Antenatal Care Guideline (GL956) protocols and guidelines/Maternity...3.0 Standards for Antenatal Care The following should be observed when planning and implementing antenatal care:

Antenatal Care Guideline (GL956)

Approval and Authorisation Approval Group Job Title, Chair of Committee Date Maternity & Children’s Services Clinical Governance Committee

Chair Maternity Clinical Governance Committee

6th October 2017

Change History Version Date Author Reason 2.5 Feb 2019 J Young (Screening

coordinator) Pg 12 – 5.4 Specialist Midwifery services – Screening MWs details amended Pg 15 / 16 – minor changes

2.6 June 2019 L Perkins (Consultant MW)

Live change to page 5 criteria to address requests for change of maternity provider

2.7 August 2019 A Mansfield Pg 15 CP flowchart updated Removal of reference to Emotional wellbeing packs pg14/15

Author: Kerry Taylor, Jean Sangha, L Perkins Date: August 2019 Job Title: Community Midwife Team Lead, Matron

for CMW & Rushey, Consultant MW Review Date: October 2019

Policy Lead: Group Director Urgent Care Version: V2.7 August 2019 V2.0 ratified 6/10/17

Location: Policy hub/ Clinical/ Maternity /Antenatal/ GL956 This document is valid only on date last printed Page 1 of 32

Antenatal Care guideline (GL956) August 2019 This guideline should be read in conjunction with the following policies, protocols and guidelines:

• Antenatal Screening protocol (CG474) • Antenatal Sickle Cell and Thalassaemia (SCAT) Screening Programme (CG475) • Anti D guideline (GL786) • Bariatric guideline (GL791) • Bariatric management of the super obese BMI 50+ (GL959) • Booking women after 12+6 completed weeks of pregnancy (GL795) • Breech third trimester - Antenatal (GL799) • Consultant Referral Criteria (GL810) • Down’s, Edward’s & Patau’s syndromes screening protocol (CG481) • Fundal Height measurement guideline (GL847) • Diabetes in Pregnancy (GL983) • Cultural Issues and Non-English speaking Women (GL814) • Hepatitis C (GL852) • Induction of labour and augmentation of PLRoM in prolonged

pregnancy guideline (GL861) • Maternity patients requiring an interpreter protocol (CG495) • Late Booking >12+6 weeks (GL838) • Management of HIV positive women and their baby policy (CG490) • Hypertension – management in pregnancy guideline (GL952) • Twin & Multiple pregnancies management (GL928) • Non attendees at Antenatal clinics/No access Visits protocol (CG499) • Planning place of birth (GL887) • Poppy team (GL889) • Record keeping standards (GL901) • Small for Gestational Age (GL916) • Protocol in relation to the risk and vulnerability factors for the babies of mothers

with problem drug and alcohol use (CG504) • Guideline when caring for women who misuse substances - but who are NOT

already registered on a Methadone or Buprenorphine (Subutex or Suboxone) regime (GL922)

• Working with substance misusing parents leaflet for staff • Syphilis Policy (CG505)

Author: Kerry Taylor, Jean Sangha, L Perkins Date: August 2019 Job Title: Community Midwife Team Lead, Matron for

CMW & Rushey, Consultant MW Review Date: October 2019



http://www.royalberkshire.nhs.uk/antenatal.htm





http://www.royalberkshire.nhs.uk/medical-conditions-and-complications.htm















http://www.royalberkshire.nhs.uk/social-issues-and-public-health.htm




http://www.royalberkshire.nhs.uk/intrapartum.htm


















http://www.royalberkshire.nhs.uk/professional-guidelines.htm

http://www.royalberkshire.nhs.uk/professional-guidelines.htm











Antenatal Care guideline (GL956) August 2019 CONTENTS 1.0 Introduction & Aim ............................................................................................. 5

2.0 Purpose and Principles of Antenatal Care ....................................................... 5

3.0 Standards for Antenatal Care ............................................................................ 6

3.1 Location ................................................................................................... 6

3.2 Equality and Diversity ............................................................................. 7

3.3 Interpreter Services ................................................................................. 7

4.0 Responsibilities and Accountabilities in the Community Setting .................. 8

4.1 General Practitioner ................................................................................ 8

4.2 ‘Pre-booking’ Appointment .................................................................... 8

4.3 Community Midwife ................................................................................ 8

4.4 Maternity Support Worker in AN Care in the Community .................... 9

4.5 The Poppy Team.................................................................................... 10

4.6 Documentation ...................................................................................... 11

4.7 Health Visitor ......................................................................................... 11

5.0 Hospital Antenatal Clinics ............................................................................... 12

5.1 Referral process .................................................................................... 12

5.2 Consultant Antenatal Clinics ............................................................... 12

5.3 Anaesthetic Care Plan .......................................................................... 12

5.4 Specialist Midwifery Services .............................................................. 12

6.0 Booking Appointment ...................................................................................... 13

6.1 Screening for important risk factors at the booking appointment: .. 14

6.1.1 History of congenital/inherited disorders ........................................... 14

6.1.2 New residents to UK ............................................................................. 14

6.2 Mental Health ......................................................................................... 14

6.3 Screening Tests .................................................................................... 15

6.3.1 Booking bloods are taken with consent for: ....................................... 15

6.3.2 Hepatitis C Screening ........................................................................... 15

6.3.3 Screening Fetal anomalies ................................................................... 16

6.3.4 Urine testing .......................................................................................... 16

6.3.5 Testing for Chlamydia ........................................................................... 16

6.3.6 Women who decline screening tests ................................................... 17





Antenatal Care guideline (GL956) August 2019 7.0 Health and wellbeing for all pregnant women ............................................... 17

7.1 Nutritional supplements and dietary advice .................................................. 17

7.2 Folic Acid prophylaxis ..................................................................................... 17

7.3 Vitamin D supplements .................................................................................... 18

7.4 Health Promotion ............................................................................................. 18

7.4.1 Smoking ............................................................................................................ 18

