Download 3.2.1 Referral for Antenatal Care

GUIDELINES AND PROTOCOLS RELATING TO THE PROVISION OF
ANTENATAL CARE
Contents
1
2
3
BACKGROUND ............................................................................................................ 2
AIMS AND OBJECTIVES ............................................................................................. 2
MANAGEMENT ............................................................................................................ 2
3.1 RISK ASSESSMENT PROCESS ........................................................................... 2
3.1.1 initial antenatal risk assessment & referral ....................................................... 2
3.1.2 ongoing risk assessment and referral .............................................................. 3
3.2 PATTERN OF ANTENATAL CARE ........................................................................ 3
3.2.1 Referral for Antenatal Care .............................................................................. 4
3.2.2 Schedule of Appointments and care ................................................................ 4
3.2.3 Responsibilities of the different staff groups ..................................................... 8
3.2.4 Weighing in pregnancy ..................................................................................... 8
3.2.5 Smoking in pregnancy ...................................................................................... 8
3.3 MANAGEMENT OF ANTENATAL DEFAULTERS ................................................. 9
3.3.1 Midwife Community Clinic ................................................................................ 9
3.3.2 Missed Hospital Antenatal Clinic Appointments (see Appendix C) ................. 10
3.3.3 Antenatal Day Unit non-attendance ( see Appendix D) ................................. 11
3.3.4 Fetal Assessment Unit ................................................................................... 11
3.3.5 Radiology ....................................................................................................... 11
3.3.6 Maternity assessment centre (MAC) .............................................................. 11
3.3.7 Delivery Suite (Induction of Labour)……………………………………………..12
5 EVIDENCE BASE ....................................................................................................... 12
6 MONITORING COMPLAINCE .................................................................................... 12
Appendix A: Antenatal Care Pathway and Information Guide……………………………….14
Appendix B: Process for referral for newly identified risk factors in the antenatal period....15
Appendix C Antenatal defaulter process (Midwifery clinics / Hospital Consultant Clinics...16
Appendix D: Antenatal Defaulter process (Antenatal Day Unit)……………………………..17
Appendix E: Antenatal Defaulter process (MAC / Antenatal ward)………………………….18
Appendix F: Antenatal Risk Assessment………………………………………………………19
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1
BACKGROUND
“Care during pregnancy should enable a woman to make informed decisions, based on
her needs, having discussed matters fully with the professionals involved” (NICE 2008).
For women with uncomplicated pregnancies, the provision of antenatal care should be
based on the recommendations from the NICE Guidance (2008). The pattern of antenatal
visits outlined within this guideline should be viewed as a minimum baseline with any other
visits arranged according to individual women’s needs and in negotiation with the woman.
Women with complicated pregnancies may require additional care dependant on the
nature of the complication and individual need.
2
AIMS AND OBJECTIVES
The aim of this guideline is to provide a baseline for the clinical care of all women with
uncomplicated pregnancies, and to outline a basic care pathway for women with
complicated pregnancies.
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3.1
MANAGEMENT
RISK ASSESSMENT PROCESS
3.1.1 INITIAL ANTENATAL RISK ASSESSMENT & REFERRAL
Clinical risk assessment is a continuous process undertaken throughout antenatal period
and reviewed again at the onset of labour. A full antenatal booking risk assessment should
be undertaken and documented before 12 completed weeks of pregnancy using the
Antenatal Risk assessment form (appendix F) and a referral sent to the Referral Booking
Service (RBS). This will identify any women with known risk factors. The referral is then
passed to the antenatal clinic where the clinical information is reviewed and triaged by the
midwifery staff regarding the need for, and timing of, any hospital appointments.
The risk assessment includes information about medical conditions to be considered,
including anaesthetic history, factors from previous pregnancies, lifestyle considerations
and women who may decline blood products. It also includes specific risk assessments for
 appropriate place of birth
 perinatal mental health
 venous thromboembolism
The lead professional should be clearly identified on the risk assessment form along with
the date and gestation at which the assessment was completed. The completed risk
assessment form stays in the Hand Held Records.
Women with identified risk factors should be advised to have maternity team based care,
and this will be identified on the risk assessment form. However, if they request either a
homebirth or delivery in the midwife led unit, they should still be referred to the hospital for
further discussions and review by a consultant obstetrician.
Once reviewed by an obstetrician, an individual management plan should be developed
and documented in the woman’s Hand Held record. This should be reviewed at each
antenatal contact and any changes to the plan clearly documented along with the reason
why and a new management plan developed.
2
Women planning a homebirth should have an additional risk assessment undertaken at 36
weeks to ensure that their choice is still appropriate and that all arrangements are in place.
For full details see Homebirth guidelines
3.1.2 ONGOING RISK ASSESSMENT AND REFERRAL
At each antenatal contact, a woman should be reviewed for any additional risks that have
emerged or developed during the pregnancy. Any newly identified risk factors should be
recorded on the Antenatal Risk Assessment form along with any actions undertaken
including change of lead professional.
Actions may include review by a midwife or obstetrician on the Antenatal Day Unit,
Maternity Assessment Centre, Antenatal Clinic or Delivery Suite dependant on the nature
and urgency of the risk factor identified (see appendix B).
Conversely, some risk factors may no longer be present or resolve and care should be
adjusted appropriately including referral back to midwife led care. In this instance, women
should be asked to arrange an appointment with their named community midwife.
The reason for any referral in the antenatal period should be documented in the woman’s
hand held records with additional information provided in a letter if required.
3.2
PATTERN OF ANTENATAL CARE
Recommended Pattern of Care for Women receiving Midwife led care
 Booking Visits (before 12+6 weeks).
 Ultrasound scan for dating at 10-12 weeks gestation
 Antenatal clinic visits at 16, 25, 28, 31, 34, 36, 38, 40, and 41 weeks for
nulliparous women.
 Antenatal clinic visits at 16, 28, 34, 36 , 38, and 41 weeks for parous women.
 Ultrasound scan for fetal anomaly at 20 - 22 weeks gestation.
Recommended Pattern of care for Women receiving Maternity Team based Care
When a woman is referred for maternity team based care at any point in the pregnancy,
the main hospital notes should be made available for review by the Obstetrician. Once a
referral is received, the antenatal clinic administration team will request the main hospital
notes from the medical records department and ensure they are available at each
appointment with an Obstetrician.
An individual management plan will be devised including timing of both hospital and
community visits, however, all women should still have a named named midwife as a point
of contact and to provide on-going support. The named midwife should be identified in the
woman’s Hand Held Record.
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3.2.1 REFERRAL FOR ANTENATAL CARE
Pregnant women wishing to arrange antenatal care usually contact either their GP or a
community midwife. On notification of a pregnancy, an appointment should be offered to
see the community midwife as soon as possible at which time a formal antenatal booking
and risk assessment can be commenced and a referral made to RBS. The aim should be
to complete a full booking visit before 12 completed weeks of pregnancy.
Women who are referred to the maternity service later than 12+6 weeks of pregnancy
should have completed a formal antenatal booking within 2 weeks of referral.
3.2.2 SCHEDULE OF APPOINTMENTS AND CARE
Formal Antenatal Booking
Because of the large volume of information needs in early pregnancy the ‘booking’ visit
may require two appointments. As early in the pregnancy as possible a full antenatal risk
assessment should be undertaken and a referral sent to the Referral Booking Service
(RBS). The referral is then passed to the antenatal clinic where the clinical information is
reviewed and triaged by the midwifery staff regarding the need for, and timing of, any
hospital appointments. If 2 appointments are required to complete the full booking then the
second appointment must take place no later than 2 weeks after the first appointment and
before 12 completed weeks of pregnancy.
Women should be given their Hand Held Maternity Records at the initial appointment.
During the booking process the woman should be given information to enable her to
discuss issues and ask questions.
During the booking process the midwife should:

