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					Gloucestershire PCT

                                                         Gloucestershire
                                                                   Primary Care Trust

      Policies, Protocols, Guidelines and Procedures




                   PATIENT CARE PATHWAY & SERVICE PROTOCOL
              FOR ANTENATAL SMOKING CESSATION ADVICE and SUPPORT




   This document may be made available to the public and persons outside of the Trust as part of the
                   Trust’s compliance with the Freedom of Information Act 2000.




The most up to date policy will always be available under Policies and Procedures on the PCT’s Intranet.
If you require this document in a different language or format please contact Michelle Poole, Head of
Midwifery, Gloucestershire Primary Care Trust.




Last Reviewed: New               Review Date: January 2012         Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                       Page 1 of 11
    Gloucestershire PCT
    POLICY AUTHORISATION FORM

                                     ANTENATAL SMOKING CESSATION ADVICE and
    NAME OF POLICY:                  SUPPORT
1
    JOB TITLE OF AUTHOR:             Michael Richardson: Service Co-ordinator (GSAS)


    DIRECTOR:                        Shona Arora


    NAME OF GROUP:                   PCT Clinical Policy Group
    (if applicable)

                                     EQUALITY AND DIVERSITY
    An Equality & Diversity assessment has been completed                Date Completed:
    (Please contact the Equality & Diversity Manager 01452 389496

2                                  CONSULTATION
    NAME OF GROUP (S) (complete where relevant)                          DATE CONSIDERED

    Name of Local Committee or Specialist Group?

    Name of Countywide Committee or Specialist Group? County Wide
                                                          Policy
                                                          YES / NO
    Other relevant Forum/Individual?
    Head of Midwifery for Gloucestershire PCT                               November 2008
    Assistant directors for Women and children‟s services GHNHSFT


3                   APPROVED BY BOARD/AUTHORISED GROUP/DIRECTOR
    NAME i.e. Trust Board                                  DATE APPROVED
                       PCT Clinical Policy Group
                     TO BE REVIEWED BY: (Author)             DATE TO BE
                                                              REVIEWED:
    Michael Richardson                                       January 2012

4                           TO BE COMPLETED BY CO-ORDINATOR
    HARD COPY ISSUED

    POLICY NUMBER:                                               CMC12

    DATE PLACED ON INTRANET:                                     To be confirmed




    Last Reviewed: New               Review Date: January 2012      Issue date:
    Policy: Community : Antenatal Smoking Cessation Advice
    Author: Michael Richardson                                                    Page 2 of 11
Gloucestershire PCT

                                POLICY UPDATES/CHANGES
                         (AFTER BOARD/DESIGNATED GROUP APPROVAL)
Date          Summary of Changes            Author/Editor    Approved by             Version
                                                                                     No.




CONTENTS
   Section                               Section Heading                            Page
                                                                                   Number
        1         AIMS                                                                4

        2         OBJECTIVES                                                           4

        3         BACKGROUND                                                           4
       3.1        Health risks to unborn babies                                        5
       3.2        Health risks for children                                            5
       3.3        Further Information                                                  5
        4         TARGET AUDIENCE                                                      6
       4.1        Structures in Place                                                  6
        5         SCOPE OF SERVICE
       5.1        Who will be included?                                                6
       5.2        Who will not be included?                                            6
        6         PROTOCOL DETAILS                                                     7

        7         COMMUNICATION OF POLICY                                              7

        8         MONITORING and EVALUATION                                           7-8

         9        RISKS and BENEFITS
        9.1       Key risks                                                            8
        9.2       Key benefits                                                         8
        10        COST IMPLICATIONS
       10.1       Resource Needs                                                       8
       11.0       TRAINING                                                             8

       12         REFERENCES                                                           8

 Appendix 1       Pathway for Antenatal Women                                         9
 Appendix 2       Prompt cards for Midwives                                           10
 Appendix 3       Referral form                                                       11




Last Reviewed: New               Review Date: January 2012      Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                    Page 3 of 11
Gloucestershire PCT


        ANTENATAL SMOKING CESSATION ADVICE and SUPPORT

1.0 Aims: To reduce smoking prevalence in pregnant smokers within
    Gloucestershire by utilising a midwifery led “opt-out” referral processes to a
    specialist smoking service.
1.1 The aim is for Gloucestershire Stop Smoking Service (GSAS) to see all
pregnant smokers who opt in to the pathway, who otherwise would not have
taken up an offer of stop smoking support on their own volition. GSAS will
provide them with an opportunity to discuss their smoking, have help and support
to quit and ensure they have information on keeping children safe from second
hand smoke. The ultimate aim is to improve maternal, foetal and family health.