7.4.2 Alcohol .............................................................................................................. 18

7.5 Observations: ................................................................................................... 19

7.5.1 Height and Weight ............................................................................................ 19

7.5.2 Obesity (Body Mass Index (BMI) >35kgs/m2) ................................................ 19

7.5.2.1 BMI 30-34.9kgs/m2 ...................................................................................... 19

7.5.2.2 BMI >35kgs/m2 ............................................................................................ 19

7.5.2.3 BMI >40kgs/m2 ............................................................................................ 19

7.6 Women at risk of pre-eclampsia ..................................................................... 20

7.6.1 Moderate Risk Factors ..................................................................................... 20

7.6.2 High Risk Factors ............................................................................................. 20

7.7 Diabetes screening in pregnancy at approximately 28 weeks: .................... 20

7.8 Mothers with established diabetes: ................................................................ 21

8.0 Antenatal Appointment Schedule ................................................................... 21

8.1 Fundal Height Measurements ......................................................................... 21

8.2 Fetal Movements .............................................................................................. 21

8.3 Anti D prophylaxis ............................................................................................ 22

8.4 Membrane Sweeping ........................................................................................ 22

8.5 Induction of labour ........................................................................................... 22

8.6 Prolonged pregnancy....................................................................................... 22

9.0 Day Assessment Unit (DAU) ............................................................................ 22

9.1 Criteria for referral ............................................................................................ 22

9.2 Women presenting with unexplained minor antepartum haemorrhage ...... 23

10.0 Antenatal parenthood preparation classes .................................................... 23

11.0 Late Booking/Missed Appointments............................................................... 24

12.0 Standards .......................................................................................................... 24

13.0 References ........................................................................................................ 25

14.0 Appendices ....................................................................................................... 27 Author: Kerry Taylor, Jean Sangha, L Perkins Date: August 2019 Job Title: Community Midwife Team Lead, Matron for




Antenatal Care guideline (GL956) August 2019 14.1 Antenatal management of anaemia ................................................................ 27

14.2 Hepatitis C screening pathway ....................................................................... 28

14.3 MRSA pathway ................................................................................................. 29

14.4 Referral process for Community midwives AT booking ............................... 30

14.5 Child protection Process for maternity .......................................................... 31

14.6 Reduced fetal movement flow chart ............................................................... 32

1.0 Introduction & Aim The purpose of this guideline is to assist all professional groups involved in providing antenatal care to pregnant women. It aims to promote a consistent, efficient and evidence based approach to the provision of antenatal care. It also provides a framework and schedule for the delivery of care in the community and hospital setting. It does not however, replace individualised care and management. This guideline does not provide detail on managing medical conditions. This information can be found on the Policy hub under Maternity guidelines on the hospital intranet site or from outside the Trust via the internet at http://www.royalberkshire.nhs.uk/maternity-guidelines-and-policies.htm Our aim is to provide women with antenatal care in an area local to them by a team of midwives. Community midwives, GPs, Obstetricians, Anaesthetists, Specialist Midwives, Health Visitors and Local Authorities will all work together to ensure the package of care offered to women is individualised and meets her needs as suggested in the Better Births review (2016).

2.0 Purpose and Principles of Antenatal Care The antenatal period is defined from conception to the birth of the baby. The purpose of antenatal care is to maintain and improve the woman’s health and wellbeing by: Monitor maternal and fetal wellbeing to prevent and manage health problems

related to pregnancy To provide education and advice on health and wellbeing during and after

pregnancy A time for preparation for labour, the birth and preparation for parenthood Pregnancy is a normal physiological process and as such, any interventions

offered should have known benefits and be acceptable to the pregnant woman.

Each antenatal appointment should be structured and focused with adequate time for discussion to enable the women to make informed choices and to discuss concerns and anxieties.





http://www.royalberkshire.nhs.uk/maternity-guidelines-and-policies.htm

Antenatal Care guideline (GL956) August 2019

All women should be encouraged to seek antenatal care ideally by 8 weeks’ gestation in order to discuss antenatal screening and to ensure that tests are undertaken in accordance with the UK National Screening Programme and Standards. The woman should be informed who will be providing her care and her options as to where the care will be provided. In the event that a change of maternity provider is requested by a woman after she has already booked for our service, the reason for the request to change should be explored with her. When referrals are received from other maternity services for a woman wishing to transfer her care to the Royal Berkshire NHSFT, the reason for this request to change should be explored by us as her new provider.

3.0 Standards for Antenatal Care The following should be observed when planning and implementing antenatal care: 3.1 Location

Antenatal care is provided in a variety of settings such as GP surgeries, children’s centres, hospital, the woman’s home or in other community based settings. Wherever the care is provided it should be welcoming and accessible. The woman’s privacy and dignity should be maintained at all times and discussions around sensitive issues such as domestic and/or sexual abuse, psychiatric illness and illicit drug and alcohol when confidentiality is important. The environment in which antenatal care is provided should be risk assessed to ensure safety for the woman and family. There should be no electrical, sharps or trip hazards. As a minimum there should be access to: Hand washing facilities/hand sanitizer A suitable examination couch/bed with appropriate load allowance A sphygmometer to measure blood pressure and urine testing

equipment Weighing scales Height measurement Disposable measuring tapes to measure symphysis fundal height A sonicaid or pinnard Pathology supplies and request forms A container for safely discarding sharps Transport for blood tests/specimens to the laboratory Access to pathology results where possible CO monitor Relevant information leaflets






3.2 Equality and Diversity All health care professionals should respect the diversity and individuality of people with disabilities. The disability may be physical, mental, sensory or a learning disability. First and foremost the woman should be seen as an individual with a disability rather than the disability. All care must be compliant with the Disabilities Discrimination Act (1997) which emphasizes the duty of care concerning access, quality of services, communication awareness and makes it unlawful to provide a lower standard of care to a disabled person. Also the Disability Equality Duty (2006) requires that public authorities demonstrate positive attitudes to promote equal opportunities for people living with disabilities. Midwives have a key role in supporting the pregnant woman with a disability and should demonstrate disability awareness. They may be required to work in collaboration across service boundaries to provide the best possible care tailored to the individual woman’s needs. Midwives need to find out how the pregnancy will impact on the disability by establishing whether there is a need to refer for specialist advice such as genetic counselling or whether medications, such as anti-depressants are safe to take during pregnancy. The midwife needs to be aware of organisations that can provide information and support and the benefits that can be claimed. Good communication and a clear plan should be developed with the mother in preparation for childbirth and care when home. A visit to the hospital may be arranged to address any care or equipment needs.

