Antenatal care

Short Text

Routine care for the healthy pregnant woman

Introduction

This pathway covers routine antenatal care for all healthy pregnant women. Its ethos is that pregnancy is a normal physiological process and that any interventions offered should have known benefits and be acceptable to pregnant women. The pathway covers baseline clinical care of all healthy woman with an uncomplicated singleton pregnancy. It provides details about information to give to women at specific times during their pregnancy and the checks and tests that should be carried out at each antenatal appointment.
The pathway provides criteria for referral of women who need additional care during their pregnancy. It also links to the pathways on multiple pregnancy, and pregnancy and complex social factors.

Source guidance

The NICE guidance that was used to create the pathway.
Caesarean section. NICE clinical guideline 132 (2011)
Antenatal care. NICE clinical guideline 62 (2008)
Intrapartum care. NICE clinical guideline 55 (2007)
Pregnancy (rhesus negative women) - routine anti-D (review). NICE technology appraisal guidance 156 (2008)

Quality standards

Quality statements

Services – access to antenatal care

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are supported to access antenatal care, ideally by 10 weeks 0 days.

Quality measure

Structure
a) Evidence of local services that ensure antenatal care is readily and easily accessible.
b) Evidence of local arrangements to encourage pregnant women to access and maintain contact with antenatal care services.
Process
Proportion of pregnant women missing a scheduled antenatal appointment who are followed up within locally defined timescales.
Numerator – the number of women in the denominator followed up within locally defined timescales.
Denominator – the number of pregnant women missing a scheduled antenatal appointment.
Outcome
a) Pregnant women accessing antenatal care who are seen for booking by 10 weeks 0 days.
b) Pregnant women accessing antenatal care who are seen for booking by 12 weeks 6 days.
c) Pregnant women accessing antenatal care who are seen for booking by 20 weeks 0 days.
d) Median gestation at booking.
e) Pregnant women accessing antenatal care attend at least the recommended number of antenatal appointments.

What the quality statement means for each audience

Service providers ensure that systems are in place to support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Healthcare and social care professionals support pregnant women to access antenatal care, ideally by 10 weeks 0 days. This includes following up women who have missed a scheduled antenatal appointment.
Commissioners ensure they commission services that are readily and easily accessible and that support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Pregnant women are encouraged to see a healthcare professional about their pregnancy as early as possible and have regular check-ups from their midwife or doctor throughout their pregnancy (antenatal care). This may include being contacted by their midwife or doctor if they miss a check-up.

Source guidance

NICE clinical guideline 62 recommendations 1.1.1.1, 1.2.3.1, 1.2.5.1, 1.6.3.3 and appendix D (antenatal appointments).
NICE clinical guideline 110 recommendations 1.1.1, 1.1.2 (key priorities for implementation) and 1.2.8.

Data sources

Structure
a) and b) Local data collection. The NICE clinical guideline 110 baseline assessment tool can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
Process
Local data collection.
Outcome
a), b) c) and d) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given your pregnancy notes?)’. Possible responses are: before 8 weeks, 8 or 9 weeks, 10 or 11 weeks, 12 weeks and 13 or more weeks. The total number of respondents is also stated.
b) The Integrated Performance Measure Access to Midwifery is the collection of data to monitor women seen by a midwife or maternity health professional. This includes a national performance measure on the ‘percentage of women who have seen a midwife or a maternity healthcare professional for health and social care assessment of needs, risks and choices by 12 weeks and 6 days’. This is monitored by the Department of Health on a quarterly basis.
e) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the date of attendance at an antenatal appointment (excluding first contact and booking). The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many antenatal check-ups did you have in total?’ Possible responses are: none, 1–6, 7–9, 10–14, 15 or more. The total number of respondents is also stated.

Definitions

NICE full clinical guideline 62 acknowledges that the ‘booking appointment’ needs to be earlier in pregnancy (ideally by 10 weeks) than may have traditionally occurred.
NICE clinical guideline 62 recommends that the schedule of antenatal appointments is determined by the woman’s needs. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of 10 appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of 7 appointments should be adequate.
Follow-up after a missed appointment may be undertaken by the maternity service or other community-based service the woman is in contact with, such as a children's centre, addiction service or GP. Follow-up should be via a method of contact that is appropriate to the woman, which may include:
  • text message
  • letter
  • telephone
  • community or home visit.

Equality and diversity considerations

Pregnant women include women with complex social needs who may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE clinical guideline 110 has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Services – continuity of care

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are cared for by a named midwife throughout their pregnancy.

Quality measure

Structure
a) Evidence of local arrangements and audit to ensure that pregnant women are cared for by a named midwife throughout their pregnancy.
b) Evidence of local arrangements to ensure that systems are in place to coordinate a pregnant woman's care should her named midwife not be available.
Process
The proportion of pregnant women with a named midwife.
Numerator – the number of women in the denominator with a named midwife.
Denominator – the number of pregnant women accessing antenatal care.
Outcome
Pregnant women's satisfaction with the continuity of their antenatal care.

What the quality statement means for each audience

Service providers ensure that systems are in place to enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Healthcare and social care professionals follow local systems and guidance to provide continuity of care to pregnant women through the provision of a named midwife.
Commissioners ensure they commission services that enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Pregnant women are cared for a by a named midwife throughout their pregnancy.

Source guidance

NICE clinical guideline 62 recommendation 1.2.2.1.
Maternity matters: choice, access and continuity of care in a safe service section 2.1.2–2.1.4 Continuity of midwifery care.

Data sources

Structure
a) and b) Local data collection.
Process
Local data collection.
Outcome
Local data collection. The Care Quality Commission Maternity Services Survey 2010 asks the question 'If you saw a midwife for your antenatal check-ups, did you see the same one every time?' Possible responses are: yes, every time; yes, most of the time; or no.

Definitions

A named midwife is a named registered midwife who is responsible for providing all or most of a woman's antenatal and postnatal care and coordinating care should they not be available (definition adapted from Maternity matters: choice, access and continuity of care in a safe service).

Services – record keeping

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.
b) Evidence of local audit to monitor the completeness and accuracy of antenatal test results in women's hand-held maternity notes.
Process
Proportion of pregnant women accessing antenatal care who have a complete record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy.
Numerator – the number of women in the denominator with a complete record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy.
Denominator – the number of pregnant women accessing antenatal care.

What the quality statement means for each audience

Service providers ensure that systems are in place to maintain a complete record of the minimum set of antenatal test results in women's hand-held maternity notes.
Healthcare professionals ensure that women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.
Commissioners ensure they commission services that maintain a complete record of the minimum set of antenatal test results in women's hand-held maternity notes.
Pregnant women are given a complete record of the minimum set of their antenatal test results in their hand-held maternity notes.

Source guidance

NICE clinical guideline 62 recommendation 1.2.4.2.
NICE clinical guideline 110 recommendation 1.1.10.

Data sources

Structure
a) and b) Local data collection.
Process

Definitions

The minimum set of tests for routine scheduled antenatal care has been developed from the appointment schedule in appendix D of NICE clinical guideline 62.
Investigation
Timing
Blood pressure
All routine appointments
Urine test for proteinuria
All routine appointments
Blood group and rhesus D status
At booking
Haemoglobinopathies screen
At booking
Hepatitis B virus screen
At booking
HIV screen
At booking
Rubella susceptibility
At booking
Syphilis screen
At booking
MSU for asymptomatic bacteriuria
At booking
Height, weight and body mass index
At booking
Haemoglobin
At booking and 28 weeks
Red-cell alloantibodies
At booking and 28 weeks
Ultrasound scan to determine gestational age
Between 10 weeks 0 days and 13 weeks 6 days
Down's syndrome screen
Combined test: between 10 weeks 0 days and 14 weeks 1 day
Serum quadruple test:
14 weeks 2 days to 20 weeks 0 days
Ultrasound screen for structural anomalies
Between 18 weeks 0 days and 20 weeks 6 days
Measure of symphysis–fundal height
Fetal presentation
All routine appointments from 25 weeks
36 weeks
Women should be able to make an informed choice about whether to accept or decline each test, and notes should include a record of any tests offered and declined as well as the results of tests accepted

Equality and diversity considerations

Hand-held maternity notes and the information within them should be accessible to all women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.
Women should be able to choose whether to have all the results of their antenatal tests documented in their hand-held maternity notes. This may be particularly important when information is sensitive (for example, positive screening results for HIV, hepatitis B virus and syphilis). Where a woman declines to have antenatal test results documented in her hand-held notes, the results should instead be recorded within other medical notes.

Risk assessment – body mass index

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their body mass index calculated and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Process
a) Proportion of pregnant women accessing antenatal care whose body mass index is calculated and recorded at the booking appointment.
Numerator – the number of women in the denominator whose body mass index is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment who are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Numerator – the number of women in the denominator offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Denominator – the number of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment.
Outcome
Women with a body mass index of 30 kg/m2 or more feel confident to make decisions about healthy eating and physical activity during their pregnancy.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Healthcare professionals offer women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice on healthy eating and physical activity or if they are not appropriately trained to do this, refer them to an appropriately trained person.
Commissioners ensure they commission services that offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered advice relevant to them from an appropriately trained person on healthy eating and physical activity.

Source guidance

NICE clinical guideline 62 recommendations 1.2.2.2 and 1.5.1.1.

