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First-rate care for women with problems in pregnancy

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VOL: 97, ISSUE: 24, PAGE NO: 38

Linda Scott, BSc, RGN, is nursing sister at the Pregnancy Support Centre, Simpson Memorial Maternity Pavilion, Edinburgh

A new centre to care for women experiencing recurrent miscarriages or other pregnancy-related problems has been set up following a joint venture between Lothian University Hospitals NHS Trust and Standard Life Assurance Company.

A new centre to care for women experiencing recurrent miscarriages or other pregnancy-related problems has been set up following a joint venture between Lothian University Hospitals NHS Trust and Standard Life Assurance Company.

To celebrate 175 years in business, Standard Life asked local hospitals to suggest projects that would improve patient care. Staff at the trust's reproductive medicine directorate proposed a unit for women having problems in pregnancy. The bid was successful and on February 28, 2000, the Standard Life Pregnancy Support Centre opened.

The unit is designed to deal specifically with patients experiencing problems in pregnancy. Patients seen in the centre are those who are bleeding, who have pain in the first trimester of pregnancy or require investigation of foetal abnormality. The centre also provides investigation and follow-up care for patients who have had recurrent miscarriage (defined as three or more consecutive miscarriages).

Miscarriage occurs in 10-20% of clinical pregnancies (Royal College of Obstetricians and Gynaecologists, 2000) and can be a traumatic experience. It is important that patients who attend for medical care of this condition are treated with compassion and given sensitive, individualised care from staff who have specialist skills.

The money from Standard Life has been spent creating a less clinical environment for women who have miscarried. Previously these patients were seen on a gynaecology day bed unit and followed up in gynaecology outpatients, an environment that was not designed to cope with their needs.

The nurse-led service is staffed by a nursing sister (job share), a part-time staff nurse, a full-time and a part-time clinical support worker. The centre also has a sonographer to provide ultrasound scanning and, time permitting, to train the sisters in the use of ultrasound equipment.

Setting up the centre
Since a change in service would have a considerable impact on the nursing and medical staff who had previously been involved in caring for these patients, we endeavoured to reduce their concerns by establishing pathways of communication through education and support.

Multidisciplinary open days were held and staff were provided with written information about the remit of the unit.

All GPs who needed to access the system were contacted by letter and informed of the guidelines for referral. They were invited to attend the centre to view the facilities.

We also contacted the Miscarriage Association and the Stillbirth and Neonatal Death Society, informing them of our existence and inviting their staff to our open day.

Planning the patient's journey
We made an estimate of our workload based on the number of patients attending the day bed unit with problems in early pregnancy. The average number of new patient appointments was 156 a month.

The average number of return patient appointments was 114, of which 28 were for repeat human chorionic gonadotropin (HCG) alone. To be able to see this number of patients we estimated that we would require seven patient ultrasound slots and six return patient slots a day.

In addition, we have four appointment slots for patients who attend for reassurance ultrasounds, blood tests and support following miscarriage.

We operate an appointment system, so that patients do not have to wait too long to be seen.

Referral system
We had to decide how patients would be referred and which categories of patients were suitable to be seen at the centre. Referral guidelines were devised with the aim of reducing the number of inappropriate referrals. These guidelines were agreed by a steering group of nurse managers and medical staff.

Patients suitable for review:

- Women with early pregnancy bleeding (before 13 weeks' gestation) after a positive pregnancy test, including spotting, light bleeding and moderate bleeding;

- Pregnant women experiencing pain (cramp-like pain only);

- Women who have had a previous ectopic pregnancy but no adverse symptoms in their current pregnancy (for ultrasound scan to confirm intrauterine pregnancy);

- Women who have miscarried, for informal nurse counselling;

- Pregnant women with a history of miscarriage (for reassurance ultrasound scan). Patients who have attended the centre in a previous pregnancy will be given the option to self-refer for this service in subsequent pregnancies;

- Women who have had recurrent miscarriages, for investigation.

Patients unsuitable for review:

In the following cases, it was decided that women should be referred directly to the registrar on call for gynaecology:

- Heavy vaginal bleeding in early pregnancy;

- Suspected ectopic pregnancy;

- Pain in early pregnancy (sharp/severe);

- Patient has attended the booking clinic.

