Maternity care pathways by btj20746

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									Maternity care pathways



In developing this pathway, we aim to provide maternity
services commissioners with valuable guidance so that they
may safely and effectively meet the demands of their local
population.

The pathway also describes what women can expect on
their maternity journey.
Maternity best practice



                                                                     Maternity best practice




                              Go to pre-pregnancy       Go to antenatal care      Go to intrapartum care   Go to postnatal care




1 Maternity best practice
 Quick info:
 Scope:
  •t his pathway provides a broad overview of the key steps in maternity, including:
     •p re-pregnancy care
     • antenatal care
     •c are during labour and delivery
     • postnatal care
 The pathway is based on UK National Health Service policies and schedules.
1 Pre-pregnancy care



                                           Pre-pregnancy                                  The Pregnancy Care
                                                                                          Planner and the
                                                                                          Pregnancy Book

                                           Contact with
                                           healthcare
                                           professional



                                           Is the woman planning
                                           pregnancy?




                  No                                               Yes



                  Access to healthcare                             Consider all of the
                                                                   following


                  Pre-existing medical,
                  surgical and/or
                  psychiatric conditions




Newly identified          Pre-existing medical,      Screening -                Eating habits (Body    Nutritional advice,       Health and lifestyle
medical, mental health    surgical and/or            information and advice     Mass Index)            vitamins, prescriptions   advice to woman and
and social needs          psychiatric conditions                                                       and over-the-counter      partner
                                                                                                       medicines




                                                                   Once pregnant, refer
                                                                   for antenatal care



                                                                   Go to antenatal care
1 Pre-pregnancy care
1 Pre-pregnancy
 Quick info:
 Scope:
  •t his pathway gives an overview of what to expect when planning pregnancy. The pathway is based on UK National Health
    Service policies and schedules.
 Associated maternity standards:
  • standard 1: looking forward to pregnancy
  • standard 2: pre-pregnancy care for women with existing medical conditions or significant family or obstetric history
  • standard 3: access to maternity care
  • standard 6: pre-existing medical conditions in pregnancy
  • standard 8: pre-existing and developing mental health conditions in pregnancy
  • standard 7: women with social needs
  • standard 21: choice and appropriate care
  • standard 22: communication
  • standard 23: training and professional competence
  • standard 24: documentation and confidentiality
  • standard 25: clinical governance


2 The Pregnancy Care Planner and the Pregnancy Book
 Quick info:
  • The Pregnancy Care Planner is the NHS guide to having a baby
  •t he Department of Health Pregnancy Book contains information for women on what to do, how to cope and how to get the most
    from pregnancy and the new baby


3 Contact with healthcare professional
 Quick info:
  •f or example GP, practice nurse, family planning clinic, midwife etc


4 Is the woman planning pregnancy?
 Quick info:
  •a sk the woman if she has had previous pregnancies and if so, what was the experience and what was the outcome
  •o ffer information on place of birth and vaginal birth after caesarean (VBAC)
  • if previous pregnancy problem(s) are identified, offer advice and refer according to individual need, ensuring woman continues
    on maternity pathway


5 No
 Quick info:
  • if woman is not planning pregnancy, consider the next two stages


6 Yes
 Quick info:
  •f or women planning pregnancy


7 Access to healthcare
 Quick info:
  •o ffer advice regarding access to healthcare should the woman change her mind
1 Pre-pregnancy care
  •p rovide advice on choice of and how to access a healthcare professional and pregnancy advice in the future
  •p rovide contraception advice as appropriate and refer to NHS Direct for information
  •o ffer general good health advice on smoking, alcohol, BMI and substance misuse
  •p rovide pre-pregnancy leaflet


8 Consider all of the following
 Quick info:
 If woman is planning pregnancy, consider the following steps


9 Pre-existing medical, surgical and/or psychiatric conditions
 Quick info:
 Pre-existing medical, surgical and/or psychiatric disorders:
  •o ffer advice on pre-existing conditions which could impact on pregnancy outcome
  •o ffer advice on risk of pre-existing condition to pregnancy and risk of pregnancy to condition
  •r eview medication(s) and advise of its risks and benefits in pregnancy
  •c onsider specialist advice
  •c onsider additional information, care and treatment, and refer according to individual need
  • if healthcare professional or woman has significant concerns, refer to GP for further assessment
  •a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman, couple and/or family
      •f or further information refer to the NICE mental health guidance


10 Newly identified medical, mental health and social needs
 Quick info:
  •a ssess medical needs and refer as appropriate, ensuring woman continues on maternity pathway
  •a ssess mental health (current, new onset and/or past incidence):
     • if mental health needs are identified refer to ‘Pre-existing physical and/or psychiatric disorders’
     •f or further information refer to the NICE mental health guidance
  •a ssess social needs and refer according to individual need, ensuring woman continues on maternity pathway
  •o ffer advice on risk of condition to pregnancy and risk of pregnancy to condition
     •f or further information on diabetes, refer to Diabetes UK advice on preconception care for women with diabetes and to NICE
       diabetes in pregnancy guidance
  •c onsider additional information, care and treatment and refer to primary or specialist services according to individual need,
   ensuring woman continues on maternity pathway


