Care Pathway for women experiencing Mid-trimester ... protocols and... · 1.1 Feb 2017 A...

© RBFT Women experiencing MToP on Delivery Suite Care Pathway (V2.0) of 22

Care Pathway for women experiencing Mid-trimester Termination of Pregnancy on

Delivery Suite

Patient likes to be known as Patient name NHS no

Affix patient label here

Consultant

Planned date

Named Midwife

Date of admission

Ward

Known Allergies

CODE Paper colouring

Midwives responsibility White Assessment

TX Doctors responsibility Yellow Admission

Version 2.0 August 2018 Review before August 2020

Approval Group Date

Maternity Clinical Governance 13th July 2018

Change History

Version Date Author(s), Job title Reason

1.1 Feb 2017 A Wood-Blagrove (Bereavement MW), J Siddall (Consultant Obstetrician)

Pilot version being trialled in house

1.2 June 2017 A Wood-Blagrove (Bereavement MW), J Siddall (Consultant Obstetrician)

Final version

1.3 July 2018 A Wood (Bereavement MW) Updates made prior to next print run to address issues raised and changes to GL878 guidance

2.0 August 2018

A Wood (Bereavement MW) Introduction of partogram


All members of staff who are using this Pathway use black ink and fill in this section. You can then use initials when recording care

Print Name Designation Signature Initials

How to use an Integrated Care Pathway (ICP)

Firstly, if you are going to write in the ICP you need to state your Name, Job Title and give a sample signature and initials on the front of the ICP cover

If you are recording an event, which is predicted by the ICP, then you just sign against that predicted intervention in the column provided.

If your intervention is not in line with the pathway, you must record this as a variance in the variance column with the action you will take to try to bring the patient back onto the pathway.

Care given by health care assistants and student midwives / nurses must be countersigned by a registered midwife.

There are many ‘NOTES’ pages for you to write free text about the care given to the patient by you. These notes should always be dated and timed.

The ICP has been colour coded to make it easier to document your aspect of care. Black background relates to Doctors, clear background relates to Midwives and grey backgrounds relates to PAMS, but check the key prior to writing.

All ICPs are chronological so you should be able track the care given very easily


For infants born at 23+0 > 23+6 consider/discuss with neonatal team and family possible interventions if born with signs of life.


If to be admitted for termination of pregnancy: Y N Date Initial

Have parents been counselled by Consultant and written consent form completed?

Certificate A (HSA1) completed with 2 signatures

Mifepristone prescribed and administered

Misoprostol and Flagyl prescribed for administration

Essential information for all losses (Please document if not done): Y N Date Initial

Give ‘What Happens Next’ booklet and Bereavement Midwife contact card

If available (in Annexe cupboards) and/or in packs in DAU also give Willows support leaflet, ‘When a Baby Dies Before Labour Begins’ and Sands contact card/ support leaflet

Parents given date and time to return 48 hours after mifepristone Date___________________________Time______________

Give parents opportunity to see Willow Room if possible

Inform Community Midwife – leave message in Community Office if not available or on duty

Inform GP – leave message at surgery if unavailable

If feticide has been performed at RBH mifepristone will have been given prior to the procedure and all subsequent medication will have been prescribed and the Mid Trimester Termination of Pregnancy Guideline (GL878) followed. (If the feticide was done at Oxford mifepristone will have been given prior to the procedure and all subsequent medication will have been prescribed and the Mid Trimester Termination of Pregnancy Guideline (GL878) followed) Y N Date Initial

Follow guidance in medical notes, but in general: Oxytocin infusion to be started 6 hours after procedure at 100mls/hr until delivery achieved.


