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Care Pathway for women experiencing Mid-trimester Termination of Pregnancy on
Delivery Suite
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 2.0 August 2018 Review before August 2020
Approval Group Date
Maternity Clinical Governance 13th July 2018
Change History
Version Date Author(s), Job title Reason
1.1 Feb 2017 A Wood-Blagrove (Bereavement MW), J Siddall (Consultant Obstetrician)
Pilot version being trialled in house
1.2 June 2017 A Wood-Blagrove (Bereavement MW), J Siddall (Consultant Obstetrician)
Final version
1.3 July 2018 A Wood (Bereavement MW) Updates made prior to next print run to address issues raised and changes to GL878 guidance
2.0 August 2018
A Wood (Bereavement MW) Introduction of partogram
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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
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For infants born at 23+0 > 23+6 consider/discuss with neonatal team and family possible interventions if born with signs of life.
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If to be admitted for termination of pregnancy: Y N Date Initial
Have parents been counselled by Consultant and written consent form completed?
Certificate A (HSA1) completed with 2 signatures
Mifepristone prescribed and administered
Misoprostol and Flagyl prescribed for administration
Essential information for all losses (Please document if not done): Y N Date Initial
Give ‘What Happens Next’ booklet and Bereavement Midwife contact card
If available (in Annexe cupboards) and/or in packs in DAU also give Willows support leaflet, ‘When a Baby Dies Before Labour Begins’ and Sands contact card/ support leaflet
Parents given date and time to return 48 hours after mifepristone Date___________________________Time______________
Give parents opportunity to see Willow Room if possible
Inform Community Midwife – leave message in Community Office if not available or on duty
Inform GP – leave message at surgery if unavailable
If feticide has been performed at RBH mifepristone will have been given prior to the procedure and all subsequent medication will have been prescribed and the Mid Trimester Termination of Pregnancy Guideline (GL878) followed. (If the feticide was done at Oxford mifepristone will have been given prior to the procedure and all subsequent medication will have been prescribed and the Mid Trimester Termination of Pregnancy Guideline (GL878) followed) Y N Date Initial
Follow guidance in medical notes, but in general: Oxytocin infusion to be started 6 hours after procedure at 100mls/hr until delivery achieved.
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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
Drugs to be given on admission to Delivery Suite (see earlier guidance if Feticide) Y N Date Initial PV misoprostol on admission (followed by PO miso 3 hourly as prescribed on drug chart) *Take HVS prior to PV dose* NB: See sample chart for appropriate dosage For dosage see schedule in Mid-trimester Termination of
Pregnancy guideline (GL878) as appropriate.
Note: If feticide has been undertaken the first dose of Misoprostol must be given within 30-60 minutes of the procedure
PR metronidazole on admission
Syntometrine/ Oxytocin for 3rd stage regardless of gestation
Tests for TOPs: Y N Date Initial
HVS prior to first dose of misoprostol (if appropriate, e.g. TOP for PROM
MSU (if appropriate, e.g. TOP for PROM)
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 or TOP/Feticide for structural abnormality
U&Es, LFTs, Uric Acid & Renal Function (Yellow x 1)
Clotting Screen (Blue x 1)
Commence MOWS chart 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)
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N.B. Remember that if the baby is born and shows signs of life (see flow chart on page 3 of this pathway), 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 later. Advise/discuss with parents that the fetus maybe born with movement/heart rate but would not be classed as a Neonatal death unless the baby takes a breath.
At delivery:
Describe condition of baby: Baby’s weight: _________________ Gender:_______________ (see page 6) Are there obvious abnormalities? Photograph them and place photos in CTG envelope.
Describe condition of liquor:
Describe condition of placenta: Placental weight: _______________ Are there obvious abnormalities? Photograph them and place photos in CTG envelope.
Describe condition of cord (i.e. any tight knots, any entanglement etc): Are there obvious abnormalities? Photograph them and place photos in CTG envelope.
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Birth Summary:
Date Time
Onset of 1st Stage
Onset of 2nd Stage
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
ERPC to be decided by clinical need on case by case basis - ERPC performed
Y N
Total EBL
Any other maternal details affecting postnatal recovery
For the placenta: Y N Date Initial
Swab fetal surface and membranes and send for C&S (not necessary in cases of TOPs who HAVE had a positive amnio or CVS)
Place placenta in a DRY, white, labelled bucket and attach Histology request form, but keep placenta in Mortuary fridge with baby.
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After Delivery:
For babies below 22 weeks gestation, please check sex with a second Midwife before informing parents (SANDS guidelines for Professionals, 2007). If you are not sure, do not guess.
Accepted Date
Any details Declined
Date Initials
Name of baby
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 per person, either take home or store safely in CTG envelope. Consider suggesting use of “Remember my baby” photography
Memory box / Memory folder - Please explain contents to parents
Involving siblings or other family members
Religious leader for blessing/ support
Naming ceremony
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Care of baby: Y N Date Initial
IMPORTANT - Baby labelled twice with mum AND dad’s names
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 ALL Rhesus Negative mothers give Anti D 500iu – do not wait for Kleihauer results. Make sure prescribed on drug chart and form filed in notes. Use Anti D stamp for PN booklet.
Cabergoline prescribed and given? Over 20 weeks this is strongly recommended, under 20 weeks at doctors discretion or maternal request.
Ensure parents are aware of option to view baby after discharge - this however is by appointment only, ensure they have a contact card for Bereavement Midwife/Lesley Bowles.
Over 24 weeks and no signs of life (see flowchart pg 3): A feticide/TOP over 24/40 must be recorded as below to generate an NHS number for registering the baby legally Y N Date Initial
Record delivery in front of Birth Register as for live births
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: )
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For babies born who take a breath at any gestation: Even non-viable <24/40 Y N Date Initial
Record delivery in front of Birth Register
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.
Ensure baby is removed from NIPE database
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:
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
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
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Discharge checklist for all losses: Y N Date Initial
Bereavement team to inform Health Visiting team by secure email
Community Midwife informed of discharge – please DO NOT leave answer phone messages. Consider use of secure email
Enter mothers name and ‘M’ number in folder by computer so that Admin team can take details off system (CMiS etc) Make every effort to ensure that this is done to prevent distressing text reminders/ phone calls.
Ensure that postnatal notes (for bereaved parents) 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 baby removed from NIPE database if born alive
Ensure Bereavement Midwife contact details have been given and confirm for parents that follow up appointment will be sent for 6 weeks.
Inform GP – leave message at surgery if unavailable
Notes on discharge: Y N Date Initial
Notes forwarded to Delivery Suite for attention of Bereavement Midwife / Ward Clerk and placed in bottom drawer of bereavement filing cabinet for confidentiality and safekeeping
Y N
Appointment with Fetal medicine team offered
Appointment with Fetal medicine team accepted
Notes to screening midwives: Date:
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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 (AB Walker) 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 AB Walker 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)
*Community midwife please alert HV after discharge to community to
facilitate appropriate contact.*
Bereavement Midwives: 07500 123912 Ward Clerk: 0118 322 7215
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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
Addressograph label:
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 Neither 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 ………………………………………...
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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
Communal 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 Letter sent ……………………… Berkshire RG1 5AN email sent ……………………… Requisition No: ………………………
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