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Diabetes in pregnancy

About

What is covered

This pathway covers the management of diabetes and its complications from preconception to the postnatal period.
Approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre-existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The prevalence of type 1 diabetes, and especially type 2 diabetes, has increased in recent years. The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women.
Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre-eclampsia and preterm labour are more common in women with pre-existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre-existing diabetes.
This pathway contains recommendations for managing diabetes and its complications in women who are planning pregnancy and those who are already pregnant. The pathway focuses on areas where additional or different care should be offered to women with diabetes and their newborn babies. Where the evidence supports it, the pathway makes separate recommendations for women with pre-existing diabetes and women with gestational diabetes. The term 'women' is used in the pathway to refer to all females of childbearing age, including young women who have not yet transferred from paediatric to adult services.

Blood glucose and plasma glucose

This pathway refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient-held glucose meters (which use capillary blood samples) and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this pathway we use the term 'blood glucose', except when referring to concentration values.

Updates

Updates to this pathway

17 August 2016 Diabetes in adults (NICE quality standard 6) removed.
13 April 2016 Antenatal care (NICE quality standard 22) added.
18 January 2016 Diabetes in pregnancy (NICE quality standard 109) added.
19 November 2015 Links to NICE pathway on preterm labour and birth added.
24 February 2015 The new recommendations from the NICE guideline update have been added.
30 October 2014 IFCC units added for HbA1c levels.

Professional responsibilities

The recommendations in this pathway 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. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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 managing diabetes and its complications before, during and after pregnancy in an interactive flowchart

What is covered

This pathway covers the management of diabetes and its complications from preconception to the postnatal period.
Approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre-existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. The prevalence of type 1 diabetes, and especially type 2 diabetes, has increased in recent years. The incidence of gestational diabetes is also increasing as a result of higher rates of obesity in the general population and more pregnancies in older women.
Diabetes in pregnancy is associated with risks to the woman and to the developing fetus. Miscarriage, pre-eclampsia and preterm labour are more common in women with pre-existing diabetes. In addition, diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (such as hypoglycaemia) are more common in babies born to women with pre-existing diabetes.
This pathway contains recommendations for managing diabetes and its complications in women who are planning pregnancy and those who are already pregnant. The pathway focuses on areas where additional or different care should be offered to women with diabetes and their newborn babies. Where the evidence supports it, the pathway makes separate recommendations for women with pre-existing diabetes and women with gestational diabetes. The term 'women' is used in the pathway to refer to all females of childbearing age, including young women who have not yet transferred from paediatric to adult services.

Blood glucose and plasma glucose

This pathway refers frequently to circulating glucose concentrations as 'blood glucose'. A lot of the evidence linking specific circulating glucose concentrations with particular outcomes uses 'plasma' rather than 'blood' glucose. In addition, patient-held glucose meters (which use capillary blood samples) and monitoring systems are all calibrated to plasma glucose equivalents. However, the term 'blood glucose monitoring' is in very common use, so in this pathway we use the term 'blood glucose', except when referring to concentration values.

Updates

Updates to this pathway

17 August 2016 Diabetes in adults (NICE quality standard 6) removed.
13 April 2016 Antenatal care (NICE quality standard 22) added.
18 January 2016 Diabetes in pregnancy (NICE quality standard 109) added.
19 November 2015 Links to NICE pathway on preterm labour and birth added.
24 February 2015 The new recommendations from the NICE guideline update have been added.
30 October 2014 IFCC units added for HbA1c levels.

Sources

NICE guidance and other sources used to create this pathway.
Diabetes in pregnancy (2016) NICE quality standard 109
Antenatal care (2012 updated 2016) NICE quality standard 22

Quality standards

Quality statements

High-dose folic acid

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

Quality statement

Women with diabetes planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.

