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MAT/GUI/0210/FETABN
MATERNITY SERVICE GUIDELINE
TITLE:
AUTHORS:
GUIDELINE LEAD:
RATIFIED BY:
ACTIVE DATE:
RATIFICATION DATE:
REVIEW DATE:
APPLIES TO:
EXCLUSIONS:
RELATED POLICIES
THIS DOCUMENT REPLACES
1.
Referral when a fetal abnormality is
detected
Ling Wee – Fetal Medicine
Consultant,
Luxmi Velauthar – Senior Clinical
Fellow in Fetal Medicine
Lynn Bonsey- Antenatal Screening
Midwife and Supervisor of
Midwives,
Tim Bollard- Neonatal Unit IT Lead
Lynn Bonsey
Guidelines group
March 2010
February 2010
February 2013
All maternity staff
None
Maternal Antenatal Screening Tests
Guideline. Fetal Medicine
Guideline
Antenatal Booking Guideline
Neonatal Resuscitation Guideline
New Guideline
INTRODUCTION/PURPOSE OF THE GUIDELINE
The purpose of this guideline is to ensure the timely and accurate referral to a
Fetal Medicine Consultant when a fetal abnormality is detected or suspected.
This guideline also covers the support processes for parents when they have
been informed of a suspected or actual poor outcome for their baby.
This guideline has been written in accordance with the recommendations
from National Institute of Health and Clinical Excellence (NICE) (2008)
2.
IMPLEMENTATION
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A paper copy will be attached to the guideline and audit notice boards.
Emailed copies will be sent to all midwives and obstetricians
It will be available via the Trust intranet.
It will be circulated to guidelines folders.
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MAT/GUI/0210/FETABN
3.
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ROLES AND RESPONSIBILITIES
This guideline is the responsibility of all maternity unit staff to carry out clinical
care as described in the guideline, unless there is justification for variation.
4.
GUIDELINE
4.1
REFERRING A WOMAN TO THE TERTIARY CENTRE
4.1.1 When a fetal anomaly is suspected or detected by the sonographers, the
findings are to be discussed directly with the fetal medicine team on site the
same day. If referral is required to another tertiary centre, this will be
organised by the fetal medicine consultant.
4.1.2 Follow up appointments to the fetal medicine unit (FMU) will be made
depending on the findings.
4.1.3 If any fetal anomaly is detected the results will be explained to the parents
and further management options will be discussed (see Appendix 1).
4.2
REFERRING WOMEN TO NEONATAL/ SPECIALIST SERVICES
4.2.1 If fetal anomaly is detected that is amenable to surgery, appropriate follow up
will be made. There is a combined fetal medicine/Neonatal surgery clinic held
at least bimonthly.
4.2.2 However if fetal cardiac anomaly is detected, referral will be made to a
perinatal cardiologist at Great Ormond Street Hospital or another appropriate
hospital. The specialist referral form can be found in FMU/antenatal clinic.
Although Barts and The London NHS Trust is a tertiary referral centre
occasionally it is appropriate to refer to another tertiary centre.
4.2.3 Multi-professional team will be informed as appropriate by email, or letter
(often verbal information is given also).
4.2.4 Multi-disciplinary meetings are held at least bimonthly. All pending cases of
fetal abnormalities are discussed in this forum. Representatives include,
Senior Midwife for Fetal Medicine and/or Antenatal and Newborn Screening
Midwife, obstetric consultant, fetal medicine consultant, neonatology
consultant, geneticist, neonatal surgical team, neonatal nursing team,
perinatal cardiology team (from Great Ormond Street). .
4.3
COMMUNICATION BETWEEN OBSTETRIC, NEONATAL AND
SPECIALIST STAFF IN THE ANTENATAL PERIOD
4.3.1 All management options and plans for care (including intrapartum care,
presence of neonatal team at birth) will be documented in the hand held
Pregnancy Notes on the Management Plan page and Special Features
section (key points from Management Plan). This section also identifies if a
Neonatal Doctor (Barts and The London NHS Trust neonatal services support
Maternity) needs to be present, what grade the doctor should be and reason
for presence required.
4.3.2 Copies of ultrasound scan (USS) report will be posted to the General
Practitioner (GP), named obstetrician and other specialities involved in the
care. A copy is filed in the Maternity Records - Pregnancy Notes.
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MAT/GUI/0210/FETABN
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4.3.3 Referral letters and copies of USS reports will be sent to the Neonatal Team
as required. These will then be filed in the pending cases folder. This folder is
located on Elizabeth Ward (Neonatal Unit).
