MAT/GUI/0410/ANBOOK
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MATERNITY SERVICE GUIDELINE
TITLE:
AUTHORS:
GUIDELINE LEAD:
RATIFIED BY:
ACTIVE DATE:
RATIFICATION DATE:
REVIEW DATE:
APPLIES TO:
EXCLUSIONS:
RELATED POLICIES
THIS DOCUMENT REPLACES
Antenatal care Booking and Missed
Appointment Guidelines
Del Beckford, Supervisor of
Midwives
Helliner Robinson, PD Midwife
Denise McEneaney, Supervisor of
Midwives
Del Beckford.
Guidelines Group
February 2010
January 2010
January 2013
All maternity unit staff
None
Maternity Records Policy 2010
Antenatal Care Guidelines (V 3)
Antenatal Care Booking/DNA
Guidelines(2005),Late bookers for
Antenatal care(March 2007),DNA
Antenatal care(2007).
1.
INTRODUCTION AND PURPOSE OF THE GUIDELINE.
1.1
These guidelines aim to follow the Antenatal recommendations issued by
National Institute of Health and Clinical Excellence (NICE) (2008) the
approach to antenatal care in the UK has undergone considerable change and
antenatal care and is increasingly occurring in the primary care setting (Royal
College of Obstetricians and Gynaecologists (RCOG) 2000).
We aim to ensure that all doctors and midwives throughout East London
deliver a consistently high standard of care to pregnant women. Teams of
midwives based in the community and a small number of core midwives in
antenatal clinic provide midwifery care for women who book with the Royal
London Hospital. The service
model will continue to adapt in response to
women’s needs and best practice standards.
We aim to provide
individualised, women-centre care throughout pregnancy, labour and
puerperium (Department of Health (DH) 2007). All women will have access to
a Named Midwife and Midwifery Team who will enable women to be partners
in their care.
This Guideline is to ensure that Antenatal women are given the earliest
opportunities to access early maternity antenatal care to mothers, baby and
family. Saving mothers’ lives (Confidential Enquiry into Maternal and Child
Health (CEMACH), 2007) identifies that around 20% of women who died from
direct or indirect causes either booked for Maternity care after 20weeks
1.2
1.3
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1.4
1.5
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gestation, missed over four routine appointments, did not seek care at all or
actively concealed their pregnancies.
All women should expect a standardised approach to accessing antenatal care
which includes the booking referral pathway once pregnancy is confirmed; the
booking interview enabling a detailed medical, social and obstetric history to
be taken, the expected schedule of antenatal appointments in an
uncomplicated pregnancy and recommendations for antenatal missed
appointments whether this be midwifery clinic or consultant clinic.
This Guideline will provide a care pathway for:
Booking women for Antenatal care
Late Bookers for Antenatal Care
Missed antenatal appointments
2.
IMPLEMENTATION
2.1
The updated paper copy will be attached to guideline notice board, in each
clinical area for four weeks.
Electronic copies will be distributed to the lead Midwives in each clinical area.
The guideline will be available via the trust intranet and circulated to guidelines
folders in all care settings.
2.2
2.3
ROLES AND RESPONSIBILITIES
3.
3.1 It is the responsibility of all maternity unit staff to carry out clinical care
as
described in the guideline unless there is justification for variation and the
reason is documented. Further detail is in section 4.
4.
GUIDELINE
4.1
BOOKING APPOINTMENT STANDARDS AND PROCESS FOR ENSURING
WOMEN HAVE THEIR FIRST FULL BOOKING VISIT BY 12WEEKS 6 DAYS

Women will be offered an appointment to be booked by 12+6 weeks. The
Barts and the London ‘Your Antenatal Care’ leaflet is available from GP
surgeries, children’s centres and clinics and advises all women to refer for
first booking ideally before 9 weeks. This is to enable 2 visits in the first
trimester of pregnancy.

Women referred after 12 completed weeks will be booked within 10 working
days.

In an attempt to achieve the 12+6 weeks booking a fast track to the ‘Baby
and me’ one Stop Clinic is available where needed for women to have their
first full booking at the time of their first offered scan. Fast track Obstetric
Consultant appointments can also be made for high risk Obstetric referrals
within 5 working days or sooner if needed by contacting Antenatal Clinic
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(ANC) on 0207 377 3448. Alternatively Fax referral can be sent on 0207 377
7460 requesting urgent appointment and this will be organised as soon as
possible by the Antenatal Clinic Manager.
4.1.1
Women from Tower Hamlets will be allocated to a midwifery team depending
on the location of their GP. The teams are currently GP attached and are
divided into localities.
4.1.2
Women who are known Type 1 or 2 Diabetics will be referred to the Diabetes
Specialist Midwife for early antenatal booking.