On admission for delivery:

Consider cannulation: you are likely to require a cannula at some point, whether for ERPC, PCA or other IVs, so it may be kinder to cannulate immediately and take all bloods at this point. Order PCA pump: to have on Delivery Suite. This will ensure prompt administration of analgesia if required later. Risk Assessment: perform VTE and Waterlow scores

Drugs to be given on admission to Delivery Suite (see earlier guidance if Feticide) Y N Date Initial PV misoprostol on admission (followed by PO miso 3 hourly as prescribed on drug chart) *Take HVS prior to PV dose* NB: See sample chart for appropriate dosage For dosage see schedule in Mid-trimester Termination of

Pregnancy guideline (GL878) as appropriate.

Note: If feticide has been undertaken the first dose of Misoprostol must be given within 30-60 minutes of the procedure

PR metronidazole on admission

Syntometrine/ Oxytocin for 3rd stage regardless of gestation

Tests for TOPs: Y N Date Initial

HVS prior to first dose of misoprostol (if appropriate, e.g. TOP for PROM

MSU (if appropriate, e.g. TOP for PROM)

Full Blood Count (Purple x 1)

Group & Save & Kleihauer regardless of blood group (Pink x 1) (Same bottle but you MUST tick Kleihauer on blood form- specify that this is an IUD – ) Not indicated for <20/40 or TOP/Feticide for structural abnormality

U&Es, LFTs, Uric Acid & Renal Function (Yellow x 1)

Clotting Screen (Blue x 1)

Commence MOWS chart Use partogram where appropriate to monitor contractions, PV loss and dilation (as indicated e.g. after end of regime or maternal request, not routine 4 hourly)


N.B. Remember that if the baby is born and shows signs of life (see flow chart on page 3 of this pathway), a doctor should be asked to discretely see the baby in its live state if at all possible as a Death Certificate must be completed by them later. Advise/discuss with parents that the fetus maybe born with movement/heart rate but would not be classed as a Neonatal death unless the baby takes a breath.

At delivery:

Describe condition of baby: Baby’s weight: _________________ Gender:_______________ (see page 6) Are there obvious abnormalities? Photograph them and place photos in CTG envelope.

Describe condition of liquor:

Describe condition of placenta: Placental weight: _______________ Are there obvious abnormalities? Photograph them and place photos in CTG envelope.

Describe condition of cord (i.e. any tight knots, any entanglement etc): Are there obvious abnormalities? Photograph them and place photos in CTG envelope.


Birth Summary:

Date Time

Onset of 1st Stage

Onset of 2nd Stage

BIRTH

3rd Stage Complete

SROM / ARM

Onset of labour Spontaneous / Induced / Augmented

Analgesia used

Delivered by/ midwife responsible

Type of delivery Spontaneous vaginal / operative vaginal / LSCS

ERPC to be decided by clinical need on case by case basis - ERPC performed

Y N

Total EBL

Any other maternal details affecting postnatal recovery

For the placenta: Y N Date Initial

Swab fetal surface and membranes and send for C&S (not necessary in cases of TOPs who HAVE had a positive amnio or CVS)

Place placenta in a DRY, white, labelled bucket and attach Histology request form, but keep placenta in Mortuary fridge with baby.


After Delivery:

For babies below 22 weeks gestation, please check sex with a second Midwife before informing parents (SANDS guidelines for Professionals, 2007). If you are not sure, do not guess.

Accepted Date

Any details Declined

Date Initials

Name of baby

See and hold the baby

Time alone with the baby

Hand and foot prints

Bathe and dress the baby (if applicable)

A lock of hair (if applicable)

Photographs 1 SD card per person, either take home or store safely in CTG envelope. Consider suggesting use of “Remember my baby” photography

Memory box / Memory folder - Please explain contents to parents

Involving siblings or other family members

Religious leader for blessing/ support

Naming ceremony


Care of baby: Y N Date Initial

IMPORTANT - Baby labelled twice with mum AND dad’s names

Baby wrapped in inco sheet (not too tightly!) and placed in body bag

Baby placed in mortuary fridge and register fully filled in

Care of mother following delivery: Y N Date Initial

For ALL Rhesus Negative mothers give Anti D 500iu – do not wait for Kleihauer results. Make sure prescribed on drug chart and form filed in notes. Use Anti D stamp for PN booklet.