2.0 Objectives:
a. To refer all pregnant smokers, unless they decline, to GSAS by midwives
   where they will be offered greater opportunities for stop smoking support.
b. To give pregnant smokers the opportunity to opt out of the referral process.
c. To provide additional data to accurately assess the rate of smoking during
   pregnancy countywide.
d. To enable midwives to have professional responsibility and accountability for
   stop smoking support.
e. GSAS to offer improved opportunities for all pregnant smokers to receive
   advice on reducing the harm to their families from second hand smoke.
f. To reduce inequalities in health by targeting pregnant smokers who are in
   deprived socioeconomic groups.
g. To develop carbon monoxide reading as a routine antenatal test.
h. To reduce the rate of smoking in pregnancy by 1% per year.

3.0 Background:

Smoking during pregnancy is the greatest cause of foetal ill health and death. It
can cause serious problems including complications during labour, increased risk
of miscarriage, premature birth and stillbirth. Smoking is harmful throughout
pregnancy and stopping at any stage will be good for the baby. The most
damaging effects of smoking happen in the gestational months, four to nine. This
means that, if a mother stops smoking within the first three months of her
pregnancy, the baby is still likely to be of a healthy weight with minimal damaging
effects.

When a person smokes, over 4,000 chemicals go into the body. One of these is
the gas carbon monoxide which enters the mother‟s bloodstream and cuts down
the oxygen reaching the baby. For every cigarette smoked, the oxygen supplied
to the baby is disrupted for 15 seconds and the baby experiences reduced blood
oxygen flow for 15 minutes.



 Last Reviewed: New              Review Date: January 2012    Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                  Page 4 of
11
Gloucestershire PCT


3.1 Health risks to unborn babies of smoking pregnant women include:

      Lower birth weight.
      Slower growth of the baby.
      Higher risk of cot death.
      Damage to airways which could cause breathing problems or asthma.
      Increased risk of perinatal death – up to one third higher
      Higher risk of premature birth

The peri-natal death rate in 2005 in Gloucestershire was 7.2/1000 births. We
aspire to see a reduction in this statistic if we increase significantly the smoking
quit rate of pregnant women.


3.2 Health risks for Children

Health risks to children if they are growing up in a home where one or more
parents smoke include:

      High incidence of upper respiratory infections.
      Asthma attacks or lower respiratory infections.
      Higher risk of lung cancer in adulthood.
      Meningitis.
      'Glue ear' and partial deafness.

3.3 Further Information

3.3.1 Hospital data on maternal smoking behaviour at booking or delivery is
incomplete (more than 5% are unknown in England). Smoking rates during
pregnancy are likely to be closer to the female prevalence overall (22%) than self
report data tell us. An internet survey by Usher et al, (2000) identified a range of
barriers to women accessing stop smoking services during pregnancy, including,
fear of failure, unwillingness to seek help and lack of access to services. Other
identified barriers were fear of weight gain, denial of risk addiction and wider
social context. We need to invite more women to use effective treatment, ideally
before, or failing that during pregnancy.

3.3.2 We need better and consistent:
    Data accuracy on the prevalence of smoking in this client group,
    Referral to specialist stop smoking services,
    Engagement of pregnant women through brief interventions by midwives
       to increase client confidence in being able to quit,
    Treatment/retention,
    Supportive relapse prevention.


 Last Reviewed: New              Review Date: January 2012      Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                    Page 5 of
11
Gloucestershire PCT


3.3.3 Bauld (2008) suggests that routine screening of all pregnant women for
tobacco use via CO monitoring combined with an “opt-out” referral process will
help the above. This has been shown in pilot studies in Glasgow and South
Birmingham and now has been incorporated into their routine practice. It will also
provide an opportunity for the midwife to have a discussion with the client
regarding the need to reduce harm from second harm smoke. South Birmingham
PCT has had a successful opt out referral scheme enhanced with midwives using
carbon monoxide monitors for over a year and a half.

