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Postnatal care

About

What is covered

This NICE Pathway covers the routine postnatal care that women and their babies should receive. It includes advice on breastfeeding, and managing common and serious health problems in women and their babies after the birth.
For simplicity of language, this NICE Pathway uses the term 'woman' or 'mother' and includes all people who have given birth, even if they may not identify as women or mothers. 'Woman' is generally used but in some instances, 'mother' is used when referring to her in relation to her baby.
This NICE Pathway uses the term 'partner' to refer to the woman's chosen supporter. This could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve. The term 'parents' refers to those with the main responsibility for the care of a baby. This will often be the mother and the father, but many other family arrangements exist, including single parents.

Updates

Updates to this NICE Pathway

20 April 2021 Updated on publication of the NICE guideline update on postnatal care (NICE guideline NG194).
30 September 2016 Structure revised, and summarised recommendations replaced with full recommendations.
29 July 2015 Maternal and child nutrition (NICE quality standard 98) added.
4 June 2015 Postnatal care (NICE quality standard 37) updated.
15 July 2013 Postnatal care (NICE quality standard 37) added.

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 postnatal care in an interactive flowchart

What is covered

This NICE Pathway covers the routine postnatal care that women and their babies should receive. It includes advice on breastfeeding, and managing common and serious health problems in women and their babies after the birth.
For simplicity of language, this NICE Pathway uses the term 'woman' or 'mother' and includes all people who have given birth, even if they may not identify as women or mothers. 'Woman' is generally used but in some instances, 'mother' is used when referring to her in relation to her baby.
This NICE Pathway uses the term 'partner' to refer to the woman's chosen supporter. This could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve. The term 'parents' refers to those with the main responsibility for the care of a baby. This will often be the mother and the father, but many other family arrangements exist, including single parents.

Updates

Updates to this NICE Pathway

20 April 2021 Updated on publication of the NICE guideline update on postnatal care (NICE guideline NG194).
30 September 2016 Structure revised, and summarised recommendations replaced with full recommendations.
29 July 2015 Maternal and child nutrition (NICE quality standard 98) added.
4 June 2015 Postnatal care (NICE quality standard 37) updated.
15 July 2013 Postnatal care (NICE quality standard 37) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Postnatal care (2006 updated 2021) NICE guideline NG194
Maternal and child nutrition (2008 updated 2014) NICE guideline PH11
Division of ankyloglossia (tongue-tie) for breastfeeding (2005) NICE interventional procedures guidance 149
Maternal and child nutrition (2015) NICE quality standard 98
Postnatal care (2013 updated 2021) NICE quality standard 37

Quality standards

Maternal and child nutrition

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

Quality statements

Healthy eating in pregnancy

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Pregnant women attending antenatal and health visitor appointments are given advice on how to eat healthily in pregnancy.

Rationale

A healthy diet is important for both mother and baby throughout pregnancy because this will help them to get the nutrients they need to stay healthy and for the baby to develop and grow. Advice on how to eat healthily and foods which should be avoided will enable pregnant women to make informed choices about their diet while pregnant.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of local arrangements for midwives and health visitors to advise pregnant women how to eat healthily in pregnancy.
Data source: Local data collection.
Process
a) Proportion of pregnant women attending their antenatal booking appointment who receive advice on how to eat healthily during pregnancy from a midwife.
Numerator – the number in the denominator who receive advice on how to eat healthily during pregnancy from a midwife.
Denominator – the number of pregnant women attending their antenatal booking appointment.
Data source: Local data collection.
b) Proportion of pregnant women attending their health visitor appointment who receive advice on how to eat healthily during pregnancy.
Numerator – the number in the denominator who receive advice on how to eat healthily during pregnancy from a health visitor.
Denominator – the number of pregnant women attending their health visitor appointment.
Data source: Local data collection.
Outcome
Healthy eating in pregnancy.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary and secondary care including maternity services, community and public health providers) ensure that systems are in place for midwives and health visitors to advise pregnant women how to eat healthily during pregnancy.
Midwives and health visitors ensure that they give advice to pregnant women on how to eat healthily during pregnancy at their antenatal booking appointment and their health visitor appointment.
Commissioners (such as clinical commissioning groups or integrated care systems, NHS England and local authorities) specify that providers give advice to pregnant women on how to eat healthily during pregnancy at the antenatal booking appointment and the health visitor appointment.
Pregnant women are offered advice on how to eat healthily and which foods to avoid during pregnancy. This should happen when they have their first appointment with their midwife and when they have an appointment with their health visitor.

Source guidance

Definitions of terms used in this quality statement

Healthy eating in pregnancy
Where appropriate, the advice should include: eating 5 portions of fruit and vegetables a day and 1 portion of oily fish (for example, mackerel, sardines, pilchards, herring, trout or salmon) a week. If there are special dietary considerations then advice should be tailored to the woman’s needs and additional advice sought from a dietitian. [NICE’s guideline on maternal and child nutrition, recommendation 5]
Foods which should be avoided or limited in pregnancy
There are some foods that a pregnant woman should avoid eating because they could make her ill or harm her baby. These include raw or undercooked meat, liver, raw shellfish, some types of cheese, raw or partly cooked eggs. A detailed list of foods to limit or avoid can be found on the NHS website. [Adapted from the NHS website and expert opinion]

Structured weight-loss programme

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Women with a BMI of 30 or more after childbirth are offered a structured weight-loss programme.

