Maternity Guidelines

Please note that some documents are only available to staff via the SOPHIA platform.

A

Title	Last Review	Next Review
A&E Attenders and Pregnant Inpatients	Mar 24	Mar 27
Abbey Birth Centre: Clinical Guideline	Feb 26	Feb 29
Abbey Birth Centre: Operational Policy – see SOPHIA
Actim Partus Test in the Prediction of Preterm Labour SOP	Feb 25	Dec 28
Actim PROM SOP	May 25	May 28
Additional Responsibilities Portfolios SOP	Dec 23	Dec 26
Agency Onboarding in Maternity and the Local Induction Process SOP	Apr 26	Apr 27
Anaesthesia Guidelines: Anaesthesia and Analgesia for Breastfeeding Mothers Undergoing General Anaesthesia (Mar 26) Anaesthesia for Caesarean Section (Sep 23) Anaesthetic High-Risk Clinic Referral Criteria (Jun 25) Analgesia in Labour inc Accidental Dural Puncture (Dec 24) Antibiotic Prophylaxis for CS – see Antibiotic Guidelines via Eolas Datix Trigger List for Obstetric Anaesthesia SOP (Jun 24) Epidural Insertion and Care: Expected Standards of Practice (Dec 24) General Duties of the Obstetric Anaesthetist (Jun 25) Labour Neuraxial Pain Relief LocSSIP (Dec 24) Recognising the Deteriorating Pregnant Woman (Mar 26) Trigger List for calling an Anaesthetic Consultant (Jun 25)
Antenatal Cardiotocography	Dec 23	Dec 26
Antenatal care including booking appointment, maternity care pathway and antenatal clinical risk assessment	Nov 25	Sep 28
Antenatal Screening Presentation Scanning for Midwives SOP (Sep 23) Trisomy Samples SOP (Jul 25)	Dec 25	Dec 28
Antepartum Haemorrhage	Oct 25	Oct 28
Anti-D Prophilaxis, Fetal RH D Testing and Management of Maternal Antibodies	May 25	May 28
Aromatherapy Guideline – see SOPHIA
Aspirin in Pregnancy SOP Information for Women Taking Aspirin in Pregnancy (Mar 2023)	Aug 24	Aug 27
Assisted Vaginal Birth	Jan 25	Jan 28

B

Title	Last Review	Next Review
Baby / Child (Abduction) Security Policy – see SOPHIA
Baby Friendly Initiative: 10 steps to successful breastfeeding	Nov 22	Nov 25
BadgerNet Guidelines – see SOPHIA
BCG Vaccinations for Neonates SOP – see SOPHIA
Bereavement Care in Obstetrics, Gynaecology and Neonatalogy	Jul 25	Jul 28
Bilicocoon on Postnatal Ward	Mar 25	Mar 28
Birth After Previous Caesarean	Dec 24	Jan 28
Birth Choices	Jun 23	Jun 26
Birth Reflections and Birth Support Leaflet	Mar 24	Mar 26
Bladder Care in Pregnancy	Nov 24	Nov 27
Blood Tranfusion Policy
Bobble Hat Pathway	Jan 26	Jan 29
Breech Presentation including External Cephalic Version	Apr 26	Apr 29

C

Title	Last Review	Next Review
Capillary Blood Sugar Monitoring in Pregnancy SOP	Jun 25	Jun 28
Cardiovascular Diseases Management During Pregnancy (European Heart Journal)	Aug 18
Care and Storage of Deceased Baby SOP – see SOPHIA
Care in Surrogacy (DHSC)	Jul 21
Care of Women and Birthing People in Labour	Feb 26	Feb 29
Community Baby Referrals and Readmissions SOP	Oct 25	Oct 28
Concealed Pregnancy – see SOPHIA
Cooling and Cuddle Cot SOP – see SOPHIA
Cord Prolapse	Oct 25	Oct 28
COVID-19 Resources and Guidelines – see SOPHIA
Critically Ill Pregnant or Recently Pregnant Patient – see SOPHIA

