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Intrapartum care for women with obstetric complications

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What is covered

This interactive flowchart covers intrapartum care for women who need extra support because they have obstetric complications in their current or previous pregnancy. It covers women in spontaneous or induced labour who are at high risk of adverse outcomes for themselves or their baby because:
  • of obstetric complications in the current or previous pregnancy, labour or birth
  • the baby is identified during labour to be at risk of adverse outcomes
  • they have had no antenatal care.
Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance and the 2015 Montgomery ruling.

Updates

27 February 2020 Intrapartum care: existing medical conditions and obstetric complications (NICE quality standard 192) added.
25 April 2019 Replaced recommendations on continuous cardiotocography for women with a previous caesarean section with links to NICE's recommendations on caesarean section.

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Short Text

Everything NICE has said on intrapartum care for women with obstetric complications in an interactive flowchart

What is covered

This interactive flowchart covers intrapartum care for women who need extra support because they have obstetric complications in their current or previous pregnancy. It covers women in spontaneous or induced labour who are at high risk of adverse outcomes for themselves or their baby because:
  • of obstetric complications in the current or previous pregnancy, labour or birth
  • the baby is identified during labour to be at risk of adverse outcomes
  • they have had no antenatal care.
Supporting women to make decisions about their care is particularly important during the intrapartum period. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance and the 2015 Montgomery ruling.

Updates

27 February 2020 Intrapartum care: existing medical conditions and obstetric complications (NICE quality standard 192) added.
25 April 2019 Replaced recommendations on continuous cardiotocography for women with a previous caesarean section with links to NICE's recommendations on caesarean section.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Intrapartum care: existing medical conditions and obstetric complications

These quality statements are taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines clinical best practice in the intrapartum care of women existing medical conditions and obstetric complications and should be read in full.

Quality statements

Involving women in care planning

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice for the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with existing medical conditions or obstetric complications are involved in developing and reviewing their individualised intrapartum care plan.

Rationale

Involving a woman in developing and reviewing her intrapartum care plan enables her to discuss and make choices about her care. It allows her to be given information and opportunities for discussion to support shared decision making. Involvement of the woman allows the care plan to be tailored to her conditions or obstetric complications, her experience of these, and her preferences for labour and birth. The woman should be involved in updating the plan during pregnancy and on admission for birth to reflect changes in her conditions or obstetric complications.

Quality measures

Structure
a) Evidence of local processes to provide opportunities for pregnant women with existing medical conditions or obstetric complications to discuss and make decisions on the intrapartum management of their medical conditions or obstetric complications.
Data source: Local data collection, for example, documented procedures, service specifications and staff training on communication skills.
b) Evidence of local processes to ensure that pregnant women with existing medical conditions or obstetric complications are supported to develop an intrapartum care plan.
Data source: Local data collection, for example, service protocols and records for training in communication skills, multidisciplinary working and shared decision making.
c) Evidence of local arrangements to ensure that pregnant women with existing medical conditions or obstetric complications are supported to review their intrapartum care plan throughout pregnancy, including when their conditions change, and on admission for birth.
Data source: Local data collection, for example, service protocols and records for training in communication skills and shared decision making.
Process
a) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when developing the plan.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when developing the plan.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
b) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan, who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when reviewing the plan on admission for birth.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when reviewing the plan on admission for birth.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
c) Proportion of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan, who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when updating the plan when their medical condition changed.
Numerator – the number in the denominator who reported that they were involved as much as they wanted to be in discussing and making decisions about their care when updating the plan when their medical condition changed.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications with an individualised intrapartum care plan.
Data source: Local data collection, for example, patient surveys.
Outcome
Proportion of pregnant women with existing medical conditions or obstetric complications who felt that they were involved in preparing and reviewing their intrapartum care plan.
Numerator – the number in the denominator who were satisfied with their involvement in preparing and reviewing their intrapartum care plan.
Denominator – the number of pregnant women with existing medical conditions or obstetric complications and an intrapartum care plan.
Data source: Local data collection, for example, a patient (maternity) experience survey.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that systems are in place for pregnant women with existing medical conditions or obstetric complications to take part in shared decision making and be involved in developing and reviewing individualised plans for their intrapartum care. They also ensure that staff are trained in how to involve pregnant women in developing the plan and shared decision making.
Healthcare professionals (such as obstetric physicians, clinicians with expertise in managing medical conditions during pregnancy and midwives) ensure that during pregnancy women with existing medical conditions or obstetric complications are involved in developing and reviewing their intrapartum care plan. To help support involvement, healthcare professionals should provide the woman with information about, and opportunities to discuss, her medical conditions or obstetric complications, and discuss how they might affect intrapartum care for her and her baby.
Commissioners (clinical commissioning groups) ensure they commission services that involve pregnant women with existing medical conditions or obstetric complications in developing and reviewing their intrapartum care plan during pregnancy. Women should be provided with opportunities for discussion to support their involvement.
Pregnant women with medical conditions or complications during pregnancy or birth are cared for by staff who give them opportunities to discuss how their medical conditions or complications may affect their care and the care of their baby. Women can make choices about their care.

