CROSS HEALTH CARE BOUNDARIES MATERNITY CLINICAL GUIDELINE

Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Guideline for staff delivering care to women who have concealed their pregnancy or who are presenting for antenatal care or to give birth that are booked to receive care elsewhere. March 2013 Two Version Version One Supersedes Contact Name and Job Title (author) Bev Nield Named Midwife for safeguarding Alison Atkinson Community matron Date of submission Date on which guideline must be reviewed (this should be one to three years) Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) February 2013 February 2016 All women who present at NUH for maternity care who have concealed their pregnancy or who are booked elsewhere

Implementation date

Abstract

This guideline describes issues to consider and the actions of the practitioner when caring for a woman who has concealed her pregnancy or who is booked to receive care elsewhere.

Key Words

Unbooked, concealed pregnancy.

Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base state highest level from (1-5) 1a meta analysis of randomised controlled trials 1b at least one randomised controlled trial 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / or clinical experiences of respected authorities 5 recommended best practise based on the

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clinical experience of the guideline developer Consultation Process

Senior Midwives, Obstetricians, Neonatologists, Safeguarding Nurse Specialists, Designated Nurse for safeguarding Children and Young People.

Target audience Midwives, Obstetricians and Neonatologists. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. NHS Nottingham City and Nottingham University Hospitals NHS Trust are committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the basis of their ethnic origin, physical or mental abilities, gender, age, religious beliefs or sexual orientation. The Trusts are committed to ensuring that the public and staff are given information in a clear and concise way and in a manner that people understand. In situations where there are concerns about an individuals ability to understand information or consent to treatment because a medical condition has affected their cognitive functioning and mental capacity please refer to the Mental Capacity Act intra-agency guidance and complete appropriate documentation.

Guideline for staff delivering care to women who have concealed their pregnancy or who are presenting for ante natal care or to give birth that are booked to receive care elsewhere.
1. Introduction

Around 1 in 2500 pregnancies are concealed (ie not disclosed to family, friends or services) [Nirmal, Bethal and Bhal, 2006]. Concealment of pregnancy takes 3 different forms: (1) concealment may be conscious and deliberate by the mother, with or without the collusion of others, or (2) the pregnancy may be denied by the mother or (3) the mother may genuinely not know she is pregnant. In each case the concealed pregnancy will be unbooked. Other women will be pregnant and booked to give birth elsewhere but present to NUH when visiting the area or to deliberately avoid their known carers. They may or may not present with their hand-held midwifery records.

2.

Women who have booked elsewhere and present with or without hand-held records.

If a women presents unbooked at NUH but with hand-held records, review the records as part of the assessment and establish the reason for not delivering at the hospital where she is booked to receive care. If a woman presents unbooked at NUH without hand-held records but gives the name of the hospital where she was intending to give birth then: Contact the maternity unit where the woman is booked to give birth as soon as possible to establish if there are any safeguarding concerns about the baby. Ask whether there is any other information relevant to the medical care required by mother or baby, including (but not exclusively) whether the mother misuses drugs and if so which. Where there is no safeguarding concerns continue care as normal. Ensure that the womans community midwife is informed of the delivery; discharge date and discharge address to ensure ongoing care.
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 If Social Care is involved, establish, record and repeat back to the informant the concerns (including the category of risk), whether the baby is or will likely be subject to a child protection plan and what the birth plan is. Ask for a copy of the plan to be faxed to you. Record the name and contact details of the social worker, and the contact numbers for social care out of hours. Establish if there are any individuals in the babys immediate and extended family who pose a risk to children or staff. If so record their identity and whether there are recommended actions if they attend. Ask whether the mother is considered to be a vulnerable adult. Carry out the actions from the birth plan if there is one in place. Where there is no birth plan in place, but the mother or baby or immediate family members are known to social care, contact the social worker immediately. If they are not available, ask to speak to the duty worker (out-of-hours ring the Emergency Duty Team (EDT). Inform the Safeguarding Team for Nottingham University Hospitals; leave a message if out of hours. Ext 62921

3.

Women who present unbooked without hand-held records (concealed)

For women who are unbooked and have no hand-held records and are not booked anywhere to receive care: If presenting to community services (midwifery or General Practitioner) in labour or just delivered, arrange transfer to NUH maternity unit as soon as possible (Refer to Guideline for In utero and postnatal transfer, NUH). If the woman refuses to transfer into the maternity unit o Referral to Childrens Social Care for urgent assessment. o Inform the Supervisor of Midwives on call and the Labour Ward Coordinator, who should inform the Consultant Obstetrician and Consultant Neonatologist on call. o Inform NUH Safeguarding Team at earliest opportunity. Ascertain details of her medical, social and obstetric history, including the name and date of birth of the babys father, siblings, the name and relationship of the person they are staying with. Also ascertain the name of the womans General Practitioner (GP). Confirm this information is correct with the GP if possible. Establish presenting history, observations and assessment of fetal wellbeing.
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 Perform booking bloods with consent (group and save, full blood count, haemoglobinopathies (needed for labour) and rubella, hepatitis B and C, HIV and syphilis (needed for review in the postnatal period). This can be requested urgently (Refer to Guideline for routine infectious disease screening in pregnancy, NUH). Check the Missing Unborn Alert File (MUAF) for information on the family, and record your findings (positive or negative). If the woman has been registered as a missing person, carry out the actions on the alert. If there is no record of the woman or family in the MUAF, contact Social Care immediately to make a referral if appropriate. Follow the actions in Section 2 Ultrasound Scan should be performed to exclude multiple pregnancy. Do not give an oxytocic for 3rd stage until the absence of another fetus is confirmed either by ultrasound scan or clinical examination. Ensure neonatal personnel are present for delivery

4.

Record Keeping

In the Maternity Unit, complete medical records and Medway. Commence the safeguarding documentation and file it within the maternity notes behind a Safeguarding Divider if required. In the Community, commence the appropriate section of maternity hand-held records and register mother and baby on Systmone at the earliest opportunity, recording any relevant concerns in the safeguarding section.

5.

Discharge

To ensure a safe discharge of the baby, where a woman has no hand held records and has not booked or received care anywhere else, a multi-agency planning meeting should be convened to ensure safe discharge, if required. It is the responsibility of the neonatologist or midwife responsible for the babys care (and discharge) that such a meeting takes place. This will be held at NUH and should include the mother, significant family members (as necessary), the health professionals caring for the mother and baby, the health professionals who will continue the care, social care (if involved), the safeguarding team (as required) and housing (if necessary). The purpose of the meeting is to ensure that appropriate preparations have been made for transfer of care. All professionals should be aware of the situation and their responsibilities for monitoring and supporting the mother
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and the baby. They should ensure that appropriate preparations have been made for the baby. The outcome of this meeting should be documented in the safeguarding documentation and shared with all the agencies who attend. Consider whether the woman is entitled to any statutory benefits and complete appropriate documentation

References Department for children, schools and families (DCSF) (2010) Working together to Safeguard Children A guide to inter-agency working to safeguard and promote the welfare of children. DCSF Publications, Nottingham. Nirmal D. Thijs I. Bethal J. and Bhal P (2006) The incidence and outcome of concealed pregnancies among hospital deliveries; an 11 year population- based in South Glamoran. Journal of Obstetrics and Gynaecology. Volume 26 (2) p. 118-121 Nottingham Childrens Safeguarding Board (NCSB) (2010) Nottingham City and Nottinghamshire Child Protection Procedures Available online http://www.nottinghamcity.gov.uk/index.aspx?articleid=2327