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Antenatal care for uncomplicated pregnancies

About

What is covered

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.

Updates

Updates to this pathway

8 November 2016 High-throughput non-invasive prenatal testing for fetal RHD genotype (NICE diagnostics guidance 25) added to anaemia and blood group.
30 September 2016 Pathway restructured and summarised recommendations replaced with full recommendations.
14 March 2016 Information on risk assessment and testing for gestational diabetes updated.
9 December 2015 Intrapartum care (NICE quality standard 105) added.
29 July 2015 Maternal and child nutrition (NICE quality standard 98) added.
22 June 2015 Antenatal care (NICE quality standard 22) updated.
2 December 2014 Planning place of birth updated on publication of intrapartum care guideline CG190.
16 July 2013 Hypertension in pregnancy ((NICE quality standard 35) added and antenatal care (NICE quality standard 22) updated.
28 September 2012 Antenatal care quality standard (NICE quality standard 22) added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on antenatal care for healthy women with uncomplicated pregnancies in an interactive flowchart

What is covered

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.

Updates

Updates to this pathway

8 November 2016 High-throughput non-invasive prenatal testing for fetal RHD genotype (NICE diagnostics guidance 25) added to anaemia and blood group.
30 September 2016 Pathway restructured and summarised recommendations replaced with full recommendations.
14 March 2016 Information on risk assessment and testing for gestational diabetes updated.
9 December 2015 Intrapartum care (NICE quality standard 105) added.
29 July 2015 Maternal and child nutrition (NICE quality standard 98) added.
22 June 2015 Antenatal care (NICE quality standard 22) updated.
2 December 2014 Planning place of birth updated on publication of intrapartum care guideline CG190.
16 July 2013 Hypertension in pregnancy ((NICE quality standard 35) added and antenatal care (NICE quality standard 22) updated.
28 September 2012 Antenatal care quality standard (NICE quality standard 22) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Intrapartum care (2015) NICE quality standard 105
Maternal and child nutrition (2015) NICE quality standard 98
Hypertension in pregnancy (2013) NICE quality standard 35
Antenatal care (2012) NICE quality standard 22

Quality standards

Maternal and child nutrition

These quality statements are taken from the maternal and child nutrition quality standard. The quality standard defines clinical best practice for improving maternal and child nutrition and should be read in full.

Intrapartum care

These quality statements are taken from the intrapartum care quality standard. The quality standard defines clinical best practice for intrapartum care and should be read in full.

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.
Data source: a) and b) Local data collection. The NICE guideline CG110 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
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.
Data source: Local data collection.
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.
Data source: 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.

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

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 guideline CG62 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 guideline CG110 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.
Data source: a) and b) Local data collection.
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.
Data source: Local data collection.
Outcome
Pregnant women's satisfaction with the continuity of their antenatal care.
Data source: 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.

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

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.
Data source: a) and b) Local data collection.
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.
Data source: Local data collection. The NICE guideline CG110 baseline assessment tool and the NICE public health guidance 27 audit support, criterion 3.

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

Definitions

The minimum set of tests for routine scheduled antenatal care has been developed from the appointment schedule in appendix D of NICE guideline CG62.
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.
Data source: a) and b) Local data collection. The NICE guideline PH27 self assessment tool.
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.
Data source: 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 guideline PH27 audit support, criteria 1 and 3.
b) Local data collection.
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

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.
Data source: a) Local data collection through Maternity Services Secondary Uses Dataset b) local data collection through PHQ30 and c) local data collection.
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.
Data source: 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) Quit rates for pregnant women.
b) Smoking rates in pregnancy.
Data source: 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.