4.3.4 Where abnormalities are detected, a copy of the scan reports and relevant
letters will be kept in the Brown Fetal File Envelope in the Pregnancy Notes
and transferred to the Postnatal Notes for Baby once the baby has been born.
4.3.5 All monthly meetings of multidisciplinary teams will be minuted and an
electronic copy available on the intranet Q Drive under Fetal Medicine.
4.3.6 Paper copies will be stored in FMU and Neonatal Unit
4.3.7 All Multi-professional discussion with parents should be documented clearly in
the Pregnancy Notes, the Birth Notes and in the Postnatal Notes for Mother.
4.4
COMMUNICATION WITH THE PARENTS
4.4.1 Open Communication is vital to ensure that the parents feel fully supported
and have received quality information to enable them to make informed
decisions about their choices and care when a fetal abnormality has been
detected. All discussions and decisions should be made within a holistic
manner by the multi-disciplinary team (MDT) in partnership with the newborns
family and clearly documented in the woman’s notes. The Antenatal and
Newborn Screening Coordinator, Consultant for fetal medicine and Specialist
midwife for fetal medicine will be sources of support and advice for the
woman and her family throughout the antenatal period. The Bereavement
midwife will liaise with the Fetal Medicine team for follow up care where
necessary. (See Appendix 1 and 2)
4.5
ANTENATAL SUPPORT
4.5.1 Appendix 1 illustrates the pathway of care for those babies who have been
diagnosed with a suspected abnormality. There are also many independent
sources of support for parents outside of the clinical environment such as
charities and parent groups which can provide invaluable knowledge, care
and support for families in the decision making process. Details of these are
available from the fetal medicine department.
4.5.2 Sometimes the suspected problem is resolved without further clinical
intervention. The MDT can still offer reassurance and follow up when
necessary.
4.5.3 If parents decide to opt for fetal termination, this will be organised by FMU
(see the fetal medicine guideline).
4.6
POSTNATAL SUPPORT FOR PARENTS
4.6.1 Appendix 2 illustrates the continuing pathway of care when a baby is born.
Unfortunately not all congenital abnormalities or problems are diagnosed in
the antenatal period and only become identified after a baby is born. This
means the planning and decision making process between parents and the
MDT happens at a much later stage, however a similar plan of care will still
be required for the child within the clinical environment and beyond whenever
a diagnosis is confirmed. (see support for parents in Examination of Newborn
Guidelines)
4.7
SUPPORT FOR PARENTS AND FAMILIES FOR A CHILD THAT DIES
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4.7.1 In the event of fetal bereavement, parents will be referred to the specialist
bereavement midwife and/or the BLT bereavement counselling service or the
appropriate organisations such as Antenatal Results and Choices (ARC) /
Stillbirth and Neonatal Death Society (SANDS).
4.7.2 All parents will be given contact details to fetal medicine unit in case of
concerns.
4.7.3 An appointment will be offered at the multi-professional specialist loss clinic
and where required further referral will be made for those parents who require
genetic counselling.
4.7.4 The process of withdrawal of care should be discussed with great care and
sensitivity with parents. If parents/carers refuse to allow clinicians to withdraw
care against the MDT view that further treatment is futile, legal intervention
may be required under specific circumstances.
4.7.5 Parents and families should be involved in the withdrawal of care and their
wishes respected and supported. They may wish to have souvenir items,
such as hand prints, locks of hair etc
4.7.6 All parents will be offered chaplaincy services or support if required.
4.7.7 All parents should be offered MDT follow up and genetic counselling.
4.8
Documentation Requirements
4.8.1 As stated above, all staff are required to document discussions with parents,
referrals to other colleagues or specialities in the relevant sections of the
Pregnancy Notes. Copies of referrals, results and scans will be filed in the
Pregnancy notes. The bi-monthly MDT meeting will be minuted and electronic
copies available to members of this group.
5
BREACH OF GUIDELINES/POLICIES
The incident will be reviewed within the risk management framework. The
impact of this incident will be reviewed by the appropriate lead clinician and
feedback/ training given to staff as required.
6
MONITORING TOOL
See Appendix 3
REFERENCES
National Institute of Health and Clinical Excellence (2008) Antenatal care: Routine
care for the healthy pregnant woman London: NICE
National Health Service Fetal Anomaly Screening Programme (NHS FASP) (2008)
NHS Fetal Anomaly Screening Programme – Screening for Down’s syndrome:UK
NSC Policy recommendations 2007-2010: Model of Best Practice. London:
Department of Health.