D

Title	Last Review	Next Review
Delayed Cord Clamping – see Neonatal Guidelines
Diabetes in Pregnancy	Dec 25	Dec 28
Digital Inclusion in Maternity SOP – see SOPHIA
DNA Policy (Maternity and Maternity Ultrasound) – see SOPHIA

E

Title	Last Review	Next Review
Early Pregnancy Support Scan Clinic SOP	Jul 22	Jun 25
Educational Strategy – see SOPHIA
Elective Caesarean Section in Main Theatres SOP	Jan 26	Jan 29
Engagement of Locum Medical Staff in Obs and Gynae SOP	Mar 25	Nov 26
Entonox: Management within the Maternity Service – see SOPHIA
Epilepsy in Pregnancy	Jul 24	Jul 25
EPU Guidelines – see Gynaecology guidelines
Extreme Prematurity Delivery Guidelines – see SOPHIA
Extreme Prematurity Flowchart – see SOPHIA

F

Title	Last Review	Next Review
Failure of Maternity Doors SOP – see SOPHIA
Female Genital Mutilation (FGM): Management, Prevention and Detection in Women and Children – see SOPHIA
Fetal Anomaly Screening Programme	Apr 26	Apr 29
Fetal Growth Surveillance Pathway	Apr 26	Apr 29
Fetal Pillow and Impacted Head	Jun 23	Jun 26
Frenulotomy Guideline	Mar 25	Mar 28
Formalin Spillage – see SOPHIA

G

Title	Last Review	Next Review
Group B Strep – Prevention of Early Onset Neonatal Group B Streptococcus Infection	Mar 25	Dec 27
Growth Scan SOP – see section 6 of the fetal growth surveillance guidelines

H

Title	Last Review	Next Review
Herpes – See RCOG Guideline
HMP Bronzefield – Maternity Care of Women and Birthing People SOP	Mar 26	Mar 29
Home Blood Pressure Monitoring for Maternity SOP	Jul 23	Jul 26
Homebirth Guidelines – see SOPHIA
Homebirth SOP – see SOPHIA
Hypertension in Pregnancy	Apr 24	Apr 26
Hypoglycaemia – see Neonatal guidelines
Hyponatraemia in Pregnancy: Prevention, Diagnosis and Management – see SOPHIA

I

Title	Last Review	Next Review
Immediate Care of the Term Newborn Baby	Sep 25	Jan 28
Induction of Labour	Aug 25	Aug 28
Infant Feeding: Infant Feeding Policy (Jan 25) Infant Feeding Volunteers SOP (Dec 24) Feeding Management Pathway (May 23) Weighing Baby Pathway (Sep 24) Feeding and Nurturing Padlet	May 23	Apr 26
Infectious Diseases in Pregnancy: Hepatitis B, Hep C, HIV and Syphilis	Apr 26	Apr 29
Intrahepatic Cholestasis of Pregnancy ICP Guideline	Jun 23	Jun 26
Intrapartum Fetal Heart Rate Monitoring	Oct 25	Oct 28
Iron Deficiency Anaemia (IDA) in Pregnancy	Jun 23	Jun 26

J

Title

Last Review

Next Review

Jaundice:

Jaundice – Neonatal (Mar 2024)
Jaundice Management Quick Reference Sheet (Oct 2024)

Jan 22

Jan 25

L

Title	Last Review	Next Review
Latent Phase Management in Low Risk Women	Aug 25	Aug 28
Locations for Referral in Maternity Table	Mar 24	Mar 27
Locum Doctors Induction – see SOPHIA