Cabergoline prescribed and given? Over 20 weeks this is strongly recommended, under 20 weeks at doctors discretion or maternal request.

Ensure parents are aware of option to view baby after discharge - this however is by appointment only, ensure they have a contact card for Bereavement Midwife/Lesley Bowles.

Over 24 weeks and no signs of life (see flowchart pg 3): A feticide/TOP over 24/40 must be recorded as below to generate an NHS number for registering the baby legally Y N Date Initial

Record delivery in front of Birth Register as for live births

Stillbirth Certificate (blue book, found in bereavement filing cabinet) to be completed and given to parents. Please use your name stamp to confirm your name for the Registrar of Births, Marriages and Deaths, this is very important!

Enter delivery details onto CMiS as for live births

Complete Mortuary Form (Form A)

Complete Incident Form (Number: )


For babies born who take a breath at any gestation: Even non-viable <24/40 Y N Date Initial

Record delivery in front of Birth Register

Enter delivery details onto CMIS as for live births, ensuring that birth is recorded as a NEONATAL DEATH – an NHS number is needed in order for parents to register their birth. If this is not done, they cannot make the registration appointment.

Ensure baby is removed from NIPE database

Complete Mortuary Form (Form A)

Medical Certificate Cause of Death (yellow book) to be completed by Doctor who saw baby and issued to parents

Doctor to complete Cremation Form 4 (kept with Death Certificates) even if parents unsure of funeral arrangements as doctor may be unavailable at a later date, causing delays.

Complete DATIX Incident Form (Number:

Further decisions: Y N Date Initial

Do parents wish to have a post mortem examination?

Consent form AND clinical request form to be completed by Consultant, Registrar or trained Midwife (if Yes to PM)

Consent for placental examination if required

Completed consent forms to be kept in notes for Bereavement Midwife to arrange transport to Oxford (if Yes to PM)

Consider hospital or private burial or cremation, complete Form C


Discharge checklist for all losses: Y N Date Initial

Bereavement team to inform Health Visiting team by secure email

Community Midwife informed of discharge – please DO NOT leave answer phone messages. Consider use of secure email

Enter mothers name and ‘M’ number in folder by computer so that Admin team can take details off system (CMiS etc) Make every effort to ensure that this is done to prevent distressing text reminders/ phone calls.

Ensure that postnatal notes (for bereaved parents) completed and that mother takes these home with her. Can be found in bereavement filing cabinet.

Ensure FP10 for antibiotics/analgesia is given.

Is Anti D required? If so, has it been given and clearly stamped in the notes?

Has Cabergoline been given (if required/ requested)?

Ensure baby removed from NIPE database if born alive

Ensure Bereavement Midwife contact details have been given and confirm for parents that follow up appointment will be sent for 6 weeks.

Inform GP – leave message at surgery if unavailable

Notes on discharge: Y N Date Initial

Notes forwarded to Delivery Suite for attention of Bereavement Midwife / Ward Clerk and placed in bottom drawer of bereavement filing cabinet for confidentiality and safekeeping

Y N

Appointment with Fetal medicine team offered

Appointment with Fetal medicine team accepted

Notes to screening midwives: Date:


THIS PAGE LEFT BLANK

INTENTIONALLY

©RBFT Women experiencing MToP on Delivery Suite Care Pathway (V2.0) of 22

ENHANCED DISCHARGE SUMMARY

PLEASE DETATCH AND GIVE TO COMMUNITY MIDWIFE OFFICE

Mother had contact with bereavement midwife Yes / No / To be arranged

NB: If discharged prior to contact please inform mother that contact will be made on

midwife’s next working day (COU on Optimise)

Post Mortem Yes / No / Undecided / To be arranged

NB: Baby will travel with funeral directors (AB Walker) to JRH (Oxford). This will be

arranged by bereavement midwives on next working day. Parents have opportunity to see

baby on return.

