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Routine postnatal care of women and their babies

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1 Routine postnatal care of women and their babies
July, 2006 NOTES FOR PRESENTERS You can add your own organisation’s logo alongside the NICE logo. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself

2 Changing clinical practice
NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations to work towards implementing guidelines Compliance will be monitored by the Healthcare Commission Changes should be linked with other NICE guidance and relevant national policies NOTES FOR PRESENTERS NICE clinical guidelines aim to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills. Standards for better health, issued in July 2004 by the Department of Heath, identifies core and developmental standards for NHS organisations. Core standard C5 states that healthcare organisations should take into account nationally agreed guidance when planning and delivering treatment and care. Implementation of clinical guidelines forms part of developmental standard D2 which states that patients should receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in NICE guidance. The guideline can be read in conjunction with: National Policy National Service Framework for Children, Young People and Maternity Services National Screening Committee recommendations Department of Health publications Birth to Five SIDS and Co-Sleeping advice

3 The postnatal period The guideline covers maternal and infant care in the period after transfer from intrapartum care until the end of the postnatal period. This is usually 6–8 weeks after the birth NOTES FOR PRESENTERS Care during the first 6-8 weeks after birth Timing and content of care has altered little since the beginning of the 20th Century Crosses acute and primary healthcare sectors, with the majority taking place in the woman’s home Care currently includes routine clinical examination and observation, routine infant screening, provision of information and support and concludes with a 6-8 week postnatal examination Maternal and infant health is a continuum and as reflected in the NSF, flexibility is needed in care provision. The end of the postnatal period may vary according to the individual needs of a woman and her baby and extend beyond the 8 week period noted.

4 Need for the guideline Common health problems in the postnatal period
Dissatisfaction of those receiving care Creating services which are woman and family centred NOTES FOR PRESENTERS Common health problems - recent studies have highlighted widespread and persistent health problems experience by women after childbirth many of which are unreported by mothers and unidentified by professionals. Common health problems include both physical morbidity (backache; breast problems; perineal pain and stress incontinence) and psychological morbidity (postnatal depression). Routinely collected data on infant feeding persistently describe low uptake and duration of breastfeeding (Renfrew et al 2005) despite the many health advantages of breastfeeding for the woman and her baby. Experience of those receiving care – care has traditionally focused on routine observation with limited guidance for health care professionals on postnatal practice. Studies which have examined women’s views of their care have found that women’s own perceived needs were not met by the attending health care professionals and that duplication of visits and conflicting advice were commonly reported. Dissatisfaction with postnatal care, especially with hospital postnatal services, was reported by the Audit Commission in Whilst randomised controlled trials of revisions to postnatal care services did not improve maternal health outcomes, maternal satisfaction scores were higher than controls in two of the studies and maternal mental health scores were significantly better than controls in one study. Women and family centred care – The Guideline Development Group identified essential principles of care which should characterise all services provided during the postnatal period. These have been developed in keeping with aims of this guideline and the guideline ethos which characterises that: Core postnatal care provision is undertaken in partnership with women Care is individualised through a process of education and discussion to meet the needs of each mother-infant dyad Women’s views, beliefs and particular circumstance are respected Interventions offered are evidence based and have known benefits

5 Aim of the guideline Appropriate objectives, purpose, content and timing Best practices and competencies for assessment Information, education and support Planning Good practice in communication NOTES FOR PRESENTERS To advise on appropriate objectives, purpose, content and timing of postnatal contact and care for the woman and her baby To advise on best practices and competencies for assessment of postnatal health and management of postnatal problems in the woman and/or her infant To advise on information, education and support required during the postnatal period To advise on planning of postnatal care To consider good practice in communication between health care providers and women, their partners and other family members