11 Pre-existing medical, surgical and/or psychiatric conditions
 Quick info:
 Diabetes:
  •o ffer interim contraception until optimal control is achieved
  • educate women and partners in glycaemic control as appropriate
  • review medication(s) and inform of its risks and benefits in pregnancy consider specialist advice
  •c heck date of last review and repeat comprehensive review as appropriate
  •o ffer enhanced medical surveillance until glycaemic control is achieved
  •o ffer advice on folic acid and appropriate dose
  • once pregnant, refer back to antenatal pathway with all relevant medical and maternity information
  •f or further information, refer to Diabetes UK advice on preconception care for women with diabetes and to NICE diabetes in
    pregnancy guidance
 Other pre-existing medical, surgical and/or psychiatric disorders:
  •o ffer advice on pre-existing conditions which could impact on pregnancy outcome
  •o ffer advice on risk of pre-existing condition to pregnancy and risk of pregnancy to condition
  •r eview medication(s) and advise of its risks and benefits in pregnancy
  •o ffer advice on folic acid and appropriate dose
  •c onsider specialist advice
1 Pre-pregnancy care
  •c onsider additional information, care and treatment, and refer according to individual need, ensuring woman continues on
    maternity pathway
  • if healthcare professional or woman has significant concerns, refer to GP for further assessment
  •a ssess mental health (current, new onset or past incidence)
      •a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman/couple and/or family
      • if severe mental illness (e.g. bipolar disorder or schizophrenia) is suspected, refer to specialist mental health service,
        including, if appropriate, specialist perinatal mental health service:
          •t his should be discussed with woman and preferably with her GP
      •i nform GP in all cases if a possible current mental disorder or history of significant mental disorder is detected, even if no
        further assessment or referral is made
      •f or further information refer to the NICE mental health guidance


12 Screening - information and advice
 Quick info:
  •o ffer advice and information on screening, and offer choice, which could include:
     • Down's syndrome
     •i nfectious diseases
     • sickle cell and thalassaemia
     •f etal anomaly ultrasound 18 - 20 weeks + 6 days
     • click here for screening publications
  •o ffer screening for sickle cell disease
  •c onsider serum screening and screening for infectious diseases and sexually transmitted infections:
     •o ffer vaccinations according to individual need, including rubella
  •c onsider screening for inherited disorders as appropriate
  •e xplore alcohol, tobacco and other substance misuse in woman and partner


13 Eating habits (Body Mass Index)
 Quick info:
  •c alculate BMI and offer advice if too high or too low:
      •r efer according to individual need and culturally appropriate BMI
  • if BMI is greater than 30, screen to exclude diabetes
      • if test is positive for diabetes, refer to the diabetes in pregnancy pathway
      • if test is negative for diabetes, refer to obesity pathway
  • if BMI is too low, refer to eating disorder service according to individual need, ensuring woman continues on maternity pathway


14 Nutritional advice, vitamins, prescriptions and over-the-counter medicines
 Quick info:
  •o ffer folic acid advice according to individual need
  •o ffer dietary advice regarding healthy eating and what foods to avoid (harmful dietary substances)
  •o ffer advice on nutritional supplements
  •o ffer advice on vitamins (including importance of vitamin D) as appropriate, and advice on which vitamins to avoid
  •o ffer advice on over-the-counter medicine and advice on what to avoid
  •o ffer painkiller advice and what to avoid
  • advise to use as few prescription medicines as possible and only where the benefit outweighs the risk
  •f or further information refer to the Foods Standards Agency website


15 Health and lifestyle advice to woman and partner
 Quick info:
  •o ffer early pregnancy information leaflet if appropriate
  • where woman has no GP, refer to primary care to arrange registration
  •o ffer advice to partner (where applicable) on alcohol consumption, smoking and substance misuse as appropriate
  •o ffer information to both woman and partner (if applicable) on antenatal classes for couples and fathers
1 Pre-pregnancy care
16 Once pregnant, refer for antenatal care
 Quick info:
  • advise woman how to access maternity services and inform of choice of booking method (referral/self-referral)
  • once pregnant refer to antenatal provider at earliest opportunity, with all relevant medical information
  •o ffer information on screening. For further information, refer to screening guidance
  • if severe/complex mental illness is identified refer to specialist perinatal mental health team
  • ensure compliance with national guidelines
  •e xplain importance of booking early (within first 10 weeks) and advise how to obtain booking form
  •f or women considering termination of pregnancy, offer advice and refer as appropriate, ensuring woman is returned to maternity
    pathway when appropriate
      •f or further information, refer to the termination of pregnancy pathway and to NHS London abortion guidance
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
1 Pre-pregnancy care

Evidence summary for Pre-pregnancy
 This pathway gives an overview of what to expect when planning pregnancy. The pathway is based on UK National Health Service
 policies and schedules.
 Search date: Jun-2009

Evidence grades:
           Intervention node supported by level 1 guidelines or systematic reviews

           Intervention node supported by level 2 guidelines

           Intervention node based on expert clinical opinion

           Non-intervention node, not graded


Evidence grading:
   Graded node titles that appear on this page                                Evidence grade                        Reference IDs
   Is the woman planning pregnancy?                                                                                 9, 8, 7

   Access to healthcare                                                                                             9

   Newly identified medical, mental health and social needs                                                         1, 9, 8, 6

   Health and lifestyle advice to woman and partner                                                                 9, 8

   Once pregnant, refer for antenatal care                                                                          1, 9, 8

   Eating habits (Body Mass Index)                                                                                  9

   Screening - information and advice                                                                               9

   Pre-existing medical, surgical and/or psychiatric conditions                                                     1, 9, 8, 6, 7

   Pre-existing medical, surgical and/or psychiatric conditions                                                     9

   Nutritional advice, vitamins, prescriptions and over-the-counter                                                 9
   medicines

References
 This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice
   ID Reference
   1 Department of Health. National Service Framework for Children, Young People and Maternity Services:
        Maternity services. London: 2004.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4089101
   2 Department of Health. National service framework for children, young people and maternity services. 2004.
        http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111
   3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4126161
   4 National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal care of women and their
        babies (NICE Clinical Guideline 37). London: 2006.
        http://www.nice.org.uk/CG37
   5 National Collaborating Centre for Women's and Children's Health. Intrapartum care: management and
        delivery of care to women in labour (NICE Clinical Guideline 55). London: 2007.
1 Pre-pregnancy care
ID Reference
   http://www.nice.org.uk/CG55
6 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical
   management and service guidance (NICE Clinical Guideline 45). London: 2007.
   http://www.nice.org.uk/guidance/CG45
7 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of
   diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63).
   London: 2008.
   http://www.nice.org.uk/CG63
8 National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the
   healthy pregnant woman (NICE Clinical Guideline 62). London: 2009.
   http://www.nice.org.uk/CG62
9 NHS Choices. Health A-Z: Preconception. 2007.
   http://www.nhs.uk/conditions/Preconception/Pages/Introduction.aspx
10 NHS Choices. The pregnancy care planner. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx
11 NHS Choices. The pregnancy care planner: Bereavement. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Bereavement.aspx
12 Royal College of Nursing. Abortion care: RCN guidance for nurses, midwives and specialist community
   public health nurses. London: 2008.
   http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177
2 Commissioning antenatal care

