care pathway for women experiencing a spontaneous late ... · 2016). if you are not sure, do not...

©RBFT Women experiencing spontaneous late miscarriage or IUD on DS (V3.0) March 2020 of 24

Care Pathway for women experiencing a spontaneous late miscarriage (<24/40), neonatal

death (any gestation) or intrauterine death (>24/40) on Delivery Suite Care

Patient likes to be known as Patient name NHS no

Affix patient label here

Consultant

Planned date

Named Midwife

Date of admission

Ward

Known Allergies

CODE Paper colouring

Midwives responsibility White Assessment

TX Doctors responsibility Yellow Admission

Version 3.0 March 2020 Review before March 2022

Approval Group Date

Maternity Clinical Governance 6th March 2020

Change History

Version Date Author(s), Job title Reason

2.0 Aug 2018 A Wood (Bereavement MW) Introduction of partogram

2.1 Oct 2019 A Wood (Bereavement MW) Live change to amend HbA1c blood test bottle colour to purple from grey

2.2 Feb 2020 A Wood, H Clark (Bereavement MWs) Update guidance to GL862, informing maternity bookings, gestation, remove record in birth register, IUD/TOP Careset added


All members of staff who are using this Pathway use black ink and fill in this section. You can then use initials when recording care.

Print Name Designation Signature Initials

How to use an Integrated Care Pathway (ICP)

Firstly, if you are going to write in the ICP you need to state your Name, Job Title and give a sample signature and initials on the front of the ICP cover

If you are recording an event, which is predicted by the ICP, then you just sign against that predicted intervention in the column provided.

If your intervention is not in line with the pathway, you must record this as a variance in the variance column with the action you will take to try to bring the patient back onto the pathway.

Care given by health care assistants and student midwives / nurses must be countersigned by a registered midwife.

There are many ‘NOTES’ pages for you to write free text about the care given to the patient by you. These notes should always be dated and timed.

The ICP has been colour coded to make it easier to document your aspect of care. Black background relates to Doctors, clear background relates to Midwives and grey backgrounds relates to PAMS, but check the key prior to writing. All ICPs are chronological so you should be able track the care given very easily


For infants born at 22+3 to 23+6 consider/discuss with neonatal team and family possible interventions if born with signs of life.

See link on Extreme Pre-term birth GL895 in Maternity Guidelines (including PIL)


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On diagnosis of intrauterine death: Y N Date Initial

IUD confirmed by ultrasound scan

Parents counselled by doctor or experienced midwife regarding mode of delivery i.e. induction of labour etc.

Mifepristone prescribed and administered

Obs performed 15mins after administration of mifepristone before discharge home

Essential information for all losses: (Please document if not done)

Y N Date Initial

Give pack in DAU to include ‘What Happens Next’ booklet Bereavement Midwife contact card and information leaflet on “Mid to late pregnancy loss”

Parents given date and time to return 48 hours after mifepristone

Date________________Time_________

Parents given leaflet ‘Information for parents experiencing mid and late pregnancy loss on Delivery Suite’

Give parents opportunity to see Willow Room if possible

Inform named Community Midwife/Team Lead by– email

Inform GP – leave message at surgery if unavailable

Email maternity bookings to cancel future obstetric

Appointments [email protected]. Please copy

in [email protected]

On admission for delivery:

Consider cannulation: you are likely to require a cannula at some point, whether for ERPC, PCA or other IVs, so it may be kinder to cannulate immediately and take all bloods at this point.

Order PCA pump: to have on Delivery Suite. This will ensure prompt administration of analgesia if required later.

Risk Assessment: perform VTE and Waterlow scores

mailto:[email protected]

mailto:[email protected]


Drugs to be given on admission to Delivery Suite:

Y N Date Initial

Misoprostol and Metronidazole prescribed for administration

Give misoprostol dose according to dosage schedule in Intrauterine Death- Care of patient guideline (GL862) *Take HVS prior to PV dose*

PR metronidazole on admission

Syntometrine/ Oxytocin for 3rd stage regardless of gestation

Tests for all losses (IUD/TOP Careset): Y N Date Initial

HVS prior to first dose of misoprostol

MSU

Full Blood Count (Purple x 1)

Group & Save & Kleihauer regardless of blood group (Pink x 1)