Source guidance

Definitions of terms used in this quality statement

Involved in developing and reviewing the individualised intrapartum care plan
This can include:
  • providing tailored information in a way that can be understood
  • discussion of different care options, including risks and benefits
  • providing opportunities to ask questions
  • discussing preferences and expectations for labour and birth
  • discussing the woman’s experience and knowledge of her existing condition
  • taking into account previous discussions, planning, decisions and choices
  • making decisions together about the woman’s care.
Existing medical conditions
Medical conditions within the scope of this quality standard include:
  • heart disease
  • asthma (dependent on severity)
  • bleeding disorders
  • neurological conditions
  • obesity (BMI [kg/m2] 30 or over)
  • acute kidney injury or chronic kidney disease.
Obstetric complications
A complication arising during pregnancy, including complications relating to a previous pregnancy. Obstetric complications within the scope of this quality standard include:
  • pyrexia (high temperature or fever)
  • sepsis
  • intrapartum haemorrhage
  • breech presentation
  • suspected small-for-gestational-age baby
  • suspected large-for-gestational-age baby
  • previous caesarean section
  • labour after 42 weeks of pregnancy.

Equality and diversity considerations

Pregnant women with existing medical conditions or obstetric complications should be provided with information to support intrapartum care planning that they can easily read and understand themselves, or with support, so they can communicate effectively with healthcare professionals. The information should be accessible to women who do not speak or read English and it should be culturally appropriate. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.
For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Composition of the multidisciplinary team

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with existing medical conditions are cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy and is led by a named healthcare professional.

Rationale

Specialist advice is important to ensure the best intrapartum care for a pregnant woman with existing medical conditions. Having a multidisciplinary team that can access expertise in managing the medical conditions during pregnancy means this advice is readily available when needed. More than 1 expert may be involved if a woman has more than 1 medical condition. Designating a named healthcare professional to lead the team supports coordination of expertise and continuity of care. This promotes planning of personalised, holistic care during labour and birth to help reduce the risk of adverse outcomes for the woman and her baby.

Quality measures

Structure
a) Evidence that multidisciplinary teams caring for pregnant women with existing medical conditions can access expertise in managing the medical conditions in pregnancy.
Data source: Local data collection, for example, service protocols and local network agreements.
b) Evidence that a named healthcare professional is available to lead the multidisciplinary team caring for pregnant women with existing medical conditions.
Data source: Local data collection, for example, service protocols, local network agreements, maternity records and staff rotas.
Process
a) Proportion of pregnant women with existing medical conditions cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy.
Numerator – the number in the denominator with a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy.
Denominator – the number of pregnant women with existing medical conditions.
Data source: Local data collection, for example, audit of maternity records, emails and records of phone calls demonstrating that expertise in managing the existing medical conditions during pregnancy was accessed by the multidisciplinary team.
b) Proportion of pregnant women with existing medical conditions who were cared for by a multidisciplinary team that was led by a named healthcare professional.
Numerator – the number in the denominator who had a multidisciplinary team that was led by a named healthcare professional.
Denominator – the number of pregnant women with existing medical conditions who were cared for by a multidisciplinary team.
Data source: Local data collection, for example, audit of maternity records, emails and records of phone calls demonstrating leadership of a multidisciplinary team by a named healthcare professional.
Outcome
a) Incidence of maternal morbidity associated with an existing medical condition.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on maternal morbidity.
b) Incidence of maternal mortality associated with an existing medical condition.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on maternal mortality.
c) Incidence of neonatal mortality in babies of women with existing medical conditions.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK perinatal mortality surveillance report presents data on perinatal deaths of babies.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that protocols are in place for pregnant women with existing medical conditions to be cared for by a multidisciplinary team that can access expertise in managing the medical conditions in pregnancy. They ensure that there are rotas and systems in place for the staff with expertise to be available to give advice when needed, and for a named healthcare professional to be available to lead the team.
Healthcare professionals (such as midwives, obstetricians and obstetric anaesthetists) take part in multidisciplinary meetings to plan intrapartum care for pregnant women with existing medical conditions. They ask for input from an obstetric physician or clinician with expertise in caring for pregnant women with the medical condition by phone or email if expertise is needed. A named healthcare professional takes responsibility for leading the multidisciplinary team.
Commissioners (clinical commissioning groups) ensure that services have protocols in place for multidisciplinary teams planning intrapartum care for pregnant women with existing medical conditions to access input from obstetric physicians or clinicians with expertise in managing the medical conditions during pregnancy. They also ensure that services have arrangements so that the staff with expertise are available to give advice when needed, and for a named healthcare professional to lead the multidisciplinary team.
Pregnant women with medical conditions are cared for by a team that can get advice from healthcare professionals who are experts in the medical conditions during pregnancy. The team is led by a named healthcare professional.

