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Maternity Services Guideline Antenatal Appointments

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Maternity Services Guideline Antenatal Appointments MATERNITY SERVICES GUIDELINE ANTENATAL APPOINTMENTS GUIDELINE Version Authors Michala Little - Community Midwifery Manager Kath Chapman – Community Midwifery Team Leader Lynda Fairclough - Community Midwifery Team Leader Owner Michala Little Community Midwifery Manager Date of First issue 1994 Version 12.1 Date of Version issue September 2019 Ratified by York: Obs & Gynae Clinical Scarborough: Obs & Gynae Governance Forum Clinical Governance Forum Date Ratified 12.11.19 12.11.19 Review date September 2021 Version information Significant changes to previous version. Update September 2019 to include aspirin changes, VTE update, proteinurea guidance and safeguarding info Antenatal Appointment Guideline Version No. 12.1 November 2019 – September 2021 Page 1 of 30 Contents Section Title Page 1 Introduction & Scope 3 2 Management 3 2.1 The Booking Process 3 2.2 Criteria for Midwifery Led Care 3 2.3 Criteria for Consultant Review 4 2.4 Criteria for Planned Homebirth 5 2.5 Booking Risk Assessment 6 2.6 Frequency of A/N Visits for Low Risk Women 10 3 Links with 17 4 References 17 Appendices Appendix 1: Referral Flowchart from M/W led Care to Consultant 19 Appendix 2: Procedure for Women Who Attend Antenatal or a Community Clinic without Handheld Pregnancy Records 20 Appendix 3: Procedure for women who do not attend appointments(DNA) 21 Appendix 4: Procedure for women who decline blood products 22 Appendix 5: Procedure for Measuring Symphsis-Fundal Height 23 Appendix 6: High incidence of TB by country 24 Appendix7: Northern and Yorkshire Cleft Lip and Palate service 25 Appendix 8: Flowchart for women recommended to take low dose aspirin 26 Appendix 9: Ante natal payments pathway 27 Appendix 10: Screening for domestic abuse in pregnancy 29 Appendix 11: Pathway of care for women having blood taken for grouping and Antibody Screening’ guideline 30 Antenatal Appointment Guideline Version No. 12.1 November 2019 – September 2021 Page 2 of 30 1 Introduction & Scope This guideline is designed to provide a framework to enable the consistent provision of high quality, evidence based holistic care to pregnant women when they access services provided by York Teaching Hospital NHS Foundation Trust. This guideline is for the use of any health care professional working within maternity services. It will be mainly used by those working in the community, ante-natal clinic, ante-natal day assessment unit and ante-natal wards, but will also be a valuable point of reference for a variety of additional groups involved in the provision of ante- natal care or related services (for example GP’s Dr’s rotating into obstetrics, radiographers, ultra-sonographers, physiotherapists, nurses working on gynaecology wards etc). All professionals caring for pregnant women are responsible for their own professional practice and for working within the guidelines detailed in this document. Furthermore, each professional involved in an individual’s care is accountable for ensuring they communicate any relevant information with other professionals or agencies as deemed appropriate. 2 Management 2.1 The Booking Process Once the woman has presented in pregnancy it is the responsibility of the midwifery services to offer antenatal care by providing an initial booking appointment. This should take place as early as possible, ideally around 8 weeks, and be no later than 12 completed weeks of pregnancy - sooner if the woman has complex medical needs Women who present at any gestation after 12 weeks of pregnancy should be booked within 2 weeks as far as is practicably possible Women should receive a ‘pre-booking’ pack (usually given out by GP’s receptionists or can be collected by the woman or her representative from GP surgeries) containing the following leaflets: ‘Screening Tests for you and your baby’ (PHE 2017) ‘Congratulations on your pregnancy’ (Trust PIL) which includes details on the purpose of the booking process and how to contact a midwife Emotional Support in Pregnancy (Trust PIL) Document in the hand held notes the date that the woman made the first contact regarding this pregnancy The booking appointment is the 1st in a series of risk assessments undertaken at every appointment in the antenatal period to ensure care is provided by the appropriate health professional(s). 