NHS Grampian
Maternity Strategy
DRAFT March 2007
This strategy is available in large print and on
computer disk. Other formats and languages can be
supplied on request. Please contact NHS Grampian
Corporate Communications Team on 01224 554400 for
details.
1
CONTENTS
Summary
1.
Background
2.
Progress to Date
3.
Preconception and Early Pregnancy
4.
Public Health and Maternity Services
5.
Pregnancy and Newborn Screening
6.
Assessing and Managing Risk
7.
Training and Education
8.
Public Involvement
9.
Workforce Planning
10.
Neonatal Care
11.
Environment of Care
12.
Recommendations summary
Appendix 1
Maternity Service Profile
Appendix 2
Policy Documents and Papers
Appendix 3
A Framework for Maternity Services in Scotland
Appendix 4
Antenatal Care in Grampian Guidelines 2007
2
MATERNITY STRATEGY FOR GRAMPIAN - 2007
Summary
NHS Grampian has a long history of providing maternity care for women in a
range of settings with access to a team of health care professionals according
to the needs of the woman and her baby. At times changes to the service
become inevitable in response to new clinical evidence about the way care
should be delivered, movements in where the population reside, changes in
the health of women having babies, changes to the numbers of staff available
to deliver this care and changes to services which link in with maternity care.
The underpinning principles in providing Maternity Care is similar to all other
care in that it should be provided by staff who are suitably prepared for the
roles they perform, that the service is managed effectively and efficiently and
that the service itself is sustainable.
These issues have led to the production of a NHS Grampian Maternity
Strategy which looks at all of these influences in the context of enabling
women and their families to have the best possible experiences and
outcomes from their involvement with the Maternity Services in Grampian.
This will be achieved by reviewing the services that exist and confirming they
are fit for purpose, looking at any gaps that exist and prioritising the work
required to ensure the service remains dynamic, effective and efficient.
We know from evidence that generally healthy woman have healthy babies
and this strategy aims to ensure that women are encouraged and supported
to improve their health before, through and after pregnancy. The strategy is
centred on women and their families and also demonstrates the values and
needs of the professionals who provide the care. Initial data for 2006 indicates
that in 2006, 5,800 live babies were born in Grampian. In addition a significant
number had miscarriages and a small number (30) had stillborn babies.
Approximately 850 babies require admission to a Neonatal Unit for care
management.
NHS Grampian considers that good communication between women and
those caring for them and their babies is central to the provision of excellent
maternity care. This communication and the written information which
reinforces it play a vital part in ensuring that women feel part of any decisions
necessary about their care and in enabling choices about the care content.
This is a fundamental principle which runs through the strategy.
The strategy looks at the “pregnancy year“, reflecting the fact that good health
prior to pregnancy is highly desirable and in the control of the majority of
women. The post natal period is a time of physical and emotional adjustment
which can be influenced by factors which occur throughout the pregnancy
episode. Support in the post natal period is important to establish good
physical and emotional health. An integrated care pathway approach is and
the strategy will address this.
3
It is important that the service analyses its performance in a structured way.
Clinical risk management activity is essential for the services to reflect on
comments, complaints and clinical incidents that occur. A programme of
clinical audit provides evidence of measuring outcomes and compliance with
best practice statements The Strategy reinforces this activity and ensures that
there are strong links with NHS Grampian Clinical Governance processes.
Ensuring that staff are educated and trained well to deliver the care in all
settings where the service is delivered, is a fundamental principle in any care
setting. The strategy describes what is in place and encourages some
initiatives to ensure that the education issues are being anticipated and
addressed appropriately.
Emerging issues in Maternity Services include a growth in the number of
women with special needs, be that physical disability, mental ill health, non
English speakers, substance misusers or the very young. Multi disciplinary
and multi agency working is essential in these cases and additional time is
often required to ensure the best possible outcome for mother and baby. The
strategy recommends approaches which may assist in tackling these issues.
Public involvement in planning and delivering changes in services are crucial
to ensure that the changes are understood and acceptable to service users.
NHS Grampian gives commitment to establishing effective Liaison
Committees, the number depending on the location of services. At present we
await the outcome of the Ministerial Action Group to inform a way ahead but
we are committed to making progress in this area.
Finally NHS Grampian is committed to supporting the national work towards
promoting normality in maternity services. The strategy demonstrates the
initiatives in Grampian which will enable activity around this.
4
RECOMMENDATION SUMMARY
1.
Governance
The Maternity Services Clinical Management Board should lead
Maternity Services in Grampian by active participation of all
sectors so that key changes are discussed and debated and by
communicating more widely with the stakeholders.
The Birth Unit concept in Aberdeenshire CHP should be evaluated
over a time frame to be agreed. There should be no expansion of
this concept until that evaluation has taken place.
2.
Activity
The impact of changing demographics and ethnicity for the
Maternity Services is not yet clear and more intelligence must be
gathered around this to ensure health needs are known and
addressed as appropriate.
3.
Pre-Pregnancy Care
As well as the general activity provided by health promotion
services, more targeted activity should be designed to reach
women who are planning pregnancy so that they are in the
optimum health from the outset.
Health promotion activity in the education (school) sector
requires regular liaison with NHS maternity care providers locally
to maximise the potential of targeting pupils at the most
appropriate times.
Women requesting pre pregnancy advice should be able to
access an appropriate health professional including the midwife
on an individual basis.
Community Pharmacists should be encouraged to maximise
opportunities to participate in pre pregnancy preparation.
Provision of health education, folic acid with pregnancy testing
kits and smoking cessation support are examples of this.
4.
Public Health - Smoking
Smoking cessation interventions must be offered to every
pregnant woman who smokes and the most appropriate
arrangements made for each individual woman
5
Training and educational opportunities must be made available to
key professionals who care for pregnant women, in particular
Community Midwives who deliver the majority of a woman’s care.
Robust evaluation of outcomes must be available to inform
progress and measure success.
5.
Public Health – Domestic Abuse
Women should be asked about Domestic Abuse routinely at some
point in pregnancy which may be dependant on when a midwife
can see the woman on her own.
Midwives and others in the Pregnancy Team should have access
to awareness and routine enquiry training to ensure appropriate
skills exist to manage any disclosure which occurs.
The Maternity Services in Grampian should undertake an audit of
disclosure to assess the effects of routine enquiry.
6.
Perinatal Mental Health
Recent progress should be maintained in all aspects of the
service.
Appropriate education and training programmes for key staff
including midwives, health visitors and community psychiatric
nurses should be a priority for the newly appointed Specialist
Nurse. This can be a graduated approach including awareness
sessions on mental health and mental illness, more detailed
education for those conducting assessments and providing on
going support and specialist education for a small number who
wish to reach that level of expertise.
7.
Substance Misuse
Continue to monitor the service to ensure that it is meeting need.
Continue to develop the expertise of the wider professional
community so that skills expand in local settings.
Assess the impact on Neonatal Unit and consider alternative ways
of delivering care minimising the need for separating mother and
baby.
Consider how alcohol misuse may be impacting on Maternity
Service and pregnancy outcomes.
6
8.
Child Protection
Ensure that Child Protection remains at the forefront throughout
the pregnancy episode by providing regular awareness training
for all staff.
Continue to provide more specific training for case load holders
and those contributing to Child Protection Case Conferences.
9.
Neonatal Care
Continue to build expertise in modern neonatal care management
and reflect this in care management.
Develop and utilise the expertise of the wider team in delivering
routine care for neonates to maximise availability of cots in
Neonatal Unit.
Continue to support the service in Dr Gray’s Elgin, the Regional
Neonatal Transport Service and the Neonatal Resuscitation
Programme.
Continue to work closely with Combined Child Health Service.
10.
Risk Management
Continue to develop Risk management activity by involving as
many care providers as possible. This should include active
involvement of Supervisors of Midwives.
The outcomes of critical incident reviews must be reflected in
service improvement and education and training whenever
indicated.
Continue to develop written information for women which
contains the best available evidence presented in non technical
terms and make this available at appropriate times during the
pregnancy.
11.
Education and Training
Continue to develop relevant education events to meet the diverse
needs of the care professionals and monitor their
appropriateness.
Continue to work collaboratively with education providers as
demonstrated by the joint programme for Maternity Care
Assistants with RGU and Assisted Birth Practitioners with the
University of Bradford.
7
Continue to develop staff according to service need as well as
professional desires to ensure that the demands of a dynamic
service are being met.
12.
Public Involvement
Take steps to establish effective Maternity Services Liaison
Committee(s) accessible for women across Grampian.
13.
Workforce Planning
As far as possible prepare plans to meet the demands of
Modernising Medical Careers and Working Time Directives for
medical staff in all services.
NHS Grampian should continue to explore workforce modelling
with accredited tools for midwifery and neonatal care so that there
is evidence to support workforce resource requirement and
allowing benchmarking across Health Boards.
New roles should continue to be developed and be service driven
and supported by New Roles Framework document, ensuring that
education and training are anticipated, planned and delivered
before the roles are implemented.
Further work should be undertaken to explore the potential for
regional working and maximising potential for e Health systems.
Ensure that any developments in workforce are assessed
financially to confirm that service remains affordable and
sustainable.
14.
Care Environment
Consideration must be given to the replacement of Aberdeen
Maternity Hospital, including Neonatal Unit with a modern
purpose built facility, linked to main services in Aberdeen Royal
Infirmary.
8
1.
BACKGROUND
It is recognised that for the vast majority of women, pregnancy is not an illness
but is a major life experience with significant social and psychological impacts on
the woman and her family. However in addition some women and babies do
require specialist care and it is incumbent on NHS Grampian to ensure that the
entire service is provided to the required standard. A service description is
provided in Appendix 1.
The model of care in Grampian is designed to ensure that each woman receives
care tailored to her individual needs. Systematic reviews of trials for low-risk
women have shown that routine antenatal care for low-risk woman in community
settings by GPs and midwives appears as clinically effective as obstetrician-led
shared care, and is highly acceptable to women. Reviews also indicate that
reduced schedules of routine visits could be implemented without jeopardising
safety for mothers or babies. The model includes:

Woman-centred care according to personal needs

Locally accessible and community-based care with access to a specialist
as needed.

Fewer but systematic visits to improve consistency, continuity and reduce
duplication
Joint working supported between primary, secondary and tertiary services

This means that if all is well obstetrically and medically and the woman chooses,
her care is carried out in the community by midwives and GPs with easy referral
to Obstetricians if a complication develops. However if the complication resolves
the care is transferred back to community care.
Positive experiences and outcomes of care can be facilitated by adhering to
the principles contained in A Framework for Maternity Services in Scotland
(2001) and the subsequent Expert Group Report on Acute Maternity Services
in Scotland (EGAMS 2003). These principles are as relevant in 2007 as they
were at the outset.
These principles




Support partnership between women, their families and the
professionals providing care
Celebrate pregnancy and childbirth as normal physiological events in a
woman’s life
Seek to improve the standard of care by challenging professionals to
meet the needs of women and their families
Promote care delivered in the most appropriate setting by well trained
and educated staff using risk assessment techniques to aid clinical
decision making
9

