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A Framework for maternity services in Scotland

Pregnancy

photoThis section addresses the 9 months of pregnancy and the importance of involving all women and their partners in planning their care, with an emphasis on continuity of care and high quality relevant information.

Principle 4

Maternity services should provide a woman and family-centred, locally accessible, midwife-managed, comprehensive and effective model of care during pregnancy with clear evidence of joint working between primary, secondary and tertiary services.

 

Local Action

Level I

Community based care, midwife managed.

Level IIa

Community based care from midwife, GP or obstetrician.

Level IIb

Maternity Unit based care from obstetrician linking with GP and midwife.

Level III

Tertiary maternity unit based care from specialist consultant in maternal fetal medicine.

 

Table 13 Incremental approach to antenatal care

Level of care

Lead professional

Location of care

Clinical category

Care delivered

Investigation and location

I

Midwife (exceptionally GP)

Community/ Home as appropriate

Normal Pregnancy

Booking, health screening, supportive education, discussion regarding choice of care, general antenatal care, recognition of the abnormal pregnancy and onward referral

Routine booking and dating ultrasound

Home, community clinic or maternity unit

IIa

Midwife or GP or Consultant

Community Clinic

Women with a low or high risk pregnancy

Routine antenatal care, ambulatory antenatal advice and care for high risk pregnancy, discussion regarding ongoing care

Biophysical assessment of fetal growth and well-being

Community clinic or or maternity unit

IIb

Consultant Obstetrician ( GP/Midwife)

Maternity Unit

Women with a high risk pregnancy

Specialist antenatal care

Maternal fetal assessment including ultrasound scanning and biophysical assessment

Maternity unit, maternal fetal assessment unit, day care or antenatal in-patient ward

III

Specialist consultant in maternal fetal medicine

Tertiary maternity unit

Women with a complex or very high risk pregnancy

Highly specialist and intensive antenatal care and surveillance of mother and fetus, discussion and planning of delivery

Complex ultrasonography, fetal therapy and maternal biophysical assessment

Maternity unit, Fetal Medicine Department, day care/in-patient ward

 

Table 14 Antenatal care for first time mothers

Gestation
(weeks)

Routine/ abnormal

Carer

Location of care

Information requirements

Contenof care

Investigations

Ongoing management

8-14

R

Midwife (GP)

Home/ Community clinic

Pre-booking, screening, choice and options for type and location of care, booking including parent education and parenting skills, infant feeding, lifestyle,health promotion and education, substance misuse, domestic violence, post-natal depression. Articulation of women's requirements and wishes, including birth plan.

Booking visit including medical, obstetric and gynaecological history. Blood pressure, physical examination

Calculate expected date of delivery, booking bloods, full blood count and group, venereal disease reference laboratory, Hepatitis B, Rubella, HIV, urinalysis, dating ultrasound

Options for continuing care and care plan

<12

Ab

Consultant

Maternity unit

Bleeding in early pregnancy and pelvic pain

Medical history and examination by early pregnancy assessment service

Pregnancy test (dilution), serum HCG assay and ultrasound scanning to exclude ectopic pregnancy and confirm ongoing intrauterine pregnancy

Refer to booking or to gynaecological services

15-17

R

Midwife (GP)

Community or Maternity unit

Discussion regarding screening programme, hand-held maternity record given to women, information and discussion

Weight, height (BMI)

Alphafetoprotein and beta Human Chorionic Gonadotrophin, Down's/Neural Tube screening, Blood pressure, urinalysis, fundal height

Routine or refer to consultant

19-20

R

Consultant/ Sonographer

Maternity unit

Information and discussion

Screening programme for fetal abnormality

Detailed fetal abnormality ultrasound scan (Level III)

Routine to community Abnormal to consultant

22

R

Midwife (GP)

Community

Information and discussion

General

Blood pressure, urinalysis, fundal height

Routine

28

R

Midwife (GP)

Community

Rhesus disease, information and discussion

Screening for depression using Edinburgh Postnatal Depression Scale

Rhesus antibody check, full blood count, blood pressure, urinalysis, fundal height

