Powys Teaching Local Health Board
Directorate: Women’s and Children’s
Author: Lewis, Owen, / Title: Guideline for women at risk of Thromboembolism
Code: PtHB/MAT 0024

GUIDELINES FOR WOMEN AT RISK OF VENOUS THROMBOEMBOLISM

Code
/
Date
/ Version Number / Planned Review Date
PLHB MAT / May 2008
Jul 2012 / Initial Issue
2nd Issue - Reviewed and updated / May 2011
Jul2015
Document Owner / Approved by / Date
Nursing Director / Women’s and Children’s Directorate
Clinical Effectiveness Committee / 26/07/12
03/09/12
Document Type / Guidelines

Bwrdd Iechyd Addysgu Powys yw enw gweithredol Bwrdd Iechyd Lleol Addysgu Powys

Powys Teaching Health Board id the operational name of Powys Teaching Local Health Board

GUIDELINES FOR WOMEN AT RISK OF VENOUS THROMBOEMBOLISM

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Responsibilities / 5
Process / 5
References / 11
Appendices

For Reviewed / Updated Policies Only:

Relevant Changes / Date
Revised and updated with 1000 lives Community Early Warning Score. / July 2012

VALIDATION FORM

To be completed by the Author – no policy, procedure or guidance will be accepted without completion of this section which must remain part of the policy

Title: Guidelines for women at risk of Thromboembolism
Author:Marie Lewis, Practice Development Midwife, Donna Owen, Lead Midwife North
Directorate: Women and Children’s Service
Reviewed/Updated by: Marie Lewis, Practice Development Midwife, Donna Owen, Lead Midwife North Powys
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
  • Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives, Reviewing maternal deaths to make motherhood safer 2006-2008. CMACE, London
  • Royal College of Obstetricians and Gynaecologists. (2009) Reducing the risk of Thrombosis and Embolism during pregnancy and the Puerperium. RCOG Guideline 37 1-13 ; 2009

Consultation
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 05/07/12
Supervisor of Midwives – Powys / 05/07/12
Agreed by Head of Midwifery / 26/07/12
Agreed by Women and Childrens Directorate / 26/07/12
Health Visitors and School Nursing team / 05/07/12
Implications: Please state any training implications as a result of implementing the policy / procedure. None.
Please state any resource implications associated with the implementation. None
Please state any other implications which may arise from the implementation of this policy/procedure. None

Equality Assessment Statement Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Risk Assessment

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Woman focused midwifery policy
Race / X
Religion/ Belief / x
Sexual Orientation / X
Welsh Language / X
Human Rights / X
Are there any new or additional risks arising from the implementation of this policy?
None
Do you believe that they are adequately controlled?
N/A.

GUIDELINES FOR WOMEN AT RISK OF VENOUS THROMBOEMOLISM

Relevant to

Local guideline for all midwives working in Powys.

Purpose

To identify those at risk of Venous thromboembolism [VTE] and refer them to a consultant obstetrician.

Responsibilities

All Midwives working within Powys Local Health Board hold a recognised midwifery qualification, no additional qualifications are required to carry out this policy. It is the responsibility of individual midwives to identify if they feel that they require more training in the administration of thromboprophylaxis.

Monitoring

This policy will be monitored by the DATIX system for reporting of clinical incidents.

Process

Aim

For every clinical practitioner involved in maternity care, the safety and wellbeing of women and their families is paramount. Community Midwives are often the first point of contact for a woman receiving maternity care and have a pivotal role in risk assessing, monitoring and referring women who require additional care. The aim is not for diagnosis or treatment of thromboembolism but for prompt referral to consultant care where the appropriate elements of the VTE bundle can be utilised.

Venous thromboembolism (VTE) remains a common direct cause of maternal death in the United Kingdom (RCOG 2009; CEMACH 2011);the reports have highlighted failures in recognising risk factors for venous thromboembolism (VTE) and employing adequate prophylaxis.