Data sources

Structure
a) and b) Local data collection. The NICE public health guidance 27 self assessment tool.
Process
a) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors at booking: maternal height (global number 17209970) and weight (global number 17209960). The booking appointment date will also be available (global number 17201190). The NICE public health guidance 27 audit support, criteria 1 and 3.
b) Local data collection.

Definitions

An appropriately trained person can demonstrate expertise and competencies in weight management in pregnancy, including providing advice about nutrition and/or physical activity. This may include obstetricians, GPs, midwives, health visitors, nurses, dietitians, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).

Equality and diversity considerations

The body mass index threshold may need adapting for different groups of pregnant women (for example, women from certain ethnic groups). NICE is developing public health guidance on body mass index and waist circumference in black and minority ethnic groups. A body mass index measure is considered unsuitable for use with those under 18.

Risk assessment – smoking cessation

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment.

Quality measure

Structure
a) Evidence of local arrangements that pregnant women have their smoking status recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women who smoke are referred to an evidence-based stop smoking service.
c) Evidence of local arrangements to ensure that pregnant women who smoke and decide not to attend an evidence-based stop smoking service receive follow-up.
Process
a) Proportion of pregnant women accessing antenatal care whose smoking status is recorded at the booking appointment.
Numerator – the number of women in the denominator whose smoking status is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women who smoke who are offered a referral to an evidence-based stop smoking service.
Numerator – the number of women in the denominator who are offered a referral to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
c) Proportion of pregnant women who smoke who are referred to an evidence-based stop smoking service.
Numerator – the number of women in the denominator who are referred to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
d) Proportion of pregnant women who smoke and decide not to attend an evidence-based stop smoking service who receive follow-up.
Numerator – the number of women in the denominator who decide not to attend an evidence-based stop smoking service who receive follow-up.
Denominator – the number of pregnant women who smoke and decide not to attend an evidence-based stop smoking service.
Outcome
a) Quit rates for pregnant women.
b) Smoking rates in pregnancy.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure that all pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.
Healthcare professionals refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Commissioners ensure they commission services which refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.

Source guidance

Data source

Structure
a) Local data collection through Maternity Services Secondary Uses Dataset b) local data collection through PHQ30 and c) local data collection.
Process
a) Local data collection. The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the mother's self-reported smoking status at the Booking Appointment' (global number 17201020). b) Local data collection. c) Local data collection. d) Local data collection.
Outcome
a) Local data collection.
b) The Smoking at Time of Delivery (SATOD) collection covers information on the number of women smoking and not smoking at time of delivery (childbirth). Each PCT (and a number of care trusts) is required to submit 3 figures each quarter:
  • total number of maternities
  • number of women known to smoke at the time of delivery
  • number of women known not to smoke at the time of delivery.
From 2011/12 quarter 3 onwards, the Information Centre for Health and Social Care has taken over responsibility for publishing 'Statistics on women's smoking status at time of delivery: England' from the Department of Health. The reports from 2011/12 quarter 3 are available from the Information Centre for Health and Social Care.
The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the mother's self-reported smoking status, specifically after the birth of the baby' (global number 17207150).
PHQ30: Smoking quitters – Number of users of NHS stop smoking services who report that they are not smoking 4 weeks after setting a quit date. Data are broken down into sub-categories, which include 'Pregnant women setting a quit date and outcome'. Monitoring frequency: quarterly.

Definitions

Advice on smoking cessation should be first provided at the booking appointment and when appropriate throughout the period of antenatal care. The midwife may provide the pregnant woman with information (in a variety of formats, for example a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.
Women who smoke or have recently quit smoking should be referred to an evidence-based stop smoking service if:
  • they say they smoke, or
  • they have a carbon monoxide (CO) reading of 7 ppm or above, or
  • they say they have quit smoking in the past 2 weeks, or
  • they say they are a light or infrequent smoker but register a low CO reading (for example, 3 ppm).
[adapted from Quitting smoking in pregnancy and following childbirth (NICE public health guidance 26)]
Evidence-based stop smoking services are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit (NICE pathways: Evidence-based stop smoking services and quitlines).
At the time of referral the pregnant woman should be given the number of an evidence-based stop smoking service. This may include the number of the NHS Pregnancy Smoking Helpline (0800 1699 169), details of their website (http://smokefree.nhs.uk/smoking-and-pregnancy) and a number for a local helpline if one is available.

Risk assessment – gestational diabetes

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are offered testing for gestational diabetes if they are identified as at risk of gestational diabetes at the booking appointment.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk factors for gestational diabetes identified and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women identified as at risk of gestational diabetes at the booking appointment are offered testing for gestational diabetes.
Process
a) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who are offered testing for gestational diabetes.
Numerator – the number of women in the denominator offered testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
b) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who receive testing for gestational diabetes.
Numerator – the number of women in the denominator receiving testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Outcome
Early identification of women with gestational diabetes.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Healthcare professionals offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Commissioners ensure they commission services that offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Pregnant women with a higher than normal chance of developing gestational diabetes (a type of diabetes that occurs during pregnancy) at the booking appointment are offered a test for gestational diabetes.

Source guidance

NICE clinical guideline 62 recommendations 1.2.2.2 and 1.9.1.1 (key priority for implementation).
NICE clinical guideline 63 recommendation 1.2.2.4.

Data sources

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection. The NICE clinical guideline 62 audit support, criterion 8 and 9. The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors at booking: maternal height (global number 17209970) and weight (global number 17209960), maternal family history of diabetes (global number 17200950) and ethnic group (global number 17200030), and obstetric diagnoses from previous pregnancies including gestational diabetes mellitus (global number 17200720). The date of the booking appointment will also be available (global number 17201190).

Definitions

Risk factors are taken from NICE clinical guideline 62:
  • body mass index above 30 kg/m2
  • previous macrosomic baby weighing 4.5 kg or above
  • previous gestational diabetes
  • family history of diabetes (first-degree relative with diabetes)
  • family origin with a high prevalence of diabetes:
    • South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
    • black Caribbean
    • Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
Women with any 1 of these risk factors should be offered testing for gestational diabetes.
Testing for gestational diabetes should be carried out in accordance with NICE clinical guideline 63:
'The 2-hour 75 g oral glucose tolerance test (OGTT) should be used to test for gestational diabetes and diagnosis made using the criteria defined by the WHOFasting plasma venous glucose concentration greater than or equal to 7.0 mmol/litre or 2-hour plasma venous glucose concentration greater than or equal to 7.8 mmol/litre. World Health Organization Department of Non-communicable Disease Surveillance (1999) Definition, diagnosis and classification of diabetes mellitus and its complications. Report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus. Geneva: WHO.. Women who have had gestational diabetes in a previous pregnancy should be offered early self-monitoring of blood glucose or an OGTT at 16–18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes should be offered an OGTT at 24–28 weeks.'

Equality and diversity considerations

Any risk assessment for gestational diabetes should be corrected for family origin. Some family origins are risk factors for diabetes (see Definitions above) and people from these groups should be offered testing in accordance with the guidance.

Risk assessment – pre-eclampsia

July 2013: Quality statement 7 has been removed and is replaced by quality statement 2: Antenatal assessment of pre-eclampsia risk in Hypertension in pregnancy (NICE quality standard 35).

Risk assessment – intermediate risk of venous thromboembolism

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women at intermediate risk of venous thromboembolism at the booking appointment have specialist advice provided about their care.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women at intermediate risk of VTE at the booking appointment have specialist advice provided about their care.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE recorded at the booking appointment.
Numerator – the number of women in the denominator having their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women at intermediate risk of VTE at the booking appointment who have specialist advice provided about their care.
Numerator – the number of women in the denominator with specialist advice provided about their care.
Denominator – the number of pregnant women at intermediate risk of VTE at the booking appointment.
Outcome
Incidence of VTE in pregnant women.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide pregnant women who are at intermediate risk of VTE at the booking appointment with specialist advice.
Healthcare professionals seek or provide specialist advice for pregnant women at intermediate risk of VTE at the booking appointment.
Commissioners ensure they commission services which provide pregnant women at intermediate risk of VTE at the booking appointment with specialist advice.
Pregnant women who at the time of their booking appointment have a moderate risk of developing VTE (a blood clot) have specialist advice sought about their care.

Source guidance

NICE clinical guideline 62 recommendation 1.2.2.2.
RCOG Green-top guideline 37a recommendations 1, 4 and 6 (executive summary of recommendations).

Data sources

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.
Outcome
The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

Definitions

Definitions are taken from RCOG Green-top guideline 37a.
Intermediate risk of VTE is defined as any of the following:
  • single previous VTE with no family history or thrombophilia (inherited or acquired)
  • thrombophilia (inherited or acquired) and no VTE
  • medical comorbidities such as:
    • heart or lung disease
    • systemic lupus erythematosus
    • cancer
    • inflammatory conditions
    • nephrotic syndrome
    • sickle cell disease
    • intravenous drug use
  • surgical procedures such as appendicectomy
or 3 or more risk factors from the following list (or 2 or more risk factors from the following list if admitted to hospital):
  • age above 35 years
  • body mass index more than 30 kg/m2
  • parity 3 or more
  • smoker
  • gross varicose veins (symptomatic, above the knee or associated with phlebitis/oedema/skin changes)
  • current systemic infection
  • immobility (for at least 3 days) such as:
    • paraplegia
    • symphysis pubis dysfunction with reduced mobility
  • long-distance travel (greater than 4 hours)
  • pre-eclampsia
  • dehydration/hyperemesis/ovarian hyperstimulation syndrome
  • multiple pregnancy or assisted reproductive therapy.
Women assessed as being at intermediate risk should have specialist advice provided about their care. This would involve the healthcare professional responsible for the pregnant woman's care discussing the woman's risk factors with a specialist service (for example, a trust-nominated thrombosis in pregnancy expert or team) and acting on this advice.