3.3 Interpreter Services For women who do not speak or understand English, or who have hearing or speech impairments, the use of a professional, qualified interpreter should be offered. Ideally this needs to be identified prior to the booking appointment so that an interpreter is available for this appointment. Where it has been identified that an interpreter is required this should be noted on the front page of the hand held record so that interpreters can be arranged for all appointments, labour and during the postnatal period as required. The need for an interpreter and the language required should be documented on any referral forms so that an interpreter can be arranged for hospital appointments. For women that decline the use of an interpreter, it must be explained that an interpreter needs to be booked and present as protection for the staff member to ensure that family members/friends are translating correctly. In addition these women should be offered information on how to book Easy English antenatal classes. Women can be directly referred to the social inclusion team or the leaflet can be found in the stationary section on the maternity guidelines website.





Antenatal Care guideline (GL956) August 2019 4.0 Responsibilities and Accountabilities in the Community Setting

4.1 General Practitioner The role of the GP in antenatal care has declined in recent years since direct access to a midwife was endorsed by Changing Childbirth in 1997. Many women, however, still see their GP as the first point of contact and will continue to see their GP alternately with the midwife. The GP should be adequately trained to care for pregnancy women safely. They have an important role in antenatal care including:

• Preconception counselling and advice including prescribing the correct dose of folic acid for those women with risk factors

• Health promotion in early pregnancy regarding diet, obesity and smoking cessation

• Early referral to the midwife to ensure booking takes place before 12 weeks

• The need to be competent in recognising and managing conditions such as hyperemesis, bleeding in early pregnancy, pre-eclampsia, sepsis, headache and breathlessness throughout pregnancy, as well as other pre-existing medical conditions

• Making urgent referrals • Assessing and providing care for women with mental health and/or

substance misuse issues • They are also required to undertake a cardiovascular examination of all

women who have become resident in the UK in the last year • Ensuring early communication to the appropriate Children Services

department if there are concerns regarding child protection issues

4.2 ‘Pre-booking’ Appointment Women may choose whether they wish to see a GP for a pre-booking appointment. This appointment can provide the woman with information on healthy lifestyle considerations and early antenatal screening options. Otherwise this will be covered at their midwife booking appointment.

4.3 Community Midwife Every pregnant woman will need the support of a named midwife whom she knows and trusts throughout her pregnancy. It is important to recognise that pregnancy and birth are normal life events for most women. All midwives are required to have the necessary skills and knowledge which should be evidenced based and to be able to identify when to refer to the most appropriate clinician or specialist team. Good communication between healthcare professionals and the woman is essential to ensure she is able to make informed decisions about her care. The woman should be allocated a named midwife and a consultant obstetrician where appropriate. This should be recorded on the front page of the woman’s hand held record. Where possible the woman should be






cared for by her named midwife (NICE, 2012). There should be continuity of care throughout the antenatal period, ideally 75% of all midwifery assessments in the community should be with the named midwife. The named midwife should be identified at the booking appointment. Women should be aware of how to contact their named community midwife or their local community midwifery services. Contact details will be provided in their hand held records. The named midwife may not necessarily provide all the antenatal and postnatal care. They should be responsible for ensuring that the woman has been offered and provided with antenatal care in accordance with the antenatal care schedule. All test results should be recorded in the hand held record and the hospital held record if appropriate. It is the responsibility of either the named midwife or midwife who undertook the test to check the result and action if required; this should be done within 10 days. The community midwife, preferably the named midwife, will work in partnership with the woman in drawing up a flexible and individualised care plan for her pregnancy and labour. Her choices of where to give birth should be respected. Where possible there should be continuity of care from one or a small number of midwives to gain the woman’s trust and confidence. Where possible, the woman should be seen by no more than a maximum of 3 different midwives. All antenatal hand held notes should be returned to the hospital immediately following delivery, even if the baby is born at home.

4.4 Maternity Support Worker in AN Care in the Community The role of the maternity support worker (MSW) in antenatal care is to undertake work for which midwifery training and registration are not required. Any care provided in the antenatal period should be undertaken under direct supervision of the midwife. They should work within a clear framework which defines their role, responsibilities and arrangements for supervision. The decision to delegate a task should be made solely by the midwife based on his/her professional judgment and he/she retains responsibility and accountability for such delegation. The NHS South Central Maternity Support Worker Governance Framework advises on the monitoring of standards of practice required of Maternity Support Workers (MSWs). It is intended to ensure that MSWs undertake their work in a safe, skilled and competent manner to ensure high quality and safe patient services, in the interest of public protection. The role of the MSW is to carry out a delegated task to the agreed level of competence and to report back to a midwife following completion of a delegated task. The decision to delegate a task should be made by the midwife. The midwife will be accountable for ensuring that any delegation to a MSW is appropriate. The delegating midwife remains accountable to






the NMC and her employer for the appropriateness of that delegation. It is important that the appropriate level of supervision has previously been provided to ensure MSW competence in carrying out the delegated task (NMC, 2008). A midwife should also be responsible for reassessing the condition of the woman at appropriate intervals. Clear communication between the midwife and MSW is vital to enable the MSW to report clinical findings to the midwife which should be supported by clear written records. Thus the MSW should be allocated a midwife ‘buddy’ for their working day so that they are able to communicate back their findings to the midwife who will advise accordingly.