Rationale

Attendance on a structured weight-loss programme for women who have a BMI of 30 or more after childbirth can improve the woman’s health. If they become pregnant again, the programme can help to ensure that their nutritional status at conception is adequate to support optimal fetal growth. By losing weight the woman would reduce their risk of complications during pregnancy and childbirth, including gestational diabetes, pre-eclampsia and postpartum haemorrhage, if they subsequently became pregnant. In addition, their baby’s risk of still birth, high birthweight and subsequent obesity and diabetes would be reduced.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that women with a BMI of 30 or more after childbirth are offered a structured weight-loss programme.
Data source: Local data collection.
Process
Proportion of women with a BMI of 30 or more after childbirth attending their baby’s 6- to 8-week health visitor appointment who receive a structured weight-loss programme.
Numerator – the number in the denominator who receive a structured weight-loss programme.
Denominator – the number of women with a BMI of 30 or more after childbirth attending their baby’s 6- to 8-week health visitor appointment.
Data source: Local data collection.
Outcome
a) Obesity rates in pregnancy.
Data source: Local data collection. The Maternity Services Data Set collects data on maternal height, weight and BMI during pregnancy. Public Health England’s Obesity Profile presents data on obesity in early pregnancy in an online tool to show patterns and trends at local authority level.
b) Attendance at a weight loss programme.
Data source: Local data collection.
c) Pregnancy morbidity.
Data source: Local data collection.
d) Infant morbidity.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary and secondary care including maternity services) ensure that processes are in place for women with a BMI of 30 or more after childbirth to be offered a structured weight-loss programme.
Healthcare professionals ensure that they offer women with a BMI of 30 or more after childbirth a structured weight-loss programme.
Commissioners (clinical commissioning groups or integrated care systems, NHS England and local authority commissioners) ensure that the services they commission have processes in place to offer women with a BMI of 30 or more after childbirth a structured weight-loss programme.
Women who are overweight after having a baby (with a BMI of 30 or more) are offered support to lose weight. This should include a personal assessment and advice on diet, exercise and how to set and achieve weight-loss goals.

Source guidance

Definitions of terms used in this quality statement

BMI (body mass index)
BMI is a measure used to see if people are a healthy weight for their height.
For most adults, an ideal BMI is in the 18.5 to 24.9 range. A BMI in the range of 25 to 29.9 is overweight, 30 to 39.9 is obese and 40 or more is very obese.
These ranges are only for adults. BMI is interpreted differently for children. [Adapted from the NHS website]
Structured weight-loss programme
A structured weight-loss programme provides a personalised assessment, advice about diet and physical activity and advice on behaviour change strategies such as goal setting. [NICE’s guideline on weight management before, during and after pregnancy, recommendation 4]

Equality and diversity considerations

Women from some ethnic groups may have an increased risk of obesity at a lower BMI, for example, women of South Asian or East Asian family origin, and this should be considered by their healthcare professionals.
Care and support, and the information given about it, should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Women should have access to an interpreter or advocate if needed.
For people 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 or the equivalent standards for the devolved nations.

Healthy Start scheme

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Pregnant women and the parents and carers of children under 4 years who may be eligible for the Healthy Start scheme are given information and support to apply.

Rationale

Pregnant women and the parents and carers of children under 4 years who are eligible for the Healthy Start scheme can apply to receive coupons for vitamin supplements and food vouchers. It aims to improve health and access to a healthy diet for families on low incomes across the UK.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that pregnant women and the parents and carers of children under 4 years who may be eligible for the Healthy Start scheme receive information and support to apply.
Data source: Local data collection.
Process
a) Proportion of pregnant women who may be eligible for the Healthy Start scheme who receive information and support to apply when they attend their antenatal booking appointment.
Numerator – the number in the denominator who receive information and support to apply.
Denominator – the number of pregnant women who may be eligible for the Healthy Start scheme attending their antenatal booking appointment.
Data source: Local data collection. The Maternity Services Data Set collects data on booking appointments.
b) Proportion of 6- to 8-week health visitor appointments where parents and carers who may be eligible for the Healthy Start scheme receive information and support to apply.
Numerator – the number in the denominator where information and support to apply is given.
Denominator – the number of 6- to 8-week health visitor appointments where parents and carers may be eligible for the Healthy Start scheme.
Data source: Local data collection.
c) Proportion of 8- to 12-month development reviews where parents and carers who may be eligible for the Healthy Start scheme receive information and support to apply.
Numerator – the number in the denominator where information and support to apply is given.
Denominator – the number of 8- to 1-month developmental reviews where parents and carers may be eligible for the Healthy Start scheme.
Data source: Local data collection.
d) Proportion of 2- to 2-and-a-half-year health reviews where parents and carers who may be eligible for the Healthy Start scheme receive information and support to apply.
Numerator – the number in the denominator where information and support to apply is given.
Denominator – the number of 2- to 2-and-a-half-year health reviews where parents and carers may be eligible for the Healthy Start scheme.
Data source: Local data collection.
e) Proportion of vaccination appointments at age 3 years 5 months to 4 years where parents and carers who may be eligible for the Healthy Start scheme receive information and support to apply.
Numerator – the number in the denominator where information and support to apply is given.
Denominator – the number of vaccination appointments at age 3 years 5 months to 4 years where parents and carers may be eligible for the Healthy Start scheme.
Data source: Local data collection.
Outcome
a) Vitamin D deficiency.
Data source: Local data collection.
b) Neural tube defects.
Data source: Local data collection.
c) Iron and calcium absorption.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary, secondary, community care and public health providers) ensure that systems are in place to ensure that pregnant women and the parents and carers of children under 4 years who may be eligible are given information about the Healthy Start scheme and that an adequate supply of application forms is available for distribution by healthcare professionals.
Healthcare professionals ensure that they give information to pregnant women and the parents and carers of children under 4 years who may be eligible about the Healthy Start scheme, and provide them with support to apply, such as giving them an application form.
Commissioners (clinical commissioning groups or integrated care systems, NHS England and local authorities) ensure that providers give information to pregnant women and the parents and carers of children under 4 years who may be eligible about the Healthy Start scheme and provide them with support to apply, including having enough application forms for distribution by healthcare professionals.
Pregnant women and the parents and carers of children under 4 years who may be eligible for the Healthy Start scheme are given information about it and help to apply (including an application form from their healthcare professional). The Healthy Start scheme provides free vitamins and food vouchers to people on low incomes.