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

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 guideline PH26)]
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 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.
Data source: a) and b) Local data collection.
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.
Data source: a) and b) Local data collection. The NICE guideline CG62 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).
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

Definitions

Risk factors are taken from NICE guideline NG3:
  • 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)
  • minority ethnic family origin with a high prevalence of diabetes.
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 diabetes in pregnancy NICE guideline NG3:
Use the 2-hour 75 g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors.
Offer women who have had gestational diabetes in a previous pregnancy:
  • early self-monitoring of blood glucose or
  • a 75 g 2-hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75 g 2-hour OGTT at 24–28 weeks if the results of the first OGTT are normal.
Offer women with any of the other risk factors for gestational diabetes a 75 g 2-hour 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.
Data source: a) and b) Local data collection.
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.
Data source: a) and b) Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

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

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.
Data source: a) and b) Local data collection.
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.
Data source: a) and b) Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident (global number 17205700).

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

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.
Data source: a) and b) Local data collection.
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.
Data source: 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.
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

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.
Data source:a) and b) Local data collection.
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).
Data source: a) and b) Local data collection.
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.
Data source: 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).

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

  • Antenatal care (2008) NICE guideline CG62, recommendations 1.10.5 and 1.11.2.1.

Definitions

As detailed in NICE guideline CG62 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.
Data source: Local data collection.
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.
Data source: a), b) and c) Local data collection.
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).
Data source: 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).

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

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).
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Choosing birth setting

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

Quality statement

Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.

Rationale

Women at low risk of complications during labour and birth need information that is specific to their local or neighbouring area about safety and outcomes for women and babies in the different birth settings. This information will help women to make informed choices about where to have their baby.

Quality measures

Structure
a) Evidence of local arrangements to provide women at low risk of complications with a choice of all 4 birth settings.
Data source: Local data collection.
b) Evidence of local arrangements to provide women at low risk of complications with local information about birth outcomes.
Data source: Local data collection.
Process
a) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment of their preferred choice of birth setting.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Data source: Local data collection.
b) Proportion of women at low risk of complications with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Numerator – The number in the denominator with a recorded discussion at their antenatal booking appointment about local birth outcomes.
Denominator – The number of women at low risk of complications attending an antenatal booking appointment.
Outcome
Maternal experience and satisfaction with place of birth.
Data source: Local data collection.

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

Service providers (community, primary and secondary care services) raise awareness of maternity pathways and ensure that systems and tools are in place to offer women at low risk of complications a choice of all 4 birth settings and local information about birth outcomes to support them to make informed decisions about where to have their baby.
Healthcare professionals provide women at low risk of complications with local information about birth outcomes and rates of transfer to an obstetric unit for all birth settings, and support them to make informed decisions about where to have their baby. Healthcare professionals can adapt and use NICE's choosing place of birth resource for midwives to do this.
Commissioners (clinical commissioning groups) commission maternity services to ensure that all 4 birth settings are available in the local or a neighbouring area to women at low risk of complications. Commissioners also ensure that services provide local information about outcomes for women and babies and rates of transfer to an obstetric unit for all birth settings to support women to make informed decisions about where to have their baby. Commissioners coordinate collection of outcome data in local and neighbouring areas to help service providers and healthcare professionals giving information to women. Commissioners can refer to the costing statement for the intrapartum care guideline for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

Women at low risk of having problems during labour and birth have a choice of 4 places where they can have their baby – at home, in a midwife-led unit that is either next to a hospital obstetric unit or in a different place, or in an obstetric unit (‘labour ward’). To help women make an informed choice, they are given information by their midwife about birth outcomes and rates of transfer to an obstetric unit for their local or neighbouring area. Birth outcomes are things like the chances of needing a ventouse or forceps birth, caesarean section or episiotomy, and the risk of serious medical problems for the baby.

