The Organizational Standard of Perinatal Care

In this article we would like to share some information on regulation which influences maternity care in Poland. We start with it’s history to show the perspective and background, then there is a summary of most important provisions of the Standard. This article is dedicated mainly to midwives and other professionals who find English version of the Standard useful in their work. Separate article dedicated to non-professionals who are interested in the Standard of perinatal care in Poland is going to be shared. 

History of the Standard - Where does it come from?

First such regulation by the Ministry of Health dedicated to perinatal care in Poland was introduced in 2012 by the Ministry of Health. It was passed only after years of struggle for establishing clear regulations in the field of health care. The aim of the regulation was to improve the quality of maternity care nationwide. At the time it was a regulation focused only on the care for a woman in physiological pregnancy and birth, postpartum period and newborn care. Separate regulation was dedicated to pain management and another one to conduct in situations of adverse obstetric outcomes. In 2016 this law was challenged and due to changes in the Ministry of Health prerogatives, the Ministry was no longer able to issue medical standards. That was a serious threat to the Perinatal Care Standards existence. Strong public opposition, voiced for example with 80k signatures under a petition initiated by The Childbirth with Dignity Foundation, led to formation of a multidisciplinary working group which proposed a new regulation, this time on “organisation of care”. This regulation was passed in 2018 and entered into force on 1 January 2019. It is known as “The Regulation of the Minister of Health on Organizational Standard of Perinatal Care”. It is called SOOO or the Standard for short.

 

The most important change to the previous regulation is that this one applies to all providers of health care services in the field of perinatal care. Thus, the scope of application has extended and includes not only situations of physiological pregnancy, birth and postpartum, but also pain management and “Caring for a woman in special situations”, which are miscarriage, giving birth to a sick baby or stillbirth, no longer just dry “adverse outcome” term is used. One of the main objectives of the Standard is ensuring well-being of mother and baby and at the same time reduction of medical interventions only to those that are necessary, especially amniotomy, labor induction, stimulation of uterine contractions, opioids administration,  episiotomy, cesarean section and administering breastmilk substitutes to the newborn.

 

Below you can find a summary of the most important details of this law in particular aspects of care. 

Care during pregnancy 

The Standard regulates what should be offered to every pregnant person by the health care provider: visits, tests, exams, consultations. It emphasizes that the exercise of a patient's rights in perinatal care is especially: respecting the right of a birthing person to: participate in the decision making process, choose place of birth and the health care provider. 

Who can be the main health care provider during pregnancy in Poland?

Most popular option is a physician during a specialisation process or specialist in gynecology and obstetrics (OB-GYN). This health care provider is entitled to provide care in uncomplicated pregnancies as well as in pregnancies with complications. 

Midwife can also be the main care provider during pregnancy. Midwife is an independent health care specialist, who can look after the pregnant person, independently assist during physiological labor and birth and provide care for the parent and the baby after birth. This applies to pregnancies which unfold without complications. This choice opens a possibility of having midwifery-led continuity of care, a model of care proven by modern research to be most successful in improving not only safety of perinatal period for parents and babies but also maternal experience of pregnancy, birth and postpartum. 

 Community midwife and antenatal education

If the main care provider is not a community midwife (eng. family midwife, Basic Health Care midwife), the doctor should between 21-26 weeks gestation inform a pregnant person  that such is entitled to care from the community midwife. This should be recorded in the medical record. Care from the community midwife is refunded by NFZ (eng. National Health Fund) and before birth visits are focused on antenatal education. It would be perfect if a pregnant person chooses the same community midwife for the baby so she would visit both of them in the first days and weeks postpartum. This is a way to get continuity of care at least in part and within refunded services. For the first time the program of antenatal education is described in the Standard, which should ensure that every pregnant person, whether such chooses to have educational meetings with a community midwife or with another educator, will receive at least minimum of the most important information on pregnancy, birth and postpartum.