Risk assessment – high risk of venous thromboembolism

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women at high risk of venous thromboembolism at the booking appointment are referred to a specialist service.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women at high risk of VTE at the booking appointment are referred to a specialist service.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE recorded at the booking appointment.
Numerator – the number of women in the denominator having their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women at high risk of VTE at the booking appointment who are referred to a specialist service.
Numerator – the number of women in the denominator referred to a specialist service.
Denominator – the number of pregnant women at high risk of VTE at the booking appointment.
Outcome
Incidence of VTE in pregnant women.

What the quality statement means for each audience

Service providers ensure that systems are in place to provide pregnant women at high risk of VTE at the booking appointment with onward referral to a specialist service.
Healthcare professionals refer pregnant women at high risk of VTE at the booking appointment to a specialist service.
Commissioners ensure they commission services which provide pregnant women at high risk of VTE at the booking appointment with onward referral to a specialist service.
Pregnant women who at the time of their booking appointment have a high chance of developing VTE (a blood clot) are referred to a specialist service.

Source guidance

NICE clinical guideline 62 recommendation 1.2.2.2.
RCOG Green-top guideline 37a recommendations 1, 2, 4 and 8 (executive summary of recommendations).

Data sources

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.
Outcome
The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

Definitions

Definitions are taken from RCOG Green-top guideline 37a.
High risk of VTE is defined as any of the following:
  • single previous VTE and thrombophilia (inherited or acquired) or family history
  • single previous unprovoked/oestrogen-related VTE
  • previous recurrent VTE (more than 1).
Women assessed as being at high risk should be referred to a specialist service, for example a trust-nominated thrombosis in pregnancy expert or team.

Screening – national fetal anomaly screening programmes

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women are offered fetal screening in accordance with current UK National Screening Committee programmes.

Quality measure

Structure
Evidence of local NHS-commissioned services to ensure that all pregnant women are offered fetal screening in accordance with current UK National Screening Committee programmes.
Process
Note a pregnant woman would be offered either process a) or b) and always process c).
a) Proportion of pregnant women booking before 14 weeks 2 days who are offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day.
Numerator – the number of women in the denominator offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day.
Denominator – the number of pregnant women booking before 14 weeks 2 days.
b) Proportion of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days who are offered the quadruple screening test for Down's syndrome to take place between 14 weeks 2 days and 20 weeks 0 days.
Numerator – the number of women in the denominator offered the quadruple screening test for Down's syndrome to take place between 14 weeks 2 days and 20 weeks 0 days.
Denominator – the number of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days.
c) Proportion of pregnant women booking before 21 weeks who are offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Numerator – the number of women in the denominator offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Denominator – the number of pregnant women booking before 21 weeks.
Outcome
a) Pregnant women feel they have made an informed decision about whether to undergo fetal anomaly screening.
b) Screening uptake rates.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer fetal screening to pregnant women in accordance with current UK National Screening Committee programmes.
Healthcare professionals offer fetal screening to pregnant women in accordance with current UK National Screening Committee programmes.
Commissioners ensure they commission services that offer fetal screening to pregnant women as part of NHS care, in accordance with current UK National Screening Committee programmes.
Pregnant women who access antenatal care before 21 weeks are offered an ultrasound scan to screen for various conditions in their unborn baby.
In addition, pregnant women who access antenatal care before 20 weeks are offered screening for Down's syndrome in their unborn baby. The type of test carried out (for example, an ultrasound scan and a blood test or just a blood test) will depend on how far advanced the pregnancy is.

Source guidance

NICE clinical guideline 62 recommendations 1.7.1.1 and 1.7.2.1.
UK National Screening Committee Screening for Down's syndrome: UK NSC Policy recommendations 2011–2014 Model of best practice policy recommendations and supporting information.

Data sources

Structure
a) and b) Local data collection.
Process
a), b) and c) Local data collection.
a) The Care Quality Commission Maternity Services Survey 2010 asks the following questions: 'Did you have a dating scan? This takes place between 8–14 weeks of pregnancy' and 'Did you have any screening tests (a blood test or nuchal scan) to check whether your baby might have Down's syndrome?' Possible responses to the latter are: 'yes, a blood test only'; 'yes, a nuchal scan only'; 'yes, a nuchal scan and blood test'; and 'no, I wasn't offered any screening tests for Down's syndrome'. The total number of respondents is also stated.
a), b) and c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'whether or not screening for Down's Syndrome was offered, accepted or declined' (global number 17202360), 'date blood test sample taken for Down's Syndrome screening' (global number 17202410), 'whether or not fetal anomaly screening was offered, accepted or declined' (global number 17203180) and 'date and time on which fetal anomaly screening was undertaken' (global number 17203190).
a), b) and c) QOF indicator MAT1 – Antenatal care and screening are offered according to current local guidelines (Additional services domain).
c) The Care Quality Commission Maternity Services Survey 2010 asks the question 'Did you have a scan at around 20 weeks of pregnancy?' The total number of respondents is also stated.

Definitions

Current UK National Screening Committee programmes for fetal screening are defined here as the National Screening Committee policy on fetal anomaly screening in pregnancy, which includes both fetal anomaly ultrasound, and Down's syndrome screening.
UK National Screening Committee recommendations (Screening for Down's syndrome: UK NSC Policy recommendations 2011–2014 Model of best practice) state that the gestational age window for the combined test runs from 10 weeks 0 days to 14 weeks 1 day. The combined test is made up of linear fetal measurement of the crown-rump length to estimate fetal gestational age (dating scan), measurement of the nuchal translucency space at the back of the fetal neck, and maternal blood to measure the serum markers of pregnancy associated plasma protein A and human chorionic gonadotrophin hormone. In striking a balance between the benefits of all the markers, trusts should consider screening women around 11 weeks 2 days.
For women presenting beyond 14 weeks 1 day, the quadruple test (maternal serum) window runs from 14 weeks 2 days to 20 weeks 0 days.
The fetal anomaly ultrasound scan should be offered at first contact visit or booking visit, to take place between 18 weeks 0 days and 20 weeks 6 days.

Equality and diversity considerations

The offer and implications of screening should be understood by all women to enable them to make informed decisions. This will necessitate provision of information in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Fetal wellbeing – external cephalic version

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) are offered external cephalic version.

Quality measure

Structure
a) Evidence of local arrangements to ensure that pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) are referred for confirmatory ultrasound assessment.
b) Evidence of local arrangements to ensure that pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) are offered external cephalic version.
Process
a) Proportion of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) who are referred for confirmatory ultrasound assessment.
Numerator – the number of women in the denominator referred for confirmatory ultrasound assessment.
Denominator – the number of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins).
b) Proportion of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who are offered external cephalic version.
Numerator – the number of women in the denominator offered external cephalic version.
Denominator – the number of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins).
Outcome
a) External cephalic version rates.
b) Mode of delivery including:
  • rates of vaginal birth, emergency and elective caesarean section after successful external cephalic version
  • rates of vaginal birth, emergency and elective caesarean section after unsuccessful external cephalic version
  • rates of vaginal birth and emergency caesarean section after diagnosis of breech presentation in labour.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Healthcare professionals offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Commissioners ensure they commission services that offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.
Pregnant women with a single baby in the breech position (bottom first with knees either flexed or extended) but with no other problems at 36 weeks or later in their pregnancy are offered external cephalic version (a procedure to move the baby round to the head first position), which includes first having an ultrasound scan to confirm the baby's position.

Source guidance

NICE clinical guideline 62 recommendations 1.10.5 and 1.11.2.1.

Data sources

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.
Outcome
a) and b) Local data collection.
b) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the presentation of the (first) fetus at onset of labour (including option of breech)' (global number 17204960), 'instance of a critical incident occurring (including option of undiagnosed breech)' (global number 17205700), 'the method for delivering baby' (global number 17206160).

Definitions

As detailed in NICE clinical guideline 62 recommendation 1.11.2.1 women in labour or those with 1 or more of the following obstetric complications should not be offered external cephalic version:
  • a uterine scar or abnormality
  • fetal compromise
  • ruptured membranes
  • vaginal bleeding
  • medical conditions.
When obtaining informed consent for this procedure the woman should be provided with balanced information about the benefits and risks of external cephalic version (for example, the Royal College of Obstetricians and Gynaecologists patient information leaflet 'Turning a baby in the womb (external cephalic version) – information for you').

Equality and diversity considerations

There may be some women whose breech presentation is not identified and who are not offered an external cephalic version.

Fetal wellbeing – membrane sweeping for prolonged pregnancy

This quality statement is taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.

Quality statement

Nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women are offered this at their 41-week appointment.