6 Essential principles of care
Kindness, respect and dignity Views, beliefs and values Women’s full involvement All actions and interventions fully explained Supporting informed decisions NOTES FOR PRESENTERS The essential principles of care Women and their families should be treated with kindness, respect and dignity at all times. The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times The woman should be fully involved in planning the timing and content of each postnatal care contact. All actions and interventions carried out on the mother or baby at any time in the postnatal period need to have been fully explained and informed consent obtained This includes giving consideration to privacy and creating a clean, warm and welcoming environment in a maternity care unit. By involving the woman in planning postnatal care contacts, it will be flexible and tailored to meet her social, clinical and emotional needs and those of her baby and family Where the person from whom consent is being sought does not have the capacity to make decisions, health care professionals should follow the Department of Health guidelines – reference guide to consent for examination or treatment (2001)

7 This guideline covers Planning the content and delivery of care for woman and baby Maintaining maternal health Infant feeding Maintaining infant health NOTES FOR PRESENTERS These areas represent the recommendations considered by the Guideline Development group to be priorities for implementation. These areas are considered in the next few slides with some suggested actions for each. A review of services may highlight areas which require action to ensure effective and efficient service delivery in light of the recommendations of this guideline. It is important that these areas for improvement are built into the local action plan and steps taken to improve service delivery within an appropriate time frame and that outcomes are defined and regularly audited. Further, more detailed recommendations accompany each of the above areas and can be read within the NICE guideline.

8 Planning content and delivery of care
Documented, individualised care plan Written communication Relevant and timely information NOTES FOR PRESENTERS Recommendation 1.1.3 A documented, individualised postnatal care plan should be developed with the woman, ideally in the antenatal period or as soon as possible after birth to include: - relevant factors from the antenatal, intrapartum and immediate postnatal period - details of the healthcare professionals involved in her care and that of her baby including roles and contact details - Plans for the postnatal period Recommendation 1.1.8 - There should be local protocols about written communication, in particular about the transfer of care between clinical sectors and healthcare professionals. These protocols should be audited Recommendation 1.1.5 - Women should be offered relevant and timely information to enable them to promote their own and their babies health and well-being and to recognise and respond to problems Recommendation At each postnatal contact , women should be asked about their emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day to day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern

9 Suggested actions Local care planning documentation and use
Local protocols about written communication Quality of local information provision for effectiveness and relevance to local community Identifying the named postnatal coordinator within the care plan NOTES FOR PRESENTERS Suggested actions are not recommendations from NICE. They are advisory for your consideration Review local care planning documentation and use Review local protocols about written communication. As part of this you may wish to consider the effectiveness of verbal communication in transferring information. Review quality of local information provision for effectiveness and relevance to local community Ensure that there is a mechanism for identifying the named postnatal co-ordinator within the care plan

10 Maintaining maternal health
Signs and symptoms of potentially life-threatening conditions: postpartum haemorrhage infection pre-eclampsia/eclampsia Thromboembolism Emotional wellbeing NOTES FOR PRESENTERS Recommendation 1.2.1 At the first postnatal contact women should be advised of the signs and symptoms of potentially life threatening conditions and to contact a healthcare professional immediately if any of the following occur: Signs and symptoms of postpartum haemorrhage - sudden and profuse blood loss or persistent increased blood loss; faintness, dizziness or palpitations/tachycardia Signs and symptoms of infection – fever, shivering, abdominal pain and/or offensive vaginal loss Headaches within 72 hours of birth accompanied by one or more of the following symptoms: visual disturbances; nausea or vomiting, Signs and symptoms of thromboembolism – unilateral calf pain, redness or swelling, shortness of breath or chest pain Recommendation At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.