Source guidance

Definitions of terms used in this quality statement

Existing medical conditions
Medical conditions within the scope of this quality standard include:
  • heart disease
  • asthma (dependent on severity)
  • bleeding disorders
  • neurological conditions
  • obesity (BMI [kg/m2] 30 or over)
  • acute kidney injury or chronic kidney disease.
Multidisciplinary team
For pregnant women with existing medical conditions, the multidisciplinary team may include, as appropriate:
  • a midwife
  • an obstetrician
  • an obstetric anaesthetist
  • an obstetric physician or clinician with expertise in caring for pregnant women with the medical condition
  • a clinician with expertise in the medical condition
  • a specialty surgeon
  • a neonatologist
  • a critical care specialist
  • the woman’s GP
  • allied health professionals.
The team is led by a named healthcare professional who is responsible for facilitating communication and coordinating care.

Equality and diversity considerations

Pregnant women with existing medical conditions should be provided with information to support intrapartum care planning that they can easily read and understand themselves, or with support, so they can communicate effectively with the multidisciplinary team. The information should be accessible to women who do not speak or read English and it should be culturally appropriate. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.
For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Heart disease – risk assessment

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.

Rationale

Changes to the heart and circulation occur during pregnancy. Regular risk assessment allows planning for any additional management needed for women with heart disease who are at risk of adverse cardiovascular outcomes during labour and birth. Cardiovascular risk assessment is based on a combination of clinical, diagnostic and functional assessment. It is carried out by a multidisciplinary team that includes a cardiologist with expertise in managing the condition in pregnancy. The content and timing of risk assessment are tailored to the severity of the condition and the findings of previous assessment.

Quality measures

Structure
a) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnant women.
Data source: Local data collection, for example, service protocols, local network agreements for referral and core multidisciplinary team membership records.
b) Evidence of local arrangements for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Data source: Local data collection, for example, service protocols and local network agreements for referral.
Process
Proportion of pregnant women with heart disease who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Numerator – the number in the denominator who have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period.
Denominator – the number of pregnant women with heart disease.
Data source: Local data collection, for example, an audit of maternity records.
Outcomes
Rates of mortality during labour, birth and the early postnatal period for women with heart disease.
Data source: Local data collection. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of maternal deaths attributed to heart disease.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that local protocols and referral pathways are in place so that pregnant women with heart disease have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that staff have capacity to perform the assessments regularly and that there are rotas and systems in place for a cardiologist to be available to take part in team discussions.
Healthcare professionals (such as midwives, obstetricians, obstetric anaesthetists and cardiologists with experience of managing heart disease in pregnancy) regularly assess cardiovascular risk for pregnant women with heart disease during pregnancy and the intrapartum period through clinical, diagnostic and functional assessment. Cardiologists use their knowledge and experience to advise the multidisciplinary team on specialist aspects of intrapartum care for pregnant women with heart disease that is tailored to the woman’s individual level of risk.
Commissioners (clinical commissioning groups) ensure that they commission services that have local protocols and referral pathways in place, and the capacity for pregnant women with heart disease to have their cardiovascular risk regularly assessed during pregnancy and the intrapartum period by a multidisciplinary team that includes a cardiologist with expertise in managing heart disease in pregnancy. They ensure that services have rotas and systems in place for the cardiologist to be involved in team discussions.
Pregnant women with heart disease have regular tests to check their heart condition during pregnancy and up to 24 hours after birth by a team that includes a specialist in managing heart disease in pregnancy. This will help them and the team to plan the care needed during labour and birth.

