Day Assessment Unit Maternity Referral Clinical Guideline · Day Assessment Unit Maternity Referral...

Day Assessment Unit Maternity Referral Clinical Guideline

V2.3

March 2021

Day Assessment Unit Maternity Referral Clinical Guideline V2.3 Page 2 of 15

1. Aim/Purpose of this Guideline 1.1. The purpose of this guideline is to give guidance to midwives, obstetricians

and other health professionals on effective triage and referral pathways leading to improved outcomes for both the mother and her baby during the antenatal and postnatal period. The aims of this guideline are to:

Provide a safe and effective assessment service

Reduce inappropriate antenatal ward and Day Assessment Unit (DAU) admissions

Reduce waiting times for women who require an obstetric review

Ensure a prompt assessment of women who require an urgent obstetric opinion

Enable staff to provide appropriate management for obstetric conditions in a timely manner

Ensure women receive a referral pathway appropriate to their clinical needs

1.2. This guideline gives guidance on PRECOG referral thresholds.

1.3. This version supersedes any previous versions of this document.

1.4. This guideline makes recommendations for women and people who are

pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals.

2. The Guidance 2.1. Referrals to DAU

2.1.1. Referrals can be made through the community midwives, GP’s, hospital doctors, Emergency Department and antenatal clinic with direct contact to the Ward Clerk or Midwife working on DAU. Women are NOT able to self-refer.


2.1.2. The DAU midwives can also offer advice and triage over the telephone when a health professional is unsure of an appropriate plan of care/route of referral.

2.1.3. On admission to DAU, the DAU midwife will decide following an

assessment whether the women is suitable for discharge home or whether an obstetric review or transfer to delivery suite is required.

2.1.4. Women will be prioritised upon admission dependent on their clinical

need.

2.1.5. A MEOWS chart MUST be completed for all admissions to DAU with care escalated in line with the score and using the SBARD communication tool.

2.2. Opening Hours and Location

2.2.1. DAU is located on Wheal Rose within the Princess Alexander Maternity Wing at the Royal Cornwall Hospital.

2.2.2. DAU is staffed between the hours of 08.00 and 20.00

2.2.3. Planned admissions should be between 09.00 and 17.00

2.3. Staffing:

2.3.1. DAU is staffed by one midwife and one Maternity Support Worker.

2.3.2. Providing Obstetric Support are:

SHO for the Obstetric team

Registrar for the Gynaecology Team (09:00-17:00) or

Registrar for the Obstetric Team (17.00-20:00)

Consultant service week 0900-1700

Consultant obstetrician on call 1700-20.00

2.3.3. The obstetric team will work as part of a multidisciplinary team in partnership with the midwife, woman and her family.

2.3.4. DAU does not have a dedicated doctor. Women should be informed

that where medical input is necessary there may be a significant delay dependent on their clinical condition and the level of activity within the maternity unit at the time.

2.4 Elective Referrals Accepted by DAU

2.4.1. Intramuscular steroids - requested by a senior obstetrician

2.4.2. Obstetric Cholestasis presenting ≥ 37 weeks

2.4.3. Pre-operative Assessment DAU appointments are 7 days prior to Elective LSCS. MRSA screening in the community is to be done at least 48 hours prior to the DAU appointment.


2.4.4. Prolonged Pregnancy when Induction of Labour is Declined CTG and liquor volume scan at 40 weeks+14 days with a senior obstetric review and care plan clearly documented.

2.4.5. This assessment should also be offered for women over the age of 40

years at 40/40 +2 if induction of labour at the EDD is declined

2.4.6. Total Dose Iron Infusion Written consultant authorisation is required before the DAU appointment is made.

2.5 Emergency Referrals accepted by DAU

2.5.1. Reduced Fetal Movements Refer to Reduced Fetal Movements Guideline.

2.5.2. Any woman who is term and reporting NO fetal movements should be seen in DAU where a full antenatal check and CTG should be performed.

2.5.3. Pre-eclampsia assessment - see Appendix 4

2.5.4. Acute Abdominal pain > 18 weeks gestation

2.5.5. Significant Vaginal Bleeding > 18 weeks gestation

2.5.6. Prolonged Pre-term Spontaneous Rupture of Membranes (PPROM)

Refer to Prolonged Pre-term Spontaneous Rupture of Membranes (PPROM) clinical guideline.

2.5.7. Fall or minor Trauma involving abdomen consider risk of placental

abruption and Rhesus status, consider need for Anti D.