Source guidance

Maternal and child nutrition. NICE guideline PH11 (2008, updated 2014), recommendation 4 (key priority for implementation)

Definitions of terms used in this quality statement

Pregnant women and the parents and carers who may be eligible
Pregnant women and the parents and carers of children under 4 years of age, who are in receipt of certain benefits, may be eligible for the Healthy Start scheme. All pregnant women under the age of 18 years are eligible. Please see the Government’s Healthy Start webpage for up to date information on eligibility criteria. [Expert opinion]
Healthy Start scheme
The Healthy Start scheme provides food vouchers and coupons for vitamin supplements to pregnant women, new mothers and parents and carers with young children (under 4 years) who are on low incomes and to all pregnant women aged under 18 years. It aims to improve health and access to a healthy diet for families on low incomes across the UK. [Adapted from Healthy Start vouchers study: the views and experiences of parents, professionals and small retailers in England, executive summary]
Healthy Start maternal vitamin supplements
The Healthy Start vitamin supplement for pregnant and breastfeeding women contains folic acid to help reduce the baby’s risk of neural tube defects, vitamin C to maintain healthy body tissue, and vitamin D to help iron and calcium absorption to keep bones healthy and ensure that the baby’s bones and teeth grow strong.
Women who are eligible for the Healthy Start scheme receive coupons to obtain these vitamin supplements free of charge. Women who are not eligible for the Healthy Start scheme may be able to buy the supplements from community pharmacies and should ask their midwife or health visitor where to access the vitamins in their local area. [Adapted from the Healthy Start website and expert opinion]
Healthy Start children’s vitamin supplements
The Healthy Start supplement for children contains vitamins A, C and D, which help to strengthen the immune system, maintain healthy skin, and help with absorbing iron and calcium; keeping their bones and teeth healthy. [Adapted from the Healthy Start website]
Healthy Start food vouchers
The Healthy Start food vouchers scheme is for families eligible for other means- tested benefits and provides food vouchers to spend with local retailers. Pregnant women and parents and carers of children over 1 year and under 4 years get 1 voucher per week. Parents and carers of babies under 1 year get 2 vouchers per week. (See the Healthy Start website for more information).
The vouchers can be spent on:
  • pasteurised cow’s milk
  • fresh or frozen fruit and vegetables (with no added ingredients), which can be whole or chopped, packaged or loose
  • cow’s milk-based infant formula milk suitable from birth.
[Adapted from the Healthy Start website and expert opinion]

Equality and diversity considerations

The risk of vitamin D deficiency can be increased in people with darker skin, for example, people who are black or of Asian family origin, or people who wear clothing that covers their entire body, and this should be considered by their healthcare professionals.
Care and support, and the information given about it, should be both age-appropriate and culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Pregnant women, parents and carers should have access to an interpreter or advocate if needed.
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 or the equivalent standards for the devolved nations.

Breastfeeding

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Women receive breastfeeding support from a service that uses an evaluated, structured programme. [This statement is from NICE’s quality standard on postnatal care. For the rationale, quality measures, what the quality statement means, source guidance and definitions, please see statement 5 from the NICE quality standard on postnatal care].

Advice on introducing solid food

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Parents and carers are given advice on introducing their baby to a variety of nutritious foods to complement breastmilk or formula milk.

Rationale

It is important that babies aged around 6 months are started on solid food, with the introduction of suitable foods in addition to breastmilk or formula milk to establish a healthy and varied diet. This ensures that a varied and nutritionally adequate diet is already in place when breastmilk or formula milk are no longer given. Involving parents and carers in discussions about starting solid food when they attend the 6- to 8-week health visitor appointment with their baby helps them to introduce solid food when their baby is around 6 months, minimising poor infant outcomes associated with starting solid food earlier or later.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
a) Evidence of local arrangements to advise parents and carers how to introduce a variety of nutritious foods to their baby to complement breastmilk or formula milk.
b) Evidence of local arrangements to advise parents and carers when to introduce a variety of nutritious foods to their baby to complement breastmilk or formula milk.
Data source: Local data collection.
Process
a) Proportion of 6- to 8-week health visitor appointments where parents and carers receive advice on how to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Numerator – the number in the denominator where the parents and carers receive advice on how to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Denominator – the number of 6- to 8-week health visitor appointments.
Data source: Local data collection. The number of 6- to 8-week health visitor appointments at national, regional and local level in England is collected in Public Health England’s Health visitor service delivery metrics (2017 onwards). This data is submitted on a voluntary basis.
b) Proportion of 6- to 8-week health visitor appointments where parents and carers receive advice on when to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Numerator – the number in the denominator where the parents and carers receive advice on when to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Denominator – the number of 6- to 8-week health visitor appointments.
Data source: Local data collection. The number of 6- to 8-week health visitor appointments at national, regional and local level in England is collected in Public Health England’s Health visitor service delivery metrics (2017 onwards). This data is submitted on a voluntary basis.
Outcome
a) Introduction of solid food at around 6 months.
Data source: Local data collection.
b) Infant obesity rates.
Data source: Local data collection.
c) Faltering infant growth.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (community providers) ensure that systems are in place for parents and carers to be advised on how and when to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Health visitors ensure that they work with parents and carers, advising them at the 6- to 8-week appointment on how and when to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Commissioners (such as clinical commissioning groups or integrated care systems, NHS England and local authorities) specify that providers advise parents and carers how and when to introduce their baby to a variety of nutritious foods to complement breastmilk or formula milk.
Parents and carers are given advice on how and when to introduce their baby to different types of nutritious foods to complement breastmilk or formula milk. The health visitor explains that they should start their baby on solid food at around 6 months and introduce a wide variety of different foods to give their baby a healthy and varied diet in the first year, in addition to breastmilk or formula milk. This will help the baby to be healthy, support the development of motor skills and speech and language, and help the baby to stay at a healthy weight. Advice should also be given about the texture of food, the use of finger foods and how parents and carers can reduce the risk of choking.

Source guidance

Maternal and child nutrition. NICE guideline PH11 (2008), recommendations 4 (key priority for implementation) and 22

Definitions of terms used in this quality statement

Advice on introducing their baby to a variety of nutritious foods
This is advice that includes, but is not limited to:
  • the reasons for starting solid food at around 6 months
  • the possible effects on the baby of starting solid food earlier or later
  • the reasons for continuing breastfeeding
  • maximising breastmilk or increasing infant formula feeds for babies under 6 months who are feeding more frequently.
This information can be given by the health visitor at the mandated 6- to 8-week appointment. [Expert opinion]

Equality and diversity considerations

This information should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Parents and carers should have access to an interpreter or advocate if needed.
People from some religious groups introduce solid food to babies when they are considerably older than 6 months of age. Health visitors should be mindful of different behaviours and beliefs while highlighting the importance of introducing a range of foods at around 6 months. This requires sensitive communication to inform parents and carers of the possible impact on their baby’s health.
For people 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 or the equivalent standards for the devolved nations.

