Publication - Advice and guidance

Coronavirus (COVID-19): delivering maternity and neonatal services - update - December 2020

Guidance for NHS Boards for the management of maternity and neonatal services in Scotland in response to levels of COVID-19 infection locally, to aid Boards with local service planning.

25 page PDF

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25 page PDF

616.8 kB

Contents
Coronavirus (COVID-19): delivering maternity and neonatal services - update - December 2020
December 2020 Update: Delivering Maternity and Neonatal Services During the Covid-19 Pandemic

25 page PDF

616.8 kB

December 2020 Update: Delivering Maternity and Neonatal Services During the Covid-19 Pandemic

During the unprecedented situation created by Covid-19, NHS services have had to adapt, altering service provision and introducing measures to reduce spread of the virus to women, families and staff.

From the outset of the pandemic maternity and neonatal care has been recognised as an essential acute, integrated and community service, providing both scheduled and unscheduled care. Midwives, obstetricians and the wider maternity and neonatal workforce are required to continue to care for pregnant women, babies and families and therefore should not be redeployed outwith this setting.

The Royal College for Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have produced UK wide guidance to support organisations, staff and women and their families throughout the pandemic. This guidance underpinned that issued by The Scottish Government, including: Maternity Covid-19 Planned Care/Service Standards; Guidance for Workforce Planning for Midwifery during Covid-19 (which included a calculator to support local workforce planning and outlined service provision in line with midwifery workforce considerations); and the Maternity Critical Care Guidance.

As an essential service, Neonatal Care continued with modifications described within guidance as set out in Royal College of Paediatrics and Child Health (RCPCH), RCOG and the British Association of Perinatal Medicine (BAPM) Guidance.

Purpose

This document provides guidance for NHS Boards for the management of maternity and neonatal services in Scotland in response to levels of Covid-19 infection locally, to aid Boards with local service planning. It aims to collate guidance relevant to the essential provision of maternity and neonatal care and, additionally, interpret how that should be applied to meet the needs of women and families.

It should be read within the context of Covid-19-Scotland’s Strategic Framework which sets out how the Scottish Government’s strategic approach to suppress the virus to the lowest possible level. The Framework includes a system of 5 protection levels (ranging from 0-4). Ministers, with expert advice, will apply these levels, which can be applied locally or nationally, guided by evidence on the state of the epidemic, and only for as long as necessary. Protection Levels will be regularly reviewed, to check a local protection level a postcode checker can be found at https://www.gov.scot/check-local-covid-level/.

This document should be considered within this particular context of planning work underway within Boards, including those for winter preparedness. Local remobilisation plans should continue to be informed by the clinical prioritisation of services and national guidance/policy frameworks, including those relating to Test and Protect and Infection Prevention and Control (IPC), which are so critical to safeguarding both staff and patients alike.

This document will be updated to contextualise relevant Scottish Government and clinical guidance produced by key stakeholders including RCOG, RCM, RCPCH and BAPM. This should be read alongside Visiting Guidance in Maternity and Neonatal Settings during COVID 19 (updated version published 2 Dec).

This document has been written in partnership with healthcare professionals who care for pregnant women and babies and covers the key areas of: antenatal, intrapartum, postnatal and neonatal care, bereavement, staffing, training and national reporting, setting out minimum standards of care within each level. The Scottish Government continues to engage with service user representatives to ensure that the voice of women in the development of guidance for maternity and neonatal services, is heard.

The Scottish Government is working with Public Health Scotland, the University of Aberdeen and the Maternal and Infant Health Research Unit at the University of Dundee to undertake research which aims to look at women’s experiences of maternity services during the current pandemic, how maternity care has changed during this period and the acceptability and accessibility of changes. This will provide an understanding of what interventions should be promoted and developed after the pandemic, which should be adapted or which should be discontinued.

It should be noted that this document supersedes the Maternity Covid-19 Planned Care/Service Standards (v2 circulated 19 May).

Testing

In accordance with the letter from the Chief Nursing Officer and National Clinical Director on 27 November, asymptomatic testing of emergency admissions is being introduced from early December, including admissions to maternity units. At the time of publication, all patients who are asymptomatic at the point of admission should be tested using PCR tests. This will support the continued implementation of Infection Prevention and Control (IPC) Guidance. National clinical pathways have been developed for maternity and neonatal settings, and have been issued to Boards through Chief Executives.