Source guidance

Definitions of terms used in this quality statement

Pregnant women with heart disease
Relevant populations and heart conditions within the scope of this quality standard include:
  • women with mechanical heart valves
  • disease of the aorta
  • pulmonary arterial hypertension
  • heart failure
  • severe left-sided stenotic lesions (for example, aortic stenosis and mitral stenosis)
  • hypertrophic cardiomyopathy
  • cardiomyopathy with systolic ventricular dysfunction
  • Fontan circulation and other univentricular circulations
  • moderately severe and severe cardiovascular disease, as classified by New York Heart Association (NYHA) functional class.
Some women with heart disease are at low risk of complications and their care should be in line with NICE’s guideline on intrapartum care for healthy women and babies, whereas others need individualised specialist care.
Cardiovascular risk regularly assessed
The timing of risk assessment is tailored to the severity of the condition and the findings of previous assessment. The following should be used for the initial and ongoing assessments:

Equality and diversity considerations

Pregnant women with heart disease should be able to communicate effectively with the multidisciplinary team as part of their risk assessments. Women should have access to an interpreter, link worker or advocate if needed. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language.

Recognising and treating sepsis

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women in labour with sepsis have an immediate review by a senior clinical decision maker and antibiotics given within 1 hour if indicated.

Rationale

Physiological changes during labour may mask the early signs of sepsis. Sepsis is a medical emergency and needs urgent review from a senior clinical decision maker. The team determines whether antibiotics are needed as part of initial management, and they should be given within 1 hour of the signs of sepsis being recognised, if needed. Sepsis is associated with maternal and neonatal mortality. Unwarranted antibiotic treatment may, however, pose an unnecessary risk to the unborn baby, so senior review before prescribing is important.

Quality measures

Structure
a) Evidence of local arrangements to support escalation protocols to ensure that pregnant women in labour with sepsis are transferred from home birth and midwifery-led units to an acute setting for review and start antibiotic treatment (if indicated) within 1 hour.
Data source: Local data collection, for example, local network agreements and transfer protocols.
b) Evidence of local arrangements to ensure availability of, or access to, a senior clinical decision maker for pregnant women in labour with sepsis to have an immediate review.
Data source: Local data collection, for example, local network agreements, transfer protocols and staff rotas.
c) Evidence of local arrangements to start antibiotic treatment, if indicated, for pregnant women in labour with sepsis within 1 hour.
Data source: Local data collection, for example, system specifications and maternity record systems.
d) Evidence of local arrangements to document the decision to start antibiotic treatment for pregnant women in labour with sepsis.
Data source: Local data collection, for example, system specifications and maternity records.
Process
a) Proportion of pregnant women in labour with sepsis who have an immediate review by a senior clinical decision maker.
Numerator – the number in the denominator who have an immediate review by a senior clinical decision maker.
Denominator – the number of pregnant women in labour with sepsis.
Data source: Local data collection, for example, an audit of maternity records.
b) Proportion of pregnant women in labour with sepsis who started antibiotics within 1 hour.
Numerator – the number in the denominator who started antibiotics within 1 hour.
Denominator – the number of pregnant women in labour with sepsis who needed antibiotics.
Data source: Local data collection, for example, an audit of maternity records.
c) Proportion of pregnant women in labour with sepsis who had the rationale for the decision to start antibiotics documented.
Numerator – the number in the denominator who had the rationale for the decision to start antibiotics documented.
Denominator – the number of pregnant women in labour with sepsis who had antibiotics.
Data source: Local data collection, for example, an audit of maternity records.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that protocols, systems and pathways are in place for pregnant women in labour with sepsis to have an immediate review by a senior clinical decision maker and receive the first dose of antibiotics, if indicated, within a 1-hour timeframe. They also ensure that a senior clinical decision maker is available to perform the review and protocols are in place to document the rationale for the decision to start antibiotics.
Healthcare professionals (such as a doctor of grade core trainee 3 [CT3] or above, specialty trainee 3 [ST3] or above or an advanced nurse practitioner with antibiotic prescribing responsibilities in discussion with the consultant under whose care the woman is admitted, or a consultant covering acute medicine or anaesthetics) review pregnant women in labour with sepsis immediately. They decide whether to give antibiotics (or not) based on this review, and administer the first dose of antibiotics, if indicated, within the 1-hour timeframe. They also document the rationale for the decision to start antibiotics.
Commissioners (clinical commissioning groups) ensure that they commission services that have protocols, systems and pathways for pregnant women in labour with sepsis to have an immediate review by a senior clinical decision maker and antibiotics given within 1 hour, if indicated. They also ensure that services have capacity to perform the review and have protocols in place to document the rationale for the decision to start antibiotics
Pregnant women with sepsis are assessed by a senior healthcare professional as soon as the early signs of sepsis are recognised. As part of this assessment, a decision is made about whether antibiotics are needed, and if they are, they are started within an hour.