                                   Antenatal                                     The Pregnancy Care
                                   (once pregnant)                               Planner and the
                                                                                 Pregnancy Book


                                   First contact
                                   with healthcare
                                   professional



                                   Consider all of the
                                   following




  Provide antenatal   Principles of antenatal   Newly-identified         Pre-existing medical,
  information         care                      medical, mental health   surgical and/or
                                                and social needs         psychiatric conditions




                                   Booking appointment
                                   (ideally by 10 weeks)



                                   16 weeks appointment



                                   18 20 weeks
                                   appointment



                                   25 weeks appointment



                                   28 weeks appointment



                                   31 weeks appointment



                                   34 weeks appointment



                                   36 weeks appointment



                                   38 weeks appointment



                                   40 weeks appointment



                                   41 weeks appointment



                                   42 weeks appointment



                                   Go to intrapartum care
2 Commissioning antenatal care
1 Antenatal (once pregnant)
 Quick info:
 This pathway is based on UK National Health Service policies and schedules and gives an overview of what to expect in the
 antenatal period:
  • antenatal care should be provided by a small group of carers with whom the woman feels comfortable
  •t here should be continuity of care throughout the antenatal period
  •a system of clear referral paths should be established so that pregnant women who require additional care are managed and
    treated by the appropriate specialist teams when problems are identified
  •t he purpose and choice of screening should be explained to the woman

 Associated maternity standards:
  • standard 3: access to maternity care
  • standard 4: early pregnancy services
  • standard 5: maternity booking and planning of care
  • standard 6: pre-existing medical conditions in pregnancy
  • standard 7: women with social needs
  • standard 8: pre-existing and developing mental health conditions in pregnancy
  • standard 9: antenatal screening
  • standard 10: routine antenatal care
  • standard 11: pregnancy-related conditions
  • standard 20: supporting families who experience bereavement, pregnancy loss, stillbirth or early neonatal death
  • standard 21: choice and appropriate care
  • standard 22: communication
  • standard 23: training and professional competence
  • standard 24: documentation and confidentiality
  • standard 25: clinical governance
  • standard 26: development, implementation and review of local maternity services strategy
  • standard 27: maternity and neonatal networks
  • standard 29: infection prevention and control
  • standard 30: staffing


2 The Pregnancy Care Planner and the Pregnancy Book
 Quick info:
  • The Pregnancy Care Planner is the NHS guide to having a baby
  •t he Department of Health Pregnancy Book contains information for women on what to do, how to cope and how to get the most
    from pregnancy and the new baby


3 First contact with healthcare professional
 Quick info:
  • once pregnant refer to antenatal provider at earliest opportunity, with all relevant medical information
  • if self-referred to antenatal provider, ensure primary care is informed and provide woman with telephone number and contact
    details of midwife
  •i nform woman how to access maternity services and of choice of booking method (referral/self-referral)
  •e xplain importance of booking early (within first 10 weeks) and inform of booking form
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  • if severe/complex mental illness is identified refer to specialist perinatal mental health team
  •o ffer information on screening
      •f or further information, refer to screening guidance
  •o ffer blood tests as appropriate
  • structured hand-held maternity records should be used for antenatal care
  • undertake health, social and psychological needs assessment within first 10 weeks
  • where woman is a late booker, provide information, screen as appropriate, and refer to antenatal provider at earliest opportunity
  •g ive information (supported by written information and antenatal classes), with an opportunity to discuss issues and ask
    questions
  • book into antenatal classes
2 Commissioning antenatal care
  •f or women considering termination of pregnancy, offer advice and refer as appropriate
  • be alert to any factors clinical, psychological, cultural and/or social that may affect the health of the woman and baby



4 Consider all of the following
 Quick info:
 Consider the following steps


5 Provide antenatal information
 Quick info:
 Provide information and advice within first 10 weeks on:
  • where the woman will be seen and by whom
  •t he likely number, timing and content of antenatal appointments, participant-led antenatal classes and breastfeeding workshops
  •t he right to accept or decline a test
  •t aking as few prescription medicines as possible, and only where the benefit outweighs the risk
  •o ffer over-the-counter medicines advice and what to avoid
  •o ffer choice of place of birth as appropriate, explaining what to expect with each option available
  •v aginal birth after caesarean (VBAC)
  •f olic acid supplements
  •f ood hygiene and how to reduce risk of food-acquired infection
  • lifestyle, including smoking cessation, substance misuse and alcohol consumption - refer according to individual need, ensuring
    woman continues on maternity pathway
  •a ll antenatal screening, risks, benefits and limitations - refer to Screening tests for you and your baby for information
  •r efer to Department of Health Standards to support the UK antenatal screening programme and to and the NSC Green
    Book for information
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


6 Principles of antenatal care
 Quick info:
  •m idwives and GPs should care for women with an uncomplicated pregnancy, providing continuous care throughout the
    pregnancy:
  • obstetricians and specialist teams should be involved where additional care is needed
  • antenatal appointments should take place in a location women can easily access and at convenient times:
  •t he location should be appropriate to the needs of women and their community
  • maternity records should be structured, standardised, national maternity records, held by the woman
  •t here should be 10 appointments for first-time mothers and a minimum of seven appointments for all other women
  • each antenatal appointment should have a structure and a focus
  • appointments early in pregnancy should be longer to allow time to discuss screening so women can make informed decisions
  • if possible, incorporate routine tests into the appointments to minimise inconvenience to women
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
      •f or further information on substance misuse and other problems, refer to NICE guidance
  • be alert to the symptoms and signs of domestic abuse:
      •f or further information, refer to the Department of Health Domestic Abuse Handbook and to the CEMACH Saving Mothers
        Lives report