4.0 Target Audience:
This protocol is for midwifery staff and smoke free family advisors within
Gloucestershire PCT.

4.1 Structures in place for this service:
4.1.1 Midwifery service: Midwives in Gloucestershire provide high quality
midwifery antenatal care in various locations in Gloucestershire. These include:
    Stroud Maternity Unit
    The Gloucestershire Birth Unit, at Gloucester Royal Hospital
    St Paul‟s Wing – Delivery Unit Cheltenham Royal Hospital (combined
       midwifery and consultant led)
    Community Hospitals in the Forest of Dean
    General practices/health centres

4.1.2 Gloucestershire Stop Smoking Service (GSAS) is based at Park Road in
Gloucester. It is made up of a team of specialist stop smoking advisers that
provide support in helping smokers to give up. These advisers have various
expertise and provide services in various locations throughout the county. They
accept referrals from a variety of sources, including GPs, Practice Nurses and
self referral by the client. The service has two “stop-smoking-in-pregnancy”
advisers who will manage the referrals from the midwifery service. In most cases
these advisers will provide the stop smoking support to clients unless this is
geographically prohibited.
GSAS has an administration team that provides the necessary support needed to
provide a specialist stop smoking service.

5.0 Scope of Service

5.1 The service will be open to all women who undertake a CO monitoring and
score greater than 5 will be offered the „opt out‟ referral pathway.

5.2 What will not be included in the scope of the “opt-out” referral service?
Partners who smoke or other smokers in the household of pregnant women who
are not present at booking cannot be referred via this opt out scheme. However
information on how to access Gloucestershire Stop Smoking Service can be
given to the women for these third parties. If the women have household

 Last Reviewed: New              Review Date: January 2012    Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                   Page 6 of
11
Gloucestershire PCT


members present at booking who smoke, then they can be referred together if all
parties consent.

6.0 Protocol details.
6.1 Patient Pathway: - see flow chart in Appendix 1
   6.1.1 During the antenatal booking the patient is routinely asked if they smoke
   as part of the „booking‟ assessment.
   6.1.2 A carbon monoxide (CO) monitoring test is also offered routinely in the
   way other tests such as urine testing, BP and weight monitoring are
   performed at booking contact.
   6.1.3 If CO monitoring is refused it is recorded in their maternity records.
   6.1.4 If the client indicates they smoke, and/or their CO level reading is
   >5ppm, and they have given verbal consent, an automatic referral using an
   agreed form (appendix 2) is made into the specialist stop smoking service. A
   stop-smoking-in-pregnancy specialist will then contact the patient. The
   midwives can use the prompt cards (Appendix 3) for the phrasing of the
   result.
   6.1.5 If the client declines to be referred they will not be automatically
   referred. The discussion as regards smoking issues will be noted and raised
   appropriately at another opportunity.
   6.1.6 The stop smoking support specialist will offer the patient support in a
   mutually convenient setting of the patient‟s choice i.e. group setting, one-to-
   one in various locations e.g. antenatal clinic or other location including the
   home if only option available.
   6.1.7 If the patient accepts the support they will ideally be seen on a weekly
   basis for the first 4-6 weeks and then fortnightly up to 12 weeks and beyond
   as required.
   6.1.8 Longer term contact will be maintained by GSAS in order to prevent
   relapse through pregnancy and in the postnatal period.
   6.1.9 Attempts to contact the patient will be made by GSAS in the event of
   DNA/loss to follow ups, and appropriate relapse support given if possible.

7.0 Communication of Policy.
7.1 The Head of Service will send a memorandum to individual staff members to inform
them of the reviewed guidance.
7.2 A newsletter will also inform staff of this new protocol.
7.3 GSAS will share with their staff.

8.0 Monitoring & Evaluation:
8.1 An audit will be undertaken at least once in 3 years reviewing heath records
(including electronic and specialist‟s notes) to identify documentation relating to
the protocol.

