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A Framework for maternity services in Scotland

Postnatal and parenthood

This section considers the care needs of new parents and the support networks that need to be in place.

Local Action

• NHS Trusts should make sure that high quality midwifery care is provided both in the maternity unit and at home to facilitate the transition to motherhood;
• NHS Trusts should make sure that each home visit with mother and baby is used as an educational opportunity;
• NHS Trusts should encourage the setting up of support groups for bereavement, and postnatal depression. If these services are not available, professionals should provide one-to-one advice and/or appropriate contact numbers;
• NHS Boards should adopt a multi-disciplinary, multi-agency approach when considering the specific needs of women and their families with physical and learning disabilities in the postnatal period;
• NHS Boards should develop and implement a strategy to maintain any positive health gains made in pregnancy through appropriate professional support in the postnatal period. This should include advice on healthy diet, smoking cessation, alcohol consumption, substance misuse and physical activity;
• NHS Trusts should make sure that appropriate information is available to women and their partners about immunisation programmes for their baby.

Views

The follow-up we receive is excellent - GP/midwife/health visitor. The antenatal classes that I went to for my first baby were great and very helpful. The midwives in hospital have always been approachable and very helpful, even though they are "stretched", especially in the labour ward. (Lay focus group)

Local Action

• NHS Trusts should make sure that, wherever possible, continuity of care and carer is carried through from pregnancy into the postnatal period;
• NHS Trusts should make sure that all women have access to the support and advice of a physiotherapist in the immediate postnatal period;
• NHS Trusts should adopt a flexible approach to the provision of postnatal care with a reduction in postnatal length of stay, where appropriate care should be in accordance with the woman's choice and reinforced by a comprehensive support service in the community;
• NHS Trusts should explore with local authorities how best to plan and provide further postnatal support, in particular targeting vulnerable women and their families;
• Health professionals should take account of all available evidence when planning postnatal care, including the nature and frequency of home visits. This should be discussed with, and reflect, the needs of the woman, her baby and her family;
• NHS Trusts must make sure that 24 hour support and advice is available locally to women following transfer home from the maternity unit (midwife/ GP);
• The 6 week postnatal examination of mother and baby, normally carried out by the GP, should continue at the present time until further work has been undertaken nationally;
• NHS Trusts should make sure that local guidelines are in place for collaborative working between the midwife, the GP and health visitor;
• NHS Trusts should develop and implement a strategy and appropriate referral mechanism to address the care needs of women with physical problems subsequent to childbirth, such as perineal problems, incontinence and physiotherapy for back pain;
• Obstetric and neonatal consultant postnatal care, in collaboration with other specialist professionals, should be in place for women who had a complicated pregnancy or childbirth, a baby with problems or special needs, or if the parents have suffered the loss of their baby;
• NHS Trusts should make sure that, through effective inter-professional collaboration, any information and advice given to women and their families is consistent.

Views

The health visitor was very good, she understood my situation when I was living at home with my mum and sisters after having the baby and having no privacy. It was good to be able to talk to someone in private at the clinic who understood how I was feeling. (Lay Interview)

Being back home was dreadful at first. The baby wouldn't feed properly but the midwife picked up on the problem really quickly. The baby would only feed properly with hospital teats so they gave me a whole bag of them! The staff were great. (Lay Interview)

Overall I have been impressed by the many excellent people I have had caring for me and the baby. Particuarly good were: my hospital consultant and labour ward staff; my GP; the community midwife after the birth of the baby. (Lay Interview)

Local Action

• NHS Trusts should adopt the Neonatal Levels of Care model set out in Table 21 when considering the provision of immediate and early neonatal care. It is based on the British Association of Perinatal Medicine Guidelines adapted for this Framework, giving due consideration to local demography and clinical provision:

Table 21 Neonatal levels of care model

• most babies are cared for in the postnatal ward (Level I) and afterwards in the family home by the mother and the family, with advice and support from the midwife;
• special care of the new-born (Level II) is given in a special care unit, transitional care ward, postnatal ward or exceptionally in the home under the supervision of qualified professionals;
• high dependency and maximal intensive care (Level III and IV) should be given in an intensive or special care unit by appropriately trained specialist staff;
• effective community based support mechanisms must be in place for babies discharged home from a neonatal intensive care facility;
• as the clinical status of the baby is dynamic, transition between the different levels of care must be possible;
• local guidelines should be developed for post-discharge care and should be tailored to the clinical needs of the baby;
• care for babies who have had a complicated or complex birth, or have a possible or ongoing illness, should be given by a paediatrician or neonatologist. Care should be either in a specialist outreach or hospital based clinic, with easy access to other consultant specialist services;
• post-discharge care of the new-born depends on the level of care required after birth:

• NHS Trusts should explore further the role of advanced neonatal nurse practitioners with extended special care nursing skills when planning services and the role of community children's nurses in long-term follow-up of the chronically ill baby;
• NHS Trusts should make sure that, when a baby is not examined by a paediatrician before transfer home, failsafe mechanisms are in place for this check to be carried out by the GP or an appointment made at a baby clinic to see a paediatrician within 72 hours of birth.

Views

Having spent 17 days in Neonatal with my son, I would just like to say how wonderful all the Neonatal staff were. They helped my partner and I through a difficult time. (Lay Interview)

Local Action

• NHS Boards should work towards achieving the Scottish Executive's target of 50% of women breastfeeding their babies at 6 weeks by 2005;
• NHS Boards should, with the help of the National Breastfeeding Adviser, implement their local breastfeeding strategies;
• NHS Trusts should make sure that breastfeeding mothers, who choose to transfer home soon after birth, are given appropriate support and advice to ensure the baby continues to be well hydrated;
• All maternity units should adhere to the principles of the UNICEF/WHO Baby Friendly Hospital initiative through structured programmes of education and support for mothers and professionals;
• In line with the World Health Organisation policies, the Scottish Executive should implement the Innocenti Declaration of 1990 and future WHO operational targets arising from the Declaration;
• NHS Boards should actively nurture the setting up of peer breastfeeding education and support groups;
• An Infant Feeding Adviser should be appointed in each NHS Board area to support women and to raise breastfeeding rates through the education and training of health professionals;
• NHS Trusts should implement the NHS in Scotland Report "Breastfeeding and Returning to Work" (2000);
• When women choose not to breastfeed, health professionals should provide information and support according to the needs of women, and their partners.

Views

I had a lovely community midwife who came to visit when I brought my baby home. She helped me with problems I was having breastfeeding. I would have liked for her to have visited longer. I sort of felt 'abandoned' and scared when her visits stopped. (Lay Interview)

Local Action

• NHS Trusts should make sure that a debriefing process is offered to women and their partners at a time and location suitable to all concerned, and tailored to their individual needs;
• NHS Trusts should make sure that appropriate professional staff are trained to engage women and their partners in discussing their experiences of maternity care, whether good or bad, and working towards resolution if necessary;
• NHS Trusts should make sure that consistent themes emerging from debriefing inform service provision.

Local Action

• NHS Boards should have local strategies in place with statutory and voluntary partner agencies, to develop and implement services for women suffering from postnatal depression, in line with the Framework for Mental Health Services in Scotland template;
• NHS Trusts should make sure that training programmes are developed and implemented for professionals incorporating the identification, screening and support of women who are at risk of developing postnatal depression;
• NHS Trusts should make sure that a strategy for screening and management of postnatal depression by appropriately trained professionals is in place, using the Edinburgh Postnatal Depression Score (EPDS), augmented by the development of a multi-disciplinary Integrated Care Pathway (ICP);
• NHS Trusts should make sure that health professionals use evidence based treatment, backed up by specialist services with criteria in place for referral of women to appropriate mental health professionals with a special interest in their condition irrespective of where they live.

Further Work to be undertaken

• The Scottish Executive Health Department should set up a multi-professional group to review the content, effectiveness and timing of the 6 week postnatal examination;
• Following the review of the Hall Report, "Health for all Children", Version III, the outcome of which is due in early 2001, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists, the National Board for Nursing, Midwifery and Health Visiting for Scotland should review professional roles, and the content of the neonatal screening and surveillance programme;
• The Health Education Board for Scotland and the Chief Scientist's Office should consider carrying out research into ways of facilitating a culture shift in attitudes to breastfeeding and to improve uptake of breastfeeding;
• The Scottish Executive Health Department should audit the implementation of the "Breastfeeding and Returning to Work" Report (2000);
• NHS Boards should consider reviewing current services for women with postnatal depression and other illness with a view to developing regional mother and baby units;
• The Royal Colleges and the National Board for Nursing, Midwifery and Health Visiting for Scotland should consider with educational establishments the further development of courses in the theory of neonatal nursing.

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