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Pregnancy and complex social factors: service provision

About

What is covered

This NICE Pathway covers service provision for all pregnant women with complex social factors that is additional to routine antenatal care. It focuses on 4 population groups:
  • women who experience domestic abuse
  • women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English
  • women who misuse substances (alcohol and/or drugs)
  • under 20s.

Updates

Updates to this NICE Pathway

19 August 2021 Antenatal care (NICE quality standard 22) added.
21 December 2017 Renamed and restructured.

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 service provision for pregnant women with complex social factors in an interactive flowchart

What is covered

This NICE Pathway covers service provision for all pregnant women with complex social factors that is additional to routine antenatal care. It focuses on 4 population groups:
  • women who experience domestic abuse
  • women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English
  • women who misuse substances (alcohol and/or drugs)
  • under 20s.

Updates

Updates to this NICE Pathway

19 August 2021 Antenatal care (NICE quality standard 22) added.
21 December 2017 Renamed and restructured.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Antenatal care (2012, updated 2021) NICE quality standard 22

Quality standards

Quality statements

Services – access to antenatal care

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

Quality statement

Pregnant women are supported to access antenatal care, ideally by 10 weeks 0 days.

Quality 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 services that ensure antenatal care is readily and easily accessible.
Data source: Local data collection. The baseline assessment tool for NICE’s guideline on pregnancy and complex social factors can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
b) Evidence of local arrangements to encourage pregnant women to access and maintain contact with antenatal care services.
Data source: Local data collection. The baseline assessment tool for NICE’s guideline on pregnancy and complex social factors can be used to assess current activity related to recording information for women presenting to antenatal care with complex social needs to inform mapping of the local population and to guide service provision.
Process
Proportion of pregnant women missing a scheduled antenatal appointment who are followed up within locally defined timescales.
Numerator – the number in the denominator followed up within locally defined timescales.
Denominator – the number of pregnant women missing a scheduled antenatal appointment.
Data source: Local data collection.
Outcome
a) Pregnant women accessing antenatal care who are seen for booking by 10 weeks 0 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
b) Pregnant women accessing antenatal care who are seen for booking by 12 weeks 6 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
c) Pregnant women accessing antenatal care who are seen for booking by 20 weeks 0 days.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
d) Median gestation at booking.
Data source: The NHS Digital Maternity Services Data Set collects data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given access to your pregnancy notes)?’.
e) Pregnant women accessing antenatal care attend at least the recommended number of antenatal appointments.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Health and social care professionals support pregnant women to access antenatal care, ideally by 10 weeks 0 days. This includes following up women who have missed a scheduled antenatal appointment.
Commissioners ensure that they commission services that are readily and easily accessible and that support pregnant women to access antenatal care, ideally by 10 weeks 0 days.
Pregnant women are encouraged to see a healthcare professional about their pregnancy as early as possible and have regular check-ups from their midwife or doctor throughout their pregnancy (antenatal care). This may include being contacted by their midwife or doctor if they miss a check-up.

Source guidance

Definitions of terms used in this quality statement

Support to access antenatal care
Commissioners and providers should ensure that antenatal care can be started in a variety of straightforward ways, depending on women’s needs and circumstances, for example, by self-referral, referral by a GP, midwife or another healthcare professional or through a school nurse, community centre or refugee hostel.
At the first antenatal (booking) appointment, discuss antenatal care with the woman (and her partner) and provide her schedule of antenatal appointments (plan 10 routine antenatal appointments with a midwife or doctor for nulliparous women and 7 for parous women).
At the first antenatal (booking) appointment (and later if appropriate), discuss and give information on:
  • what antenatal care involves and why it is important
  • the planned number of antenatal appointments
  • where antenatal appointments will take place
  • which healthcare professionals will be involved in antenatal appointments
  • how to contact the midwifery team for non-urgent advice
  • how to contact the maternity service about urgent concerns, such as pain and bleeding.
[NICE’s guideline on antenatal care, recommendations 1.1.1, 1.1.7, 1.1.8, 1.3.7 and 1.3.8]
Follow-up after a missed appointment may be undertaken by the maternity service or other community-based service the woman is in contact with, such as a children’s centre, addiction service or GP. Follow-up should be via a method of contact that is appropriate to the woman, which may include:
  • text message
  • letter
  • telephone
  • community or home visit.
[NICE’s guideline on pregnancy and complex social factors, recommendation 1.2.8 and expert opinion]

Equality and diversity considerations

Pregnant women include women with complex social needs who may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE’s guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Services – continuity of care

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

Quality statement

Pregnant women are cared for by a named midwife throughout their pregnancy.