Record any language difficulties and arrange interpreter (at initial contact)

Test urine to check for proteinuria.

Measure Blood Pressure

Calculate and record BMI (if equipment available)

Take blood for Blood group and Rhesus D (RhD) status with consent*

Offer screening for HIV, Hep B, Haemoglobinopathies, anaemia, rubella
susceptibility and syphilis*

Offer screening for chlamydia (women aged 24 and under)*

Offer screening for Down’s Syndrome*

Complete smoking tracker form
The following topics must be discussed as identified on the Antenatal Care Pathway and
Information Guide (Appendix A).









Screening tests available and Ultrasound Scans
Lifestyle advice (Smoking cessation, drug and alcohol consumption, diet and
exercise)
Benefits of folic acid and vitamin D supplementation
Pattern of antenatal care, place of birth and pregnancy care services available
Mental Health
Domestic Violence
Preparation for parenthood
Breastfeeding
Food Hygiene
4



Minor complaints of pregnancy
Bleeding in pregnancy
Pregnancy Induced Hypertension and need for urinalysis
*any tests should only be undertaken after obtaining informed consent (with the use of
interpreting services if required). All discussions re screening should be documented in the
woman’s hand held records.
Women who refer or are referred to the Maternity service late (after 12 weeks) should have
their full booking completed within 2 weeks of the initial contact visit.. She should be
assessed to determine gestation if unknown and an urgent dating scan arranged.
Screening tests should be discussed and offered based on appropriateness for gestation
once this had been confirmed.
Any migrant woman who has not previously had a full medical examination in the United
Kingdom should be referred to either a GP or obstetrician to have a full medical history
taken and a clinical assessment made of their overall health. Where an interpreter is
required this should be booked by the midwife. Please refer to the Best Practice Guidance
for the use of Interprets within the Maternity Service
16 weeks
All test results received should be documented in the woman’s Hand Held Record and the
woman informed. Any abnormal test results should be explained to the woman and a plan
of care and/or treatment commenced if required. These include:
 Hb of less than 10.5 grams /dl (consider testing folate levels and commencing iron
supplementation, see guideline on management of anaemia).
 Rhesus Negative (Arrange 28 week appointment for Anti D clinic)
 Rubella non immune (document in records for immunisation following delivery)
Abnormal test results for HIV / Hep B / Syphilis and Down’s syndrome screening are sent
to the antenatal clinic and women will be contacted by a member of staff from clinic who
will arrange for any follow up treatment / appointments as required.
Any anomalies detected by ultrasound scan will be referred for medical review and/or an
appointment made to attend the prenatal clinic.
25 weeks (primip only)
 Discuss fetal anomaly scan results and document in the handheld records
 Measure and record in HHR
 . symphysis-fundal height in HHR.
 blood pressure and
 test urine for proteinuria
 Give MATB1 (primip)
28 weeks
 Blood tests for RhD antibodies and anaemia.
 Measure blood pressure and test urine for proteinuria.
 Measure and record symphysis-fundal height in HHR.
 Give MATB1 (multip)
 Ensure breastfeeding checklist completed
5
By 28 weeks the Health Visitor notification of pregnancy form should be completed and
given to the Health Visitor and a record of this made in the cross city folder record
31 weeks (primip only))
 Measure and record in HHR

symphysis-fundal height in HHR.