Promote a Regional approach to service planning and delivery
wherever appropriate
These principles form a template for maternity care throughout Grampian
whilst considering their local application in a range of geographical settings in
a mixed urban and rural environment. They are underpinned by professional
best practice statements, clinical guidelines, health reports, national and local
perinatal morbidity and mortality statistics, and consider both clinical and staff
governance as well as public expectation and involvement.
The multidisciplinary team is tailored to the needs of individual women and
their babies and includes midwives, General Practitioners, Obstetricians,
Anaesthetists, Allied Health Professionals, Neonatologists and Neonatal
Nurses, Community Psychiatric Nurses, Health Visitors, social workers and
other experts as required.
Effective Maternity Services are dependant on this group of Health
Professionals to be appropriately trained and educated to deliver the best
possible care. There are close links with the two local Universities, the Robert
Gordon University who provides pre and post registration programmes for
midwives, nurses and professions allied to health and Aberdeen University
who provides programmes for medical staff. As important are locally provided
practical skills seminars and courses where issues can be analysed in a
pragmatic way by the team of staff who deliver the care in that setting
Influences on the content and organisation of Maternity Care come from a
variety of sources including professional organisations such as the Royal
College of Obstetricians and Gynaecologists, the Royal College of Midwives,
the Royal College of Anaesthetists, the British Association of Perinatal
Medicine, the Nursing and Midwifery Council (NMC), and National Institute for
Clinical Evidence (NICE). NHS Quality Improvement Scotland (QIS) set
standards for care the most notable being the Maternity Standards which
were inspected in April 2006 and the Clinical Standards for Anaesthesia which
were inspected in mid 2005. The next standard to be inspected relates to
Pregnancy and Newborn Screening which is planned for late 2007 (date to be
confirmed). Maternity Services also participate in national reviews through the
Scottish Programme for Clinical Effectiveness in Reproductive Health
(SPCERH) which produces various publications on audits of maternal
morbidity and mortality. On a UK wide basis the service participates in
Confidential Enquiries into Maternal and Child Deaths which reports every 3
years.
Maternity Services are also subject to national Health Department planning
and directives the most pertinent being the report produced by Professor
David Kerr in 2005 which set out a national framework for service change in
NHS Scotland. Whist Maternity Services were not emphasised in this report
many services which support Maternity Services have to address the
recommendations. Messages from the change agenda are that care must be
effective, efficient and sustainable. It should be delivered in the most
appropriate setting depending on its complexity and available expertise to
10
deliver the care safely. For some services that will mean a move from large
hospital based care to more local care, for others the move will be to
centralise care in the big centres. For maternity services the model of care will
remain women focussed and midwife led, delivered locally as far as possible
with access to expert services as and when needed.
To further assess the impact of modernising the NHS on Maternity services a
Ministerial Action Group has been established to look at aspects of the
service including a Neonatal Service Review, the promotion of normality, a
review of Liaison Committees, and aspects of transport in particular in remote
areas. The outcomes of this review can not be included in this strategy but
attempts will be made to anticipate recommendations where appropriate.
Workforce planning is fundamental to how Maternity Services can be
delivered in the future. Changes to the way medical staff are trained
(Modernising Medical Careers) is already impacting on junior medical staff in
all specialties, Working Time Directives impose limits on the hours of work for
all staff groups and more flexible working patterns can limit the availability of
staff in some areas. This is being addressed at local and regional level using
manpower modelling tools for example in Neonatal Nursing and Birthrate Plus
for midwives. This is already leading to the emergence of new roles such as
Maternity Care Assistants, Assisted Birth Practitioners and Advanced
Neonatal Nurse Practitioners who will enable care to be provided in a different
way, supported by robust education preparation.
NHS Grampian has a Health Plan (Healthfit – Tomorrow’s Health Today)
which sets out how the Health Board will lead efforts to improve the health of
the people of Grampian. Maternity Services will contribute to this by promoting
health messages during the pregnancy year and working with women and
their families to make a healthy transition to new parenthood.
Appendix 2 provides a comprehensive list of documents and papers which
have influenced service provision, set out best practice guidelines, audit and
research
Governance
The Grampian Maternity Services Clinical Management Board was
established in 2001 and has been updated to reflect the changes in
organisational structures since then. This Board has the following remit and
governance arrangements
Remit
1. Develop strategic direction by determining the principles and standards of
care for maternity services throughout Grampian.
2. Raise and debate strategic maternity issues from a national, North of
Scotland and Grampian perspective, anticipating probable service
developments.
11
3. Participate in appropriate strategic planning processes to ensure that
investment in maternity services is prioritised appropriately in a climate of
strategic change and modernisation.
4. Act as an advocate for Maternity services in Grampian, at a local regional
and national level.
5. Receive, exchange and consider information from Scottish Executive
Health Department, relevant standing committees, interested parties or
any other source, which may effect maternity care provision or the
standard of that care in Grampian
6. Influence maternity service changes/developments throughout Grampian
and promote their implementation via the relevant organisational
structures.
7. Support the performance management arrangements within sectors
through identification of cross-system issues emerging from existing
reports from QIS standards, clinical risk and managerial audits, research,
and performance assessment activity and provide feedback to the
organisational structures.
8. Provide an annual report.
Accountability
The Maternity Services Clinical Management Board is accountable and
reports to the Operational Management Team through the Board Director of
Nursing who is a member of the Clinical Management Board.
Community Health Partnerships and the Acute Sector are accountable for the
delivery of maternity services against agreed principles and standards of care
as defined by the Clinical Management Board through existing operational
arrangements.
Membership
This reflects stakeholders, i.e. professionals, managers and consumers, from
the 3 Community Health Partnerships, Acute Services, Health Board and the
Ambulance Service. Others can be co opted as necessary for specific pieces
of work.
Meeting Schedule
The Board meets at least 4 times per year and can call meetings in the interim
for specific purposes. The Board also hosts an Ante Natal Infectious Diseases
Sub Group which meets twice a year.
12
Organisational Chart
North of
Scotland
Planning
Maternity
Sub Group
NHS Grampian
Board
Director of Nursing
Maternity Services
Clinical
Management
Board
Acute
Services
Aberdeen
and
Elgin
M
Aberdeensh
ire
Community
Health
Partnership
M
Aberdeen
City
Community
Health
Partnership
M
Moray
Community
Health
Partnership
M
Recommendation:
The Maternity Services Clinical Management Board should lead
Maternity Services in Grampian by active participation of all sectors so
that key changes are discussed and debated and by communicating
more widely with the stakeholders.
The Birth Unit concept in Aberdeenshire CHP should be evaluated over
a time frame to be agreed. There should be no expansion of this
concept until that evaluation has taken place.
13
Activity Statistics (Births) –
ABERDEEN
ELGIN
ABOYNE
BANFF
FRASERBURGH
PETERHEAD
HOME
TOTAL
2004
4169
863
59
53
66
103
29
5342
2005
4184
955
60
59
58
114
36
5466
2006
4416
970
82
65
74
131
44
5782
It is apparent that activity in Grampian is gradually increasing. The last year
has seen a marked increase in the number of European workers in the area
and a proportional increase in birth numbers. The workload around this
increase has been significant and communication has proven difficult. The
use of Language Line has increased sharply and this trend appears to be
continuing. The impact of this is far reaching in terms of planning to meet
further increases in activity and in preparing staff to meet the diverse needs of
these new residents. Activity numbers include births from Orkney and
Shetland so will differ from true Grampian numbers but actual activity is
required when assessing how the service is delivered . However the NHS
Grampian activity is outlined below
Maternal and newborn information 2006
Births
In the year ending 31st March 2005, there were 5339 live births and 23
stillbirths in Grampian. With a general fertility rate of 50.3 per 1000 women
aged 15 to 44 years, fertility in Grampian is slightly higher than in Scotland,
where the general fertility rate was 49.8 per 1000 women aged 15 to 44 years.
The number of live births varied by local council area. The number of births
per 1000 women aged 15 to 44 years was greatest in Moray where there
were 53.8 per 1000 women, whilst Aberdeenshire and Aberdeen city had 52.9
and 46.5 births per 1000 women aged 15 to 44 years respectively. (Figure 1)
14
Figure 1: Live births per 1000 women aged 15-44, 2005
56
54
GFR per 1000
52
50
48
46
44
42
Aberdeen city
Scotland
Grampian
Aberdeenshire
Moray
Source SMR02 ISD, 2007
In 1996, there were 6102 births and in 2005, there were 5339 births registered
in Grampian.
During the 10-year period, there has been a gradual decline in the number of
births (Figure 2). The overall reduction in births during the period was 12.5%
compared with 10.7% in Scotland over the same period.
Population projections show a year on year decrease in the population of
women aged 15-44 years from 2005-2024.
In 2024, it is estimated that there will be 74,651 women aged 15-44 years
compared to 105,660 in 2004. This represents a percentage change of 29.35%.
However recent evidence suggests that the birth rate is now rising so
projections should be treated with caution until any new trend can be
identified
15
Figure 2: Number of births (live and still) in Grampian and Scotland 1996 - 2005
70 000
60 000
Number of Live births
50 000
40 000
Scotland
Grampian
30 000
20 000
10 000
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
years
Source SMR02, ISD 2007
Birth Weight
Low birth weight (LBW) is an important measure of child health. The World
Health Organization defines low birth weight as a birth weight less than 2,500
grammes (g). Babies born weighing less than 2500 grams are at greater risk
of dying during their first year of life and have greater health and educational
problems during childhood.
In Grampian, analysis of local SMR02 file shows that low birth weight (LBW)
is increasing. Of all singleton births occurring in the year, ending 31 March
2005, in Grampian, 5.7% had a birth weight less than 2500 grams.
Analysis of trend data shows a yearly increase in the percentage of low birth
weight babies in Grampian from 4.7% in 1995/96 to 5.7% in 2005/2006.
Figure 3
Within Grampian, over the 11-year period, the percentage of singleton low
birth weight babies was highest in Aberdeen city 5.9% .Figure 4
During the same period, there has also been a year on year increase in the
percentages of babies born before 37 weeks of gestation. Figure 5
Given the relationship between low birth weight and gestation, this may
account partly for the increase in percentage of low birth weight babies born
during the 11-year period.
16
Figure 3: Percentage of live singleton low birth weight (<2500 grams) babies in
Grampian 1995/96 – 2005/06
6.00%
5.00%
Percentage
4.00%
3.00%
%
2.00%
1.00%
0.00%
1995/1996 1996/1997 1997/1998 1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006
Source: SMR02, based on singleton live births only
Figure 4: Low birth weight by Local Authority Area 1995-2006
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
Aberdeen
Ab'shire
Local Authority Area
Moray
Source: SMR02
17
Figure 5: percentage of babies with Gestation less than 37 weeks
8.00%
7.00%
6.00%
Percentage
5.00%
4.00%
%
3.00%
2.00%
1.00%
0.00%
1995/1996 1996/1997 1997/1998 1998/1999 1999/2000 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006
Source: SMR02
Infant mortality
Infant mortality is strongly associated with deprivation and is one of the
government’s key indicators for reducing health inequalities.
In 2001, stillbirth mortality rate in Grampian was 6.3 per 1000 live births, this
was higher than the average rate in Scotland and in 2005; the rate was 4.4
per 1000 live births compare to the Scottish average of 5.3 per 1000 live
births.
Similarly, between 2001 and 2005, the neonatal mortality rate in Grampian
has been below the Scottish averages except in 2003 and 2004 where it was
slightly higher. Figure 6
It is important to point out here that death in infancy (under one year) is a rare
event; as a result, one additional or one less infant death at the local level can
result in a large fluctuation in rates. As a result, the local authority data
presented below should be interpreted with caution.
18
Figure 6: Stillbirth and neonatal death rates in Grampian and Scotland 20012005
7
6
rates per 1000 live births
5
4
Stillbirth mortality rate Scotland
Stillbirth mortality rate Grampian
Neonatal mortality rate Scotland
Neonatal mortality rate Grampian
3
2
1
0
2001
2002
2003
2004
2005
Source SMR02 ISD 2007
Recommendation:
The impact of changing demographics and ethnicity for the Maternity
Services is not yet clear and more intelligence must be gathered around
this to ensure health needs are known and addressed as appropriate.
19
2.
PROGRESS TO DATE
A Framework for Maternity Services in Scotland (2001) and the subsequent
Expert Group Report on Acute Maternity Services in Scotland (EGAMS 2003)
produces a set of principles for the Maternity Service which to date have
provided the work plan for the Maternity Services in Grampian. An Action Plan
was produced which formed part of the evidence for the QIS Maternity
Standard assessment in April 2006. We await the final report. Their comments
and recommendations will be considered alongside the existing Action Plan
(Appendix 3).
3.
PRECONCEPTION AND EARLY PREGNANCY
Planning and preparation for pregnancy must be promoted by NHS Grampian
and their partner agencies so that women are influenced to be as healthy as
possible at the outset.
At present any activity that exists in the pre pregnancy period is focussed on
women with existing health problems such as diabetes, epilepsy, recurrent
miscarriage or a previous pregnancy poor outcome. More general messages
are provided by Family Planning Clinics, in the education sector and through
local and national initiatives supported by Health Promotion Department and
Public Health Leads in Community Health Partnerships.
Pre conceptual information to parents should include the following information


What becoming a parent might be like and the impact on relationships
The importance of
 Pre conceptual folic acid
 Minimising the intake of alcohol
 Not using recreational drugs
 Not smoking and having a smoke free environment
 Pre pregnancy rubella immunisation
Women also receive Ready Steady Baby publication at their first contact with
the Maternity Services and foreign language versions have been accessed in
the most common eastern bloc languages.
Recommendations:
As well as the general activity provided by health promotion services,
more targeted activity should be designed to reach women who are
planning pregnancy so that they are in the optimum health from the
outset.
20
Health promotion activity in the education (school) sector requires
regular liaison with NHS maternity care providers locally to maximise
the potential of targeting pupils at the most appropriate times.
Women requesting pre pregnancy advice should be able to access an
appropriate health professional including the midwife on an individual
basis.
Community Pharmacists should be encouraged to maximise
opportunities to participate in pre pregnancy preparation. Provision of
health education, folic acid with pregnancy testing kits and smoking
cessation support are examples of this.
4.
PUBLIC HEALTH AND MATERNITY SERVICES
Public Health activity in maternity services is fundamental when influencing
pregnancy and neonatal outcomes. Although there is broad activity around
health promotion by members of the health community, midwives in particular
consider public health activity as a major component of their roles and
responsibilities but the definition of how they discharge this responsibility is
often misunderstood.
The model which best illustrates this activity describes component parts in 4
main areas all linked but identifiable as separate entities as below
1.
2.
3.
4.
Health surveillance and problem identification
Counselling
General advice about health and health promotion
Targeting populations and working with specific groups
Each of these activities can be subdivided into 4 areas, namely
1.
2.
3.
4.
Support and screening
Parent preparation
Integrated working
Involvement with specific groups
21
The model for midwives is illustrated below but could be applied to others
involved in health promoting activities.
Support and
Screening
 Fetal and
neonatal
screening
 Maternal
Screening
 Pre conceptual
care
 Bereavement
 Teenage
Pregnancy
 Family
relationships
 Perinatal mental
health
 Cervical
screening
 Smoking
 HIV
 Alcohol
 Illicit drugs
HEALTH
SURVEILLANCE
Integrated Working
 Health
improvement
and
modernisation
programmes
 Sure Start
 Primary Care
action groups
 Health Action
zones
 Care team
COUNSELLING
MIDWIFE
TARGETTING
SPECIFIC
GROUPS
Parent Preparation
 Diet
 Exercise
 Sudden infant death
 Breast feeding
 Artificial feeding
 Family planning
 Child protection
 Safety in the home
 Immunisation
 Advancing parent age
HEALTH PROMOTION
AND ADVICE
Involvement with Specific
Groups
 Drug users
 Minority groups
 Teenage pregnancy
 Smoking cessation
 Refugees/Asylum
seekers
 Breastfeeding
All pregnant women in Grampian receive the Ready Steady Baby book ( now
available in a number of languages) as a basic introduction to health in
22
pregnancy and the immediate post natal period but the content needs
explanation and discussion as pregnancy progresses. Collaborative working
with others in the care team is essential so that the women can access their
expertise appropriately and care provided effectively.
There is however enormous potential to use midwifery knowledge and skills
constructively and to integrate the work of primary care teams, avoiding
duplication and ensuring care is woman and family centred. Domestic
violence, smoking cessation, parenting, targeting vulnerable women and
addressing post natal morbidity are all priority areas where midwives have
education preparation which must be exploited. In the future this will also be
supported by maternity care assistants. Pre school and school work is under
developed but could reap benefit.
The following section describes activities around the major public health
components of care.
a) Smoking
Recommendation 3 in Smoking Cessation Guidelines for Scotland: 2004
update states that “Specific populations of NHS patients, such as hospital in
patients and pregnant smokers should, as far as possible, be offered smoking
cessation treatment appropriate to their circumstances at locations and
schedules to suit them”.
Evidence suggests that cigarette smoking is the single largest modifiable risk
factor for pregnancy related morbidity and mortality and is a major cause of
health inequalities.
Studies have shown that 1 in 15 pregnant smokers, who would not otherwise
have given up smoking, will do so when given specialist support. Such
support is not likely to be taken up by the majority of pregnant smokers but
uptake may improve if the support is given in a convenient location to the
mother. Self help initiatives are ineffective.
Recent Guidance on smoking cessation issued by the Scottish Executive
highlights pregnant smokers as a high priority. Significant progress has been
made in recent years in understanding the best way to help smokers give up.
Supported by local and national funding the Smoking Advice Service in
Grampian has developed a range of options to support smoking cessation
including group sessions, dedicated intensive one to one sessions, and brief
interventions. The mainstays of treatment are motivational interviewing to both
encourage and then support smoking cessation. Whilst successful to a limited
extent the addition of pharmaceutical therapy such as NRT can double the
cessation rate. It is recommended that pregnant smokers should as far as
possible be offered structured one to one, face to face behavioural support in
locations that suit them.
NHS Grampian supports the use of NRT in pregnancy. Smoking causes well
documented harm to the fetus and neonate. NRT use will improve smoking
23
cessation outcomes and is recommended by health professionals in the multi
disciplinary team.
A recent study in Grampian has revealed that




1 in 5 pregnant women smoke
In Depcats 5/6 1 in 2 pregnant women smoke
The percentage of women smoking at first contact with maternity
services has risen 10% since 1995
Low birth weight babies are nearly three times more likely to be born to
those who are current smokers -9.1% compared to 3.1%
In response to this the Maternity Services have been working with the
Smoking Advice Service to prepare midwives to discuss smoking behaviours
with women constructively during pregnancy. They are able to commence
interventions suited to individual need and preference and to refer on for more
intensive interventions if needed. There have been difficulties in collecting
meaningful data to assess the effectiveness of interventions but a new system
will be commenced at the same time as the introduction of the new National
Maternity Record
Recommendations:
Smoking cessation interventions must be offered to every pregnant
woman who smokes and the most appropriate arrangements made for
each individual woman
Training and educational opportunities must be made available to key
professionals who care for pregnant women, in particular Community
Midwives who deliver the majority of a woman’s care.
Robust evaluation of outcomes must be available to inform progress
and measure success.
b) Domestic Abuse
The Confidential Enquiries into Maternal Death in the UK (Why Mothers Die
Report 2000-2005) estimates that over one third of domestic abuse incidents
start during pregnancy. Pregnancy may trigger or exacerbate male abuse in
the home. Pregnancy may indeed be a consequence of abuse and an
indication that the woman is a coercive relationship. There are strong links
between domestic abuse and adverse pregnancy outcomes and maternity
services should be particularly alert to the possibility of abuse and proactive in
its detection and management. Physical and emotional indicators such as
stress, anxiety disorders including panic attacks or depression, feelings of
isolation and inability to cope, suicide attempts or gestures of deliberate self-
24
harm may be present. These may or may not be linked to post natal
depression.
Domestic Abuse covers a range of abusive behaviours including physical,
sexual and emotional/mental abuse and control. They may occur in a close
relationship regardless of age, class, religion or ethnic group. The abuser is
often male and the victim female but this is not always the case.
The facts:





