Pre-Birth

Young babies are particularly vulnerable to abuse, and early assessment, intervention and support work carried out during the antenatal period can help minimise any potential risk of harm. This procedure sets out how to respond to concerns for unborn babies, with an emphasis on clear and regular communication between professionals working with the mother, the father and the family.

All professionals have a role in identifying and assessing families in need of additional support or where there are safeguarding concerns. In the vast majority of situations during a pregnancy, there will be no safeguarding concerns.

However, in some cases it will be clear that a co-ordinated response by agencies will be required to ensure that the appropriate support is in place during the pregnancy to best protect the baby before and following birth.

The antenatal period provides a window of opportunity for practitioners and families to work together to:

• Form relationships with a focus on the unborn baby;
• Identify risks and vulnerabilities at the earliest stage;
• Understand the impact of risk to the unborn baby when planning for their future;
• Explore and agree safety planning options;
• Assess the family's ability to adequately parent and protect the unborn baby and the baby once born;
• Identify if any assessments or referrals are required before birth; for example the use of the local Children's Services Referral Form and Child & Family Assessment;
• Ensure effective communication, liaison and joint working with adult services that are providing on-going care, treatment and support to a parent(s);
• Plan on-going interventions and support required for the child and parent(s);
• Avoid delay for the child where a legal process is likely to be needed such as Pre-proceedings, Care or Supervision Proceedings in line with the Public Law Outline.

Where professionals become aware a woman is pregnant, at whatever stage of the pregnancy, and they have concerns for the mother or unborn baby's safety and wellbeing, or that of siblings, they should not assume that Midwifery or other Health services are aware of the pregnancy or the concerns held.

Professionals should consider whether the new-born baby will be safe in the care of these parents/carers and if there is a realistic prospect of these parents/carers being able to provide adequate care throughout childhood. If not, a pre-birth assessment may be required.

Each professional should follow their agency's child protection procedures and discuss concerns with their safeguarding lead.

Parental risk factors that may indicate an increased risk to an unborn child and which may mean that a pre-birth assessment is required:

• Involvement in risk activities such as substance misuse, including drugs and/or alcohol;
• Perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met;
• Victims or perpetrators of domestic abuse;
• Identified as presenting a risk, or potential risk, to children, such as having committed a crime against children;
• A history of violent behaviours;
• May not be able to meet the unborn baby's needs e.g. significant learning difficulties and in some circumstances severe physical or mental disability;
• Are known because of historical concerns such as previous neglect, other children subject to a child protection plan, subject to legal proceedings or have been removed from parental care;
• Known because of parental involvement as a child or adult with Children's Social Care;
• Currently in care themselves or were in care as a child or young person (care leavers);
• A history of abuse in childhood;
• Are teenage/young parents;
• Recent family break up and social isolation/lack of social support;
• Any other circumstances or issues that give rise to concern.

The list is not exhaustive and, if there are a number of risk factors present, then the cumulative impact may well mean an increased risk of significant harm to the child. If in doubt, professionals should seek advice about making a referral. Each situation will be determined on a case by case basis.

Where pre-birth involvement is a result of the mother’s learning difficulties causing uncertainty as to her ability to meet the needs of the child once born, the Court of Appeal in D (A Child) [2021] EWCA Civ 787 stressed the importance of effective planning during the pregnancy for the baby’s arrival, and of taking adequate steps to ensure that the mother understands what is happening and is able to present her case.

See also Children of Parents with Learning Difficulties/Disabilities Procedure.

Safer Sleep

Sudden Infant Death Syndrome (SIDS), which was formerly called 'cot death', is the sudden and unexplained death of a baby where no cause is found. Although SIDS is rare, it still accounts for a small but significant percentage of deaths among infants across the UK every year. Every one of these deaths is a tragic and unexpected loss for a family.

Of the babies that died whilst sharing a bed with an adult, 90% died in hazardous co-sleeping arrangements.

Although there is no clear cause or explanation for why SIDS happens, research has identified a simple set of key messages for parents and carers that may help reduce the risk of it happening to their baby.

This advice should be followed at all nap times, not just overnight sleeps:

• Always place your baby on their back to sleep, with their feet at the foot of the cot. The safest place for your baby to sleep for their first 6 months is in a cot or Moses basket in the same room as you;
• Use a firm, flat, waterproof mattress that is clean and in good condition;
• Keep your baby smoke free during pregnancy and after birth. For help and advice speak to your midwife or GP;
• Breastfeed, if you can. For help and advice, you can speak to your midwife or GP;
• Never sleep on a sofa or in an armchair with your baby;
• Don’t cover your baby’s face or head while sleeping or use loose bedding;
• Don’t sleep in the same bed as your baby if you smoke, drink, take drugs or medication that may make you drowsy, or if your baby was born prematurely or was of low birth weight;
• Avoid letting your baby get too hot. A room temperature of 16-20°C, with light bedding or a lightweight well-fitting baby sleep bag is comfortable and safe for sleeping babies.