Visits

The Standard states that during physiological pregnancy there should be a consultation with the care provider at least every 3-4 weeks depending on the advancement of the pregnancy, more often when necessary. More on what consultations and tests and when should be offered you can find in the table in pdf format here.

 

The scope of preventive services and activities in the field of health promotion as well as diagnostic tests and medical consultations performed for pregnant women, including the periods of their performance.

weeks of pregnancy Preventive services provided bydoctor or midwife and activities in the field of health promotion Diagnostic tests and medical consultations
1. 2. 3.
before 10. or at the first visit
  1. The interview and physical examination.
  2. Blood pressure measurement.
  3. Examination of the mammary glands.
  4. Determination of height, weight and BMI.
  5. Pregnancy risk assessment.
  6. Promoting a healthy lifestyle.
  7. Provision of information about the possibility of testing for genetically determined diseases.
  8. In the case of midwife care, consultation with an obstetrician is obligatory.
  9. Collecting data on healthy lifestyle and eating habits, including the consumption of alcohol and other stimulants.
  1. Blood group and Rh, unless the pregnant person has a properly documented test results for blood group and Rh.
  2. Immune antibodies to red blood cells antigens.
  3. Blood morphology (blood count).
  4. Urine test.
  5. Pap smear, if it was not performed within the last 6 months.
  6. Fasting blood glucose test, optionally OGTT if a woman has risk factors of GDM.
  7. Blood test for syphilis (VDRL).
  8. Recommendation of a dental checkup.
  9. Blood test for HIV and HCV (hepatitis C virus).
  10. Toxoplasmosis test (IgG, IgM), unless the pregnant person shows a result confirming the presence of pre-pregnancy IgG antibodies.
  11. Rubella test (IgG, IgM), unless the pregnant woman was ill or was not vaccinated or in the absence of information.
  12. Blood test for TSH level (thyroid-stimulating hormone).
11-14 
  1. The interview and physical examination.
  2. Blood pressure measurement.
  3. Body mass measurement.
  4. Pregnancy risk assessment.
  5. Assessing the risk and intensity of depression symptoms.
  6. Promoting a healthy lifestyle.
An ultrasound examination according to the recommendations of the Polish Society of Gynecologists and Obstetricians (PTGiP).
15-20 
  1. The interview and physical examination.
  2. Blood pressure measurement.
  3. Body mass measurement.
  4. Pregnancy risk assessment.
  5. Promoting a healthy lifestyle.
  1. Blood morphology (blood count).
  2. Urine test.
18-22  An ultrasound examination according to the PTGiP recommendations.
21-26  Beginning of antenatal education.
21-26 
  1. The interview and physical examination.
  2. Blood pressure measurement.
  3. Body mass measurement.
  4. Pregnancy risk assessment.
  5. Promoting a healthy lifestyle.
  6. If the care provider is a midwife, consultation with an OB-GYN (24-26 weeks of pregnancy).
  1. Blood glucose testing after oral administration of 75 g glucose (at 24-26 weeks of gestation) - 3-point glucose test: before administration of glucose (on an empty stomach), after 1 and 2 hours from the administration of glucose.
  2. Urine test.
  3. Anti-D antibodies in Rh (-) women.
  4. In women with negative results in the first trimester - testing for toxoplasmosis (IgM).
27-32 
  1. The interview and physical examination.
  2. Fetal heart rate assessment.
  3. Blood pressure measurement.
  4. Body mass measurement.
  5. Pregnancy risk assessment.
  6. Promoting a healthy lifestyle.
  1. Blood morphology (blood count).
  2. Urine test.
  3. Anti-D antibodies in Rh (-) women.
  4. An ultrasound examination according to the PTGiP recommendations.
  5. Administration of anti-D immunoglobulin if indicated (28-30 weeks of gestation).
33-37 
  1. The interview and physical examination.
  2. Obstetric examination.
  3. Fetal heart rate assessment.
  4. Blood pressure measurement.
  5. Fetal movement assessment.
  6. Body mass measurement.
  7. Pregnancy risk assessment.
  8. Assessing the risk and intensity of depression symptoms.
  9. Promoting a healthy lifestyle.
  1. Blood morphology (blood count).
  2. Urine test.
  3. HBs antigen test (hepatitis B).
  4. HIV test.
  5. Vaginal and rectal culture for B-hemolytic streptococci - GBS (35-37 weeks of gestation).
  6. Test for syphilis (VRDL) and HCV (hepatitis C virus) if a pregnant person is in a group of increased population or individual risk of infection.
38-39 
  1. The interview and physical examination.
  2. Obstetric examination.
  3. Fetal movement assessment.
  4. Fetal heart rate assessment.
  5. Blood pressure measurement.
  6. Body mass measurement.
  7. Pregnancy risk assessment.
  8. Promoting a healthy lifestyle.
  9. If the care provider is a midwife, consultation with an OB-GYN.
  • Blood morphology (blood count).
  • Urine test.
immediately after 40. 
  1. The interview and physical examination.
  2. Obstetric examination.
  3. Fetal movement assessment.
  4. Blood pressure measurement.
  5. Body mass measurement.
  6. Pregnancy risk assessment.
  1. CTG examination (Cardiotocography).
  2. An ultrasound examination according to the PTGiP recommendations.
 