4.5 The Poppy Team The Poppy team is a small team of midwives who provide maternity care to women identified with complex social factors with the aim of ensuring these women receive women centred, specialised care that is individually tailored to their needs. Examples of women with complex social needs include, but are not limited to women who: • Have a history of substance misuse (alcohol and/or drugs) • Have recently arrived as a migrant, asylum seeker or refugee • Have difficulty speaking or understanding English • Are aged under 19 • Have a history of mental health problems or a disability • Have experienced domestic abuse • are living in poverty/homeless

The Poppy team either work alongside or are complementary to the existing provision of maternity care. They provide antenatal and postnatal for the most vulnerable women. The team aim to work closely with other healthcare professionals and agencies to improve communication and facilitate long term planning and on-going support for these women. The team aim to provide continuity of antenatal and postnatal care from a small number of carers, whilst liaising with other agencies to improve communication and facilitate long term planning and support for these women. This may include intrapartum care for the most vulnerable women. The team also work closely with the lead midwife with responsibility for child protection/safeguarding. They will also act as a resource for other professionals. For more information on the referral process for substance misuse and child protection see the attached flow charts at the end of this document.






It is therefore appropriate that localities give special consideration to these groups of women within the measures to pregnant women with complex social needs and how to encourage women to maintain on going contact with maternity services. The lead professional for women with multiagency/multidisciplinary needs should ensure continuing communication and support with extra or extended appointments as required. For more information and the referral process please see Poppy Team guideline GL889.

4.6 Documentation It is essential to document all findings and discussions in the woman’s hand held antenatal record and where applicable the hospital maternity notes. All pathology reports will be reviewed by the person who took the sample and is responsible for following up any action required. The results should be recorded on the investigation and results page in the hand held antenatal record and the hospital maternity record when the woman attends the consultant antenatal clinic if appropriate. This will be done by the attending midwife. The woman should have been informed of the results and if action required this too is documented in the appropriate record. Appropriate action should be taken for abnormal results as soon as possible and the woman informed.

4.7 Health Visitor The midwife should obtain verbal consent from the woman for her information to be shared with the Health Visitor. At 16 weeks the midwife should forward the booking information to the health visiting team in the locality that the woman resides. This can be undertaken by use of the maternity information system or by printing and scanning the booking pages to the health visiting hub. The information should always be forwarded via a secure nhs.net email account. By forwarding the information after 16 weeks ensures that the Health visitors are not making contact with women who may have miscarried since the initial booking appointment. This ensures there has been sharing of information between the midwife and health visitor that the woman is pregnant. This provides the health visitor with further information to provide more targeted visiting for the woman and family in the ante natal period. The midwife is expected to have regular contact with the woman’s health visiting team, preferably face-to-face meetings. Otherwise contact should be by telephone, practice notes, team email address or telephone. It is considered best practice for the midwife and health visitor to have monthly case discussions. At each meeting the midwife will discuss new bookings, and women due in the next 2 months as well as any women who have raised concerns since the last meeting.






The midwife should notify the health visitor of any relevant information during the pregnancy e.g. miscarriage, change of address or relevant personal circumstances. If there are any other social concerns, then the Midwife/Health Visitor Liaison form should also be completed and signed consent gained from the woman for this to forwarded to the health visiting hub and the local authority in which the woman resides. This form can be forwarded to the community ward clerk who will scan the form and forward weekly to the respective multidisciplinary teams. A copy should be placed in the woman’s hospital Maternity records.

5.0 Hospital Antenatal Clinics 5.1 Referral process

Antenatal care provided by consultant obstetricians and their teams is provided at the Royal Berkshire Hospital Tuesday to Friday and at the West Berkshire Community Hospital on a Thursday morning and at Wokingham Community Hospital on a Wednesday afternoon. Both the Royal Berkshire Hospital and West Berkshire Hospital have ultrasound facilities.

5.2 Consultant Antenatal Clinics Women needing particular specialist care due to their medical histories will be allocated an appointment in the relevant clinic through the Consultant Triage system used by the obstetricians.

5.3 Anaesthetic Care Plan Women who have been seen by the obstetric anaesthetist during their pregnancy will have an anaesthetic review sheet filed in their hospital held heath record. See anaesthetic antenatal clinic referral criteria for women who should see an anaesthetist during the pregnancy or labour

5.4 Specialist Midwifery Services In addition to the consultant clinics, specialist midwives are able to offer advice to both professionals and women.

• Diabetes Specialist midwife – available for advice Monday to Friday from 08.00- 16.00 or leave an answerphone message on 0118 322 7245

• Substance and Alcohol specialist midwife – available Friday mornings or leave answerphone message

• Antenatal/Newborn Screening Coordinators – available Monday to Friday 08.00-16.00. Screening Coordinator 0118 322 8507 and 0118 322 7292. A message can be left on the answerphone

• Specialist HIV midwife can be contacted Tuesdays, Thursdays and Fridays in antenatal clinic






• Safeguarding Specialist midwife can be contacted on 07768752529 or by email at [email protected]

• BAC midwife – women are identified from consultant referral forms at booking if they are suitable to be assessed antenatally by the VBAC midwife

• Consultant midwife – referral forms are available on the stationary section under Referral Forms. The consultant midwife can see women who have had previous traumatic births or who are requesting care that is against medical advice

• Rainbow care midwife – The Rainbow Clinic Team is a multi-disciplinary team comprised of Lead Consultant Obstetrician, Specialist Fetal Medicine Associate Specialist and Rainbow Specialist Midwife , all working in partnership with families to offer care women who have experienced, previous stillbirth, fetal death between 20 and 24 gestation or early neonatal death within 4 weeks of birth.

• Pre-term clinic midwife - The clinic is a Multi-Disciplinary clinic, comprising of a Fetal Medicine Consultant and a Maternity Health Care Assistant who will be working together, to provide co-ordinated and personalised care to women who are at high risk of having Pre Term Birth.

