Maternity Services Care Pathways
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Transcript of 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 care
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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1 Pre-pregnancy care
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
for 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
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
11 Pre-existing medical, surgical and/or psychiatric conditions
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 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
o ffer advice on folic acid and appropriate dose
c onsider specialist advice
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1 Pre-pregnancy care
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
for further information refer to the NICE mental health guidance
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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1 Pre-pregnancy care
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.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
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.
1 Pre-pregnancy care
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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.
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.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
1 Pre-pregnancy care
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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
25 weeks appointment
28 weeks appointment
31 weeks appointment
34 weeks appointment
36 weeks appointment
38 weeks appointment
40 weeks appointment
41 weeks appointment
Consider all of the
following
42 weeks appointment
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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2 Commissioning antenatal care
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
Associated maternity standards:
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 21: choice and appropriate care
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
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 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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2 Commissioning antenatal care
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
4 Consider all of the following
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
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
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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2 Commissioning antenatal care
c onsider additional information, care and treatment and refer to primary or specialist services according to individual need,ensuring woman continues on maternity pathway
8 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, 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
for further information refer to the NICE mental health guidance
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
for further information refer to the NICE mental health guidance
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
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
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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2 Commissioning antenatal care
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
screen and refer according to individual need, ensuring woman continues on maternity pathway
g ive specific information on:t he routine anomaly scan and refer as appropriate for:
abnormalities related to pregnancy abnormalities not related to pregnancy
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
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
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
12 25 weeks appointment
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
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
13 28 weeks appointment
Quick info:
screen and refer according to individual need, ensuring woman continues on maternity pathway
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)
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
14 31 weeks appointment
Quick info:
review, discuss and record the results of screening tests undertaken at 28 weeks
screen and refer according to individual need, ensuring woman continues on maternity pathway
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
15 34 weeks appointment
Quick info:
review, discuss and record the results of screening tests undertaken at 28 weeks
screen and refer according to individual need, ensuring woman continues on maternity pathway
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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2 Commissioning antenatal care
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
16 36 weeks appointment
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
17 38 weeks appointment
Quick info:
screen and refer according to individual need, ensuring woman continues on maternity pathway
g ive specific information on options for management of prolonged pregnancy
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
18 40 weeks appointment
Quick info:
screen and refer according to individual need, ensuring woman continues on maternity pathway
d iscuss further management of prolonged pregnancy
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
19 41 weeks appointment
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
be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
20 42 weeks appointment
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
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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2 Commissioning antenatal care
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.
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
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
25 weeks appointment 1, 8
28 weeks appointment 1, 8
31 weeks appointment 1, 8
34 weeks appointment 1, 8
36 weeks appointment 1, 8
38 weeks appointment 1, 8
40 weeks appointment 1, 8
41 weeks appointment 1, 8
42 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
This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice
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2 Commissioning antenatal care
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.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
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/CG37
5 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.
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.
http://www.nice.org.uk/CG63
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.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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3 Commissioning intrapartum care
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3 Commissioning intrapartum care
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
Associated maternity standards:
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 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 28: child protection and safeguarding babies
standard 29: infection prevention and control
standard 30: staffing
appendix 1: intrapartum care
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 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
undertake continuous risk assessment
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
undertake continuous risk assessment
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:
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
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
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_4089111
3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
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/CG37
5 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.
http://www.nice.org.uk/CG55
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ID Reference
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/CG457 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.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.
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 communitypublic health nurses. London: 2008.
http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177
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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
Associated maternity standards:
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 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 28: child protection and safeguarding babies standard 29: infection prevention and control
standard 30: staffing
2 The Pregnancy Care Planner and the Pregnancy Book
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
4 Consider all of the following
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
for information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook
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
for information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook
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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.
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
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
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.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
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/CG37
4 Commissioning postnatal care
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ID Reference
5 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.
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
diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63).
London: 2008.
http://www.nice.org.uk/CG63
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.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.aspx11 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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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