good management practices, such as detailed in the UNICEF Baby Friendly Initiative •c are of the new baby, vitamin K prophylaxis and newborn screening tests

• postnatal self-care, awareness of ‘baby blues’ and postnatal depression •o ffer support and advice according to need

17 38 weeks appointment

Quick info:

• screen and refer according to individual need, ensuring woman continues on maternity pathway •g ive specific information on options for management of prolonged pregnancy

18 40 weeks appointment

Quick info:

• screen and refer according to individual need, ensuring woman continues on maternity pathway •d iscuss further management of prolonged pregnancy

19 41 weeks appointment

Quick info:

•f or women who have not given birth by 41 weeks: •o ffer a membrane sweep

•o ffer induction of labour

• screen as appropriate, ensuring woman continues on maternity pathway

20 42 weeks appointment

Quick info:

•o ffer enhanced surveillance and support according to individual need

• from 42 weeks, offer increased monitoring to women who decline induction of labour

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2 Commissioning antenatal care

Key Dates

Due for review: 06-Aug-2011

Locally reviewed: 29-Jul-2009, by London Updated: 29-Jul-2009

Evidence summary for Antenatal care

This pathway is based on UK National Health Service policies and schedules and gives an overview of what to expect in the antenatal period.

Evidence grades:

Evidence grading:

Antenatal (once pregnant) 1, 8

Principles of antenatal care 1, 8

Provide antenatal information 1, 8

Booking appointment (ideally by 10 weeks) 1, 8

16 weeks appointment 1, 8 18 # 20 weeks appointment 1, 8 25 weeks appointment 1, 8 28 weeks appointment 1, 8 31 weeks appointment 1, 8 34 weeks appointment 1, 8 36 weeks appointment 1, 8 38 weeks appointment 1, 8 40 weeks appointment 1, 8 41 weeks appointment 1, 8 42 weeks appointment 1, 8

First contact with healthcare professional 1, 8

Pre-existing medical, surgical and/or psychiatric conditions 9

Newly-identified medical, mental health and social needs 1, 9, 8, 6

References

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2 Commissioning antenatal care

ID Reference

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3 Commissioning intrapartum care

Labour and delivery

(intrapartum)

Diagnosis of labour

Support of first stage of labour (latent stage)

Established labour

Care throughout labour

Indications for transfer

Second stage of labour

Third stage of labour

Care of the baby and woman immediately after birth

Breastfeeding - within first hour after birth

Go to postnatal care

Link to the Pregnancy Care Planner and the Pregnancy Book

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3 Commissioning intrapartum care

1 Labour and delivery (intrapartum)

Quick info:

Scope:

•t his pathway is for women during the labour and delivery period and covers from the onset of labour to immediately after birth. It is based on UK National Health Service policies and schedules

Associated maternity standards: • standard 12: intrapartum care

• standard 13: neonatal care and assessment

• standard 14: postnatal assessment and care of the mother • standard 15: supporting infant feeding

• standard 16: care of babies requiring additional support • standard 17: care of babies born prematurely

• standard 18: promotion of healthy parent-infant relationships • standard 19: transition to parenthood

• standard 28: child protection and safeguarding babies • standard 29: infection prevention and control

• standard 30: staffing • appendix 1: intrapartum care

2 The Pregnancy Care Planner and the Pregnancy Book

Quick info:

3 Diagnosis of labour

Quick info:

Diagnosis of start of labour - this setting could be: • home

• obstetric-led unit •m idwife-led unit

4 Support of first stage of labour (latent stage)

Quick info:

•g ive opportunity to review choices and options available •d iscuss birth plan and choice and mode of delivery

•s upport the diagnosis of labour in the appropriate setting, according to individual need - this setting could be: • home

• obstetric-led unit •m idwife-led unit

• appropriately manage onset of painful regular contractions

•c onsider individualised/specialist care plans containing details of support needed and who to contact if concerned

5 Established labour

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3 Commissioning intrapartum care

Quick info:

•o ffer 1:1 midwifery care in labour regardless of intrapartum setting • undertake risk assessment with referral to appropriate birth setting

6 Care throughout labour

Quick info:

• undertake continuous risk assessment •o ffer consistent information and advice

•p rovide appropriate support, including analgesia:

•f or the Pain Relief In Labour leaflet, refer to the Obstetric Anaesthetists Association website •r efer or transfer as appropriate

•g ive support in labour:

•a woman in established labour should receive supportive 1:1 care

•a woman in established labour should not be left on her own except for short periods or at the woman’s request • women should be encouraged to have support by birth partner(s) of their choice

7 Indications for transfer

Quick info:

• clear pathways and guidelines on the indications for, and the process of transfer to, an obstetric unit should be established •t here should be no barriers to rapid transfer in an emergency

