RCOG and RCM set new guidelines for minimum antenatal and postnatal maternity care standards during COVID-19

The Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have published new guidelines setting out recommended minimum standards of safe antenatal and postnatal care during the COVID-19 pandemic. The new guidelines highlight the importance of maintaining safe provision of maternity services during the NHS’s priority response to coronavirus, to ensure that mothers and babies are not at risk of harm from stillbirth, maternal death and other childbirth-related injury. 

With maternity services losing midwives as a result of self-isolation or redeployment to coronavirus frontline care, the RCM are also calling for maternity services to be ring-fenced, to keep midwives available for mothers and babies in maternity care.

Why have RCOG published new maternity guidelines?

Whilst many less urgent NHS services are being reduced or closed down to make way for coronavirus treatment, RCOG have told the government that proper maternity services must remain available. RCOG refer to studies which have repeatedly proved that maternity care is essential. International and UK-based research has found that women who do not attend antenatal services are at increased risk of poor childbirth outcomes, including maternal death, stillbirth and other types of harm to mother and baby. World Health Organisation (WHO) guidance recommends a minimum of eight antenatal contacts (maternity appointments) for low-risk women in pregnancy. There is evidence from some ‘lower and middle income countries’ that the risk of perinatal mortality increases where there have been five (or fewer) antenatal visits.

There is no specific research data on how that risk changes if antenatal visits are replaced with remote assessments. However, we know that many important elements of antenatal care, such as checks of blood pressure, urine, fetal growth and blood tests, need the mother to attend in person. RCOG emphasise that routine antenatal care is essential for detecting common and potentially dangerous complications of pregnancy, including pre-eclampsia, gestational diabetes, and asymptomatic (no obvious symptoms) urine infection.

Maternity patients’ safety is put at risk when unusual circumstances, such as social distancing and patients’ fears of attending hospital in the current pandemic, create uncertainty about expected levels of antenatal care. Whilst distancing remains necessary wherever possible, and fear of hospitals is understandably heightened in pregnancy, it is important to remember that devastating injury to mothers and babies can arise even from apparently minor lapses in the mother’s antenatal and maternity care.

Working together, the RCOG and RCM have responded to this uncertainty by issuing guidance setting out clearly what they believe to be the minimum level of safe but streamlined antenatal and postnatal care that maternity units should provide during the coronavirus pandemic. Non-essential face-to-face meetings are reduced, COVID-19 infection control advice is given, and care priorities (triage) set out for when limited resources might not stretch to cover every patient’s need. They say that the new guidance is intended to set out which elements of routine antenatal and postnatal care are essential and which could be modified, given the national recommendations for social distancing of pregnant women. 

Dr Edward Morris, President of the RCOG, said:

"We welcome the rapid and largely successful implementation of remote access to antenatal care throughout the UK, ensuring women receive high-quality care and regular access to essential services while minimising the need for travel to antenatal clinics and face-to-face contact with healthcare staff. However it’s important to remember that some pregnant women have underlying conditions that require additional antenatal monitoring to ensure the wellbeing of the women and her baby. The guidance published today seeks to offer pragmatic advice to doctors and midwives on the management of common medical disorders in pregnancy during the coronavirus pandemic. It recognises that antenatal care is essential, and balances the need to provide appropriate care to ensure the best possible pregnancy outcomes for women and their babies against the need to protect particularly vulnerable women from the risk of coronavirus infection.”

Gill Walton, CEO of the Royal College of Midwives, said:

“We know that this is a worrying time for pregnant women and they are, understandably, doing all they can to ensure the health and safety of themselves and their baby. Antenatal appointments are there to do just that, which is why it’s so important to continue to attend them. If you are pregnant, with no coronavirus symptoms, you should continue to go to your antenatal appointments as usual, while following the social distancing guidance of keeping a two-metre distance from others and using private transport if possible. Even if you have symptoms, contact your midwife and they will work with you to ensure you continue to get the care and support you and your baby need.”