11 Suggested actions Local protocols within primary and secondary care
Continuous professional development programmes Maternity and Care of the Newborn Competence Frameworks Clinical Negligence Scheme for Trusts (CNST) standards NOTES FOR PRESENTERS Suggested actions are not recommendations from NICE. They are advisory for your consideration Review local protocols within primary and secondary care related to management of specific symptoms and the assessment of emotional wellbeing Review ongoing continuous professional development programmes to ensure adequate training of relevant professionals Ensure that all staff are working within the Maternity and Care of the Newborn Competency Frameworks where appropriate Review performance regularly against relevant CNST standards (care within the first 24 hours following delivery) The competencies required for Maternity and Care of the Newborn can be viewed at Other competencies include: maternal and newborn physical examinations supporting breastfeeding women recognising the signs and symptoms of maternal mental health problems  recognising risks, signs and symptoms of domestic and child abuse and knowing who to contact for advice. [1.1.10, ]

12 Infant feeding Programme to encourage breastfeeding, using an externally evaluated structured programme using the Baby Friendly Initiative as a minimum standard Support of breastfeeding initiation and continuation NOTES FOR PRESENTERS All healthcare providers (hospitals and community) should implement an externally evaluated structured programme that encourages breastfeeding using the Baby Friendly Initiative (BFI) as a minimum standard. This doesn’t preclude trusts using other externally evaluated structured programmes but the minimum standard is provided by BFI. The Evidence into Practice briefing commissioned from the Public Health Collaborating Centre in Maternal and Child Nutrition by the Health Development Agency (HDA) before the HDA merged with NICE in 2005 has also been published by NICE. Its recommendations relate to public health interventions which can help increase and maintain breastfeeding rates, promoting health in the long term for both baby and mother. The briefing complements chapter 5 of the clinical guideline. The existing structure of the BFI provides detailed advice about how to implement an externally evaluated structured programme. More information can be found at: The guideline acknowledges the needs of women who choose to give their babies formula feed in recommendations: All women and carers who are giving their babies formula feed should be offered appropriate and tailored advice on formula feeding to ensure this is undertaken as safely as possible, and optimises infant development, health and nutritional needs. A woman who wishes to feed her baby formula milk should be taught how to make feeds using correct, measured quantities of formula, as based on the manufacturer’s instructions and how to clean/sterilise feeding bottles and teats and store formula milk.

13 Suggested actions Look at the UNICEF UK Baby Friendly Initiative which provides one possible framework for implementing an externally evaluated, structured programme which supports breastfeeding. This can be used by NHS trusts, other healthcare facilities and higher education institutions NOTES FOR PRESENTERS Suggested actions are not recommendations from NICE. They are advisory for your consideration These are some of the key steps to implement Ensure that recognition of the value of and commitment to external accreditation is secured at board/trust level Develop a local strategy and establish a funding agreement for implementation across primary and secondary care with auditable milestones Develop a detailed action plan based on local resources and accreditation requirements Develop local roles, policies and materials to support the programme Educate staff and build partnerships across the local health economy which can support implementation. Implement and get accredited!

14 Maintaining infant health
Information and guidance offered to enable parents to: assess their baby’s general condition identify signs and symptoms of common health problems seen in babies contact a healthcare professional or emergency service if required NOTES FOR PRESENTERS This information should be offered at each postnatal contact This is recommendation 1.4.2 Other recommendations related to maintaining infant health provide the framework for the healthcare professional, with the parents, to facilitate the health and wellbeing of a baby up to 8 weeks old. This section in the guidance lays out the care to be given to a healthy baby and support to be offered to the parents. It is designed to be read in conjunction with Birth to Five

15 Suggested actions Distribution of ‘Birth to five’
Quality of local information Named postnatal coordinator within the care plan Maternity and Care of the Newborn Competence Frameworks NOTES FOR PRESENTERS Suggested actions are not recommendations from NICE. They are advisory for your consideration There may need to be a review of numbers of deliveries locally to ensure that adequate stocks of Birth to Five are provided. Distribution mechanisms may require changes to ensure that women and their families have timely access to the information contained within Birth to Five. There may be the option of locally purchasing sufficient quantities for all mothers in your locality The NICE information for the public document may also provide useful information to women and their families. It is likely that the professional fulfilling the role of the named postnatal care co-ordinator will change over time within the postnatal period. Postnatal care documentation should make this explicit and an appropriate section of the postnatal care plan should be able to reflect the name. role and contact numbers of the current co-ordinator The competencies required for Maternity and Care of the Newborn can be viewed at Other competencies include: maternal and newborn physical examinations supporting breastfeeding women recognising risks, signs and symptoms of domestic and child abuse and knowing who to contact for advice. [1.2.24]