blood pressure and

test urine for proteinuria.
 Discuss and record blood results (enclosing hard copy if available) in the HHR
 Discuss pattern of fetal movements and when to report any changes
34 weeks
 Measure and record in HHR
 symphysis-fundal height in HHR.
 blood pressure and
 test urine for proteinuria.
 Discuss pattern of fetal movements and when to report any changes
 Discuss bed sharing leaflet and Trust Policy
 Review choice of place of birth. If homebirth requested complete necessary
documentation
36 weeks
 Measure and record in HHR
 symphysis-fundal height in HHR.
 blood pressure and
 test urine for proteinuria
 presentation of the baby. For women whose babies are in the breech position
refer to consultant
 Discuss pattern of fetal movements and when to report any changes
 Discuss labour, birth and coping strategies
 Discuss Breastfeeding
 Discuss Vitamin K Prophylaxis
 Discuss newborn screening tests
38 weeks
 Measure and record in HHR

symphysis-fundal height in HHR.

blood pressure and

test urine for proteinuria

presentation of the baby For women whose babies are in the breech
position refer to consultant
 Discuss pattern of fetal movements and when to report any changes
 Discuss the benefits of a membrane sweep and if agreed and within protocol for
community arrange date and time for this procedure at 40 and 41 weeks (primip) and
41 weeks (multip). This discussion should be supported by a full overall risk
assessment and evaluation of pregnancy. Any woman with identified risk factors should
be referred to a consultant clinic for further assessment
 Check and record Weight (for anaesthetic purposes)
6
40 weeks (primip)
 Measure and record in HHR

symphysis-fundal height in HHR.

blood pressure and

test urine for proteinuria

presentation of the baby
 Discuss pattern of fetal movements and when to report any changes
 Undertake membrane sweep membrane sweep and if agreed and within protocol for
community arrange date and time for this procedure post 41 weeks (multip). This
discussion should be supported by a full overall risk assessment and evaluation of
pregnancy. Any woman with identified risk factors should be referred to a consultant
clinic for further assessment
41 weeks
 Measure and record in HHR
 symphysis-fundal height in HHR.
 blood pressure and
 test urine for proteinuria.
 Discuss pattern of fetal movements and when to report any changes
 Discuss NICE Guidelines for Induction of Labour (NICE 2008)
 Midwife to arrange a date for induction of labour for ‘low risk’ women, where
consultants have agreed that direct booking is appropriate. Otherwise, advice should
be sought when labour has not commenced by this time.
 Perform membrane if agreed with woman sweep and within protocol for community
guideline.
From 42 weeks
Women who decline induction of labour should be offered a consultant appointment.
Consultant would offer antenatal monitoring consisting of increased antenatal monitoring
consisting of at least twice-weekly CTG, and ultrasound estimation of maximum amniotic
pool depth.
Additional Information
While the above is a guideline for practice, women should be advised that they can contact
a midwife for advice and support at any time.
Present NICE guidance (2008) states that abdominal palpation for fetal presentation
should not be offered prior to 36 weeks due to its inaccuracy and the discomfort it may
cause. However many women like to know the position their baby is in. Therefore,
midwives may palpate as long as women are aware of the possible inaccuracy and
discomfort of the procedure.
NICE (2008) states that auscultation of the fetal heart may confirm that the fetus is alive
but is unlikely to have any predicative value and routine listening is not recommended.
However, the majority of women like to hear their baby’s heartbeat and therefore midwives
can provide this service at the request of the mother. If the fetal heart is auscultated, the
rate should be documented in the hand held records.
7
NICE (2008) do not recommend women are routinely advised to monitor frequency of
foetal movements. Any discussion about fetal movements and what is classed as normal
should be documented din the woman’s hand held records.
Haematology, Pathology and Ultrasound Scan Requests

The midwife is responsible for ensuring that the request forms are completed
correctly, and includes the GPs name and surgery code.

The midwife taking the blood must complete all blood request forms at the time the
sample is taken. (a Maternity Support Worker can complete the form but this must be
signed by a midwife or GP