Quality measure

Structure
Evidence of local arrangements to ensure that nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women are offered this at their 41-week appointment.
Process
a) Proportion of nulliparous pregnant women attending a 40-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of nulliparous pregnant women attending a 40-week antenatal appointment.
b) Proportion of nulliparous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of nulliparous pregnant women attending a 41-week antenatal appointment.
c) Proportion of parous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping.
Numerator – the number of women in the denominator offered a vaginal examination for membrane sweeping.
Denominator – the number of parous pregnant women attending a 41-week antenatal appointment.
Outcome
a) Rates of induction of labour for women with prolonged pregnancy.
b) Mode of delivery for women with prolonged pregnancy including:
  • spontaneous vaginal birth
  • instrumental vaginal birth
  • elective or emergency caesarean section.
c) Rates of stillbirth beyond 40 weeks gestation (where there is no underlying medical cause).

What the quality statement means for each audience

Service providers ensure that systems are in place to offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women the same at their 41-week appointment.
Healthcare professionals offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women the same at their 41-week appointment.
Commissioners ensure they commission services that offer nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women the same at their 41-week appointment.
Pregnant women having their first baby are offered a vaginal examination at their 40- and 41-week antenatal appointments to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massages the cervix, to help start labour.
Pregnant women having their second or later baby are offered a vaginal examination at their 41-week appointment to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massages the cervix, to help start labour.

Source guidance

NICE clinical guideline 62 recommendation 1.11.1.1.
NICE clinical guideline 70 recommendations 1.3.1.2 and 1.3.1.3.

Data sources

Structure
Local data collection.
Process
a), b) and c) Local data collection.
Outcome
a), b) and c) Local data collection.
a), b) and c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on 'the medical induction of labour' (global number 17204740), 'the method for delivering baby' (global number 17206160) and neonatal death (global number 17209680).

Pre-pregnancy advice for women with treated hypertension

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women of childbearing potential with treated hypertension are given information annually about safe antihypertensive treatment during pregnancy.

Rationale

Information can be provided to women who may become pregnant about safe antihypertensive treatment during pregnancy as part of an annual review of hypertension care. Women should be informed about potential risks, including the risk of congenital abnormalities, linked to particular antihypertensive drugs. This should enable women to arrange a discussion with the healthcare professional responsible for managing their hypertension about alternative antihypertensive treatments if they are planning pregnancy or become pregnant.

Quality measures

Structure
Evidence of local arrangements to ensure that women of childbearing potential with treated hypertension are given information annually about safe antihypertensive treatment during pregnancy.
Data source: Local data collection.
Process
Proportion of women who have had treated hypertension for 12 months or longer who received information about safe antihypertensive treatment during pregnancy in the past 12 months.
Numerator: the number of women in the denominator who received information about safe antihypertensive treatment during pregnancy in the past 12 months.
Denominator: the number of women of childbearing potential who have had treated hypertension for 12 months or longer.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to give women of childbearing potential with treated hypertension information annually about safe antihypertensive treatment in pregnancy.
Healthcare professionals give information annually to women of childbearing potential with treated hypertension about safe antihypertensive treatment in pregnancy.
Commissioners ensure they commission services that give information annually to women of childbearing potential with treated hypertension about safe antihypertensive treatment in pregnancy.

What the quality statement means for patients, service users and carers

Women who are having treatment for hypertension (high blood pressure) and who may become pregnant are given information annually about safe treatment for high blood pressure during pregnancy.

Source guidance

Definitions of terms used in this quality statement

Safe antihypertensive treatment
  • Women taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) should be provided with information to advise that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy, and discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
  • Women taking chlorothiazide should be provided with information to advise that: there may be an increased risk of congenital abnormality and neonatal complications if these drugs are taken during pregnancy, and to discuss other antihypertensive treatment with the healthcare professional responsible for managing their hypertension, if they are planning pregnancy.
  • Women who take antihypertensive treatments other than ACE inhibitors, ARBs or chlorothiazide should be provided with information to advise that the limited evidence available has not shown an increased risk of congenital malformation with such treatments.
Treated hypertension is hypertension that is treated with 1 or more antihypertensive drug.

Equality and diversity considerations

'Childbearing potential' should be determined for women on an individual basis. Access to information about safe antihypertensive treatment during pregnancy should not be determined solely by age, because childbearing potential is also dependent on factors other than age.
Where information is provided, there must be equal access to information for all women, including those with additional needs, such as physical or learning disabilities, and those who do not speak or read English. Women receiving information should have access to an interpreter or advocate if needed.

Antenatal assessment of pre-eclampsia risk

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.
This quality statement updates and replaces Quality statement 7: Risk assessment - pre-eclampsia in Antenatal care (NICE quality standard 22).

Quality statement

Pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75 mg of aspirin to take daily from 12 weeks until birth.

Rationale

Aspirin prophylaxis, unless contraindicated, reduces the occurrence of pre-eclampsia, preterm birth and fetal and neonatal mortality in women at increased risk of developing the condition (if they have 1 high risk factor or more than 1 moderate risk factor for pre-eclampsia).

Quality measures

Structure
a) Evidence of local arrangements to ensure that pregnant women have their risk factors for pre-eclampsia identified and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women at increased risk of pre-eclampsia at the booking appointment are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Data source: Local data collection.
Process
a) Proportion of pregnant women who have their risk factors for pre-eclampsia identified and recorded at the booking appointment.
Numerator: the number of women in the denominator whose risk factors for pre-eclampsia are identified and recorded.
Denominator: the number of pregnant women attending a booking appointment.
Data source: The Maternity Services Secondary Uses Dataset collects data on the following risk factors at booking: hypertension, renal disease, diabetes, autoimmune disease (global number 17200350) and obstetric diagnoses from previous pregnancies including 'severe pre-eclampsia requiring preterm birth', 'eclampsia' and 'gestational hypertension' (global number 17200720).
b) Proportion of pregnant women at increased risk of pre-eclampsia at the booking appointment who are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Numerator: the number of women in the denominator offered a prescription of 75 mg of aspirin to take daily from 12 weeks until birth.
Denominator: the number of pregnant women at increased risk of pre-eclampsia and without contraindications to aspirin at the booking appointment.
Data source: Local data collection.
Outcome
Incidence of pre-eclampsia in women at increased risk of developing pre-eclampsia.
Data source: The Maternity Services Secondary Uses Dataset collects data on obstetric conditions diagnosed in the current pregnancy, including severe pre-eclampsia, severe pre-eclampsia requiring preterm birth and eclampsia (global number 17203940).

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that systems are in place to offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Healthcare professionals offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.
Commissioners ensure they commission services that offer pregnant women at increased risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until birth.

What the quality statement means for patients, service users and carers

Pregnant women who have a higher risk of developing pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) are offered a prescription of aspirin (unless this is unsuitable) to take every day from 12 weeks of pregnancy until their baby is born.

Source guidance

Definitions of terms used in this quality statement

The booking appointment is the appointment where the woman enters the maternity care pathway. See Antenatal appointments (schedule and content) in NICE clinical guideline 62.
Contraindications to taking aspirin include, but are not limited to: aspirin allergy; medical conditions precluding the use of aspirin; present use of another drug with the potential to interact with aspirin.
Note: aspirin did not have UK marketing authorisation for the indication in question at the time of publication of NICE clinical guideline 107 (August 2010). Informed consent should be obtained and documented.
Increased risk of pre-eclampsia Women are at an increased risk of pre-eclampsia if they have 1 high risk factor or more than 1 moderate risk factor for pre-eclampsia.
High risk factors include:
  • hypertensive disease in a previous pregnancy
  • chronic kidney disease
  • autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes
  • chronic hypertension.
Moderate risk factors include:
  • first pregnancy
  • age 40 years or older
  • pregnancy interval of more than 10 years
  • body mass index (BMI) of 35 kg/m2 or more at first visit
  • family history of pre-eclampsia
  • multiple pregnancy.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24-hour urine collection result greater than 300 mg protein).

Antenatal blood pressure targets

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with hypertension in pregnancy have a blood pressure target set below 150/100 mmHg or, if they also have target organ damage, below 140/90 mmHg.

Rationale

Antihypertensive treatment should aim to lower blood pressure from the moderate or severe range, while avoiding excessive reductions that may affect fetal growth. It is recommended that women with evidence of target organ damage from hypertension will need a lower target blood pressure.

Quality measures

Structure
a) Evidence of local arrangements to ensure that pregnant women who have hypertension without target organ damage have a blood pressure target of below 150/100 mmHg.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women who have hypertension and target organ damage have a blood pressure target of below 140/90 mmHg.
Data source: Local data collection.
Outcome
Rate of pregnant women with hypertension who maintain their target blood pressure throughout their pregnancy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements to set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg if they have target organ damage, and to maintain blood pressures to these targets throughout pregnancy.
Healthcare professionals set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg if they have target organ damage, and ensure that these blood pressures are maintained throughout pregnancy.
Commissioners ensure they commission services that set target blood pressures for pregnant women who have hypertension of below 150/100 mmHg, or below 140/90 mmHg for women with target organ damage, and ensure that these blood pressures are maintained throughout pregnancy.

What the quality statement means for patients, service users and carers

Pregnant women with hypertension (high blood pressure) receive treatment aimed at keeping their blood pressure below 150/100 mmHg, or below 140/90 mmHg if their high blood pressure has led to problems with their eyes, heart or kidneys.

Source guidance

Definitions of terms used in this quality statement

Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).
Target organ damage Left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy are examples of target organ damage. See NICE clinical guideline 127 recommendation 1.2.6.