7 Newly-identified medical, mental health and social needs
 Quick info:
  •a ssess medical needs and refer as appropriate, ensuring woman continues on maternity pathway
  •a ssess mental health (current, new onset and/or past incidence):
     • if mental health needs are identified refer to ‘Pre-existing physical and/or psychiatric disorders’
     •f or further information refer to the NICE mental health guidance
  •a ssess social needs and refer according to individual need, ensuring woman continues on maternity pathway
  •o ffer advice on risk of condition to pregnancy and risk of pregnancy to condition
2 Commissioning antenatal care
  •c onsider additional information, care and treatment and refer to primary or specialist services according to individual need,
   ensuring woman continues on maternity pathway


8 Pre-existing medical, surgical and/or psychiatric conditions
 Quick info:
 Pre-existing medical, surgical and/or psychiatric disorders:
  •o ffer advice on pre-existing conditions which could impact on pregnancy outcome
  •o ffer advice on risk of pre-existing condition to pregnancy and risk of pregnancy to condition
  •r eview medication(s) and advise of its risks and benefits in pregnancy
  •c onsider specialist advice
  •c onsider additional information, care and treatment, and refer according to individual need, ensuring woman continues on
    maternity pathway
  • if healthcare professional or woman has significant concerns, refer to GP for further assessment
  •a ssess mental health (current, new onset or past incidence):
      •a ssess need or anticipated need for psychological or psychotherapeutic treatment for woman/couple and/or family
      • if severe mental illness (e.g. bipolar disorder or schizophrenia) is suspected, refer to specialist mental health service,
        including, if appropriate, specialist perinatal mental health service:
          •t his should be discussed with woman and preferably with her GP
      •i nform GP in all cases if a possible current mental disorder or history of significant mental disorder is detected, even if no
        further assessment or referral is made
      •f or further information refer to the NICE mental health guidance


9 Booking appointment (ideally by 10 weeks)
 Quick info:
  •i dentify women who may need additional care and plan pattern of care for the pregnancy
  •c alculate BMI and manage and/or refer according to individual need, ensuring woman continues on maternity pathway
  •a sk recommended questions to identify those at risk of and those with current mental health problems
      •r efer women with current or previous severe/complex mental health needs to specialist perinatal mental health services
      •f or further information refer to the NICE mental health guidance
  •o ffer blood tests as appropriate
  •o ffer screening as appropriate and refer according to individual need, ensuring woman remains on maternity pathway
  •f or further information refer to UK National Screening Committee
  •o ffer early ultrasound scan for gestational age assessment and ultrasound for structural anomalies
  •i dentify women who have had genital mutilation (FGM) and refer according to individual need, ensuring woman continues on
    maternity pathway
  •a sk about woman’s occupation to identify potential risks
  •g ive specific information on:
      •t he pregnancy care pathway
      •p lanning place of birth (refer to NICE Intrapartum guidance)
      •b reastfeeding, including workshops
      • participant-led antenatal classes
      • maternity benefits
  •f or women choosing screening, arrange as appropriate:
      •b lood tests, ideally before 10 weeks
      •u rine tests
      •u ltrasound scan to determine gestational age
      • Down’s syndrome screening
      •u ltrasound screening for structural anomalies, normally between 18 weeks and 20 weeks 6 days
  • undertake full health and social needs assessment
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


10 16 weeks appointment
 Quick info:
  •r eview, discuss and record the results of screening tests:
     •r efer according to individual need, ensuring woman continues on maternity pathway
2 Commissioning antenatal care
     •r equest permission to inform other healthcare professionals involved in her pregnancy and the Healthcare Protection Unit
     •o ffer to screen partner and children as appropriate
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  •g ive specific information on:
     •t he routine anomaly scan and refer as appropriate for:
        • abnormalities related to pregnancy
        • abnormalities not related to pregnancy
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby



11 18     20 weeks appointment
 Quick info:
  • if the woman chooses, an ultrasound scan should be performed between 18 weeks 0 days and 20 weeks 6 days to detect
    structural anomalies
  •o ffer counselling and support as appropriate
  •f or a woman whose placenta extends across the internal cervical os, offer another scan at 32 weeks
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


12 25 weeks appointment
 Quick info:
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  • measure fundal height and refer as appropriate, ensuring woman continues on maternity pathway
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


13 28 weeks appointment
 Quick info:
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  •o ffer a second screening for anaemia and atypical red-cell alloantibodies, and hepatitis B
  • obtain maternal consent to give baby vaccinations at birth according to individual need
  •o ffer anti-D prophylaxis to women who are rhesus D-negative 1
  •c heck for reduced fetal movement depending on normality of episodes
     •r efer for fetal wellbeing assessment according to individual need, ensuring woman continues on maternity pathway
  • screen for eclampsia and refer as appropriate, ensuring woman continues on maternity pathway (refer to Action on Pre-
    eclampsia website for further information)
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


14 31 weeks appointment
 Quick info:
  •r eview, discuss and record the results of screening tests undertaken at 28 weeks
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


15 34 weeks appointment
 Quick info:
  •r eview, discuss and record the results of screening tests undertaken at 28 weeks
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  •o ffer a second dose of anti-D prophylaxis to women who are rhesus D-negative1
  •g ive specific information on:
     •p reparation for labour and birth, including the birth plan
     •t he postnatal period, including the postnatal plan
2 Commissioning antenatal care
  • start planning of postnatal care
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