Copies of the results will be sent to the named midwife or GP surgery. The midwife
will be responsible for informing either the general practitioner or consultant, once
she is aware, in cases of abnormal results.
There must be no delay by any midwife, once she is aware, in seeking medical assistance
and ensuring appropriate measures are in place to deal with problems arising.
3.2.3 RESPONSIBILITIES OF THE DIFFERENT STAFF GROUPS
Midwife
The midwife is responsible for undertaking the initial booking and risk assessment which
includes identifying women with any risk factors that would require medical review. The
midwife is also responsible for sending the referral form to Referral and Booking Service.
The midwife is also responsible for following up any women miss any antenatal
appointments and maintaining a record of missed appointments. This may be the hospital
midwife or community midwife depending on the appointment missed.
Obsteterician
The obstetrician should review all women with an identified risk factors and develop an
individual management plan which should be documented clearly in the hand held records
and reviewed at each antenatal contact.
Ultrasonographer
The ultrasonographer is responsible for reporting any women who miss a scan
appointment to the midwife in charge of clinic for appropriate follow up.
3.2.4 WEIGHING IN PREGNANCY
Accurate assessment of body mass index (BMI) is essential in any pregnant woman and
should be performed at first contact. Maternal weight and height should be measured (selfreported weight is not acceptable) and the woman’s body mass index should be calculated
and documented in the woman’s hand held records (weight [kg]/height[m] 2), the antenatal
risk assessment form and the antenatal referral form.
If unable to calculate a BMI due to equipment weight capacity i.e. the woman is heavier
than 150kgs, then access to bariatric weighing scales can be arranged via Outpatient
services
Repeated weighing during pregnancy should be confined to circumstances where clinical
management is likely to be influenced. It is useful to undertake a further weighing at 38
weeks which can be used for anaesthetic purposes if required.
3.2.5 SMOKING IN PREGNANCY
8
At the first contact visit, the woman’s smoking status should be discussed with her and if
she smokes then she should be informed about the risks of smoking on the unborn child
(low birth weight babies / preterm labour) and the hazards of exposure to second hand
smoke.
3.3
MANAGEMENT OF ANTENATAL DEFAULTERS
National reports highlight that women who die during pregnancy are more likely to book
after 24 weeks or to have missed over 4 antenatal appointments. Ethnic groups other than
white, who speak little or no English, are twice as likely to die as others, whilst women from
disadvantaged groups are 20 times more likely to die than those women in the top 2
groups. Other groups of women at risk are also those from the travelling community, those
who are subject to domestic violence, asylum seekers, and the under 18’s. These are the
groups of women who are also most likely not to attend for antenatal care. These groups
considered at high risk should be monitored regarding their attendance for antenatal care.
Outlined below are the processes in place to ensure that women who miss appointments
are followed up and seen.
3.3.1 MIDWIFE COMMUNITY CLINIC
At booking the midwife should plan how care will be provided with the woman and
document this in her notes. Women should understand the importance of attending the
antenatal clinic during pregnancy and if there are any perceived problems with attending
appointments these should be discussed and alternative arrangements made.
It is the responsibility of the woman to inform the Midwife, GP and hospital of any change
of address; this needs to be highlighted at the booking interview. If this information is not
updated on the IT systems it will impact on maternity care provision in the community for
all health professionals but particularly community midwives and health visitors.
Each midwife should use the Cross City Care Summary Form to keep a record of all
women booked. This summary is to form the basis of the community midwives register and
should be taken to the antenatal clinics. Should a woman miss their appointment this must
be recorded on the Cross City Care Summary Form including the action taken.
Following the booking appointment the midwife must make the first antenatal clinic
appointment to ensure the woman is in the ‘system’. This will enable the midwife to make
the appropriate follow up should she not attend.
For a woman viewed as vulnerable and those women who access services late in
pregnancy it is essential that continuity is maintained. Wherever possible to facilitate this,
care should be continued by the booking midwife.
3.3.1.1 FIRST MISSED ANTENATAL APPOINTMENT - (SEE APPENDIX C)

Midwife to check with GP/hospital if still pregnant, not an inpatient, and if
details are correct

Midwife to telephone with further appointment or post if unable to speak to or
not on telephone

If able to speak with woman, identify reasons for non-attendance

The use of a professional translation service must be sought where there are
communication issues
9

Record missed appointment in midwives own record of attendances either at
the GP’s or Drop In Centre diary or in hospital notes depending upon the site
of the appointment.
3.3.1.2 SECOND CONSECUTIVE MISSED APPOINTMENT - (SEE APPENDIX C)

Midwife to check with GP/hospital if still pregnant, not an inpatient, and if
details are correct

Discuss with GP and Health Visitor and notify in writing that the 2
appointments have been missed

Community Midwife to visit the known address as soon as possible with
further appointment, identify reasons for non-attendance. If the woman is not
in then one further attempt should be made to visit.*

Formulate individual plan of care if appropriate offer alternative venue i.e.
Drop In centre

Offer full antenatal assessment

Document discussion and assessment in hand held record or hospital
records

If still unable to contact - record missed appointment, in midwives own record
of attendances either at the GP’s or Drop In Centre diary. A further
appointment should be sent to the known address. Complete Communication
form and identify all actions taken
Every possible action should be taken to ensure that women who miss 2 or more
consecutive appointments are followed up and seen. All attempts to make contact should
be documented in the Cross City Care Summary Form.
This guidance is written assuming non-attendance at consecutive appointments. Where
there is sporadic non-attendance the midwife should follow from point 4, and complete
Communication Form if a pattern is emerging
3.3.2 MISSED HOSPITAL ANTENATAL CLINIC APPOINTMENTS (SEE APPENDIX C)
3.3.2.1 FIRST MISSED HOSPITAL ANTENATAL CLINIC APPOINTMENT
 If a woman misses a hospital antenatal clinic appoint on one occasion
administrative staff check with EPU that a failed pregnancy has not occurred.
 Re-send a new appointment for the following weeks’ clinic.
 If the pregnancy has failed staff record on the IT system that no further
appointments to be sent.
 Antenatal clinic midwife to document actions in defaulter diary/ folder
3.3.2.2 SECOND CONSECUTIVE MISSED APPOINTMENT
 Midwife to check on system that woman still pregnant
 Antenatal clinic midwife to inform community midwife and ask to visit woman
 Community Midwife to visit the known address as soon as possible with further
appointment, identify reasons for non-attendance. If the woman is not in then one
further attempt should be made to visit.
 Formulate individual plan of care if appropriate offer alternative venue i.e. Drop In
centre
10