Assessing women with severe hypertension in pregnancy

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Pregnant women with severe hypertension are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertension in pregnancy.

Rationale

Effective and safe control of severe hypertension is the most important aspect of critical care management, because the main causes of maternal death and severe maternal morbidity (including stroke) are the consequence of poorly controlled hypertension. Women with severe hypertension in pregnancy should be referred from primary care or emergency departments as soon as possible to receive assessment from healthcare professionals with expertise in managing hypertensive disorders. This is essential to ensure early identification of pre-eclampsia and the provision of critical care where it is needed.

Quality measures

Structure
Evidence of local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Data source: Local data collection.
Process
Proportion of women with severe hypertension who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Numerator: the number of women in the denominator who are admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Denominator: the number of pregnant women with severe hypertension.
Data source: Local data collection.
Outcome
Number of women with severe hypertension in pregnancy who have a stroke.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements for pregnant women with severe hypertension to be admitted for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Healthcare professionals admit pregnant women with severe hypertension for a full assessment, carried out by a healthcare professional trained in managing hypertensive disorders in pregnancy.
Commissioners ensure they commission services that admit pregnant women with severe hypertension for a full assessment, carried out by a a healthcare professional trained in managing hypertensive disorders in pregnancy.

What the quality statement means for patients, service users and carers

Pregnant women with severe hypertension (high blood pressure) are admitted to hospital for a full assessment, carried out by a healthcare professional trained in managing high blood pressure and related conditions in pregnancy.

Source guidance

Definitions of terms used in this quality statement

Full assessment should include blood pressure measurements, proteinuria testing and blood tests in accordance with those set out for severe gestational hypertension and pre-eclampsia with severe hypertension in tables 1 and 2 of recommendations 1.4.1.3 and 1.5.1.2 respectively.
Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).
Severe hypertension Systolic blood pressure is 160 mmHg or greater or diastolic blood pressure is 110 mmHg or greater.

Admission to hospital for women with pre-eclampsia

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with a diagnosis of pre-eclampsia are admitted to hospital and monitored daily.

Rationale

Women with pre-eclampsia should be admitted to hospital to enable their condition to be fully assessed and its progress monitored. High-quality care should include an integrated package of care for women with pre-eclampsia that includes admission and daily monitoring. Some women may need to stay in hospital until after the birth of their baby. For other women, daily monitoring may be possible if pre-eclampsia is stable and if the woman has easy access to monitoring services, and can be readmitted to hospital if her clinical condition deteriorates.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women with a diagnosis of pre-eclampsia are admitted to hospital.
Data source: Local data collection.
b) Evidence of local arrangements for women with pre-eclampsia to receive an integrated package of care that includes daily monitoring of their condition.
Data source: Local data collection.
Process
a) The proportion of women with a diagnosis of pre-eclampsia who are admitted to hospital.
Numerator: the number of women in the denominator who are admitted to hospital when pre-eclampsia is diagnosed.
Denominator: the number of women with pre-eclampsia.
Data source: Local data collection.
b) The proportion of women with pre-eclampsia who are monitored daily.
Numerator: the number of women in the denominator who are monitored daily.
Denominator: the number of women who have pre-eclampsia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for women with a diagnosis of pre-eclampsia to be admitted to hospital and for their condition to be monitored daily.
Healthcare professionals admit women with a diagnosis of pre-eclampsia to hospital and monitor their condition daily.
Commissioners ensure they commission services that admit women with a diagnosis of pre-eclampsia to hospital and monitor their condition daily.

What the quality statement means for patients, service users and carers

Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) are admitted to hospital and have their condition monitored every day (while in hospital and at home if they go home before their baby is born).

Source guidance

  • Hypertension in pregnancy (NICE clinical guideline 107) recommendation 1.5.1.2 (key priority for implementation).

Definitions of terms used in this quality statement

Integrated package of care NICE clinical guideline 107 recommends admission to hospital for women with pre-eclampsia as part of an integrated package of care. This covers admission to hospital, treatment, measurement of blood pressure, testing for proteinuria and blood tests.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein).

Planning mode and timing of birth for women with pre-eclampsia

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.

Rationale

Some women who have pre-eclampsia with mild or moderate hypertension will progress to severe pre-eclampsia, which is associated with serious adverse outcomes. Because the progress of the condition differs between women, a consultant-led plan should be developed for each woman with pre-eclampsia including acceptable thresholds for intervention of all monitored thresholds (maternal and fetal) for early birth. This will be agreed with the pregnant woman, updated as needed, and will supersede any original birth plan.

Quality measures

Structure
Evidence of local arrangements to ensure that women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Data source: Local data collection.
Process
Women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth documented in their notes.
Numerator – the number of women in the denominator who have an agreed consultant obstetrician-led plan for the timing and mode of birth documented in their notes.
Denominator – the number of women who have given birth who had pre-eclampsia.
Data source: The Maternity Services Secondary Uses Dataset collects data on the date a care plan has been created or changed. This covers antenatal, birth and postnatal care plans (global number 17201890). Data are also collected on the stage to which the plan applies (global number 17201900) and the professional category of the clinician with overall responsibility for care during the pregnancy (global number 17201920).
Outcome
a) Feedback from women who have had pre-eclampsia that they felt sufficiently involved in planning the timing and mode of the birth of their baby.
Data source: Local data collection.
b) Number of maternal deaths of women with pre-eclampsia.
Data source: Local data collection.
c) Number of fetal deaths for women with pre-eclampsia.
Data source: Local data collection.
d) Number of admissions of women with pre-eclampsia to intensive care units (ICU).
Data source: Local data collection.
e) Number of admissions of babies born to women with pre-eclampsia to neonatal intensive care units (NICU).
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that there are local arrangements in place for women with pre-eclampsia to have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Healthcare professionals ensure that women with pre-eclampsia have an agreed consultant obstetrician-led plan for the timing and mode of birth.
Commissioners ensure they commission services that develop an agreed consultant obstetrician-led plan for the timing and mode of birth for women with pre-eclampsia.

What the quality statement means for patients, service users and carers

Women with pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) and their consultant obstetrician agree a plan for when and how they will give birth and that the plan is followed.

Source guidance

Definitions of terms used in this quality statement

The consultant obstetrician-led plan should be agreed with both the pregnant woman and the multidisciplinary team providing the woman's care, including other specialists, in particular anaesthetists. This should be done as soon after admission as possible. The birth should be according to the most up-to-date version of the plan.
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein).
Timing and mode of birth For indications for timing and mode of birth, see NICE clinical guideline 107 recommendations 1.5.2.1-1.5.2.7

Transfer of information about ongoing management

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women who have had hypertension in pregnancy have a plan for ongoing antihypertensive management included in their postnatal care plan, which is communicated to their GP when they are transferred to community care after the birth.

Rationale

There are particular risks to women who have had hypertension in pregnancy (such as the risk of stroke) in the immediate postnatal period. The development of an individualised care plan for women who have had hypertension in pregnancy before they are transferred to community care should support ongoing antihypertensive management and enable risks to be monitored and addressed, including variations in blood pressure.

Quality measures

Structure
Evidence of local arrangements to communicate a plan for ongoing antihypertensive management for women who had hypertension in pregnancy to their GP when they are transferred to community care after the birth.
Data source: Local data collection.
Process
The proportion of women with hypertension in pregnancy for whom a plan for ongoing antihypertensive management is communicated to their GP when they are transferred to community care after the birth.
Numerator: the number of women in the denominator for whom a plan for ongoing antihypertensive management is communicated to their GP when they are transferred to community care after the birth.
Denominator: the number of women who have given birth who had hypertension in pregnancy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place to communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.
Healthcare professionals communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.
Commissioners ensure they commission services that communicate a plan for ongoing antihypertensive management to GPs of women who had hypertension in pregnancy when they are transferred to community care after the birth.

What the quality statement means for patients, service users and carers

Women who had hypertension (high blood pressure) in pregnancy have a plan for continuing management of their blood pressure, which is communicated to their GP when they go home after their baby is born.

Source guidance

Definitions of terms used in this quality statement

A plan for ongoing antihypertensive management should include information about postpartum management, including a plan for ongoing management. NICE clinical guideline 107 recommends that a care plan should be written for women with gestational hypertension or pre-eclampsia who have given birth and are being transferred to community care that includes all of the following:
  • who will provide follow-up care, including medical review if needed
  • frequency of blood pressure monitoring needed
  • thresholds for reducing or stopping treatment
  • indications for referral to primary care for blood pressure review.
The plan for women with pre-eclampsia should also include self-monitoring for symptoms.
Community care Transfer to the care of a community midwife or health visitor.
Hypertension in pregnancy This definition includes chronic hypertension (present at the booking visit or before 20 weeks of pregnancy; this could include pre-existing hypertension), gestational hypertension (new hypertension presenting after 20 weeks without proteinuria) and pre-eclampsia (new hypertension presenting after 20 weeks with significant proteinuria [urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24 hour urine collection result greater than 300 mg protein]).

Communicating information about future risks

This quality statement is taken from the hypertension in pregnancy quality standard. The quality standard defines clinical best practice for hypertension in pregnancy and should be read in full.

Quality statement

Women who have had gestational hypertension or pre-eclampsia discuss future pregnancy and lifetime cardiovascular risks during a medical review at their 6–8 week postnatal medical check.

