Guidelines for This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and/or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction The midwife undertaking the booking visit with a pregnant woman has the responsibility to offer the choice for maternity care. Risk assessment should be a continuous process throughout pregnancy. However, a formal risk assessment must be undertaken using the Trust Risk Assessment form (appendix 2) at booking. If risks are identified during the continual risk assessment process a referral will be made to the relevant antenatal clinic where the clinical manager will triage all referrals to the appropriate consultant clinic. All referrals should be made on form (appendix 3) Judi Barratt Lead Clinician(s) Clinical Midwife Specialist Guideline reviewed and approved by Obstetric Clinical Governance Committee on: 19 th September 2014 This guideline should not be used after end of: 19 th September 2016 WAHT-OBS-027 Page 1 of 12 Version 8.1
Key amendments to this guideline Date Amendment By: 03/10/2004 Approved by Dr Newrick on behalf of CEC 06.03.2009 Revised version agreed at Labour Ward Forum Mrs J A Barratt 16.11.2009 Guideline revised by Mrs J A Barratt in conjunction with ANC Mrs J A Barratt Managers 31.10.10 During booking visit the women should undergo risk assessment for venous thromboembolism. This is in addition to the above antenatal risk assessment form. See guideline WAHT-OBS-012 for the risk assessment form (WR2068) and the process of referral. Mrs.L.Thirumalaiku mar 12.04.11 Extended for a further period without amendment Mrs J A Barratt 07.10.11 Agreed by Core MGDG to extend for a further period without Miss R Imtiaz amendment to allow time for further review. 15.06.12 Change to title from Guidelines for the identification of lead professional for a woman s maternity care. Revised Risk Assessment form, and arrangements for referrals. Rabia Imtiaz Karen Kokoska Judi Barratt 26/06/2014 Guideline approved by Obstetric guidelines group 14/07/2014 Minor changes made to incorporate change in practice associated with development of Meadow Birth Centre. Added women who refuse transfusing for criteria for consultant opinion and plan of care 14/07/14 Slight changes to Risk assessment and referral forms see Appendix 1 and 2 Patti Paine Margaret Stewart Mrs L Thirumalaikumar Val Tristram/Patti Paine WAHT-OBS-027 Page 2 of 12 Version 8.1
Guidelines for Introduction The midwife undertaking the antenatal booking visit has the responsibility to offer women the choice for maternity care. Worcestershire Acute Hospitals NHS Trust offers women four choices: Midwife Led Care with birth on the Meadow Birth Centre Midwife Led care with birth at home Midwife led care with Birth on the consultant unit Consultant led care with birth on the consultant unit The Risk Assessment Form is included in every booking pack. Following the booking the Risk Assessment form should be attached to the patient held pregnancy notes. Guideline Risk assessment should be a continuous process throughout pregnancy. See appendix 1. However, a formal risk assessment must be undertaken using the Risk Assessment Form (appendix 2) at booking. At 36 weeks a reassessment should take place by the professional providing care (midwife/ obstetrician) and documented on page 11 in the pregnancy notes. If risks are identified during the continual risk assessment process a referral will be made to the relevant antenatal clinic where the clinical manager will triage all referrals to the appropriate consultant clinic. All consultant referrals should be made on form (appendix 3). Women who do not have any risks identified can be booked for midwife led care and may choose to birth at home, Meadow Birth Centre or consultant unit. Women electing hospital birth may choose Worcestershire Royal Hospital (WRH) or Alexandra Hospital, Redditch. Midwife Led Care At the booking appointment the community midwife identifies the appropriate lead professional using the risk assessment form. Antenatal care will be shared between community midwife and the woman s GP. Women may birth in the Meadow Birth Centre, at home or in the Consultant Led Birth Suite Consultant Led Care At the booking appointment the community midwife identifies the appropriate lead professional using the risk assessment form. Where risk factors are identified an appointment at the consultant antenatal clinic will be offered to plan subsequent care, this should include a schedule of appointments with GP/community midwife built around the woman s individual needs. The referral is received by the antenatal clinic and appointments are made according to the woman s needs as indicated on the Midwife/GP referral letter. Appointment letters are sent WAHT-OBS-027 Page 3 of 12 Version 8.1