Offer full antenatal assessment
Document discussion and assessment in hand held record.
If still unable to contact - record missed appointment, in midwives own record of
attendances either at the GP’s or Drop In Centre diary or hospital notes depending
upon the site of the appointment. A further appointment should be sent to the known
address. Complete Communication form and identify all actions taken
Inform antenatal clinic team leader of actions using defaulter notification form
Antenatal team leader complete actions in defaulter diary/ folder)
3.3.3 ANTENATAL DAY UNIT NON-ATTENDANCE ( SEE APPENDIX D)
3.3.3.1 FIRST MISSED APPOINTMENT
 Midwife to check on PAS system any recent activity (admission to MAC, Ward or
Delivery Suite). Check all details correct. Check still pregnant.
 Midwife to telephone with further ANDC appointment or arrange admission to MAC/
Antenatal Ward or Delivery Suite if urgent or if ANDU is closed.
 If unable to contact or no phone number available, ANDU Midwife to contact
Community Midwife by phone to arrange a further appointment, home visit or
hospital admission depending on risk identified.
 If able to speak with the woman, identify reasons for non-attendance and arrange
further appointment
 Use appropriate translator if required for effective communication
 Record missed appointments in hospital records or document on ANDU yellow
attendance sheet. Place in ANDU file under DNA
3.3.3.2 SECOND MISSED APPOINTMENT
 Repeat as for first appointment
 Arrange community midwife home visit to known address as soon as possible to
offer full antenatal assessment of risk and formulate an individual plan of care
(follow process for second missed appointment from * in section 3.3.2.2)
3.3.4 FETAL ASSESSMENT UNIT
If a woman does not attend - inform staff in antenatal clinic and follow process for missed
appointment in antenatal clinic.
3.3.5 RADIOLOGY
Radiology staff compile daily list of non attenders and send to antenatal clinic. Antenatal
clinic follow process for missed appointment in antenatal clinic.
3.3.6 MATERNITY ASSESSMENT CENTRE (MAC)
3.3.6.1 FIRST MISSED APPOINTMENT
 Midwife to check on PAS system any recent activity (admission to MAC, Ward or
Delivery Suite). Check all details correct. Check still pregnant.
 Midwife to telephone with further appointment or arrange admission or Delivery
Suite if urgent.
 If unable to contact or no phone number available, Midwife to contact Community
Midwife by phone to arrange a further appointment, home visit or hospital admission
depending on risk identified.
11



If able to speak with the woman, identify reasons for non-attendance and arrange
further appointment
Use appropriate translator if required for effective communication
Record missed appointments in MAC SBAR book
3.3.6.2 SECOND MISSED APPOINTMENT
 Repeat as for first appointment
 Arrange community midwife home visit to known address as soon as possible to
offer full antenatal assessment of risk and formulate an individual plan of care
(follow process for second missed appointment from * in section 3.3.2.2
3.3.7 DELIVERY SUITE (WOMEN BOOKED FOR INDUCTION OF LABOUR)
 Midwife to check on PAS system any recent activity (admission to MAC or Ward).
Check all details correct. Check still pregnant.
 Midwife to telephone to arrange admission
 If unable to contact or no phone number available, Midwife to contact Community
Midwife by phone to arrange for woman to come in
 If able to speak with the woman, identify reasons for non-attendance and arrange to
come in
 Use appropriate translator if required for effective communication
 Record missed appointments in Delivery suite SBAR telephone contact book
4
EVIDENCE BASE
(1) National Institute of Clinical Excellence (2008) Induction of Labour. NICE: London
(2) National Institute of Clinical Excellence (2008) Antenatal care: Routine care for
the healthy pregnant woman. NICE London.
(3) NHSLA (2009) CNST Maternity Clinical Risk Management Standards
Also refer to the following Guidelines / Protocols:The management of anaemia during Pregnancy and the Postnatal Period
The management of induction of labour in post term low risk women (membrane sweep)
5
MONITORING COMPLAINCE
An audit will be carried out in accordance with the Maternity services Audit Plan. Audit
criteria include:
 Number of women booked before 12 completed weeks of pregnancy
 Number of women booked after 12+6 weeks gestation seen within 2 weeks of
referral
 All migrant women who have not had full medical examination have medical
history taken and clinical assessment made of their overall health (interpreter used
where required)
 Health records available for all women when required
 Compliance with guideline in relation to follow up of women who fail to attend
antenatal appointments
 Timing and completion of antenatal risk assessments
 referral for women with identified risks
12


Development of an individual management plan for women with identified risks
Documentation of above
Audit results will be presented at the Women’s Services Clinical Governance and Audit
meeting and an action plan developed as necessary. A lead will be appointed for
monitoring of the action plan, including re-audit, and the status of the action plan reported
to the Women’s Services Clinical Governance and Risk management Forum
WSCG&RMF) quarterly. Audit results will be included in the Maternity Quarterly risk
management report and any resulting changes disseminated via the Maternity Services
Forum, Team Leaders Forum, and Supervisors Forum.
13
Appendix A
Antenatal Care Pathway and Information Guide
Weeks
Primip
Multip
Action
Complete Risk
Assessment
including choice
of place of birth
BMI
Formal
antenatal
booking


Bloods
BP check
Urinalysis
Information

Signature
Screening Tests and USS
Lifestyle advice (Smoking cessation,
drug and alcohol consumption)
Folic Acid supplementation
PIH and urinalysis
Domestic Violence
Breastfeeding
General information that may also be
included
Food hygiene
Minor complaints
Bleeding in Pregnancy
Birth preparation
Diet and Vit D supplementation
Exercise (including pelvic floor)
For further information see
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107302
11+0Dating Scan +/- Combined screening test
13+6
BP
Discuss and record blood test results


16
Urinalysis
20
Anomaly Scan
SFH, BP,
MATB1
25

Urinalysis
SFH, BP,
MATB1 (Multip)
Urinalysis
Ensure breastfeeding checklist


28
Rhesus Bloods,
completed
FBC
SFH, BP,
31

Urinalysis
SFH, BP,
Discuss Bed Sharing leaflet and Trust policy
34


Urinalysis
Review choice of place of birth
SFH, BP,
Discuss labour, birth and coping
Urinalysis
strategies (Birth Plan)