GPs were sent a copy of the guidelines and instructions for referral, including the telephone number, opening hours and advice on what action to take outside the centre's opening hours.

Protocols and standard letters for patient and GP information were written. These were agreed by the steering group to ensure safe and acceptable professional practice.

Many distressed patients are not able to comprehend or remember everything that has been said to them. On each occasion that a patient has an appointment at the pregnancy support centre she is given a letter describing what has taken place and what to expect next. This information is discussed with her to ascertain that she fully understands her care.

Her GP is then faxed a letter to ensure that he/she has the most up-to-date information about the patient. Patients' medical details are stored on a database and should prove to be of great benefit for future audit and research.

We see an average of 60 patients each week requiring various interventions (see box).

Non-continuing pregnancy
Following confirmation of a non-continuing pregnancy, patients are given a full explanation of their ultrasound scan and offered the opportunity to see the image. A hard copy is retained if they decline, as they may wish to see it at a later date. Women who find themselves in this position are offered a choice of management:

Expectant management, where the patient allows herself to miscarry 'naturally' without any surgical or medical intervention. If the patient decides to follow this course she is given an appointment to attend the centre for follow-up in one week's time. In the standard patient letter there is information on what to expect and how to contact the centre for further advice or any support that may be required.

Surgical evacuation of uterus carried out under general anaesthetic in the gynaecology day case unit. Documentation is completed and preoperative bloods are taken while the patient is in the centre. There is no routine follow-up for these patients but they are informed that nurse counselling is available.

Medical management, involving administration of mifepristone (200mg orally) at the centre. Documentation is completed and blood is taken to determine full blood count and blood group. After 48 hours the patient is admitted to the gynaecological day bed unit where the treatment is continued. These patients are given an appointment to attend the pregnancy support centre for follow-up ultrasound two weeks after their medical management, to ensure that the products of conception have all been passed. All patients opting for surgical or medical management who are considered to be 'at risk,' as defined by the Scottish Intercollegiate Guideline Network (2000), are screened for Chlamydia trachomatis.

Statistics to date
So far, 33% of patients have chosen expectant management. They are most likely to choose this option if they have already started to bleed. Many women are of the opinion that if the process of miscarrying has begun, it should be allowed to continue naturally. We find that the majority of these patients have had a complete miscarriage when they are seen at their review appointment.

If this is not the case they are offered the choice to continue or take up another option. Most report that they are able to cope with the experience and that being in the privacy of their home makes it more tolerable.

Just under a quarter (22%) of patients have chosen surgical evacuation and 1% have chosen medical management, the most common reasons being that they wish to have control over the timing of the process due to work or family commitments or because they are apprehensive and would prefer to be in hospital.

The remainder of patients we see with early foetal demise are found, by ultrasound scan, to have had a complete miscarriage.

Patients who have a miscarriage are advised that they can self-refer for follow-up nursing support if they have difficulty coming to terms with their loss. They are also offered the opportunity to self-refer for ultrasound scanning in their next pregnancy when they are eight weeks pregnant. The purpose is to determine how their pregnancy is progressing and to allow patients to access ultrasound at an earlier date than their booking appointment. Both of these services are well used.

To achieve clinical effectiveness we use a multidisciplinary team approach and endeavour to apply the principles of clinical governance (Ridgeway and Maxwell, 2001). We have regular advisory group meetings with trust staff who work in areas associated with the centre.

Since we opened we have had positive feedback from both patients and medical staff who have used the service. Many patients have commented on the sense of security they derive from having a special place that they can telephone or come to when they are experiencing problems. The service will be audited on a continual basis to ensure an optimum level of quality care. At present we are undertaking a patient satisfaction survey.

The patient's 'new journey' is through a seamless service that provides support at a distressing time. The psychological benefits of specialised units to deal with problems in early pregnancy are immeasurable.

We are confident that we can continue to evolve. We are currently undertaking research into the outcome of pregnancies in women who have had recurrent miscarriages. We are also recruiting patients for a study by the andrology department into the male factor in miscarriage. We believe that the pregnancy support centre is of great benefit to both patients and staff.

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