Advice on Healthy Start food vouchers

This quality statement is taken from the nutrition: improving maternal and child nutrition quality standard. The quality standard defines clinical best practice in improving maternal and child nutrition and should be read in full.

Quality statement

Parents and carers receiving Healthy Start food vouchers are offered advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.

Rationale

Including more fruit and vegetables increases the nutrients in a diet and can help people to manage their body weight. Healthy diets rich in fruit and vegetables may also help to reduce the risk of heart disease, stroke, cancer and other chronic diseases. It is important that service providers such as local authorities, local health services and voluntary organisations provide advice to parents and carers to ensure that they use the food vouchers to increase the amount of fruit and vegetables their family eats. This may also help to reduce outcomes associated with poor nutrition.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of local arrangements to offer parents and carers receiving Healthy Start food vouchers advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Data source: Local data collection.
Process
a) Proportion of 6- to 8-week health visitor appointments where parents and carers receiving Healthy Start food vouchers receive advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Numerator – the number in the denominator where advice is given on how to use the vouchers to increase the amount of fruit and vegetables in their family’s diet.
Denominator – the number of 6- to 8-week health visitor appointments where the parents and carers are receiving Healthy Start food vouchers.
Data source: Local data collection.
b) Proportion of 8- to 12-month developmental reviews where parents and carers receiving Healthy Start food vouchers receive advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Numerator – the number in the denominator where advice is given on how to use the vouchers to increase the amount of fruit and vegetables in their family’s diet.
Denominator – the number of 8- to 12-month developmental reviews where the parents and carers are receiving Healthy Start food vouchers.
Data source: Local data collection.
c) Proportion of 2- to 2-and-a-half-year health reviews where parents and carers receiving Healthy Start food vouchers receive advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Numerator – the number in the denominator where advice is given on how to use the vouchers to increase the amount of fruit and vegetables in their family’s diet.
Denominator – the number of 2- to 2-and-a-half-year health reviews where the parents and carers are receiving Healthy Start food vouchers.
Data source: Local data collection.
d) Proportion of vaccination appointments at age 3 years and 5 months to 4 years where parents and carers receiving Healthy Start food vouchers receive advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Numerator – the number in the denominator where advice is given on how to use the vouchers to increase the amount of fruit and vegetables in their family’s diet.
Denominator – the number of vaccination appointments at age 3 years and 5 months to 4 years where the parents and carers are receiving Healthy Start food vouchers.
Data source: Local data collection.
Outcome
a) Fruit and vegetable intake.
b) Obesity.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as children’s centres, local authorities, local strategic partnerships, local health services and voluntary organisations) ensure that they offer parents and carers receiving Healthy Start food vouchers advice on how to use them to increase the amount of fruit and vegetables in their family’s diet.
Healthcare and public health professionals ensure that they explain to parents and carers receiving Healthy Start food vouchers how they can use them to increase the amount of fruit and vegetables in their family’s diet.
Commissioners (such as clinical commissioning groups or integrated care systems, NHS England, local authorities and local businesses that fund or provide community projects) specify that services offer parents and carers receiving Healthy Start food vouchers advice on using them to increase the amount of fruit and vegetables in their family’s diet.
People and carers receiving Healthy Start food vouchers are offered advice on how to use their vouchers to increase the amount of fruit and vegetables in their family’s diet. Eating more fruit and vegetables will help to improve their health and help them to stay at a healthy weight, and it may reduce their family’s risk of developing some illnesses.

Source guidance

Maternal and child health. NICE guideline PH11 (2008, updated 2014), recommendations 4 (key priority for implementation) and 22

Definitions of terms used in this quality statement

Healthy Start scheme
The Healthy Start scheme provides food vouchers and coupons for vitamin supplements to pregnant women, new mothers and parents and carers with young children (under 4 years) who are on low incomes and to all pregnant women aged under 18 years. It aims to improve health and access to a healthy diet for families on low incomes across the UK. [Adapted from Healthy Start vouchers study: the views and experiences of parents, professionals and small retailers in England, executive summary]
Healthy Start food vouchers
The Healthy Start food vouchers scheme is for families eligible for other means-tested benefits and provides food vouchers to spend with local retailers. Pregnant women and parents and carers of children over 1 year and under 4 years get 1 voucher per week. Parents and carers of babies under 1 year get 2 vouchers per week. (See the Healthy Start website for more information).
The vouchers can be spent on:
  • pasteurised cow’s milk
  • fresh or frozen fruit and vegetables (with no added ingredients), which can be whole or chopped, packaged or loose
  • cow’s milk-based infant formula milk suitable from birth.
Advice on how to use Healthy Start Vouchers
This is advice which includes, but is not limited to:
  • the shops, markets and local and community food delivery services where the vouchers can be used and how these can be accessed, for example, by public transport
  • the types of food that the vouchers can be used to buy.
  • simple healthy recipes using food bought with the vouchers, taking the family circumstances into account, for example, their religion and culture, and the size of the family.
Advice can be given by primary and secondary healthcare professionals, public health nutritionists, dietitians and at children’s centres, health centres, nursery schools and other community settings. It can be provided in a number of ways, including formal and informal group sessions and one-to-one discussions, and using practical cook and eat sessions, leaflets and online resources (for example, step-by-step cooking demonstrations). This advice can be given at any time, but particularly when eligibility for the Healthy Start food vouchers is established and then on an ongoing basis as needed. [Expert opinion]

Equality and diversity considerations

The information given should be both age-appropriate and culturally appropriate and sensitive to those who may have limited cooking skills and cooking equipment. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Pregnant women, parents and carers should have access to an interpreter or advocate if needed.
For people 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 or the equivalent standards for the devolved nations.

Continuity of care

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

Quality statement

This statement has been removed. For full details, see update information in the NICE quality standard.

Maternal health – potentially serious conditions

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

Quality statement

Women are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.