  1. With normal CTG and USG results and with proper feeling of fetal movements - another examination in 7 days with repeat CTG and ultrasound. During this visit, the date of hospitalization should be set, so that the delivery takes place before the end of week 42. In the event of deviations from norms - individualization of procedure.

Care Plan and Birth Plan preparation

The care provider is obligated to prepare a birth plan and plan of care during pregnancy with a pregnant person. They are both based on a pregnant person’s individual situation and preferences. The plan of care includes tests and exams a pregnant person should consider during pregnancy and time of their performance. It is good to consider what type of care a pregnant person needs in the last weeks of pregnancy given chosen birth place and common procedures there. The birth plan is a document focused specifically on a pregnant person’s preferences during labor, birth, first hours after birth and the newborn care. Both of those plans are official documents and should be included in medical records. It would be desired if the birth plan was discussed with a care provider who will be assisting during labor beforehand. If it is not possible, it is recommended to have a few copies of a birth plan and plan of care during pregnancy and to hand them over right away on admission to the hospital with other documents. 

Place of birth

Standard includes regulations on choosing the place of labor (they may be found in the section dedicated to preparation of the birth plan). It gives a pregnant person the right to choose a place of birth in a hospital or in an out-of-hospital setting and obtain comprehensive information on the selected place of birth, including indications and contraindications. Also if only this is possible, the health care facilities should create an opportunity for a pregnant person to visit a hospital, including maternity ward before birth. This creates a possibility to get to know the hospital and staff working there. Additionally, such visits should include a consultation with an anesthesiologist if regional analgesia is expected to be used by a birthing person and should offer an opportunity to fill in all necessary paperwork.

Care during birth

What should always happen? - respect, information, consent

The main point of the Standard dedicated to care during birth obliges health care providers to establish good contact with a birthing person and to understand the importance of posture, words and tone of voice during the conversation with the birthing person. The staff members are obligated to ask about the birthing person’s needs and expectations, answers should be used by the care providers to support and guide the birthing person during labor. The privacy of the birther and her sense of intimacy should always be respected. Interaction should always start with a care provider introducing herself/himself and explaining her/his role in the process. Care during labor should be continuous and as much as possible adapted to a birthing person’s needs. The biggest change relates to the possibility of having meals or snacks during labor - Standard regulates that  “ the decision whether a birthing person can eat during labor is made by the main care provider”. As it may sound too cautious, we believe this is a step forward, before the new Standard was introduced, there had been only provision on the allowance of drinking clear fluids during labor.  