Rationale

High-dose folic acid supplements (5 mg/day) should be prescribed for women with diabetes who are planning a pregnancy from at least 3 months before conception until 12 weeks of gestation. This is because these women are at greater risk of having a baby with a neural tube defect. The benefits of high-dose folic acid supplementation should be discussed with the woman during preconception counselling as part of her preparation for pregnancy.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women with diabetes planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Process
a) Proportion of pregnant women with type 1 diabetes prescribed 5 mg/day folic acid from at least 3 months before conception.
Numerator – the number in the denominator prescribed 5 mg/day folic acid from at least 3 months before conception.
Denominator – the number of pregnant women with type 1 diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
b) Proportion of pregnant women with type 2 diabetes prescribed 5 mg/day folic acid from at least 3 months before conception.
Numerator – the number in the denominator prescribed 5 mg/day folic acid from at least 3 months before conception.
Denominator – the number of pregnant women with type 2 diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
Neural tube defects.
Data source: National Pregnancy in Diabetes Audit and local data collection.

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

Service providers (in primary and secondary care) ensure that they have systems and processes in place so that women with diabetes who are planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.
Healthcare professionals (GPs, community midwives and healthcare professionals in joint diabetes and antenatal care teams) ensure that they prescribe 5 mg/day folic acid for women with diabetes who are planning a pregnancy, from at least 3 months before conception. Healthcare professionals also ensure that they advise women with diabetes who are planning a pregnancy about the benefits of taking high-dose folic acid as part of preconception counselling.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission pre-pregnancy services in which 5 mg/day folic acid is prescribed for women with diabetes who are planning a pregnancy, from at least 3 months before conception.

What the quality statement means for patients

Women with diabetes who are planning a pregnancy are given a prescription for high-dose folic acid (one 5 mg tablet a day) for at least 3 months before they get pregnant and for the first 12 weeks of pregnancy. This helps to lower the chances of the baby having a condition called a neural tube defect (for example, spina bifida).

Source guidance

First contact with joint diabetes and antenatal care team

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

Quality statement

Women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.

Rationale

Women with diabetes who become pregnant need extra care in addition to routine antenatal care. Members of the joint diabetes and antenatal care team are able to ensure that specialist care is delivered to minimise adverse pregnancy outcomes. Immediate access to the joint diabetes and antenatal care team within 1 week of her pregnancy being confirmed will help to ensure that a woman’s diabetes is controlled during early pregnancy, when there in an increased risk of fetal loss and anomalies. It will also help to ensure that the woman’s care is planned appropriately throughout her pregnancy.

Quality measures

Structure
a) Evidence of local arrangements to provide a joint diabetes and antenatal care team.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Data source: Local data collection.
Process
Proportion of women with pre-existing diabetes who are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Numerator – the number in the denominator who are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Denominator – the number of pregnant women with pre-existing diabetes.
Outcome
a) Maternal satisfaction.
Data source: Local data collection.
b) Perinatal morbidity.
Data source: Local data collection.
c) Perinatal mortality.
Data source: Local data collection.
d) Maternal adverse outcomes.
Data source: Local data collection.

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

Service providers (in secondary care) ensure that referral pathways are in place so that pregnant women with pre-existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of the pregnancy being confirmed.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they see pregnant women with pre-existing diabetes within 1 week of the pregnancy being confirmed.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission joint diabetes and antenatal care teams that see pregnant women with pre-existing diabetes within 1 week of the pregnancy being confirmed.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant have an appointment with a joint diabetes and antenatal care team within 1 week of telling a doctor, nurse or midwife that they are pregnant.

Source guidance

Definitions of terms used in this quality statement

Joint diabetes and antenatal care team
A clinic with a multidisciplinary team consisting of an obstetrician, a diabetes physician, a diabetes specialist nurse, a midwife and a dietitian.
Pregnancy confirmed
The notification of a positive pregnancy test to a healthcare professional. This may be a GP, practice nurse, midwife or member of the secondary care diabetes team.
[Expert opinion]

Measuring HbA1c levels at booking appointment

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

Quality statement

Pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.