Rationale

Women are at an increased risk of experiencing serious health events in the immediate hours, days and weeks following the birth, some of which could lead to maternal death or severe morbidity. Providing women with information about the symptoms and signs that may indicate a serious physical illness or mental health condition may prompt them to seek medical advice without delay and avoid unnecessary deaths and severe morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that women are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Data source: Local data collection.
Process
The proportion of women who are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Numerator – the number in the denominator who are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Denominator – the number of women who have given birth.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable maternal morbidity and mortality.
Data source: Local data collection. The Healthcare Quality Improvement Partnership’s Maternal, Newborn and Infant Clinical Outcome Review Programme (undertaken by MBRRACE-UK) reports on rates of maternal death and severe maternal morbidity.
b) Women who have given birth feel informed about symptoms and signs of potentially serious postnatal conditions.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women to be advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Midwives advise women, at the first postnatal contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Commissioners ensure that they commission services that advise women, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Women are given advice by their midwife at their first postnatal contact about the symptoms and signs of potentially serious conditions that should prompt them to seek medical advice without delay.

Source guidance

Definitions of terms used in this quality statement

First postnatal midwife contact
The first postnatal midwife contact should take place within 36 hours after transfer of care from the place of birth or after a home birth. [NICE’s guideline on postnatal care, recommendation 1.1.14]
Symptoms and signs of potentially serious conditions
The following symptoms and signs are suggestive of potentially serious physical conditions in the woman:
  • sudden or very heavy vaginal bleeding, or persistent or increased vaginal bleeding, which could indicate retained placental tissue or endometritis
  • abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell, which could indicate infection
  • leg swelling and tenderness, or shortness of breath, which could indicate venous thromboembolism
  • chest pain, which could indicate venous thromboembolism or cardiac problems
  • persistent or severe headache, which could indicate hypertension, pre-eclampsia, postdural-puncture headache, migraine, intracranial pathology or infection
  • worsening reddening and swelling of breasts persisting for more than 24 hours despite self-management, which could indicate mastitis
  • symptoms or signs of potentially serious conditions that do not respond to treatment.
[NICE’s guideline on postnatal care, recommendation 1.2.4]
The following symptoms and signs are suggestive of potentially serious mental health conditions in the woman:
  • severe depression, such as feeling extreme unnecessary worry, being unable to concentrate due to distraction from depressive feelings
  • severe anxiety, such as uncontrollable feeling of panic, being unable to cope or becoming obsessive
  • the desire to hurt others or yourself, including thoughts about taking your own life
  • confused and disturbed thoughts, which could include other people telling you that you are imagining things (hallucinations and delusions).

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Written and verbal information should be appropriate for the woman’s level of literacy, culture and language.

Infant health – serious illness

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

Quality statement

Women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.

Rationale

Babies may experience serious health conditions in the immediate hours, days and weeks following the birth, which can lead to severe illness or in rare cases, death. Providing the mother or main carer with verbal and written information about the symptoms and signs that might indicate their baby has a serious health problem may result in them contacting emergency services more promptly. This information should be provided within 24 hours of the birth.

Quality measures

Structure
Evidence of local arrangements to ensure that women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Data source: Local data collection.
Process
The proportion of women or main carers of babies who are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Numerator – the number in the denominator who are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Denominator – the number of mothers or main carers of babies.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable infant morbidity and mortality.
Data source: Local data collection. The NHS Digital Maternity Services Data Set collects data on neonatal deaths. The Healthcare Quality Improvement Partnership’s perinatal mortality surveillance report (MBRRACE-UK) reports on rates of perinatal death.
b) Women and main carers feel informed about symptoms and signs of serious illness in the baby.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women or main carers of babies to be advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Healthcare practitioners advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Commissioners ensure that they commission services that advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Women or the main carer of the baby are given advice within 24 hours of the birth about symptoms and signs of serious illness in the baby, for which they need to contact emergency services.

Source guidance

Definitions of terms used in this quality statement

Symptoms and signs of serious illness in the baby
The following symptoms and signs are suggestive of serious illness in a baby:
  • appearing pale, ashen, mottled or blue (cyanosis)
  • unresponsive or unrousable
  • having a weak, abnormally high-pitched or continuous cry
  • abnormal breathing pattern, such as:
    • grunting respirations
    • increased respiratory rate (over 60 breaths/minute)
    • chest indrawing
  • temperature of 38°C or over or under 36°C
  • non-blanching rash
  • bulging fontanelle
  • neck stiffness
  • seizures
  • focal neurological signs
  • diarrhoea associated with dehydration
  • frequent forceful (projectile) vomiting
  • bilious vomiting (green or yellow-green vomit).
  • within the first 24 hours after the birth:
    • has not passed urine
    • has not passed faeces (meconium)
    • develops a yellow skin colour (jaundice).
[NICE’s guideline on postnatal care, recommendations 1.3.2 and 1.4.9, NICE’s guideline on jaundice in newborn babies under 28 days, recommendation 1.1.1 and expert opinion]
Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]

Equality and diversity considerations

Communication and information-giving between women or main carers of babies (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Infant health – bed sharing

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

Quality statement

Women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.

Rationale

There are risk factors associated with sudden unexpected death in infancy when bed sharing. Discussing safer bed-sharing practices and the circumstances in which bed sharing with a baby is strongly advised against with women, their partner or main carers of babies will support them to establish safer infant sleeping habits.