out to women via the post. Urgent appointments can be requested by telephone by the community midwife who will inform the woman. The consultant led Antenatal Clinics are situated at: Worcestershire Royal Hospital Alexandra Hospital, Redditch Kidderminster Treatment Centre Princess of Wales Community Hospital Evesham Community Hospital Timing of initial consultant appointments: Routine Appointment = 16-20 weeks. Early Appointment = within 3-4 weeks (medical conditions, recurrent miscarriage, familial genetic disorder, substance misuse, mono-chorionic twin pregnancies, rhesus antibodies) Urgent Appointment = offered within the week (fetal abnormality, insulin dependent diabetic, unstable medical condition, autoimmune disease, VTE risk score of 3 or more ) Referral to a consultant for an obstetric opinion A Consultant opinion may be sought at any time in the antenatal period if the midwife has concerns re the appropriate lead professional and if necessary the woman should be seen by a consultant. The referral for obstetric opinion should preferably be made using the referral form (Appendix 3). If an urgent opinion is required and no antenatal clinic appointment with the consultant is available, the referring midwife should arrange for the woman to be seen by the on-call consultant in the Day Assessment Unit or on Birth Suite. Reasons for the referral should be documented in the woman s Pregnancy tes on the management plan page, and on the referral form. A plan of care, including details of the current lead professional, should be recorded in the woman s pregnancy notes and the current with updated as necessary lead professional documented on the front page of the pregnancy notes. Where the consultant agrees midwife led care is suitable, the woman is returned to the care of the community midwife and GP. The consultant should document the recommended lead professional and the plan of care in the pregnancy notes and in the hospital case-notes if available. The woman should be advised when her next appointment with the community midwife is. Referral to other specialities At booking women should be referred to a specialist midwife if appropriate (page 11 Pregnancy notes) on the requisite form and the form given to the specialist midwife. This referral form should be placed in the medical records. Every woman should be referred to their Health Visitor using form which is forwarded to the appropriate HV teams Referral to other specialties is made by letter from an obstetrician/ midwife after review in the antenatal clinic. There are specific referral forms for some of the specialties e.g. mental health, anaesthetic, and physiotherapy. This list is not exhaustive. Homebirth with known risk factors Women with known risk factors who choose to birth anywhere other than the consultant unit should be carefully counselled by a consultant obstetrician emphasising the risks associated with their choice. The community midwife informs the Supervisor of Midwives of the homebirth against advice using Guideline WAHT-OBS-057 Home Birth, appendix B. A Supervisor of Midwives should also meet with the woman to ensure she is making an informed choice. If following adequate counselling the mother is still requesting birth anywhere other than a consultant led delivery suite; then a multidisciplinary meeting should be considered involving midwives, obstetrician and supervisor of midwives. WAHT-OBS-027 Page 4 of 12 Version 8.1
Monitoring tool STANDARDS: Item % Exceptions Women booked for appropriate care pathway in accordance with risk assessment form 100% Woman s choice Documentation to include place of birth discussed at booking 100% Women referred by midwives to Consultant for decision on whether 100% consultant led care is advisable must be seen by a Consultant Where no Consultant Antenatal Clinic appointment available 100% women must be reviewed by Consultant on call in the Day Care Unit, Meadow Birth centre or Ward A clear plan of care should be recorded for the woman s care at all times 100% How will monitoring be carried out? Clinical Audit Who will monitor compliance with the guideline? Obstetric Clinical Governance Committee References Changing Childbirth : a report of the expert maternity group. August 1993, HMSO ISBN 0113216238 NICE Guideline 6 : Antenatal Care Routine Care of the Healthy Pregnant Woman, October 2003. Enkin, M. Keirse, MJNC Renfre, M.T. Neilson, J. (1995) A Guide to Effective Care in Pregnancy & Childbirth, 2 nd Edition, Oxford Medical Publications, Oxford pp 364-371 Community antenatal care handbook 1997 Mike Wildes, Ralph Settatree WAHT-OBS-027 Page 5 of 12 Version 8.1
Appendix 1 WAHT-OBS-027 Page 6 of 12 Version 8.1
Appendix 2 WAHT-OBS-027 Page 7 of 12 Version 8.1
WAHT-OBS-027 Page 8 of 12 Version 8.1
Appendix 3 WAHT-OBS-027 Page 9 of 12 Version 8.1
CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Karen Kokoska Maternity Risk Manager Rabia Imtiaz Consultant Obstetrician Jasmin Farmer Antenatal Clinic Manager Theresa Meredy Antenatal Clinic Manager Valerie Tristram Antenatal Clinic Manager Alison Tilley Community Midwife Judi Barratt Clinical Midwife Specialist Circulated to the following individuals for comments Name Designation Mr S Agwu Mrs P Arya Mrs A Blackwell Miss R Duckett Mrs S Ghosh Mr J Hughes Consultant Obstetrician/Gynaecology Miss M Pathak Mrs J Shahid Miss D Sinha Miss L Thirumalaikumar Mr A Thomson Clinical Director - Mr J Uhiara Patti Paine Head of Midwifery Karen Kokoska Maternity Services Risk Manager Rachel Carter Matron IP WRH Margaret Stewart Matron OP-Community Alison Talbot Matron IP Alexandra Hospital User representatives LW Forum Midwife members of MGDG (For consultation with their peers) J A Barratt Clinical Midwife Specialist J Martin Midwife, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital H Walker Community Midwife, Kidderminster V Tristram Midwife, Kidderminster Hospital/Supervisor of Midwives R Williams Midwife, WRH WAHT-OBS-027 Page 10 of 12 Version 8.1
Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Yes Pregnant women only Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? N/A 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources. WAHT-OBS-027 Page 11 of 12 Version 8.1
Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/ 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: ne If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-OBS-027 Page 12 of 12 Version 8.1