Source guidance

  • Intrapartum care (2014) NICE guideline CG190, recommendations 1.1.2 (key priority for implementation), 1.1.3 and 1.1.6 (key priority for implementation)
  • Antenatal care (2008) NICE guideline CG62, recommendation 1.1.1.1

Definitions of terms used in this quality statement

4 birth settings
The 4 settings where a woman at low risk of complications may choose to have her baby are: at home, in a freestanding midwifery unit, in an alongside midwifery unit and in an obstetric unit.
[Intrapartum care (NICE guideline CG190) recommendation 1.1.2]
Birth outcomes
Outcomes for women for each planned place of birth include rates of spontaneous vaginal birth, transfer to obstetric unit, obstetric intervention and delivering a baby with or without serious medical problems.
[Adapted from intrapartum care (NICE guideline CG190) recommendation 1.1.3]

One-to-one care

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

Quality statement

Women in established labour have one-to-one care and support from an assigned midwife.

Rationale

One-to-one care will increase the likelihood of the woman having a ‘normal’ vaginal birth without interventions, and will contribute to reducing both the length of labour and the number of operative deliveries. Care will not necessarily be given by the same midwife for the whole labour.

Quality measures

Structure
Evidence of midwifery staff available to provide one-to-one care to women in established labour in each birth setting.
Data source: Local data collection.
Process
Midwifery staffing levels as in the NICE guideline on safe midwifery staffing for maternity settings.
Numerator – The number of women in the denominator who receive one-to-one care from an assigned midwife during established labour.
Denominator – The number of women in established labour in a time period.
Data source: Local data collection.
Outcome
a) Neonatal morbidity.
Data source: Local data collection.
b) Maternal morbidity.
Data source: Local data collection.
c) Maternal satisfaction and experience of care.
Data source: Local data collection.

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

Service providers (for all 4 birth settings) ensure that recommended midwifery staffing ratios are maintained so that women in established labour have one-to-one care and support from an assigned midwife.
Healthcare professionals (assigned midwives) give one-to-one care to each woman in established labour and are solely dedicated to the care of that woman.
Commissioners (clinical commissioning groups) commission services that have systems in place to maintain recommended midwifery staffing ratios, so that women in established labour have one-to-one care and support from an assigned midwife. Commissioners can refer to the costing statement for the intrapartum care guideline for more information about the likely resource impact of this quality statement, which will depend on local circumstances.

What the quality statement means for women and their companions

A woman in labour is cared for by a midwife who is looking after just her – this is called ‘one-to-one care’. She might not have the same midwife for the whole of labour. One-to-one care aims to ensure that the woman has a good experience of care and reduces the likelihood of problems for her and her baby.

Source guidance

Definitions of terms used in this quality statement

Established labour
Labour is established when:
  • there are regular painful contractions and
  • there is progressive cervical dilatation from 4 cm.
[Intrapartum care (NICE guideline CG190) recommendation 1.3.1] 

Cardiotocography and the initial assessment of a woman in labour

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

Quality statement

Women at low risk of complications do not have cardiotocography as part of the initial assessment of labour.

Rationale

Cardiotocography is not appropriate in the initial assessment of women at low risk of complications who are in labour. This is because it may lead to unnecessary interventions and does not provide any benefit to the baby.

Quality measures

Structure
Evidence of local arrangements to ensure that cardiotocography is not used in the initial assessment of women at low risk of complications who are in labour.
Data source: Local data collection.
Process
Proportion of women at low risk of complications in labour who have cardiotocography as part of the initial assessment.
Numerator – The number in the denominator who have cardiotocography as part of the initial assessment.
Denominator – The number of initial assessments of women at low risk of complications in labour.
Data source: Local data collection.
Outcome
Women having cardiotocography in the initial assessment of labour.
Data source: Local data collection.

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

Service providers (for freestanding midwifery units, alongside midwifery units and obstetric units) have protocols in place to ensure that cardiotocography is not used in the initial assessment of women at low risk of complications who are in labour.
Healthcare professionals (midwives and obstetricians) do not use cardiotocography in the initial assessment of women at low risk of complications who are in labour.
Commissioners (clinical commissioning groups) specify and check that providers do not use cardiotocography in the initial assessment of women at low risk of complications who are in labour.