Nearly 30% of all women are likely to suffer domestic abuse sometime in
their lives
Nationally 90% of victims are female and the perpetrator male
59% of reported incidents in Grampian involve repeat victims
Reported incidents of domestic abuse are higher in Aberdeen city than in
Aberdeenshire or Moray
Women experiencing this type of violence may present at the maternity
service as their first formal point of contact
All women should be routinely asked if they are experiencing domestic abuse
during their pregnancy and the issue raised again in the first few months
following delivery. When professionals openly discuss domestic abuse it is
easier for women to disclose information. Health care workers may be
reluctant to enquire about domestic abuse for a number of reasons, but
research evidence indicates that a substantial number of women want the
health care worker to prompt discussion. With training and appropriate
resources health care workers will be more confident in their responsibility to
give women permission to speak out about their experience. As part of the
NHS Grampian strategy and action plan awareness raising and training for
midwives is being rolled out during 2006. There will be guidelines and
resource packs distributed to health care workers to ensure access to
appropriate information for support.
Recommendations:
Women should be asked about Domestic Abuse routinely at some point
in pregnancy which may be dependant on when a midwife can see the
woman on her own.
Midwives and others in the Pregnancy Team should have access to
awareness and routine enquiry training to ensure appropriate skills exist
to manage any disclosure which occurs.
The Maternity Services in Grampian should undertake an audit of
disclosure to assess the effects of routine enquiry.
25
c) Perinatal Mental Health
A number of strategic documents stress the importance of a coordinated
approach to perinatal mental illness. These include NHS MEL (27) that
emphasises the need for all health boards to establish in integrated care
pathway for women suffering mental ill health in the peri natal period. Others
include




SIGN Guideline (No60): Postnatal depression and Perinatal Psychosis,
2003
A Framework for Mental Health Services in Scotland, 1999
The CRAG report on Early Intervention in Postnatal Depression, 1996
The Confidential Inquiry into Maternal and Child Deaths 2000-2002,
2004
The national programme for Improving Mental Health and Well Being Action
Plan 2003-2006 (Scottish Executive) identifies improving infant mental health
in the early years as a priority area. “Ensuring the best possible start for
children in their early years, promoting their mental health and that of their
parents, and working to prevent and reduce the impact of mental health
problems are key priorities”.
In Grampian there is no co-coordinated and systematic approach to the
identification and management of perinatal mental illness. Pockets of good
practice exist but the result of this approach is gaps and inconsistencies in
services for women and their families.
There is no systematic approach to training and education around perinatal
mental illness. Some areas have set up local education events, some staff
have been sent on training days and conferences run by a variety of NHS and
academic institutions. Midwives, Health Visitors and Mental Health nurses are
key to how successful the implementation of the guidelines will be and work
has yet to be completed on information sharing and record keeping to ensure
appropriate service delivery.
Based on 6000 births per annum in Grampian, 600-900 will suffer from post
natal depression. The majority of these women will be managed in primary
care settings and will not require the interventions of mental health services.
Around 12 will develop a psychotic illness and will need specialist care. Within
Grampian it is not possible to determine actual figures as the incidence of
perinatal mental ill health is not collected. This makes it impossible to assess
whether the expected numbers are being identified and managed, whether
services need targeted in specific areas or whether educational activity and
other support should be targeted at particular teams.
The implementation of the new Mental Health Act has implications for the
perinatal period. There is on going debate regarding a specialist in patient unit
for mothers and babies who have severe post natal illness – central guidance
suggests that mothers and babies should not be accommodated in general
psychiatric wards. In Grampian it is estimated that a facility dedicated to such
26
women would be occupied 12 weeks of the year. A location in the Royal
Cornhill Hospital has now been identified and a facility also exists in Dr Gray’s
hospital in Elgin.
Key issues to be addressed include:




Leadership and professional support to those involved in identification
and management of such women
Establishment of evidence based models of care for perinatal mental
illness that complement and develop the work currently in place
Implementation and evaluation of an integrated care pathway across
maternity services, primary care and mental health services, plus
linkages with other agencies including the voluntary sector
Establishment of a liaison role with key agencies and stakeholders
involved in the protection of children, such as the designated doctor
and Nurse Consultant for Child Protection and social work
departments.
Recent progress
At the end of 2006 a full time Specialist Nurse has been appointed to begin to
address some of the issues highlighted above.
Consultant Psychiatrists at Cornhill Hospital and Clinical Lead for Obstetrics in
Aberdeen Maternity Hospital are exploring the development of a more
integrated service for women with existing mental ill health issues and the
joint management of those with pregnancy related anxiety conditions.
The in patient facility in Cornhill will be available in the near future and
effective liaison arrangements between services are being organised.
Recommendations:
Recent progress should be maintained in all aspects of the service.
Appropriate education and training programmes for key staff including
midwives, health visitors and community psychiatric nurses should be a
priority for the newly appointed Specialist Nurse. This can be a
graduated approach including awareness sessions on mental health and
mental illness, more detailed education for those conducting
assessments and providing on going support and specialist education
for a small number who wish to reach that level of expertise.
d) Substance Misuse
Substance Misuse in pregnancy affects a small number of women in
Grampian each year (<90) but the impact of that creates major challenges for
the service. The majority of the substance misusers live in and around
27
Aberdeen but all areas of Grampian can be involved. The next biggest
number stay in Banff and Buchan around Fraserburgh and a local drugs
service is situated there.
Grampian has a multidisciplinary and multiagency approach to women who
abuse substances. The team includes consultant obstetrician, consultant
psychiatrist, consultant neonatologist, specialist midwives, community
psychiatric nurses, health visitor, drugs action worker, child protection team
and social work. These people work together as a team providing
individualised care for a very complex group of women, partners and babies.
The care pathway follows the recommendations of the Scottish Executive
Effective Intervention Unit as outlined in Integrated Care Pathways 8: drug
misuse in pregnancy and reproductive health. Social Work services are
addressed by the teams in Aberdeenshire and Moray for women who reside
there.
The aim of the service is to ensure that women and their partners find the
service accessible, that harm reduction strategies are offered to increase
stability and careful assessments are in place to ensure that child protection is
a high priority. Care is delivered in a supportive environment; it is community
and out patient based as far as possible but in patient care is available to
assist stability and to manage the often complex needs of these women.
Support packages are put in place to address the needs of individual women
and these continue long after the baby has gone home. Ante natal education
takes the form of parenting sessions where lifestyle changes, relationship
changes, demands of a baby, need to prepare for the baby and establishing
some routines around the baby’s needs. The uptake of this programme is
variable but it is evaluated well by those who attend.
All births occur in Aberdeen Maternity Hospital. Approximately 75% of the
babies require to be cared for in Neonatal Unit the remainder staying in
hospital for a minimum of 5 days for assessment of withdrawal.
Training and education feature heavily for the staff in this service. The work is
challenging and training supports the staff to feel comfortable in this
environment. There is a range of educational opportunities including work
shadowing members of the team, modular short courses provided by
STRADA Scottish Training on Drugs and Alcohol, degree module provided by
Aberdeen University, and Child Protection training at various levels in house
and via the University of Dundee.
One major change in the service in 2006 was to change the role of the Post
Natal Support Health Visitor to one of supporting generic Health Visitors to
develop expertise in managing these women within their case loads. This has
changed the emphasis of care in the post natal period in particular but also in
the antenatal period when assessments are being made concerning Child
Protection.
28
Recommendations:
Continue to monitor the service to ensure that it is meeting need.
Continue to develop the expertise of the wider professional community
so that skills expand in local settings.
Assess the impact on Neonatal Unit and consider alternative ways of
delivering care minimising the need for separating mother and baby.
Consider how alcohol misuse may be impacting on Maternity Service
and pregnancy outcomes.
e) Child Protection
Child Protection is embedded with Maternity Services in Grampian through a
programme of awareness and links with Domestic Abuse and Substance
Misuse. Trainers have been prepared in key areas across Grampian and
training takes place on a regular basis. All new staff have an Induction Pack
raising awareness about Child Protection issues and outlining the personal
responsibilities all have towards children in their care.
Maternity Services have a Lead Doctor and Lead Midwife designated as
contacts for Child protection issues as they arise and both are members of the
NHS Grampian Child Protection and Vulnerable Children Action group.
The Consultant Nurse for Child Protection in NHS Grampian has a close
working relationship with the Maternity Services and she is a member of the
Midtrimester Review Group for substance misuse management which meets
monthly.
Midwives and Health Visitors communicate concerns by opening a family
record for vulnerable mothers and children. This record is designed to ensure
that appropriate information is shared and handed over when caregivers
change during the pregnancy year.
Recommendation:
Ensure that Child Protection remains at the forefront throughout the
pregnancy episode by providing regular awareness training for all
staff.
Continue to provide more specific training for case load holders and
those contributing to Child Protection Case Conferences.
29
f) Breast Feeding
NHS Grampian has a Breast Feeding Strategy which will be updated in 2007.
The main focus of activity around breast feeding is the work taking place for
Baby Friendly Accreditation in both Aberdeen Maternity Hospital and Dr
Gray’s in Elgin. A programme of activity has been established through a
steering group in conjunction with a UNICEF advisor who will offer support
and guidance as the process unfolds.
NHS Grampian will support this initiative and appreciates that the activity
required for the accreditation is onerous on the service so will not set separate
objectives around this topic.
5.
PREGNANCY AND NEWBORN SCREENING
As part of their routine care in pregnancy, women in Grampian have their
health status reviewed, a history taken to identify any relevant medical, family
or obstetric concerns and lifestyle issues discussed. Routine tests including
urinalysis, FBC and blood group are performed.
In addition, there are formal screening programmes aimed at detecting
specific problems either in the mother or the foetus.
Current screening programmes in pregnancy:
All pregnant women in Grampian are offered screening for Down Syndrome
and Neural Tube Defect as well as screening for selected infectious diseases,
namely, HIV, Hepatitis B, Rubella and Syphilis.
1. Down Syndrome and Neural Tube Defect:
The aim of screening is to reduce the burden of serious foetal abnormality by
identifying women who are at increased risk of having a baby with these
conditions. Other significant chromosomal abnormalities may be detected in
the course of this screening.
All pregnant women attending for antenatal care are provided with information
about the tests early in their pregnancy to enable them to make an informed
decision about whether or not to proceed with the screening tests. Screening
involves testing serum taken at 16 weeks gestation for markers - AFP and
hCG and a detailed ultrasound scan at 20 weeks.
Women whose results indicate a higher chance of foetal abnormality are
offered a definitive diagnostic test eg chorionic villus sampling or
amniocentesis. The purpose, benefits and possible outcomes are discussed
with the women/parents as well as the possible options available to them
should a positive diagnosis be made.
30
2. Infectious Diseases Screening:
Prior to screening, women are provided with information about the tests being
offered, which diseases will be screened for and the rationale behind
screening for these particular conditions. The aim of screening for HIV,
Hepatitis B and Syphilis is to enable the detection of these conditions early in
the pregnancy so that measures may be put in place to reduce the risk of the
foetus acquiring the infection at all or reduce the risk of the foetus acquiring
the worst sequelae of the infections. Treatment either during or after the
pregnancy may also be offered to the mother. In the case of rubella the aim is
to identify women who are not immune to rubella and who can be offered
vaccination following the end of the pregnancy to protect the foetus in any
subsequent pregnancy. A venous sample is taken at 16 weeks gestation for
testing for the presence of antibodies. Confirmatory tests may then be
performed on any initially positive tests.
Future screening programme developments:
NHS Grampian is now involved in a programme of work, along with other
boards in Scotland and the Central Coordinating Unit for screening
programmes in Scotland, to improve the coordination of screening across
Scotland and in particular to:




develop standard national information returns in association with
ISD
introduce a national laboratory information management system
introduce a core training scheme for staff involved in testing and
supporting patients which will improve the information to
women/parents. This involves a central lead trainer and a local
facilitator.
establish a quality assurance structure within NHS Grampian.
Locally, there will be a requirement to ensure that the correct structures are in
place for the monitoring of each of the screening programmes and that data
are collected routinely to allow the annual reporting of the performance of the
screening programmes.
There is already agreement about the data items required to monitor HIV
testing and the other infectious diseases. These include number of women
offered the tests, the standard for which is 100%, the number of tests
performed, the number of positive results and the number of refusals. It also
hoped to be able to collect information on why women refuse all or some of
the tests.
It will also be necessary to ensure that changes to screening policy and to the
delivery of screening can be implemented in Grampian. The Maternity
Services Clinical Management Board will take a lead in advising NHS
Grampian on what changes are required and the implications of these for
staffing, equipment, the laboratory and finance. In order to introduce 1st
trimester screening for Down Syndrome and Neural Tube Defect it will be
31
necessary to introduce nuchal translucency ultrasound measurement at 13
weeks gestation. This will be combined with an estimation of maternal free
beta hCG and maternal age to provide an estimate of risk. The detailed 20
week anomaly scan is already available in Grampian.
Consideration is currently being given to the policy Scotland should adopt for
screening for various serious, inherited blood disorders such as the
thalassaemias and sickle cell disease. In England there is a programme
underway to offer thalassaemia screening to all women and screening for
haemoglobin variants (sickle cell) to “at risk” groups based on their ethnic
background. In Grampian such testing is already available to those women
who may be at increased risk of having an affected baby.
Newborn Screening:
Babies are checked for a range of health problems which may be present
from birth and which are detectable by physical examination by a trained
health professional, doctor or midwife. These include heart murmurs,
congenital dislocation of the hip, the red reflex in the eye etc.
Current formal newborn screening programme:
A formal screening programme is available for babies to look for 3 serious
metabolic disorders. These are congenital hypothyroidism, phenylketonuria
and cystic fibrosis. The objective of the screening programme is to identify
these specific disorders as soon after birth as possible and before the onset of
recognisable clinical symptoms. For those babies found to have one of these
conditions treatment can then be started immediately in order to reduce the
potentially very serious consequences of the untreated disease.
Parents are provided with information about the tests and their midwife will
obtain their consent for the tests. The test takes the form of collecting 4 spots
of blood on a specially prepared card by pricking the baby’s heel with a device
designed specifically for the purpose. This is to ensure that 4 adequate spots
for testing are obtained. The specimen should be taken between Day 5 and
Day 7. For babies who are receiving special care or particular treatments
these arrangements may need to be varied in order to ensure the test is not
invalidated.
The cards with the blood spot specimens from all babies born in Scotland are
then sent to the newborn screening laboratory in the Institute of Medical
Genetics at Yorkhill, Glasgow. Once tested the laboratory reports all negative
and positive results back to the board’s child health department. For those
babies who test positive protocols are in place for informing parents and the
babies’ subsequent management. In Grampian there is a named paediatrician
responsible for the management of babies with each of the conditions.
In order to provide a failsafe mechanism the child health department in
Grampian checks receipt of results and in particular identifies babies for
whom no result has been received by Day 20. Checks are made on these
32
babies to ascertain why there is no result and to arrange for testing or
retesting to be done if necessary.
The laboratory in Glasgow feeds back information on the babies tested from
each board area on a regular basis to allow the performance of the screening
programme to be monitored. Of particular concern is the level of uptake.
Ideally, all babies should be tested as phenylketonuria and congenital
hypothyroidism especially are amenable to treatment and the brain damage
which could result from the disease being left untreated can be completely
avoided. Although not conclusive there is some evidence to suggest that
uptake has dropped slightly with the introduction of informed consent and the
need to ask parents’ permission to store the blood spot card. This will require
close monitoring and additional research may be required to look at the
reasons for parents refusing to give consent and the best way to encourage
uptake.
In July 2005 NHS Grampian introduced universal newborn hearing screening.
Prior to this babies had their hearing checked by their Health Visitor at age 8
months using a test known as the Distraction Test. This test had been in use
for many years but research in recent years had shown that it did not satisfy
the modern criteria for an effective and reliable screening test. By contrast it
is clear that by testing babies’ hearing at birth it is possible to detect up to
90% of bilateral, moderate to profound, congenital sensorineural deafness.
(Some deafness only develops over time and will not be detectable for a few
years).
Parents are first given information about the screening test a few weeks
before the baby is born. Then shortly after birth, often before the baby goes
home, the hearing test is carried out by a trained professional using the
Otoacoustic Emissions Test. This involves placing a small, soft-tipped
earpiece in the outer part of the baby’s ear. This sends a clicking sound down
the ear which generates an echo in the inner part of the ear which can be
analysed by the computer. If the baby’s ears do not appear to respond then
further tests are carried out. If a significant hearing loss is confirmed the baby
can be fitted with hearing aids at an early age to aid the acquisition of speech,
language and social skills which would otherwise be delayed or
underdeveloped. Also, the baby’s parents are provided with ongoing support
both from the NHS and the local education department.
Future developments in newborn screening:
Two major developments in newborn screening are expected in the next few
years. One involves developing, on a national basis, screening for
haemoglobinopathies (sickle cell disease). Already in Grampian babies from
families who may be at risk of these serious inherited blood disorders are
offered screening. In England the policy which is being implemented is to offer
sickle cell screening to all infants as a routine part of the current newborn
blood spot screening programme as described above. A decision will be made
in the next year or two about whether all babies in Scotland should be offered
this screening or whether it should continue on a targeted basis.
33
The other anticipated development involves introducing screening for a
serious metabolic disorder known as Medium Chain Acyl-Coenzyme A
Dehydrogenase Deficiency, or MCADD for short. MCADD is a rare condition
which results in the affected children being intolerant of various stresses such
as illness or fasting. Serious symptoms and even death can result from the
crisis caused. A pilot study has shown, however, that if the parents of
affected children take some simple precautions then the worst effects of the
condition can be avoided. Testing for this condition can be carried out on the
blood spot which is already obtained from babies a few days old using the
Tandem Mass Spectrometer at Yorkhill Hospital in Glasgow. Information for
parents will require to be developed and training for midwives provided so that
they can explain fully the reasons for the test and the implications of the
results.
6.
NEONATAL CARE
The Neonatal Unit in Aberdeen Maternity Hospital is the tertiary referral centre
for Grampian, Orkney and Shetland and it also provides care for infants
requiring neonatal surgery from Highland. Neonates with cardiac
abnormalities or who require extra corporeal membrane oxygenation (ECMO)
require transfer outwith Grampian. The Unit shares responsibility with
Ninewells in Dundee for Regional Neonatal Transport for any baby who
requires transfer to a tertiary centre for ongoing care.
Dr Gray’s in Elgin have a Special Care baby service for babies born there
from 34 weeks gestation and aim to transfer women before that gestation
should a premature birth be anticipated. They provide a stabilisation and
transfer service for neonates born unexpectedly at or below this gestation.
The service in Dr Gray’s is heavily dependant on midwives with additional
neonatal training to sustain the service along with local paediatricians.
Support for this from Aberdeen is essential both in terms of on going advice
and education and updating opportunities.
A basic requirement of all staff dealing with births in any setting is the
successful completion of the Neonatal Resuscitation Programme (NRP) which
is an accredited, assessed modular programme delivered by Neonatal Unit
throughout Grampian. This has also been accessed by Highland, Orkney and
Shetland and creates a consistency of care management for neonates
requiring resuscitation.
Pressure points in this service include both medical and nurse staffing to keep
pace with activity. The impact of Modernising Medical Careers (MMC) has led
to the development of Neonatal Nurse Practitioners and a programme is in
place to further increase their numbers and to develop this new role. This is
likely to challenge recruitment of such experts largely from an already scarce
resource of neonatal nurses. This has been recognised as a national issue by
NES who are putting in place a range of educational opportunities to
encourage neonatal nursing staff development thereby creating career
34
opportunities. As the implications of MMC become clearer further redesign of
the service is likely.
Part of the work of the Ministerial Action Group for Maternity Services is a
review of Neonatal Services in Scotland. We await the recommendations due
in autumn 2007.
Recommendations:
Continue to build expertise in modern neonatal care management and
reflect this in care management.
Develop and utilise the expertise of the wider team in delivering routine
care for neonates to maximise availability of cots in Neonatal Unit.
Continue to support the service in Dr Gray’s Elgin, the Regional
Neonatal Transport Service and the Neonatal Resuscitation Programme.
Continue to work closely with Combined Child Health Service.
7.
ASSESSING AND MANAGING RISK
Maternity care professionals must take steps on a regular basis to manage
risk effectively and be able to discuss this meaningfully with the women they
care for. The whole risk management process is a dynamic one and there is
no such thing as no risk for any woman using the service. Practice needs to
reflect this but protocols and guidelines also need to reflect that normality
does exist and in the vast majority of occasions healthy women will give birth
to healthy babies.
A core element of maternity practice is to manage risk effectively and to
develop critical incident reporting systems where such occurrences can be
analysed and appropriate actions taken as a result. Such a system exists in
both Aberdeen Maternity Hospital and Dr Gray’s Elgin where monthly Risk
Management meeting occur and in the Aberdeenshire Units analysis occurs
as and when incidents occur.
In NHS Grampian Maternity Services a guideline approach has been adopted
in all settings. An example of this is provided in Appendix 4 where the Ante
Natal Care in Grampian 2007 guidelines are included. These demonstrate
exclusion criteria where care needs referral for Obstetrician assessment but
also provide guidance about how to continue community based management
for some common conditions. These are made available for all practitioners
and a pocket size format is available for ease of reference. Labour Ward
Guidelines also exist, reviewed every 3 years. They demonstrate the evidence
base for each individual guideline and are an excellent learning tool for
anyone working in Labour settings. Guidelines also exist in the Early
Pregnancy Unit and in Ultrasound scanning. This approach creates a
35
benchmark for good practice and facilitates audit to monitor, assess and
evaluate practice.
Risk Management activity is underpinned by education and training.
Examples of this are emergency drill procedures which take place in all
locations which enable the maternity care professionals to explore and
rehearse responses to clinical incidents. NHS Grampian has also invested in
an Accredited Neonatal Resuscitation programme which all maternity care
professionals must pass before they are deemed fit to participate in
resuscitation events. This is a multidisciplinary approach and includes student
midwives in the third year of their programme. This fosters team working.
Involving women in discussions about risk is crucial if women are to feel
involved in the decision making about their care. Women do need to make
difficult decisions in pregnancy and may need to weigh up the risks and
benefits of their options considering wider issues than purely clinical ones. It is
therefore important that the clinical information is to a high standard.
Written information is available for a number of common scenarios such as
pain relief in labour including the siting of an epidural, the effects of having a
caesarean section, information about multiple pregnancies and about
amniocentesis. This information requires explanation as well as written
information and developing skills in this area is an ongoing process.
Clinical Governance around risk management is addressed through Clinical
Managers being part of the incident review processes. Written reports are
produced and distributed widely through the Maternity Service so that learning
can take place and issues which are relevant to other services are highlighted
through the Clinical Governance Committee as necessary.
Recommendations:
Continue to develop Risk management activity by involving as many
care providers as possible. This should include active involvement of
Supervisors of Midwives.
The outcomes of critical incident reviews must be reflected in service
improvement and education and training whenever indicated.
Continue to develop written information for women which contains the
best available evidence presented in non technical terms and make this
available at appropriate times during the pregnancy.
8.
TRAINING AND EDUCATION
In order for Maternity Services in Grampian to have the ability to deliver a high
quality of care while meeting the needs of the clients the workforce needs to
be competent, motivated and confident to continuously learn, change and
36
develop. This strategy utilises the aims of the Scottish Executives strategy for
lifelong learning (Scottish Executive, 1999) which is as relevant now as when
first written ‘A well-educated workforce can provide patients and their families with fast,
responsive, high quality health care that is designed to meet their needs. And
patients can be secure in the knowledge that the staff who care for them have
kept their skills and knowledge up to date’ (Scottish Executive, 2003a).
In order to achieve this the framework below has been developed.
Improving opportunity and access to learning




Provide equal access and opportunity for all staff to develop and
maintain their knowledge and skills throughout their career.
Ensure the appraisal system and Personal Development Plans are
utilised to identify learning needs.
Staff who do not have professional qualifications must have access to
education and training thus allowing all members of the team the
opportunity to develop knowledge and gain skills and obtain relevant
qualifications.
Develop and make full use of e-learning facilities to facilitate access to
training and education across Grampian (Scottish Executive, 2003b).
Effective Education and Development.




Prioritisation of training and education needs will take place annually,
ensuring that staff are developed to meet the needs of the service.
Interprofessional learning opportunities should be developed and
utilised where appropriate.
Learning and development can take place in many different settings
and does not have to involve formal training courses.
Effective collaborative relationships will be maintained with Higher
Education Institutes and other external agencies in order to facilitate
the development of training and education opportunities.
Developing a Responsive Workforce



Staff should be encouraged to take responsibility for their own learning.
Support should be given to the development of new and enhanced
roles.
Opportunities and support for staff involvement in audit and research to
affect organisational and personal learning must be developed.
The content of the sections above have demonstrated a healthy education
culture within Maternity Services.
37
Recommendations:
Continue to develop relevant education events to meet the diverse
needs of the care professionals and monitor their appropriateness.
Continue to work collaboratively with education providers as
demonstrated by the joint programme for Maternity Care Assistants with
RGU and Assisted Birth Practitioners with the University of Bradford.
Continue to develop staff according to service need as well as
professional desires to ensure that the demands of a dynamic service
are being met.
9.
PUBLIC INVOLVEMENT
Public involvement in planning and delivering changes in services is crucial to
ensure that the changes are informed by, understood by and are acceptable
to service users. The maternity service uses a number of ways to gather
feedback from people using services and is keen to develop this further. NHS
Grampian gives commitment to establishing effective Maternity Liaison
Committees – this will be informed by the outcome of the Ministerial Action
Group and by listening to local women about how they would like to be
involved.
Maternity services in Grampian are committed to gathering and listening to
the views of women using services and ensuring public involvement when
planning and delivering changes to services. This commitment is supported
by the NHS Grampian Board Patient Focus Public Involvement Committee
who has highlighted maternity services as a priority area in its Action Plan
2007-08.
The Aberdeenshire Review has demonstrated that the public are very
committed to the maternity services in Grampian and have given valuable
feedback about their experiences using the service. This feedback has helped
inform proposals and has contributed to significant improvements to the
physical environment at Aberdeen Maternity Hospital. Public feedback has
also informed the development of a survey which will gather the views of
women about their experiences in Aberdeen Maternity Hospital after delivery.
Other examples of involvement include consumer representation on the
Clinical Management Board; feedback on parenting sessions provided to
people misusing substances and feedback from women attending the
breastfeeding centre.
However, ensuring longer term engagement such as public representation on
Maternity Liaison Committees remains more challenging, although the service
does target individuals to participate on working groups and discussion
groups when developing new guidelines, looking at written information or
38
reviewing how services are running. The Moray Liaison Committee has
secured excellent public representation and remains active and participates
constructively in Maternity issues in that area. It is highly desirable that more
formal Liaison Committees are established around areas where care is
provided and this approach is starting to be developed in Aberdeenshire
around the proposed birth units. The Ministerial Action Group has a working
Group looking at Liaison Committees and guidance from that Group will help
to inform the way ahead in Grampian, together with listening to local women
about how best to involve them in the work of the Liaison Committees.
The Strategy also outlines a range of other initiatives which will seek to
include the views of women. Examples include research into why some
women refuse consent for specific screening tests and working towards
UNICEF Baby Friendly Accreditation.
Recommendation:
Take steps to establish effective Maternity Services Liaison
Committee(s) accessible for women across Grampian.
9. WORKFORCE PLANNING
The unique requirements for Maternity Services require constant availability of
midwifery, obstetric, anaesthetic and neonatal cover at all times and requires
specific strategies to ensure that services are sustainable. At present the
challenge is to manage the workload and workforce requirements during a
period of change happening nationally and in response to drivers beyond our
control. Such influences are








the impact of the European Working Time Directives on all services
the reforms created by Modernising Medical Careers on all services
the proposal that in units with more than 4000 deliveries per annum
that on site Consultant Obstetrician presence is needed for 60 hours
per week in 2008 and for 96 hours per week by 2009 – the current
presence is 40 hours per week
the expectation that non medical staff will expand their roles to include
that previously done by medical staff
service changes introduced by Scottish Executive including new
scanning procedures requiring more resources in terms of time, skills,
personnel and equipment;
the introduction of more screening tests requiring midwives in particular
to spend more time in obtaining informed consent and results feedback
greater emphasis on public health initiatives such as smoking
cessation, domestic abuse, breastfeeding and mental health requiring
more discussion with women and documentation to evidence this
demographic changes leading to increased workload in particular with
European immigrants
39

increased complexity in both mental and physical health as well as
increasing social deprivation in a growing number of families
In addition, service provision will require to be considered on a regional as
well as a local basis using clinical networks to ensure