Rationale

The long-term risks for women who have had hypertension in pregnancy include developing high blood pressure and an increased lifetime cardiovascular risk. Increased awareness and surveillance may lead to earlier intervention, such as antihypertensive treatment, with likely benefits for the woman. Women should be made aware of risks in future pregnancies resulting from hypertension in a previous pregnancy.

Quality measures

Structure
Evidence of local arrangements for women who have had gestational hypertension or pre-eclampsia to have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Data source: Local data collection.
Process
The proportion of women who have had gestational hypertension or pre-eclampsia who have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Numerator: the number of women in the denominator who have a discussion about future related risks.
Denominator: the number of women who have had gestational hypertension or pre-eclampsia who have a medical review at their 6–8 week postnatal check.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that local arrangements are in place for women who have had gestational hypertension or pre-eclampsia to have a discussion about future related risks during the medical review at their 6–8 week postnatal medical check.
Healthcare professionals discuss future related risks with women who have had gestational hypertension or pre-eclampsia during the medical review at their 6–8 week postnatal medical check.
Commissioners ensure that they commission services that discuss future related risks with women who have had gestational hypertension or pre-eclampsia during the medical review at their 6–8 week postnatal medical check.

What the quality statement means for patients, service users and carers

Women who have had gestational hypertension (new high blood pressure starting after 20 weeks of pregnancy) or pre-eclampsia (a pregnancy-related rise in blood pressure with protein in the urine that happens in some pregnancies) have an appointment with their doctor or midwife 6 to 8 weeks after they have had their baby, at which they discuss their risk of having problems with their blood pressure or pregnancies in the future.

Source guidance

Definitions of terms used in this quality statement

Future pregnancy and lifetime cardiovascular risk
NICE clinical guideline 107 recommends that women who have had gestational hypertension or pre-eclampsia should be told that these conditions are associated with an increased risk of developing high blood pressure and its complications in later life.
NICE clinical guideline 107 recommends that women who have had gestational hypertension should be told that their risk of developing:
  • gestational hypertension in a future pregnancy ranges from about 1 in 6 (16%) pregnancies to about 1 in 2 (47%) pregnancies
  • pre-eclampsia in a future pregnancy ranges from 1 in 50 (2%) to about 1 in 14 (7%) pregnancies.
Women who have had pre-eclampsia should be told that their risk of developing:
  • gestational hypertension in a future pregnancy ranges from about 1 in 8 (13%) pregnancies to about 1 in 2 (53%) pregnancies
  • pre-eclampsia in a future pregnancy is up to about 1 in 6 (16%) pregnancies
  • pre-eclampsia in a future pregnancy is about 1 in 4 (25%) pregnancies if their pre-eclampsia was complicated by severe pre-eclampsia, HELLP syndrome or eclampsia and led to birth before 34 weeks, and about 1 in 2 (55%) pregnancies if it led to birth before 28 weeks.
Gestational hypertension New hypertension presenting after 20 weeks of pregnancy without significant proteinuria.
Medical review
NICE clinical guideline 107 recommends that women who have had gestational hypertension or pre-eclampsia should be offered a medical review at their postnatal check, which takes place 6–8 weeks after birth. (Topic expert group consensus was that this would be carried out by a GP or an appropriately trained midwife.)
Pre-eclampsia New hypertension presenting after 20 weeks of pregnancy with significant proteinuria (urinary protein:creatinine ratio greater than 30 mg/mmol or a validated 24-hour urine collection result greater than 300 mg protein).

Determining chorionicity and amnionicity

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have the chorionicity and amnionicity of their pregnancy determined using ultrasound and recorded between 11 weeks 0 days and 13 weeks 6 days.

Rationale

If fetuses share a placenta, there is a greater risk of complications. Determining chorionicity and amnionicity allows women to be assigned the correct plan of care for their pregnancy.
Pregnancy risks, clinical management and subsequent outcomes are different for monochorionic and dichorionic twin pregnancies (and for monochorionic, dichorionic and trichorionic triplet pregnancies). Therefore, accurate determination of chorionicity is important.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who receive an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who received an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy of greater than 14 weeks' gestation.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on:
  • Offer status – dating ultrasound scan (global number 17201960).
  • Gestation – dating ultrasound scan (global number 17202010).
  • Number of fetuses – dating ultrasound scan (global number 17202020).
Outcomes
Determination of chorionicity and amnionicity.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission specialist services that provide ultrasound scanning between 11 weeks 0 days and 13 weeks 6 days for women with a multiple pregnancy to determine and record the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days of their pregnancy. This is to see whether the babies share the same placenta (chorionicity) and amniotic sac (amnionicity). This information is recorded in the woman's notes

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.1.1.1 (key priority for implementation) and 1.1.2.1 (key priority for implementation).

Definitions

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
Chorionicity
The number of chorionic (outer) membranes that surround the fetuses in a multiple pregnancy. If there is only 1 membrane, the pregnancy is described as monochorionic; if there are 2, the pregnancy is described as dichorionic; and if it is a triplet pregnancy with 3 membranes, the pregnancy is described as trichorionic. Monochorionic twin pregnancies and dichorionic and monochorionic triplet pregnancies carry higher risks because fetuses share a placenta.
Amnionicity
The number of amnions (inner membranes) that surround fetuses in a multiple pregnancy. Pregnancies with 1 amnion (so that all fetuses share 1 amniotic sac) are described as monoamniotic; twin or triplet pregnancies with 2 amnions are diamniotic; and triplet pregnancies with 3 amnions are triamniotic.
Ultrasound scan
An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and membrane thickness.
Note: Antenatal care (NICE clinical guideline 62) recommends determination of gestational age from 10 weeks 0 days. However, the aim in Multiple pregnancy (NICE clinical guideline 129) is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).
Recording the chorionicity and amnionicity
The chorionicity and amnionicity of the pregnancy should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image (of Lambda or T sign) should be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the woman's hand-held maternity notes and their hospital notes.

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. Pregnancy and complex social factors (NICE clinical guideline 110) includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Labelling the fetuses

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have their fetuses labelled using ultrasound and recorded between 11 weeks 0 days and 13 weeks 6 days.

Rationale

Labelling the fetuses and recording this in the notes at the dating scan, using left and right, or upper and lower, allows the fetuses to be consistently identified throughout the pregnancy. It also takes into account that the 'leading' fetus may change as pregnancy progresses and labelling by number can cause confusion, particularly with left and right fetuses.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days to determine and record the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Numerator – the number of women in the denominator who have had their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Denominator – the number of women with a multiple pregnancy of greater than 14 weeks' gestation.
Data source: Local data collection.
Outcomes
Consistent identification of fetuses in multiple pregnancies.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Healthcare practitioners ensure that women with a multiple pregnancy have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.
Commissioners ensure that that they commission specialist services for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11 weeks 0 days and 13 weeks 6 days.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 0 days and 13 weeks 6 days of their pregnancy to record the positions of their babies.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendation 1.1.2.2 (key priority for implementation).

Definitions

Ultrasound scan
An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and membrane thickness.
Note: Antenatal care (NICE clinical guideline 62) recommends determination of gestational age from 10 weeks 0 days. However, the aim in Multiple pregnancy (NICE clinical guideline 129) is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).
Labelling the fetuses
Labelling of the fetuses should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image should also be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the women's hand-held maternity notes and their hospital notes.
The fetuses should be labelled using either the lateral orientation (left and right) or the vertical orientation (upper and lower). Labelling of fetuses should be carried out at all ultrasound scans to ensure consistent identification throughout the pregnancy.

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. Pregnancy and complex social factors (NICE clinical guideline 110) includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Composition of the multidisciplinary core team

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are cared for by a multidisciplinary core team.

Rationale

Women with a multiple pregnancy should have their clinical care provided by a multidisciplinary core team because of the increased risks and complications associated with multiple births. Members of this team will have the expertise needed to provide high-quality care for women with a multiple pregnancy. It may be appropriate for the multidisciplinary core team to refer women to the community midwifery team for some of their additional antenatal appointments.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to be cared for by a multidisciplinary core team.
Healthcare practitioners ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Commissioners ensure that they commission services for women with a multiple pregnancy to be cared for by a multidisciplinary core team.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are cared for by a team of healthcare professionals with different skills and roles (for example, specialist doctors, specialist midwives and ultrasound operators).

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.2.3.1 (key priority for implementation), 1.2.3.3 (key priority for implementation) and 1.2.3.4 (key priority for implementation).

Definitions

Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
The multidisciplinary core team should coordinate clinical care for women with twin and triplet pregnancies to:
  • minimise the number of hospital visits
  • provide care as close to the woman's home as possible
  • provide continuity of care within and between hospitals and the community; the community includes GPs in primary care, and community midwives and health visitors.
The multidisciplinary core team should offer information and emotional support specific to twin and triplet pregnancies at their first contact with the woman and provide ongoing opportunities for further discussion and advice including:
  • antenatal and postnatal mental health and wellbeing
  • antenatal nutrition
  • the risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation
  • likely timing and possible modes of delivery
  • breastfeeding
  • parenting.

Care planning

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a care plan that specifies the timing of appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.

Rationale

Women with a multiple pregnancy should have most of their antenatal appointments with a member of the multidisciplinary core team. The number of appointments and ultrasound scans a woman should have depends on the chorionicity and amnionicity of her pregnancy and any associated risk factors or complications.
Women should have a record of the expected number of antenatal appointments they should attend, who they should have them with and where they will take place.