(Lullaby Trust)

Fathers play an important role during pregnancy and after. The National Service Framework for Children, Young People and Maternity Services (2004) states:

'The involvement of prospective and new fathers in a child's life is extremely important for maximising the life-long wellbeing and outcomes of the child regardless of whether the father is resident or not. Pregnancy and birth are the first major opportunities to engage fathers in appropriate care and upbringing of children' (NSF, 2004).

It is important that agencies working with other members of the family refer in to First Contact where there are concerns It is important that all agencies involved in pre and post-birth assessment and support, fully consider the significant role of fathers and wider family members in the care of the baby even if the parents are not living together and, where possible, involve them in the assessment. This should include the father's and other family/household members' attitude towards the pregnancy, the mother and newborn child and his thoughts, feelings and expectations about becoming a parent.

Information should also be gathered about fathers and partners, as well as any other significant members who are not the biological father at the earliest opportunity to ensure that any risk factors can be identified. A failure to do so may mean that practitioners are not able to accurately assess what mothers and other family/household members might be saying about the father's role, the contribution which they may make to the care of the baby and support of the mother, or the risks which they might present to them. Background police and other checks should be made at an early stage on relevant cases to ascertain any potential risk factors.

Involving fathers and any significant others in a positive way is important in ensuring a comprehensive assessment can be carried out and any possible risks fully considered. Agencies working with those members should take the opportunity to contribute to the pre-birth plan co-ordinated through the responsibly Health Trust Maternity Services.

ICON is a parenting programme that supports parents to manage infant crying and help prevent traumatic head trauma (Shaken Baby Syndrome), which can result in devastating injuries and even death in infants. In Durham online posters have been developed– with men/ male cares being the targeted audience.

The key message is that ICON should be discussed at every opportunity with new parents.

When any professional becomes aware that a woman (or the partner of a man with whom they are working) is pregnant and they are of the view that there will be a need for additional support for the unborn child who will be vulnerable due to the circumstances of their service user, they should inform maternity services of their service involvement and highlight any vulnerabilities they have identified.

A Child & Family Assessment can be undertaken in relation to the unborn child. If the mother is under 18, they should be offered an assessment.

Where a professional is concerned that an unborn child or other children in the family may be at risk of, or suffering, harm, they should seek advice from their agency Safeguarding Lead without delay who will consider whether to refer to Children's Social Care - see Referrals Procedure.

A contact should be progressed to First Contact from 10 weeks’ gestation, a referral will then be progressed to either the Pre-birth Intervention Service or Families First Team. An assessment will be completed within 25 working days of the referral. This will identify support on intervention to inform the pre-birth assessment.

Consideration should be given as to whether a legal planning meeting is required - between 16 and 20 weeks’ gestation. Where agreed threshold is met to enter into PLO a pre-proceedings meeting under the Public Law Outline will take place every 4-6 weeks. The PLO meeting will outline the expectations in relation to progressing relevant assessments and set timescales. Where the assessment concludes the removal of the child a PLO review meeting should take place at 32–35 weeks’ gestation.

A pre-birth assessment will be completed by 28 weeks and finalised at 29 weeks of pregnancy, at which point consideration should be given to the most appropriate next steps, at a multi- agency planning meeting. If it is clear from the Pre-birth Assessment that there is reasonable cause to believe the baby will be at risk of significant harm when born, this meeting should take the form of a Strategy Meeting. The purpose of the meeting  is to consider the findings and recommendations from the report and make plans about next steps in relation to support and any necessary intervention to protect the baby. The Assessment should be shared with the parents and a pre-proceedings meeting will be convened which will allow parents the opportunity to challenge the proposed plan. Consideration will need to be given around the need to request a Pre-birth Initial Child Protection Conference.

Previous Child subject to Public Proceedings

When a professional becomes aware that a parent has had a previous child subject to public care proceedings a referral should be progressed to First Contact at the earliest opportunity. First Contact will then assess each case on a case by case basis and progress the referral to the appropriate team.

In those cases, a pre-proceedings meeting is to be held under the Public Law at  the earliest opportunity, in some circumstances this maybe before 16 weeks of pregnancy.

Plan to Remove from Birth

Where the assessment concludes the removal of the child a pre-proceedings PLO meeting will need to be arranged to seek parents agreement to place the baby outside of their immediate care under Section 20. If the parents do not agree to Section 20, consideration should be given to making an application to court to seek an Interim Care Order. The Social Work Evidence Template  and Interim Care Plan should be prepared at least 5 to 7  weeks prior to child's delivery date, where appropriate these should be shared with parents' legal representation in advance of proceedings being issued. The application should be made on the day of the child's birth.