16 36 weeks appointment
 Quick info:
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  • measure fundal height and refer as appropriate, ensuring woman continues on maternity pathway
  •c heck the position of the baby:
     • if breech is suspected, offer external cephalic version
     •r efer as appropriate, ensuring woman continues on maternity pathway
  •g ive specific information (at or before 36 weeks) on:
     •b reastfeeding technique and good management practices, such as detailed in the UNICEF Baby Friendly Initiative
     •c are of the new baby, vitamin K prophylaxis and newborn screening tests
     • postnatal self-care, awareness of ‘baby blues’ and postnatal depression
     •o ffer support and advice according to need
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


17 38 weeks appointment
 Quick info:
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  •g ive specific information on options for management of prolonged pregnancy
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


18 40 weeks appointment
 Quick info:
  • screen and refer according to individual need, ensuring woman continues on maternity pathway
  •d iscuss further management of prolonged pregnancy
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


19 41 weeks appointment
 Quick info:
  •f or women who have not given birth by 41 weeks:
     •o ffer a membrane sweep
     •o ffer induction of labour
     • screen as appropriate, ensuring woman continues on maternity pathway
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby


20 42 weeks appointment
 Quick info:
  •o ffer enhanced surveillance and support according to individual need
  • from 42 weeks, offer increased monitoring to women who decline induction of labour
  • be alert to any factors - clinical, psychological, cultural and/or social - that may affect the health of the woman and baby
2 Commissioning antenatal care
Key Dates
 Due for review: 06-Aug-2011
 Locally reviewed: 29-Jul-2009, by London
 Updated: 29-Jul-2009

Evidence summary for Antenatal care
 This pathway is based on UK National Health Service policies and schedules and gives an overview of what to expect in the
 antenatal period.
 Search date: Jun-2009

Evidence grades:
           Intervention node supported by level 1 guidelines or systematic reviews

           Intervention node supported by level 2 guidelines

           Intervention node based on expert clinical opinion

           Non-intervention node, not graded


Evidence grading:
   Graded node titles that appear on this page                                Evidence grade                        Reference IDs
   Antenatal (once pregnant)                                                                                        1, 8

   Principles of antenatal care                                                                                     1, 8

   Provide antenatal information                                                                                    1, 8

   Booking appointment (ideally by 10 weeks)                                                                        1, 8

   16 weeks appointment                                                                                             1, 8

   18 # 20 weeks appointment                                                                                        1, 8

   25 weeks appointment                                                                                             1, 8

   28 weeks appointment                                                                                             1, 8

   31 weeks appointment                                                                                             1, 8

   34 weeks appointment                                                                                             1, 8

   36 weeks appointment                                                                                             1, 8

   38 weeks appointment                                                                                             1, 8

   40 weeks appointment                                                                                             1, 8

   41 weeks appointment                                                                                             1, 8

   42 weeks appointment                                                                                             1, 8

   First contact with healthcare professional                                                                       1, 8

   Pre-existing medical, surgical and/or psychiatric conditions                                                     9

   Newly-identified medical, mental health and social needs                                                         1, 9, 8, 6


References
 This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice
2 Commissioning antenatal care
ID Reference
1 Department of Health. National Service Framework for Children, Young People and Maternity Services:
   Maternity services. London: 2004.
   http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
   DH_4089101
2 Department of Health. National service framework for children, young people and maternity services. 2004.
   http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111
3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.
   http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
   DH_4126161
4 National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal care of women and their
   babies (NICE Clinical Guideline 37). London: 2006.
   http://www.nice.org.uk/CG37
5 National Collaborating Centre for Women's and Children's Health. Intrapartum care: management and
   delivery of care to women in labour (NICE Clinical Guideline 55). London: 2007.
   http://www.nice.org.uk/CG55
6 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical
   management and service guidance (NICE Clinical Guideline 45). London: 2007.
   http://www.nice.org.uk/guidance/CG45
7 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of
   diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63).
   London: 2008.
   http://www.nice.org.uk/CG63
8 National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the
   healthy pregnant woman (NICE Clinical Guideline 62). London: 2009.
   http://www.nice.org.uk/CG62
9 NHS Choices. Health A-Z: Preconception. 2007.
   http://www.nhs.uk/conditions/Preconception/Pages/Introduction.aspx
10 NHS Choices. The pregnancy care planner. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx
11 NHS Choices. The pregnancy care planner: Bereavement. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Bereavement.aspx
12 Royal College of Nursing. Abortion care: RCN guidance for nurses, midwives and specialist community
   public health nurses. London: 2008.
   http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177
3 Commissioning intrapartum care

           Labour and delivery        Link to the Pregnancy
           (intrapartum)              Care Planner and the
                                      Pregnancy Book


           Diagnosis of labour



           Support of first stage
           of labour (latent stage)



           Established labour



           Care throughout
           labour



           Indications for transfer



           Second stage of
           labour



           Third stage of labour



           Care of the baby and
           woman immediately
           after birth



           Breastfeeding - within
           first hour after birth



           Go to postnatal care
3 Commissioning intrapartum care
1 Labour and delivery (intrapartum)
 Quick info:
 Scope:
  •t his pathway is for women during the labour and delivery period and covers from the onset of labour to immediately after birth. It
    is based on UK National Health Service policies and schedules
 Associated maternity standards:
  • standard 12: intrapartum care
  • standard 13: neonatal care and assessment
  • standard 14: postnatal assessment and care of the mother
  • standard 15: supporting infant feeding
  • standard 16: care of babies requiring additional support
  • standard 17: care of babies born prematurely
  • standard 18: promotion of healthy parent-infant relationships
  • standard 19: transition to parenthood
  • standard 20: supporting families who experience bereavement, pregnancy loss, stillbirth or early neonatal death
  • standard 21: choice and appropriate care
  • standard 22: communication
  • standard 23: training and professional competence
  • standard 24: documentation and confidentiality
  • standard 25: clinical governance
  • standard 26: development, implementation and review of local maternity services strategy
  • standard 27: maternity and neonatal networks
  • standard 28: child protection and safeguarding babies
  • standard 29: infection prevention and control
  • standard 30: staffing
  • appendix 1: intrapartum care


