London Ambulance Service Maternity Care Policy PDF 2017

Maternity Care Policy (formally known as the Obstetric Care Policy) Ref. No. OP/035 Title: Maternity Care Policy Page 1 of 29 DOCUMENT PROFILE and CONTROL. Purpose of the document: To ensure that the provision of maternity care provided by...

Maternity Care Policy (formally known as the Obstetric Care Policy) Ref. No. OP/035 Title: Maternity Care Policy Page 1 of 29 DOCUMENT PROFILE and CONTROL. Purpose of the document: To ensure that the provision of maternity care provided by the Trust is delivered in accordance with the UK Ambulance services Clinical Practice Guidelines (JRCALC 2016), in use at the time. Throughout the document, these guidelines will be referred to as “clinical practice guidelines”. Sponsor Department: Medical Directorate Author/Reviewer: Medical Director. To be reviewed by Service Consultant Midwife Advisor. To be reviewed by January 2019 or as required as detailed below. Document Status: Final Amendment History Date *Vers Author/Contributor Amendment Details ion 01/05/19 4.6 Consultant Midwife Due to number of Practice Lead for Pre Hospital amendments, joint review of Maternity Care guidance with external/internal teams commencing on 20/05/19 and alongside audit findings 07/12/17 4.5 IG Manager Document Profile and Control update 09/11/17 4.4 Consultant Midwife Advisor Wording amendment for consistency 21/04/17 4.3 IG Manager Document Profile and Control update 08/03/17 4.2 Consultant Midwife Advisor Further amendment 07/03/17 4.1 Consultant Midwife Advisor Amendments following PMAG 01/02/17 3.3 IG Manager Document Profile and Control update and formatting Ref. No. OP/035 Title: Maternity Care Policy Page 2 of 29 08/11/16 3.2 Consultant Midwife Advisor Rename to reflect the External Reviewers: renaming of the clinical Stephanie Michaelides Midwifery practice guidelines. Lecturer, Programme Leader for Rewritten to reflect the range Neonatal Care, Middlesex of maternity calls to which the University. LAS respond in carrying out Clare Capito the commissioned role London Local Supervisory Support Midwife Sally Luck Clinical Quality Manager (Patient Safety and Maternity) NHS England London LAS Education Manager – Keith Miller, Claire Henderson. 03/02/14 3.1 IG Manager Document Profile and Control Ref. No. OP/035 Title: Maternity Care Policy Page 3 of 29  update 14/01/14 2.2 Snr Clinical Adviser Re-word to S.6.5 in the light of the recent 2013 JRCALC Guidelines update and the recommendation from SI report (SI 2012 – 21226). 26/09/12 2.1 Consultant Midwife Advisor Minor amendment following approval – reference to maternal hand held notes 07/09/12 1.8 IG Manager Document Profile & Control update 07/09/12 1.7 Deputy Medical Director Minor amendments 03/09/12 1.6 AD CS Review & update 30/08/12 1.5 Governance Manager Rework of scope, responsibilities and general policies to include specifics on obstetrics emergencies. Addition of references to Control Room Procedures 11/07/12 1.4 Consultant Midwife Advisor Minor amendments and addition of monitoring table 26/08/10 1.3 Senior Clinical Advisor Minor amendments to responsibilities, education and monitoring sections. 03/06/10 1.2 Assist Head of CARU Added introduction 12/12/08 1.1 Assist Head of CARU 8.1.3 amended 24/09/08 0.1 Clinical Education Manager and first draft Medical Director *Version Control Note: All documents in development are indicated by minor versions i.e. 0.1; 0.2 etc. The first version of a document to be approved for release is given major version 1.0. Upon review the first version of a revised document is given the designation 1.1, the second 1.2 etc. until the revised version is approved, whereupon it becomes version 2.0. The system continues in numerical order each time a document is reviewed and approved. For Approval By: Date Approved Version PMAG 02/02/17 4.0 SMT 22/01/14 3.0 Associate Directors Group 14/09/12 2.0 Senior Management group 29/09//08 1.0 Clinical Governance Committee 12/11//08 1.0 Ratified by (If appropriate): Ref. No. OP/035 Title: Maternity Care Policy Page 3 of 29 Published on: Date By Dept The Pulse 07/12/17 (v4.5) Digital Media Officer Comms The Pulse 24/04/17 (v4.3) Governance Administrator G&A The Pulse 03/02/14 (v3.1) Governance Co-ordinator GCT The Pulse 05/10/12 (v2.1) Governance Co-ordinator GCT The Pulse 05/10/10 Governance Administrator GCT LAS Website 07/12/17 (v4.5) Digital Media Officer Comms LAS Website 24/04/17 (v4.3) Governance Administrator G&A LAS Website 03/02/14 (v3.1) Governance Co-ordinator GCT LAS Website 05/10/12 (v2.1) Governance Administrator GCT LAS Website 05/10/10 Governance Administrator GCT Announced Date By Dept on: The RIB 25/04/17 IG Manager G&A The RIB 04/02/14 IG Manager GCT The RIB 09/10/12 IG Manager GCT Equality Analysis completed By on 14/02/17 Medical Directorate team 29/06/10 Medical Directorate team Staffside reviewed on By Links to Related documents or references providing additional information Ref. No. Title Version 2018 LAS London Wide