Locally provided, practical and safe out of hours care
As much care as possible provided in local settings
Equity of access for specialist services
The best use of training and education opportunities for the health care
team
Work has already started in Grampian to address these issues locally;
Grampian has midwives with expertise in early pregnancy management,
undertaking ultrasound scanning, managing pregnancy loss by agreed
protocols and providing follow up discussion with those suffering pregnancy
losses. This happens in both Aberdeen and Elgin.
Midwives and radiographers perform level 1 and 2 obstetric scanning
throughout Grampian with level 3 scanning being performed in Aberdeen and
Elgin. Some GPs are also expanding their expertise in scanning. Education
and training around this is mandatory to ensure effective governance of this
service.
Selected midwives in Aberdeen and Elgin are being prepared as assisted
birth practitioners by completing an education programme via the University of
Bradford as well as competency assessment locally. This will allow them to
perform ventouse and forceps deliveries and fetal blood sampling. This will
assist the workload management in both areas and provide additional
expertise when activity is highest.
Dr Gray’s in Elgin sustain their neonatal service by midwives to providing
special care for neonates and stabilisation and transfer service for very
premature or ill neonates requiring transfer out of Elgin. This service is
however fragile as a limited number of midwives can be expected to sustain
the expertise required.
A programme to prepare Advanced Neonatal Nurse Practitioners to join the
medical staff rota has been in place since 2005. From April 2007 three of
these will be in post. By 2009/10, 8 will be in post some recruited externally
and the others being recruited and prepared from local availability of Neonatal
Nurses. Preparation of Neonatal Nurses is also on going with recruitment now
centred on Children’s nurses.
Maternity Care Assistants have now been recognised as an essential
development in modern maternity care delivery. A programme supporting this
role development is starting in Robert Gordon University Aberdeen in May
2007. Grampian will be using this opportunity to look at the skill mix within
teams and moving towards this model of care.
40
Recommendations:
As far as possible prepare plans to meet the demands of Modernising
Medical Careers and Working Time Directives for medical staff in all
services.
NHS Grampian should continue to explore workforce modelling with
accredited tools for midwifery and neonatal care so that there is
evidence to support workforce resource requirement and allowing
benchmarking across Health Boards.
New roles should continue to be developed and be service driven and
supported by New Roles Framework document, ensuring that education
and training are anticipated, planned and delivered before the roles are
implemented.
Further work should be undertaken to explore the potential for regional
working and maximising potential for e Health systems.
Ensure that any developments in workforce are assessed financially to
confirm that service remains affordable and sustainable.
11.
ENVIRONMENT OF CARE
The environment of care for Maternity services needs to strike the balance of
providing clinical safety alongside a relaxed and friendly approach to women,
the majority of whom are not ill. Much of this is supported by a woman
centred approach to care, involving women in decision making, exhibiting
good communication skills and following the principle that normality exists
until such times as complications develop. Supporting this model is also the
approach that as much care as possible is provided outwith hospital settings
and as near to the woman’s local services as possible. It is however also
important that the physical environment within hospital is to a satisfactory
standard. Modern facilities exist in Dr Gray’s in Elgin and there will be
opportunity to review the location of services in the Aberdeenshire Units as a
result of their review. The facilities in Aberdeen Maternity Hospital are now in
need of significant upgrading with improved physical connections to the
services in ARI and Children’s Hospital. Ideally a relocation of the Hospital is
desirable to meet the demands of a tertiary maternity service, including a re
provision the Neonatal Unit which now requires more clinical space to cope
with the expanding complex neonatal care requirements.
Recommendation:
Consideration must be given to the replacement of Aberdeen Maternity
Hospital, including Neonatal Unit with a modern purpose built facility,
linked to main services in Aberdeen Royal Infirmary.
41
12.
RECOMMENDATION SUMMARY
1.
Governance
The Maternity Services Clinical Management Board should lead
Maternity Services in Grampian by active participation of all
sectors so that key changes are discussed and debated and by
communicating more widely with the stakeholders.
The Birth Unit concept in Aberdeenshire CHP should be evaluated
over a time frame to be agreed. There should be no expansion of
this concept until that evaluation has taken place.
2.
Activity
The impact of changing demographics and ethnicity for the
Maternity Services is not yet clear and more intelligence must be
gathered around this to ensure health needs are known and
addressed as appropriate.
3.
Pre-Pregnancy Care
As well as the general activity provided by health promotion
services, more targeted activity should be designed to reach
women who are planning pregnancy so that they are in the
optimum health from the outset.
Health promotion activity in the education (school) sector
requires regular liaison with NHS maternity care providers locally
to maximise the potential of targeting pupils at the most
appropriate times.
Women requesting pre pregnancy advice should be able to
access an appropriate health professional including the midwife
on an individual basis.
Community Pharmacists should be encouraged to maximise
opportunities to participate in pre pregnancy preparation.
Provision of health education, folic acid with pregnancy testing
kits and smoking cessation support are examples of this.
4.
Public Health - Smoking
Smoking cessation interventions must be offered to every
pregnant woman who smokes and the most appropriate
arrangements made for each individual woman
42
Training and educational opportunities must be made available to
key professionals who care for pregnant women, in particular
Community Midwives who deliver the majority of a woman’s care.
Robust evaluation of outcomes must be available to inform
progress and measure success.
5.
Public Health – Domestic Abuse
Women should be asked about Domestic Abuse routinely at some
point in pregnancy which may be dependant on when a midwife
can see the woman on her own.
Midwives and others in the Pregnancy Team should have access
to awareness and routine enquiry training to ensure appropriate
skills exist to manage any disclosure which occurs.
The Maternity Services in Grampian should undertake an audit of
disclosure to assess the effects of routine enquiry.
6.
Perinatal Mental Health
Recent progress should be maintained in all aspects of the
service.
Appropriate education and training programmes for key staff
including midwives, health visitors and community psychiatric
nurses should be a priority for the newly appointed Specialist
Nurse. This can be a graduated approach including awareness
sessions on mental health and mental illness, more detailed
education for those conducting assessments and providing on
going support and specialist education for a small number who
wish to reach that level of expertise.
7.
Substance Misuse
Continue to monitor the service to ensure that it is meeting need.
Continue to develop the expertise of the wider professional
community so that skills expand in local settings.
Assess the impact on Neonatal Unit and consider alternative ways
of delivering care minimising the need for separating mother and
baby.
Consider how alcohol misuse may be impacting on Maternity
Service and pregnancy outcomes.
43
8.
Child Protection
Ensure that Child Protection remains at the forefront throughout
the pregnancy episode by providing regular awareness training
for all staff.
Continue to provide more specific training for case load holders
and those contributing to Child Protection Case Conferences.
9.
Neonatal Care
Continue to build expertise in modern neonatal care management
and reflect this in care management.
Develop and utilise the expertise of the wider team in delivering
routine care for neonates to maximise availability of cots in
Neonatal Unit.
Continue to support the service in Dr Gray’s Elgin, the Regional
Neonatal Transport Service and the Neonatal Resuscitation
Programme.
Continue to work closely with Combined Child Health Service.
10.
Risk Management
Continue to develop Risk management activity by involving as
many care providers as possible. This should include active
involvement of Supervisors of Midwives.
The outcomes of critical incident reviews must be reflected in
service improvement and education and training whenever
indicated.
Continue to develop written information for women which
contains the best available evidence presented in non technical
terms and make this available at appropriate times during the
pregnancy.
11.
Education and Training
Continue to develop relevant education events to meet the diverse
needs of the care professionals and monitor their
appropriateness.
Continue to work collaboratively with education providers as
demonstrated by the joint programme for Maternity Care
Assistants with RGU and Assisted Birth Practitioners with the
University of Bradford.
44
Continue to develop staff according to service need as well as
professional desires to ensure that the demands of a dynamic
service are being met.
12.
Public Involvement
Take steps to establish effective Maternity Services Liaison
Committee(s) accessible for women across Grampian.
13.
Workforce Planning
As far as possible prepare plans to meet the demands of
Modernising Medical Careers and Working Time Directives for
medical staff in all services.
NHS Grampian should continue to explore workforce modelling
with accredited tools for midwifery and neonatal care so that there
is evidence to support workforce resource requirement and
allowing benchmarking across Health Boards.
New roles should continue to be developed and be service driven
and supported by New Roles Framework document, ensuring that
education and training are anticipated, planned and delivered
before the roles are implemented.
Further work should be undertaken to explore the potential for
regional working and maximising potential for e Health systems.
Ensure that any developments in workforce are assessed
financially to confirm that service remains affordable and
sustainable.
14.
Care Environment
Consideration must be given to the replacement of Aberdeen
Maternity Hospital, including Neonatal Unit with a modern
purpose built facility, linked to main services in Aberdeen Royal
Infirmary.
45
Aberdeen Maternity Hospital
APPENDIX 1
The model of care in Grampian is designed to ensure that each woman receives
care tailored to her individual needs. Systematic reviews of trials for low-risk
women have shown that routine antenatal care for low-risk woman in community
settings by GPs and midwives appears as clinically effective as obstetrician-led
shared care, and is highly acceptable to women. Reviews also indicate that
reduced schedules of routine visits could be implemented without jeopardising
safety for mothers or babies. The model includes:

Woman-centred care according to personal needs

Locally accessible and community-based care with access to a specialist
as needed.

Fewer but systematic visits to improve consistency, continuity and reduce
duplication
Joint working supported between primary, secondary and tertiary services

This means that if all is well obstetrically and medically and the woman chooses,
her care is carried out in the community by midwives and GPs with easy referral
to Obstetricians if a complication develops. However if the complication resolves
the care is transferred back to community care.
Level 3 Care is provided in Aberdeen Maternity Hospital which is the tertiary
referral centre for Grampian, Orkney and Shetland, as well as the local
maternity hospital for women who reside in and around Aberdeen. It
comprises of

Community Midwifery service for women in and around Aberdeen.
They provide Community based ante natal care, parenthood education,
home delivery service and post natal care until mother and baby are
suitable for transfer to Health Visitor.

Ante Natal Clinic – mainly Consultant specialist clinics and referral
clinics for those women with existing or developing complications in
pregnancy.

Ultrasound scanning - all women have access to an early scan around
10-12 weeks gestation and a detailed anomaly scan at 18-20 weeks
gestation. Amniocentesis and chorionic villus sampling is carried out
as appropriate. At this point nuchal translucency scanning service is
not available except on a private basis.

Pregnancy Loss service – all women with threatened or actual
pregnancy loss are accommodated in Rubislaw an 8 bed area
dedicated for this service. This is a 24 hour, 7 day service staffed by
midwives choosing to work in this area.
46

Assessment and induction of labour area – Westburn provides a 24
hour a day service for women requiring assessment of a complication
of pregnancy with the aim of managing the problem quickly with
minimal need for hospital admission. In addition there is a 6 bed area
for women requiring induction of labour. Women are managed in this
area until such times as their cervix is favourable for induction to take
place or until labour has established.

Labour suite – this comprises of labour rooms, a midwife managed
delivery area, obstetric theatres, high dependency area and recovery
area. There is a water birth room. Women are retained in labour ward
until they are fit for transfer to the ante natal or post natal wards and
can go home soon after delivery if both mother and baby are well.

Ante and post natal areas – 3 wards are mixed ante and post natal
areas leading to continuity of care for those admitted in the antenatal
period into the post natal period. Consultants are attached to these
wards. One ward (24 beds) specialises in fetal medicine, one (13 beds)
specialises in women with substance misuse and the other (24 beds) is
more generalist. Length of stay is on average 2.8 days for all wards.

Neonatal Unit – this is the tertiary referral centre for Grampian, Orkney
and Shetland and also undertakes the surgical care of babies from
Highland. The unit also participates in the north region Neonatal
Transport system, with on average alternate weeks on call to deliver
this service.
Dr Gray’s Hospital, Elgin
Level 2b Care is provided in Dr Gray’s Hospital, Elgin. The service is
Consultant led with SHO rotational posts. There is no middle medical tier for
Obstetrics/Gynaecology or Paediatrics.

Community Midwifery service for women in Moray.
Provides Community based ante natal care, parenthood education,
home delivery service and post natal care until mother and baby are
suitable for transfer to Health Visitor.

Ante Natal Clinic – mainly Consultant antenatal clinics and specialist
clinics for those women with existing or developing complications in
pregnancy – and includes a joint Medical / Obstetric Clinic with
Consultant Physician.

Ultrasound scanning - all women have access to an early scan around
10-12 weeks gestation and a detailed anomaly scan at 20-21 weeks
gestation. Amniocentesis is carried out. At this point nuchal
translucency scanning service is not routinely offered.
47

Pregnancy Loss service – all women with threatened or actual
pregnancy loss are seen in the Early Pregnancy Assessment Unit. This
service is available between 08.30 to 16.30 Monday to Friday and is
staffed by two midwives trained in obstetric ultrasound. Facilities are
available for medical or surgical evacuation following early fetal
demise. Outwith these times, emergency cover is provided by
Consultants if required.

Pregnancy Day Assessment care is available, Monday to Friday within
the clinic area and at weekends, within the Obstetric Unit.

Service for Women abusing substances. Hospital based midwife and
Consultant Obstetrician work with local Drug and Alcohol Team and
Social Work, offering support.

Teenage mothers and families have a designated midwife who works
with National Children’s Home offering support.

Women in early labour or who are undergoing induction of labour are
managed in the ward area until such times as their cervix is favourable
for induction to take place or until labour has established and then
transferred to Labour Suite.

Labour suite – this comprises of 4 labour rooms. There are no facilities
for water birth within the hospital. Theatre facilities are on a separate
floor. Epidural anaesthesia is not available for labouring women but
Spinal anaesthetic is available for any surgical or instrumental
intervention. Care in labour is midwifery led unless deviation from the
norm requires consultant input. There is not a separate Midwives Unit.

Dr Gray’s Medical Service can offer High Dependency Care but women
requiring Intensive Care will be transferred to ARI or other tertiary unit.

Ante and post natal areas – there are designated ante and post natal
areas leading to continuity of care for those admitted in the antenatal
period into the post natal period. Length of stay is on average 2.8 days.

Neonatal service.
There are 4 Consultant Paediatricians.
Midwives who have completed an appropriate Neonatal Nursing
Course provide care.
Facilities comprise - Stabilisation and Transfer facilities and a Special
Care Baby Unit. Babies are retrieved by North Region Neonatal
Retrieval Team. Dr Gray’s staff does not participate in this.

Consultant Outreach Antenatal Clinics are held at Buckie, Keith, Huntly
and Banff.
48
Aberdeenshire Units