M

Title	Last Review	Next Review
Management of Blood and Microbiology Test Results SOP	Apr 25	Apr 28
Management of In-Utero Transfers (including preterm labour, ruptured membranes, pre-eclampsia, fetal growth restriction) In-Utero Transfer Principles – Southeast Regional Maternity Team NHS England – see SOPHIA	Mar 25	Mar 28
Management of Lactation Following Baby Loss	Dec 24	Dec 27
Management of Pregnant Women with Obesity or Bariatric Surgery	Oct 24	Oct 27
Managing Screening Incidents SOP	Feb 25	Jan 28
Marsden Manual – see SOPHIA
Maternal Death – see SOPHIA
Maternal Medicine Network (MMN) Networked Maternal Medicine Services in London (Dec 2021) Surrey Heartlands LMNS Maternity COVID Guidance – see SOPHIA Surrey Heartlands Maternal Medicine Network Pathway – see SOPHIA
Maternal Sepsis During and Following Pregnancy Sepsis Risk Assessment and Quick Reference Guide – see SOPHIA	Feb 26	Feb 29
Maternity Day Assessment Unit (MDAU) – Clinical and Operational SOP	Mar 25	Mar 28
Maternity Immunisation Clinic SOP	Aug 25	Aug 28
Maternity Safeguarding Policy – see SOPHIA
Maternity Operational Co-ordinator (MOC) SOP – see SOPHIA
Maternity Unit Escalation Policy – see SOPHIA
Measles Exposure or Infection in Pregnancy Guidance – see SOPHIA (SWLaSH MMN)
Medical Staffing Escalation Policy – see SOPHIA
Metocloprmaide PGD – see SOPHIA
Midwives Exemptions	Mar 25	Mar 26
Moxibustion for Breech Presentation	Feb 23	Feb 26
Multiple Pregnancy Guideline	Oct 24	Oct 27

N

Title	Last Review	Next Review
Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum – see SOPHIA
Neonatal Attendance at Birth SOP	Nov 23	Nov 26
Neonatal Deterioration: Escalation and Monitoring Guideline – see SOPHIA
Neonatal Resuscitation at Birth – see Neonatal Guidelines
Newborn Bloodspot Screening	Dec 25	Dec 28
Newborn Security Policy incorporating Baby Abduction – see Baby / Child (Abduction) Security Policy	Apr 21	Apr 24
Nicotine Replacement Therapy (NRT) SOP – see SOPHIA
NIPE – Newborn and Infant Physical Examination – see SOPHIA
Non-Attendance at clinic appointments or non-access visits for children under 18 years of age – see Paediatric guidelines

O

Title	Last Review	Next Review
Obs and Gynae Ultrasound Guidelines – see SOPHIA
Obstetric Referral Indications to Antenatal Clinic (SOP)	Nov 25	Nov 28
Omeprazole PGD – see SOPHIA
Oral Glucose Tolerance Test (OGTT) SOP – see SOPHIA
Ovarian Cysts in Pregnancy SOP	Mar 25	Mar 28
Overnight Visitors: Overnight Visitors SOP (Oct 24) Expectations of Overnight Visitors (Nov 24) Supporting your Partner at Night on the Maternity Ward Leaflet (Nov 24)	Oct 24	Nov 27
Oxytocin (Syntocinon) to Induce / Augment Labour	Jan 25	Jan 28

P

Title	Last Review	Next Review
Pandemic Flu – see SOPHIA
Perinatal Mental Health Guideline – see SOPHIA
Perinatal Optimisation Guideline	Dec 23	Dec 26
Perinatal Pelvic Care in Pregnancy	Nov 24	Nov 27
Perinatal Post Mortem Consent	Aug 23	Sep 26
Placental Histology and Obstetric Clinical Follow-up SOP	Jun 23	Jun 26
PMA Lead and Sessional PMA SOP	Dec 24	Dec 27
Postnatal Care: Postnatal Care Guideline (Apr 26) Postnatal Community Care Leaflet (Mar 23)	Apr 26	Apr 29
Postnatal Review by Doctors on Postnatal Ward (SOP) – see SOPHIA
Postpartum Haemorrhage – see SOPHIA
Pregnancy Loss – Leaflet	Jul 23	Jul 26
Pregnancy Loss – Post 24 Weeks	Dec 25	Jun 28
Pregnancy Loss – Pre 24 Weeks	Dec 25	Jan 28
Preterm Labour and Birth: Prevention and Management	Jul 26	Jul 29