 Pain management

This part of the Standard  gathers provisions about non-pharmacological methods of pain management that should be accessible to all birthing people. It also describes how pharmacological methods should be used, especially regional analgesia - epidural. However,  there is no provision that guarantees access to it to all birthing people. The birthing person has the right to pain management and the care providers should inform the birthing person on methods accessible in this particular healthcare facility.

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Fotografia Anna Wibig Obiektywnie Najpiękniejsze

The Standard includes the following non-pharmacological methods of pain management:

- physical activity during labor and taking positions that lower pain sensations, movement naturally alleviates pain, during labor itself the birthing person has the right to walk, dance, rock, squat, use birthing ball, sako bag or bars, mattress, birthing chair;

- breathing techniques and relaxation exercises;

- physiotherapy methods, including: relaxing massage, warm and cold compresses in places where you feel pain, TENS - Transcutaneous nerve stimulation;

- water immersion;

- acupuncture;

- acupressure.

Among pharmacological methods listed there are:

- inhalation analgesia;

- intravenous or intramuscular use of opioids;

- regional and local analgesia.


The Standard says that in case of pharmacological methods, there is a need for closer monitoring of the condition of both the birthing person and the fetus, and later the birthing person and the newborn.

Four stages of a labor

Next part of the Standard describes procedures that should take place during particular phases of labor, certain tasks for the medical staff, we are going to go through some of them below. Here we are giving you also definitions provided by the Standard, which influence the practice.

“Being in labor” is defined as having uterus contractions that result in cervix dilation. 


First stage of labor is labor from regular uterus contractions that result in cervix dilation until reaching full dilation of the cervix. Lack of progress in labor in this stage is defined as change of dilation of the cervix less than 0,5 cm per hour assessed in 4h interval. When this happens an OB-GYN steps in and joins the care provider’s team. 

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Fotografia Anna Wibig Obiektywnie Najpiękniejsze

As to what may happen during the first stage of labor the most important part is that the main care provider, probably a midwife, has to discuss with a birthing person the birth plan. All “on admission” procedures should take place after a birthing person consents to them, perineal shaving or enema should be performed only on a birthing person’s request and placing of intravenous cannula should be performed only if medically indicated. At this point the birthing person should be informed on pain management options available in the facility. From the start the priority of the care provider should be facilitating the physiological process of labor and avoiding disturbances, that includes for example enabling and encouraging the birthing person to move and adapt positions that her body dictates her to adapt, especially vertical labor positions. Intermittent auscultation, every 15-30 minutes is preferred method of fetal heartbeat assessment. Continuous fetal monitoring with a CTG (cardiotocograph) machine should be used only in medically indicated cases, this option of fetal monitoring is unfortunately often associated with movement restrictions due to equipment requirements, not all maternity wards in Poland have wireless devices. Presence of a birthing partner of choice should be encouraged and supported by the staff.

 

Second stage of labor is defined as the time between full dilation of the cervix and birth of the baby. The Standard says that this time should not be longer than 2h or 3h when the birthing person is using the epidural. If this stage of labor is longer than 2h an OB-GYN is taking over as the main care provider and he is making a decision if labor can continue or there should be an intervention based on clinical situation. In the second stage of labor fetal heart rate should be assessed more often, preferably after every uterus contraction. Also in this stage of labor, a birthing person should be able to get into the most comfortable position, especially adapting vertical positions should be encouraged and supported by the care provider. Pushing should be spontaneous and not routinely dictated by a midwife or a doctor. The main care provider is obligated to protect the perineum and episiotomy may only be performed when medical indication occurs. 

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Fotografia Anna Wibig Obiektywnie Najpiękniejsze

Third stage of labor is defined as from the moment that baby is born up to the moment that the placenta detaches and is born. The Standard says that this stage should not be longer than 1 hour. The newborn baby should be placed on the birthing person's belly in immediate skin to skin contact. This first contact may be interrupted only if the mother or the baby are in a life or health threatening condition. This interruption and it’s reason have to be noted in medical records. Assessment of the newborn condition (Apgar score) should take place on mothers belly, the neonatal examination should be performed after the fourth stage of labor and the first contact. The cord is to be clamped and cut after it stops pulsating but not sooner than 1 minute after the baby is born. Medications to aid uterus shrinking or expulsion of the placenta should be administered if needed. Routine active management of the third stage by uterus massage and cord traction is not recommended.    