(Same bottle but you MUST tick Kleihauer on blood form - specify that this is an IUD)

Not indicated for <20/40

U&Es, LFTs, Uric Acid & Renal Function (Yellow x 1)

Clotting Screen (Blue x 1)

Lupus Anticoagulant (Blue x 4)

Test cannot be completed without all 4 bottles

HbA1c (Purple x 1)

TORCH & Parvovirus (Yellow x 1 Lab requires full bottle)

N.B. Ensure these tests added if not in care set

Anticardiolipin Antibody / Antinuclear Antibody (Yellow x 1)

Commence MOWS chart following administration of Misoprostol hourly observations of temperature, pulse, respiration, blood pressure.

Commence PCA chart/VIP chart as appropriate. Use partogram where appropriate to monitor contractions, PV loss and dilation (as indicated, e.g. after end of regime or maternal request, not routine 4 hourly).

N.B. Remember that if the baby is born with signs of life (please see flow chart page 3) a doctor should be asked to discretely see the baby in its live state if at all possible as a Death Certificate must be completed by them. It is imperative that the certifying doctor also completes an online referral to the Coroner for any baby NOT SEEN ALIVE by the certifying doctor. https://www.reading.gov.uk/coroners

Always THINK whether it is appropriate before crash calling a neonatologist. At gestations below 22+3resuscitation is likely to be futile and may cause more distress to the family.


At delivery:

Describe condition of baby:

Gestation: ________________

Baby’s weight: _________________

Gender:_______________ (for babies less than 22 weeks see page 6)

Are there obvious abnormalities? Consider use of Medical Photography if clinically relevant

Describe condition of liquor:

Describe condition of placenta:

Placental weight: _______________

Are there obvious abnormalities? Consider use of Medical Photography if clinically relevant.

Describe condition of cord (i.e. any tight knots, any entanglement etc.):

Are there obvious abnormalities? Consider use of Medical Photography if clinically relevant

For the placenta: Y N Date Initial

Swab fetal surface and membranes and send for C&S

Place placenta in a DRY, white, labelled bucket but keep placenta in Mortuary

fridge with baby.


Birth Summary:

Date Time

Onset of 1st Stage

Onset of 2ndStage

BIRTH

3rd Stage Complete

SROM / ARM

Onset of labour Spontaneous / Induced / Augmented

Analgesia used

Delivered by/ midwife responsible

Type of delivery Spontaneous vaginal / operative vaginal /

LSCS

Name of doctor performing delivery if applicable

ERPC performed Y N

Total EBL

Any other maternal details affecting postnatal recovery


After Delivery:

For babies below 22 weeks gestation, please check sex with a second Midwife before informing

parents (SANDS Pregnancy Loss and the Death of a Baby: Guidelines for professionals 4th ed.

2016). If you are not sure, do not guess.

Accepted Date

Any details

Declined Date

Initials

Name of baby

Gender

See and hold the baby

Time alone with the baby

Hand and foot prints

Bathe and dress the baby (if applicable)

A lock of hair

(if applicable)

Photographs

1 SD card to be given to family. Do not offer to store in notes. Consider suggesting use of “Remember my baby” photography

Memory box

Please explain contents to parents

Involving siblings or other family members

Religious leader/chaplain for blessing/support/naming


Care of baby: Y N Date Initial

IMPORTANT - Baby labelled twice with mum AND dad’s names, mother’s hospital/NHS number

Baby wrapped in inco sheet (not too tightly!) and placed in body bag

Baby placed in mortuary fridge and register fully filled in

Care of mother following delivery: Y N Date Initial

For Rhesus Negative mothers give Anti D 1500iu – if fDNA positive or unknown - do not wait for Kleihauer results. Make sure prescribed on drug chart and form filed in notes.

Cabergoline prescribed and given? Over 20 weeks this is strongly recommended, under 20 weeks at doctors discretion or maternal request but mother must be offered option of prescription so she can decide.

Ensure parents are aware of option to see baby after discharge this however, is by appointment only. Ensure they have a contact card for Bereavement Midwife/Lesley Bowles and know to contact Delivery Suite if out of hours.

Further decisions: Y N Date Initial

Do parents wish to have a post mortem examination?

