Maternity Services Care Pathways

7/29/2019 Maternity Services Care Pathways

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In developing this pathway, we aim to provide maternityservices commissioners with valuable guidance so that theymay safely and effectively meet the demands of their localpopulation.

The pathway also describes what women can expect ontheir maternity journey.

Maternity care pathways


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Maternity best practice

Maternity best practice

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


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1 Pre-pregnancy care


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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 Planneris 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 mostfrom pregnancy and the new baby

3 Contact with healthcare professional

Quick info:

for 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 continueson maternity pathway

5 No

Quick info:

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

6 Yes

Quick info:

for women planning pregnancy

7 Access to healthcare

Quick info:

o ffer advice regarding access to healthcare should the woman change her mind


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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 outcomeo ffer advice on risk of pre-existing condition to pregnancy and risk of pregnancy to condition

review 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

for 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 pathwaya 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


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

for 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


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

for further information, refer to Diabetes UK advice on preconception care for women with diabetes and to NICE diabetes inpregnancy guidance

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



o ffer advice on folic acid and appropriate dose



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c onsider additional information, care and treatment, and refer according to individual need, ensuring woman continues onmaternity 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


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 thalassaemiafetal 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 rubellac 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:refer 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 needo ffer dietary advice regarding healthy eating and what foods to avoid (harmful dietary substances)

o ffer advice on nutritional supplementso 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

for 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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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

for women considering termination of pregnancy, offer advice and refer as appropriate, ensuring woman is returned to maternity

pathway when appropriate

for further information, refer to the termination of pregnancy pathway and to NHS London abortion guidance be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


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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_40891113 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.


DH_4126161

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/CG375 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

http://www.nice.org.uk/CG55

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.http://www.nice.org.uk/CG62

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









Consider all of the

following


Go to intrapartum care

First contact

with healthcareprofessional

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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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 theantenatal 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


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 22: communication standard 23: training and professional competence

standard 24: documentation and confidentiality

standard 25: clinical governance

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


Quick info:


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

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 teamo ffer information on screening

for 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 opportunityg ive information (supported by written information and antenatal classes), with an opportunity to discuss issues and ask

questions

book into antenatal classes


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for 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


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 workshopst 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)folic acid supplements

food 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

refer to Department of Health Standards to support the UK antenatal screening programme and to and the NSC GreenBook 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 womant 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


for further information on substance misuse and other problems, refer to NICE guidance be alert to the symptoms and signs of domestic abuse:

for 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 disordersfor further information refer to the NICE mental health guidance

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


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


Quick info:

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




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 assessmenta 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


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

refer women with current or previous severe/complex mental health needs to specialist perinatal mental health services


o ffer blood tests as appropriateo ffer screening as appropriate and refer according to individual need, ensuring woman remains on maternity pathway

for 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 womans 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

for women choosing screening, arrange as appropriate:

b lood tests, ideally before 10 weeks

u rine tests

u ltrasound scan to determine gestational age

Downs syndrome screeningu 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:

review, discuss and record the results of screening tests:

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


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request permission to inform other healthcare professionals involved in her pregnancy and the Healthcare Protection Unit

o ffer to screen partner and children as appropriate


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

for 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



Quick info:


measure fundal height and refer as appropriate, ensuring woman continues on maternity pathway



Quick info:


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 episodesrefer 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 toAction on Pre-

eclampsia website for further information)



Quick info:

review, discuss and record the results of screening tests undertaken at 28 weeks




Quick info:

review, discuss and record the results of screening tests undertaken at 28 weeks


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


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

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


Quick info:


g ive specific information on options for management of prolonged pregnancy



Quick info:


d iscuss further management of prolonged pregnancy



Quick info:

for 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



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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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










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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ID Reference



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




DH_4126161


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




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


London: 2008.