What the quality statement means for women and their companions

Women who are at low risk of having problems during labour do not have electronic monitoring of the baby’s heartbeat (that is, being connected to a monitor) as part of the first checks when they go into labour.

Source guidance

Definitions of terms used in this quality statement

Established labour
Labour is established when:
  • there are regular painful contractions and
  • there is progressive cervical dilatation from 4 cm.
[Intrapartum care (NICE guideline CG190) recommendation 1.3.1]

Stopping cardiotocography

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

Quality statement

Women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

Rationale

Cardiotocography is offered to women if intermittent auscultation indicates possible fetal heart rate abnormalities. However, cardiotocography that is started for this reason should be stopped if the trace is normal for 20 minutes, because it restricts the woman’s movement and can cause labour to slow down. This can lead to a cascade of interventions that may result in adverse birth outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications having cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Data source: Local data collection.
Process
Proportion of women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Numerator – The number in the denominator who have the cardiotocograph removed.
Denominator – The number of women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation and who have a normal trace for 20 minutes.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

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

Service providers (for freestanding midwifery units, alongside midwifery units and obstetric units) have evidence of local arrangements to ensure that protocols are in place so that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.
Healthcare professionals (midwives and obstetricians) remove the cardiotocograph if the trace is normal for 20 minutes for women at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women in labour at low risk of complications who have cardiotocography because of concern arising from intermittent auscultation have the cardiotocograph removed if the trace is normal for 20 minutes.

What the quality statement means for women and their companions

Women who are at low risk of problems during labour, but who have electronic monitoring because of possible concerns about the baby's heartbeat, are taken off the monitor if the baby’s heartbeat is normal for 20 minutes.

Source guidance

  • Intrapartum care (2014) NICE guideline CG190, recommendations 1.4.12 and 1.10.7

Definitions of terms used in this quality statement

Normal cardiotocograph trace
A normal trace has the following normal/reassuring features:
  • baseline fetal heart rate of 100 to 160 beats per minute and
  • baseline variability of 5 beats per minute or more and
  • no or early decelerations.
[Intrapartum care (NICE guideline CG190) table 10]

Interventions during labour

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

Quality statement

Women at low risk of complications are not offered amniotomy or oxytocin if labour is progressing normally.

Rationale

For women at low risk of complications, amniotomy and oxytocin do not reduce the incidence of caesarean section, increase the incidence of spontaneous vaginal births or contribute to improved neonatal outcomes. They are therefore unnecessary for women at low risk of complications if labour is progressing normally.

Quality measures

Structure
Evidence of local arrangements to ensure that women at low risk of complications who are in labour that is progressing normally do not have amniotomy or oxytocin.
Data source: Local data collection.
Process
Proportion of women at low risk of complications whose labour is progressing normally who do not have amniotomy or oxytocin.
Numerator – The number in the denominator who do not have amniotomy or oxytocin.
Denominator – The number of women at low risk of complications whose labour is progressing normally.
Data source: Local data collection.
Outcome
a) The number of women in labour that is progressing normally having amniotomy or oxytocin.
Data source: Local data collection.
b) Maternal satisfaction and experience of care.
Data source: Local data collection.

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

Service providers (for all 4 birth settings) have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.
Healthcare professionals (midwives and obstetricians) do not offer amniotomy or oxytocin to women at low risk of complications whose labour is progressing normally.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women at low risk of complications whose labour is progressing normally are not offered amniotomy or oxytocin.

What the quality statement means for women and their companions

Women who are at low risk of having problems and whose labour is progressing normally are not offered amniotomy (having their waters broken) or oxytocin (a medicine given through a drip that speeds up labour).