2.5.8. Postnatal Women who require an urgent review e.g. hypertension, acute wound or perineal infections or post epidural headache.

2.5.9. Suspected Intrauterine Death

2.5.10. Referral from scan department :

If SGA is diagnosed for the first time after 35/40 (see SGA guideline)

If there are serious concerns regarding acute fetal well-being. An SGA fetus with abnormal umbilical artery Doppler (but present endiastolic flow) needs not attend DAU but should be referred to fetal medicine unit for twice weekly review (see SGA guideline).

There is absent endiastolic flow USS has shown abnormal growth, liquor or Doppler requiring an urgent CTG and obstetric review.

2.5.11. Suspected Pre-Term Labour Assessment or Term Labour

Assessment out of hours. Between the hours of 17:00-21:00, the DAU Midwife will triage calls from the woman and invite her to DAU for an assessment if required.


2.6. Referrals not accepted by DAU DAU referral is not always the most appropriate pathway for women. Consider other professionals: Community Midwife (CMW), General Practitioner (GP), Physiotherapist or referral to the named Consultant Obstetric Clinic. See Appendix 3 for referrals which will not be accepted by DAU along with the appropriate route for referral.

2.7. Frequent Attenders

Women who have a third admission through the same day maternity triage service (not a routine DAU appointment) either on Delivery Suite or DAU within an 8 week period, must have the next available appointment made with their named consultant.

3. Monitoring compliance and effectiveness Element to be monitored

Audit of inappropriate referrals to DAU

Were all referrals made by a health professional – no self-referrals?

Were there any unplanned admissions made between 09.00 and 17.00? (except reduced fetal movements)

Were all of the women referred with abdominal pain or vaginal bleeding >18/40?

Were any women with decelerations on auscultation in the community setting admitted to DAU?

Were any term labour assessments sent to DAU between the hours of 9-5, 7 days a week?

Were any women requiring cholestasis assessment at


practice and lessons to be shared

by the Audit midwife within a time frame agreed on the action plan.

The results of the audit will be distributed to all staff through the Patient Safety/Audit Newsletter.

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust

service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876http://www.rcht.nhs.uk/GET/d10268876http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Day Assessment Unit Maternity Referral Clinical Guideline V2.3

This document replaces (exact title of previous version):

Day Assessment Unit Maternity Referral Clinical Guideline V2.2

Date Issued/Approved: March 2021

Date Valid From: March 2021

Date Valid To: October 2021

Directorate / Department responsible (author/owner):

Sarah Harvey-Hurst Antenatal Ward Manager

Contact details: 01872-255036

Brief summary of contents

The aim of this guideline is to give guidance to midwives, obstetricians and other health professions upon when and when not to refer women to the DAU. This guideline will enable staff to provide, in a timely manner, appropriate management for obstetric conditions, leading to improved outcomes for both the mother and her baby during the antenatal and postnatal period.

Suggested Keywords:

DAU, cholestasis, pre-op, anaesthetic review, IOL, iron, IUGR, PPROM, rupture, membranes, reduced, movements ectopic, pre-eclampsia, bleeding, fall, trauma, diarrhoea, vomiting, PRECOG, hyperemesis, chicken, postnatal, NNU, labour, IUD, ultrasound, scan

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route (names of committees)/consultation:

Maternity Guidelines Group Care Group Board

General Manager confirming approval processes:

Mary Baulch

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana


Links to key external standards N/A

Related Documents:

UK guideline on the management of iron deficiency in pregnancy, BCSH, July 2011 Bayoumeu F, Subiran-Buisset C, Baka NE, Legagneur H, Monnier-Barbarino P, Laxenaire MC.

Iron therapy in iron deficiency anaemia in pregnancy: intravenous route versus oral route. Am J Obstet Gynecol. 2002;186:518-522 Brabin, B.J., Hakimi,M., Pelletier,D. (2001)

An analysis of anaemia and pregnancy related maternal mortality. Journal of Nutrition 131, 604S- 615S Bhandal N, Russell R.

Intravenous versus oral iron therapy for postpartum anaemia. BJOG 2006; 113:1248-1252 Gravier A, Descargues G, Marpeau L.

How to avoid transfusion in the post-partum period: importance of an intravenous iron supplement]. J Gynecol Obstet Biol Reprod (Paris). 1999;28:77-78

Hand book of Obstetric Medicine, second edition, Catherine Nelson Piercy

M. Muñoz et al. Patient blood management in obstetrics: management of anaemia and haematinic deficiencies

in pregnancy and in the post‐partum period: NATA consensus statement. Transfus Med 2018;28:22–39.