2 The Pregnancy Care Planner and the Pregnancy Book
 Quick info:
  • The Pregnancy Care Planner is the NHS guide to having a baby
  •t he Department of Health Pregnancy Book contains information for women on what to do, how to cope and how to get the most
    from pregnancy and the new baby


3 Diagnosis of labour
 Quick info:
 Diagnosis of start of labour - this setting could be:
  • home
  • obstetric-led unit
  •m idwife-led unit


4 Support of first stage of labour (latent stage)
 Quick info:
  •g ive opportunity to review choices and options available
     •d iscuss birth plan and choice and mode of delivery
  •s upport the diagnosis of labour in the appropriate setting, according to individual need - this setting could be:
     • home
     • obstetric-led unit
     •m idwife-led unit
  • appropriately manage onset of painful regular contractions
  •c onsider individualised/specialist care plans containing details of support needed and who to contact if concerned


5 Established labour
3 Commissioning intrapartum care
 Quick info:
  •o ffer 1:1 midwifery care in labour regardless of intrapartum setting
  • undertake risk assessment with referral to appropriate birth setting


6 Care throughout labour
 Quick info:
  • undertake continuous risk assessment
  •o ffer consistent information and advice
  •p rovide appropriate support, including analgesia:
     •f or the Pain Relief In Labour leaflet, refer to the Obstetric Anaesthetists Association website
  •r efer or transfer as appropriate
  •g ive support in labour:
     •a woman in established labour should receive supportive 1:1 care
     •a woman in established labour should not be left on her own except for short periods or at the woman’s request
  • women should be encouraged to have support by birth partner(s) of their choice


7 Indications for transfer
 Quick info:
  • clear pathways and guidelines on the indications for, and the process of transfer to, an obstetric unit should be established
  •t here should be no barriers to rapid transfer in an emergency
  • clear pathways and guidelines should also be developed for the continued care of women once they have transferred:
      •t hese pathways should include arrangements for times when the nearest obstetric or neonatal unit is closed to admissions
  • if the emergency is such that transfer is not possible, open access must be given on-site for any appropriate staff to deal with
    whatever emergency has arisen
  •t here should be continuous audit of the appropriateness of, the reason for, and speed of transfer
  •c onversely, the audit also needs to consider circumstances in which transfer was indicated but did not occur
  •t he audit should include time taken to see an obstetrician or neonatologist and the time from admission to birth


8 Second stage of labour
 Quick info:
  •p rovide appropriate support according to individual risk level
  • undertake continuous risk assessment
  •o ffer consistent information and advice
  •p rovide appropriate support, including analgesia
  •r efer or transfer according to individual need, ensuring woman continues on maternity pathway
  •g ive support in labour:
     •a woman in established labour should receive supportive 1:1 care
     •a woman in established labour should not be left on her own except for short periods or at the woman’s request
     • women should be encouraged to have support by birth partner(s) of their choice


9 Third stage of labour
 Quick info:
  •p rovide appropriate support according to individual risk level
  • undertake continuous risk assessment
  •o ffer consistent information and advice
  •p rovide appropriate support, including analgesia
  •r efer or transfer as appropriate
  •p lacenta delivery - offer choice according to individual risk level:
     •p rovide active management where appropriate
     •p rovide physiological management where appropriate
3 Commissioning intrapartum care
10 Care of the baby and woman immediately after birth
  Quick info:
   • undertake appropriate assessment of baby and mother
   •o ffer appropriate neonatal care and support where required
   •f acilitate uninterrupted skin-to skin contact as soon as possible after the birth for both the mother and father (if applicable) within
     first hour after birth
   • if baby is transferred to Neonatal Intensive Care Unit (NICU), prioritise mother spending as much time as possible with her
     baby:
       • limited visits should be due to clinical, not practical/operational, reasons


11 Breastfeeding - within first hour after birth
  Quick info:
   • encourage and initiate breastfeeding by offering support, information and advice as appropriate
   •o ffer support and advice as appropriate to prevent and/or manage common breastfeeding problems
   •f or further information, refer to the Department of Health's guidance on breastfeeding
   •a ll healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff
     and parents:
      • each provider should identify a lead healthcare professional responsible for implementing this policy
   •a ll maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated,
     structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a
     minimum standard
3 Commissioning intrapartum care
Evidence summary for Intrapartum care
 This pathway is for women during the labour and delivery period and covers from the onset of labour to immediately after birth. It is
 based on UK National Health Service policies and schedules.
 Search date: Jun-2009

Evidence grades:
           Intervention node supported by level 1 guidelines or systematic reviews

           Intervention node supported by level 2 guidelines

           Intervention node based on expert clinical opinion

           Non-intervention node, not graded


Evidence grading:
   Graded node titles that appear on this page                                Evidence grade                        Reference IDs
   Diagnosis of labour                                                                                              5

   Support of first stage of labour (latent stage)                                                                  5

   Established labour                                                                                               5

   Care throughout labour                                                                                           5

   Indications for transfer                                                                                         5

   Second stage of labour                                                                                           5

   Third stage of labour                                                                                            5

   Care of the baby and woman immediately after birth                                                               5

   Breastfeeding - within first hour after birth                                                                    1, 5, 4