Women who live outside Tower Hamlets will be referred to City Team
Midwives
4.1.3
4.2
REFERRAL PROCESS
4.2.1
Self or Direct referral:
Women may self refer directly to a midwife by contacting the Community
Midwives on 020 7377 7658. The Community Administration Manager will
identify the appropriate midwifery team to contact the woman within 5 days of
the referral to arrange a booking appointment
4.2.2 GP/Midwife Referral
This is the most common referral route. A standardised booking referral form
is completed by the GP/Midwife and faxed to Antenatal Clinic using agreed
proforma.
Address
Antenatal Clinic
1st Floor, Outpatient's Department
The Royal London Hospital
Whitechapel Road
London E1 1BB
Fax number
020 7377 7460
4.2.3
The majority of GP surgeries have a regular midwifery clinic and the GP
reception staff will arrange the midwifery booking appointment. This
information will be recorded on the GP referral form.
4.3
4.3.1
4.3.2
REFERRAL ADMINISTRATION PROCESS
Hospital based Antenatal Clinic Maternity Staff:
GP Pregnancy Referral letters to be date stamped on receipt by maternity
staff in ANC. All referral letters are logged in the “referral book” kept in ANC
Antenatal clinic midwifery team to review and triage all referrals within
2
working days of receipt, and identify those with high-risk pregnancies,
ensuring woman is booked under care of appropriate obstetric
consultant
team.
Ensure the referrer had documented the woman’s last menstrual period date
(LMP) and confirm the expected date of delivery (EDD).
4.3.3
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4.3.4
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Send copy of GP referral form plus 2 scan request forms (one for dating
and/or combined screening and one for anomaly scan) to the Obstetric
Ultrasound Department (Basement, Holland Wing). Ultrasound clerk will post
appointment and information leaflet to woman.
4.3.5
Outpatient Clerks (allocated to Hospital Based Antenatal Clinic)
Identify existing hospital number or allocate hospital record number for new
women to the hospital.
4.3.6 Print set of patient Identification (ID) labels.
4.3.7 Request main hospital notes and file these in Maternity Library (located in
Antenatal Clinic). This ensures that health records from previous pregnancies
and main hospital records are available for review by clinicians.
4.3.8
Book appointment by telephoning the woman with a choice of appointment
date/s and time/s with appropriate consultant for high risk women (ANC
midwife will provide guidance for admin staff on this).
4.3.9 All low risk women to be booked under allocated community midwifery team
or consultant midwife as ‘lead professional.’ The lead professional must be
documented on the front of the woman’s notes and CRS
4.3.10 ANC clerk to contact woman with a choice of appointment date/s and time/s
for booking history
4.3.11 Community Administration Manager
Daily collection (Monday – Friday) of GP referral letters from designated area
in the antenatal clinic and distribute to the appropriate community teams to
arrange booking appointments within agreed timeframe if not already done.
Enter women’s details on ‘GP Referrals’ database.
4.3.12 Community Based Midwives
Arrange a booking appointment for women within agreed timeframe if not
already done. If there are no available booking appointments in the GP clinic,
midwife to discuss with the woman and offer a home booking.
4.4
4.4.1
4.4.2
4.4.3
BOOKING APPOINTMENT DOCUMENTATION
All women will be seen by a midwife for the booking appointment. During this
appointment, a thorough health and social needs assessment will take place
following the guidance in the Antenatal Care Guidelines. This information
should be recorded in the maternity handheld records as identify in the
Maternity Records Guideline.
Clinical assessment for migrant women who have not had a full medical
examination in the United Kingdom. Migrant women should have a full
medical assessment including a heart and lung check. This will usually be
completed on the GP referral form but if this is missing, or the woman has
self referred, the midwife will arrange an appointment at the GP surgery (or
hospital antenatal clinic if the woman is not registered with a GP) to have this
examination carried out. This will be documented in the pregnancy notes as
completed on page 3 medical history under physical examination
All low risk women to be booked under allocated community midwifery team
or consultant midwife as ‘lead professional.’ The lead professional must be
documented on the front of the woman’s notes and CRS If the lead
professional is changed from midwife to consultant during the antenatal
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4.4.4
4.4.5
4.4.6
4.4.7
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period, the consultant confirming this change must complete a proforma titled
‘Change to Consultant Led Care’. This needs to be sent to the community
team or consultant midwife (whoever was previous lead professional) and
GP. ANC clerks will change lead professional on CRS
Community Midwives to complete Antenatal clinic diaries or clinic log sheets
(bookings and follow up's) and forward to Community Administrative
manager to update GP Referral database (this database monitors gestation
at booking).
Hospital based midwives to complete Antenatal Clinic Booking information to
monitor gestation at booking.
The booking Midwife to complete PAS form following all bookings and return
to the hospital Antenatal Clinic. ANC clerk will enter social details on CRS
and add to ‘Booked List (EDD must be confirmed.)