Aboyne
Banff
Fraserburgh
Peterhead
All of the above are small Community Maternity Units providing a similar
service. This is an integrated hospital and community model where midwives
provide ante natal care, labour care for those women who choose to give birth
in the local Unit or at home and post natal care mainly in the community. All
except Aboyne support Consultant Ante Natal Clinics for those who require
Obstetric referral and all have Ultrasound scanning facilities, Aboyne having
this provided nearby in Banchory.
The Units have been subject to a review over the last 2 years and the
following agreement has been reached. The Unit in Peterhead will remain a
24 hour a day 7 day a week service and will be the main Unit in north
Aberdeenshire. The Unit at Huntly has closed and the Units at Aboyne,
Fraserburgh and Banff will become Birth Units where low risk women may
choose to give birth locally, be returned to Community Care soon after the
birth and have care continued at home. Accordingly there will be no in patient
post natal care beyond the immediate post birth period. Ante natal care will
remain unchanged. This change will be implemented once final arrangements
have been agreed.
Outwith the Units the service in Aberdeenshire is delivered by locality based
Community Midwife Teams and GPs if they so wish. Home births are offered,
the majority in Aberdeenshire taking place in central Aberdeenshire where no
Unit exists. In South Aberdeenshire where no Unit exists the demand for
home birth is very low.
Consultant Ante Natal Clinics take place in Stonehaven, Peterhead,
Fraserburgh, Banff, Buckie, Forres, Keith, and Huntly.
49
Policy Documents and Papers
APPENDIX 2
Advisory Group to Review the Scottish Medical Workforce (2002). Future
practice: proposals of an advisory group to review the Scottish medical
workforce. The Temple Report, Edinburgh. SEHD
British Association of Perinatal Medicine (2001) Standards for hospitals
providing neonatal intensive and high dependency care. 2nd edition BAPM
Department of Health (2004) The New Agenda for Change. A pay system
which applies to all NHS employed staff, except very senior managers and
those covered by the doctors’ and dentists’ pay review.
Department of Health (2004) The NHS Knowledge and Skills Framework and
the Development Review Process. Final Draft.
Department of Health (2004), Scottish Executive Health Dept and Dept
Health, Social Services and Public Safety, Northern Ireland. Why Mothers
Die. Sixth Report on the Confidential Enquiries into Maternal Deaths in the
United Kingdom, 2000-2002.London. RCPG Press. . (plus earlier versions)
Department of Health, Department for Education and Skills (2004). National
Service Framework for Children, Young People and Maternity Services.
London, DOH .
Expert Advisory Group on Caesarean Section in Scotland (2001). Report and
recommendations to the chief medical officer of the Scottish Executive Health
Department. SEHD.
Health Education Board for Scotland – various breast feeding publications.
Health Scotland and ASH Scotland (2004) Smoking Cessation Guidelines for
Scotland. Edinburgh
Healthcare Commission: investigation into 10 maternal deaths at or following
delivery at Northwick Park Hospital, London between 2002 and 2005. London:
Healthcare Commission; 2006.
Hidden Harm: Responding to the needs of children of problem drug users.
The report of an Inquiry by the Advisory Council on the misuse of drugs.
Home Office: London; 2003.
National Collaborating Centre for Women’s and Children’s Health (2004).
Caesarean Section. Clinical Guideline. RCOG Press. London.
National Collaborating Centre for Women’s and Children’s Health (2003) Ante
Natal Care; Routine care for Healthy Pregnant Women. RCOG Press.
London.
50
National Collaborating Centre for Women’s and Children’s Health (2006).
Routine Postnatal care of women and their babies. Clinical Guideline 37.
RCOG Press. London.
National Collaborating Centre for Women’s and Children’s Health (2006 draft).
Gyidelines for Intrapartum Care:care of healthy mothers and babies during
childbirth. Clinical Guideline. RCOG Press. London.
NHS Education for Scotland: Maternity Care Assistants (2006). Edinburgh
NHS Grampian 2002. Breast Feeding Strategy.
NHS Quality Improvement Scotland 2004. Maternal History Taking: Best
Practice Statement. Edinburgh.
NHS Quality Improvement Scotland 2004. Routine Examination of the
Newborn: Best Practice Statement. Edinburgh.
NHS Quality Improvement Scotland 2005. Clinical Standards: anaesthesia:
care before, during and after anaesthesia. Edinburgh
NHS Quality Improvement Scotland March 2005. Maternity Services. Clinical
Standards. Edinburgh.
NHS Scotland Information and Statistics Division (ISD) National statistics
release. Scottish Perinatal and Infant Mortality and Morbidity Report Publication 26 - 2005 Rennie AM, Hundley V et al (1998) Women’s Priorities for Care Before and
after Delivery. British Journal of Midwifery. Vol6 No; pp 434-438
Royal College of Anaesthetists (1999) Guidelines for the provision of
Anaesthetic Services.
Royal College of Midwives (2000) Vision 2000, RCM, London.
Royal College of Midwives (2000) Midwifery Practice in the Post natal period:
Recommendations for Practice. RCM. London.
Royal College of Midwives (2004) Preparation of Maternity Care Assistants;
Prepared to Care: Fit for Purpose Programme. RCM. London.
Royal college of Midwives (2003) Valuing Practice: a springboard for
midwifery education. RCM. London.
Royal College of Obstetricians and Gynaecologists, Royal College of
Anaesthetists, Royal College of Paediatrics and Child Health, Royal College
of Midwives (2006) Towards Safer Childbirth: Minimum Standards for Service
Provision and Care in Labour Report of a Joint Working Party.
51
RCOG: The Future role of the Consultant in Scotland – service Provision and
Workforce Planning. Scottish Committee of RCOG Report, (December 2005)
Royal College of Obstetricians and Gynaecologists and Royal College of
Paediatrics and Child Health (1997) report of a Joint Working Party on Fetal
Abnormalities. Guidelines for Screening, Diagnosis and Management. RCOG
and PCPCH, London.
Royal College of Obstetricians and Gynaecologists and Royal College of
Radiologists (1995) Guidance on Ultrasound Procedures in Early Pregnancy.
RCOG and RCR, London.
Royal College of Psychiatrists (2001). Perinatal Mental Health services.
Recommendations for Provision of Services for Childbearing Women. CR88.
RCP. London.
Scottish Executive. (1999). Learning Together: a strategy for education,
training and lifelong learning for all staff in the National Health Service in
Scotland. Edinburgh: The Stationary Office.
Scottish Executive. (2003a). Ongoing Learning and Development in
NHSScotland. Planning Manual. Edinburgh: The Stationary Office.
Scottish Executive. (2003b). Exploiting the Power of Knowledge in NHS
Scotland – A National Strategy. Edinburgh: The Stationary Office.
Scottish Executive (1999). NHS Management Executive Letter 40: New Deal
for Junior doctors.
Scottish Executive. Responding to Domestic Abuse: Guidelines for Health
Care Workers in NHS Scotland. Edinburgh (2003)
Scottish Executive Health Department Feb 2001. Framework for Maternity
Services in Scotland Edinburgh. SEHD
Scottish Executive Health Department Dec 2002. implementing a framework
for maternity services in Scotland. Report of the Expert Group on Acute
Maternity Services (EGAMS). Edinburgh. SEHD.
Scottish Executive (2003). Getting our Priorities Right: policy and Practice
Guidelines for Working with Children and Families Affected by Problem drug
Use. Edinburgh. SEHD.
Scottish Executive Health Department (2001) Nursing for Health. A Review of
the Contribution of nurses, midwives and health visitors to Improving the
Public’s Health. Edinburgh. SEHD.
Scottish Executive Health Department (2004) Fair to all, Personal to Each: the
next steps for NHS Scotland. Edinburgh. SEHD
52
Scottish Executive Health Department (2005) Building a Health Service fit for
the Future: a National Framework for service change in NHS Scotland.
Chaired by Prof David Kerr (2004-05). Edinburgh . SEHD
Scottish Executive Health Department.(2004) National Workforce Unit.
Scottish Health Workforce Plan 2004 baseline. Edinburgh
Scottish Executive Health Department (2000) Our National Health. A plan for
action, a plan for change. Edinburgh. SEHD.
Scottish Executive Health Department (2002) Promoting Health and
Supporting Inclusion. Edinburgh. SEHD.
Scottish Intercollegiate Guideline Network SIGN (2002) Post natal depression
and puerperal psychosis. Guideline 60
Scottish Office MEL (1999) 27 Services for women with Postnatal Depression.
Scottish Office (1999) Towards a Healthier Scotland: a white Paper on Health.
Edinburgh.
Scottish Programme for Clinical effectiveness in Reproductive Health (2001):
Scottish Audit of the Prevention of Medical Emergencies in Labour. An audit
of Progress Towards Safer Childbirth.
Scottish Programme for Clinical effectiveness in Reproductive Health (1999):
Caesarean Section in Scotland: current practice and recommendations for the
future.
Scottish Programme for Clinical effectiveness in Reproductive Health (2006).
Scottish Confidential Audit of Severe Maternal Morbidity. 3rd Annual Report
2005
Scottish Programme for Clinical effectiveness in Reproductive Health (2006).
Scotland-wide Learning from Intrapartum Critical Events. Covering events in
2005
Stillbirth and Neonatal Death Society. Pregnancy Loss and the loss of a baby.
Guidelines for Health Professionals (2nd edition) London: Sands.
Tucker J, Hall M et al (1996) Should Obstetricians see women with normal
pregnancies? A Multicentred Random controlled trial of routine Antenatal care
by GPs and Midwives compared to shared care. BMJ.312: pp 554-559.
53
A Framework for Maternity Services in Scotland
APPENDIX 3
NHS Grampian 2006
Group: Preconception and very early pregnancy (Principles 1-3)
Principle
1. Good health before and during early
pregnancy benefits the woman, her
unborn baby and the wider family. All
women of reproductive age should be
empowered and encouraged to be as
healthy as possible.
Progress to date
Information is available in
Community pharmacies, schools,
Community Centres, Health Points
and other appropriate sites which
target women to consider their health
needs.
Areas for Action
Further develop where and
how such information is
provided
Priority
Low
Lead
Public Health
Leads in CHPs
Preconception care is available but
mainly accessed formally by those
who have been pregnant in the past
and often targeted to those with
existing medical problems.
There is a need to review
how preconception care is
delivered across the local
health system in Grampian
Low
Public Health
Leads in CHPs
The Grampian Sexual Health
Strategy 2005 has been agreed.
(Appendix 1)
Implement the Sexual Health
strategy
Low
Dr Gillian Flett
Maternity Service providers work with
colleagues in Public Heath and
Health Promotion
Develop a targeted health
needs approach to promoting
good health before and
during early pregnancy
High
Public Health
Leads in CHPs/J
Milne, L
Campbell
Smoking interventions training and
education is occurring. Grampian has
highest rate of smoking for young
women regardless of deprivation.
(Appendix 2)
Further development of the
NHS Grampian activity to
reduce the number of women
who smoke during pregnancy
High
David Gow
54
Principle
2. Specific pre-conception services should
be available to women with a poor
obstetric or medical history, a previous
poor fetal or obstetric outcome, or where
there is a family history of significant
illness.
Progress to date
A consultant led pre pregnancy
service is available for all categories
listed, including genetic counselling.
3. There should be specific services for In Aberdeen and Elgin there is a
women with complications in early dedicated early pregnancy unit
pregnancy.
available at all times with open
access to all who require the service.
55
Areas for Action
Increase awareness of this in
the primary care settings to
encourage appropriate
referral
Priority
Low
Lead
Dr N Smith/Dr
D Evans
Continue to audit various
aspects of the service
Low
Dr N Smith/Dr D
Evans
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Pregnancy (Principles 4-8)
Principle
4. Maternity services should provide a
woman and family-centred,
locally
accessible,
midwife-managed,
comprehensive and effective model of
care during pregnancy with clear evidence
of joint working between primary,
secondary and tertiary services.
Progress to date
Maternity Care in Grampian follows
agreed Guidelines designed to
provide ante and post natal care in
community settings by midwives and
general practitioners with referral to
Obstetricians only if necessary or if
the woman chooses it. These
guidelines include risk identification
and management protocols.
Areas for Action
Update these in 2006
The majority of pregnancy bookings
are done by midwives in local Health
Centres and GP Practices or at
home. The midwife coordinates care
creating holistic approach for wider
care needs.
No new action required
Consultant Ante Natal Clinics are
held in 9 towns in Grampian reducing
need for complex care centred in
Aberdeen or Elgin.
No new action required
A review of the delivery services
provided in Aberdeenshire has taken
place in 2005, taking the views of the
public using many approaches
including Focus Groups, Public
meetings, questionnaires and e mail.
(Appendix 3)
Implement decisions around
the Consultation
56
Priority
High
Lead
Dr N Smith/
CMM G Porter
High
Mr J Stuart
Principle
4. (contd) Maternity services should
provide a woman and family-centred,
locally accessible, midwife-managed,
comprehensive and effective model of
care during pregnancy with clear evidence
of joint working between primary,
secondary and tertiary services.
Progress to date
User involvement is effective in
Aberdeenshire and Moray but is
more difficult to engage service users
in Aberdeen except in specific
groups such as Stillbirth and
Neonatal Death Society, National
Childbirth Trust, Breast Feeding
groups.
Areas for Action
Continue to strengthen public
involvement in service
development wherever
possible and use outcomes of
public consultations in 2005.
Explore alternative means of
involving service users in
Aberdeen with Grampian
Corporate Communication
Team
Priority
High
Lead
J Milne
Level 1 and 2 Ultrasound scanning is
available across Grampian provided
by Midwives and Radiographers.
Invasive scanning is performed in
Aberdeen and Elgin by Obstetricians.
Continue to develop
community based services
where appropriate
Medium
Dr N Smith
Mr A Riddoch
NHS Grampian has established a
Maternity Services Clinical
Management Board which includes
CHPs, Acute Sector, Health Board
and lay representatives. (Appendix 4)
Continue to strengthen
activity of Board to promote
formal mechanisms for
working thus creating
consistency of approach to
care across sectors and
Health Board
High
Dr S Macphee
(Chair)/
Office bearers
NHS Grampian takes part in the
North of Scotland Planning sub
group for Maternity Services
Framework development and
implementation.
Regional Planning
Conference held in February
2006 will set priorities for
further integration of service
delivery
High
Mrs E Smith/
Maternity
Services Clinical
Management
Board
57
Principle
5. Maternity services should provide
parent education programmes that
address normal pregnancy and the
treatment of complications developing
during pregnancy.
A comprehensive
health
promotion
programme
and
opportunities for discussion about the
effects of parenthood on relationships
should be offered.
Progress to date
Parent education programmes are
available in local areas across
Grampian.
Areas for Action
Continue to evaluate
programmes to ensure they
are meeting need, including
activity in hard to reach
groups
Priority
Medium
Lead
J Milne
Women and partners with Substance
Misuse problems are targeted for
Antenatal Peers Early Education
Partnership (PEEP) programme.
(Appendix 5)
Evaluate effectiveness of the
programme and develop
according to outcomes
mid 2006
M Stafford
Education programmes can be
tailored to individual need e.g. Young
Parents Group in Elgin, one to one
sessions for those with disability,
Twins Group.
Continue to respond to need
AMH leads a group that examines
information leaflets both developed
locally and produced commercially to
confirm that they are fit for purpose.
This information is given to all
women and forms basis of
programmes of education for women
and partners.
All women receive Ready Steady
Baby booklet.
No new action required
58
J Milne
L Campbell
ETaylor
Principle
6. A comprehensive antenatal diagnostic
and screening service should be available
and offered to women in order to detect,
where possible, any maternal problems or
fetal abnormalities at an early stage.
7. Maternity services should make sure
that
women's
circumstances
are
assessed holistically and that social and
psychological needs are identified and
managed appropriately.
Progress to date
Screening programmes in place
adhere to national guidelines,
including Hep B, HIV, Syphilis and
rubella. These are offered to all
women.
Areas for Action
An audit to identify women
who refuse infectious
diseases screening is taking
place in 2006
Sickle Cell test and Thalassaemia
test are offered to selected groups in
early pregnancy.
No new action at present
Women are offered 2 routine scans
in pregnancy, one around 10-12
weeks and another at around 20
weeks for fetal anomaly. All scan
staff have undertaken appropriate
education programmes.
NHS Grampian has prepared
a case for the introduction of
Nuchal screening as per
Health Technology
Assessment Advice 5, Feb
2004
Serum screening for Down’s
Syndrome and Spina Bifida take
place at 16 weeks gestation.
Domestic Abuse policies and referral
pathways have been updated and
will be re launched in April/May 2006.
The preparation for this has included
training needs analysis for
multiagency staff including maternity
staff and the preparation of a number
of key trainers across Grampian to
cascade training and give additional
support to professionals as needed.
Routine enquiry will become the
norm during pregnancy care.
Appendix 6
No new action
59
Provide training for all case
load holders and those
working in assessment units
in early 2006
Priority
Medium
Lead
Dr A Shetty
Medium
Dr S MacPhee
High
J Milne
Principle
7. (contd)Maternity services should make
sure that women's circumstances are
assessed holistically and that social and
psychological needs are identified and
managed appropriately.
Progress to date
Substance Misuse – a multi
disciplinary and multiagency
approach is in place for women and
their families, and in AMH one ward
specialises in caring for these
women when in patients. A
Substance Misuse working group is
in place to ensure that any changes
in the overall service are reflected in
care management across Grampian.
Key workers are in place in
Aberdeen, Elgin and Aberdeenshire.
(Appendix 7)
Areas for Action
Update multi professional
guidelines by mid 2006
Priority
Medium
Lead
J Milne
Child Protection – there has been
significant investment in Child
Protection Services across sectors
with clear messages about
Accountability, Education and
training and Communication.
(Appendix 8)
Continue to provide targeted
multi professional education
and training throughout 2006
and beyond
High
P Smart
New Guidelines for Perinatal Mental
Health launched in early 2006.
( Appendix 9)
Provide awareness and
training packages for staff as
appropriate, identify
resources to facilitate this
High
H Robbins
60
Principle
7. (contd) Maternity services should make
sure that women's circumstances are
assessed holistically and that social and
psychological needs are identified and
managed appropriately.
Progress to date
There is a multiagency approach to
Public Health and Social Inclusion
across Grampian with midwives and
health visitors taking the lead in
addressing care needs. Moray has
an active relationship with National
Children’s Homes.
Areas for Action
At present there are no
outcome measures to confirm
that services are focussed
effectively on population
needs or trends. Midwifery
data base introduced in April
2006 will assist with this
(Appendix 10)
8. Health professionals should recognise
the important role of partners, and make
sure they are encouraged and supported
to take a full and active role in pregnancy
and childbirth.
This is embedded in practice.
No new action required
Couples classes are provided in
Parenthood education with evening
classes provided as well as daytime.
PEEP classes for substance
misusers include partners and other
family members as desired.
Partners are welcomed at all ante
natal visits and have long periods of
access in post natal period.
(Appendix 11)
61
Priority
Medium
Lead
J Milne/L
Campbell/E
Taylor
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Childbirth (Principles 9-11)
Principle
9. Maternity services, including obstetric
and neonatal services, should provide a
fully
integrated
childbirth
service
responsive to the needs of mothers and
their new-born babies.
Progress to date
The existing configurations of
services in Grampian may change in
response to the Aberdeenshire
Review. At the beginning of 2006
delivery services are available in
Aberdeen, Elgin, Aboyne, Banff,
Fraserburgh and Peterhead, all of
which have local guidelines allowing
women to deliver locally if they are
suitable and wish to do so.
Areas for Action
There will be a need to review
information about services in
response to outcome of
Review
Priority
High
Lead
J Milne/E Taylor
Community Units have access to
advice from Aberdeen and Elgin
throughout the 24 hour day.
Out of Hours service will need
to be agreed and
communicated if any change
to service occurs
High
J Milne/E Taylor
GMed
The vast majority of staff in
Community Units have completed
Neonatal Resuscitation Programme
and adult resuscitation programme.
The majority has also undergone an
updated Emergency Care
Programme dealing with common
maternity emergencies, including
transfer strategies.
Similar programmes occur in
Aberdeen and Elgin.
The acquisition and
maintenance of skills is a
continuous process. The
Scottish Multiprofessional
Maternity Development
Programme (SMMDP)
supports this process and a
local programme for providing
and accessing these needs to
be developed and agreed.
This will have resource
implications
High
J Milne
62
Principle
9. (contd) Maternity services, including
obstetric and neonatal services, should
provide a fully integrated childbirth service
responsive to the needs of mothers and
