Guidance and Resources for the Postnatal 8 Week Check, During the COVID-19 Crisis

The COVID-19 crisis has changed the way we work in primary care and we have rapidly adapted to new ways of working. Wherever possible, consultations are now being undertaken remotely. It is paramount that General Practice continues to maintain access and services for people who need urgent care, support for pre-existing conditions and essential routine care that is non COVID-19 related. The 6-8 week postnatal check is essential routine care.
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NHS England have confirmed that the 6-week check can safely be conducted in person at 8 weeks to coincide with the first primary childhood immunisations; minimising attendance at the practice (14 April 2020).

Due to COVID-19 many providers have reduced the frequency of face to face/in person contacts with families during their postnatal period. Patients will only be seen in person by the health visiting service if they are highly vulnerable, otherwise these contacts are being done remotely by telephone or video.

This means the only NHS face to face/in person contact with new mothers and babies is the GP 8 week check

This postnatal check is a key and vital opportunity to identify:

  • Physical Health Needs in the Infant and Mother
  • Perinatal Mental Health Issues
  • Safeguarding Concerns

Summary points

  • The 6-8 week postnatal check remains as essential routine care; NHS England have confirmed that the 6-week check should be conducted in person at 8 weeks to coincide with the first immunisations
  • To minimise patient time in the surgery you may wish to consider conducting the history taking and discussion over the phone prior to the face-to-face baby and maternal check
  • Use of Arden’s template is recommended for postnatal check. Child safeguarding issues to consider: perinatal mental health, domestic abuse, safe sleep advice (see Every Sleep Counts Toolkit), and crying/abusive head trauma (see ICON).
  • Although our working practice has changed, safeguarding children continues to remain a priority. Referrals to Children Services continue to operate as normal via Interagency Referral Form

Perinatal Mental Health

RED FLAG PRESENTATIONS - should prompt urgent senior psychiatric assessment:

  • Recent significant change in mental state or emergence of new symptoms
  • New thoughts or acts of violence or self-harm
  • New or persistent thoughts of incompetency as mother or estrangement from the infant

Amber risk factors for Perinatal Mental Health- (indicators of increased future risk):

  • Prev history of mental health problems (especially psychotic disorders)
  • Psychological disturbance during pregnancy
  • Poor social support
  • Poor relationship with partner
  • Baby blues
  • Recent major life events
  • Unplanned pregnancy
  • Unemployment
  • Family history of bipolar or postpartum psychosis
  • Antenatal parental stress
  • Antenatal thyroid dysfunction
  • Depression in the father of the child
  • Current, or history of, substance misuse
  • Neonatal low birth weight or illness, stillbirth and SIDS
  • Having 2 or more children

How to refer to the Perinatal Mental Health Team

Information on Southern Health NHS website

  • Check bed availability via nhswebbeds.co.uk
  • IN HOURS (9-5) - Call the Perinatal MH Team on 01962 897780 – even just for advice

OUT OF HOURS: Contact the Mother and Baby unit directly- 01962 897711- they will email referral paperwork for you to complete

For evidence-based information from experienced specialist pharmacists regarding any medication and potential interactions with breast feeding (anti-depressants etc.), email The Breastfeeding Network- Drugs in Breastfeeding - druginformation@breastfeedingnetwork.org.uk

Health visiting service support

During COVID-19, most contacts with Health Visitors and patients will be via telephone or video appointment. The only face to face contact will be when there is an ‘assessed and compelling case for doing so’. This decision will be made with advice from senior practitioners and safeguarding colleagues, and include information from partners such health and local authority children’s services.

IF YOU HAVE QUERIES, QUESTIONS OR CONCERNS ABOUT A CHILD (e.g. weight monitoring OR HV FOLLOW UP CARE), PLEASE CONTACT YOUR LOCAL HEALTH VISITING TEAM (link below) IN THE USUAL WAY

To find your practices local health visiting team, please click on the link below: Find your local HV or email your HV Team via their generic email

Audiology screening: This service is continuing via maternity post-delivery in the usual way, however, any babies that require further assessment in the community, are being referred but WILL NOT be seen until community services resume post covid-19 (parents will be contact in due course).

Hip/Ophthalmic Referrals: NHSE has advised that GPs should continue to refer patients to secondary care using the usual pathways and to base judgments around urgency of need on usual clinical thresholds (taking into consideration need for non-face to face consultations, likely delays in recommencement of routine elective activity, and communicating likely delays to patients at point of referral).' Secondary care will hold clinical responsibility for GP referrals and will follow these up in due course.