Consent form AND clinical request form to be completed by Consultant, Registrar or trained Midwife (if Yes to PM)

Consent for placental examination if required

Consent for genetic testing

Completed consent forms to be kept in notes for Bereavement Midwife to arrange transport to Oxford (if Yes to PM)

Consider hospital or private burial or cremation, complete Form C

Documentation to be completed: Please follow the applicable option i.e. under or over 24 weeks etc and complete the necessary documentation


Under 24 weeks and no signs of life: Y N Date Initial

Complete Mortuary Form and Non Viable Certificate

(Forms A & B)

RBH / For Louis Certificate for parents (not legally applicable, copy available in For Louis boxes)

Over 24 weeks and no signs of life (see flowchart pg 3): Y N Date Initial

Stillbirth Certificate (blue book, found in bereavement filing cabinet) to be completed and given to parents.

Please use your name stamp to confirm your name for the Registrar of Births, Marriages and Deaths, this is very important!

Enter delivery details onto CMiS as for live births

Complete Mortuary Form (Form A)

Complete Incident Form (Number: )

YOU MUST CALL THE CORONER’S OFFICER 01189 372 300 IF THE BABY DIED AFTER ADMISSION FOR DELIVERY (EITHER IN LABOUR OR SHORTLY AFTER), OR IF A BBA AND NOT MACERATED.

For babies born with signs of life at any gestation Even non-viable <24/40 Y N Date Initial

Enter delivery details onto CMIS as for live births, ensuring that birth is recorded as a NEONATAL DEATH – an NHS number is needed in order for parents to register their birth. If this is not done, they cannot make the registration appointment.

Complete Mortuary Form (Form A)

Medical Certificate Cause of Death (yellow book) to be completed by Doctor who saw baby and issued to parents

Doctor to complete Cremation Form 4 (kept with Death Certificates) even if parents unsure of funeral arrangements as doctor may be unavailable at a later date, causing delays.

Complete DATIX Incident Form (Number: )


Discharge checklist for all losses: Y N Date Initial

Bereavement team to inform Health Visiting team by secure email and add EPR flag

Community Midwife informed of discharge – ensure discharge letter on Discharge clipboard located on Marsh ward.

Please advise GP: you MUST leave message on voicemail if out of hours

Ensure that postnatal notes (for bereaved parents >24/40 or NND) completed and that mother takes these home with her. Can be found in bereavement filing cabinet.

Ensure FP10 for antibiotics/analgesia is given.

Is Anti D required?

If so, has it been given and clearly stamped in the notes?

Has Cabergoline been given (if required/ requested)?

Ensure Bereavement Midwife contact details have been given and confirm for parents that the Bereavement team will arrange the follow up appointment

If under 24 weeks: Y N Date Initial

Discharge mother from hospital using admissions and discharges facility on CMiS. Attach letter to PN notes

Copy of discharge letter to Discharge Clipboard located on Marsh ward.

Handwrite any necessary information such as ERPC etc.

Please ensure pregnancy loss is highlighted

Copy of discharge letter sent by post to GP

Handwrite any necessary information such as ERPC etc



If over 24 weeks (or neonatal death at any gestation): Y N Date Initial

Discharge from hospital on computer and print off discharge letters as for normal discharge. Attach to PN notes

Copy of computer discharge letter to Discharge Folder


Copy of computer discharge letter by post to GP


Ensure that Stillbirth/Neonatal Death Certificates issued (if required) and that parents know how and where to register their baby

Notes on discharge: Y N Date Initial

Notes forwarded to Delivery Suite for attention of Bereavement Midwife / Ward Clerk and placed in bereavement filing cabinet for confidentiality and safekeeping


Postnatal follow up (Bereavement Midwife) Y N

Appointment offered?

Appointment accepted?

PM done and results available?

Positive results

Genetics

HVS

MSU

Full Blood Count

Group & Save & Kleihauer regardless of blood group (

U&Es, LFTs, Uric Acid & Renal Function (

Clotting Screen)

Lupus Anticoagulant

HbA1c & Glucose

TORCH & Parvovirus

Anti-cardiolipin Antibody / Antinuclear Antibody

Placenta

Date of delivery

Name of father

Name & Gender of baby

©RBFT Women experiencing spontaneous late miscarriage or IUD on DS (V3.0) February 2020 of 24

ENHANCED DISCHARGE SUMMARY

PLEASE DETATCH AND GIVE TO COMMUNITY MIDWIFE OFFICE

Mother had contact with bereavement midwife Yes / No / To be arranged

NB: If discharged prior to contact please inform mother that contact will be made on

midwife’s next working day (COU on Optimise)

Post Mortem Yes / No / Undecided / To be arranged

NB: Baby will travel with funeral directors (Tomalin and Son) to JRH (Oxford). This will

be arranged by bereavement midwives on next working day. Parents have opportunity

to see baby on return.