 

Fourth stage of labor is two hours after the placenta is born. During this time “skin to skin” contact between mother and baby should be continued. The care provider should monitor how the mother's uterus is shrinking and if there is no additional bleeding. Up to 500 ml of blood loss during birth is considered normal. This is estimated in the third and the fourth stages of labor. If the mother has any injuries this is the time when they are going to be examined and if needed sutures may be placed. If the mother plans to breastfeed she should get help from the care provider in the first latching of the baby if needed in those 2h. It is possible that the baby will just get to the breast when it is ready and latch on it’s own, in this case the care provider should just observe how the mother and baby are doing. 

Newborn care

This part is dedicated mainly to how care for a newborn in a postnatal ward should look like. Basic care system is “rooming-in”, it means that during hospital stay the baby is in the same room as a mother. It is recommended that all routine medical and care procedures are performed in this room, in mother’s presence and with her consent. The examination of the baby by a neonatologist should take place within 12 h after but not in the first 2h postpartum. At least one of the parents should be present during this examination.

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Fotografia Anna Wibig Obiektywnie Najpiękniejsze

 

List of routine tests and medical procedures which should be offered to all newborns:

- prophylaxis of eye infection with Neisseria gonorrhoeae (which causes gonorrhoea, and in newborn can cause serious eye infection) also known as Credé procedure;

- prophylaxis of bleeding caused by vitamin K deficiency, usually it’s a shot with vitamin K;

- vaccination according to current recommendations (this comes with establishing a immunization record for the baby which will be then passed to your Basic Health Clinic), vaccination should be performed after examination by a doctor, who will qualify the newborn to be vaccinated or advices vaccination to be postponed; 

- prophylaxis of rickets in form of oral vitamin D supplementation according to current recommendations;

- if needed anti-HBS immunoglobulin;

- after 48h from birth, a dried blood spot test that is able to detect for example phenylketonuria, cystic fibrosis or congenital hypothyroidism, blood drops are collected from punctures the newborn’s heel on special tissue. 

- hearing screening;

- pulse oximeter test, which is able to detect early any cardiological problems in the newborn;

- assessement of suckling skills.

 All of those procedures should take place after parental consent and parents have the right to be present. Many of those procedures can be performed with a baby in the parent's arms, which can reduce the baby's distress.

Breastfeeding support 

In the Standard there are many provisions that are aimed on ensuring that mother is going to get adequate support in breastfeeding. It starts during antenatal education, continues after birth in birth room, where in the first 2h postpartum breastfeeding should take place and then in maternity ward the staff should also provide support in form of:

- information about advantages of breastfeeding and feeding with mother’s milk based upon current state of knowledge;

- instructions on breastfeeding techniques, positions and indicators of successful feeding;

- observation of breastfeeding, making sure that the baby feeds successfully and introducing interventions if they are needed for example to improve baby’s suckling technique.

Additionally formula should be given to the baby only when prescribed by a doctor or on mother’s request. The Standard also introduces a ban on advertisement of breastmilk substitutes and accessories connected to them in healthcare facilities which provide care for pregnant, birthing people and newborns. The healthcare facilities are obligated to provide access to lactation supporting equipment such as breast pumps.

Before a mother is discharged from the hospital it is preferred that she indicates which Basic Healthcare Clinic has been chosen to care for the baby. Hospital then can transfer documents such as the immunisation record directly to another healthcare provider and notify the baby's community midwife that the baby is born and she should offer a visit. If a mother hasn't chosen such a Basic Healthcare Clinic she should be informed of such possibility, especially about visits of the community midwife.