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




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





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3 Commissioning intrapartum care


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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


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





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

standard 28: child protection and safeguarding babies

standard 29: infection prevention and control

standard 30: staffing

appendix 1: intrapartum care


Quick info:


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 Diagnosis of labour

Quick info:

Diagnosis of start of labour - this setting could be:

home

obstetric-led unitm 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 deliverys 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 contractionsc onsider individualised/specialist care plans containing details of support needed and who to contact if concerned

5 Established labour


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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 advicep rovide appropriate support, including analgesia:

for the Pain Relief In Labourleaflet, refer to the Obstetric Anaesthetists Association website

refer 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 womans 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 establishedt 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 occurt 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


o ffer consistent information and advice

p rovide appropriate support, including analgesia

refer 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 womans 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


o ffer consistent information and advice

p rovide appropriate support, including analgesia

refer or transfer as appropriatep lacenta delivery - offer choice according to individual risk level:

p rovide active management where appropriatep rovide physiological management where appropriate


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10 Care of the baby and woman immediately after birth

Quick info:

undertake appropriate assessment of baby and mothero ffer appropriate neonatal care and support where required

facilitate 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 problemsfor 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 aminimum standard


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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.Search date: Jun-2009

Evidence grades:





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

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


ID Reference




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.


DH_4126161


babies (NICE Clinical Guideline 37). London: 2006.http://www.nice.org.uk/CG37





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ID Reference


management and service guidance (NICE Clinical Guideline 45). London: 2007.

http://www.nice.org.uk/guidance/CG457 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of


London: 2008.http://www.nice.org.uk/CG63

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


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

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


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



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4 Commissioning postnatal care


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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


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 20: supporting families who experience bereavement, pregnancy loss, stillbirth or early neonatal death






standard 26: development, implementation and review of local maternity services strategy

standard 27: maternity and neonatal networks

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

standard 30: staffing


Quick info:

The Pregnancy Care Planneris the NHS guide to having a babyt 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 First hours after birth

Quick info:

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

recommend 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 needresults of observations and assessment, and vaccinations, should be recorded in the national Personal Child Health Records

(PCHR) and any other baby health recordi nform the Child Health Department as appropriate

for 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 antenatallyc omplete newborn physical examination should be performed within 72 hours of birth


Quick info:Consider the following steps during the first hours after birth


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

Quick info:

encourage and initiate breastfeeding by offering support, information and advice as appropriateo ffer support and advice as appropriate to prevent and/or manage common breastfeeding problems

for 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.

facilitate 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

Quick info:

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

refer 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)

Quick info:

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

review and re-start specialist pathway as appropriate

8 Agree discharge or transfer plan

Quick info:

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

Quick info:

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

agree a communications plan with the GP/primary care practitioner


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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 babya rrange for hepatitis B vaccination to be given to baby at:

1 month

2 months

12 months (booster)

10 First days after birth

Quick info:

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

Quick info:

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 onmaternity 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.

for further information, refer to NICE mental health guidance

review 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

for information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook

12 Six to eight week check

Quick info:

t he following should be covered:

physical health

c ontraceptive advice

b reastfeeding status and supporti mmunisation

six to eight week infant physical examination

results of newborn bloodspot

nutrition

a lcohol consumption

s ubstance misuset 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


13 Eight to 20 weeks

Quick info: ensure systems are in place to identify high-risk women and babies

refer according to individual need, ensuring women continue on maternity pathway



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c ontinue to assess for signs and symptoms of mental health problems and refer according to individual needo 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.


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


ID Reference


Maternity services. London: 2004.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/

DH_4089101




DH_4126161


babies (NICE Clinical Guideline 37). London: 2006.




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ID Reference



http://www.nice.org.uk/CG556 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/CG457 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of


London: 2008.


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





http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx11 NHS Choices. The pregnancy care planner: Bereavement. 2009.







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About Map of Medicine

The Map of Medicine is an online clinical knowledge

resource implemented throughout the UK and availa-ble to patients via NHS Choices. More than 1500 pages,organised into over 350 care pathways spanning caresettings, are presented in an easy-to-use visual format,offering evidence-based and up-to-date informationacross all specialties.

The Maternity pathway is available to NHS healthcareprofessionals at http://london.mapofmedicine.com/*

*Access is via your NHS Athens account

Documents

Maternity Services Care Pathways