Remobilisation

Scotland has moved forward with the Remobilisation of services in line with the principles from Re-mobilise, Recover, Re-design: the framework for NHS Scotland. These principles should be applied to maternity and neonatal services so that services at each stage are:

SAFE: Creating the safest environment and conditions for maternity services to best meet the needs of the population while putting the safety and wellbeing of the maternity and neonatal workforce on a par with the rest of the population.

Integrated: In recognising the crucial interdependencies between the different parts of the health and social care system and with other parts of society, planning approaches should identify the important connections between services and systems and take account of partners including local government, staff and service users. This will highlight the interdependencies and put in place processes to ensure resources are allocated where they are most needed to ensure the whole system operates effectively and efficiently.

Quality: As services are remobilised the highest standards of care will be maintained that prioritises shared decision making with women and families. Safe sustainable high quality maternity care rooted in individual and staff wellbeing.

Close to home: Services close to people’s homes. While the pandemic has valued technology this is within the context of personal connection that listens to what matters to women and their families. Going forward there is a need to minimise unnecessary travel by providing care within the community and closer to home. We will evaluate and develop the role of virtual consultations within a person centred approach, ensuring that all care is proportionate to need.

Prevention: We will increase our work on prevention focusing on the public health role of maternity and neonatal services in improving the future health of population.

Equality: This pandemic has exposed and exacerbated deep rooted health and social inequalities. Maternity and neonatal services will act to mitigate against these by ensuring that services are provided in way that is proportionate to need. Services will focus on how to support those who are most vulnerable (clinically and socially).

Sustainability: Maternity and Neonatal Services need to ensure financial sustainability, while reducing inequalities and improve health and wellbeing.

The Best Start

The majority of maternity services continued to implement Best Start throughout the first wave of the pandemic, and in some cases continuing to roll out parts of the programme. Teams have introduced innovations at pace in response to the pandemic, such as the use of technology, home monitoring and new ways of delivering care which support Best Start aims of bringing care closer to home, keeping mother and baby together and individualising care for pregnant women, new mothers and babies. With Boards again focused on the rising incidence of COVID in many areas, which must be the priority, maternity and neonatal teams are encouraged to maintain the progress they have made and to take forward innovation where they are able to do so. The Best Start team are ready to work with and support Boards where as required. Recognising that capacity will vary across the country, Scottish Government will not be requesting implementation plans or monitoring progress at this stage.

Restoring Clinical Pathways and Improving the Quality of Care: Antenatal Care

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Where services can support it, they should deliver the full pathway of antenatal maternity care, with appropriate IPC measures in place to protect women and staff:
  • Maintain increased vigilance when caring for women with Covid risk factors for deterioration and hospital admission:
    • Black, Asian and other minority ethnic groups.
    • Maternal age 35 years and over.
    • Being overweight or obese.
    • Respiratory and cardiac comorbidities.
    • Pre-existing med conditions such as Type 1 or 2 Diabetes or Hypertension *.
    • Living in areas or households of increased socioeconomic deprivation.
  • Maintain increased vigilance for vulnerable women who are more susceptible to poor outcomes.
    • All women should be asked about their mental wellbeing at every appointment and referred for additional support as required.
    • All women should be asked about money concerns and referred for additional support as required.
  • Continue providing information for pregnant women on NHS Inform and badgernet, with local information also available via badgernet and local internet/social media platforms.
  • Continue to develop use of Near Me and remote blood pressure monitoring to supplement and enhance the routine schedule of care and to increase access/deliver person centred care - subject to individual risk assessment.
  • Continue Baby Box registration between 18 – 20 or 28 week appointment.
  • For antenatal home visits, where anyone in the family does not live in the same household (unless part of the extended household), the expectation is that they should observe indoor physical distancing and not be Covid positive, self-isolating or showing any symptoms of coronavirus as per national guidance.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 – 1, plus:

  • As an essential service, maternity care continues with potential modifications described within:
    • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued 8 May, attached at Annex A).
  • Where there is significant staff absence and services can no longer sustain in person antenatal care in line with QIS Pathways for Care, antenatal appointments can be reduced as per the RCM/RCOG schedule, to a minimum of 8 appointments (6 face to face). This should be returned to the routine schedule of visits as soon as possible.
  • Appointments that do not require hands on maternal and/or fetal assessment can be held using Near Me, these are outlined in RCOG/RCM as 16 and 25 week appointments.
  • For planned home visits, the expectation is that no one outside the household or extended household should be in the home.
  • Travel across local authority borders in different levels can continue for essential antenatal, intrapartum and postnatal care provision if they are not available in your local area. Maximise use of Near Me and remote monitoring to reduce unnecessary travel.
  • Travel restrictions provide exemptions for travel across levels to accompany a pregnant woman or child for scheduled or unscheduled care, or to visit a person in hospital.
Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As levels 2 – 3.

Parent Education, Birth Preparation and Peer Support

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Continue to promote access to ‘understanding your pregnancy, labour, birth and your baby’, online antenatal education package.
  • Antenatal and postnatal group sessions continue, virtually or in person subject to risk assessment and appropriate physical distancing.
    • Midwifery Teams can engage their local TEC support for advice on the recommended platforms to use where virtual sessions are used.
  • Breastfeeding support to continue in person or virtually, subject to risk assessment and appropriate physical distancing.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 – 1, plus;

  • Travel across local authority borders in different levels can continue for essential antenatal and postnatal education provision and parenting support. Maximise use of Near Me and remote monitoring to reduce unnecessary travel.
Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As Levels 2- 3, plus:

  • Pause in person breastfeeding support. Pause in person antenatal and postnatal group sessions, but continue virtual and online antenatal and postnatal education and breastfeeding support.

Restoring Clinical Pathways and Improving the Quality of Care: Intrapartum Care

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Where services can support it, they should deliver the full pathway of intrapartum maternity care, with appropriate

IPC measures in place to protect women and staff:

  • Provide full range of birth options including care in AMU/FMU, obstetric unit and homebirth.
  • Provide care for critically ill women in line with Maternity Critical Care Guidance.
  • Optimise physiological birth.
  • Continue delayed cord clamping.
  • If no other risk factors and induction of labour indicated, offer outpatient home induction.
  • For homebirths, where anyone in the family does not live in the same household (unless part of the extended household), the expectation is that they should observe indoor physical distancing and not be Covid positive, self- isolating or showing any symptoms of coronavirus as per national guidance.
  • Hospital birth is recommended for a Covid positive or symptomatic mother.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 - 1, plus:

  • As an essential service, maternity care continued with potential modifications described within:
    • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued 8 May, attached at Annex A).
  • Consider scaled approach to full service provision and maintaining birthplace options based on workforce and transport pressures, as per

RCOG/RCM Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic.

  • For planned home births no one outside the household or extended household should be in the home, the expectation is that birth partners should observe indoor

physical distancing and not be Covid positive, self- isolating or showing any symptoms of coronavirus as per national guidance.

Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As Levels 2 – 3.

Restoring Clinical Pathways and Improving the Quality of Care: Postnatal Care

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Where services can support it they should deliver the full pathway of postnatal care, with appropriate IPC measures in place to protect women and staff:
  • RCOG/RCM Guidance on Infection in Pregnancy
  • Maintain increased vigilance when caring for women with
  • Covid risk factors for deterioration and hospital admission
    • Black, Asian and other minority ethnic groups
    • Maternal age 35 years and over
    • Being Overweight or Obese
    • Respiratory and cardiac comorbidities
    • Pre-existing med conditions such as Type 1 or 2 Diabetes or Hypertension *
    • Living in areas or households of increased socioeconomic deprivation.
  • Maintain increased vigilance for vulnerable women who are more susceptible to poor outcomes.
    • All women should be asked about their mental wellbeing at every visit and referred for additional support as required.
    • All women should be asked about money concerns and referred for additional support as required.
  • Continue providing information for pregnant women on NHS Inform and badgernet, with local information also available via badgernet and local internet/social media platforms.
  • Continued to develop use of Near Me and remote monitoring to supplement and enhance the routine schedule of care and to increase access/deliver person centred care - subject to individual risk assessment.
  • For postnatal home visits, where anyone in the family home does not live in the same household (unless part of the extended household), the expectation is that they should observe indoor physical distancing and not be Covid positive, self-isolating or showing any symptoms of coronavirus as per national guidance.
  • National Bereavement Care Pathway (NCBP) early adopter Boards to continue with the pilot across all five pathways in all sites.
  • All aspects of normal bereavement care to be provided for both parents and access to bereavement space to continue.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 - 1, plus:

  • As an essential service, Maternity care continued with potential modifications described within:
    • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued 8 May, attached at Annex A).
  • Where there is significant staff absence and services can no longer sustain in person postnatal care in line with QIS Pathways for Care, prioritise home visits when hands on assessment required and for BAME or vulnerable women more at risk of poor outcomes.
  • Travel restrictions provide exemptions for travel across levels to accompany a woman or child for scheduled or unscheduled care, or to visit a person in hospital.
  • National Bereavement Care Pathways (NBCP) early adopter boards to continue with the pilot as far as capacity allows.
  • All aspects of normal bereavement care to be provided for both parents and access to bereavement space to continue.
Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As levels 2 – 3.

Neonatal Care

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Keeping Families Together:
    • Both parents able to attend neonatal wards to provide essential care for their baby as per guidance issued by BAPM and Bliss, provided they are not covid positive, self-isolating or showing any symptoms of the virus, as per national guidance.
    • Parents should be offered opportunities to remove face masks when it is safe to do so, to encourage bonding.
    • Skin to skin and kangaroo care to continue.
    • Resume Bliss Baby Charter process where possible.
  • Continue providing information for new parents on NHS Inform and badgernet, with local information also available via badgernet and local internet/social media platforms.
  • Continue use of Near Me and Vcreate to supplement and enhance the routine schedule of care and to increase access/deliver person centred care - subject to individual risk assessment.
  • National Bereavement Care Pathway (NCBP) early adopter Boards to continue with the pilot across all five pathways in all sites.
  • All aspects of normal bereavement care to be provided for both parents and access to bereavement space to continue.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 - 1, plus:

  • As an essential service, neonatal care continued with modifications described within guidance issued by the Perinatal Network on 20 March, and as set out in RCPCH, RCOG and BAPM Guidance.
  • Parents are permitted to Travel across local authority borders in different levels to be with their baby in hospital or attend appointments.
  • Parents who do not have access to a private car, can claim reimbursement for one return taxi journey between their home and hospital, each day, in levels two to four, through the Neonatal Expenses Fund.
  • National Bereavement Care Pathways (NBCP) early adopter boards to continue with the pilot as far as capacity allows.
  • All aspects of normal bereavement care to be provided for both parents and access to bereavement space to continue.
Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As Levels 2 -3.

Training

Living with Covid-19 (Levels 0-1 low incidence of the virus with isolated clusters, and low community transmission)
  • Postgraduate training: In person/or blended training to be resumed where paused, including Core Mandatory Training and CPD.
Protective Measures depending on local virus prevalence
(Levels 2-3 increased incidence of the virus, with multiple clusters and increased community transmission)

As Levels 0 -1, plus:

  • Postgraduate training: In person/or blended training to be continued where staffing levels allow, in particular core mandatory and essential training for safety should be continued where possible.
Restricted Measures
(Level 4 very high or rapidly increasing incidence, and widespread community transmission which may pose a threat to the NHS to cope)

As Levels 2-3.

Policy Implementation and input to Audits

  • Collect and submit required data for all women admitted to hospital who have tested positive for covid-19 though the UKOSS study.
  • Collect and submit required data for all babies admitted to hospital who have tested positive for covid-19 through the BPSU study.
  • Best Start: local implementation of the redesign of maternity and neonatal services as set out in The Best Start can continue commensurate with capacity, staffing levels and virus management. No requirement to submit data or plans, however the Best Start team are ready to work with any Boards that have capacity to take forward Best Start improvement work.
  • Best Start: Resume Baby Bliss Charter Accreditation Process where there is capacity to do so.
  • Continue local improvement and reporting for MCQIC,
  • All national clinical audit and confidential enquiries data submission to resume (where paused).

At all levels, this guidance is underpinned by key detailed guidance, as follows:


Contact

Email: Amy.Brown@gov.scot