Funeral Yes / No / To be arranged

NB: Discussed and arranged by bereavement midwives. Usually ‘contract’ funeral (burial or

cremation) with AB Walker at Henley Road Crematorium (approx. fortnight after delivery), or

private funeral.

Community Midwife to: Phone / Visit

Reason for TOP/IUD/NND (if known)

Any concerns

Baby’s name (if applicable)

*Community midwife please alert HV after discharge to community to

facilitate appropriate contact.*

Bereavement Midwives: 07500 123912 Ward Clerk: 0118 322 7215



INTENTIONALLY

©RBFT Women experiencing MToP on Delivery Suite Care Pathway (V2.0) of 22

FORM A

Maternity Unit, Maternity & Children’s Services Burial / Cremation Form (Mortuary Use)

Please complete this form for ALL babies and leave in the mother’s notes

Addressograph label:

Baby details (please circle): Male Female Names: (if any) ……………………………………………..………... Surname if different to Mothers: …………………………………………………..….. Date & Time of Birth: ………………………...……...…...……………...… Date & Time of Death: ……………………………………………………..... Death on (please circle): Delivery Suite Buscot

Consultant Obstetrician: ………………………………………………………. Consultant Paediatrician (if any): ………………………………………………………. Name of Doctor/Midwife in attendance: ………………………………………………………. If Stillbirth/NND Certificate issued, name of issuer (please print): ………………………………………………………. Cause of Death: ………………………………………………………………………...

…………………………………………………………………………………………………….

Religion: …………………………………………………………………………………. For: Post Mortem Yes No Histology Yes No Neither Yes No

Undecided Yes No



INTENTIONALLY


FORM B

Maternity Unit, Maternity & Children’s Services Non-Viable Burial/Cremation

Certificate of Medical Practitioner or Midwife, in respect of a

baby born dead before 24 weeks gestation

I HEREBY CERTIFY that I have examined THE BABY OF

Name …………………………………………………………

Address …………………………………………………………

…………………………………………………………

…………………………………………………………

…………………………………………………………

…………………………………………………………

Delivered on …………………………………………………………

and that this baby was less than 24 weeks gestation

Name …………………………………………………………

Signature …………………………………………………………

Address (work) …………………………………………………………

Phone Number …………………………………………………………

Date …………………………………………………………

Registered Qualifications ………………………………………...



INTENTIONALLY


FORM C

Maternity Unit, Maternity & Children’s Services Hospital Funeral Arrangements following Pregnancy Related Loss

Baby(ies) Name & Surname …………………………………………………………………………………....

Date of Birth …………………………………………………………………….……………...

Parents Full Name ……………………………………………………….…….... PLEASE PRINT

Address ………………………………………………………………………….…………...

………………………………………………………………………….…………...

Telephone ………………………………………………………………………….………...

Religion ………………………………………………………………………….…………...

Burial in Communal Grave: Yes No

Cremation: Yes No

Sensitive disposal: Yes No

Communal Cremation: Yes No

Hospital Chaplain to be present: Yes No

Service in Henley Road Chapel: Yes No

To collect ashes: Yes No

Parents wish to be informed: Yes No

Parents to attend: Yes No

I certify that I consent to the Royal Berkshire NHS Foundation Trust making the arrangements for the

*burial/cremation of my/our baby’s remains

Signature ……………………………………………… Date …………………………………

Please return the completed form as soon as possible, together with any Release Certificate that will be

received from the Registrar of Birth, Deaths and Marriages should you have needed to register your

baby’s birth and/or death to the address below:

Ward Clerk Official Use Delivery Suite Date of funeral ……………………… Maternity Unit Parents informed ……………………… Royal Berkshire Hospital Date informed ……………………… Reading Letter sent ……………………… Berkshire RG1 5AN email sent ……………………… Requisition No: ………………………



INTENTIONALLY

Care Pathway for women experiencing Mid-trimester ... protocols and... · 1.1 Feb 2017 A...

Documents

Transcript of Care Pathway for women experiencing Mid-trimester ... protocols and... · 1.1 Feb 2017 A...