Source guidance

Definitions of terms used in this quality statement

Senior clinical decision maker
A healthcare professional who is authorised to prescribe antibiotics, such as a doctor of grade core trainee 3 (CT3) or above, or a specialty trainee 3 (ST3) or above. Equivalent roles include an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements. The senior clinical review should involve discussion with a consultant. This is the consultant under whose care the woman is admitted, or a consultant covering acute medicine or anaesthetics. [NICE's guideline on sepsis recommendation 1.6.1, footnotes]

Women with no antenatal care

This quality statement is taken from the intrapartum care: existing medical conditions and obstetric complications quality standard. The quality standard defines best clinical practice in the intrapartum care of women with existing medical conditions and obstetric complications and should be read in full.

Quality statement

Pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination, and assessment of their medical, psychological, and social history.

Rationale

Women in labour with no antenatal care are at increased risk of serious obstetric and medical complications for themselves and their babies because there is no baseline information and no birth plan. Assessment of the woman’s medical, psychological and social history, as far as possible, as well obstetric assessment and medical examination, is likely to establish the reason she has not accessed antenatal care. It also indicates the likelihood of complications during labour and birth and identifies the woman’s preferences and needs. A complete assessment helps reduce the risk of adverse outcomes during labour and birth, recognise potential vulnerability and safeguarding concerns, and allows planning of further support, such as postnatal care and continuity of midwifery care.

Quality measures

Structure
a) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician.
Data source: Local data collection, for example, written protocols, service specifications, and staff rotas.
b) Evidence of local processes to ensure that pregnant women who present in labour with no antenatal care have an assessment of their medical, psychological and social history.
Data source: Local data collection, for example, written protocols, service specifications, staff training records.
c) Evidence of training for healthcare professionals on understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Data source: Local data collection, for example, staff training records.
Process
a) Proportion of pregnant women who present in labour with no antenatal care who have an obstetric assessment and medical examination.
Numerator – the number in the denominator who had an obstetric assessment and medical examination.
Denominator – the number of pregnant women who present in labour with no antenatal care.
Data source: Local data collection, for example, audit of maternity records.
b) Proportion of pregnant women who present in labour with no antenatal care who have an assessment of their medical, psychological and social history.
Numerator – the number in the denominator who have an assessment of their medical, psychological and social history.
Denominator – the number of pregnant women who present in labour with no antenatal care.
Data source: Local data collection, for example, audit of maternity records.
Outcomes
a) Incidence of maternal mortality associated with no antenatal care on presentation in labour.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of women who died and had received no antenatal care.
b) Incidence of neonatal mortality associated with no antenatal care for the mother on presentation in labour.
Data source: Local data collection, for example, audit of maternity records. The MBRRACE-UK Confidential Enquiries into Maternal Deaths and Morbidity reports on the number of neonatal deaths for women who received no antenatal care.