Kirwan, D. & NHS FASP (2010) NHS FASP : 18+0 to 20+6 weeks anomaly scan:
National Standards and Guideance for England. Exeter: NHS FASP.
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APPENDIX 1
Pathway for action following identification of abnormal or suspected fetal
abnormality on ultrasound scan
Abnormality suspected on initial USS
Discuss concerns with woman and partner
Refer to Fetal Medicine for detailed scan
No abnormality detected:
Reassure woman
Document clearly in hand held notes
Abnormality confirmed:
Convey result to woman
Offer counselling and opportunity to discuss
options available
Management Plan discussed and decided.
Inform GP and named Obstetric Consultant
Document all discussion in hand held notes
Follow-up in Fetal Medicine:
Ongoing discussion re management with parents.
Liase with Multidisciplinary Team as appropriate
Support groups offered
Document plan of care clearly in woman’s handheld notes including:
All discussions with obstetric team, named
neonatologist, named community midwife, clinical
genetics, GP and haematology if appropriate.
Plan for management in labour where appropriate
Plan for presence of neonatal team at birth where
appropriate
Appropriate investigations
Plan for postnatal follow up in appropriate clinic, and
genetic counselling if required.
If TOP required:
Arrange admission to appropriate
department
Inform Community Midwife and GP
Inform Chaplain
Offer Support group information
Provide contact numbers for emergency
Abnormality or Problem Resolved
Discussion with MDT if any further follow
up required
Continue to support woman and her
family, communicating at all times with all
professionals involved in her care.
Appendix 2: Pathway for Birth/Post natal care and Continuing Support for Parents (continued on next page)
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MAT/GUI/0210/FETABN
APPENDIX 2
Pathway for Birth/Post-Natal care and Continuing Support for Parents
Appendix 1: Pathway for action following identification of abnormal or suspected Fetal abnormality on
ultrasound scan
C
Continuing input from
Support Services and
organisations
Counselling and
Information giving
Admission to Labour Ward
and Post Natal Ward
Admission to NNU not
required
BIRTH
Undetected abnormality
noted
No previous diagnosis
Continuing management
discussion from Monthly Fetal
Medicine meeting
Multidisciplinary Team input for
strategic management of care
Agreed plan of care with family
clearly documented
Admission to Neonatal Unit
Confirmation of Diagnosis and plan of care
discussed and documented
Medical /Surgical Care given as required
Discharge planning with Family and Multidisciplinary Team Input
Planned care for baby out of the clinical environment discussed and
organised with the family and the MDT
Paediatric Ward
HOME
Death
Withdrawal of
Care
Community Support/CCNT/Social
Services
Community Neonatal Nurse/Health
Visitor
Support Services BLISS/SANDS etc
Hospice
Respite Care
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MAT/GUI/0210/FETABN
APPENDIX 3
Monitoring Referral when a fetal abnormality is detected
Key Element to
be monitored
Lead
Monitoring
tool
Monitoring
Frequency
Committee to review
the results and receive
the reports
Acting on
recommendations
Implementation of practice
changes and
lessons learned.
Sharing best practice
Women are
referred to a
tertiary centre or
specialist /
neonatal services
when required
Fetal medicine
team
Fetal medicine
notes
audit
Monthly
Antenatal screening
committee and Fetal
Medicine Team to identify
actions. Review changes
required and guidelines for
practice
Antenatal screening
committee
Action plans monitored for
implementation of changes
in practice
Best practice will be shared
through presentation of audit
and findings advertised on
audit boards
Women are kept
informed
throughout the
process
Fetal medicine
team
Fetal medicine
notes
audit
Monthly
Antenatal screening
committee and fetal
medicine team to identify
actions and compliance with
pathway of care
Antenatal Screening
Committee
Best practice will be shared
through presentation of audit
and findings advertised on
audit boards
Communication
between Obstetric
/ neonatal and
specialist staff in
the antenatal
period
Fetal medicine
team
Fetal medicine
notes
audit
Monthly
Antenatal screening
committee and fetal
medicine team to identify
actions and compliance with
pathway of care
Antenatal Screening
Committee / Specialist
Loss Team
Best practice will be shared
through presentation of audit
and findings advertised on
audit boards
Documentation of
all
communications
and referral
processes
Fetal medicine
team
Fetal medicine
notes
audit
Monthly
Antenatal screening
committee and fetal
medicine team to identify
actions and compliance with
pathway of care
Antenatal Screening
Committee / Specialist
Loss Team
Action plans monitored for
implementation of changes
in practice
Best practice will be shared
through presentation of audit
and findings advertised on
audit boards
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