6.0 Booking Appointment The booking appointment is primarily a process of risk assessment, information giving and health promotion. The information above at the pre-booking appointment should also be covered. A full medical, social and family history should be taken as detailed on the CMiS booking screen. Adequate time should be allowed to take an accurate history. All women should be directed to the Royal Berkshire Hospital Maternity website which provides podcasts of facilities within the maternity unit. She should be encouraged to download the Bounty App for RBFT leaflets and information on pregnancy and labour. They should also be given a Bounty pack containing: - Useful Contact Numbers - Team’s sticker - Screening consent form - NHS Screening booklet – Screening Tests for You and Your Baby (also

available online at: https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief)

- Ante natal care schedule - Maternity Voices information - Parent education information leaflet - Maternity Care Schedule - Kick Count leaflet





mailto:[email protected]

https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief

https://www.gov.uk/government/publications/screening-tests-for-you-and-your-baby-description-in-brief


- Have you considered a Home birth leaflet - MW/Health Visitor Liaison form if identified as needing extra support - Friends & Family questionnaire - Mothers and Others guide, Pregnancy, Feeding & Parenting - Fundal height measurement includes Pre-Eclampsia screening - Letter providing information about elective caesarean requests for maternal

request only

All women should be given the NHS Pregnancy website for advice at http://www.nhs.uk/Conditions/pregnancy-and-baby/

The named midwife is identified at the booking appointment and her name and contact details recorded on the front page of the woman’s hand held maternity record. A sticker with the team members’ contact numbers, who may also provide care, should also be attached to the notes. For all clients who are aged under 19 at booking a Child Sexual Expolitation Screening Tool, Poppy Team referral should be completed.

6.1 Screening for important risk factors at the booking appointment: 6.1.1 History of congenital/inherited disorders Women with a personal or close family history of congenital or inherited disorders should be referred as soon as possible for consultant antenatal care in the usual way. These women will usually be seen for counselling by the appropriate consultant specialist.

6.1.2 New residents to UK Women who are new residents of the UK (less than one year) such as asylum seekers/immigrants should have a full medical examination performed by their General Practitioner. They should also be given a patient registration form to complete and the midwife should inform the hospital overseas department. Women who are asylum seekers or refugees should be referred to the Poppy Team and should still be referred to overseas department

6.2 Mental Health Unidentified or inadequately treated mental illness during pregnancy and following birth can have serious consequences. Joint working arrangements between maternity and mental health services should be provided. All women should be asked about previous psychiatric disorder or a family history of serious mental health issues early in the pregnancy as follows:

• past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression





http://www.nhs.uk/Conditions/pregnancy-and-baby/


• previous treatment by a psychiatrist/specialist mental health team including inpatient care

• A family history of perinatal mental illness.

Additional questions should be asked (Whooley questions):

• During the past month, have you often been bothered by feeling down, depressed or hopeless?

• During the past month, have you often been bothered by having little interest or pleasure in doing things?

A third question should be considered if the woman answers 'yes' to either of the initial questions:

• Is this something you feel you need or want help with?

Where the midwife identifies a woman with significant mental health concerns she/he should refer to the GP. The woman should be assessed by the psychiatric team and a plan of care recorded in the pathway. A written management plan of care covering pregnancy, delivery and the postnatal period should be made. This should include increased contact with specialist mental health services (including, if appropriate, specialist perinatal mental health services). This must be recorded in all versions of the woman's notes (her hand held record, hospital held record and primary care and mental health notes) and communicated to the woman and all relevant healthcare professionals. Contact numbers for the mental health team should be readily available

6.3 Screening Tests

6.3.1 Booking bloods are taken with consent for: o Full blood count o Blood group and antibodies o Serology (Hepatitis B, syphilis and HIV) o Haemoglobinopathy (Sickle cell & Thalassaemia)

6.3.2 Hepatitis C Screening

If a woman volunteers’ information about risk factors below she may be hepatitis C positive. She should be counselled regarding screening and her wishes documented:

• Women with current history of substance misuse or a history of injecting drug use – these women should be referred to the






consultant obstetrician responsible for women with addiction. The woman will be counselled regarding screening for hepatitis C following the guidance for care (see GL852 under Maternity / Medical conditions & complications).

• Women with HIV can be co-infected with hepatitis C • History of blood transfusion or blood products or organ donation

prior to 1991, including women transfused in childhood i.e.as part of treatment in Special Care baby Unit for prematurity.

• History of haemodialysis, particularly if dialysed outside the UK • Exposure to infected blood via sharing toothbrushes, razors or

drug smoking paraphernalia i.e., crack pipe • Tattoos, body piercing, traditional body marking practices,

acupuncture, dental or invasive medical treatment with unsterile equipment or in countries where infection control may be poor.

• Occupational exposure to blood known to be infected with hepatitis C. The risk from percutaneous exposure is estimated at 3% (9), the risk via mucocutaneous exposure very much lower.

• Regular sexual partner is hepatitis C virus positive • Horizontal spread from a member of the same regular

household. • Originating from, or resident for a long period of time, countries

with high prevalence of hepatitis C i.e. Egypt, South East Asia. In 2007 there was a department of health campaign to raise awareness of hepatitis C among ethnic minority groups (10).

• Vertical transmission (mother to baby)

6.3.3 Screening Fetal anomalies Women should be given opportunity to discuss screening options for fetal abnormalities. PHE screening booklet to be given and consent for testing where able, completed and returned to the women to bring to USS appointment.

6.3.4 Urine testing

A MSU should be obtained and sent for microscopy and sensitivity at booking. The woman’s urine should be dip stick tested for protein and sugar at every antenatal appointment. Refer to Management of Hypertension guidelines and management of glycosuria in pregnancy

6.3.5 Testing for Chlamydia

At booking appointment women under 25 years should be informed about the high prevalence of chlamydia Testing can be undertaken






by referring to the sexual health clinic or taking a urine or LVS sample.