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 and audit to ensure that pregnant women are cared for by a named midwife throughout their pregnancy.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that systems are in place to coordinate a pregnant woman’s care should her named midwife not be available.
Data source: Local data collection.
Process
Proportion of pregnant women with a named midwife.
Numerator – the number in the denominator with a named midwife.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.
Outcome
Pregnant women’s satisfaction with the continuity of their antenatal care.
Data source: Local data collection. The Care Quality Commission Maternity Services Survey asks the question ‘At your antenatal check-ups, did you see the same midwife every time?’

What the quality statement means for different audiences

Service providers ensure that systems are in place to enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Healthcare professionals follow local systems and guidance to provide continuity of care to pregnant women through the provision of a named midwife.
Commissioners ensure they commission services that enable pregnant women to be cared for by a named midwife throughout their pregnancy.
Pregnant women are cared for a by a named midwife throughout their pregnancy.

Source guidance

Antenatal care. NICE guideline NG201 (2021), recommendation 1.1.12

Definitions of terms used in this quality statement

Named midwife
Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional who cares for her. The Better Births 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 that the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods [NICE’s guideline on antenatal care, terms used in this guideline]

Services – record keeping

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

Quality statement

Pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.

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 ensure that pregnant women have a complete record of the minimum set of antenatal test results in their maternity notes.
Data source: Local data collection.
b) Evidence of local audit to monitor the completeness and accuracy of antenatal test results in women’s maternity notes.
Data source: Local data collection.
Process
Proportion of pregnant women accessing antenatal care who have a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.
Numerator – the number in the denominator with a complete record of the minimum set of antenatal test results in their maternity notes, appropriate to their stage of pregnancy.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to maintain a complete record of the minimum set of antenatal test results in women’s maternity notes.
Healthcare professionals ensure that women have a complete record of the minimum set of antenatal test results in their maternity notes.
Commissioners ensure that they commission services that maintain a complete record of the minimum set of antenatal test results in women’s maternity notes.
Pregnant women are given a complete record of the minimum set of their antenatal test results in their maternity notes.

Source guidance

Definitions of terms used in this quality statement

Minimum set of antenatal test results
Table 1 minimum set of tests for routine scheduled antenatal care
Investigation
Timing
Blood pressure
All routine appointments
Urine test for proteinuria
All routine appointments
Full blood count, blood group and rhesus D status
At booking or first scan if booking appointment was not face to face
Height, weight and body mass index
At booking or first scan if booking appointment was not face to face
Sickle cell and thalassaemia screen
At booking
Hepatitis B virus screen
At booking
HIV screen
At booking
Syphilis screen
At booking
Ultrasound scan to determine gestational age and detect multiple pregnancy
Between 11 weeks 2 days and 14 weeks 1 day
Screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome
Offer at booking
Ultrasound scan between 11 weeks 2 days and 14 weeks 1 day
Ultrasound screen for fetal anomalies
Offer at booking
Between 18 weeks 0 days and 20 weeks 6 days
Measure of symphysis fundal height
All routine appointments after 24 weeks 0 days
Full blood count, blood group and antibodies
At 28 weeks
Abdominal palpation to identify possible breech presentation
All routine appointments from 36 weeks 0 days
Note that women should be able to make an informed choice about whether to accept or decline each test, and notes should include a record of any tests offered and declined as well as the results of tests accepted. [NICE’s guideline on antenatal care, schedule of antenatal appointments]

Equality and diversity considerations

Maternity notes and the information within them should be accessible to all women, including women who do not speak or read English and those with additional needs such as physical, sensory or learning disabilities.
Women should be able to choose whether to have all the results of their antenatal tests documented in their maternity notes. This may be particularly important when information is sensitive (for example, positive screening results for HIV, hepatitis B virus and syphilis). Where a woman declines to have antenatal test results documented in her maternity notes, the results should instead be recorded within other medical notes. It is therefore appropriate that localities give special consideration to these groups of women within the measures. NICE’s guideline on pregnancy and complex social factors has recommendations about how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Risk assessment – body mass index

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

Quality statement

Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.