Bruising in babies

REMEMBER Bruising in babies is very rare and must be considered abuse until proven otherwise. If any professional thinks a skin mark on a baby could be a bruise they must refer to Children’s Services via a phone call under the bruising protocol in the usual way.

Children’s Services will then arrange an examination in person with a consultant paediatrician. Bruising Protocol

Making a referral to Children’s Services in Hampshire: This referral needs to be completed via the inter-agency referral form (IARF) which can be found here

CONTACT NUMBERS FOR LOCAL AUTHORITY CHILDREN’S SERVICES:


Hampshire

Office Hours: 01329 225379

Out of Hours: 0300 555 1373

Southampton

Office Hours: 02380 832 300


Portsmouth

Office Hours: 02392 839 111

Out of Hours: 0300 555 1373

Isle of White

Office Hours: 0300 300 0901

Out of Hours: 0300 3000117


Digital Imagery of Birthmarks/? Bruising during COVID-19

If ANY (e.g. social worker), professional is sent a digital image directly from a parent we recommend that the baby is seen in person for a full physical examination by an appropriate health professional (for example; midwife, health visitor or GP).

If a HEALTH professional is sent a digital image directly from a parent we recommend the baby is seen in person for a full physical examination by an appropriate health professional.

If a health professional is asked for a second opinion on a probable BIRTHMARK, by another health colleague, we recommend that the child is seen in person for a full physical examination.

In some situations digital images may enable a health professional to make a correct diagnosis, and avoid the need for the child to be examined in person. An example might be a large cavernous haemangioma (strawberry birthmark). However, if there is any uncertainty the child should be seen in person for a full physical examination. The use of digital images should only be considered a temporary approach during coronavirus.

Otherwise it is business as usual

ICON and abusive head trauma

Abusive Head Trauma of babies is most common during 6-12 weeks of life. This is correlated with the peak in infant crying. The 8 week check is a key opportunity to reinforce the below info:

Abusive head trauma (AHT) key points:

  • AHT is Child Abuse and is 100% preventable
  • 70% of babies that are shaken by a male caregiver/father
  • Risk is increased at times of stress within families
  • It results in catastrophic injuries
  • It is often triggered by caregiver's lack of ability to cope with a crying baby
  • There is an association between economic hardship and the incidence of AHT

Challenges of COVID-19:

  • Massive time of stress
  • Loss of income
  • Self-isolation with children and potentially at-risk adults
  • Social distancing is restricting activities that might enhance support

Resources for professionals and patients

See the ICON Toolkit from the HSCP webpage / See the ICON patient leaflet

Safe sleep advice

Key Messages to Reinforce:

  • The safest place for your baby to sleep is in their own cot or Moses basket
  • Always place baby on their back to sleep with feet to foot of cot
  • Do not cover the baby’s face or head or use loose bedding
  • Use a firm, flat waterproof mattress in good condition
  • Do not use ‘sleep positioners’ including wedges, supports or straps that prevent the baby moving
  • Baby should sleep in their own cot in same room as parents for the first 6 months of life (day and night)
  • Avoid allowing your baby to become too hot. A room temperature of 16- 20C with light bedding is recommended
  • Do not sleep or nap with your baby on a sofa or armchair
  • Do not use a car seat, swing, bouncy seat, stroller, baby carrier or infant sling for routine sleep
  • Never fall asleep with your baby, in any circumstance if anyone has drunk alcohol, taken drugs or medicine that might make them sleepy
  • Do not sleep with your baby if they were born prematurely or weigh under 2.5kg or 5.5lbs when they were born as risks are increased.
  • Keep your baby’s environment smoke free during pregnancy and after the birth

Do not place pillows, cot bumpers and soft toys in the cot

Safe Sleep:

Hampshire Safeguarding

Children’s Partnership – Every Sleep Counts Toolkit - Website

Every Sleep Counts is a programme of prevention aimed at parents and carers

  • It supports professionals to deliver consistent key safe sleep messages at numerous touch points during pregnancy and after birth
  • It brings together information on multiple risk factors associated with safe sleep

The Lullaby Trust - Website

The Lullaby Trust raises awareness of sudden infant death syndrome (SIDS), provides expert advice on safer sleep for babies and offers emotional support for bereaved families

Domestic violence and abuse

If you have a concern that there is potential Domestic Violence and Abuse (DVA), consider referral to Hampshire Stop DA Services for victims and Hampton Trust for perpetrators. See section 9 of this document for resources of support for victims and perpetrators. The IRIS Guidance has been developed specifically for GP’s during COVID-19 and recommends the following when discussing DVA with patients remotely:

If it isn’t then ask for a suggested safe time to call back. Be aware that situations change quickly and that risk is dynamic.

room.