Birth Response Plans

For all babies where there are any safeguarding concerns, a formal Birth Response Plan will need to be completed. This is a multi-agency plan which helps everyone to be clear about their roles and responsibilities, and what actions are to take place immediately following the birth to keep the baby safe.

A draft birth response plan should be formulated within the strategy meeting which takes place and should be taken to the Initial Child Protection Conference to be discussed and further developed. Depending on the hospital it is either the Social Worker or the Safeguarding Midwife who completes the paperwork this is a multi-agency document with contribution from all those involved. The Social Worker is responsible for co-ordinating the discussion and the Safeguarding Midwife is responsible for completing and distributing the report (Emergency Duty Team, hospitals and Police).

The following should be discussed and agreed in relation to the birth response plan:

• How long the baby will stay in hospital (for babies born to drug and/or alcohol misusing mothers there needs to be a period of time to monitor for withdrawal symptoms). Babies born to mothers who misuse drugs and/or alcohol or who require neonatal abstinence syndrome observation will require a minimum of 72 hours observation following birth. If the baby displays signs of withdrawal the admission would be prolonged and is unique to the baby's condition;
• To identify whether it is safe for mother to be unsupervised with her baby on the ward and if not, discussion needs to take place as to who is a suitable person to undertake the supervisory role;
• The arrangements for the immediate protection of the baby if the risk assessment has highlighted serious risks to the child e.g. from parental drug and/or alcohol misuse, mental health concerns, domestic abuse;
• The risk that the parents might seek to remove the baby from the hospital especially if the plan is to remove the baby at birth;
• To identify whether it is for mother to be unsupervised with her baby on the ward and if not, discussion needs to take place as to who is a suitable person to undertake the supervisory role;
• The plan for the baby upon discharge;
• Identification of appropriate alternative carers within the family, family network or foster placement;
• Contingency plans should be in place in the event of a sudden change in circumstances;
• It is important that when a baby is born out of hours, the Emergency Duty Team are contacted and updated. They will have a copy of the Pre-Birth Response Plan and will liaise with the hospital to ensure that safeguarding arrangements are in place.

It is an essential part of the birth response plan that consideration is given to the need to take police protection if mother is not consenting to section 20 and there is an imminent risk to the baby.

All relevant agencies attending the Initial Child Protection Conference will receive a copy of the birth response plan. The Safeguarding Midwife / Team will distribute the birth response plan to Police to Durham and Darlington Hospitals and the Social Worker will distribute to Police where it is North Tees, Sunderland or Gateshead Hospitals where it has been deemed appropriate, i.e. where Police Powers of Protection are likely to be requested. The birth response plan should be uploaded onto the child's electronic record and the social worker should highlight the main actions agreed within the case summary on the child's electronic record.

The birth response plan should only be amended after formal discussion and agreement between the social worker and the specialist midwife, and with the approval of the social care team manager. The plan can only be updated by the safeguarding midwife lead; this avoids any confusion and any changes being made that health leads may not become aware of.

Pre-birth Initial Child Protection Conference

A Pre-birth Initial Child Protection Conference (see Child Protection Conferences Procedure) may be required if Children's Social Care assess that the child is at risk of significant harm. A pre-birth conference should share relevant information and develop a Child Protection Plan if required. The timing of the conference should take into account the expected date of delivery and ideally take place by 30-32 weeks of the pregnancy, or earlier if there is a history of premature birth or concealed pregnancy.

If a decision is made that the unborn child will be made the subject of a Child Protection Plan from birth, a Core Group should be established at the Initial child protection conference and meet within 10 working days from the conference. A Child Protection Review will need to take place within 4 weeks following the baby's birth.

Pre-Discharge Meeting

Following birth, a pre discharge meeting must be held to co-ordinate a multi-agency plan of visiting to the family following discharge which will keep the child safe and provide appropriate support to the family. This meeting should be chaired by the allocated social worker and the focus of this meeting will be to identify a clear plan of expectations of parents and agencies following discharge from hospital.

A detailed pre-birth assessment can provide an early opportunity to develop a good working relationship with parents during the pregnancy, especially where there are concerns. It can mean that vulnerable parents can be offered support early on, allowing them the best opportunity to parent their child safely and effectively. Importantly, it helps identify babies who may be at risk of significant harm, and can be used to develop plans to safeguard them.

There are some potential issues that can arise. The involvement of social care (especially if there is a decision to remove the baby at birth) can result in the parents going missing or the mother not attending hospital at the time of birth.

It may have an adverse effect on the parents' mental or physical health or heighten the risks that had raised the concerns in the first place. The fear of losing the baby may undermine the attachment and bonding process between the parent and child. There is a danger that the mother may end up harming herself or her unborn baby or seeking to terminate her pregnancy.

It is vital that there is good communication with the pregnant woman, the birth father and, if different, her current partner in order to reduce the chance of such issues arising.

Pre-Birth Flowchart