Rationale

Measuring a woman’s HbA1c levels can be used to determine the level of risk for her pregnancy. Women who had diabetes before they became pregnant should have their HbA1c levels measured during early pregnancy to identify the risk of potential adverse pregnancy outcomes and to ensure that any identified risks are managed.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Process
Proportion of pregnant women with pre-existing diabetes who have their HbA1c levels measured at their booking appointment.
Numerator – the number in the denominator who have their HbA1c levels measured at their booking appointment.
Denominator – the number of pregnant women with pre-existing diabetes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
a) Mode of birth.
Data source: National Pregnancy in Diabetes Audit and local data collection.
b) Adverse fetal outcomes.
Data source: National Pregnancy in Diabetes Audit and local data collection.
c) Maternal diabetic complications.
Data source: National Pregnancy in Diabetes Audit and local data collection.

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

Service providers (in secondary care) ensure that systems are in place so that pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.
Healthcare professionals (in antenatal care and in joint diabetes and antenatal care teams) ensure that they measure the HbA1c levels of pregnant women with pre-existing diabetes at the booking appointment.
Commissioners (clinical commissioning groups) ensure that they commission services in which pregnant women with pre-existing diabetes have their HbA1c levels measured at their booking appointment.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant have their HbA1c levels measured at their booking appointment (their first official antenatal appointment).

Source guidance

Definitions of terms used in this quality statement

Booking appointment
A woman with diabetes will usually have a booking appointment with the joint diabetes and antenatal care team by 10 weeks of pregnancy. In some cases this appointment may take place earlier in the pregnancy.
[Diabetes in pregnancy (NICE guideline NG3) and expert opinion]

Equality and diversity considerations

Pregnant women with diabetes and complex social needs may be less likely to access or maintain contact with antenatal care services, and may present to a service later than 10 weeks. Services should give special consideration to these groups of women and ensure that they have their HbA1c levels measured at the earliest opportunity.  

Referral for retinal assessment

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

Quality statement

Pregnant women with pre-existing diabetes are referred at their booking appointment for retinal assessment.

Rationale

Pregnant women with pre-existing diabetes can have an increased risk of progression of diabetic retinopathy. Women should therefore be screened for diabetic retinopathy regularly during pregnancy. Early assessment ensures that treatment can start as soon as possible, and can act as a baseline to observe any further deterioration. A referral for retinal assessment should be offered at the booking appointment unless the woman has had an assessment in the last 3 months.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that pregnant women with pre-existing diabetes are referred at their booking appointment for retinal assessment.
Data source: Local data collection.
Process
a) Proportion of pregnant women with pre-existing diabetes who are referred at their booking appointment for retinal assessment.
Numerator – the number in the denominator who are referred at their booking appointment for retinal assessment.
Denominator – the number of pregnant women with pre-existing diabetes attending a booking appointment who have not had retinal assessment in the last 3 months.
Data source: Local data collection.
b) Proportion of pregnant women with pre-existing diabetes who have a retinal assessment in the first 3 months of pregnancy.
Numerator – the number in the denominator who have a retinal assessment in the first 3 months of pregnancy.
Denominator – the number of pregnant women with pre-existing diabetes referred at their booking appointment for a retinal assessment.
Data source: National Pregnancy in Diabetes Audit and local data collection.
Outcome
a) Rates of diabetic retinopathy during pregnancy.
Data source: Local data collection.
b) Diabetic retinopathy progression during pregnancy.
Data source: Local data collection.

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

Service providers (in primary and secondary care) ensure that pregnant women with pre-existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they refer pregnant women with pre-existing diabetes at their booking appointment for a retinal assessment, unless the woman has had a retinal assessment in the last 3 months.
Commissioners (clinical commissioning groups) ensure that they commission services in which pregnant women with pre-existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months. Commissioners also ensure that services communicate the results of retinal assessments to the joint diabetes and antenatal care team.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant are referred at their booking appointment for a screening check for eye damage (retinopathy) if they have not had this type of check in the last 3 months.

