Guidance on key objectives for NHS Boards, August 2008
Throughout these objectives, it is anticipated that women will continue to have choice in relation to their care and that all professionals will continue to communicate with women in a way which supports them making informed decisions.1
1. Implementation of the midwife as the first point of professional contact in pregnancy
Once the woman has confirmed her pregnancy, it is expected that she will self refer or be directed to a midwife, who where possible should be the first point of professional contact.1,2,3,4 The midwife should undertake an initial risk assessment, making reference to nationally agreed referral criteria and stream the women to the appropriate care package for her individual need.1,2,3 This will facilitate early risk assessment and booking with maternity services prior to 12 weeks gestation.4
2. Implementation of the lead maternity professional based on risk
Normally the midwife would be lead professional, with caseload responsibility for healthy women experiencing uncomplicated pregnancies, throughout the antenatal, intrapartum and postnatal periods.1,2,3 Where the midwife is caseload holder, the midwife would be named as such on the Scottish Woman Held Maternity Record (SWHMR) and would have professional accountability for the case, as outlined in the relevant Nursing and Midwifery Council regulations (NMC).5,6 This would be explicit in Board SMR returns to the Information Services Division (ISD).
The midwife as lead professional
Continuity of carer and care has been a key policy principle since the early 1990s.1,3,7,8,9 Further, randomised controlled trial outcomes from then highlighted that women value continuity of carer in the antenatal and postnatal periods.10,11,12 It is, therefore, recommended that a named midwife is allocated as the lead professional for the woman's antenatal care. Where possible, this midwife should plan and provide the majority of the woman's antenatal care, with support from the wider midwifery team as required. Where the antenatal named midwife is a community midwife, ideally she should continue the woman's postnatal care at home, with support from the wider midwifery team as required. The antenatal named midwife should be recorded as the lead professional on SWHMR and on SMR returns to ISD. Where a team leader/manager is in place, the named midwife providing the majority of clinical care should continue to be identified as lead professional.5,6 Due to the unplanned nature of labour, it is not expected that the named antenatal midwife provides intrapartum care for the woman. During intrapartum care, it is recommended that a named midwife is allocated as the lead professional for the woman's labour on a shift to shift basis. The named midwife should be recorded as the lead professional for intrapartum care in SWHMR and on SMR returns to ISD.
Women with more complex needs would normally have obstetric led care, delivered by the wider maternity team, including midwives, throughout these periods.1,2,3,4 Within this team, neonatologists would have initial responsibility for medical care of the ill baby. Where the obstetrician is caseload holder, the obstetrician would be named as such on SWHMR and would have professional accountability for the case. This would be explicit in Board SMR returns to ISD.
It is expected that women will transfer between midwife led and maternity team care as risk alters.1,2,3,4 However, it is anticipated that women will continue to have choice in relation to the lead professional for their care.
General practitioners have ongoing responsibility for the woman's medical care throughout pregnancy and post birth, including responsibility for the baby's ongoing medical care as required. Care of healthy mothers and babies normally transfers to the health visitor anytime from day 10 postnatal and they have responsibility for the ongoing care of healthy children until school age.
3. Implementation of normal birth pathways regardless of birth setting
It is anticipated that all women who meet the national criteria for the midwife led normal birth pathways would have the opportunity to join these pathways. This would be implemented in all maternity unit and labour suite settings across NHS Scotland. It is expected that healthy women, presenting in labour with uncomplicated pregnancies, will not routinely have an admission cardiotocograph (CTG - electronic monitoring of the fetal heart).13,14
References
1. Scottish Executive (2001) A framework for maternity services in Scotland. Edinburgh: The Scottish Office.
2. Scottish Executive (2003). Implementing a Framework for Maternity Services in Scotland. Overview Report of the Expert Group on Acute Maternity Services. Edinburgh: The Scottish Office.
3. Department of Health (2007). Maternity Matters. Choice, access and continuity of care in a safe service. London: Department of Health.
4. CEMACH (2007). Saving Mother's Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. London: CEMACH.
5. NMC (2004). Midwives Rules and Standards. London: NMC.
6. NMC (2008). The NMC code of conduct: standards for conduct, performance and ethics. London: NMC.
7. Department of Health and Social Services. (1993) Changing Childbirth. Part 1: Report of the Expert Maternity Group. London: HMSO.
8. House of Commons Health Committee. (1992) Second Report, Session 1991-92 - Maternity Services. London: HMSO.
9. The Scottish Office Home and Health Department. (1993) Provision of Maternity Services in Scotland. A Policy Review. Edinburgh: HMSO.
10. Turnbull D, Shields N, McGinley M, Holmes A, Cheyne H, Reid M, Young D, Gilmour H. Can midwife-managed units improve continuity of care? British Journal of Midwifery 1999; 7: 499-503.
11. Shields N, Holmes A, Cheyne H, McGinley M, Young D, Gilmour H, Turnbull D, Reid M. Knowing your midwife during labour. British Journal of Midwifery 1999; 7: 504-510.
12. Shields N, Turnbull D, Reid M, Holmes A, McGinley M, Smith L. Satisfaction with midwife managed care in different time periods: a randomised controlled trial of 1299 women. Midwifery 1998; 14: 85-93.
13. NICE (2007). Intrapartum care: management and delivery of care to women in labour. London: NICE.
14. RCOG (2001). National Evidence Based Guideline: The use of EFM. London: RCOG.