Maternity Divert 3.0 2013 LAS London Wide Maternity Divert Policy 2.0 TP/018 Suspected Cases of Child Abuse Procedure and Recognition of Abuse notes. OP/021 Sharing of Information Agreement between LAS and Metropolitan Police Service Child Protection Unit. OP031 Policy for Consent to Examination or Treatment 3.3 Operational Procedure (OP/028) - Procedure for Specific Named Patient Protocols and No Resuscitation Orders / Advanced Directives. OP039 Resuscitation Policy TP056 Core Training Policy (inc. Training Needs Analysis) OP060 Control Services – Call Taking Procedures 1.8 OP061 Control Services – Dispatch Procedures 1.0 TP006 Serious Incident Policy and Procedure JRCALC UK Ambulance Services Clinical Practice Ref. No. OP/035 Title: Maternity Care Policy Page 4 of 29 Guidance Guidelines (2016) Document Status: This is a controlled record as are the document(s) to which it relates. Whilst all or any part of it may be printed, the electronic version maintained in P&P-File remains the controlled master copy. Any printed copies are neither controlled nor substantive. Ref. No. OP/035 Title: Maternity Care Policy Page 5 of 29 1. Introduction The most important aspect of managing a “maternity call” is to ensure a rapid and accurate assessment of the mother, and where birth has occurred, an assessment of the newborn baby. The Trust recognises that maternity and neonatal care can be high risk for both the mother and her new born baby notably when birth occurs, unplanned, in the pre- hospital setting. This guidance includes, and makes reference to, additional London Ambulance Service (LAS) guidance to ensure staff can discharge their duties safely and effectively. For ambulance service clinicians, the demarcation of pregnancy is considered between whether or not the pregnancy is more or less than 20 completed weeks of pregnancy. This differentiates the location to which a mother will be conveyed as well as ensuring the most appropriate clinician assesses the woman. The current practice is to:  Convey a mother of less than 20 completed weeks of gestation i.e. up to 19 weeks plus 6 days (19+6 weeks) to the emergency department for assessment unless the maternity unit advises of an alternative location during the pre-alert, (and where indicated the baby, if born will accompany her).  A mother of 20 completed weeks or more will be conveyed to a maternity unit for assessment; the location will be determined by the history detailed during the assessment of the attending crew and in the first instance it should be the nearest maternity unit (this may not be the booked unit).  A mother who has recently given birth may be conveyed initially to the nearest ED with an Obstetric Unit. The ED may indicate, during the pre- alert, to direct the ambulance clinician to the maternity unit where the woman is up to and including 14 days post-deliver, however, this may be up to 6 weeks This maternity guidance should be viewed alongside the current clinical practice guidelines. Whereby further evidence becomes available that impacts upon pre- hospital maternity care, this guidance will be reviewed to reflect any changes to practice required. Within the LAS, the Consultant Midwife role and the Practice Leads for Pre Hospital Maternity Care act as a professional point of contact for the Maternity Services across London and also act as the conduit for the maternity risk leads (employed within each maternity service) in ensuring that risk and governance are escalated to the respective trusts, as well as where a maternity unit has concerns with the delivery of pre-hospital care by the LAS. Ref. No. OP/035 Title: Maternity Care Policy Page 6 of 29 2. Scope The policy embraces the guidance in the Clinical Practice Guidelines (2017) on Maternity care (including Obstetrics and Gynaecology). It also details the specific management pathways across London that are unique to the management of women and babies within this area as well as those that are not alluded to in the above guidance, but require clarification to ensure that staff can discharge their duty to patients in the course of their clinical practice. The guidance acknowledges that pregnancy, birth, and the postnatal period are covered herein, however, there is further detail in regards the management of fetal tissue and pregnancy remains as well as resuscitation of the newborn at the extreme of viability (less than 24 completed weeks of pregnancy) Whilst the postnatal period is commonly considered to be up to and including the 6 weeks after birth, consideration is given to the occurrence of secondary postpartum haemorrhage that can occur up to 12 weeks after birth and late maternal deaths up to 12 months. 