Source guidance

  • Intrapartum care (2014) NICE guideline CG190, recommendations 1.12.11 and 1.12.12

Definitions of terms used in this quality statement

Normal labour and normal progression of labour
The NICE full guideline on intrapartum care adopts the World Health Organization definition of a normal labour: ‘labour is normal when it is spontaneous in onset, low risk at the start and remaining so throughout labour and birth. The baby is born spontaneously and in the vertex position between 37–42 completed weeks of pregnancy. After birth woman and baby are in good condition’.

Delayed cord clamping

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

Quality statement

Women do not have the cord clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.

Rationale

The benefits of delayed cord clamping include higher haemoglobin concentrations, a decreased risk of iron deficiency and greater vascular stability in babies. If they wish, women can ask healthcare professionals to wait longer to clamp the cord.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians do not clamp the cord earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Process
a) Proportion of cords clamped earlier than 1 minute after the birth where there is not a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped after 1 minute after the birth.
Denominator – The number of babies born where there is no concern about cord integrity or the baby’s heartbeat.
b) Proportion of cords clamped earlier than 1 minute where there is a concern about cord integrity or the baby’s heartbeat.
Numerator – The number in the denominator where the cord is clamped earlier than 1 minute after the birth.
Denominator – the number of babies born where there is a concern about cord integrity or the baby’s heartbeat.
Data source: Local data collection.
Outcome
Maternal satisfaction and experience of care.
Data source: Local data collection.

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

Service providers (for all 4 birth settings) have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Healthcare professionals (midwives and obstetricians) do not clamp the cord earlier than 1 minute after the birth unless there is concern about cord integrity or the baby’s heartbeat.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that the cord is not clamped earlier than 1 minute after the birth unless there is a concern about cord integrity or the baby’s heartbeat.

What the quality statement means for women and their companions

Women who have just given birth do not have the cord clamped for at least 1 minute after the birth unless there are concerns about the baby. This is to allow more blood to reach the baby and may help to prevent anaemia.

Source guidance

  • Intrapartum care (2014) NICE guideline CG190, recommendation 1.14.14 (key priority for implementation)

Definitions of terms used in this quality statement

Cord integrity
Concerns would arise over cord integrity if the cord was damaged in any way, if it had snapped during delivery or if there was bleeding to the cord. Definitions of cord integrity are not limited to those stated here.
[Expert opinion]
Concern about the baby’s heartbeat
Concern would arise if, after delivery, the baby has a heartbeat below 60 beats/minute that is not getting faster.
[Adapted from intrapartum care (NICE guideline CG190), recommendation 1.14.14]

Skin-to-skin contact

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

Quality statement

Women have skin-to-skin contact with their babies after the birth.

Rationale

Skin-to-skin contact with babies soon after birth has been shown to promote the initiation of breastfeeding and protect against the negative effects of mother–baby separation.

Quality measures

Structure
Evidence of local arrangements to ensure that midwives and obstetricians encourage women to have skin to skin contact with their babies after the birth.
Data source: Local data collection.
Process
Proportion of women with a record of having skin to skin contact with their babies after the birth .
Numerator – The number in the denominator where there is a record of the woman having skin to skin contact with the babyIt is important that this happens as soon as possible, but timescales should be determined locally, depending on the setting and whether the baby and mother are stable..
Denominator – The number of babies born.
Data source: Local data collection.
Outcome
Women’s satisfaction with the support received to have skin to skin contact with their babies after the birth.
Data source: Local data collection.

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

Service providers (for all 4 birth settings) have protocols in place for midwives and obstetricians to encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Healthcare professionals (midwives and obstetricians) encourage women to have skin-to-skin contact with their babies as soon as possible after the birth.
Commissioners (clinical commissioning groups) specify and check that service providers have protocols in place to ensure that women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

What the quality statement means for women and their companions

Women are encouraged to have skin-to-skin contact with their babies as soon as possible after the birth.