Quality measure

Structure
a) Evidence of local arrangements to ensure that women with a multiple pregnancy have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
b) Evidence of local audit to monitor the completeness and accuracy of the antenatal care plan for women with a multiple pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy.
Data source: Local data collection.
Outcome
Women feel informed about their care and know which healthcare professionals they should see and when.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013/14 indicator 4.5 'Women's experience of maternity services'.
The Care Quality Commission's Maternity services survey 2010 collected data on singleton and multiple births and asked the questions 'Roughly how many antenatal check-ups did you have in total?' and 'Roughly how may ultrasound scans did you have in total during this pregnancy?'. The total number of respondents is also stated, although results are not broken down by singleton or multiple pregnancies.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a care plan that has the dates and times of all their antenatal care appointments and details of who the appointments are with.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendation 1.1.2.11 (key priority for implementation) and recommendations 1.2.3.5, 1.2.3.6, 1.2.3.7 and 1.2.3.8.

Definitions

Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancies, and who works regularly with women with multiple pregnancies.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
Care plan
A care plan should be provided at determination of chorionicity, which specifies the frequency and timing of antenatal care appointments. The care plan should contain the recommended schedule of specialist antenatal appointments according to the chorionicity and amnionicity of a pregnancy, as detailed in NICE clinical guideline 129: schedule of specialist antenatal appointments.
Women may be seen for additional antenatal appointments in the community with healthcare professionals outside the multidisciplinary core team, such as neonatal unit staff, community midwives and GPs. The scheduling of these appointments will be coordinated by the multidisciplinary core team.

Monitoring for fetal complications

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.

Rationale

Multiple pregnancies are associated with increased risk of fetal complications. Fetal growth restriction is more likely to occur in monochorionic and dichorionic multiple pregnancies. There is a risk of feto-fetal transfusion syndrome with monochorionic multiple pregnancies. Therefore, it is important to monitor monochorionic and dichorionic multiple pregnancies closely for fetal complications in order to manage them effectively should they arise.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
a) The proportion of women with a monochorionic multiple pregnancy who are monitored for feto-fetal transfusion syndrome using ultrasound from 16 weeks and fortnightly until 24 weeks.
Numerator – the number of women in the denominator who were monitored for feto-fetal transfusion syndrome using ultrasound from 16 weeks and fortnightly until 24 weeks.
Denominator – the number of women with a monochorionic multiple pregnancy and a gestational age greater than 24 weeks.
Data source: Local data collection.
b) The proportion of women with a multiple pregnancy who receive an estimate of fetal weight discordance using 2 or more biometric parameters at each ultrasound scan from 20 weeks.
Numerator – the number of women in the denominator who received an estimate of fetal weight discordance using 2 or more biometric parameters at each ultrasound scan from 20 weeks.
Denominator – the number of women with a multiple pregnancy and a gestational age greater than 20 weeks.
Data source: Local data collection.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure that women with a multiple pregnancy can be monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that monitor women with a multiple pregnancy for fetal complications according to the chorionicity and amnionicity of their pregnancy.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are monitored to check the babies for any complications (for example, to check the babies' growth and blood flow) in a way that is appropriate for their pregnancy.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.3.4.2, 1.3.4.3 and 1.3.5.2.

Definitions

Fetal growth restriction
A difference in size of 25% or more between twins or triplets, known as fetal weight discordance, is a clinically significant indicator of fetal growth restriction. The number of scans women receive to monitor for fetal growth restriction is determined by the amnionicity and chorionicity of the pregnancy and should follow the recommended schedule of specialist antenatal appointments, as detailed in NICE clinical guideline 129: schedule of specialist antenatal appointments.
Fetal biometric parameters
Standard antenatal ultrasound measures to assess the growth and wellbeing of the fetus and monitor for fetal weight discordance, they include:
  • head circumference
  • abdominal circumference
  • femoral length.
Feto-fetal transfusion syndrome
Feto-fetal transfusion syndrome is a complication of monochorionic multiple pregnancies, in which shared blood vessels in the placenta cause an imbalance in the flow of blood from one fetus to another. The fetus with less blood is referred to as the donor, whereas the fetus with too much blood is called the recipient. There are significant risks to both fetuses. Feto-fetal transfusion syndrome is also referred to as twin-to-twin transfusion syndrome in twin pregnancies.

Involving a consultant from a tertiary level fetal medicine centre

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Rationale

Collaborative care between local services and tertiary level fetal medicine centres allows access to appropriate knowledge and expertise, and tertiary level neonatal and paediatric services when needed, while maintaining the focus on delivery of care locally.
A consultant from a tertiary level fetal medicine centre needs to be involved in some of the decisions about the care provided for women with a higher-risk multiple pregnancy, or if there are complications. It may be more suitable to involve the consultant in planning and managing care rather than referring a woman directly.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Data source: Local data collection.
Process
a) The proportion of women with a higher-risk multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a higher-risk multiple pregnancy.
Data source: Local data collection.
b) The proportion of women with a complicated multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a complicated multiple pregnancy.
Data source: Local data collection.
Outcome
Infant and maternal mortality and morbidity.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on neonatal death (global number 17209680). Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) collects data on: 'all deaths of pregnant women and women up to one year following the end of the pregnancy' and 'neonatal deaths'.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Healthcare practitioners ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Commissioners ensure that they commission services for women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an expert in fetal medicine involved in their care if their pregnancy is higher risk or if there are complications.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.6.1.1 and 1.3.2.6.

Definitions

Tertiary level fetal medicine centre
A regionally commissioned tertiary level centre with the experience and expertise for managing complicated twin and triplet pregnancies.
Involving a consultant from a tertiary level fetal medicine centre
Involving a consultant from a tertiary level fetal medicine centre can either be through seeking an opinion and then recording the discussion in the woman's notes, or referring a woman with a higher-risk or complicated multiple pregnancy to a tertiary level fetal medicine centre.
NICE clinical guideline 129 recommendation 1.6.1.1 advises the seeking of a consultant opinion from a tertiary level fetal medicine centre for higher-risk multiple pregnancies or complicated multiple pregnancies.
Higher-risk multiple pregnancies are defined as:
  • monochorionic monoamniotic twin pregnancies
  • monochorionic monoamniotic triplet pregnancies
  • monochorionic diamniotic triplet pregnancies
  • dichorionic diamniotic triplet pregnancies.
Complicated multiple pregnancies are defined as those with:
  • discordant fetal growth
  • fetal anomaly
  • discordant fetal death
  • feto-fetal transfusion syndrome.
In addition, NICE clinical guideline 129 recommendation 1.3.2.6 advises women with twin and triplet pregnancies who have a high risk of Down's syndrome to be offered referral to a fetal medicine specialist in a tertiary level fetal medicine centre.

Equality and diversity considerations

The woman's preferences should be taken into account when referring them for a consultant opinion at a tertiary level fetal medicine centre. An opinion may be sought from a consultant at a tertiary level fetal medicine centre if the centre is a long distance from the woman's home and it is clinically appropriate to do so.
Care should be delivered locally where possible to minimise inconvenience and anxiety for women and their partners. But anxiety caused by travelling further for an appointment needs to be weighed against the anxiety of an unclear diagnosis or prognosis.
Women from some cultural backgrounds may prefer to have their antenatal examinations undertaken by female members of staff. NHS maternity services are organised so that such preferences can be accounted for and have arrangements in place for female chaperones if needed.

Advice and preparation for preterm birth

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.

Rationale

The multidisciplinary core team have expert knowledge in managing multiple pregnancies. Women with a multiple pregnancy are at increased risk of maternal and fetal complications in pregnancy and preterm birth. It is important that they are given advice on the possible risks, signs and symptoms of preterm labour so that they know what to expect and who to contact quickly if such symptoms arise. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Numerator – the number of women in the denominator who have had a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Denominator – the number of women with a multiple pregnancy that is greater than 24 weeks' gestation.
Data source: Local data collection. NHS Maternity Statistics - 2010/2011:
  • 'Complications during non-delivery obstetric episodes, 2010/11 (Table 24).
  • Singleton, twin and higher order multiple deliveries by gestation and birth status, 2010/11 (Table 26).'
Outcome
Levels of satisfaction with support and confidence to recognise the signs and symptoms of preterm labour.
Data source: Local data collection. Data will also be collected against NHS Outcomes Framework 2013/14: indicator 4.5 'Women's experience of maternity services'.
The Care Quality Commission's Maternity services survey 2010 collected data on singleton and multiple births and asked the questions 'Thinking about your antenatal care, were you spoken to in a way that you could understand?' and 'Thinking about your antenatal care, were you involved enough in decisions about your care?'. The total number of respondents is also stated, although results are not broken down by singleton or multiple pregnancies.

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Healthcare practitioners ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Commissioners ensure that they commission services in which women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) discuss the risks and signs of an early (preterm) labour with one or more members of their healthcare team. The discussion should take place by 24 weeks of their pregnancy and also cover the possible problems associated with an early birth.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.2.3.4 and 1.7.1.4.