The booking midwife to enter maternal booking assessment details on CRS
such as Medical, Family & Obstetric history.
4.5
BABY AND ME - ONE STOP CLINIC
4.5.1
This is a new service in the maternal and Fetal assessment Clinic has been
developed to support the booking process, assist risk assessment for the
woman and agreement of appropriate care pathway. This contact also offers
the woman the opportunity to discuss early pregnancy information, maternal
screening results and to discus and questions regarding combined screening
tests.
This contact is being implemented in 2010, and by July 2010 will be offered
to all women. Access to this clinic will be linked to the dating/combined
screening appointment.
4.5.2
4.6
LATE BOOKINGS
4.6.1
Ascertain the reason for late referral and stress the importance of regular
antenatal care. Ensure the appointment is arranged within 2 weeks of receipt
of the referral (or fast track as required) see 4.1.
If a woman has booked too late to make use of screening tests, explain and
document this. Highlight late booking as risk factor on page 11 of the
Pregnancy Notes.
The blood pressure in the 2nd trimester may not reflect the true blood
pressure of the woman due to the physiological drop in the 2 nd trimester.
Note BMI may not be as accurate depending on gestation. If the woman
knows her early pregnancy weight, calculate Body Mass Index according to
this.
Discuss with named Supervisor of Midwives/Community Midwifery Manager
if you have concerns and require support to plan future care.
4.6.2
4.6.3
4.6.4
4.7
MISSED BOOKING OR FOLLOW UP APPOINTMENT GUIDEANCE
(OFTEN CALLED DNA’S). PLEASE SEE FLOW CHART Appendix 1.
4.7.1
Non attendance has a strong correlation with poor maternal and neonatal
outcomes. It is essential that a proactive and innovative approach is taken by
all maternity staff to support early and regular contact with maternity services.
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4.7.2
4.7.3
4.7.4
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Women will usually attend if they understand the reason for the appointment,
is at a time that is manageable for them. Where possible, antenatal contacts
should be offered in community locations, close to the woman’s home and at
a time that is convenient to the woman.
Midwives must update CRS if a woman fails to attend her booking of follow
up appointment and offer subsequent appointment.
Medical staff will liaise with midwifery staff to support attendance if the
woman did not attend (DNA) and initiate the guidance in Appendix 1 as
necessary.
Administrative staff must support the maternity team in organising
appointments and generating appointment letters.
5
PROCESS FOR ARRANGING AVAILABILITY OF HEALTH RECORDS
5.1.
Initialising Maternity Records

The referral letter will be completed by the first professional that the woman
refers herself to. This may be her Midwife or General practitioner.
The referral letter should be completed using the clinical risk assessment
(antenatal) guideline which will classify that the women will be booked for
Team Care (High Risk) or Midwife Led Care (low risk). This box MUST be
ticked to enable direct referral to the appropriate pathway of care.
The woman’s maternity record will be ordered on receipt of the referral form
and will be filed in the ‘mini maternity library’, for access at any time that the
woman is admitted to the hospital.
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5.2
Mini Maternity Library

The clerk will file all of the women’s main hospital records received from
medical records into the mini maternity library. They will remain in the library
for the remainder of the pregnancy and retrieved as required for all
CONSULTANT LED CLINICS, ALL JOINT CLINICS and ANY HOSPITAL
ADMISSION.
The main hospital record will not be required for LOW RISK MIDWIFE LED
CLINICS.
On a daily basis records received will be checked off on the list prior to filing.
Any records that are not received in a reasonable time frame must be
reordered.
The clerk in the mini maternity library is responsible for retrieving the hospital
notes for the clinics as required and refilling them on their return.
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5.3
Process for requesting notes from previous pregnancies (not at Barts
and the London NHS Trust) but a copy required based on high risk
condition or other concerns

If following obstetric review it is important that copies of notes are retrieved
from another maternity unit a letter will be sent from the Consultant or lead
midwife for Antenatal Clinic and a copy of the letter kept in the woman’s
handheld record. When notes arrive at the antenatal clinic they will be filed in
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the Main Maternity record for review at subsequent appointments as
required.
6.
6.1
BREACH OF GUIDELINES
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.
7.
7.1
MONITORING COMPLIANCE
See Appendix 2
REFERENCES:
1. Department of Health, Welsh Office, Scottish Office Department &
Department of Health and Social Services, Northern Ireland. (1998)
Why mothers die: report on confidential enquiries into maternal
Deaths in the UK 1994-1996.London: Statutory Office
2. Confidential Enquiry into Maternity and Child Health (2007) Saving
Mothers’ Lives. Reviewing maternal deaths to make motherhood
safer-2003-2005. London: CEMACH
3. Confidential Enquiries into Maternal Deaths in the United Kingdom
(2001) Why mothers die 1997-1999: the fifth report of the
confidential enquiry into maternal deaths in the U.K. London:
CEMD. Available at: www.cmace.org.uk
4. Department of Health (2007) Maternity Matters: Choice, access
and continuity of care in a safe service. London: DH.
