Coronavirus (COVID-19) delivering maternity and neonatal services through the pandemic: beyond Level Zero - guidance

Delivering Maternity and Neonatal Services: Beyond Level Zero

Introduction

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: This Guidance; 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.

Guidance for Visiting in Maternity and Neonatal Settings is also available and should be read alongside this guidance.

Purpose

This document provides guidance for NHS Boards for the management of maternity and neonatal services in Scotland in its continued response to COVID-19 and 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. Scotland has now moved beyond the Protection Levels system. The COVID-19 pandemic, however, is not over and with the emergence of the omicron variant we must continue to focus on suppressing the virus to a level consistent with alleviating its harms while we recover Coronavirus in Scotland - gov.scot (www.gov.scot).

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) and vaccination 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 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 based on Boards risk assessments. 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 could be promoted and developed after the pandemic, which could be adapted, or which could be discontinued.

Testing

Asymptomatic testing of emergency admissions was introduced from early December 2020, 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.

Vaccination

COVID-19 vaccines are now strongly recommended in pregnancy. Vaccination is the best way to protect against the known risks of COVID-19 in pregnancy for both women and babies, including admission of the woman to intensive care and premature birth of the baby.

Pregnant women should now be considered as a clinical risk group and part of priority group 6 within the vaccination programme and those aged under 18 who are pregnant, should receive primary vaccination in line with other groups at high risk.

Women may wish to discuss the benefits and risks of having the vaccine with their healthcare professional and reach a joint decision based on individual circumstances. However, alongside the non-pregnant population, pregnant women can receive a COVID-19 vaccine even if they have not had a discussion with a healthcare professional. Further guidance for professionals on vaccination in pregnancy has been produced by RCOG and RCM.

All visitors should take an LFD test and have received a negative result ahead of every visit. Ward staff are not being asked to verify negative results on a visitor’s arrival, but should make clear these new expectations alongside the existing protections to every visitor in advance.

Self-Isolation for Maternity and Neonatal Staff

Those identified as close contacts of someone who has tested positive for COVID19 are no longer required to automatically self-isolate if they are double vaccinated with the 2nd dose of COVID-19 vaccine at least two weeks prior to exposure to the case, have received a covid-19 booster vaccination, have no COVID-19 cardinal symptoms (i.e: a new continuous cough or high temperature of 37.8 or above or a loss of, or change in, normal sense of taste or smell (anosmia)) and return a negative PCR test taken after exposure to the case. These circumstances are set out in the Policy Framework which is available on the SHOW website.

As a cohort, pregnant women and neonatal babies are not considered to be in the high clinical risk category in the context of staff exemption from self-isolation, unless they have another condition that puts them into that high-risk category (for example are on chemotherapy, immune-suppressants such as pre/immediately post-transplant, or those who have profound immune-deficiency). Whilst pregnant women in the third trimester at more risk if they catch COVID-19, and pregnant women are largely unvaccinated, the staff who are caring for them will have taken PCR and lateral flow tests and will be wearing PPE, so the risks of any transmission will be very small. Babies (even those in neonatal care) will only suffer mild symptoms of COVID-19 and so are at low risk. Boards can take decisions locally about categories of patients that are considered high risk, but for clarity, this need not include pregnant women and neonates as a whole cohort, whilst recognising that there may be a small number of pregnant women and babies who will need to be protected as they have specific additional co-morbidity that make them high risk.

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. 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 remaining on an emergency footing and focused on the rising incidence of COVID-19 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 required. Recognising that capacity will vary across the country, Scottish Government will not be requesting implementation plans or monitoring progress at this stage. An extension to the program in recognition of the importance of the forward plan and the impact of the pandemic on implementation has been agreed.

Antenatal Care

Normal Service Provision

• 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:
  • Person centred care delivered for all women.
  • Routine schedule of antenatal visits for all women as per QIS Pathways for Care. including 8 – 10 in person antenatal appointments.
  • Provide additional tailored care for women with additional medical, social and psychological needs.
  • Face to face CO₂ monitoring provision to be re-instated subject to risk assessment.
  • Provide care for critically ill women in line with Maternity Critical Care Guidance.
  • Coronavirus (COVID-19): consultations outlines principles for reducing potential transmission within outpatient and primary care settings.
  • Follow RCM Antenatal and Postnatal Services Guidance in the Evolving Covid-19 Pandemic
• 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 socio economic deprivation.
• Maintain increased vigilance and ensure culturally appropriate care for vulnerable women and have a reduced threshold for face-to-face care, investigation and referral.
  • 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 Technology Enabled Care 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.
• 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-19 positive, self- isolating or showing any symptoms of coronavirus as per national guidance.