Source guidance

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
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Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low-risk multiparous women (sources: Birthplace 2011; Blix et al. 2012)

Number of incidences per 1000 multiparous women giving birth
Home
Freestanding midwifery unit
Alongside midwifery unit
Obstetric unit
Spontaneous vaginal birth
984*
980
967
927*
Transfer to an obstetric unit
115*
94
125
10**
Regional analgesia (epidural and/or spinal)***
28*
40
60
121*
Episiotomy
15*
23
35
56*
Caesarean birth
7*
8
10
35*
Instrumental birth (forceps or ventouse)
9*
12
23
38*
Blood transfusion
4
4
5
8
* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011).
** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise.
*** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia.

Outcomes for the baby for each planned place of birth: low-risk multiparous women (source: Birthplace 2011)

Number of babies per 1000 births
Home
Freestanding midwifery unit
Alongside midwifery unit
Obstetric unit
Babies without serious medical problems
997
997
998
997
Babies with serious medical problems*
3
3
2
3
* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. Stillbirths after the start of care in labour and death of the baby in the first week of life accounted for 13% of the events. Fractured humerus and clavicle were uncommon outcomes (less than 4% of adverse events). For the frequency of these events (how often any of them actually occurred), see types and frequencies of serious medical problems that can affect babies.

Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low-risk nulliparous women (sources: Birthplace 2011; Blix et al. 2012)

Number of incidences per 1000 nulliparous women giving birth
Home
Freestanding midwifery unit
Alongside midwifery unit
Obstetric unit
Spontaneous vaginal birth
794*
813
765
688*
Transfer to an obstetric unit
450*
363
402
10**
Regional analgesia (epidural and/or spinal)***
218*
200
240
349*
Episiotomy
165*
165
216
242*
Caesarean birth
80*
69
76
121*
Instrumental birth (forceps or ventouse)
126*
118
159
191*
Blood transfusion
12
8
11
16
* Figures from Birthplace 2011 and Blix et al. 2012 (all other figures from Birthplace 2011).
** Estimated transfer rate from an obstetric unit to a different obstetric unit owing to lack of capacity or expertise.
*** Blix reported epidural analgesia and Birthplace reported spinal or epidural analgesia.

Outcomes for the baby for each planned place of birth: low-risk nulliparous women (source: Birthplace 2011)

Number of babies per 1000 births
Home
Freestanding midwifery unit
Alongside midwifery unit
Obstetric unit
Babies without serious medical problems
991
995
995
995
Babies with serious medical problems*
9
5
5
5
* Serious medical problems were combined in the study: neonatal encephalopathy and meconium aspiration syndrome were the most common adverse events, together accounting for 75% of the total. Stillbirths after the start of care in labour and death of the baby in the first week of life accounted for 13% of the events. Fractured humerus and clavicle were uncommon outcomes – less than 4% of adverse events. For the frequency of these events (how often any of them actually occurred), see types and frequencies of serious medical problems that can affect babies.

Primary reasons for transfer to an obstetric unit (source: Birthplace 2011)

Primary reason for transfer to an obstetric unit*
Number of women transferred (% of total transferred from each setting)
From home (n=3529)
From a freestanding midwifery unit (n=2457)
From an alongside midwifery unit (n=4401)
Delay during first or second stage of labour
1144 (32.4%)
912 (37.1%)
1548 (35.2%)
Abnormal fetal heart rate
246 (7.0%)
259 (10.5%)
477 (10.8%)
Request for regional analgesia
180 (5.1%)
163 (6.6%)
585 (13.3%)
Meconium staining
432 (12.2%)
301 (12.2%)
538 (12.2%)
Retained placenta
250 (7.0%)
179 (7.3%)
203 (4.6%)
Repair of perineal trauma
386 (10.9%)
184 (7.5%)
369 (8.4%)
Neonatal concerns (postpartum)
180 (5.1%)
63 (2.6%)
5 (0.0%)
Other
711 (20.1%)
396 (16.2%)
676 (16.3%)
* Main reason for transfer to an obstetric unit for each woman (there may be more than 1 reason).