References
 This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice
   ID Reference
   1 Department of Health. National Service Framework for Children, Young People and Maternity Services:
        Maternity services. London: 2004.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4089101
   2 Department of Health. National service framework for children, young people and maternity services. 2004.
        http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111
   3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4126161
   4 National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal care of women and their
        babies (NICE Clinical Guideline 37). London: 2006.
        http://www.nice.org.uk/CG37
   5 National Collaborating Centre for Women's and Children's Health. Intrapartum care: management and
        delivery of care to women in labour (NICE Clinical Guideline 55). London: 2007.
        http://www.nice.org.uk/CG55
3 Commissioning intrapartum care
ID Reference
6 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical
   management and service guidance (NICE Clinical Guideline 45). London: 2007.
   http://www.nice.org.uk/guidance/CG45
7 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of
   diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63).
   London: 2008.
   http://www.nice.org.uk/CG63
8 National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the
   healthy pregnant woman (NICE Clinical Guideline 62). London: 2009.
   http://www.nice.org.uk/CG62
9 NHS Choices. Health A-Z: Preconception. 2007.
   http://www.nhs.uk/conditions/Preconception/Pages/Introduction.aspx
10 NHS Choices. The pregnancy care planner. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx
11 NHS Choices. The pregnancy care planner: Bereavement. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Bereavement.aspx
12 Royal College of Nursing. Abortion care: RCN guidance for nurses, midwives and specialist community
   public health nurses. London: 2008.
   http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177
4 Commissioning postnatal care
4 Commissioning postnatal care
1 Postnatal
  Quick info:
  Scope:
   •t his pathway is an overview of care during the postnatal period. It is based on UK National Health Service policies and
     schedules
  Associated maternity standards:
   • standard 12: intrapartum care
   • standard 13: neonatal care and assessment
   • standard 14: postnatal assessment and care of the mother
   • standard 15: supporting infant feeding
   • standard 16: care of babies requiring additional support
   • standard 17: care of babies born prematurely
   • standard 18: promotion of healthy parent-infant relationships
   • standard 19: transition to parenthood
   • standard 20: supporting families who experience bereavement, pregnancy loss, stillbirth or early neonatal death
   • standard 21: choice and appropriate care
   • standard 22: communication
   • standard 23: training and professional competence
   • standard 24: documentation and confidentiality
   • standard 25: clinical governance
   • standard 26: development, implementation and review of local maternity services strategy
   • standard 27: maternity and neonatal networks
   • standard 28: child protection and safeguarding babies
   • standard 29: infection prevention and control
   • standard 30: staffing


2 The Pregnancy Care Planner and the Pregnancy Book
  Quick info:
   • The Pregnancy Care Planner is the NHS guide to having a baby
   •t he Department of Health Pregnancy Book contains information for women on what to do, how to cope and how to get the most
     from pregnancy and the new baby


3 First hours after birth
  Quick info:
   • undertake observations and assessment of woman
   • undertake observations and assessment of baby:
      •r ecommend Vitamin K and offer choice of intramuscular first, as most clinically and cost effective
      •w ithin first 24 hours, with maternal consent, give vaccinations to baby according to individual need
      •r esults of observations and assessment, and vaccinations, should be recorded in the national Personal Child Health Records
        (PCHR) and any other baby health record
      •i nform the Child Health Department as appropriate
      •f or further information refer to Department of Health guidance and the NSC Green Book
      •i nvolve partner where applicable and appropriate
   • ensure systems are in place to identify high-risk women and refer as appropriate, ensuring women continues on maternity
     pathway
   •i mplement any specialist care plan agreed antenatally
   •c omplete newborn physical examination should be performed within 72 hours of birth


4 Consider all of the following
  Quick info:
  Consider the following steps during the first hours after birth
4 Commissioning postnatal care
5 Promote bonding by encouraging and initiating breastfeeding and skin-to-skin contact
 Quick info:
  • encourage and initiate breastfeeding by offering support, information and advice as appropriate
  •o ffer support and advice as appropriate to prevent and/or manage common breastfeeding problems
  •f or further information, refer to the Department of Health's guidance on breastfeeding
  •a ll healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff
    and parents
      • each provider should identify a lead healthcare professional responsible for implementing this policy
  •a ll maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated,
    structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a
    minimum standard.
  •f acilitate uninterrupted skin-to skin contact as soon as possible after the birth for both the mother and father (if applicable) within
    first hour after birth


6 Assessment and management of physical and mental health
 Quick info:
  • manage major morbidity in mother and infant
  • physical health:
     •a rrange appropriate treatment eg for high blood pressure, perineal care
  • mental health:
     •a ssess need for additional care and/or treatment from relevant healthcare professionals
     •i mplement any specialist care plan agreed antenatally
     •r efer for specialist psychiatric assessment and treatment as appropriate
     • women who need inpatient care for a mental disorder within 12 months of childbirth should normally be admitted to a
       specialist mother and baby unit, unless there are specific reasons for not doing so


7 Agree postnatal plan of care (for up to three months according to individual need)
 Quick info:
  • agree community-based postnatal plan of care with woman according to physical, psychological and social need
     •o ffer choice of location of community-based postnatal support
     •a ssess additional needs and respond as appropriate e.g. translation services
  • agree location of first community-based postnatal contact, to take place within 24 hours of discharge from place of birth
  •r eview and re-start specialist pathway as appropriate


8 Agree discharge or transfer plan
 Quick info:
  • agree discharge or transfer plan
     • ensure appropriate communication with GP and primary care
     • ensure appropriate communication with multi-disciplinary teams
     • ensure management plans are in place
  •p rior to discharge, give MMR (mumps, measles and rubella) vaccination to women not immune to rubella and record in
    Personal Child Health Record
  • woman will either be discharged home or remain with provider
  •a minimum of three community based postnatal contacts should take place should take place following discharge


9 Provider communications with GP/primary care and Child Health Department
 Quick info:
  •t he provider should hand over to the GP/primary care:
     • ensure appropriate communication with GP, and other professionals involved, on woman's experience and difficulties on
       discharge
     • agree a communications plan with the GP/primary care practitioner
4 Commissioning postnatal care
  •i nform GP, health visitor and Child Health professional of:
      •b irth and woman's experience
      • hepatitis B status of woman
      •v accinations given to baby
  •a rrange for hepatitis B vaccination to be given to baby at:
      •1 month
      •2 months
      • 12 months (booster)