36
Check
Breastfeeding Information
presentation
Vit K prophylaxis
Newborn screening tests
38


SFH, BP,
Arrange post dates appointment and discuss IOL and
14
40

41
weeks


Urinalysis
SFH, BP,
Urinalysis
membrane sweep (M)
Arrange post dates appointment and discuss IOL and
membrane sweep(P)
SFH, BP,
Urinalysis
Perform membrane sweep and book hospital induction
15
Appendix B: Process for referral for newly identified risk factors in the antenatal period
Urgent Referrals (consider admission to MAC / Delivery Suite or ANDU)
Reasons for urgent referral include:
 Antepartum haemorrhage
 Reduced fetal movements
 Hypertension
 Premature rupture of membranes
 Hyperemesis
 Premature labour
 Any urgent clinical concerns requiring medical review
The midwife can discuss the case with the on call Obstetric Consultant if necessary who
can be contacted via switchboard (LGI 0113 243 2799 / SJUH 0113 243 3144)
Non urgent referral
Timing of non urgent referrals depends on the nature of the problem. When a referral to
maternity team care is indicated, the midwife should discuss the situation with the woman,
advising her of the need for an obstetric opinion and a suitable appointment arranged.
 If the woman refuses the advice to transfer her care then the midwife will continue to
provide the care, and discuss the case with the supervisor of midwives and a senior
obstetrician (ST3 or above).
 The midwife will document, in full, the discussion with the woman and the outcome.
16
Appendix C
Antenatal defaulter process (Midwifery Clinics and Hospital Consultant clinic)
DNA Midwifery Clinic
DNA Consultant Clinic
Confirm still pregnant via EPU
No


Yes
Cancel further
appointments
Inform GP and HV
Midwifery Clinic


Hospital AN Clinic
1st missed appointment
Telephone with further appointment
(or post)
Record missed appointment on
cross city summary form


2nd Missed appointment
Inform Community Midwife to
follow process from *
2nd consecutive missed appointment *
 Visit known address with further
appointment
 Identify reason for non attendance
 Offer AN assessment
 Formulate plan of care
If not at address one
further appointment
to be made

1st missed appointment
Send repeat appointment
Document in defaulter diary /
folder


Document in cross city summary
form
Inform GP / HV
Complete communication form


Disucss with Team Leader
Consider referral to social services
17
Appendix D Antenatal defaulter process (Antenatal day Unit (ANDU)
Antenatal defaulter process pathway fro Antenatal day Unit (ANDU)
DNA Antenatal day Unit




1st Episode
Midwife to check on PAS system for any recent
activity (Admission to MAC, ward or Delivery Suite)
Check all details are correct
Check if still pregnant
Midwife to telephone with further ANDU appointment
or arrange immediate admission to MAC / AN ward /
Delivery Suite if urgent or if ANDU closed
If unable to contact or no phone number available,
ANDU Midwife to contact Community Midwife by phone
to arrange a further appointment, home visit or hospital
admission on risk identified
If able to speak with the woman, identify reason for non
attendance and arrange further appointment
Use appropriate translator if required for effective
communication
Record missed appointments in hospital records (if
available) or document on ANDU yellow attendance
sheet
Place in ANDU file under DNA
2nd Missed Episode



Repeat as above
Arrange Community Midwife home visit to known
address as soon as possible
Offer full antenatal assessment and formulate
individual pan of care (refer to AN Defaulter
pathway for Midwifery clinics and Hospital
Consultant Clinics from *)
18
Appendix E
PROVENANCE
Antenatal defaulter process pathway from Maternity Assessment Centre
DNA Maternity Assessment
Centre




1st Episode
Midwife to check on PAS system for any recent
activity (Admission to MAC, ward or Delivery Suite)
Check all details are correct
Check if still pregnant
Midwife to telephone with further appointment or
arrange immediate admission to MAC / AN ward /
Delivery Suite if urgent
If unable to contact or no phone number available,
Midwife to contact Community Midwife by phone to
arrange a further appointment, home visit or hospital
admission on risk identified
If able to speak with the woman, identify reason for non
attendance and arrange further appointment
Use appropriate translator if required for effective
communication
Record missed appointments in hospital records (if
available) or document in MAC SBAR book
2nd Missed Episode



Repeat as above
Arrange Community Midwife home visit to known
address as soon as possible
Offer full antenatal assessment and formulate
individual pan of care (refer to AN Defaulter
pathway for Midwifery clinics and Hospital
Consultant Clinics from *)
19
Addressograph
Appendix F - Antenatal Risk Assessment
A full risk assessment must be undertaken and documented at booking. In addition, if any new risks emerge or are identified
during the antenatal period they should be documented in the table below. The lead professional will only change if the
woman has been reviewed by an obstetrician and this is identified in the plan of care
Advice given re flu vaccine uptake during seasonal flu campaign
Date advice given
Signature and designation
Date
Gestation
Risk(s) identified
Action taken
Lead Professional
Signature
Print Name
(if any)
Document reason (circle to indicate)
for referral to anc
1st
Booking
contact Gestation
MLC / MTC
(weeks)
PBR Pathway Please tick one option:
Standard ☐
Intermediate ☐
Intensive ☐
MLC / MTC
MLC / MTC
MLC / MTC
MLC / MTC
MLC / MTC
MLC / MTC
20
21
Addressograph
INITIAL FULL BOOKING ANTENATAL RISK ASSESSMENT
Consultant appointment if indicated at approximately 12 weeks and with dating scan
If Immediate Consultant appointment required - next available consultant clinic
(Please indicate on referral form)
Booked
Antenatal Care
Midwife Led Care
Maternity Team Care
Named
Midwife
Named Consultant
Midwifery Team Name
Discussion on venues for antenatal care
Children’s Centre (please state)
Health centre (please state)
Initial preferred
choice of venue
GP Surgery (please state
Hospital
SJUH
LGI
Other i.e. trust / Hospital (please state)
Initial discussion on Choice of Place of Birth
Initial preferred choice
of place of birth:
Home
SJUH
Other (please specify)
LGI
Name of booking Midwife
Cross border care - Please specify which midwifery
service will provide PN Care
Signature of booking midwife
Date
THIRD TRIMESTER REVIEW
Review of choice of
place of birth
Home
Date
SJUH
LGI
Signed
Other (please specify)
Designation
The following require a review at 36-38 weeks with Obstetrician to discuss timing of birth:

Comment
Previous shoulder dystocia
Previous late stillbirth / neonatal
death
Previous abruption
Primigravida with maternal age >40
22
Reviewed by
PAST MEDICAL / SURGICAL HISTORY
Risk
No
RISK FACTOR
1
Smoking
2
Cardiovascular disease
3
Liver/Renal disease- including
unexplained proteinuria
(see Current Pregnancy)
4
Epilepsy
(On medication and/or confirmed
diagnosis within last 12 months)
Diabetes/Gestational Diabetes
5
6
7
8
9
10
11a
11b
12
13
Family history of Diabetes in first
degree relative
Endocrine disease eg thyroid
Any chronic disease requiring
prescribed drugs
Auto Immune Disease under the care of
Rheumatologist
Gastrointestinal disease
eg Crohns, ulcerative colitis
Haemoglobinopathies
Venous Thromboembolism
Please complete VTE Risk Assessment
at back of booklet
Other haematologic conditions (eg
haemophilia, thrombocytopaenia less
than 100 x109 on booking bloods
Skeletal abnormality including
previous fracture of pelvis
Previous uterine surgery ie,
MANAGEMENT
Complete FAB form and refer to FAB services if
woman ready to quit. Ensure women have contact
numbers for self-referral. Check smoking status at
each antenatal visit
Immediate Consultant appointment to plan
appropriate care. Possible referral to Cardiac Clinic
If prosthetic heart valve for urgent discussion
regarding anticoagulation regime/ follow up with an
on call consultant
Consultant appointment to plan appropriate care
LGI- Refer to J.Tay
SJH Refer to Medical/Obstetric Epilepsy Clinic
at booking- ask woman to be accompanied to joint
clinic by someone who witnesses seizures if possible
Refer to joint Medical/Obstetric Diabetic Clinic
immediately
Please follow GTT screening criteria - please
note in Special Instructions in notes
All women (LGI and SJUH) to be referred to Joint
Endocrine ANC (SJUH) within 7-14 days of booking.
If thyroid take blood sample at booking for TFT, TSH
- result then available for joint clinic
Consultant appointment to plan appropriate care
Consultant appointment to plan appropriate care
SJH refer to J.Shillito LGI refer to any Consultant
Consultant appointment to plan appropriate care
Screen partner and refer to Antenatal Screening
Coordinator. Refer to Obstetric Haematology Clinic if
woman has Thalassaemia Major or Sickle Cell
Disease
-(not if Sickle Cell trait)
Personal history of DVT - Consultant appointment to
plan appropriate care
Personal history of PE - Refer to Obstetric
Haematology Clinic
Family history of VTE - Consultant appointment
Refer to Obstetric Haematology Clinic
Consultant appointment to plan appropriate care
Consultant appointment to plan appropriate care
23
()
if risk
present
myomectomy
14
15
16
17
Neurological disorders
Respiratory disorders including TB
Asthma -requiring oral steroid therapy /
hospital admission
Any previous anaesthetic problemregional/general
Current or past history of malignant
disease
Consultant appointment to plan appropriate care
Consultant appointment to plan appropriate care
Referral for anaesthetic opinion during pregnancy
Consultant appointment to plan appropriate care
PREVIOUS OBSTETRIC HISTORY
18
Previous Eclampsia, pre-eclampsia,
HELPP syndrome or unexplained
hypertension.
19
Previous LSCS
Consultant appointment to plan appropriate care
Previous stillbirth/NND
Consultant appointment to agree plan & gestation for
birth. Also complete third trimester review on
pge 2
20
21
22
23
24
Any previous child with a mental or
physical disability ie cerebral palsy
Any previous child with a congenital
abnormality or significant family history
Recurrent miscarriages ie 3 under 12
weeks gestation.
One mid trimester loss
Previous preterm delivery <37weeks
Previous cervical/ uterine surgery e.g.
LLETZ or formal cone knife biopsy (not
24a
single treatment or colposcopy)
Gynae medical history
25
26
27
28
29
30
Previous cervical suture
Rhesus disease or other significant
blood group antibodies
Perinatal mental health
- Puerperal psychosis or postnatal
depression requiring medication
- psychiatric disorder (on medication)
- eating disorders
Any previous small baby
ie <5th centile or < 2500gms
Any previous large baby
ie >95th centile or >4500gms
Previous shoulder dystocia
Consultant referral
Consultant appointment
Refer to Fetal medicine Clinic
Consultant appointment and referral by midwife of all
women to Recurrent Miscarriage Clinic at SJH
Refer to Consultant
Prev delivery <32 weeks – Consultant referral consider referral to prematurity clinic
Consultant appointment - for speculum examination
and HVS/IECS to determine requirement for cervical
scans
Consultant appointment +/- referral to Prematurity
clinic/early consultant appointment. Refer by 10
weeks
Consultant referral.
Screen for antibody titres
Complete perinatal mental health risk assessment at
back of booklet
Consultant referral
Refer to relevant agencies ie mental health team,
Pregnancy support midwife, Social Services
Consultant appointment
Consultant referral
Screening for Gestational Diabetes
Consultant referral - For individualised care plan &
agee gestation for birth. Also requires third
trimester review - complete section on page 2
24
31
Previous 3rd/4th degree tear
Consultant referral
32
Significant APH or PPH
APH/ placental abruption -requiring
transfusion or necessitating delivery.
PPH if required transfusion
Consultant referral - also requires third trimester
review - complete section on page 2
CURRENT PREGNANCY
33
High BMI