5. National Institute of Health and Clinical Excellence (NICE) (2008)
Antenatal care: Routine care for the healthy pregnant woman.
London: NICE
6. Petrou, S. Kupek, E. Vause, S. Maresh, M. (2003) Antenatal visits
and adverse perinatal outcomes: results from a British population –
based study. European Journal of Obstetrics and Gynecology and
Reporductive Biology. 106(1), pp40-49.
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Appendix 1
Woman does not attend appointment (DNA)
Check EDD – has she given birth/miscarried? TOP
Yes – No
further action
required
Hospital Clinic
1st DNA, another appt is sent
out to woman by ANC clerk
Woman attends appointment. Record previous
DNA and reason in Pregnancy Notes. Stress
importance of regular attendance.
Community Midwives
1st DNA, call woman to
arrange next appointment or
send letter if not available
2nd non attendance
Midwife to contact woman, and/or speak to GP to
ascertain if she has been seen by GP (or CMW’s if
she has DNA’d hospital ANC). Ask if the woman
has booked elsewhere. Confirm known address
and contact details with GP.
Arrange home visit by Community Midwife to do
an ANC check, booking and/or arrange follow up
appointments.
If referred to City Team, follow as above and refer
to CMW in the area where woman lives. Request
home visit and encourage woman to attend next
appt. Request feedback from CMW following
home visit.
Woman attends appointment. Record previous
DNA and reason in Pregnancy Notes. Stress
importance of regular attendance.
If in any doubt at any stage, liaise
with either the Band 7 Midwife
Area/Team Manager or Community
Manager/Matron or your named
Supervisor of Midwives
Document in pregnancy record all
discussions and plans for care –
page 11 pregnancy notes
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Recording non
attendance:
Record on CRS
Ensure next
appointment
booked
Woman did not attend appt., process above
repeated. If unable to contact woman (no known
address or has left last known address and no
contact Tel number), inform SOM.
Consider Child Protection alert to London
hospitals. Inform GP. Liaise with Social Worker if
applicable.
Take off booked list if woman has
moved to another area
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Monitoring
lead
Monitoring
tool
Monitoring time frame.
Elements to be monitored
Responsibilities of different staff
groups related to giving and
documenting pt information at
different stages of pregnancy
Audit and
Quality midwife
and community
manager
Community
GP Referral
database
Monitor timeframes on
database
Community
admin
manager
Community
GP Referral
database
Continuous – reported
monthly on maternity
dashboard
APPENDIX 2
Timeframe of receipt of referral
in ANC, receipt by CMW’s and
date of booking
Continuous audit of gestation at
booking
Process for ensuring that
women who refer > 12 weeks
are booked within 2 weeks
Process for clinical assessment
of migrant women including
completion of heart and lung
check
Audit and
Quality audit
lead
Availability of health records
Lead ANC
midwife
Missed appointments
DNA recorded on CRS
Next appointment booked
Referral to CMW’s if DNA’d
twice.
Audit and
Quality Audit
midwife Lead
ANC midwife
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Notes audit
Audit tool to
monitor
number of
health
records
available
Audit tool to
monitor
booking and
follow up
DNA’s
Dashboard reported
externally to the trust
monthly
Monthly – 10 sets of notes
(incorporate in
documentation audit)
Community midwifery
audit for high risk women
(Gateway team)
Quarterly audit for 1 week
period of hospital based
antenatal clinic sessions.
Completed every 3
months
Quarterly audit for 1 week
period of hospital based
clinic sessions
Committee to receive
the report.
Action plan lead
committee
Implementing and
sharing best practice
The Maternity and
Gynaecology Audit
Committee will receive
completed reports. Audit
feedback and resultant
action plans will be fed
back to the maternity and
Gynaecology governance
Board
Acting on
recommendation
s and Lead(s)
The Maternity and
Gynaecology Audit
Committee will
lead on the action
plan.
Change in practice and
lessons to be shared
The leads of the Maternity
and Gynaecology Audit
Committee will be
expected to read and
interrogate the report to
identify deficiencies in the
record keeping system.
Minutes will be clearly
documented.
Any deficiencies will be
addressed through multiprofessional action
planning. Actions will be
taken through teaching
where necessary.
Recommendations
will be allocated to
key areas of
practice with
identified leads.
Required actions
will be identified
and completed in a
specified
timeframe and
monitored by the
Maternity and
Gynaecology audit
committee.
Required changes to
practice will be identified
and actioned within a
specific time frame
documented in the
agreed action plan. A
lead member of the team
will be identified to take
each change forward
where appropriate.
Lessons will be shared
with all the relevant
stakeholders.