16 Costs and savings Use NICE costing tools to identify recommendations with the greatest impact on resources savings savings are linked to the reduction in the incidence of certain childhood disease because of the protective effects of breastfeeding costs structured programme that encourages breastfeeding including training NOTES FOR PRESENTERS Because of the breadth and complexity of the guideline, the NICE costing report focuses on the recommendations that are considered to have the greatest impact on resources and will therefore require the most additional resources to implement or those that will generate savings. They relate to the protective effects of breastfeeding and the costs of implementing the Baby Friendly Initiative (recommended as a minimum standard) The costing tools can be accessed via the NICE website (www.nice.org.uk/CG037).

17 NICE into practice guides
NOTES FOR PRESENTERS These tools can be found on the NICE website here:

18 Access tools online Costing tools costing report costing template
Audit criteria Available from: NOTES FOR PRESENTERS This guideline is supported by a number of implementation tools, all of which are accessible via the NICE website

19 Access the guideline online
quick reference guide – a summary NICE guideline – all of the recommendations full guideline – all of the evidence and rationale ‘Information for the public’ – a version for people using the NHS in England and Whales All found at: NOTES FOR PRESENTERS The guideline is available in a number of formats. You can download them from the NICE website. or order hard copies of the quick reference guide or ‘Understanding NICE guidance’ by calling the NHS Response Line on Please refer to the accompanying implementation for the policy context and useful links.

20 Care pathway Key components – maintaining maternal health, infant feeding, and maintaining infant health Time bands – first 24 hours, first week and first 2–8 weeks after birth Action levels – emergency, urgent and non-urgent Includes – core information, core care and areas for concern NOTES FOR PRESENTERS The remaining three slides are optional for use in your presentation. They provide a brief description of the structure of the postnatal care pathway and the links between the key elements. They provide two examples of recommendations from the guideline and demonstrate how care should be planned and delivered within certain time frames and with varying degrees of urgency The care pathway is designed to ensure that care is relevant, timely and based upon evidence of effectiveness of action The links between each of the components, time bands, action levels and care, action and information support professionals in practice in the Quick Reference Guide and support women and families in the ‘Understanding NICE guidance’ also produced by NICE The next two slides demonstrate the links between specific recommendations and action to be taken

21 Example: signs of thromboembolism
Area for concern: unilateral calf pain and redness or swelling Time band 24 hours Maintaining maternal health Emergency action NOTES FOR PRESENTERS Recommendation 1.2.1 At the first postnatal contact, women should be advised of the signs and symptoms of potentially life-threatening conditions and to contact their healthcare professional immediately or call for emergency help if any signs and symptoms occur. Signs and symptoms: unilateral calf pain, redness or swelling, shortness of breath or chest pain Condition: thromboembolism So for example, if a woman complains of unilateral calf pain, redness, swelling, shortness of breath or chest pain ( area for concern), in the first 24 hours (time band) following delivery, the care pathway for maintaining maternal health (key component) advises that she should report this to a health care professional or emergency services (emergency action)

22 Example: routine immunisations
Core care Time band 2–6 weeks Offer routine baby immunisations NOTES FOR PRESENTERS A scenario to demonstrate the interaction of the elements of the care pathway: Recommendation: Parents should be offered routine immunisations for their baby according to the schedule recommended by the Department of Health Therefore, within the 2-6 week timeband, part of the healthcare professionals core care to the family would be to offer routine immunisations


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