Medical conditions indicating increased risk suggesting planned birth at an obstetric unit

Disease area
Medical condition
Cardiovascular
Confirmed cardiac disease
Hypertensive disorders
Respiratory
Asthma requiring an increase in treatment or hospital treatment
Cystic fibrosis
Haematological
Haemoglobinopathies – sickle-cell disease, beta-thalassaemia major
History of thromboembolic disorders
Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/litre
Von Willebrand's disease
Bleeding disorder in the woman or unborn baby
Atypical antibodies which carry a risk of haemolytic disease of the newborn
Endocrine
Hyperthyroidism
Diabetes
Infective
Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended
Hepatitis B/C with abnormal liver function tests
Carrier of/infected with HIV
Toxoplasmosis – women receiving treatment
Current active infection of chicken pox/rubella/genital herpes in the woman or baby
Tuberculosis under treatment
Immune
Systemic lupus erythematosus
Scleroderma
Renal
Abnormal renal function
Renal disease requiring supervision by a renal specialist
Neurological
Epilepsy
Myasthenia gravis
Previous cerebrovascular accident
Gastrointestinal
Liver disease associated with current abnormal liver function tests
Psychiatric
Psychiatric disorder requiring current inpatient care

Other factors indicating increased risk suggesting planned birth at an obstetric unit

Factor
Additional information
Previous complications
Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty
Previous baby with neonatal encephalopathy
Pre-eclampsia requiring preterm birth
Placental abruption with adverse outcome
Eclampsia
Uterine rupture
Primary postpartum haemorrhage requiring additional treatment or blood transfusion
Retained placenta requiring manual removal in theatre
Caesarean section
Shoulder dystocia
Current pregnancy
Multiple birth
Placenta praevia
Pre-eclampsia or pregnancy-induced hypertension
Preterm labour or preterm prelabour rupture of membranes
Placental abruption
Anaemia – haemoglobin less than 85 g/litre at onset of labour
Confirmed intrauterine death
Induction of labour
Substance misuse
Alcohol dependency requiring assessment or treatment
Onset of gestational diabetes
Malpresentation – breech or transverse lie
BMI at booking of greater than 35 kg/m2
Recurrent antepartum haemorrhage
Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity on ultrasound)
Abnormal fetal heart rate/Doppler studies
Ultrasound diagnosis of oligo-/polyhydramnios
Previous gynaecological history
Myomectomy
Hysterotomy

Medical conditions indicating individual assessment when planning place of birth

Disease area
Medical condition
Cardiovascular
Cardiac disease without intrapartum implications
Haematological
Atypical antibodies not putting the baby at risk of haemolytic disease
Sickle-cell trait
Thalassaemia trait
Anaemia – haemoglobin 85–105 g/litre at onset of labour
Infective
Hepatitis B/C with normal liver function tests
Immune
Non-specific connective tissue disorders
Endocrine
Unstable hypothyroidism such that a change in treatment is required
Skeletal/neurological
Spinal abnormalities
Previous fractured pelvis
Neurological deficits
Gastrointestinal
Liver disease without current abnormal liver function
Crohn's disease
Ulcerative colitis

Other factors indicating individual assessment when planning place of birth

Factor
Additional information
Previous complications
Stillbirth/neonatal death with a known non-recurrent cause
Pre-eclampsia developing at term
Placental abruption with good outcome
History of previous baby more than 4.5 kg
Extensive vaginal, cervical, or third- or fourth-degree perineal trauma
Previous term baby with jaundice requiring exchange transfusion
Current pregnancy
Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation)
BMI at booking of 30–35 kg/m2
Blood pressure of 140 mmHg systolic or 90 mmHg diastolic or more on two occasions
Clinical or ultrasound suspicion of macrosomia
Para 4 or more
Recreational drug use
Under current outpatient psychiatric care
Age over 35 at booking
Fetal indications
Fetal abnormality
Previous gynaecological history
Major gynaecological surgery
Cone biopsy or large loop excision of the transformation zone
Fibroids