Q

Title	Last Review	Next Review
Quality, Safety, and Risk Framework	Mar 26	Mar 29

R

Title	Last Review	Next Review
Ratification of Clinical Guidelines in Maternity SOP – see SOPHIA
Recognising the Deteriorating Pregnant Woman	Mar 26	Mar 29
Reduced Fetal Movement Guideline	Nov 23	Nov 26
Reportable Perinatal Incidents to External Organisations – see SOPHIA
Retained Placenta	Jun 25	Jun 28
Roles and Responsibilities of the Consultant providing acute care in Obstetrics and Gynaecology SOP – see SOPHIA

S

Title	Last Review	Next Review
Safe Sleeping Guidance for Babies (Bed Sharing / Co-sleeping)	Sep 25	Sep 28
Self-Administered Medication for Post-operative Caesarean Section – see SOPHIA
Sensitive Disposal Form 12-23+6 weeks – see SOPHIA
Sepsis During and Following Pregnancy Sepsis Risk Assessment and Quick Reference Guide – see SOPHIA	Feb 26	Feb 29
SHOTTS Guideline	Nov 25	Oct 28
Shoulder Dystocia Guidelines	Jun 23	Jun 26
Sickle Cell: Antenatal and Newborn Sickle Cell and Thalassaemia Screening Programme Guideline	Jul 26	Jul 29
Sickle Cell Disease in Pregnancy (RCOG)	Jul 11
Spontaneous Rupture of Membranes (SROM) at Term	Apr 23	May 26
Staff Guide for Ward Audits – see SOPHIA

T

Title	Last Review	Next Review
Thyroid Disease in Pregnancy – see SOPHIA
Tobacco Dependency Treatment Service for Maternity Patients SOP – see SOPHIA
Tommy’s Application SOP Standardised Blood Pressure Measurement – see SOPHIA	Dec 23	Dec 26
Transfer of Deceased Babies to the Mortuary – see SOPHIA
Transfer to SPH Maternity and Neonatal Unit – Leaflet	Mar 24	Jan 25
Transitional Care: Management of Neonates on Transitional Care and the Postnatal Ward – see SOPHIA Jaundice – Neonatal (Mar 24) Jaundice Management Quick Reference Sheet (Oct 24) Weighing babies and well baby clinic pathway (Sep 24) Patient leaflet: Transitional Care Unit – see SOPHIA Patient leaflet: Transitional Care Unit (for Joan Booker Patients) – see SOPHIA
Triage Operational and Job Roles SOP	Apr 25	Apr 28
Triage and BSOTS Clinical Guideline	Oct 25	Oct 28
Triage Standardised Telephone Advice – see SOPHIA

U

Title	Last Review	Next Review
Ultrasound Guideline – see SOPHIA
Ultrasound Guideline DNA – see SOPHIA
Uterine Inversion	Mar 25	Mar 28

V

Title	Last Review	Next Review
Vaginal Cell Salvage Guideline	Jan 25	Jan 28
Guidance on the investigation, diagnosis and management of viral illness (plus syphilis), or exposure to viral rash illness, in pregnancy [UK HSA]	Aug 24
Venous Thromboembolism: Investigation and Treatment of Pregnant and Postnatal Women Thrombosis UK / OUH: VTE and Pregnancy (Feb 22)	Mar 25	Mar 28
Vitamin K: Post discharge Vitamin K supplementation for High risk preterm babies (Feb 24) A Parent’s Guide (Mar 24)

W

Title	Last Review	Next Review
Waterbirth: The use of the pool for labour and birth	Feb 26	Feb 29
Weighing Baby Pathway	Sep 24	Sep 27
Women that Decline Blood Products – see Blood Tranfusion Policy