All test results will be reviewed by the midwife who arranged the test. The results will be discussed with the woman and recorded in her hand held notes on the investigation and results page at the next antenatal appointment. Abnormal results will be discussed and acted upon.

6.3.6 Women who decline screening tests Where a woman declines any of the routine screening tests this should be clearly documented in the woman’s hand held and/or the hospital maternity record. The screening midwife should be informed of any screening blood tests that are declined. Women who decline booking screening tests should be re-offered again at 16 weeks. See Antenatal Screening Protocol CG474 for further information.

7.0 Health and wellbeing for all pregnant women The following advice is to be covered in early pregnancy, usually, but not exclusively at the Booking Appointment.

7.1 Nutritional supplements and dietary advice All women should be advised of the importance of a healthy diet during pregnancy and which foods to avoid. All women should be directed to information in the Bounty magazine, the NHS Pregnancy Website and/or the Healthy Eating in Pregnancy Leaflet on the Royal Berkshire Hospital website, which all contain information on foods to avoid and food hygiene, including how to reduce the risk of a food acquired infection. Within the pregnancy notes women should be encouraged to read page 24 which provides general information about maintaining a healthy lifestyle.

7.2 Folic Acid prophylaxis All women should be advised to take folic acid (400 mcg daily) prior to conception (for at least 3 months) and up to 12 weeks of pregnancy to reduce the risk of neural tube defects. Women with the following risk factors should be recommended to take 5mg folic acid rather than 400mcg: • BMI >30 kg/m2 • The woman or her partner have a neural tube defect • The woman has had a previous pregnancy affected by a neural tube

defect • The woman or her partner have a family history of neural tube defects • The woman has diabetes • The woman is taking anti-epileptic medication






7.3 Vitamin D supplements All women should be advised to take vitamin D supplements (10mcg daily) during pregnancy and after birth if breast feeding and continue until they stop breast feeding. This is available in Healthy Start multivitamins which can be purchased over the counter. This is particularly important for women from the following groups

• Women from South East Asia, Caribbean, Middle Eastern countries • Women who are housebound or remain covered when outside • Women whose diet does not include oily fish, eggs, meat or fortified

margarine or breakfast cereal • Women whose BMI is greater than 30 kg/m2 Women should be advised of the risks of taking large doses of Vitamin A in foods such as liver and liver patê.

7.4 Health Promotion 7.4.1 Smoking

Pregnant women who are current smokers or have given up smoking in since finding out they are pregnant must be referred to the smoking cessation services. They should be advised of the dangers to the fetus of smoke inhalation and should be referred to an evidence-based smoking cessation service. A CO reading should be taken on all women at booking and levels higher than 7 require a referral to smoking cessation services. These women should have a CO reading at every midwife appointment and the opportunity for Health promotion encouraged. They should also be advised that smoking in the same environment as the baby can be harmful. Women who may decline CO monitoring should be advised that other environmental factors could contribute to carbon monoxide levels being raised such as exhaust fumes and leaky gas appliances.

7.4.2 Alcohol It is recommended by the Department of Health that pregnant women, or women trying to become pregnant, should avoid alcohol altogether. Additionally women should be advised of the risks of miscarriage in the first three months of pregnancy. Women should be informed that getting drunk or binge drinking can be harmful to the fetus and increases the risk of the baby developing fetal alcohol syndrome.






7.5 Observations: 7.5.1 Height and Weight

This should be undertaken at booking and the BMI calculated. It is not acceptable to ask the mother to estimate her height and weight, both should be measured with the appropriate measuring tools.

Following the booking appointment antenatal care schedule should be followed. Women identified as high-risk should be booked under consultant care and individual guidelines for the particular condition followed.

7.5.2 Obesity (Body Mass Index (BMI) >35kgs/m2) Obese women have a higher risk of complications during pregnancy and delivery which increases with a rising BMI. The woman should be weighed at booking and the BMI index calculated and recorded in the antenatal hand held record. Women who book with a BMI of 30kgs/m2 or more should receive personalised advice from an appropriately trained professional on healthy eating and physical activity. Weight reduction dieting in pregnancy is not advised. The Healthy Eating in Pregnancy patient information leaflet should be given.

7.5.2.1 BMI 30-34.9kgs/m2 Women with a BMI 30-34kgs/m2 do not need to be referred for consultant led care unless they have other risk factors. This should be documented on the observation page of the yellow fold out sheet in the woman’s hand held records.

7.5.2.2 BMI >35kgs/m2 Women with a BMI > 35kgs/m2 should be referred to the antenatal clinic for consultant led care and should be advised to give birth within the main delivery suite. Multips up to 40 BMI can deliver on MLU. The bariatric checklist will be completed by the antenatal clinic midwife or doctor and should be filed next to the consultant care plan (green sheet) in the hospital maternal health record.

7.5.2.3 BMI >40kgs/m2 Women with a BMI of 40kgs/m2 or more should be referred to an obstetric anaesthetist by the antenatal clinic midwife. The anaesthetist will assess the anaesthetic risks and agree a management plan which will be filed in the woman’s hospital records next to the green consultant care plan. A copy of the care plan will be held on the anaesthetic database in the event of the hospital record being mislaid.






The referral will be done by the antenatal clinic midwife attending the woman in the antenatal clinic. Women who weigh over 150kgs will require an individual care plan to assess her mobility and safe working load. The AN clinic staff will need to liaise with the Manual Handling team as equipment may need to be borrowed or hired either in advance or at the time for the duration of the woman’s stay in the maternity unit. See guidelines for the Management of the Pregnant Bariatric Woman =>30 (GL791) and Management of the super obese pregnant women BMI =>50 (GL959).

7.6 Women at risk of pre-eclampsia Hypertensive disease predating pregnancy, or occurring for the first time in pregnancy, is common. Proteinuric hypertension (PET) is associated with increased maternal and fetal/neonatal morbidity.