• clear pathways and guidelines should also be developed for the continued care of women once they have transferred: •t hese pathways should include arrangements for times when the nearest obstetric or neonatal unit is closed to admissions • if the emergency is such that transfer is not possible, open access must be given on-site for any appropriate staff to deal with

whatever emergency has arisen

•t here should be continuous audit of the appropriateness of, the reason for, and speed of transfer

•c onversely, the audit also needs to consider circumstances in which transfer was indicated but did not occur •t he audit should include time taken to see an obstetrician or neonatologist and the time from admission to birth

8 Second stage of labour

Quick info:

•p rovide appropriate support according to individual risk level • undertake continuous risk assessment

•o ffer consistent information and advice

•p rovide appropriate support, including analgesia

•r efer or transfer according to individual need, ensuring woman continues on maternity pathway •g ive support in labour:

•a woman in established labour should receive supportive 1:1 care

•a woman in established labour should not be left on her own except for short periods or at the woman’s request • women should be encouraged to have support by birth partner(s) of their choice

9 Third stage of labour

Quick info:

•p rovide appropriate support according to individual risk level • undertake continuous risk assessment

•o ffer consistent information and advice

•p rovide appropriate support, including analgesia •r efer or transfer as appropriate

•p lacenta delivery - offer choice according to individual risk level: •p rovide active management where appropriate

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3 Commissioning intrapartum care

10 Care of the baby and woman immediately after birth

Quick info:

• undertake appropriate assessment of baby and mother •o ffer appropriate neonatal care and support where required

•f acilitate uninterrupted skin-to skin contact as soon as possible after the birth for both the mother and father (if applicable) within first hour after birth

• if baby is transferred to Neonatal Intensive Care Unit (NICU), prioritise mother spending as much time as possible with her baby:

• limited visits should be due to clinical, not practical/operational, reasons

11 Breastfeeding - within first hour after birth

Quick info:

• encourage and initiate breastfeeding by offering support, information and advice as appropriate •o ffer support and advice as appropriate to prevent and/or manage common breastfeeding problems •f or further information, refer to the Department of Health's guidance on breastfeeding

•a ll healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff and parents:

• each provider should identify a lead healthcare professional responsible for implementing this policy

•a ll maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a minimum standard

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3 Commissioning intrapartum care

Evidence summary for Intrapartum care

This pathway is for women during the labour and delivery period and covers from the onset of labour to immediately after birth. It is based on UK National Health Service policies and schedules.

Evidence grades:

Evidence grading:

Diagnosis of labour 5

Support of first stage of labour (latent stage) 5

Established labour 5

Care throughout labour 5

Indications for transfer 5

Second stage of labour 5

Third stage of labour 5

Care of the baby and woman immediately after birth 5

Breastfeeding - within first hour after birth 1, 5, 4

References

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3 Commissioning intrapartum care

ID Reference

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4 Commissioning postnatal care

1 Postnatal

Quick info:

Scope:

•t his pathway is an overview of care during the postnatal period. It is based on UK National Health Service policies and schedules

Associated maternity standards: • standard 12: intrapartum care

• standard 13: neonatal care and assessment

• standard 14: postnatal assessment and care of the mother • standard 15: supporting infant feeding

• standard 16: care of babies requiring additional support • standard 17: care of babies born prematurely

• standard 18: promotion of healthy parent-infant relationships • standard 19: transition to parenthood

• standard 28: child protection and safeguarding babies • standard 29: infection prevention and control

• standard 30: staffing

2 The Pregnancy Care Planner and the Pregnancy Book

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3 First hours after birth

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• undertake observations and assessment of woman • undertake observations and assessment of baby:

•r ecommend Vitamin K and offer choice of intramuscular first, as most clinically and cost effective •w ithin first 24 hours, with maternal consent, give vaccinations to baby according to individual need

•r esults of observations and assessment, and vaccinations, should be recorded in the national Personal Child Health Records (PCHR) and any other baby health record

•i nform the Child Health Department as appropriate

•f or further information refer to Department of Health guidance and the NSC Green Book •i nvolve partner where applicable and appropriate

• ensure systems are in place to identify high-risk women and refer as appropriate, ensuring women continues on maternity pathway

•i mplement any specialist care plan agreed antenatally

•c omplete newborn physical examination should be performed within 72 hours of birth

4 Consider all of the following

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4 Commissioning postnatal care

5 Promote bonding by encouraging and initiating breastfeeding and skin-to-skin contact

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• encourage and initiate breastfeeding by offering support, information and advice as appropriate •o ffer support and advice as appropriate to prevent and/or manage common breastfeeding problems •f or further information, refer to the Department of Health's guidance on breastfeeding

•a ll healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff and parents

• each provider should identify a lead healthcare professional responsible for implementing this policy

•a ll maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a minimum standard.