3. Objectives The Key objectives of the policy are: To provide safe, effective and evidence based emergency maternity and neonatal care outlined in the Clinical Practice Guidelines (2017) and focusing on the special responsibilities with regard to the treatment of women experiencing normal and abnormal labour or birth and any obstetric complication, prior, during and after labour (antenatal, labour and postnatal period.) (The postnatal period being classified as the time from birth of the baby, delivery of the placenta and membranes to six completed weeks after the birth or delivery has taken place. Of note, is that the postnatal period in considering some complications, may extend up to 12 weeks postpartum.) To ensure that staff are equipped with the necessary knowledge and skills to exercise their respective clinical roles within the LAS. To ensure that all grades of staff provide compassionate care in line with their individual scope of practice to which they are employed, including the respective professional code of conduct including those for paramedics, and where attending, midwives. Ref. No. OP/035 Title: Maternity Care Policy Page 7 of 29 4. Responsibilities 4.1 The Clinical Safety and Standards Committee has overall responsibility for managing compliance with the requirements of this policy. VICKY CHECK THIS 4.2 The Medical Director has overall responsibility for the implementation of this policy in accordance with the Clinical Practice Guidelines and for ensuring that all clinical and appropriate non-clinical staff deliver care in accordance with this policy. 4.3 The LAS Consultant Midwife and the Practice Leads for Pre Hospital Maternity Care will advise the Medical Director of current best practice that may be adopted by the LAS over and above that of the Clinical Practice Guidelines for emergency maternity care. The LAS Consultant Midwife will engage with other Trusts’ maternity services to ensure that their processes and procedures are aligned with LAS Control Services and Operational policies. 4.4 All Clinical Staff should ensure that they maintain and update their maternity care assessment, diagnosis and treatment skills according to the training needs analysis (Appendix 11) 4.5 All Control Room staff should ensure that they follow the relevant Control Services Call Taking (OP060) and Dispatch (OP061) Procedures when handling maternity calls, and ensure that they apply internal and external escalatory measures where a pre-attendance assessment indicates that the mother and/or baby may be at risk. If there is risk of delay to clinical staff arriving on scene, the Watch Manager / Area Controller will decide whether to make the request for a midwife to attend whilst the crew are en route. 5. Policy Statement 5.1 The London Ambulance Service NHS Trust (the ‘Trust’) supports the Clinical Practice Guidelines (2016). The Trust recognises that the treatment of pregnant women, women in labour and birthing, and newborn babies require additional measures to ensure that appropriate care is delivered. 5.2 This policy is designed to be read in conjunction with other Trust policies which are detailed on page 4. 6. General Policy – Process for Managing Emergency Maternity Care 6.1 The Trust acknowledges that the best clinical care for a women who is experiencing an abnormal labour or birth is for her to be transferred for further care at the nearest maternity unit in a timely and safe manner.. Ref. No. OP/035 Title: Maternity Care Policy Page 8 of 29 6.2 For some women in normal labour it is appropriate for them to receive an enhanced clinical telephone assessment in order for them to identify who Ref. No. OP/035 Title: Maternity Care Policy Page 9 of 29  can safely and appropriately make their own way to their chosen place for birth i.e. birthing centre or labour ward 7. Telephone Triage for maternity advice 7.1 Every maternity unit is available for midwifery advice, 24 hours a day. This is available for LAS staff whom can contact either the maternity triage (if available) or labour ward:  By use of the woman’s phone, contact the booked maternity unit using the contact details at the front of the maternity hand held records.  Via the clinical hub (this can enable the teleconferencing of the conversation and recording into the patient record if required) 7.2 For those maternity calls requiring further triaging, the clinician in the clinical hub can contact the “Triage” service, within the booked maternity unit, for midwifery advice. This telephone advice can be relayed to the woman directly through the conferenced telephone line and then manually recorded into the call log as a record, including the name of the midwife providing the clinical information. Where the woman is discharged on scene, the woman should be instructed to call her midwife back in the first instance if she has concerns. 7.3 Where an ambulance clinician arrives on scene and assesses either a pregnant woman or a woman who has recently given birth in the previous 10-15 days, advice should be sought from the local maternity unit, and where appropriate, the ambulance clinician may discharge the woman from their care with the relevant advice including a plan for any on-going follow- up. The name of the midwife (including the name of the maternity unit where advice was sought) must be documented in the hand held maternity records (where available) (including the postnatal records up to 10-15 days) and the patient record form (PRF). A copy of the PRF should remain with the maternity notes where care is discharged on scene. 