Quality measures

Structure
Evidence of local arrangements to ensure that women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Data source: Local data collection.
Process
Proportion of postnatal contacts in which women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Numerator – the number in the denominator in which women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
Outcome
a) Incidence of sudden infant death syndrome (SIDS).
b) Women, their partner and main carers of babies know about safer bed-sharing practices.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that information about safer bed-sharing practices is available, and that healthcare professionals are trained to discuss safer bed-sharing practices with women, their partner or main carers of babies.
Healthcare practitioners ensure that they understand and can explain safer bed-sharing practices, and that they have discussions about this with women, their partner or the main carers of babies.
Commissioners ensure that they commission services that provide information about safer bed-sharing practices, and that train healthcare professionals to discuss this with women, their partner or main carers of babies.
Women, their partner or main carers of babies have discussions about safer bed-sharing practices with their healthcare professional. This should include how to keep their baby safe if they share a bed with their baby and when they should not share a bed with their baby.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.3.13 and 1.3.14

Definitions of terms used in this quality statement

Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]
Safer bed-sharing practices
Discussions about bed sharing should include:
  • safer practices for bed sharing, including:
    • making sure the baby sleeps on a firm, flat mattress, lying face up (rather than face down or on their side)
    • not sleeping on a sofa or chair with the baby
    • not having pillows or duvets near the baby
    • not having other children or pets in the bed when sharing a bed with a baby
  • advice not to share a bed with their baby if their baby was low birth weight or if either parent:
    • has had 2 or more units of alcohol
    • smokes
    • has taken medicine that causes drowsiness
    • has used recreational drugs.
[NICE’s guideline on postnatal care, recommendations 1.3.13 and 1.3.14]

Equality and diversity considerations

Communication and information-giving between women, their partners or main carers of babies (and their families), and members of the maternity team are key aspects of this statement. Relevant adjustments should be in place for people with communication difficulties, and those who do not speak or read English. Verbal and written information should be appropriate for the person’s level of literacy, culture, language and family circumstances. Bed sharing can be intentional or a necessity, but all women, their partners or main carers of babies should be given information in a format they can understand, irrespective of their culture.

Breastfeeding

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

Quality statement

Women receive breastfeeding support from a service that uses an evaluated, structured programme.

Rationale

Breastfeeding contributes to the health of both the mother and child in the short and longer term. Women should be made aware of these benefits and those who choose to breastfeed should be supported by a service that is evidence-based and delivers an externally audited, structured programme. Delivery of breastfeeding support should be coordinated across the different sectors.

Quality measures

Structure
Evidence of local arrangements for breastfeeding support to be provided through a service that uses an evaluated, structured programme.
Data source: Local data collection.
Process
a) Proportion of women who receive breastfeeding support through a service that uses an evaluated, structured programme.
Numerator – the number in the denominator who receive breastfeeding support through a service that uses an evaluated, structured programme.
Denominator – the number of women who breastfeed (exclusively or partially).
Data source: Local data collection.
b) Proportion of women who wanted to continue breastfeeding but stopped before they had planned to.
Numerator – the number in the denominator who wanted to continue breastfeeding but stopped before they had planned to.
Denominator – the number of women who breastfed (exclusively or partially).
Data source: Local data collection.
Outcome
a) Rates of breastfeeding initiation.
Data source: The NHS Digital Maternity Services Data Set reports percentage of babies receiving breast milk as first feed.
b) Rates of exclusive or partial breastfeeding on discharge from hospital and at 6 to 8 weeks after the birth.
c) Women’s satisfaction with breastfeeding support.
Data source: The Care Quality Commission maternity services survey collects information about women’s experiences of maternity care and this includes a section on infant feeding.

What the quality statement means for different audiences

Service providers ensure that women receive breastfeeding support through a service that uses an evaluated, structured programme.
Healthcare practitioners ensure that women receive breastfeeding support through an integrated service that uses an evaluated, structured programme.
Commissioners ensure that they commission a service that delivers breastfeeding support through an evaluated, structured programme.
Women receive breastfeeding support through a service that uses an evaluated, structured programme.

Source guidance

Maternal and child nutrition. NICE guideline PH11 (2008, updated 2014), recommendations 1 and 7

Definitions of terms used in this quality statement

Structured programme
All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the UNICEF Baby Friendly Initiative as a minimum standard. If providers implement a locally developed programme, this should be evidence-based, structured, and undergo external evaluation. The structured programme should be delivered and coordinated across all providers, including hospital, primary, community and children’s centre settings. Breastfeeding outcomes should be monitored across all services. [Adapted from NICE’s guideline on maternal and child nutrition, recommendation 7]
Breastfeeding support
All people involved in delivering breastfeeding support should receive the approriate training and undergo assessment of competencies for their role. This includes employed staff and volunteer workers in all sectors, for example, hospitals, community settings, children’s centres and peer supporter services.

Equality and diversity considerations

Breastfeeding support should be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Women should have access to an interpreter or advocate if needed. Special consideration will be needed if the mother and baby have been separated for any reason, for example, if the baby has been admitted to neonatal care or the baby has been taken into care.

Formula feeding

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

Quality statement

Information about bottle feeding is discussed with women or main carers of formula-fed babies.

Rationale

Babies who are fully or partially formula-fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm and are life threatening and require the baby to be admitted to hospital. The mother or main carer of the baby needs consistent, evidence-based advice about how to sterilise feeding equipment and safely prepare formula milk.

Quality measures

Structure
Evidence of local arrangements to ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Data source: Local data collection.
Process
The proportion of women or main carers of formula-fed babies who have information about bottle feeding discussed with them.
Numerator – the number in the denominator who have information about bottle feeding discussed with them.
Denominator – the number of women or main carers of formula-fed babies.
Data source: Local data collection.
Outcome
a) Rates of hospital admissions for formula feeding-related conditions.
Data source: Local data collection.
b) Women’s and main carers’ knowledge of how to sterilise feeding equipment and safely prepare formula milk.
Data source: Local data collection, for example, use of patient surveys.
c) Women’s and main carers’ satisfaction with feeding support.
Data source: The Care Quality Commission maternity services survey collects information about women’s experiences of maternity care and this includes a section on infant feeding.

What the quality statement means for different audiences

Service providers ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Healthcare practitioners discuss information about bottle feeding with women or main carers of formula-fed babies.
Commissioners ensure that they commission services in which information about bottle feeding is discussed with women or main carers of formula-fed babies.
Women or main carers of formula-fed babies have the opportunity to discuss information about bottle feeding.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.5.18 and 1.5.19

Definitions of terms used in this quality statement

Formula-fed baby
This statement relates to mothers and main carers who totally or partially formula feed their baby, and breastfeeding mothers who plan to formula feed their baby. [Expert opinion]
Information about bottle feeding
The woman or main carer of the baby should have a one-to-one discussion about safe formula feeding and face-to face support supplemented with written, digital or telephone information.
Face-to-face formula feeding support should include:
  • advice about responsive bottle feeding and help to recognise feeding cues
  • offering to observe a feed
  • positions for holding a baby for bottle feeding and the dangers of ‘prop’ feeding
  • advice about how to pace bottle feeding and how to recognise signs that a baby has had enough milk (because it is possible to overfeed a formula-fed baby), and advice about other ways than feeding that can comfort and soothe the baby
  • how to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact and the potential benefit of minimising the number of people regularly feeding the baby.
[NICE’s guideline on postnatal care, recommendations 1.5.18 and 1.5.19]
Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]

Equality and diversity considerations

Communication and information-giving between women or main carers of babies (and their families), and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Verbal and written information should be appropriate in terms of women’s (and their families) level of literacy, culture, language and family circumstances.