•f acilitate uninterrupted skin-to skin contact as soon as possible after the birth for both the mother and father (if applicable) within first hour after birth

6 Assessment and management of physical and mental health

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• manage major morbidity in mother and infant • physical health:

•a rrange appropriate treatment eg for high blood pressure, perineal care • mental health:

•a ssess need for additional care and/or treatment from relevant healthcare professionals •i mplement any specialist care plan agreed antenatally

•r efer for specialist psychiatric assessment and treatment as appropriate

• women who need inpatient care for a mental disorder within 12 months of childbirth should normally be admitted to a specialist mother and baby unit, unless there are specific reasons for not doing so

7 Agree postnatal plan of care (for up to three months according to individual need)

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• agree community-based postnatal plan of care with woman according to physical, psychological and social need •o ffer choice of location of community-based postnatal support

•a ssess additional needs and respond as appropriate e.g. translation services

• agree location of first community-based postnatal contact, to take place within 24 hours of discharge from place of birth •r eview and re-start specialist pathway as appropriate

8 Agree discharge or transfer plan

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• agree discharge or transfer plan

• ensure appropriate communication with GP and primary care • ensure appropriate communication with multi-disciplinary teams • ensure management plans are in place

•p rior to discharge, give MMR (mumps, measles and rubella) vaccination to women not immune to rubella and record in Personal Child Health Record

• woman will either be discharged home or remain with provider

•a minimum of three community based postnatal contacts should take place should take place following discharge

9 Provider communications with GP/primary care and Child Health Department

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•t he provider should hand over to the GP/primary care:

• ensure appropriate communication with GP, and other professionals involved, on woman's experience and difficulties on discharge

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4 Commissioning postnatal care

•i nform GP, health visitor and Child Health professional of: •b irth and woman's experience

• hepatitis B status of woman •v accinations given to baby

•a rrange for hepatitis B vaccination to be given to baby at: •1 month

•2 months

• 12 months (booster)

10 First days after birth

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•c omplete newborn physical examination should be performed within 72 hours of birth • newborn bloodspots to be taken between day five and eight

11 Minimum of one postnatal contact at home within first 10 days

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•w ithin first 10 days there should be a minimum of one postnatal contact at home

• agree minimum of three community based postnatal contacts at woman's choice of location:

• number and frequency of contacts should be based on individual medical, psychological and social needs

• ensure systems are in place to identify high-risk women and refer according to individual need, ensuring women continue on maternity pathway

•l ength of postnatal period should be defined by individual medical, psychological and social need

• at each postnatal contact, women should be asked about their emotional well-being recommended questions to screen for mental health problems should be asked at first contact.

•f or further information, refer to NICE mental health guidance •r eview and re-start specialist pathway as appropriate

• healthcare professionals should be alert to risk factors and signs and symptoms of child abuse, neglect and inadequate bonding, and if there is raised concern, should follow local child protection policies

•f or information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook

12 Six to eight week check

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•t he following should be covered: • physical health

•c ontraceptive advice

•b reastfeeding status and support •i mmunisation

• six to eight week infant physical examination •r esults of newborn bloodspot

• nutrition

•a lcohol consumption •s ubstance misuse •t obacco

•c ontinue to assess for signs and symptoms of mental health problems and refer according to individual need, ensuring woman continues on maternity pathway

•f or information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook

13 Eight to 20 weeks

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• ensure systems are in place to identify high-risk women and babies

•r efer according to individual need, ensuring women continue on maternity pathway

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4 Commissioning postnatal care

•c ontinue to assess for signs and symptoms of mental health problems and refer according to individual need •o ffer extra support if needed

•a rrange for GP review if indicated and consider need for referral to specialist perinatal mental health services •t he length of the postnatal period should be set according to medical, psychological and social need

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Evidence summary for Postnatal care

This pathway is an overview of care during the postnatal period. It is based on UK National Health Service policies and schedules. Search date: Jun-2009

Evidence grades:

Evidence grading:

First hours after birth 1, 4

First days after birth 4

Promote bonding by encouraging and initiating breastfeeding and

skin-to-skin contact 1, 4

Assessment and management of physical and mental health 4

Agree postnatal plan of care (for up to three months according to

individual need) 4

Agree discharge or transfer plan 4

Provider communications with GP/primary care and Child Health

Department 4

Minimum of one postnatal contact at home within first 10 days 4

First community based contact at home or at choice of location 4

Six to eight week check 4

Eight to 20 weeks 4

References

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ID Reference

http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177

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