2.2 Criteria For Midwife Led Care (See Appendix 1 for referral details) Women with low risk pregnancies will have a midwife as their lead professional. The midwife, as the lead professional, must be responsible for all aspects of the pregnancy and will make referral to appropriate professionals as required or as requested by the woman. Antenatal Appointment Guideline Version No. 12.1 November 2019 – September 2021 Page 3 of 30 At each antenatal contact the risk assessment must be reviewed to ensure women remain within the correct care pathway. If the woman becomes high risk at any stage during the pregnancy, she must be referred for a Consultant appointment and update management plan in the handheld notes. 2.3 Referral Criteria for Consultant Review All women with ‘high-risk’ pregnancies must be booked for consultant led care and a pregnancy management plan formulated and documented in the handheld notes. Previous pregnancy notes will be available for ANC appointments for all women who have previously delivered in the Trust. For women who have previously delivered outside York Trust and whose consultant requests the notes e.g. previous complicated delivery, the consultant’s secretary will contact the previous Trust by letter and request a record of the previous pregnancy(ies). Options for antenatal care will be discussed with the woman and any women appropriate for midwife led care will be referred back to the midwife. This will be documented in the management plan. Medical indicators: Cardiac disease including hypertension Renal disease Endocrine disorders Liver disorders A diagnosis of psychiatric illness or any history of severe mental illness (requiring psychiatric or CMHT involvement – current or historical) – refer to perinatal mental health guideline Medicated for depression/anxiety in current pregnancy Previous puerperal psychosis High risk VTE assessment Autoimmune disorders Genetic disorders Epilepsy requiring anticonvulsant drugs Malignant disease Severe asthma (not well controlled or ongoing respiratory team input) Drug misuse including alcohol HIV, syphilis, HBV or Hep C positive (also inform screening team) Genital herpes simplex (whether primary or recurrent) Obesity (BMI ≥ 35 at 1st contact) Previous anaesthetic difficulties Antenatal Appointment Guideline Version No. 12.1 November 2019 – September 2021 Page 4 of 30 Obstetric indicators: h/o any of the following Recurrent miscarriage (3 or more consecutive pregnancy losses with the same partner or a mid-trimester loss) IVF/clomid induced pregnancy Age 40 or above Grand multiparity - more than 4 deliveries (definition from NICE, RCOG) More than 6 pregnancies (regardless of parity) Previous pre-term birth (<37weeks) Severe pre-eclampsia, HELLP syndrome or eclampsia Rhesus iso-immunisation or other significant blood group antibodies. Please also refer to antibody care plan in ‘Pathway of care for women having blood taken for grouping and Antibody Screening’ guideline (Appendix 11). Uterine surgery, including LSCS, myomectomy, (cone biopsy and LLETZ if this is the 1st pregnancy following this procedure) Previous retained placenta on two or more occasions Previous postpartum haemorrhage Previous stillbirth or neonatal death Previous baby small for gestational age (less than 5th centile) A previous baby with congenital anomaly (structural or chromosomal) Previous impaired GTT Previous 3rd/4th degree tear Any positive GBS screening in any pregnancy must be screened by midwife Requesting homebirth against guidance or advice (at any point of pregnancy) Women who decline blood products Social indicators (more at risk of complications developing): Teenagers (<18) Safeguarding issues 2.4 Criteria for Planned Home Birth Better Births (2016) states ‘Women need clear unbiased information to help them make decisions about where to give birth, including: the chances of receiving interventions; availability of pain management; on site availability of obstetric and neonatal services; and the frequency and likely duration of transfer. Such information needs to be personalised according to their individual circumstances’. This statement is informed by the Birthplace Study, undertaken by the National Perinatal Epidemiology Unit (NPEU, accessed online and last updated 2017) which found that: For women having a second or subsequent baby, home births and midwifery unit births appear to be safe for the baby and offer benefits for the mother For multiparous women, there were no significant differences in adverse perinatal outcomes between planned home births or midwifery unit births and planned births in obstetric units. Antenatal Appointment Guideline Version No. 12.1 November 2019 – September 2021 Page 5 of 30 For multiparous women, birth in a non-obstetric unit setting significantly and substantially reduced the odds of having an intrapartum caesarean section, instrumental delivery or episiotomy. For women having a first baby, a planned home birth increases the risk for the baby For nulliparous women, there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units For women having a first baby, there is a fairly high probability
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