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

Antenatal care quality standard

These quality statements are taken from the antenatal care quality standard. The quality standard defines clinical best practice in antenatal care and should be read in full.
1Services – access to antenatal care
2Services – continuity of care
3Services – record keeping
4Risk assessment – body mass index
5Risk assessment – smoking cessation
6Risk assessment – gestational diabetes
7Risk assessment – pre-eclampsia
8Risk assessment – intermediate risk of venous thromboembolism
9Risk assessment – high risk of venous thromboembolism
10Screening – national fetal anomaly screening programmes
11Fetal wellbeing – external cephalic version
12Fetal wellbeing – membrane sweeping for prolonged pregnancy

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
Local data collection. The NICE clinical guideline 110 baseline assessment tool and the NICE public health guidance 27 audit support, criterion 3.

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.
NICE public health guidance 11 recommendation 6.
NICE public health guidance 27 recommendation 2.

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

NICE public health guidance 26 recommendation 1.

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

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 pre-eclampsia at the booking appointment are offered a prescription of 75 mg of aspirin to take daily from 12 weeks until at least 36 weeks.

Quality measure

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.
b) Evidence of local arrangements to ensure that pregnant women at high 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 at least 36 weeks.
Process
a) Proportion of pregnant women accessing antenatal care 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 at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
b) Proportion of pregnant women at high risk of pre-eclampsia at the booking appointment who are prescribed 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks.
Numerator – the number of women in the denominator prescribed 75 mg of aspirin to take daily from 12 weeks until at least 36 weeks.
Denominator – the number of pregnant women at high risk of pre-eclampsia and without contraindications to aspirin at the booking appointment.
Outcome
Incidence of pre-eclampsia in women at high risk of developing pre-eclampsia.

What the quality statement means for each audience

Service providers ensure that systems are in place to offer pregnant women at high risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks.
Healthcare professionals offer pregnant women at high risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks.
Commissioners ensure they commission services that offer pregnant women at high risk of pre-eclampsia at the booking appointment a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks.
Pregnant women at high risk of developing pre-eclampsia (a serious condition that can occur during pregnancy) at the booking appointment, are offered a prescription for aspirin (unless this is unsuitable) to take every day from 12 weeks until at least 36 weeks.

Source guidance

NICE clinical guideline 107 recommendation 1.1.2.1 (key priority for implementation).

Data sources

Structure
a) and b) Local data collection. b) The NICE clinical guideline 107 baseline assessment tool.
Process
a) Local data collection. The Maternity Services Secondary Uses Dataset, once implemented, will collect 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 pre-term birth', 'eclampsia' and 'gestational hypertension' (global number 17200720).
b) Local data collection.

Definitions

Pregnant women at high risk of pre-eclampsia are defined in NICE clinical guideline 107 as those with any of the following:
  • hypertensive disease during a previous pregnancy
  • chronic kidney disease
  • autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes
  • chronic hypertension.
Contraindications to taking aspirin include, but are not limited to:
  • aspirin allergy
  • medical condition precluding the use of aspirin
  • present use of another drug with the potential to interact adversely 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.

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.
UK National Screening Committee Fetal anomaly screening programme 18+0 to {20+6 weeks} fetal anomaly scan national standards and guidance for England standard 1.

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).

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.
Antenatal care and diabetes in pregnancy: costing report
Routine antenatal anti-D prophylaxis for women who are rhesus D negative: costing statement
Antenatal care and diabetes in pregnancy: costing template
Intrapartum care: costing statement
Antenatal care quality standard: quality standard support

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.
Antenatal care (complications of pregnancy): education tool
Antenatal care: slide set
Intrapartum care: slide set

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.
Antenatal care
Intrapartum care
Pregnancy (rhesus negative women) - routine anti-D (review)
NICE has also written information for the public on the NICE quality standard on antenatal care

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 someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their 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.

Updates to this pathway

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

Routine care for all pregnant women

View the 'Routine care for all pregnant women' path

Women needing additional care

Women needing additional 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) 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)
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

4Risk assessment – body mass index
5Risk assessment – smoking cessation
6Risk assessment – gestational diabetes
7Risk assessment – pre-eclampsia
8Risk assessment – intermediate risk of venous thromboembolism
9Risk assessment – high risk of venous thromboembolism

Implementation tools

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Antenatal care (complications of pregnancy): education tool

Source guidance

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CG62

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

7Risk assessment – pre-eclampsia

Source guidance

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CG62

Diabetes in pregnancy pathway

View the 'Diabetes in pregnancy overview' path

Hypertension in pregnancy

Hypertension in pregnancy

Hypertension in pregnancy

NICE has produced a clinical guideline on hypertension in pregnancy.

Quality standards

7Risk assessment – pre-eclampsia

Source guidance

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CG62

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

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: April 2013

Copyright © 2013 National Institute for Health and Care Excellence. All Rights Reserved.

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