BMI 30-34 Book GTT for 26 weeks
BMI 35-39 (Obese) refer for GTT- advise Maternity
Team Care BMI > 40 (Morbidly Obese) refer to
consultant - advise enhanced Midwifery Care
Pathway
Refer to Anaesthetist/ book GTT at 16 & 26 wks
34
Unexplained proteinuria (with/without
hypertension)
ie 1+ protein on more than 2 occasions
after 20 weeks gestation
35
Hypertension.
If diastolic>90 or systolic>160, Consultant referral
and refer to Antenatal Day Unit if > 26 weeks
36
Multiple pregnancy
Immediate consultant referral
LGI or SJUH refer to Multiple Pregnancy Clinic
following diagnosis
37
Para 6 or above
Consultant referral if midwife has any concerns or
history of previous 3rd stage complications.
38
Maternal age- > 40 if primigravida
Consultant referral for appropriate screening and
growth scans. Also requires third trimester
review - complete section on page 2
39
Female circumcision
Consultant referral to FGM Clinic
Every Wednesday at SJUH
Consultant referral
Consultant referral if:
a) history of Haemolytic disease
b)antibodies of 4IU/ml c) titre of 1:32 or greater
d)rapidly rising titre if found refer to Fetal Medicine
Clinic
Consultant referral
40
Atypical antibodies known to cause
Haemolytic Disease of the Newborn
41
Bloodborn virus ie HIV,
Hep B, Hep C.
42
Uterine anomaly known or identified in
this pregnancy including fibroids
Consultant referral
43
Concerns re mode of delivery including
previous difficult instrumental delivery
Consultant referral
44
IVF pregnancy
Consultant referral for growth scans & term
appointment
45
Child protection concerns
Inform senior nurse child protection
Complete communication form, follow Trust
25
guidelines
Possible referral to social services
46
Maternal age 17 or under
If age 17 or under referral to teenage pregnancy
midwives and then must be Maternity Team Care in
pregnancy
If 18 follow enhanced teenage care pathway for age
group
Housing:
Household members – please list:
Address for post delivery:
Name, DOB and address of baby’s father:
47
Social circumstances
(Teenage Pregnancy)
48
Asylum Seeker / Refugee / Homeless
49
Drug / alcohol misuse
50
Domestic Violence
51
DNA (Did not attend)
52
53
Moral objection to receiving
Blood products
Any other risk factor not already
identified
54
Learning Difficulties/ Disability
55
Surrogate pregnancy
Other agency involvement:
Please complete above and refer to teenage care
pathway
Refer to Haamla Midwifery Team,
Refer to specialist consultant clinic
Refer to specialist midwife, other agencies and
health professionals where appropriate
Complete communication form
Document follow Domestic Violence Guideline
Follow guidance relating to DNA’s in the Protocols
relating to the Provison of Antenatal Care
Guideline
Refer to consultant
Patient can obtain form from meeting house
Consult with obstetrician / ANC to detemrione
appropriate referral pathway
Complete LD trigger list and pathway. Discuss with
community team leader
Refer to antenatal clinic team leader
26
Protocols Relating to the Provision of Antenatal Care
Author(s)
Paula Jenkins (Risk Management Midwife, SJUH, ext 65367)
Contact name
Paula Jenkins (Risk Management Midwife, SJUH, ext 65367)
Approval process Maternity Services Forum (previously Women’s Services Governance and
for amendments
Risk Forum)
December 2009 (LHP version 1.0)
Amalgamation of:
 Guidelines for the Provision of Antenatal Care , Author: Paula Jenkins (Risk
Management Midwife), Publication July 2007
 Management of Antenatal Defaulters , Author: Jean Milner (CNST Support
Midwife)Publication May 2006
First Issue Date
Version no:
LHP Version 3.0
Review Date:
June 2015
Women’s service Clinical Governance and Risk Management Forum (LHP
version 1.0 October 09)
Amendments approved by MSF (22/06/2012 LHP version 3.0)
Approved and
Ratified by
Consultation Process
Maternity Services Guideline Group / Maternity Services Forum, Maternity Services Governance
and Risk Forum / Obstetricians / Team Leaders / Supervisors of Midwives
Scope of guidance
Clinical
P
condition
Patient Group
Professional
Group
Distribution
List
Pregnant women
All pregnant women booked to deliver within the Leeds teaching Hospitals NHS
Trust
All Health Care Professionals involved in the provision of antenatal care within
the Leeds Teaching Hospitals NHS Trust
All Obstetricians within the Women and Children's Division.
Lead Clinician (Midwifery and Neonates)
Head of Midwifery
Matrons (midwifery and neonatal)
Clinical Midwifery Team Leaders (for distribution to midwives within their areas)
Dissemination Via Risk Management Midwife
Audit and
Monitoring
Will be carried out in accordance with Maternity Services Audit Plan
Broad Recommendations
All pregnant women should be offered a high standard of antenatal care based on the best
available evidence
Equity and Diversity
Leeds Teaching Hospitals NHS Trust believes in fairness, equity and above all values diversity in
all dealings, both as providers of health services and employers of people. The Trust is committed
to eliminating discrimination on the basis of gender, age, disability, race, religion, sexuality or
social class. We aim to provide accessible services, delivered in a way that respects the needs of
27
each individual and does not exclude anyone. By demonstrating these beliefs the Trust aims to
ensure that it develops a healthcare workforce that is diverse, non discriminatory and appropriate
to deliver modern healthcare.
28