Women with 1 high risk factor or 2 or more moderate risk factors for developing pre-eclampsia should take 75mgs of Aspirin daily, from 12 weeks until delivery. This is thought to reduce the risk of pre-eclampsia. Women should be assessed by the following risks at their booking appointment:

7.6.1 Moderate Risk Factors • First pregnancy • Age equal or >40 years at conception • BMI equal or >35 at booking visit • Pregnancy interval >10 years • Family history of pre-eclampsia (mother/sister) • Multiple pregnancy

7.6.2 High Risk Factors • Chronic hypertension requiring treatment • Previous hypertension in pregnancy • Chronic kidney disease • Autoimmune disease e.g. systemic lupus erythematosus or

antiphopholipid syndrome • Type 1 or 2 diabetes

7.7 Diabetes screening in pregnancy at approximately 28 weeks: • Body mass index > 35 kg/m2

• Previous Macrosomic baby weighing 4.5 kg or above

• Previous gestational diabetes (refer to 'Diabetes in pregnancy' (NICE clinical guideline 63) – OGTT should be done as soon as possible after booking and 28 weeks in this case






• Family history of diabetes (first-degree relative with diabetes)

• Family origin with a high prevalence of diabetes: o South Asian (specifically women whose country of family origin

is India, Pakistan or Bangladesh) o Black African and Caribbean o Middle Eastern (specifically women whose country of family

origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt)

o History of polycystic ovarian syndrome o Previous unexplained IUD

Women should be identified at booking and an appointment made by the midwife at 16 week appointment to have OGTT undertaken between 24-28 weeks of pregnancy. The appointment is made by the maternity back office calling 0118 322 7279. The Diabetes team will review the results

7.8 Mothers with established diabetes: The GP or community midwife should contact the diabetic specialist midwives as soon as the pregnancy is confirmed, even before the booking history is where possible. If this is not possible then this should be done at booking by telephone.

8.0 Antenatal Appointment Schedule At each antenatal appointment the woman should have her blood pressure measured and urinalysis to detect proteinuria and glucose. From 26 weeks gestation the fetal heart should be auscultated and symphysis fundal height measured and plotted.

8.1 Fundal Height Measurements From 24 weeks gestation the fundal height should be measured and recorded at all routine antenatal appointments. This will be plotted on the graph in the antenatal hand held notes. Where there is a discrepancy of more than 3cm below gestational age, or if a measurement is static from the last appointment, the woman should be referred to an obstetrician. Where possible the number of professionals attending the woman should be kept to a minimum to reduce errors. See Measuring Fundal Height guideline (GL847) & Small for gestational age guideline (GL916).

8.2 Fetal Movements Women should be advised to observe for fetal movements from 16 weeks onward. Women should be advised to report significantly reduced or sudden alteration in the movements as normal fetal movements are a sign of fetal wellbeing. Women with reduced fetal movements under 28 weeks should attend their GP for auscultation of the fetal heart. Women over 28 weeks should be referred or self-refer to the DAU or Delivery Suite out of






hours for a CTG. See Reduced Fetal Movement guideline (GL903) for further information and also flowchart at end of this document.

8.3 Anti D prophylaxis Anti D is recommended for all pregnant non-sensitised rhesus negative women. If the mother is Rhs Negative she will be offered fetal RhD screening. Blood will be taken to determine the fetal blood group. At 28/40 the results will be reviewed and if the baby is RhD Negative the mother will not require Anti-D injection. If the fetal blood test is RhD positive an appointment for Anti-D injection will be booked for 30/40 gestation. For further details please see Anti D guideline (GL786)

8.4 Membrane Sweeping Membrane sweeping prior to induction of labour has shown to be effective in reducing the need for other induction methods and as such should be offered to all women prior to booking for induction of labour. Primigravida women should be offered this at 40 and 41 weeks, and multigravida women should be offered this at 41 weeks.

8.5 Induction of labour Low risk women should be offered an induction of labour at approximately 41+5 gestation and should be given an induction of labour leaflet. Inductions can be booked during antenatal clinic sessions on ext. 8923, or outside clinic hours via the Induction Suite on ext. 7245. High risk women must be booked by a consultant or obstetric trainee. See induction of labour guideline

8.6 Prolonged pregnancy If a woman declines induction she should be given an appointment in an obstetric antenatal clinic as soon as possible to discuss the risks and have further follow up arranged.

9.0 Day Assessment Unit (DAU) The role of the DAU is to provide an assessment and monitoring facility for women who have developed complications after 15 completed weeks of pregnancy. Prior to this gestation women should be referred to Gynaecology services unless the woman is suffering from hyperemesis.

The DAU does not replace the Antenatal Clinic and unless the condition is urgent the woman should be made an antenatal clinic appointment.

9.1 Criteria for referral Women with hyperemesis at any gestation






Women who require monitoring of high risk conditions such as pre-eclampsia or cholestasis

Women with unexplained abdominal pain >15 completed weeks Vaginal bleeding >15 completed weeks Women who are booked for elective caesarean section for pre-

operative clerking and admission on the day of surgery Women undergoing induction of labour with Prostaglandins External cephalic version (Friday mornings only) Postnatal women with wound infections either abdominal or perineal

who having first been assessed by the GP and have not responded to a course of antibiotics

Women who are asymptomatic and whose BP readings are classified as ‘mild to moderate’ DO NOT need same day referral, whether or not there is proteinuria. These women can be referred to the Antenatal Clinic, to be seen within three days. If possible they should be seen in their usual consultant clinic if applicable. If there is concern or an appointment cannot be arranged within 3 days contact the DAU who will decide whether the patient needs interim review. Women who are acutely unwell, or whose BP readings fall within the range ‘severe’ should be referred for SAME DAY assessment. Woman whose blood pressure is >160/110 should be transferred to the DAU or Delivery Suite out of hours by ambulance and accompanied by a professional. Heavy proteinuria, in a ‘well woman’ is not necessarily due to PET. This list is not exhaustive and there may be other conditions whereby it would be appropriate to refer the woman to the DAU. Referral can be made by a midwife, GP, Westcall or hospital doctor. The woman may self-refer. For further advice ring the DAU on 0118 322 8741. See Hypertension guideline (GL952).