Postpartum period

The postpartum period covered by the Standard’s provisions is six weeks after birth. In this time mother and the baby are entitled to continuous professional care at the place of their residence or stay. This care is primarily provided by the community midwife, who should visit them at home at least 4 times, more visits may take place if needed.

 

What can the community midwife do during postpartum visits?
The midwife is obligated to:

- assess mother’s and baby’s general condition (including mother’s mental condition to assess the risk of postpartum depression);

- assess and examine baby’s development and weight gain;

- give all necessary advice and information on breastfeeding and encourage mother to breastfeed;

- give all necessary advice and information on newborn care (like bathing or umbilical cord stump hygiene), healthy lifestyle and diet, coping with stress, family planning methods, cervical and breast cancer prophylaxis etc.;

- inform parents about recommended vaccination schedule for the baby and prophylactic pediatric appointments;

- inform mother about visit to OB-GYN 8 weeks postpartum being recommended ;

 

If the mother requires such help, it is within the midwife’s scope of practice to remove sutures from perineum or belly during the visit. She may also offer basic lactation consultation and suggest solutions for any problems with breastfeeding. If the difficulty you face exceeds her competence, the midwife will refer you to another specialist or institution.

After 8 weeks of life the care over the baby is moved to the care of the community nurse. Care over mother, including lactation support, is continued by the community midwife.

 

Caring for a woman in special situations

“Special situations” include diagnosis of a serious disease or a defect of the child during pregnancy, miscarriage, stillbirth, giving birth to a baby who is unable to live outside of the womb, sick or with a congenital anomaly.

If a pregnant person finds herself in such a situation she is entitled to care based upon respect and she has the right to trust that all medical staff are aware of her situation in order to act with as much sensitivity as possible and are prepared to care for her. After the diagnosis is communicated she should have all the time she needs to prepare for further discussion of her healthcare plan and decision making process, in which she has the right to fully participate and should be able to get psychological support, support from family, someone close or clergyman of the religion she believes in, according to her wishes. This may be postponed only if her condition requires urgent medical intervention. If there is diagnosis of incurable disease or severe congenital abnormality during pregnancy or after birth, she should be informed of the possibility to get palliative and hospice care, this is offered mostly in healthcare facilities on 3rd. level of care system and also by dedicated non-governmental organizations organizations.

 

When she is admitted to a healthcare facility, if only this is possible in this facility, she should not be together with women pregnant or after birth, who have given birth to healthy babies. The staff members should introduce themselves and explain their role in care. All procedures should be performed with her consent. After birth she should be able to say goodbye to the baby, with people close to her, relatives present, if this is what she wants. 

She should be fully informed about:

- her health;

-  that she can seek further psychological support and what organizations and institutions offer such support; 

- what rights she has in this situation: her legal status when it comes to marital status records, social security, labor law and that there is a possibility of organising a burial.

She should get lactation help based on her individual situation and the current medical knowledge.

What if the care provided was not compliant with the Standard? 

Despite our regulations having been in force for quite some time now, it still happens that pregnant and birthing people do not get help compliant with the Standard. As a citizen using public or private medical services each can express their opinion on care received and send it to the healthcare provider. In fact the healthcare facilities should themselves monitor indicators of healthcare quality such as satisfaction of pregnant and birthing people who use their services. The Standard described in this article is closely related to the Patients Rights Act and as a patient everyone has a right to address the Patient Rights Ombudsman and present the situation, what was the care like in the facility one went to. Currently tools offered by the Childbirth with Dignity Foundation are in Polish but if legal advice is needed one may write to the Foundation in English. As an organisation we believe that every official signal that goes to the hospital management, the Ombudsman or other authorities that shows a birthing person’s perspective is an important step on the way to make perinatal care in Poland better for our future births of generations to come. 

 

Anna Kwiatek-Kucharska

sfinansowano przez Narodowy Instytut Wolności ze środków Programu Rozwoju Organizacji Obywatelskich

 

Rozpoczynamy KAMYKI 2020! – Chorągiew Łódzka ZHP

 

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