Care Pathway for women experiencing Mid-trimester ......©RBFT Women experiencing MToP on Delivery...

©RBFT Women experiencing MToP on Delivery Suite Care Pathway (V3.0 March 2020) of 24

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 3.0 March 2020 Review before March 2022

Approval Group Date

Maternity Clinical Governance 6th March 2020

Change History

Version Date Author(s), Job title Reason

2.0 August 2018

A Wood (Bereavement MW) Introduction of partogram

2.1 Oct 2019 A Wood (Bereavement MW) Live change to amend HbA1c blood test bottle colour to purple from grey

3.0 February 2020

A Wood, H Clark (Bereavement MWs) Remove record in birth register, update informing maternity bookings and blood tests, discharge process updated, medication updated to reflect new guidance in GL878


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


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

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

Certificate A (HSA1) completed with 2 signatures

Mifepristone prescribed and administered

Essential information for all losses:

(Please document if not done) Y N Date Initals

Give pack in DAU to include ‘What Happens Next’ booklet,

Bereavement Midwife contact card and MIL ‘Mid to late

pregnancy loss’

Parents given date and time to return 48 hours after mifepristone

Date___________________________Time______________

Give parents opportunity to see Willow Room if possible

Inform named Community Midwife/Team Lead by email

Inform GP – leave message at surgery if unavailable

Email maternity bookings to cancel future obstetric appointments

[email protected]. Please copy in

[email protected]

If feticide has been performed mifepristone will have been given prior to the procedure. Please refer to Feticide and Mid Trimester Termination of Pregnancy Guideline (GL878) for dosage schedule

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

mailto:[email protected]

mailto:[email protected]


Drugs to be given on admission to Delivery Suite (see earlier guidance if Feticide)

Y N Date Initals

Misoprostol and Metronidazole prescribed for administration

Give misoprostol dose according to gestation

*Take HVS prior to first 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 TOP for Fetal Abnormality Y N Date Initals

Group & Save (Pink x 1)

Full Blood Count (Purple x 1)

Tests for other TOPs (PROM/other – please check with Consultant for tests required (IUD/TOP Care set): Y N Date Initals

HVS prior to first dose of misoprostol

MSU

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

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

Clotting Screen (Blue x 1)

Lupus Anticoagulant (Blue x 4) Test cannot be completed without all 4 bottles

HbA1c (Purple x 1)

TORCH & Parvovirus (Yellow x 1 Lab requires full bottle) NB Ensure these tests added if not in care set

Anticardiolipin Antibody / Antinuclear Antibody (Yellow x 1)


Commence MOWS chart following administration of Misoprostol hourly observations of temperature, pulse, respiration, blood pressure and fluid balance. Commence PCA chart/VIP chart as appropriate. 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 with signs of life (please see flow chart page 3) 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. It is imperative that the certifying doctor also completes an online referral to the Coroner for any baby NOT SEEN ALIVE by the certifying doctor.

At delivery:

Describe condition of baby:

Baby’s weight: _________________

Gender:_______________ (see page 6)

Are there obvious abnormalities? Consider use

of Medical Photography if clinically relevant

Describe condition of liquor:

Describe condition of placenta:

Placental weight: _______________



Describe condition of cord (i.e. any tight knots,

any entanglement etc):




Birth Summary:

Date Time

Onset of 1st Stage

Onset of 2ndStage

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

Name of doctor performing delivery if applicable

ERPC performed Y N

Total EBL

Any other maternal details affecting postnatal recovery

For the placenta: Y N Date Initals

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, 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 to be given to family. Do NOT store in notes. Consider suggesting use of “Remember my baby” photography

Memory box - Please explain contents to parents

Involving siblings or other family members

Religious leader/chaplain for blessing/ support/naming


Care of baby: Y N Date Initals

IMPORTANT - Baby labelled twice with mum AND dad’s

names, mother’s hospital/NHS number

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 Initals

For Rhesus Negative mothers give Anti D 1500iu if fDNA

positive or unknown– do not

wait for Kleihauer results. Make sure prescribed on drug chart

and form filed in notes.

Cabergoline prescribed and given? Over 20 weeks this is

strongly recommended, under 20 weeks at doctor’s discretion

or maternal request but mother must be offered option of

prescription so she can decide

Ensure parents are aware of option to see baby after

discharge - this however is by appointment only. Ensure they

have a contact card for Bereavement Midwife/Lesley Bowles and know to contact Delivery Suite if out of hours.

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 a NHS number for registering the baby legally.

Y N Date Initials

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 with signs of life at any gestation: Even non-viable <24/40

Y N Date Initals

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.

Complete Mortuary Form (Form A)

Medical Certificate Cause of Death (yellow book) to be completed by Doctor who saw baby and issued to parents (see note regarding online Coroner referral)

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 Initals

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

Consent for genetic testing

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


If under 24 weeks: Y N Date Initals

Discharge mother from hospital using admissions and discharges facility on CMiS. Attach letter to PN notes

Copy of discharge letter to Discharge Clipboard on Marsh ward

Handwrite any necessary information such as ERPC etc.

Please ensure pregnancy loss is highlighted

Copy of discharge letter sent by post to GP

Handwrite any necessary information such as ERPC etc.


If over 24 weeks (or neonatal death at any gestation):

Y N Date Initals

Discharge from hospital on computer and print off discharge letters as for normal discharge. Attach to PN notes

Copy of computer discharge letter to Discharge Folder


Copy of computer discharge letter by post to GP


Ensure that Stillbirth/Neonatal Death Certificates issued (if required) and that parents know how and where to register their baby


Discharge checklist for all losses: Y N Date Initals

Bereavement team to inform Health Visiting team by secure email and add EPR flag

Community Midwife informed of discharge – ensure discharge

letter on Discharge clipboard located on Marsh ward.

Inform GP – leave message at surgery if unavailable

Ensure that postnatal notes (for bereaved parents) completed

and that mother takes these home with her. Can be found in

bereavement filing cabinet/cupboard in annexe.

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 Bereavement Midwife contact details have been given

and confirm for parents that Bereavement team will arrange follow up appointment

Notes on discharge: Y N Date Initals

Notes forwarded to Delivery Suite for attention of

Bereavement Midwife / Ward Clerk and placed in 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:



INTENTIONALLY


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 (Tomalin and Son) 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 Tomalin and Son 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)

Bereavement Midwives: 07500 123912 Ward Clerk: 0118 322 7215



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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

Genetics Yes No Undecided Yes No



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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 …………………………………………….



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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

Shared 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 Royal Berkshire Hospital Parents informed ……………………… Reading Berkshire RG1 5AN Date informed ………………………

Requisition No: ………………………



INTENTIONALLY

Care Pathway for women experiencing Mid-trimester ......©RBFT Women experiencing MToP on Delivery...

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