Routine

32

R

Midwife (GP)

Community

Information and discussion

General

Blood pressure, urinalysis, fundal height

Routine

34-36

R

Midwife (Consultant)

Maternity unit or community

Information and discussion

Review of pregnancy and

Rhesus antibody check, blood pressure, physical examination

Routine urinalysis, fundal height, clinical size and lie, presentation

36-40

R

Midwife (GP)

Community

Information and discussion

General

Blood pressure, urinalysis, fundal height and presentation

Routine

41+

R

Midwife (Consultant)

Maternity unit

Discussion relating to birth

Review of pregnancy, discussion

Cervical scoring, blood pressure, urinalysis, regarding induction and vaginal examination

Induction planning fundal height and presentation

* For low risk women, the midwife is the lead carer; some low risk women may opt for the GP to be the lead carer
* There appears to be a strong professional opinion that it may be appropriate to see a consultant obstetrician at 34/36 weeks and 41 weeks
* This integrated antenatal care plan may be adapted for local circumstances
* Following referral to NICE the Scottish Executive Health Department and the Royal College of Obstetricians Scottish Council will be debating prophylactic use of Anti D

Table 15 The Antenatal care model

Diagram

Views

I think, as you say, a lot of it's just historical, they're used to seeing a consultant and a midwife and in the end, it's just changing attitudes I think. (Professional Focus Group)

There's a cultural obstacle. We've created that environment in pregnancy where people think they need to see a doctor in order for something to be OK and that's clearly not the case. It's a culture thing to start saying to people, this is something that's normal. (Professional Focus Group)

Women don't want to travel 50 miles to get a scan. They want it locally and they want it in a flexible time because most women now are working well into their pregnancy, 34 and 36 weeks some of them. So you want to have the services at a time that's reasonable, and at a time when they can actually attend. (Professional Focus Group)

I would like more of a link person such as the community midwife. Somebody that I could go and say that I'm worried about something and chat informally. But this didn't happen with the community midwife attached to my GP practice. I phoned to get an appointment and they said that it would be 3 weeks before I could get an appointment. So I had to go to my GP, who wasn't any help with what I was worried about. (Lay Focus Group)

My GP was not helpful, sympathetic or caring on a personal/emotional level, but was very good when I developed complications (high blood pressure). I'd have preferred my antenatal visits to be with a midwife. (Lay Interview)

Principle 5

Maternity services should provide parent education programmes that address normal pregnancy and the treatment of complications developing during pregnancy. A comprehensive health promotion programme and opportunities for discussion about the effects of parenthood on relationships should be offered.

 

Local Action

Views

You need more staff, you need more time. Midwives especially are key workers. If they run the busy antenatal clinic and see 50 ladies at once, they don't have the time to sit down and talk to each individual woman. If somebody's got a crisis, they do their best. (Professional Focus Groups)

I was very happy with the excellent care I received both before and after the birth. I used all the advice I received and the books I got provided with helped a great deal too. (Lay Interview)

Principle 6

A comprehensive antenatal diagnostic and screening service should be available and offered to women in order to detect, where possible, any maternal problems or fetal abnormalities at an early stage.

 

Local Action

Principle 7

Maternity services should make sure that women's circumstances are assessed holistically and that social and psychological needs are identified and managed appropriately.

 

Local Action

Views

Can I just say about desires and.htmirations, is it perhaps mainly that they actually don't know what they are. If you're only maybe 17 or 18 and you're pregnant, you're having a baby, you don't know what should happen and you don't know until afterwards what you would have wanted and what you don't want to happen. (Professional Focus Group)

Women are different. The needs of a 15 year old are a lot different to the needs of a 30 year old professional woman. We need to start looking at individual needs. (Professional Focus Group)

Principle 8

Health professionals should recognise the important role of partners, and make sure they are encouraged and supported to take a full and active role in pregnancy and childbirth.

 

Local Action

Views

The only time my husband was ever involved was when we went to the Parentcraft classes together. Once you've had the baby the father should be given the opportunity to actually get involved with the baby in the hospital. (Lay Focus Group)

Further Work to be undertaken

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