Source guidance

Definitions of terms used in this quality statement

Retinal assessment
A retinal assessment should be done by digital imaging with mydriasis (dilation of the pupils) using tropicamide, in accordance with the National Screening Committee’s diabetic retinopathy screening programme.
[Diabetes in pregnancy (NICE guideline NG3) recommendation 1.3.24]
Booking appointment
A woman with diabetes will usually have a booking appointment with the joint diabetes and antenatal care team by 10 weeks of pregnancy. In some cases this appointment may take place earlier in the pregnancy.
[Diabetes in pregnancy (NICE guideline NG3) and expert opinion]

Equality and diversity considerations

Pregnant women with diabetes and complex social needs may be less likely to access or maintain contact with antenatal care services, and may present to a service later than 10 weeks. Services should give special consideration to these groups of women and ensure that they are referred for a retinal assessment at the earliest opportunity.  

Review after a diagnosis of gestational diabetes

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

Quality statement

Women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.

Rationale

Women diagnosed with gestational diabetes should have specialist advice and treatment in a timely manner, and should be reviewed by members of the joint diabetes and antenatal care team within 1 week of being diagnosed. The joint team should provide the woman with advice, including why gestational diabetes occurs, potential risks and complications, and treatments aimed at reducing those risks.

Quality measures

Structure
a) Evidence of local arrangements to provide a joint diabetes and antenatal care team.
Data source: Local data collection.
b) Evidence of local arrangements and written clinical protocols to ensure that women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Data source: Local data collection.
Process
Proportion of women diagnosed with gestational diabetes who are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Numerator – the number in the denominator who are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Denominator – the number of women diagnosed with gestational diabetes.
Data source: Local data collection.
Outcome
a) Maternal satisfaction.
Data source: Local data collection.
b) Perinatal morbidity.
Data source: Local data collection.
c) Perinatal mortality.
Data source: Local data collection.
d) Maternal adverse outcomes.
Data source: Local data collection.

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

Service providers (in secondary and community care) ensure that referral pathways are in place so that women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they see women diagnosed with gestational diabetes within 1 week of diagnosis.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission services in which women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.

What the quality statement means for patients

Pregnant women who are diagnosed with gestational diabetes (that is, diabetes that develops during pregnancy) have an appointment with a joint diabetes and antenatal care team within 1 week of their diagnosis.

Source guidance

Definitions of terms used in this quality statement

Joint diabetes and antenatal care team
A clinic with a multidisciplinary team consisting of an obstetrician, a diabetes physician, a diabetes specialist nurse, a midwife and a dietitian.
Diagnosis of gestational diabetes
Diagnose gestational diabetes (using a 75 g 2-hour oral glucose tolerance test) if the woman has either:
  • a fasting plasma glucose level of 5.6 mmol/litre or above or
  • a 2-hour plasma glucose level of 7.8 mmol/litre or above.
[Adapted from Diabetes in pregnancy (NICE guideline NG3) recommendations 1.2.6 and 1.2.8]

Self-monitoring of blood glucose levels during pregnancy

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

Quality statement

Pregnant women with diabetes are supported to self-monitor their blood glucose levels.