Summary of product characteristics – Ferrous Sulphate Jul 2018

Summary of product characteristics- Ferinject (Ferric Carboxymaltose) Dec 2018

Training Need Identified? No

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Midwifery and Obstetrics


Version Control Table

Date Version No

Summary of Changes Changes Made by

(Name and Job Title)

4th December 2014

V1.0 Initial Issue

Karen Stoyles Supervisor of Midwives Kerry Jenkin Midwife Kerry Jenkin November

2017 V2.0

Term SROM assessment in DAU Opening hours amended and located added Maternity Triage Line information Appendix 3 – referrals not accepted by DAU Appendix 3 – PRECOG recommendation replacing adapted referral thresholds Table for referrals not appropriate for DAU created and moved to Appendices Anaesthetic review criteria amended Hyperemesis appendix removed

Magda Kudas Antenatal Ward Sister Sarah Harvey-Hurst Deputy Ward Sister

6th September 2018

V2.1 Addition of MEOWS charting following IS Sarah Harvey-Hurst Deputy Ward Sister

April 2020 V2.2 Addition of frequent attenders requirement for named consultant appointment

Sarah Harvey-Hurst Ward Manager

February 2021

V2.3

2.5.2 Any woman who is term and reporting NO fetal movements should be seen in DAU where a full antenatal check and CTG should be performed.

Kate Putman, Bereavement Midwife

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment

Are there concerns that the policy could have a positive / negative impact on:

Protected Characteristics:

Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Section 1: Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed Day Assessment Unit Maternity Referral Clinical Guideline V2.3

Directorate and service area: Obstetrics and gynaecology

New or existing document: Existing

Name of individual completing assessment: Kate Putman, Bereavement Midwife

Telephone: 01872 25 5036

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

The aim of this guideline is to give guidance to midwives, obstetricians and other health professions upon when and when not to refer women to the DAU.

2. Policy Objectives

For women with obstetric complications an appropriate and timely referral to the DAU.

3. Policy – intended Outcomes

Improved outcomes for both the mother and her baby during the antenatal and postnatal periods. Improved patient experience.

4. How will you measure the outcome?

Compliance Monitoring Tool

5. Who is intended to benefit from the policy?

All pregnant and newly delivered women.

6a). Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Maternity Guidelines meeting Care Group Board

c). What was the outcome of the consultation?

Agreed

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Sex (male, female, non-binary, asexual etc.)

X

Gender reassignment

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, (bisexual, gay, heterosexual, lesbian)

X

If all characteristics are ticked ‘no’, and this is not a major working service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted

risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Kate Putman

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docxmailto:[email protected]


Appendix 3.

Referrals NOT routinely accepted by DAU Abdominal pain or vaginal bleeding below 18 weeks gestation

CMW to review and refer to GP if still concerned. If emergency assessment is needed (? Miscarriage) then refer to Eden if under 14 and to DAU if over 14 weeks of gestation.

Abnormal Fetal Heart Rate Women with decelerations on auscultation detected in the community setting should be admitted directly to Delivery Suite.

Chronic Conditions Chronic conditions, including Pelvic Girdle Pain (PGP) and chronic pain should be referred to the appropriate health professional e.g. GP or obstetric clinic if thought to be related to the pregnancy. If unable to book an appointment at the obstetric clinic email the consultant.

Diarrhoea and Vomiting There are no facilities in DAU for a woman needing isolation. In the absence of severe dehydration the woman should be managed in the community, unless diabetic on insulin. These women should be admitted to Wheal Rose 01872 25 2149 or Delivery Suite 01872 25 2361 for immediate review.

Chicken pox Any patient unwell with Chicken pox either discuss with Service week/ or on call Consultant

Term Labour Assessment This should be done by the Community Midwives 9-5 seven days a week

Ectopic Fetal Heart Beats When ectopic fetal heart beats are detected, the CMW must record maternal pulse and repeat auscultation and maternal pulse in 48 hours. If ectopic beats still present then refer to Fetal Medicine Centre 01872 25 3092 for on-going management.

Large for Dates Large for dates is not an indication for scan unless polyhydramnios is suspected. If polyhydramnios is suspected a scan should be booked via Main Ultrasound on MAXIMS.