New minimum standards for antenatal and postnatal care

Key features of the new minimum standards for antenatal and postnatal maternity care during COVID-19 distancing include:

• A minimum of six face-to-face (in person) antenatal consultations should take place.
• Where possible, unnecessary hospital admissions should be avoided by ensuring that women are seen in one-stop clinics which cover all their medical and obstetric needs in the same visit. Low risk women should, if possible, be offered a virtual booking appointment or a one-stop clinic appointment that includes booking and a scan.
• Where it is safe to do so, new innovations, such as home monitoring of blood pressure, should be used to reduce the need for antenatal visits.
• In carrying out risk assessments to decide who needs face-to-face antenatal care, women with certain vulnerabilities, including psycho-social and safeguarding issues, and medical and/or obstetric complications should be prioritised.
• In the event of staff shortages, scans should be prioritised in the following order:
  • Anomaly scan (18 -23 weeks);
  • Ultrasound with or without screening (at 11+2 weeks -14+1 weeks)
  • Growth scans.
• Where a woman needs a face-to-face consultation because she needs a physical examination and/or screening, the maternity unit must have a system in place to check whether she has symptoms suggestive of COVID-19, or if she meets the ‘stay at home’ guidance. This check may be done by a telephone call before the appointment and/or by assessment at the entry to the maternity setting.
• If a woman attends an antenatal appointment but describes COVID-19 symptoms, she should be advised to return home immediately. A member of the clinical staff should then make contact with the woman to risk assess whether an urgent home antenatal appointment is required, or whether the scheduled appointment can be delayed for a period of 7 or 14 days.
• Up to 50% of women have a condition or complication that means they need additional appointments or multi-disciplinary care during pregnancy. Any additional appointments that do not require measurement of fundal height, blood or urine tests, or scans, should take place remotely via video or teleconferencing. 
• Maternity clinics should aim to carry out as many assessments remotely (such as by telephone or video) as possible to comply with social distancing measures recommended for pregnant women and maternity staff. Remote assessments also allow the pregnant woman’s partner to be present.
• Women will generally follow their schedule of care with their midwives. Appointments with obstetricians will be targeted, as ‘triaged’ by a consultant, and take place by telephone, to discuss any proposed plan of care with the woman.
• Timely screening must continue to be offered for the following critical screening programmes:
  • Sickle cell and thalassaemia (SCT)
  • Infectious disease in pregnancy screening (IDPS)
  • Fetal anomaly screening (FASP)
  • Eye screening for pregnant women with existing type 1 and type 2 diabetes.
• Women should attend screening or scanning appointments alone if possible or with a maximum of one partner or other person. COVID-19 checks should take place before the appointment, which should be postponed until after isolation if necessary.
• Each unit must decide how best to manage rebooking of appointments, including blood tests and/or scans. The woman should be informed of her new appointment, not to attend and what to do if she develops symptoms. There must be local failsafe systems in place to ensure that all women are re-offered and attend their new appointments and protocols for following up of women who do not attend.
• At all remote appointments, women should be asked about their wellbeing and about fetal movements if they are in the third trimester of pregnancy. Any woman who is concerned about fetal movements or physical wellbeing should be advised to visit a designated unit.
• Where a home visit is preferable to a clinic visit, maternity staff must be provided with personal protection equipment (PPE) and follow strict infection control procedures.
• Maternity units should consider using outpatient induction of labour for low-risk women, or scheduling a woman’s post-dates appointment on a day when induction of labour can be commenced. 
• The guidance lists circumstances where delay in seeing a patient in a fetal medicine unit is not clinically acceptable. These include where laser ablation (for twin to twin transfusion syndrome) or intrauterine transfusion is required or there is severe intra uterine growth restriction (IUGR).
• A minimum of three postnatal follow ups (at day 1, day 5 and day 10) should be provided by a combination of face-to-face and remote visits, according to the mother and baby’s needs.
• Face-to-face postnatal visits should be prioritised for women with:
  • Psycho-social vulnerabilities
  • Operative birth
  • Premature or low birthweight baby
  • Other medical or neonatal complexities
• Where possible, women should receive continuity of midwifery care.​

Boyes Turner welcome RCOG and RCM’s clarification of minimum maternity care standards

These are unprecedented times in which we must all accept some disruption to the normal routines of our lives. The NHS has had to reconfigure its resources around the most urgent and dangerous conditions. In order to meet this challenge, many NHS staff are daily putting their own lives at risk.

Medical and midwifery leaders, all current or former NHS employees, through their professional bodies, the RCOG and RCM, have spoken out, urging the government to recognise that maternity services also provide essential and urgent care. Where maternity safety is compromised, the tragedy of maternal death, stillbirth or brain injury to a child is not only devastating to the individual and their family, but also has long-term consequences for the maternity staff involved and financial implications for the NHS as a whole.

We welcome RCOG and RCM’s important reminder that maternity safety remains a critical concern, and the clarification that these new, and hopefully temporary, minimum care guidelines provide. We hope that clear guidance will empower maternity services units to better protect and care for the patients they serve in today’s otherwise uncertain environment.

If you are caring for a child or young adult who has suffered cerebral palsy or disability from birth or neonatal injury, and would like to find out more about making a compensation claim, contact us by email at cerebralpalsy@boyesturner.com