Definitions

The timeframe of 'by 24 weeks' is included based on expert consensus.
Preterm labour
The risk of preterm birth is higher in multiple pregnancies. About 60% of twins are delivered by 37 weeks and 10% before 32 weeks, and 75% of triplets are delivered by 35 weeks.
The benefits and risks of targeted corticosteroids for fetal lung maturation should be discussed when providing information about preterm labour.
The signs and symptoms of preterm labour include more frequent and regular contractions, ruptured membranes, unusual or severe backache or other pain.
The potential need for neonatal management and the role of neonatal networks, including the possibility of admission of babies to a neonatal unit after birth, should also be discussed. Where possible, staff from the neonatal unit should be involved in the discussion and women should be provided with appropriate information about the neonatal services.

Equality and diversity considerations

Information on the risks, signs and symptoms of preterm labour should be understood by all women so that they can feel fully informed. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Preparation for birth

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 32 weeks with one or more members of the multidisciplinary core team about the timing of birth and possible modes of delivery so that a birth plan can be agreed.

Rationale

Most women with multiple pregnancies deliver by 37 weeks either spontaneously or electively. This discussion should include the risks and benefits of different modes of birth and how they are managed to enable women to make an informed decision about their birth preference. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measure

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery.
Numerator – the number of women in the denominator who have had a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery.
Denominator – the number of women with a multiple pregnancy of 32 weeks or more.
Data source: Local data collection. The Clinical Negligence Scheme for Trusts (CNST) Maternity Standards 2013/14 includes requirements for services to have discussion on the timing and mode of birth:
'Standard 3: high-risk conditions – criterion 4: multiple pregnancy and birth:
Level 1: the maternity service has approved documentation for the management of multiple pregnancy and birth, which as a minimum must include the:
  • requirement for providing information on the risks and benefits of different modes of delivery to support women in planning for birth.
  • requirement to discuss the planned and agreed place and timing of birth.'
Outcome
Women feel well informed and able to make decisions that reflect what is important to them about the options for delivery.
Data source: Local data collection. The Maternity Services Secondary Uses Data Set, once implemented, will collect data on delivery method (global number 2016160) and gestational age at birth (global number 17206120). Data will also be collected NHS Outcomes Framework 2013/14: indicator 4.5 'Women's experience of maternity services'

What the quality statement means for each audience

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Healthcare practitioners from the multidisciplinary core team ensure that the timing of birth and possible modes of delivery are discussed with women with a multiple pregnancy by 32 weeks so that a birth plan can be agreed.
Commissioners ensure that they commission services so that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.

What the quality statement means for patients, service users and carers

Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a discussion with one or more members of their healthcare team about the timing of the birth and how they want their babies to be delivered. This discussion needs to take place by 32 weeks of their pregnancy and include agreement of their birth plan.

Source guidance

Multiple pregnancy (NICE clinical guideline 129) recommendations 1.7.1.1 to 1.7.1.7 and recommendation 1.7.1.8 (key priority for implementation).

Definitions

The timeframe of 'by 32 weeks' is included based on expert consensus and adaption of NICE clinical guideline 129 recommendation 1.7.1.1.
Based on their expert consensus, where possible, staff from the neonatal unit should be involved in the discussion and women should be provided with appropriate information about the neonatal services.

Equality and diversity considerations

Information on the timing of birth and possible modes of delivery should be understood by all women to enable them to make informed decisions. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities, and women who do not speak or read English).

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
NICE has also written information for the public on the NICE quality standards on antenatal care, hypertension in pregnancy and multiple pregnancy.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

21 February 2014 Minor maintenance updates.
23 October 2013 NICE pathway links to diet, obesity and maternal and child nutrition added to this pathway.
17 September 2013 Multiple pregnancy quality standard (QS46) added to pathway.
23 August 2013 Minor maintenance updates.
23 July 2013 Link to pregnant women with varicose veins in the varicose veins in the legs pathway added to managing common symptoms of pregnancy in this pathway.
16 July 2013 Hypertension in pregnancy quality standard (QS35) added to pathway and Antenatal care quality standard (QS22) updated. Vision Amniotic Leak Detector to assess unexplained vaginal wetness in pregnancy (NICE medical technology guidance 15) added to the antenatal care overview path.
19 April 2013 Minor maintenance updates.
1 February 2013 Minor maintenance updates.
14 December 2012 Minor maintenance.
28 September 2012 Antenatal care quality standard (QS22) added to pathway.
10 August 2012 Minor maintenance.
6 April 2012 Cross references to epilepsy pathway and pregnancy and complex social factors pathway updated in Overview path (slug reference to node). Map reference node added on Overview path to pathway for women with pregnancy and complex social factors.

Supporting information

Glossary

Antenatal care

Antenatal care

Women with pre-existing conditions or risk factors

Women with pre-existing conditions or risk factors

Women with pre-existing conditions or risk factors

The pathway makes recommendations on baseline clinical care for all pregnant women. Pregnant women with the following conditions usually require additional care:
  • Renal disease
  • Psychiatric disorders (being treated with medication) (see the antenatal and postnatal mental health pathway)
  • Haematological disorders
  • Autoimmune disorders
  • Epilepsy requiring anticonvulsant drugs (see the epilepsy pathway)
  • Malignant disease
  • Severe asthma
  • Use of recreational drugs such as heroin, cocaine (including crack cocaine) and ecstasy
  • HIV or HBV infection
  • Obesity (body mass index 30 kg/m2 or above) (see NICE public health guidance on weight management and the NICE pathways on diet, obesity, and maternal and child nutrition), or underweight (body mass index below 18 kg/m2) (see NICE public health guidance on weight management).
  • Higher risk of developing complications, for example, women aged 40 and older, women who smoke (see the smoking pathway).
For women with hypertension see the hypertension in pregnancy pathway.
A system of clear referral paths should be established so that pregnant women who require additional care are managed and treated by the appropriate specialist teams when problems are identified.

Quality standards

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Antenatal care quality standard

Hypertension in pregnancy quality standard

Implementation tools

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Source guidance

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Women who had problems in a previous pregnancy

Women who had problems in a previous pregnancy

Women who had problems in a previous pregnancy

Women who have experienced any of the following in previous pregnancies usually require additional care:
A system of clear referral paths should be established so that pregnant women who require additional care are managed and treated by the appropriate specialist teams when problems are identified.

Quality standards

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Hypertension in pregnancy quality standard

Source guidance

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Diabetes in pregnancy pathway

View the 'Diabetes in pregnancy overview' path

Hypertension in pregnancy pathway

View the 'Hypertension in pregnancy overview' path

Multiple (twin or triplet) pregnancy pathway

View the 'Multiple pregnancy overview' path

Pregnancy and complex social factors pathway

View the 'Pregnancy and complex social factors overview' path

Ectopic pregnancy and miscarriage pathway

View the 'Ectopic pregnancy and miscarriage overview' path

Women with unexplained vaginal wetness in pregnancy

Women with unexplained vaginal wetness in pregnancy

Women with unexplained vaginal wetness in pregnancy

NICE medical technologies guidance

NICE medical technologies guidance addresses specific technologies notified to NICE by manufacturers. The 'case for adoption' is based on the claimed advantages of introducing the specific technology compared with current management of the condition. This case is reviewed against the evidence submitted and expert advice. If the case for adopting the technology is supported then the technology has been found to offer advantages to patients and the NHS. The specific recommendations on individual technologies are not intended to limit use of other relevant technologies which may offer similar advantages. The following medical technology guidance is relevant to this part of the pathway.

Vision Amniotic Leak Detector to assess unexplained vaginal wetness in pregnancy

The case for adopting the Vision Amniotic Leak Detector (ALD), when issued by a midwife or other healthcare worker, is supported by the evidence. The available evidence suggests that the device can reliably exclude amniotic fluid leak as a cause of vaginal wetness in pregnancy, avoiding the need for a speculum examination and its associated discomforts. Using the device in the community could prevent unnecessary referrals to secondary care antenatal day units or maternity triage services for speculum examinations, releasing clinical time.
The Vision ALD should be considered for use in pregnant women with unexplained vaginal wetness.
Based on cost modelling, using the Vision ALD is estimated to be cost saving in scenarios considered to be clinically likely, by avoiding the need for referral to an antenatal day unit. When issued by a midwife or other healthcare worker in a primary care setting, cost savings per woman of up to £24.01 (for prelabour rupture of membranes; PROM) and £18.25 (for preterm prelabour rupture of membranes; PPROM) could be achieved. When issued by a community midwife in a woman's home, Vision ALD is associated with an estimated cost saving of up to £21.01 per woman for PROM and £15.25 per woman for PPROM.
These recommendations are from Vision Amniotic Leak Detector to assess unexplained vaginal wetness in pregnancy (NICE medical technology guidance 15).
NICE has written information for the public explaining the guidance on Vision Amniotic Leak Detector.

Implementation tools

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Source guidance

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Interventional procedures for some complications in pregnancy

Interventional procedures for some complications in pregnancy

Interventional procedures for some complications in pregnancy

Fetal abnormalities

NICE has published interventional procedures guidance on the following procedures:

Recurrent pregnancy loss

NICE has produced guidance on laparoscopic cerclage for prevention of recurrent pregnancy loss due to cervical incompetence (NICE interventional procedures guidance 228).

Oligohydramnios

NICE has produced guidance on therapeutic amnioinfusion for oligohydramnios during pregnancy (excluding labour) (NICE interventional procedure guidance 192).

Paths in this pathway

Pathway created: November 2011 Last updated: February 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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