8.2 GSAS monitors all smoking quit attempts according to DOH guidelines and
reports are submitted quarterly to DOH, SHA and PCT. Data is also analysed by

 Last Reviewed: New              Review Date: January 2012      Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                    Page 7 of
11
Gloucestershire PCT


postcode in order to ascertain our level of success of helping people to quit in
areas of inequalities.
8.3 The PCT has Vital Signs monitoring to be reported to SHA in relation to the
numbers of women who smoke at the time of birth.

9.0 Risks and benefits.
9.1 Key risks
9.1.1 Sensitivity, tact, experience and training is required when addressing
smoking in pregnancy with clients. Women report guilt, anxiety, and added stress
from victim blaming messages.
9.1.2 Women often feel pressured into stopping smoking, feel guilty, and are less
likely to admit to continue smoking.

It is important therefore that midwives receive appropriate brief intervention
training in order to boost patients‟ confidence in stopping smoking.

9.2 Key benefits
9.2.1 A reduction in smoking prevalence in pregnant women in Gloucestershire
leading to maternal/fetal health gain.
9.2.2 Supports midwives to provide a holistic care package to pregnant women.


10. Cost Implications.
10.1 Identified resource needs:
    Referral pads
    Carbon monoxide foetal monitors for midwives with attachments.
    Prompt cards
    Health promotion literature and information on GSAS.
Funding is available through GSAS for these resources.

11.0 Training:
11.1         Stop-Smoking-Support Brief Intervention training to midwives
(including the principles of health behaviour change).
11.2         Training in the use of carbon monoxide foetal monitors
    This will be provided by GSAS.


12.0 References.
Bauld et al (2008)xxxx
Usher et al, (2000) xxxxx




 Last Reviewed: New              Review Date: January 2012     Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                   Page 8 of
11
Gloucestershire PCT


Pathway for Antenatal care Smoking cessation Advice and Support Appendix 1
                      Pregnant woman presents to MW at booking


    MW assesses smoking status and measures CO level to help identify whether
               patient is a smoker, non-smoker or passive smoker


                   CO reading <5                        CO reading >5



        Most likely non-Smoker (unless                Smoker/Passive Smoker
             identified by history)


                                            MW advises patient using appropriate
                                            prompt cards (see later) and requests
               Midwife continues            permission to refer to stop smoking service
               normal antenatal
                booking process
                                                                     Patient agrees. MW
                                       Patient declines and
                                                                     fills in referral form
                                       exercises their “opt-
                                                                     and sends it to stop
                                       out” choice
                                                                       smoking service

         MW offers patient appropriate stop smoking                Stop Smoking Service
      support literature and how to access support/effects           contacts patient by
         of second hand smoke, & continues normal                    phone and if patient
                    antenatal booking process                        agrees to receiving
                                                                    support, appointment
                                                                   letter is sent to patient.


                                         Patient receives stop smoking support from
                                        specialist stop smoking service in addition to
                                       appropriate routine antenatal support from MW


 Last Reviewed: New              Review Date: January 2012     Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                   Page 9 of
11
Gloucestershire PCT


           Referral form to GSAS for midwifery staff.                 Appendix 2




 Last Reviewed: New              Review Date: January 2012   Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                 Page 10
of 11
Gloucestershire PCT



                   Prompt cards for Midwifery staff.                        Appendix 3


As part of the midwifery training the midwives will be supplied with a prompt card
to guide them in what to say.

Prompt Card for people who report as non-smokers but have CO >5

 “As your carbon monoxides reading is over 5, you may be inhaling second
 hand smoke and it is now part of our routine antenatal care to pass your details
 on to the stop smoking service unless you object to this. They will give you
 information on how to keep yourself and baby safe from second hand smoke. Is
 that OK?”


Prompt Card for people who report as smokers and/or have CO >5

 “As you are a smoker, it is now part of our routine antenatal care to pass your
 details on to the stop smoking service unless you object to this. Is that OK?”




 Last Reviewed: New              Review Date: January 2012         Issue date:
Policy: Community : Antenatal Smoking Cessation Advice
Author: Michael Richardson                                                       Page 11
of 11

				
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