Rationale

Women with diabetes need to be able to self-monitor their blood glucose during pregnancy. Some women with type 2 diabetes and all women with gestational diabetes will not have been monitoring their blood glucose levels at all before pregnancy and will start doing so. For women with type 1 diabetes, and some women with type 2 diabetes, frequency of monitoring will increase from 4 times a day to up to 10 times per day. More frequent monitoring will help women to maintain good blood glucose control throughout pregnancy. This in turn will reduce the risk of adverse outcomes, such as a baby that is large for gestational age, trauma during birth, neonatal hypoglycaemia and perinatal death. The likelihood of induction of labour and caesarean section should also be lower. Support should be provided to ensure that women have access to appropriate blood glucose meters and are prescribed enough testing strips, and know how to use them.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that pregnant women with diabetes are supported to self-monitor their blood glucose levels.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with diabetes have access to appropriate blood glucose meters and are prescribed enough testing strips.
Data source: Local data collection.
Process
a) Proportion of pregnant women with diabetes who feel supported to self-monitor their blood glucose levels.
Numerator – the number in the denominator who feel supported to self-monitor their blood glucose levels.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
b) Proportion of pregnant women with diabetes who have an appropriate blood glucose meter.
Numerator – the number in the denominator who have an appropriate blood glucose meter.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
c) Proportion of pregnant women with diabetes who are prescribed enough blood glucose testing strips.
Numerator – the number in the denominator who are prescribed enough blood glucose testing strips.
Denominator – the number of pregnant women with diabetes.
Data source: Local data collection.
Outcome
a) Adverse fetal outcomes.
Data source: Local data collection.
b) Maternal diabetic complications.
Data source: Local data collection.

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

Service providers (in primary and secondary care) ensure that pregnant women with diabetes have an appropriate blood glucose meter and are prescribed enough testing strips, and so are supported to self-monitor their blood glucose levels during pregnancy.
Healthcare professionals (GPs, community midwives and healthcare professionals in joint diabetes and antenatal care teams) support pregnant women with diabetes to self-monitor their blood glucose levels during pregnancy, including ensuring that the woman has an appropriate blood glucose meter and is prescribed enough testing strips.
Commissioners (NHS England area teams and clinical commissioning groups) commission services that ensure that pregnant women with diabetes have an appropriate blood glucose meter and are prescribed enough testing strips, and so are supported to self-monitor their blood glucose levels.

What the quality statement means for patients

Pregnant women with diabetes are supported to monitor their own blood glucose levels during pregnancy. They are given a blood glucose meter that suits them, and are prescribed enough testing strips for their needs.

Source guidance

Definitions

Appropriate blood glucose meter
Ensure that blood glucose meters meet current ISO standards and take the needs of the woman with diabetes into account.
[Adapted from Type 1 diabetes (NICE guideline NG17) recommendation 1.6.17]

Equality and diversity considerations

When advising women to start or increase the frequency of blood glucose monitoring, take into account that some women may be anxious and feel pressure to adjust and overly regulate their blood glucose levels.

Annual HbA1c testing after gestational diabetes

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

Quality statement

Women who have had gestational diabetes have an annual HbA1c test.

Rationale

Women who have had gestational diabetes are at increased risk of getting it again in future pregnancies. They are also at higher risk of type 2 diabetes: if they are not diagnosed with type 2 diabetes in the immediate postnatal period, they are still at high risk of developing it in the future. Early detection of type 2 diabetes by annual HbA1c testing in primary care can delay disease progression and reduce the risk of complications. Annual testing can also reduce the risk of uncontrolled or undetected diabetes in future pregnancies.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that women who have had gestational diabetes have an annual HbA1c test.
Data source: Local data collection.
Process
Proportion of women who have had gestational diabetes who have an annual HbA1c test.
Numerator – the number in the denominator who have had an HbA1c test in the last 12 months.
Denominator – the number of women who have had gestational diabetes and whose baby was born at least 12 months ago.
Data source: GP Patient Survey and local data collection.
Outcome
Earlier detection of type 2 diabetes.
Data source: Local data collection.

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

Service providers (in primary care) ensure that systems are in place so that women who have had gestational diabetes have an annual HbA1c test.
Healthcare professionals (in primary care) ensure that they test HbA1c levels annually for women who have had gestational diabetes.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that they commission services that provide annual HbA1c testing for women who have had gestational diabetes.

What the quality statement means for patients

Women who have had gestational diabetes have the HbA1c levels in their blood measured once a year. This is to check whether they have type 2 diabetes, or are at risk of getting it.