Action

Assessment of risk for all women should be made at booking. A clear history should be taken and the booking VTE risk assessment completed.This should be clearly documented in the hand held records. Those women identified to be at risk of venous thromboembolism should be referred to an obstetrician for an early appointment.

Deep Vein Thrombosis Risk Assessment
Booking
All women to be assessed by midwife at first/booking appointment.
Indications for consideration of antenatal thromboprophylaxis
YES / NO / YES / NO
Previous DVT/PE / Antithrombin deficiency
Systemic lupus erythematosis / Sickle cell disease
Antiphospholipid syndrome / Myeloproliferative disorder
BMI ≥45kg/m2
Consider referral to anaesthetist as per local guidance / Assessed by
Date / Signature
If one or more Indications (above) present, woman to be referred for obstetric led care and consideration of antenatal thromboprophylaxis.
Referred to (if appropriate): Date:
Please refer to local guidance re referral timeframes and follow-up.

This assessment needs to form part of any further risk assessment following identification of risk factors (and referral) or during any AN hospital admission.

NEW ONSET OR TRANSIENT RISKS

Midwives should be aware of the risk factors of venous thromboembolism. Continual risk assessment should be part of midwives routine practice and should be documented in the client’s notes. Risk factors, which can be avoided, should be discussed with the woman.

For women who have been admitted to the District General Hospital [DGH] with additional risk factors the inpatient assessment will have been conducted; however Powys midwives must check that this has been completed.

Possible additional risk factors include:

  • Surgical procedure in pregnancy or puerperium e.g. evacuation of retained products of conception, postpartum sterilisation.
  • Hyperemesis
  • Dehydration
  • Varicose veins with phlebitis
  • Immobility (more than 3 days bed rest)
  • Pre-eclampsia
  • Excessive blood loss
  • Significant medical co-morbidities
  • Active Cancer/ cancer treatment
  • Sepsis

Women still require normal antenatal care and advice regardless of their additional risk factors.

Women who present with signs of thromboembolism during pregnancy should be referred to the nearest DGH for review by the obstetric team.

Clients who require thromboprophylaxis should be supported in its use by their midwifery team.

For clients who have identified risk factors for VTE but who still wish to birth in Powys advice should be sought from a consultant obstetrician during the antenatal period. A detailed plan should be recorded in the hand held notes and discussed with a supervisor of midwives.A clinical alert should be sent to all midwives who may be potentially involved with her care.

Postnatal Care

All women should be re-assessed for risk factors for VTE during the postnatal period.

Ensure thromboprophylaxis (TEDS & Clexane for 5 days) has been prescribed following birth with one or more factor / Yes / No / Women receiving thromboprophylaxis during pregnancy should continue treatment for 6 weeks postpartum
PPH 1500ml
Red blood cell transfusion or transfusion of coagulation factors
Caesarean section (elective or emergency)
Still-birth
BMI >40kg/m2 / Signature
Date
Sepsis
Complex vaginal delivery (Consider thromboprophylaxis)
Thromboprophylaxis required
Delay commencement until 6 hours following epidural catheter removal or completion of spinal anaesthesia. Encourage early mobilisation, hydration and awareness of symptoms of VTE in all women.
Prescription of postnatal Thromboprophylaxis: As table above.
To be calculated using booking weight.

Postnataly the midwife should support the client in the administration of thromboprophylaxis where prescribed. The client should have been educated in its administration while in the District General Hospital (DGH).

In the event of women being discharged from a DGH who have not been taught self administration the midwife must ensure that the drug chart is sent home with the woman. Once the final dose is administered the drug chart should be photocopied and stored in Powys notes and the original returned to the DGH.

The named-midwife should ensure a follow up appointment is made with the consultant obstetrician if it is necessary.

References:

Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives, Reviewing maternal deaths to make motherhood safer 2006-2008. CMACE, London

Royal College of Obstetricians and Gynaecologists.(2009)Reducing the risk of Thrombosis and Embolism during pregnancy and the Puerperium. RCOG Guideline 37 1-13 ; 2009

Issue Date: 2009
Status: Final / Page 1 of 9 / Review Date: 2015
Approved by:CEC