Funeral Yes / No / To be arranged

NB: Discussed and arranged by bereavement midwives. Usually ‘contract’ funeral (burial or cremation) with Tomalin and Son at Henley Road Crematorium (approx. fortnight after delivery), or private funeral.

Community Midwife to: Phone / Visit

Reason for TOP/IUD/NND (if known)

Any concerns

Baby’s name (if applicable)

Bereavement Midwives: 07500 123912 Ward Clerk: 0118 322 7215



INTENTIONALLY


FORM A

Maternity Unit, Maternity & Children’s Services Burial / Cremation Form (Mortuary Use)

Please complete this form for ALL babies and leave in the mother’s notes

Baby details (please circle): Male Female Names: (if any) ……………………………………………..………... Surname if different to Mothers: …………………………………………………..….. Date & Time of Birth: ………………………...……...…...……………...… Date & Time of Death: ……………………………………………………..... Death on (please circle): Delivery Suite Buscot

Consultant Obstetrician: ………………………………………………………. Consultant Paediatrician (if any): ………………………………………………………. Name of Doctor/Midwife in attendance: ………………………………………………………. If Stillbirth/NND Certificate issued, name of issuer (please print): ………………………………………………………. Cause of Death: ………………………………………………………………………...

…………………………………………………………………………………………………….

Religion: …………………………………………………………………………………. For: Post Mortem Yes No

Histology Yes No

Genetics Yes No

Undecided Yes No



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FORM B

Maternity Unit, Maternity & Children’s Services Non-Viable Burial/Cremation

Certificate of Medical Practitioner or Midwife, in respect of a

baby born dead before 24 weeks gestation

I HEREBY CERTIFY that I have examined THE BABY OF

Name …………………………………………………………

Address …………………………………………………………

…………………………………………………………

…………………………………………………………

…………………………………………………………

…………………………………………………………

Delivered on …………………………………………………………

and that this baby was less than 24 weeks gestation

Name …………………………………………………………

Signature …………………………………………………………

Address (work) …………………………………………………………

Phone Number …………………………………………………………

Date …………………………………………………………

Registered Qualifications ………………………………………...



INTENTIONALLY


FORM C

Maternity Unit, Maternity & Children’s Services Hospital Funeral Arrangements following Pregnancy Related Loss

Baby(ies) Name & Surname …………………………………………………………………………………....

Date of Birth …………………………………………………………………….……………...

Parents Full Name ……………………………………………………….…….... PLEASE PRINT

Address ………………………………………………………………………….…………...

………………………………………………………………………….…………...

Telephone ………………………………………………………………………….………...

Religion ………………………………………………………………………….…………...

Burial in Communal Grave: Yes No

Cremation: Yes No

Sensitive disposal: Yes No

Shared Cremation: Yes No

Hospital Chaplain to be present: Yes No

Service in Henley Road Chapel: Yes No

To collect ashes: Yes No

Parents wish to be informed: Yes No

Parents to attend: Yes No

I certify that I consent to the Royal Berkshire NHS Foundation Trust making the arrangements for the

*burial/cremation of my/our baby’s remains

Signature ……………………………………………… Date …………………………………

Please return the completed form as soon as possible, together with any Release Certificate that will

be received from the Registrar of Birth, Deaths and Marriages should you have needed to register

your baby’s birth and/or death to the address below:

Ward Clerk Official Use Delivery Suite Date of funeral……..…………………… Maternity Unit Parents informed……..…………………… Royal Berkshire Hospital Date informed……..…………………… Reading ……..…………………… Berkshire RG1 5AN ……..…………………… Requisition No for PM: …………………… Requisition No for funeral: ……………


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care pathway for women experiencing a spontaneous late ... · 2016). if you are not sure, do not...

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