Source guidance

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

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

Professional responsibilities

The recommendations in this pathway 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. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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

Timetable of antenatal appointments

Appointment
Care for women with diabetes during pregnancyWomen with diabetes should also receive routine care according to the schedule of appointments in the NICE pathway on antenatal care for uncomplicated pregnancies, including appointments at 25 weeks (for nulliparous women) and 34 weeks, but with the exception of the appointment for nulliparous women at 31 weeks.
Booking appointment (joint diabetes and antenatal care) – ideally by 10 weeks
Discuss information, education and advice about how diabetes will affect the pregnancy, birth and early parenting (such as breastfeeding and initial care of the baby).
If the woman has been attending for preconception care and advice, continue to provide information, education and advice in relation to achieving optimal blood glucose control (including dietary advice).
If the woman has not attended for preconception care and advice, give information, education and advice for the first time, take a clinical history to establish the extent of diabetes-related complications (including neuropathy and vascular disease), and review medicines for diabetes and its complications. NICE has produced a pathway on medicines optimisation.
Offer retinal assessment for women with pre-existing diabetes unless the woman has been assessed in the last 3 months.
Offer renal assessment for women with pre-existing diabetes if this has not been performed in the last 3 months.
Arrange contact with the joint diabetes and antenatal clinic every 1–2 weeks throughout pregnancy for all women with diabetes.
Measure HbA1c levels for women with pre-existing diabetes to determine the level of risk for the pregnancy.
Offer self-monitoring of blood glucose or a 75 g 2-hour OGTT as soon as possible for women with a history of gestational diabetes who book in the first trimester.
Confirm viability of pregnancy and gestational age at 7–9 weeks.
16 weeks
Offer retinal assessment at 16–20 weeks to women with pre-existing diabetes if diabetic retinopathy was present at their first antenatal clinic visit.
Offer self-monitoring of blood glucose or a 75 g 2-hour OGTT as soon as possible for women with a history of gestational diabetes who book in the second trimester.
20 weeks
Offer an ultrasound scan for detecting fetal structural abnormalities, including examination of the fetal heart (4 chambers, outflow tracts and 3 vessels).
28 weeks
Offer ultrasound monitoring of fetal growth and amniotic fluid volume.
Offer retinal assessment to all women with pre-existing diabetes.
Women diagnosed with gestational diabetes as a result of routine antenatal testing at 24–28 weeks enter the care pathway.
32 weeks
Offer ultrasound monitoring of fetal growth and amniotic fluid volume.
Offer nulliparous women all routine investigations normally scheduled for 31 weeks in routine antenatal care.
34 weeks
No additional or different care for women with diabetes.
36 weeks
Offer ultrasound monitoring of fetal growth and amniotic fluid volume.
Provide information and advice about:
  • timing, mode and management of birth
  • analgesia and anaesthesia
  • changes to blood glucose-lowering therapy during and after birth
  • care of the baby after birth
  • initiation of breastfeeding and the effect of breastfeeding on blood glucose control
  • contraception and follow-up.
37+0 weeks to 38+6 weeks
Offer induction of labour, or caesarean section if indicated, to women with type 1 or type 2 diabetes; otherwise await spontaneous labour.
38 weeks
Offer tests of fetal wellbeing.
39 weeks
Offer tests of fetal wellbeing.
Advise women with uncomplicated gestational diabetes to give birth no later than 40+6 weeks.

Glossary

means the repeated and unpredicted occurrence of hypoglycaemia requiring third-party assistance that results in continuing anxiety about recurrence and is associated with significant adverse effect on quality of life
estimated glomerular filtration rate
glycated haemoglobin
care for patients requiring detailed observation or intervention, including support for a single failing organ system or postoperative care and those 'stepping down' from higher levels of care
oral glucose tolerance test

Paths in this pathway

Pathway created: May 2011 Last updated: November 2016

© NICE 2016

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