Moderate to High Workforce Pressures Managed Locally with Contingencies in Place

• As an essential service, maternity care continues with potential modifications described within:
  • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued August 2021, 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 inRCOG/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 can continue for essential antenatal, intrapartum and postnatal care provision if they are not available in your local area. Maximise use of Technology Enabled Care and remote monitoring to reduce unnecessary travel.

Parent Education, Breastfeeding and Peer Support

Normal Service Provision

• 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.

Moderate to high Workforce Pressures Managed Locally with Contingencies in Place

• Breastfeeding support to continue in person or virtually, subject to risk assessment and appropriate physical distancing.
• Travel across local authority borders can continue for essential antenatal and postnatal education provision and parenting support. Maximise use of Technology Enabled Care and remote monitoring to reduce unnecessary travel.
• Breastfeeding support should continue to ensure that breastfeeding is established, however it is recognised that in high workforce pressures situations, staff may need to work flexibly to ensure essential clinical services are maintained.

Intrapartum Care

Normal Service Provision

• 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.
  • Hospital birth is recommended for a COVID-19 positive or symptomatic mother.

Moderate to high Workforce Pressures Managed Locally with Contingencies in Place

• As an essential service, maternity care continued with potential modifications described within:
  • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued August 2021, 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.

Postnatal Care

Normal Service Provision

• 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:
  • Provide routine schedule of postnatal care including in person visits as per QIS Pathways for Care.
  • Provide additional tailored care for women and families with additional medical, social and psychological needs
  • Provide care for critically ill women in line with Maternity Critical Care Guidance.
  • Coronavirus (COVID-19): outpatient and primary care consultations outlines some principles for reducing potential transmission within outpatient and primary care settings.
  • Follow RCM Antenatal and Postnatal Services Guidance in the Evolving Covid-19 Pandemic
• 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 and ensure culturally appropriate care for vulnerable women and have a reduced threshold for face-to-face care, investigation and referral.
  • 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 Technology Enabled Care 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-19 positive, self- isolating or showing any symptoms of coronavirus as per national guidance.
• National Bereavement Care Pathway (NBCP) 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.

Moderate to high Workforce Pressures Managed Locally with Contingencies in Place

• As an essential service, Maternity care continued with potential modifications described within:
  • Guidance for Workforce Planning for Midwifery Services During COVID-19 (issued August 2021, 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.
• 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.

Neonatal Care

Normal Service Provision

• 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-19 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.
• 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 Technology Enabled Care and Vcreate to supplement and enhance the routine schedule of care and to increase access/deliver person centred care, subject to individual risk assessment.
• Continue and develop processes for supported discharge at home allowing babies and families to be at home earlier (liaison support and service led innovations).
• National Bereavement Care Pathway (NBCP) 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.

Moderate to high Workforce Pressures Managed Locally with Contingencies in Place

• As an essential service, neonatal care continued with modifications described within guidance as set out in RCPCH, RCOG and BAPM Guidance.
• Parents are permitted to Travel across local authority borders 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, through the Young Patients Family 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.

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 Best Start can continue commensurate with capacity, staffing levels and virus management. There is 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).

This guidance is underpinned by key detailed guidance, as follows:

• Scottish Government Information and Support on Covid-19.
• Scottish Government Guidance on use of face masks in hospitals is available at https://www.gov.scot/publications/coronavirus-covid-19-interim-guidance-on-the-extended-use-of-face-masks-in-hospitals- and-care-homes/.
• HPS Four Nation Guidance on use of PPE is available at https://www.hps.scot.nhs.uk/a-to-z-of-topics/covid-19/infection- prevention-and-control-ipc-guidance-in-healthcare-settings/ with addendum for Scotland: National Infection Prevention and Control Manual: Scottish COVID-19 Infection Prevention and Control Addendum for Acute Settings: http://www.nipcm.hps.scot.nhs.uk/scottish-covid-19-infection-prevention-and-control-addendum-for-acute-settings/
• BAPM Guidance on the classification of mothers and newborns for care pathways.
• Technology Enabled Care Guidance: Continued use of Technology Enabled Care. All Boards have a TEC lead and Maternity Teams should speak with them for support in using appropriate technology to deliver care and education.
• Family Support Directory for parent information in one place, including Baby Boxes, Ready Steady Baby, and bereavement. support etc.
• The National Bereavement Care Pathways COVID-19 webpage provides information on support organisations for both staff and patients can be found here https://www.nbcpscotland.org.uk/covid-19/.