  • Ask if the patient feels safe and if there is any immediate danger. Always advise calling 999 if there is any immediate danger. If the patient is unable to do this, offer to do this instead.
  • Consider use of ‘closed’ questions when asking about safety – questions with ‘yes/no’ answers may help your patient share that they are being harmed, even if they cannot talk freely (e.g. Have you ever been hurt by this person?, Have you ever felt frightened?)
    • Validate the patient’s experience with phrases like ‘I believe you’ or ‘This is not your fault.’ A patient will be in an extremely vulnerable situation if self-isolating with the perpetrator.
    • Ask about what support the patient has and what support they might need.
  • Consider need to refer to Hampshire Stop Domestic Abuse service and The Hampton Trust as per the above hyperlinks.
  • Signpost to relevant services/resources as per section 10 of this document.
  • Ask the patient if the abuse is getting worse
  • Ask if the patient feels unsafe to stay in the home/is in immediate danger.
  • If the patient says yes, they feel unsafe to stay in the home/are in
  • If there are also children in the home, make an immediate safeguarding referral
  • Consider whether a safeguarding referral is needed if there are any children and/or vulnerable adults at risk and follow your usual practice safeguarding procedures.
  • These cases can be challenging to manage – discuss with your Practice Safeguarding Lead, your colleagues or your local safeguarding professionals if you need further advice and guidance.
  • Consider whether you, or one of your colleagues, can call the patient again, to offer support and agree what timeframe for this is realistic and appropriate Consider need to refer to Hampshire Stop Domestic Abuse service and The Hampton Trust as per the above hyperlinks.
  • Signpost to relevant services/resources as per section 10 of this document. Make sure you document all enquiries, concerns, disclosures and referrals on the patient’s record. Ensure you code any disclosure on the medical records of any children or vulnerable adults in the household.
  • See the RCGP national recording guidance on domestic abuse for more detail.

Importance of accessing medical care through the COVID-19 crisis

Wessex LMC has produced a statement for parents that we strongly support; please reiterate this message to your patients:

“COVID19 is unlikely to cause a serious illness in children, but please remember children can still become seriously unwell from other causes that are always around. Please do not let concerns over COVID19 stop you from contacting medical services. If you are not sure if your child needs to be seen please go to https://www.what0-18.nhs.uk/national for advice or contact 111 or your GP. For information about crying babies go to https://what0- 18.nhs.uk/parentscarers/worried-your-baby-unwell-under-3-months/my-baby-crying- excessively. If your child is severely unwell call 999 or go to ED.”

Patients attendance for their 8 week check

We recommend that surgeries send new parents/carers a text message of encouragement to attend their 8 week postnatal check.

The suggested wording would be:

‘Your postnatal and baby check are due at 8 weeks, this is very important for your health and the health of your baby. Please do not let concerns over COVID19 stop you from having these checks. The surgery is doing everything possible to minimize your risk of catching COVID19.’

Vaccinations

NHS England has stressed the importance to maintain good vaccine uptake and coverage of immunisations. Where practices experience high demand on services, it is important to prioritise time sensitive vaccines for babies, children and pregnant women:

All routine childhood immunisations offered to babies and infants including vaccines due at one year of age including the first MMR dose

All doses of targeted hepatitis B vaccines for at-risk infants should also be offered in a timely manner

Maternal postnatal template

Mental health screening questions

  • Is motherhood everything you thought it would be?
  • In the past month have you felt little interest or pleasure in doing things?
  • In the past month have you often felt down, depressed or hopeless?
  • During the past month have you been feeling anxious, nervous or on edge?
  • During the past month have you not been able to stop or control worrying?
  • Is this something we can help you with?

link to RCGP perinatal mental health toolkit

Domestic Abuse screening questions

  • How are things at home?
  • Have you ever felt frightened or had to change your behaviour due to someone you have a close relationship with?

Social Support

  • Who is at home to support you?
  • Have you or your family ever received help or support from children’s services?
  • How is your partner coping with parenthood? (If concerns consider need to offer partner an appointment)

Postnatal health education

  • Do you feel your baby is crying excessively?
  • ICON advice discussed and leaflet given
  • Safe sleeping advice (including avoiding co-sleeping)
  • Dadpad for support for partners (not yet a free resource)

Physical health

  • Type of delivery
  • Feeding details
  • Postnatal examination
  • Contraception
  • Smear
  • Smoking status
  • Alcohol consumption
  • History of substance misuse

Click here for formal evaluation

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