9.2 Women presenting with unexplained minor antepartum haemorrhage Pregnancies complicated by unexplained APH are at increased risk of adverse maternal and perinatal outcomes. Junior medical staff covering DAU are advised to discuss the management of these women with a senior obstetrician.

10.0 Antenatal parenthood preparation classes At 16/40 appointment first time mothers should be encouraged to book a parent education class from 28 weeks. For further information on booking classes in the






hospital setting, women should be given the NCT website http://www.nct.org.uk/BerkshireAntenatal for a free class.

Feeding classes are drop in for any mothers and dates and times can be accessed online at http://www.royalberkshire.nhs.uk/infant_feeding.htm.

Community midwife to consider giving appointment for this session as standard.

11.0 Late Booking/Missed Appointments Women who attend for booking after 12+6 weeks (late bookers) or regularly miss appointments are much more likely to be vulnerable or socially excluded. These women and their babies are also more likely to experience serious health problems and higher death rates, including the mothers being at higher risk of committing suicide. 17% of all maternal deaths in the UK between 2003-2005 were of women who booked after 22 weeks gestation, missed over four routine antenatal appointments, or did not seek care at all (CEMACH, Saving Mothers’ Lives, 2007). Women who miss appointments should be followed up by the community midwifery service or other community-based service with who the woman is in contact, such as a children's Centre, addiction service or GP. All attempts at communication must be clearly documented in the woman’s hospital held record and/or in the midwife’s diary. An electronic antenatal attendance record should be maintained for every antenatal mother in the midwife’s caseload. This caseload file should be accessible to other staff who may need to provide cover and can then update this attendance tool or follow up any non-attenders. Follow-up appointments should be made after the consultation and placed in the electronic diary and recorded for the woman in her notes. Where there are concerns about the woman this should be raised with the Community Matron or Director of Midwifery. See Late Booking 12+6 week’s guideline (GL795) and Non Attendees at Antenatal Clinics/No access visits protocol (CG499).

12.0 Standards

• Lead professional documented at booking and any changes in pregnancy

• Choice of birth recorded • Patient smoking status recorded at booking • Named midwife documented in booking notes • Continuity of care regarding number of midwives in antenatal period • Documentation of late bookers and reason





http://www.nct.org.uk/BerkshireAntenatal

http://www.royalberkshire.nhs.uk/infant_feeding.htm


• Documentation of missed appointments, contact with expectant mother and new appointment

• Antenatal screening leaflet given

13.0 References 13.1 Confidential Enquiries into Maternity and Child Health (2007). Saving

Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer. 13.2 Centre for Maternal and Child Enquiries (CMACE, 2011) Perinatal

Mortality. London. Available at www.cmace.org.uk 13.3 Department of Health. (1997). Changing Childbirth. London. Department

of Health. 13.4 Department of Health (2004). National Standards for Children, young

people and Maternity: Maternity Services. London available at www.dh.gov.uk

13.5 Department of Health. (2007). Maternity Matters: Choice, access and continuity of care in a safe service. London. Department of Health. Available at: www.dh.gov.uk

13.6 Kings Fund. (2010). The Role of GPs in maternity Care – What does the future hold.

13.7 National Institute of Clinical Excellence (NICE) 2012. Quality Standards for Antenatal Care. Available at www.nice.org.uk

13.8 National Institute for Health and Clinical Excellence (NICE), (2007). Antenatal and Postnatal Mental Health: Clinical Management and service guidance. London, NICE. Available at www.nice.org.uk

13.9 National Institute of Clinical Excellence (NICE). (2008). Antenatal Care: Routine Care for the Healthy Pregnant Woman, London: NICE. Available at www.nice.org.uk

13.10 National Institute for Health and Clinical Excellence (NICE), (2010). Pregnancy and Complex Social Factors: A Model for Service Provision for Pregnant Women with Complex Social Factors. London. NICE. Available at www.nice.org.uk

13.11 National Institute for Health and Clinical Excellence. (NICE), (2010). Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors CG110. London, NICE available at www.nice.org.uk

13.12 Nursing and Midwifery Council (2015) The Code; Professional Standards for Practice and Behaviour for Nurses and Midwives. NMC, London https://www.nmc.org.uk/standards/code/





http://www.dh.gov.uk/

http://www.nice.org.uk/





https://www.nmc.org.uk/standards/code/


13.13 Royal College of Nursing (2007). Pregnancy and Disability: RCN guidance for nurses and midwives. London. Available at www.rcn.org.uk

13.14 Royal College of Midwives (2013) Maternity Support Workers: Position statement. London. Available at www.rcom.org.uk

13.15 Royal College of Obstetricians and Gynaecologists (2008) Standards for Maternity Care – Report for a Working Party. London. Available at www.rcog.org.uk





http://www.rcn.org.uk/

http://www.rcom.org.uk/

http://www.rcog.org.uk/


14.0 Appendices

14.1 Antenatal management of anaemia






14.2 Hepatitis C screening pathway






14.3 MRSA pathway

Author: Kerry Taylor, Jean Sangha Date: August 2019 Job Title: Community Midwife Team Lead, Matron for CMW & Rushey Review Date: October 2019 Policy Lead: Group Director Urgent Care Version: V2.7 August 2019

V2.0 ratified 6/10/17 Location: Policy hub/ Clinical/ Maternity /Antenatal/ GL956 This document is valid only on date last printed Page 29 of 32


14.4 Referral process for Community midwives AT booking

Author: Kerry Taylor, Jean Sangha Date: August 2019 Job Title: Community Midwife Team Lead, Matron for

CMW & Rushey Review Date: October 2019




14.5 Child protection Process for maternity






14.6 Reduced fetal movement flow chart





Antenatal Care Guideline (GL956) protocols and guidelines/Maternity...3.0 Standards for Antenatal Care The following should be observed when planning and implementing antenatal care:

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