their new-born babies.
Progress to date
Aberdeen and Elgin have a Lead
Consultant Obstetrician for high risk
antenatal, intrapartum and post natal
care.
Areas for Action
Through workforce planning
identify the impact of
Modernising Medical Careers
for the multiprofessional team
in 2006
Priority
High
Lead
Dr P Booth
A programme to prepare midwives
as Assisted Birth Practitioners has
commenced in Aberdeen and Elgin.
Evaluate the introduction of
Midwife Assisted birth
Practitioners in Aberdeen and
Elgin by the end of 2006
High
J McConville
Several Midwives in Aberdeen have
completed a module in High
dependency Care for the ill Obstetric
woman.
Consider succession planning
and maintenance of skills by
April 2006
Medium
J McConville
Access to Neonatal Intensive Care is
in place and advice is available from
the Unit at all times.
Elgin has an established Special
Care service and has prepared
midwives with extended skills to
participate in stabilisation and
transfer of ill and very premature
neonates.
No new action is required
63
Principle
9. (contd) Maternity services, including
obstetric and neonatal services, should
provide a fully integrated childbirth service
responsive to the needs of mothers and
their new-born babies.
Progress to date
There is a lead Consultant
Anaesthetist attached to the service
in Aberdeen Maternity Hospital who
is responsible for the planning and
delivery of related anaesthetic care
including running a clinic for those
who have experienced pain or
anaesthetic problems in previous
pregnancies.
Dr Gray’s Elgin have a named
Consultant Anaesthetist responsible
for Obstetric care.
Areas for Action
No new action required
Priority
Lead
10. One-to-one midwifery care should be
given to women during labour and
childbirth in order to make sure they have
individualised attention and support,
preferably with continuity of care.
This is adhered to in Community
Units and in Elgin. Aberdeen aspires
to this and does all possible to
ensure it happens. However it is not
always possible.
Local audit done at regular
intervals
Low
J Milne/ L
Campbell/E
Taylor
11. Women have the right to choose how
and where they give birth. This choice
should be supported by high quality
information and evidence-based clinical
advice that allows them to take part in the
decision making process.
Women exercise choice to give birth
in a range of settings.
Update any information in
light of decisions reached by
Aberdeenshire Review
High
J Milne
This may be affected by the outcome
of the Aberdeenshire Maternity
Services Review.
Work on types and content of
the information and promote
consistency in how this is
discussed with women
64
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Postnatal and Parenthood (Principles 12-17)
Principle
12. Maternity services should provide
postnatal care to facilitate the transition to
motherhood by making sure that ill health
is prevented or detected and managed
appropriately. Women and their partners
should be supported to make a confident
and effective transition to parenthood.
Progress to date
Transition to parenthood is supported
on an individual basis following
discussion on care needs with the
woman. They encompass physical
recovery from birth, emotional
wellbeing and the ability to care for
the new baby competently and
confidently.
Community midwives provide care
tailored to individual women’s needs
for a length of time negotiated with
woman and her health visitor if
problems remain unresolved.
Areas for Action
Consider NICE guidelines on
Post Natal Care when
available after July 06
Best practice guidelines are followed
in terms of prophylactic antibiotics
and thrombolysis prior to all
caesarean sections.
No new action
NHS Grampian participates in post
section infection surveillance.
System is still being
developed and national action
planned
Bladder and bowel function are
assessed post delivery and should a
3rd or 4th degree tear occur this is
reviewed at Consultant Clinic 3
months post delivery.
No new action
65
Priority
Medium
Lead
J Milne
Medium
Dr P Daniellian
Dr D Evans
Principle
12. (contd) Maternity services should
provide postnatal care to facilitate the
transition to motherhood by making sure
that ill health is prevented or detected and
managed appropriately. Women and their
partners should be supported to make a
confident and effective transition to
parenthood.
Progress to date
Perinatal Mental Health Guidelines
have been launched to promote early
identification, assessment and
management of mental ill health (as
Principle 7).
Areas for Action
Implementation of Perinatal
Mental Health Guidelines with
training in early 2006
Implementation of Routine
Enquiry for Domestic Abuse
In mid 2006
Women who experience pregnancy
loss are accommodated in a
dedicated area and have opportunity
to discuss events with relevant
professionals once all investigations
have been reported.
No new action
13. Midwives, Health Visitors, GPs and
Professional Allied to Medicine should
adopt a flexible approach to postnatal
care working in partnership with women
and other agencies. This will make sure
that
the
most
appropriate
and
experienced professional is the care
provider at any given time according to
the needs of the women and her baby.
Midwives and Health visitors provide
majority of post natal care with as
much continuity of carer as possible.
Some traditional practice still exists.
14. Acute and Primary Care NHS Trusts
should jointly plan and provide a fully
integrated neonatal service responsive to
the needs of new-born babies and their
parents.
A business plan has been developed
to introduce Neonatal Nurse
Practitioners to AMH. 5 are currently
in training.
66
Priority
High
Lead
J Milne/ETaylor
Establish a Working Group to
further develop evidence
based post natal care
including the possibility of
introducing Maternity Care
Assistant
High
Jenny McNicol
Develop guidelines for
postnatal length of hospital
stay
High
J Milne/E Taylor
Response awaited
Dr P Booth
Principle
14. (contd) Acute and Primary Care NHS
Trusts should jointly plan and provide a
fully
integrated
neonatal
service
responsive to the needs of new-born
babies and their parents.
15. Maternity services should promote,
support and sustain breastfeeding.
Women should be informed of its'
benefits, while being supported in their
chosen mode of infant feeding.
Progress to date
Midwives in Elgin have completed
SMMDP to enable them to undertake
routine examination of newborn.
Areas for Action
Establish need to extend this
within AMH and in CMU
Midwives in Elgin have undertaken
Stabilisation and Transfer Courses.
No new action
North of Scotland Neonatal Transport
Service has been established.
Monitor effectiveness via
regional transport lead
NHS Grampian has Breast Feeding
strategy and an implementation
group.
(Appendix 12)
No new action required
Women receive consistent written
information in form of UNICEF
leaflets
No action required
In house training for qualified and
unqualified staff including medical
staff occurs on a regular basis.
Move to mandatory training
schedules as per
requirements for Baby
Friendly status
Robert Gordon University have
committed to Baby Friendly approach
to student midwife and health visitor
programmes.
67
Priority
Medium
Lead
Dr M Munro
Low
Dr P Booth
High
J McNicol
Principle
15. (contd) Maternity services should
promote, support and sustain
breastfeeding. Women should be
informed of its' benefits, while being
supported in their chosen mode of infant
feeding.
16. Women and their partners should be
given the opportunity to reflect/debrief on
their experiences of pregnancy and
childbirth in the postnatal period, with a
health professional.
Progress to date
Although Breast Feeding rates vary
across the Health Board area in 2005
NHS Grampian met the target of
45% of women breast feeding at 8
weeks post delivery.
Areas for Action
Continue targeted
interventions to make
progress in low breast
feeding areas
Priority
High
AMH and Elgin are actively working
towards Baby Friendly Accreditation.
Work towards achievement of
this for AMH and Elgin by
2008
High
J Forrest/J
Milne/L
Campbell
Unicef training has been targeted to
30 midwives and health visitors in
2005/6. These will act as key
individuals for promoting consistent,
best practice.
No new action
A Breast Feeding Centre has opened
in AMH to provide expert
assessment and assistance for those
having breast feeding problems both
in hospital or at home and as a
training centre for learners or
inexperienced staff.
Continue to evaluate and
educate
Low
M Ogden
This forms part of the post natal care
package by Community Midwives
and is carried on by Health Visitor if
issues are revealed later to her. This
has not been subject to evaluation.
Consider the approach to
reflection/debriefing to ensure
individual needs are being
met.
This may need a research
approach
Low
J McNicol
68
Lead
M Ogden
Principle
17. There should be a comprehensive,
multi-professional, multi-agency service
for women who have, or are at risk of,
postnatal depression and other mental
illness.
Progress to date
This links to Principles 7 and 12
69
Areas for Action
Debate about the in patient
management of post natal
depression is not complete
Priority
Medium
Lead
Dr J Callander
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Service organisation and provision (Principles 18-21)
Principle
18. Maternity care should be organised to
provide a flexible, appropriate, clinically
effective and accessible service in
response to the needs of women.
Progress to date
NHS Grampian has established a
Maternity Services Clinical
Management Board to oversee the
provision of Maternity Services in
Grampian. ( Appendix 4)
Areas for Action
Strengthen work of this Board
Priority
High
Lead
Dr S Macphee
There is a North of Scotland
Planning sub group for Maternity
Services.
Grampian continues to
participate in the work of NOS
group while liaising with
Tayside
High
E Smith
Wide consultation with the women in
Aberdeenshire regarding maternity
service provision took place in
2005/6.
(Appendix 3)
Continue to use a range of
methods to engage service
users in monitoring and
development of services
High
Mr J Stuart
Moray has an active Maternity
Service Liaison Committee.
Utilise feedback to inform
need for change both locally
and more widely in Grampian
High
Dr D Evans
Midwives have well developed
Continuing Professional
Development structures in place
through Supervision of Midwives
processes to ensure they are
meeting needs of service.
Continue to monitor
compliance with training
plans
Medium
J Milne
70
Principle
18. (contd) Maternity care should be
organised
to
provide
a
flexible,
appropriate, clinically effective and
accessible service in response to the
needs of women.
19. Maternity services should adopt a
holistic approach to care during
pregnancy, childbirth and the postnatal
period to maximise and improve continuity
of care and continuity of carer for women.
Progress to date
Clinical Audit activity is a regular
feature of education and training
sessions with findings published for
action planning.
Areas for Action
Continue to promote
multidisciplinary approach to
audit
Priority
Medium
Lead
Dr N Smith
Midwifery workforce planning is
under discussion in light of workforce
and workload planning agenda and
locally in light of the Aberdeenshire
Review.
Develop role of maternity
care assistant as appropriate
Medium
J Milne
Principles of continuity of care/ carer
are promoted within the constraints
of family friendly work patterns,
EWTD, part time working etc.
No new action required
Each woman has an identified
midwife to lead her holistic and
midwifery care irrespective of risk.
20. Maternity services should be tailored
to the needs of the individual woman.
Services should be provided by multidisciplinary and multi-agency teams with
an understanding of professional roles to
maximise
the
quality
and
comprehensiveness of care, ensuring
safety for both mother and baby.
Principle followed is that each
woman’s needs are assessed
individually and her care is tailored to
what she needs at that time.
Continue to audit this as part
of the routine record audit
performed by Supervisors of
Midwives
Low
J Milne
Role development is a planned
process engaging stakeholders e.g.
introduction of midwife assisted birth
practitioners, Advanced Neonatal
Nurse Practitioners.
Evaluate the impacts of the
introduction of new roles
High
J Milne/ J
McConville
71
Principle
20. (contd) Maternity services should be
tailored to the needs of the individual
woman. Services should be provided by
multi-disciplinary and multi-agency teams
with an understanding of professional
roles to maximise the quality and
comprehensiveness of care, ensuring
safety for both mother and baby.
21. Maternity services should agree
arrangements for both in-utero transfer
and the transfer of a recently delivered
mother and/or her new-born baby to a
linked secondary or tertiary unit.
Progress to date
Opportunities for joint
multiprofessional learning occur
within areas such as Neonatal
resuscitation, basic obstetric life
support, substance misuse, child
protection, breast feeding, control of
infection, thereby promoting team
approaches to care and
understanding of capabilities and
responsibilities.
Areas for Action
Ensure that clinical workforce
planning and training plans
are integral to service
planning and developments
Priority
Low
Lead
J Milne
AHPs have an important role in
health care team, in particular
physiotherapists and dieticians.
Strengthen these roles
whenever possible
Low
Professional
leads
Social work input has increased in
line with the complex needs of many
service users. Support from social
care and Family Centres is
encouraged.
Liaise closely with Social
Work services to ensure that
demand and capacity issues
are understood
Medium
J Milne/E Taylor
Security systems are in place for
mothers and babies.
Review Policy and systems in
2006
Low
J Milne
The North Neonatal Transport team
is in place as part of the national
transport network.
Continue to monitor all
aspects of the service
High
Dr C
Hauptfleisch/D
Buist
Protocols and training are in place to
support this activity.
72
Principle
21. (contd) Maternity services should
agree arrangements for both in-utero
transfer and the transfer of a recently
delivered mother and/or her new-born
baby to a linked secondary or tertiary unit.
Progress to date
Transport protocols are in place for
transferring women during
pregnancy, in labour and for women
and babies in the post natal period.
Areas for Action
Review protocols within 2
years and immediately should
services change
The need to transfer women outwith
Grampian as Neonatal Unit is unable
to accept intensive care baby
continues In 2005 this occurred in 48
cases.
Participate in National Audit
Protocols for transferring women
during pregnancy, in labour and in
post natal period are available.
No new action
73
Priority
High
Lead
E Taylor
Dr P Booth
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Risk assessment and management (Principle 22)
Principle
22. All health professionals must have a
clear understanding of the concept of risk
assessment and management to improve
the quality of care and safety for mothers
and babies, while reducing preventable
adverse clinical incidents.
Progress to date
NHS Grampian has a risk
assessment tool which underpins
understanding of risk as a concept.
(Appendix 13)
Areas for Action
No new action
Priority
Lead
Ante Natal Care in Grampian
Guidelines contain risk assessment
criteria and information about referral
pathways should complications
develop.
(Appendix 14)
For review in 2006
High
Dr N Smith/G
Porter
Decisions about appropriate place of
care are made taking geographical
etc issues into consideration.
Continue to ensure that these
are reflected in any protocols
and policies developed in
response to Aberdeenshire
review
High
Lead clinicians
Clinical Risk management meetings
for maternal and neonatal care are
held in AMH and Elgin monthly and
in CMUs following identified clinical
incidents. Reports are generated
from these meetings as learning
points for Grampian wide service.
Establish a system to audit
implementation of
recommendations from
incident reviews
Medium
Dr P Booth
74
Principle
22. (contd) All health professionals must
have a clear understanding of the concept
of risk assessment and management to
improve the quality of care and safety for
mothers and babies, while reducing
preventable adverse clinical incidents.
Progress to date
Intrapartum obstetric emergency
sessions are held regularly in all
labour settings.
Areas for Action
No new action
Risk management is a regular
agenda item on Supervisor of
Midwives bi monthly meetings.
No new action
75
Priority
Lead
A Framework for Maternity Services in Scotland
NHS Grampian 2006
Group: Information and communication (Principles 23-27)
Principle
23. Planning and provision of maternity
services at national and local level must
be underpinned by an appropriate and
comprehensive database.
24. Public and professional consultation
must be fundamental to the planning,
development and provision of local
maternity services.
Progress to date
PROTOS Maternity Information
System is in place in Labour Ward
AMH. Technical problems have been
evident as Company has changed
hands. This has prevented progress
in further developing the system.
Areas for Action
Aim to resolve IM&T
problems with PROTOS in
early 2006
AMH has a Maternal and Neonatal
data Bank serviced by University of
Aberdeen. This holds clinical data for
more than 50 years.
No new action
Neonatal IT system is under
development.
Aim to implement during 2006
A wide range of methods have been
used to consult and involve the
service users, the public and staff
during the Aberdeenshire Review
process in 2005m and 2006. This
has informed services across
Grampian.
Continue to develop a range
of ways of engaging the
public in influencing the
provision of Maternity
Services in Grampian and in
Aberdeen in particular
There is an active Liaison Committee
in Moray.
No new action
76
Priority
Medium
Lead
Dr P Danielian
Dr M Munro
High
CHP leads
J Milne
Principle
24. (contd) Public and professional
consultation must be fundamental to the
planning, development and provision of
local maternity services.
25. High quality communication between
professionals and women and their
families,
and
professionals
and
colleagues, must be central to the
provision of excellent maternity care.
Progress to date
User groups such as National
Childbirth Trust, Still Birth and
Neonatal Death society have access
for regular contacts.
Areas for Action
Strengthen these contacts as
Principle 4
Partnership working with staff is an
underlying principle of all service
change and development as
evidenced by approach to
Aberdeenshire review, introduction of
new roles.
No new action
All women regardless of risk have a
named midwife who is responsible
for the coordination of her midwifery
and social care needs. This includes
sharing information at relevant times.
No new action
Women receive written information
which has been vetted by a
professional group.
No new action
Whenever possible nationally
produced information leaflets re
screening tests are used and staff
trained in their use prior to launch.
No new action
NHS Grampian has a policy about
the quality of information leaflets
developed in house
(Appendix 15)
No new action
77
Priority
High
Lead
J Milne
Principle
25. (contd) High quality communication
between professionals and women and
their families, and professionals and
colleagues, must be central to the
provision of excellent maternity care.
Progress to date
Interpreter services are easy to
access via Language Line system
Areas for Action
No new action
Interprofessional communication and
collaboration includes
 Regular clinical risk
management meetings
 Labour Ward Forum
 Supervisor of Midwives in
Grampian meetings
 Joint management of
complicated cases e.g.
diabetes, epilepsy,
haematology, genetics,
anaesthetic difficulties
 Audit meetings
 Practice meetings in GP
settings
 Substance Misuse multi
agency, multi disciplinary
working group
No new action
Telemedicine facility exists between
ultrasound departments in Aberdeen
and Elgin but this requires upgrading.
Neonatal Unit has system for cardiac
scanning which connects to Yorkhill,
Glasgow.
78
Priority
Lead
Principle
26. Women of reproductive age should
have easy access to evidence based
information and to services covering
continuous
reproductive
healthcare
regardless of their initial point of contact.
Progress to date
Grampian has a number of Health
Points where information can be
accessed.
Health premises have a range of
information on display.
27. There should be a national, unified When this is available Grampian will
and standardised woman-held maternity implement.
record that is available and accessible to
both women and professionals.
At present all women carry their own
records and present them at all care
contacts.
79
Areas for Action
Monitor the update of
information and assess what
is used and requested if not
provided
Priority
Lead
CHP public
Health Leads
Appendices ( available on request)
No 1 NHS Grampian Sexual Health Strategy 2005
No 2 Smoking Interventions Group Minutes
No 3 Aberdeenshire Review Report (pending)
No4 Maternity Services Clinical Management Board Remit, Constitution.
No 5 Parents as Early Education Partners (PEEP)
No 6 Domestic Abuse Patient Policy ( final draft 2006)
No 7 Substance Misuse Service. Guidelines
No 8 Towards a Child Protection Strategy for NHS Grampian Dec 2003
No 9 NHS Grampian Good Practice Guidelines for the Management of Perinatal Mental
Health (July 2005)
No 10 Midwifery Data Base pilot
No 11 Visiting Policies
No 12 NHS Breast Feeding Strategy and Policy
No 13 NHS Grampian Risk Assessment Tool
No 14 Ante natal Care in Grampian Guidelines (Jan 2007)
No 15 Information Policy
80
ANTENATAL CARE IN GRAMPIAN - 2007
Systematic reviews of trials for low-risk women 1-3 have shown that routine antenatal care for low-risk woman in
community settings by GPs and midwives appears as clinically effective as obstetrician-led shared care, and is
highly acceptable to women.1 Reviews also indicate that reduced schedules of routine visits could be implemented
without jeopardising safety for mothers or babies.1-3 This second collaborative revision of the Grampian antenatal
care protocol (2007) takes account of current SIGN guidelines 4-8 and aims to meet the main principles outlined in
the Framework for Maternity Services in Scotland. 9
These include:
 Woman-centred care according to personal needs