Infant health – physical examination

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

Quality statement

Babies have a complete 6- to 8-week physical examination.

Rationale

The purpose of the examination is to identify babies more likely to have conditions that would benefit from further investigation and management. This includes an overall physical examination as well as screening for eye problems, congenital heart defects, developmental dysplasia of the hip and undescended testicles. Most babies will be healthy, but the small number of babies who do have serious problems will benefit from prompt identification. Early treatment can improve the health of the baby and prevent or reduce disability.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents or main carers of babies are offered an appointment for the baby to attend for a 6- to 8-week physical examination.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a system is in place to monitor the competency of practitioners undertaking a 6- to 8-week physical examination.
Data source: Local data collection.
Process
Proportion of babies who had a 6- to 8-week physical examination.
Numerator – the number in the denominator who had a 6- to 8-week physical examination.
Denominator – the number of babies aged 8 weeks.
Data source: Local data collection could include data collected for the Public Health England newborn and infant physical examination (NIPE) screening programme.
Outcomes
a) Incidence of physical abnormalities in babies.
Data source: Local data collection.
b) Health outcomes associated with early intervention for babies with physical abnormalities.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that babies are offered a complete 6- to 8-week physical examination.
Healthcare practitioners ensure that they perform a complete 6- to 8-week physical examination of babies and that they maintain the necessary competencies for this role.
Commissioners ensure that they commission services that offer a complete 6- to 8-week physical examination for babies, which is carried out in a timely manner and by a competent practitioner.
The mother or main carer of the baby is given the opportunity for their baby to have a complete 6- to 8-week physical examination, which is carried out in a timely manner and by a competent practitioner.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.3.3, 1.3.4 and 1.3.5

Definitions of terms used in this quality statement

6- to 8-week physical examination
The 6- to 8-week physical examination should include:
  • checking the baby’s:
    • appearance, including colour, breathing, behaviour, activity and posture
    • head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features
    • eyes: opacities, red reflex and colour of sclera
    • neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry
    • heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume
    • lungs: respiratory effort, rate and lung sounds
    • abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord
    • genitalia and anus: completeness and patency and undescended testes in boys
    • spine: inspect and palpate bony structures and check integrity of the skin
    • skin: colour and texture as well as any birthmarks or rashes
    • central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned
    • hips: symmetry of the limbs, Barlow and Ortolani's manoeuvres
    • cry: assess sound
    • social smiling and visual fixing and following
  • measuring the baby’s weight and head circumference and plotting the results on a growth chart.
[NICE’s guideline on postnatal care, recommendations 1.3.3, 1.3.4 and 1.3.5]

Maternal health – weight management

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

Quality statement

Women with a body mass index (BMI) of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.

Rationale

The woman’s eating habits and physical activity levels could influence the health behaviour of the wider family, including children who are developing habits that may remain with them for life. Supporting the woman in the postnatal period to change her eating habits and physical activity levels may improve her health, her infant’s health and the health of the wider family. It may also improve the outcomes of future pregnancies.
Women who are obese during pregnancy face increased risks of complications that include gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death. Risks for the infant include fetal death, stillbirth, shoulder dystocia, and macrosomia. Infants of obese women face health risks in childhood including diabetes and obesity in later life.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women have their BMI assessed and recorded at the 6- to 8-week postnatal check.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that the local workforce has appropriate numbers of staff trained to deliver healthy eating and physical activity services to postnatal women.
Data source: Local data collection.
Process
a) The proportion of women who have their BMI recorded at the 6- to 8-week postnatal check.
Numerator – the number in the denominator who have their BMI recorded.
Denominator – the number of women who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
b) The proportion of women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check who are offered a referral for advice on healthy eating and physical activity.
Numerator – the number in the denominator who are offered a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
c) The proportion of women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check who accept a referral for advice on healthy eating and physical activity.
Numerator – the number in the denominator who accept a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
Outcome
Women feel able to make informed decisions about healthy eating, physical activity and weight management for themselves and their family.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check to be offered a referral for advice on healthy eating and physical activity.
Healthcare practitioners offer women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check a referral for advice on healthy eating and physical activity.
Commissioners ensure that they commission services that offer women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check a referral for advice on healthy eating and physical activity.
Women who have a body mass index of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

Structured programme
Women should be offered a referral to an individual or group-based service that uses a structured programme. Services should deliver a structured programme that:
  • addresses the reasons why women may find it difficult to lose weight, particularly after pregnancy
  • is tailored to the needs of an individual or group
  • combines advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 minutes on at least 5 days of the week)
  • identifies and addresses individual barriers to change
  • provides ongoing support over a sufficient period of time to allow for sustained lifestyle changes.
Services should be delivered by an appropriately trained person. This is someone who can demonstrate expertise and competencies in healthy eating and/or physical activity, including weight management for women in the postnatal period. This may include midwives, health visitors, obstetricians, dietitians, GPs, nurses, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).
Women who choose not to accept a referral should be given information about where they can get support on healthy eating and physical activity in future.
[Adapted with expert group consensus from NICE’s guideline on weight management before, during and after pregnancy, recommendations 3 and 4, and NICE’s guideline on maternal and child nutrition, recommendation 6]

Equality and diversity considerations

Women should be able to access services that are appropriate to their cultural and religious beliefs, and that make relevant adjustments for anyone who has communication difficulties, and for those who do not speak or read English.

Emotional wellbeing and bonding with the baby

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

Quality statement

Women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.

