A Framework for Maternity Services in Scotland: page 7

A Framework for maternity services in Scotland

Pregnancy

This 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

NHS Boards should adopt a flexible approach in planning the provision of care during pregnancy taking account of the local population and geography. They should consider:
local consultation and public involvement in the planning and development of pregnancy services;
the midwife being the lead professional in the majority of low risk pregnancies, and in some circumstances, being the first professional contact to confirm pregnancy, book, assess risk and plan care;
women continuing to see their GP and obstetrician if they choose;
making sure all women have a named midwife, to co-ordinate their care from confirmation of pregnancy through to parenthood;
providing essentially community based, midwife managed care in pregnancy, within a multi-disciplinary team, and appropriate access to secondary and tertiary services with the role of each professional being defined within a shared and integrated system;
ways of improving communication with women, and their partners, to make sure that they are involved in the management of their pregnancy;
professionals making sure that informed discussion between the woman and her lead professional takes place to allow the woman to design, devise, and draw up an individual Birth Plan;
and the number of antenatal visits;
supporting and caring for healthy pregnant women and their extended families, including appropriate access and information on screening tests, monitoring the progress of pregnancy and the well-being of the mother and her unborn baby, and planning for their future;
providing information, support, and referral on social issues and needs.
The Royal College of Obstetricians and Gynaecologists developed a model outlining 3 levels of care during pregnancy. This has been adapted to reflect maternity needs in Scotland. NHS Boards should take the Scottish Framework model into account when planning care for pregnant women. This is described in Table 13. It demonstrates that the following levels of care need to be addressed:

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 (ą 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

women should be given the opportunity to choose their lead professional. It would most often be the midwife, but may be the GP or the consultant obstetrician;
a woman should have continuous risk assessment throughout the pregnancy, taking into account that risk status is dynamic and may change over time;
care should be targeted at a suitable level according to the needs of the woman, and it should be provided by the most appropriate professional;
women may move between different levels of care, in both directions. Transition should be underpinned by local guidelines and referral arrangements;
development of an integrated antenatal service should mean that women with low risk pregnancies are cared for in the community with midwives, the lead professional and caseload holder, working in partnership with general practitioners. Agreed criteria and guidelines for referral to other levels of care should be developed and implemented (Level I);
community based consultant clinics should be available for women with low risk pregnancies who choose a consultant referral or who need a higher level of care. The midwife should retain the role as lead professional (Level IIa);
a woman with a high risk pregnancy should have a consultant obstetrician as the lead professional, sharing care with midwives, GPs and other specialists such as diabetologists and cardiologists where appropriate, according to her needs. Community based consultant clinics should be encouraged particularly in remote and rural areas. Routine or specialist antenatal care may be provided in a secondary care setting, in a maternity unit. Or, highly complex antenatal care may be provided within a regional or tertiary maternity unit (Level IIb and Level III);
a flexible pattern of antenatal services should be in place in the community with access to day care facilities and maternal fetal assessment units. Women should only be admitted to hospital when professionals agree that community care is inappropriate;
women with current and ongoing health conditions likely to impact on the outcome of their pregnancy should be identified to make sure that expert multi-disciplinary care and support is provided;
assessment of risk should be repeated towards the end of pregnancy to provide up-to-date information so that the woman and her carers can reassess the plans made for childbirth;
the care of any pregnant women attending an Accident and Emergency Department, regardless of gestation, should be discussed with the duty obstetrician/gynaecologist.
NHS Trusts should develop and implement an explicit plan for antenatal care appropriate to all women regardless of risk;
Table 14 provides a suggested and consensus Antenatal Care Plan for first time mothers with a normal pregnancy which should be considered as the basis for antenatal care planning;

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

For mothers who are having a second or subsequent baby and the pregnancy is normal, the antenatal care plan for first time mothers outlined in Table 14 should be adapted providing the same core clinical care but suggested antenatal visits should be at booking, and at 16, 20 (scan), 22, 28, 34, 38 and 41 weeks;
Table 15 outlines a suggested antenatal care model which can be adapted depending on local circumstances an professional working patterns.