Locally accessible and community-based care with access to a specialist as needed.

Fewer but systematic visits to improve consistency, continuity and reduce duplication (see Care Plan)
Joint working supported between primary, secondary and tertiary services

WOMEN WHO NEED SPECIALIST REFERRAL AT BOOKING
Previous Obstetric Problems
Medical Conditions
Current Pregnancy
Perinatal death / morbidity including
anomaly
Diabetes Mellitus / Endocrine
disorders
Age <16 years or >40 years
 3 first trimester miscarriages/one or
more midtrimester miscarriages
Essential hypertension
Women requesting
CVS/amniocentesis
Preterm delivery < 34 weeks gestation Cardiac disease
Multiple pregnancy
Low birth weight < 2.5kg at term
Renal disease
Hepatitis carrier
Hypertension requiring medication
and/or delivery
Epilepsy
HIV positive
Caesarean section or difficult delivery
Booking BMI < 18 or ≥35
Alcohol/Substance misuse
Postpartum haemorrhage > 1000mls
and any other 3rd stage complication
Genetic disorder / significant family
history
Requests obstetric specialist
Perineal problems
Haematological problems
Previous uterine or cervical surgery
Previous psychiatric illness or
current illness requiring treatment
Previous treatment for CIN, record in
notes under special features. No need
for referral
Any other serious problems including major surgery
References
1. Khan-Neelofur D, Gulmezoglu M, Villar J. Who should provide routine antenatal care for low-risk women, and how often? A systematic review of randomised
controlled trials. Paed Perinatal Epid 2: 7-26 suppl. 2 1998.
2. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy (Cochrane Review). The Cochrane
Database Syst Rev 2002; 2: CDOOO934.
3. Carroli G, Villar J, Khan-neelofur D et al. WHO Systematic Review of randomised controlled trials of routine antenatal care. Lancet 2001; 357: 1565-70.
4. http://www.sign.ac. uk/guidelines/fulltext/55/section8.html. Management of diabetes in pregnancy.
5. http://www.sign.ac.uk/pdf/sign60.pdf. Postnatal depression and puerperal psychosis.
6. http://www.sign.ac. uk/guidelines/sogap/sogap2.html. The management of mild non-proteinuric hypertension in pregnancy
7. http://www.sign.ac.uk/guidelines/sogap/sogapl.html. The management of pregnancy in women with epilepsy
8. http://www.sign.ac.uk/guidelines/fulltext/42/references.html. Management of genital Chlamydia trachomatis infection
9. http://www.nice.org.uk. Antenatal Care. Routine care for the healthy pregnant woman
10. Scottish Executive Health Department. A Framework for Maternity Services in Scotland. Edinburgh, Scottish Executive, 2001
81
CARE PLAN FOR WOMEN WITH NORMAL PREGNANCIES
This minimal care plan should be carried out with the woman’s understanding and consent and amplified according to needs. All care, investigations
and screening tests are offered, if declined this should be recorded in the woman’s records.
Gestation
Content Of Care
Investigations
Information and discussion
Personnel
Location
8-12
weeks
or
first visit
to
Obstetric, Family
And
Medical history
Height
Weight
BP
Calculate BMI
Calculate EDD [based on
LMP]
MSSU screen for
asymptomatic
bacteriuria
Ready Steady Baby book
Information leaflets
FW 8[exemption certificate]
Options for care and place of delivery
GP,C/M and HV roles and contact numbers
Parenthood Classes - community/hospital
Breast Feeding
Smoking cessation advice and contacts.
alcohol, substance misuse. child protection,
domestic abuse contacts. contact with infectionsRubella etc.
diet, posture and exercise.
All 16 week blood tests
Midwife/GP
Local surgery
Book detailed scan
Obstetrician/
Sonographer
AMH, Elgin or
local hospital
Obtain informed consent for blood tests prior to
taking blood
Discuss Detailed Ultrasound Scan
Health Promotion topics as above
Breast Feeding
car seatbelts
Complete BCG/TB form
Midwife/GP
Local surgery
midwife/
GP
Domestic abuse – routine
enquiry
Assess emotional well
being
Refer for appropriate care
Commence smoking
interventions if accepted
12 weeks
16 weeks
Consultant referral and/or
Ultrasound scan
[Calculate final EDD]
BP
Domestic abuse – routine
enquiry if not done at
booking
Under 25years offer
routine urine screening
for Chlamydia
Sickle Cell Test
[Afro-Caribbean and
Asian]
Thalassaemia Test
[Mediterranean, Asian,
Oriental or family
history]
BCG/TB form
Thyroid function tests
if history of thyroid
disease
If planning
CVS/Amnio check
Rhesus status
FBC
Blood group
Hepatitis B, Rubella,
Syphilis, HIV
Down’s syndrome and
Spina Bifida screening
82
Gestation
20 weeks
24 weeks
primigrav
ida only
28 weeks
Content of Care
Detailed ultrasound scan
BP
Fetal heart
Fundal height in cm
BP
Oedema
Fundal height cm/liquor
volume
Fetal heart and movements
Offer Anti D Rh
negative
31 weeks
primigrav
ida only
34 weeks
BP
Oedema
Fundal height cm/liquor
volume
Fetal heart and movements
BP
Oedema
Fundal height cm/liquor
volume
Fetal heart and movements
Investigations
Urinalysis
Urinalysis
FBC
Blood group
Random blood Glucose
Repeat offer of
virology screen if
previously refused
36 weeks
Information re Anti D if Rh Negative
Mat B1 – employment issues
Ensure Breast Feeding Antenatal check list is
complete by 32 weeks gestation
Give invite to Breast Feeding workshop
Reminder for parenthood education
Mat B1-employment issues for parous women
Commence discussions on –
Social and domestic arrangements
Place of delivery
Preparation for hospital
Record Birth plan
Urinalysis
Urinalysis
Give out Hearing Screening leaflet
Personnel
Sonographer
Midwife/GP
Location
AMH, Elgin or
local hospital
Local surgery
Midwife/GP
Local surgery
Midwife/GP
Local surgery
Midwife/GP
Local surgery
Midwife/GP
Local surgery
Discuss and record discharge plan
Commence discussions on –
When to contact hospital
Patterns of Postnatal visiting
Support available in Postnatal period
Post natal depression
Assess emotional well
being
Offer Anti D if Rh
Negative
weight
BP
Oedema
Fundal height cm/liquor
volume
Fetal heart and movements
Presentation
Information and Discussion
Urinalysis
If previous
Group B streptococcal
infection send low
vaginal swab and rectal
swab
Discuss and plan normal labour
83
Gestation
38 weeks
40 weeks
primigrav
ida only
41
Content of Care
BP
Oedema
Fundal height cm/liquor
volume
Fetal heart and movements
Presentation
As above
As above
Investigations
Urinalysis
Information and Discussion
Discuss and plan membrane sweep at term +
if appropriate
Discuss induction of labour
[usually at Term plus 12 –14 days]
Personnel
Location
Urinalysis
Urinalysis
Offer membrane sweep
Offer and plan induction of labour
NB
 Diagnostic blood pressure [BP] should be recorded as Point V Korokoff - the point of disappearance of sounds.
 Follow-up procedures for women who fail to attend for antenatal care must be adhered to
84
Midwife/GP
Local surgery
PROTOCOLS FOR PROBLEMS ARISING IN PREGNANCY
p
RPROBLEM
PLAN
Abnormal infection screen
[HIV, Hepatitis B, Syphilis]
Discuss results, repeat blood test as requested
by virology and refer to lead Obstetrician and
other specialist Consultants
Positive Group B streptococcal infection in this
pregnancy or previous infected baby
Hyperemesis with ketonuria
Glycosuria ++
Random plasma glucose >5.5 mmol/l or
glucose >7.0mmol/l < 2 hours after food
Plan antibiotic cover in labour AMH / Elgin
Haematuria
Hb < 100g/l
Blood group antibodies
+ve hCG, abdominal pain, no bleeding,
intrauterine pregnancy NOT confirmed
Haemorrhage < 24weeks
with or without pain
Haemorrhage  24 weeks
Suspected deep venous thrombosis
Polyhydramnios
Reduced fetal movements
Suspected intra-uterine death
Abnormal presentation after 36 weeks
Symptomatic vaginal discharge
Rupture of membranes <37weeks
MSSU, treat, refer to ANC if persists
Treat, if no response in 3-4 weeks refer to ANC
Await AMH / Elgin Consultant response
Admit Early Pregnancy Unit, Ward 3 Elgin or
Ward 42/43 ARI
Admit Early Pregnancy Unit Ward 3 Elgin or
Rubislaw AMH
Admit to assessment unit AMH / Elgin
Admit to assessment unit AMH / Elgin
Refer to Consultant, Antenatal Clinic
Check fetal heart and refer to assessment unit
for cardiotocography (CTG) if 26 weeks
Admit assessment unit AMH / Elgin
Refer for scan
Speculum  Low Vaginal Swab
Admit Assessment Unit AMH / Elgin
Rupture of membranes 37weeks
Fundal height 3cm less than gestational age
Non localised pruritis in pregnancy
Admit to place of delivery
Refer to first available Antenatal Clinic
Refer to first available Antenatal Clinic
Prolonged pregnancy [Term + 14 days]
[i.e. if declines induction of labour]
Refer to Consultant Antenatal Clinic
Admit AMH, Elgin or local Unit if agreed
Random plasma glucose
Book Oral Glucose Tolerance Test. Fasting
blood glucose not appropriate in pregnancy.
Proteinuria in Pregnancy
Proteinuria (+) without hypertension
Proteinuria ++ without hypertension
22weeks gestation
MSSU
Refer to AMH or Elgin
NON-PROTEINURIC PREGNANCY INDUCED HYPERTENSION
1] Hypertension recorded, at Clinic, during
routine antenatal care
2] If sustained diastolic >100mmHg or
diastolic increment >25mmHg


Check BP on  2 occasions, 1/2hr apart. If
sustained diastolic 90-100 check BP and
urinalysis twice-weekly
Refer to Assessment Unit, AMH or Elgin
Local Units – Peterhead Community Hospital. Fraserburgh Hospital. Aboyne Maternity, Chalmers
Hospital, Banff, Dr Gray’s, Elgin.
Assessment Units -Ward 3, Dr Gray’s, Elgin. Westburn Ward, Aberdeen Maternity Hospital
(Jan 07 edition)