Rationale

The baby’s relationship with the mother has a significant impact on the baby’s social and emotional development. In turn, the woman's ability to provide a nurturing relationship is partly dependent on her own emotional wellbeing. Regular assessment of the woman’s emotional wellbeing, including bonding with her baby, may lead to earlier detection of problems.

Quality measures

Structure
Evidence of local arrangements that women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Data source: Local data collection.
Process
Proportion of postnatal contacts that include an assessment of the woman’s emotional wellbeing, including bonding with their baby.
Numerator – the number in the denominator that include an assessment of the woman’s emotional wellbeing, including bonding with their baby.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
Outcome
a) Incidence of postnatal mental health problems.
Data source: Local data collection.
b) Incidence of baby-to-mother emotional attachment problems.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place so that women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Healthcare practitioners ensure that they assess women’s emotional wellbeing, including bonding with their baby, at each postnatal contact.
Commissioners ensure that they commission services that have local agreements to ensure women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.2.2, 1.3.15 and 1.3.17

Definitions of terms used in this quality statement

Postnatal contacts
Women and their babies should receive the number of postnatal contacts that are appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby’s home or another setting such as a GP practice, children’s centre or this could be a hospital setting where women and/or the baby requires extended inpatient care. [Expert opinion]
Emotional wellbeing
Being happy and confident and not anxious or depressed. [NICE’s guideline on social and emotional wellbeing: early years, glossary]
Bonding
Bonding is the positive emotional and psychological connection that the parent develops with the baby [NICE’s guideline on postnatal care, terms used in this guideline section]

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Maternal health – mental wellbeing

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

Quality statement

This statement has been removed. In 2016, NICE published a separate quality standard on antenatal and postnatal mental health, which focuses on this area of care in more detail. For more details, see update information in the NICE quality standard.

Parent–baby attachment

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

Quality statement

This statement has been removed. For full details, see update information in the NICE quality 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

Be aware that the 2020 MBRRACE-UK reports on maternal and perinatal mortality showed that women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring. The reports showed that:
  • compared with white women (8 per 100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:
    • 4 times higher in black women (34 per 100,000)
    • 3 times higher in mixed ethnicity women (25 per 100,000)
    • 2 times higher in Asian women (15 per 100,000; does not include Chinese women)
  • the neonatal mortality rate is around 50% higher in black and Asian babies compared with white babies (17 per 10,000 compared with 25 per 10,000)
  • women living in the most deprived areas are more than 2.5 times more likely to die compared with women living in the least deprived areas (6 per 100,000 compared with 15 per 100,000)
  • the neonatal mortality rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many babies dying in the most deprived areas compared with the least deprived areas (12 per 10,000 compared with 22 per 10,000).

Bonding and emotional attachment

Bonding is the positive emotional and psychological connection that the parent develops with the baby.
Emotional attachment refers to the relationship between the baby and parent, driven by innate behaviour and which ensures the baby's proximity to the parent and safety. Its development is a complex and dynamic process dependent on sensitive and emotionally attuned parent interactions supporting healthy infant psychological and social development and a secure attachment. Babies form attachments with a variety of caregivers but the first, and usually most significant of these, will be with the mother and/or father.

Continuity of carer

Better Births, a report by the National Maternity Review, defines continuity of carer as consistency in the midwifery team (between 4 and 8 individuals) that provides care for the woman and her baby throughout pregnancy, labour and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods.
For the purpose of these recommendations, the definition of continuity of carer in the Better Births report has been adapted to include not just the midwifery team but any healthcare team involved in the care of the woman and her baby, including the health visitor team. It emphasises the importance of effective information transfer between the individuals within the team. Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional(s) who cares for her. For more information, see the NHS Implementing Better Births: continuity of carer.

Effective feed

In general, effective feeding includes the baby showing readiness to feed, rhythmic sucking, calmness during the feed and satisfactory weight gain. For a first feed at the breast or with a bottle, effective feeding is shown by the baby latching to the breast or drawing the teat into mouth when offered and showing some rhythmic sucking.

Effective feeding

In general, effective feeding includes the baby showing readiness to feed, rhythmic sucking, calmness during the feed and satisfactory weight gain. For a first feed at the breast or with a bottle, effective feeding is shown by the baby latching to the breast or drawing the teat into mouth when offered and showing some rhythmic sucking.

Responsive breastfeeding

Responsive feeding means feeding in response to the baby's cues. It recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between the baby and mother (or parent in case of bottle feeding). Responsive breastfeeding also involves a mother responding to her own desire to feed for her comfort or convenience. Responsive bottle feeding involves holding the baby close, pacing the feeds and avoiding forcing the baby to finish the feed by recognising signs that the baby has had enough milk, and to reduce the risk of overfeeding. For more information, see the UNICEF Baby Friendly Initiative (BFI) information sheet on responsive feeding.

Responsive bottle feeding

Responsive feeding means feeding in response to the baby's cues. It recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between the baby and mother (or parent in case of bottle feeding). Responsive breastfeeding also involves a mother responding to her own desire to feed for her comfort or convenience. Responsive bottle feeding involves holding the baby close, pacing the feeds and avoiding forcing the baby to finish the feed by recognising signs that the baby has had enough milk, and to reduce the risk of overfeeding. For more information, see the UNICEF Baby Friendly Initiative (BFI) information sheet on responsive feeding.

Glossary

(first infant formula or 'first milk' is the type of formula milk that is suitable for a baby from birth to 12 months)
(under UK law, infant formula is the term used to describe a food intended to satisfy, by itself, the nutritional needs of infants during the first months of life. The Department of Health advises that infant formula may be used on its own for the first 6 months)
(a birth weight of less than 2,500 grams regardless of gestational age)
(those with the main responsibility for the care of a baby – this will often be the mother and the father, but many other family arrangements exist, including single parents)
(the woman's chosen supporter – this could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve)
(the woman's chosen supporter – this could be the baby's father, the woman's partner, a family member or friend, or anyone who the woman feels supported by or wishes to involve)
(when a baby's feeding bottle is propped against a pillow or other support, rather than the baby and the bottle being held when feeding)

Paths in this pathway

Pathway created: May 2011 Last updated: October 2021

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