What the quality statement means for different audiences

Service providers (NHS hospital trusts) ensure that they have written protocols and service specifications in place so that pregnant women presenting in labour with no antenatal care have an obstetric assessment and medical examination by an obstetrician. They also ensure that staff are trained in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Obstetricians lead an obstetric assessment and medical examination of pregnant women who present in labour with no antenatal care so that they can plan further testing and management. Midwives or obstetricians sensitively and respectfully assess the woman’s medical, psychological and social history. This enables care for labour and birth to be planned, in line with the risk of adverse outcomes and the woman’s preferences. Midwives and obstetricians also look for signs of potential vulnerability and safeguarding concerns, identify the need for further support, such as postnatal care, and offer referral to other services as needed.
Commissioners (clinical commissioning groups) ensure that they commission services that provide an obstetric assessment and medical examination by an obstetrician for pregnant women who present in labour with no antenatal care. They also ensure that services train staff in understanding multiple disadvantage, supporting women with complex social factors and trauma-informed care.
Pregnant women in labour who have not had care during pregnancy have a range of assessments, led by healthcare professionals specialising in childbirth, so that they can discuss their preferences and be supported to plan their care during labour and birth. Any potential concerns about the woman’s welfare and her baby’s can be identified and further support after birth planned.

Source guidance

Definitions of terms used in this quality statement

Obstetric assessment and medical examination
Assessments in line with those described in NICE’s guideline on intrapartum care for healthy women and babies, section 1.4, and assessment of the unborn baby as described in NICE’s guideline on intrapartum care for women with existing medical conditions and obstetric complications and their babies, recommendation 1.18.6. This includes listening to the woman’s story and taking into account her preferences and her emotional and psychological needs when performing an initial assessment. [NICE’s guideline on intrapartum care for healthy women and babies]
Assessment of medical, psychological and social history
This should be undertaken as fully as possible to establish the woman’s life situation and, if possible, to find out why she has not accessed antenatal care. This, in combination with medical and obstetric assessments, indicates her risk of complications during labour and birth. She should also be asked who (if anyone) she would like to support her as her birth companion(s) during labour.
Potential vulnerability and safeguarding concerns should be sensitively explored.

Equality and diversity considerations

A woman’s language needs should be established and women with difficulty understanding, speaking and reading English should have access to an interpreter, link worker or advocate. The interpreter, link worker or advocate should not be a member of the woman’s family, her legal guardian or her partner, and they should communicate with the woman in her preferred language. This enables women who have difficulty speaking and reading English to give their own account of their situation.
Women with no antenatal care should also be provided with information that they can easily read and understand themselves, or with support, so they can communicate effectively with healthcare professionals during assessments. Information should be accessible to women who do not speak or read English and it should be culturally appropriate.
For women with no antenatal care who have additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

Supporting information

Routine maternal observations for women in labour with fever, suspected sepsis, sepsis or intrapartum haemorrhage

Complication
Frequency of maternal observations1
Pulse
Blood pressure
Respiratory rate
Temperature
Level of consciousness (AVPU)
Oxygen saturation
Urine
Fever
Hourly
4-hourly, and hourly in the second stage
4-hourly
Hourly
Hourly
4-hourly
Record output
Suspected sepsis – concern insufficient for antibiotic treatment
Hourly
4-hourly, and hourly in the second stage
4-hourly
Hourly
Hourly
4-hourly
Record output
Sepsis or suspected sepsis – on antibiotic treatment
Continuous, or at least every 30 minutes
Continuous, or at least every 30 minutes
Continuous, or at least every 30 minutes
Hourly
Every 30 minutes
Continuous, or at least every 30 minutes
Record output, hourly if catheterised
Intrapartum haemorrhage
At least hourly
At least 4-hourly, and at least hourly in the second stage
At least 4-hourly
At least 4-hourly
Hourly
At least 4-hourly
Record output, hourly if catheterised
1 The frequency of observations should be adjusted if necessary based on the level of clinical concern.

Routine maternal observations for women in labour with breech presentation, suspected small- or large-for-gestational-age baby, previous caesarean section, onset of labour after 42 weeks or no antenatal care, and no other reasons for concern

Frequency of maternal observations1
Pulse
Blood pressure
Respiratory rate
Temperature
Level of consciousness (AVPU)
Oxygen saturation
Urine
Hourly
4-hourly, and hourly in the second stage
Not required routinely
4-hourly
Not required routinely
Not required routinely
Record output
1 The frequency of observations should be adjusted if necessary based on the level of clinical concern.

Glossary

alert, voice, pain, unresponsive
from the onset of labour (spontaneous or induced) to 24 hours after birth
includes spinal, epidural and combined spinal–epidural techniques
includes spinal, epidural and combined spinal–epidural techniques

Paths in this pathway

Pathway created: March 2019 Last updated: February 2020

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