Types and frequencies of serious medical problems that can affect babies

Numbers and proportions of the individual components of the composite adverse outcomes measure recorded in the Birthplace UK (2011) study
Outcome
Actual number of babies affected out of [63,955 to 64,535]* (number per 1000)
Percentage of all adverse outcomes measured
Stillbirth after start of care in labour
14 out of 64,535 (0.22 per 1000)
5%
Death of the baby in the first week after birth
18 out of 64,292 (0.28 per 1000)
7%
Neonatal encephalopathy (disordered brain function caused by oxygen deprivation before or during birth) (clinical diagnosis)
102 out of 63,955 (1.6 per 1000)
40%
Meconium aspiration syndrome (the baby breathes meconium into their lungs)
86 out of 63,955 (1.3 per 1000)
34%
Brachial plexus injury
24 out of 63,955 (0.38 per 1000)
9%
Bone fractures
11 out of 63,955 (0.17 per 1000)
4%
TOTAL (of all outcomes included in the 'adverse outcome' composite measure)
255 out of 63,955 to 64,535) (approx. 4 per 1000)
99%**
Note: Each of the categories above are mutually exclusive and outcomes listed higher in the table take precedence over outcomes listed lower down. For example, if a baby with neonatal encephalopathy died within 7 days the outcome is classified as an early neonatal death.
* Denominator varies because of missing values.
** Does not equal 100% because of rounding.
Adverse outcome: in order to be able to count enough adverse events to be able to say that the results recorded are not just a result of chance, the Birthplace UK (2011) study used a composite definition of 'adverse outcome'. The definition includes the following outcomes: stillbirth during labour, death of the baby in the first week after birth, neonatal encephalopathy (disordered brain function caused by oxygen deprivation before or during birth), meconium aspiration syndrome, and physical birth injuries (brachial plexus injury and bone fractures). The term 'serious medical problems' has been used to describe this composite outcome in the recommendations.
The pathway covers recommendations on baseline clinical care for all pregnant women. It does not offer information on the additional care that some women will require. Pregnant women with the following conditions usually require care that is additional to that detailed in this pathway:
  • cardiac disease, including hypertension
  • renal disease
  • endocrine disorders or diabetes requiring insulin
  • psychiatric disorders (being treated with medication)
  • haematological disorders
  • autoimmune disorders
  • epilepsy requiring anticonvulsant drugs
  • 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 at first contact) or underweight (body mass index below 18 kg/m2 at first contact)
  • higher risk of developing complications, for example, women aged 40 and older, women who smoke
  • women who are particularly vulnerable (such as teenagers) or who lack social support.
Women who have experienced any of the following in previous pregnancies:
  • recurrent miscarriage (three or more consecutive pregnancy losses or a mid-trimester loss)
  • preterm birth
  • severe pre-eclampsia, (H) hemolytic anaemia, (EL) elevated liver enzymes, and (LP) low platelet count (HELLP syndrome) or eclampsia
  • rhesus isoimmunisation or other significant blood group antibodies
  • uterine surgery including caesarean section, myomectomy or cone biopsy
  • antenatal or postpartum haemorrhage on two occasions
  • puerperal psychosis
  • grand multiparity (more than six pregnancies)
  • a stillbirth or neonatal death
  • a small-for-gestational-age infant (below 5th centile)
  • a large-for-gestational-age infant (above 95th centile)
  • a baby weighing below 2.5 kg or above 4.5 kg
  • a baby with a congenital abnormality (structural or chromosomal).

Glossary

external cephalic version
Midwives Information and Resource Service
routine antenatal anti-D prophylaxis
rhesus D

Paths in this pathway

Pathway created: November 2011 Last updated: January 2017

© NICE 2017

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