Obstetric Cholestasis Refer to Obstetric Cholestasis Guideline. Initial assessment, blood tests and diagnosis are made in the community unless the woman presents after 37 weeks in which case a referral to DAU should be made.

Postnatal Woman with Baby on Neonatal Unit (NNU)

All routine postnatal checks on fit, well women should be undertaken by the CMW. If the baby remains on NNU the CMW will contact the woman and formulate an individualised plan of care. An agreed visit schedule with the named midwife will include at least one assessment at home or postnatal clinic.

Presentation Scans Presentation scans should be arranged after 36 weeks by contacting Maternity Scanning Clerk on 2682


Pre Labour Rupture of Membranes at Term (TERM PROM)

Refer to the Pre Labour Rupture of Membranes at Term (Term PROM) clinical guideline. Term PROM is to be managed within the community setting unless risk factors are identified. If meconium or bleeding is present, admit via Delivery Suite (DS). However, if an effective speculum examination is not possible at home, referral may be made to DAU.

Small for Gestational Age / Fetal Growth Restriction

Women with symphysis fundal height below the shaded area on the growth chart should be scanned by fetal medicine by contacting Maternity Scanning Clerk (2682). Follow up, if indicated as planned by referring to woman’s named obstetric team.

Spotting

Spotting/minor post coital/old brown loss or minimal mucous blood loss with normal fetal movements.

Trauma

All serious trauma/RTA/head injury require admission to the Emergency Department (ED) with obstetric input as required.

Anaesthetic Review

All Anaesthetic reviews must now be undertaken in clinic excluding those for an elective caesarean section.

Hyperemesis See clinical guideline for management within the community setting. Referral for admission should be made by the GP to the On Call Registrar with admission directly to Wheal Rose.


Appendix. 4

PRECOG recommendation 5 Community monitoring thresholds for further action Description Definition Action by midwife/GP PRECOG

Grade

New hypertension

without proteinuria after

20 weeks

Diastolic BP ≥ 90 and <

100mmHg

Refer for hospital step-up assessment

within 48 hours

C

Diastolic BP ≥ 90 and <

100mmHg with

significant symptoms*

Refer for same day hospital step-up

assessment

C

Systolic BP ≥ 160 mmHg Refer for same day hospital step-up

assessment

C

Diastolic BP ≥ 100mmHg Refer for same day hospital step-up

assessment

C

New hypertension and

proteinuria after 20

weeks

Diastolic BP ≥ 90mmHg

and new proteinuria ≥ 1+

on dipstick


assessment

A



on dipstick

Arrange immediate admission A

Systolic BP ≥ 170mmHg


on dipstick




on dipstick and



New proteinuria without

hypertension after 20

weeks

1+ on dipstick Repeat pre-eclampsia assessment in

community within 1 week.

C

2+ or more on dipstick Refer for hospital step-up assessment

within 48 hours

C

≥ 1+ on dipstick with



assessment

C

Maternal symptoms or

fetal signs and symptoms

without new hypertension

or proteinuria

Headache and or visual

disturbances with

diastolic blood pressure

less than 90mmHg and a

trace or no protein

Follow local protocols for

investigation. Consider reducing

interval before next PRECOG

assessment

C

Epigastric pain with

diastolic blood pressure

less than 90mmHg and a

trace or no protein


assessment

C

Reduced movements or

small for gestational age

infant with diastolic blood

pressure less than

90mmHg and a trace or

no protein

Follow local protocols for investigation

of fetal compromise. Consider

reducing interval before next full pre-

eclampsia assessment

C

*Symptoms include: epigastric pain, vomiting, headache, visual disturbances, reduced fetal movements, small for gestational age infant.


Description of symptoms [GPP]

As there are limited data from studies, the following are descriptions and comments from the pre-eclampsia

specialists in the PRECOG group and from CEMD [Good Practice Points]:

Headache and visual disturbances

Severe pounding headache, partial loss of visual acuity, bright/flashing visual disturbances.

Migraines can continue during pregnancy and any migraine can be excruciating without being life-

threatening or associated with signs of pre-eclampsia.

A headache of sufficient severity to seek medical advice. (CEMD)

Epigastric pain

Epigastric pain, especially if severe or associated with vomiting. The most sinister epigastric pain is

described by the sufferer as severe and is associated with definite tenderness to deep epigastric

palpation (the woman winces).

New epigastric pain (CEMD). Taken from PRECOG: The Pre-eclampsia Community Guideline

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