Table 15 The Antenatal care model

Diagram

NHS Trusts should develop local guidelines for selective investigations throughout pregnancy. Appendix 5, Table 16 provides examples of selective and non-routine investigation;
specific criteria should be developed to identify women who require routine specialist referral at booking. Specialist care should be primarily provided by a consultant obstetrician with other consultant specialists as appropriate, as outlined in Appendix 5, Table 17a-c;
an explicit and easily understood referral process and implementation guidelines should be developed for the management of women with problems occurring during pregnancy;
Appendix 5, Table 18 identifies problems that require specialist advice and possible ongoing management during pregnancy;
Appendix 5, Table 19 identifies common conditions associated with pregnancy for which local treatment and referral guidelines should be in place;
these tables should be available to all professionals.

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

NHS Trusts should review all existing models of parent education;
Every woman should have an individual parent education plan as an integral part of her care during pregnancy and the postnatal period;
NHS Trusts should raise awareness among pregnant women and their families of factors likely to affect the outcome of their pregnancies and their babies' wellbeing. This should include the importance of breastfeeding, advice and guidance on diet, lifestyle, smoking, alcohol, substance misuse and sexually transmitted and communicable disease;
NHS Trusts should make sure that there are clear referral mechanisms to physiotherapy services for advice and management of back pain and other problems encountered during pregnancy;
The CRAG recommendations on Parent Education (April 1995) should be the basis for development of local parent education programmes, but they should also incorporate:
local consultation and public involvement;
appointment of a parent support and education co-ordinator in each NHS Board area to make sure that advice and support on parenting skills and education is widely available and accessible to women and their partners;
a regular review, audit and evaluation of the quality and content of parent education sessions to make sure that these prepare women, and their partners, for parenthood, for example, accessibility and appropriate information;
the collaboration of professionals and voluntary organisations to promote parent education throughout pregnancy and in the postnatal period;
an emphasis in the parent education curriculum on the wider long-term implications of childbirth and parenting for women and their partners;
the availability of parent education for all women, and their partners, whether or not they attend formal sessions;
flexible parent education sessions to meet the needs of women who work and their partners;
a postnatal educational support programme;
training for midwives, health visitors and other professionals to equip them with the knowledge and educational skills needed to provide quality parent support and education;
the use of every episode of clinical care as an opportunity for parent support and education;
the exploration by NHS Boards of alternative settings for parent education such as family centres or healthy living centres through initiatives such as Sure Start Scotland;
information on entitlement to free prescriptions and free dental services during pregnancy;
information on the rights of mothers and partners in the workplace during and after pregnancy;
information on the Benefits and Allowances that are available during and after pregnancy, for example, Sure Start Maternity Grant.

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

NHS Boards should make sure that there is a comprehensive local screening programme in operation which adheres to national guidelines;
Health professionals should make sure that the implications of screening tests are fully discussed with women, and their partners, in a way that allows them to make an informed choice;
Only experienced radiographers and trained medical and midwifery staff should provide scanning at Levels I and II (Level I for dating, Level II for fetal well-being and biophysical assessment);
Only experienced operators should perform ultrasound screening for fetal abnormalities, and invasive fetal diagnostic procedures, such as chorionic villus sampling and amniocentesis;
All professionals who are involved in counselling women undergoing antenatal screening must be trained and experienced.

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

NHS Trusts should make sure that all professionals receive training and support in:
identification, sensitive assessment, communication skills and support for women who are victims of past or ongoing domestic violence in line with "Preventing Violence Against Women, an Action Plan for the Scottish Executive.";
child protection issues;
identification, screening, referral and support of women who have or are at risk of developing postnatal depression and other mental illness in a non-stigmatising way;
monitoring and support of women with particular needs such as pregnant schoolgirls, unsupported women, women from minority ethnic communities, women in prison, asylum seekers and refugees and women with severe social problems such as homelessness or alcohol/substance misuse.
NHS Trusts must make sure that local mechanisms for referral to other professionals and to statutory and voluntary services are developed and implemented in co-operation with Social Inclusion Partnerships (SIPs);
NHS Trusts should make sure that Integrated Care Pathways are developed and implemented for women with specific social needs who need multi-agency care and support.

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

Health professionals should make sure that, wherever possible, and when women wish, partners are involved in the discussion and decision making process;
Health professionals should make sure that partners are involved in parent education and support sessions, should they wish to be, and all steps taken to ensure that they do not feel marginalised.

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

NHS Trusts should identify the women and their partners who do not attend parent education and support sessions and discover their reasons to provide services that reflect their needs.
The Scottish Executive Health Department should set up a national forum for parent support and education co-ordinators to make sure that innovation and good practice is shared;
The Scottish Executive Health Department will publish guidance for all health professionals on Domestic Violence in Pregnancy.

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