10 First days after birth
 Quick info:
  •c omplete newborn physical examination should be performed within 72 hours of birth
  • newborn bloodspots to be taken between day five and eight


11 Minimum of one postnatal contact at home within first 10 days
 Quick info:
  •w ithin first 10 days there should be a minimum of one postnatal contact at home
  • agree minimum of three community based postnatal contacts at woman's choice of location:
     • number and frequency of contacts should be based on individual medical, psychological and social needs
     • ensure systems are in place to identify high-risk women and refer according to individual need, ensuring women continue on
       maternity pathway
     •l ength of postnatal period should be defined by individual medical, psychological and social need
     • at each postnatal contact, women should be asked about their emotional well-being recommended questions to screen for
       mental health problems should be asked at first contact.
     •f or further information, refer to NICE mental health guidance
     •r eview and re-start specialist pathway as appropriate
     • healthcare professionals should be alert to risk factors and signs and symptoms of child abuse, neglect and inadequate
       bonding, and if there is raised concern, should follow local child protection policies
     •f or information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook


12 Six to eight week check
 Quick info:
  •t he following should be covered:
     • physical health
     •c ontraceptive advice
     •b reastfeeding status and support
     •i mmunisation
     • six to eight week infant physical examination
      •r esults of newborn bloodspot
      • nutrition
      •a lcohol consumption
      •s ubstance misuse
      •t obacco
  •c ontinue to assess for signs and symptoms of mental health problems and refer according to individual need, ensuring woman
    continues on maternity pathway
  •f or information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook


13 Eight to 20 weeks
 Quick info:
  • ensure systems are in place to identify high-risk women and babies
     •r efer according to individual need, ensuring women continue on maternity pathway
     •f or information on domestic abuse, refer to the Department of Health Domestic Abuse Handbook
4 Commissioning postnatal care
•c ontinue to assess for signs and symptoms of mental health problems and refer according to individual need
   •o ffer extra support if needed
   •a rrange for GP review if indicated and consider need for referral to specialist perinatal mental health services
•t he length of the postnatal period should be set according to medical, psychological and social need
4 Commissioning postnatal care
Evidence summary for Postnatal care
 This pathway is an overview of care during the postnatal period. It is based on UK National Health Service policies and schedules.
 Search date: Jun-2009

Evidence grades:
           Intervention node supported by level 1 guidelines or systematic reviews

           Intervention node supported by level 2 guidelines

           Intervention node based on expert clinical opinion

           Non-intervention node, not graded


Evidence grading:
   Graded node titles that appear on this page                                Evidence grade                        Reference IDs
   First hours after birth                                                                                          1, 4

   First days after birth                                                                                           4

   Promote bonding by encouraging and initiating breastfeeding and                                                  1, 4
   skin-to-skin contact
   Assessment and management of physical and mental health                                                          4

   Agree postnatal plan of care (for up to three months according to                                                4
   individual need)
   Agree discharge or transfer plan                                                                                 4

   Provider communications with GP/primary care and Child Health                                                    4
   Department
   Minimum of one postnatal contact at home within first 10 days                                                    4

   First community based contact at home or at choice of location                                                   4

   Six to eight week check                                                                                          4

   Eight to 20 weeks                                                                                                4


References
 This is a list of all the references that have passed critical appraisal for use in the pathway Maternity best practice
   ID Reference
   1 Department of Health. National Service Framework for Children, Young People and Maternity Services:
        Maternity services. London: 2004.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4089101
   2 Department of Health. National service framework for children, young people and maternity services. 2004.
        http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111
   3 Department of Health. Responding to domestic abuse: A handbook for health professionals. London: 2005.
        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
        DH_4126161
   4 National Collaborating Centre for Primary Care. Postnatal care: Routine postnatal care of women and their
        babies (NICE Clinical Guideline 37). London: 2006.
        http://www.nice.org.uk/CG37
4 Commissioning postnatal care
ID Reference
5 National Collaborating Centre for Women's and Children's Health. Intrapartum care: management and
   delivery of care to women in labour (NICE Clinical Guideline 55). London: 2007.
   http://www.nice.org.uk/CG55
6 National Collaborating Centre for Mental Health. Antenatal and postnatal mental health: clinical
   management and service guidance (NICE Clinical Guideline 45). London: 2007.
   http://www.nice.org.uk/guidance/CG45
7 National Collaborating Centre for Women's and Children's Health. Diabetes in pregnancy: management of
   diabetes and its complications from pre-conception to the postnatal period (NICE Clinical Guideline 63).
   London: 2008.
   http://www.nice.org.uk/CG63
8 National Collaborating Centre for Women's and Children's Health. Antenatal care: routine care for the
   healthy pregnant woman (NICE Clinical Guideline 62). London: 2009.
   http://www.nice.org.uk/CG62
9 NHS Choices. Health A-Z: Preconception. 2007.
   http://www.nhs.uk/conditions/Preconception/Pages/Introduction.aspx
10 NHS Choices. The pregnancy care planner. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/PregnancyHome.aspx
11 NHS Choices. The pregnancy care planner: Bereavement. 2009.
   http://www.nhs.uk/Planners/pregnancycareplanner/Pages/Bereavement.aspx
12 Royal College of Nursing. Abortion care: RCN guidance for nurses, midwives and specialist community
   public health nurses. London: 2008.
   http://www.library.nhs.uk/womenshealth/ViewResource.aspx?resID=297177
About Map of Medicine



The Map of Medicine is an online clinical knowledge
resource implemented throughout the UK and availa-
ble to patients via NHS Choices. More than 1500 pages,
organised into over 350 care pathways spanning care
settings, are presented in an easy-to-use visual format,
offering evidence-based and up-to-date information
across all specialties.

The Maternity pathway is available to NHS healthcare
professionals at http://london.mapofmedicine.com/ *

*Access is via your NHS Athens account

								
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