8 The Booked Maternity Unit versus the Nearest Unit 8.1 The majority of women will have booked at a maternity unit by 10-12 weeks of gestation. They will be furnished with a set of maternity records that will detail the relevant maternity and medical history noting significant risk factors. Each maternity unit in London uses a different set of notes. The booked maternity unit is the unit whereby a woman will either receive her antenatal care or plan her birth there (or both). She may also plan to have a homebirth. 8.2 A woman can choose to book her “planned” maternity care and birth in a maternity service of her choosing. The following detail the current options available to women to plan for her birth Ref. No. OP/035 Title: Maternity Care Policy Page 10 of 29   Home birth – care will be provided either by community midwives from the local/nearest geographical maternity service or by independent midwives (employed directly by the woman).  Stand-alone birth centre – For women at low risk of complications. Currently there are three, Edgware Birth Centre, Barkantine Birth Centre and Barking Community Birth Centre (run by midwives and requests for ambulance conveyance from these sites will be through the Health Care Professionals line).  Birth centre within a maternity unit – For women at low risk of complications and enable transfer to a labour ward if required  Labour ward within a maternity unit – These are for women with existing risk factors and those women that choose to opt for epidural anaesthesia for pain relief in labour. 8.3 The booked maternity unit may not be the nearest maternity unit. In the context of the LAS, when a woman calls the emergency service, she should be taken to the nearest maternity unit for a maternal and fetal assessment as soon as reasonably possible even if this is not the booked maternity unit. It is not appropriate for the emergency services to be used as a “taxi” service and as such, where the woman reports a normal history, the ambulance clinician, should engage the midwife in the booked unit in the discussion about on-going plans for care and organise a taxi or the woman can make her own arrangements where safe to do so. This should not involve conveying the mother where the risk assessment by the midwife does not identify any signs or symptoms that are immediately life threatening and require a time critical transfer. It is appropriate therefore to discharge the woman with advice. 8.4 In an emergency, the mother may require immediate maternity care, which can be provided at a nearby maternity unit. In the situation where the booked unit is likely to incur a delay to the receipt of emergency care, then the nearest maternity unit should be located and the mother taken there. 8.5 Where the LAS attend a woman, that is more than 20 weeks gestation, if she is unbooked for maternity care, this information must be conveyed to the nearest maternity unit. 8.6 Unless a maternity unit is on divert (the activity of the London Maternity Units is managed through the LAS London-Wide Divert Policy), a mother needs to be seen at the nearest maternity unit and should be taken there. Crews should ensure the clinical coordination desk (PD09) is provided with the information about the emergency and where the planned destination is. Where staff are not familiar with a particular maternity unit or if staff feel the woman is clinically unstable, a request for maternity staff to meet them at ED or a designated entrance can be helpful to expedite rapid midwifery or obstetric involvement and reduce delays incurred by locating the point of care, or navigation of lifts. Ref. No. OP/035 Title: Maternity Care Policy Page 10 of 29 8.7 Where a midwife is required to attend the scene or home to assist LAS staff, the midwife will be attending from the maternity unit responsible for the Ref. No. OP/035 Title: Maternity Care Policy Page 11 of 29  geographical delivery of community care in the area and this is likely to be the nearest maternity unit. This may not be the booked unit if the mother does not live in the nearby area. To identify which maternity unit is responsible for care, crews should contact clinical Hub, who can contact the respective maternity unit to provide appropriate guidance where required. 8.8 Except if the maternity unit is on divert, a request for a midwife to attend the scene to assist is a reasonable request and should be complied with by the nearest maternity unit. If clinical advice is sought, the clinical hub or the advanced paramedic practitioner can be contacted to provide further information; this is particularly important in the following scenarios where additional clinical advice and instructions can be provided as well as leadership support on scene:  Pre-eclampsia/eclampsia  Pre-term birth