Quality 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 offer pregnant women the option to have their body mass index calculated and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Process
a) Proportion of pregnant women accessing antenatal care whose body mass index is calculated and recorded at the booking appointment.
Numerator – the number in the denominator whose body mass index is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: The NHS Digital Maternity Services Data Set collects data on the BMI of the mother at booking. Areas may wish to consider setting a local target that reflects expectations that some women may decide not to have their body mass index calculated.
b) Proportion of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment who are offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Numerator – the number in the denominator offered personalised advice from an appropriately trained person on healthy eating and physical activity.
Denominator – the number of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment.
Data source: Local data collection. The NHS Digital Maternity Services Data Set collects data on the BMI of the mother at booking.
Outcome
Women with a body mass index of 30 kg/m2 or more feel confident to make decisions about healthy eating and physical activity during their pregnancy.
Data source: Local data collection, for example, local survey.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Healthcare professionals offer women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice on healthy eating and physical activity or, if they are not appropriately trained to do this, refer them to an appropriately trained person.
Commissioners ensure they commission services that offer pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained person on healthy eating and physical activity.
Pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered advice relevant to them from an appropriately trained person on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

An appropriately trained person
Someone who can demonstrate expertise and competencies in weight management in pregnancy, including providing advice about nutrition and/or physical activity. This may include obstetricians, GPs, midwives, health visitors, nurses, dietitians, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary). [Expert opinion]

Equality and diversity considerations

The body mass index threshold may need adapting for different groups of pregnant women (for example, women from certain ethnic groups). A body mass index measure is considered unsuitable for use with those under 18.

Risk assessment – smoking cessation

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

Quality statement

Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment.

Quality 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 that pregnant women have their smoking status recorded at the booking appointment.
Data source: NHS Digital’s Maternity Services Data Set collects data on smoking status at the booking appointment.
b) Evidence of local arrangements to ensure that pregnant women who smoke are referred to an evidence-based stop smoking service.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that pregnant women who smoke and decide not to attend an evidence-based stop smoking service receive follow-up.
Data source: Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care whose smoking status is recorded at the booking appointment.
Numerator – the number in the denominator whose smoking status is recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: NHS Digital’s Maternity Services Data Set collects data on smoking status at the booking appointment.
b) Proportion of pregnant women who smoke who are offered a referral to an evidence-based stop smoking service.
Numerator – the number in the denominator who are offered a referral to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
Data source: Local data collection.
c) Proportion of pregnant women who smoke who are referred to an evidence-based stop smoking service.
Numerator – the number in the denominator who are referred to an evidence-based stop smoking service.
Denominator – the number of pregnant women accessing antenatal care who smoke.
Data source: Local data collection.
d) Proportion of pregnant women who smoke and decide not to attend an evidence-based stop smoking service who receive follow-up.
Numerator – the number in the denominator who decide not to attend an evidence-based stop smoking service who receive follow-up.
Denominator – the number of pregnant women who smoke and decide not to attend an evidence-based stop smoking service.
Data source: Local data collection.
Outcome
a) Quit rates for pregnant women.
Data source: Local data collection. NHS Digital’s statistics on NHS Stop Smoking Services in England includes quit rates for pregnant women who set a quit date.
b) Smoking rates in pregnancy.
Data source: NHS Digital Statistics on women's smoking status at time of delivery: England collects data on smoking status at the time of delivery.

What the quality statement means for different audiences

Service providers ensure that systems are in place to ensure that all pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.
Healthcare professionals refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Commissioners ensure they commission services which refer all pregnant women who smoke to an evidence-based stop smoking service at their booking appointment.
Pregnant women who smoke are referred to an evidence-based stop smoking service at their booking appointment.

Source guidance

Definitions of terms used in this quality statement

Advice on smoking cessation
Advice should be first provided at the booking appointment and when appropriate throughout the period of antenatal care. The midwife may provide the pregnant woman with information (in a variety of formats, for example a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to second-hand smoke for both mother and baby.
Women who smoke or have recently quit smoking should be referred to an evidence-based stop smoking service if:
  • they say they smoke, or
  • they have a carbon monoxide (CO) reading of 7 ppm or above, or
  • they say they have quit smoking in the past 2 weeks, or
  • they say they are a light or infrequent smoker but register a low CO reading (for example, 3 ppm).
Evidence-based stop smoking services
Local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. The professionals involved may include midwives who have been specially trained to help pregnant women who smoke to quit (NICE’s Pathway on stop smoking interventions and services).
At the time of referral, the pregnant woman should be given the number of an evidence-based stop smoking service. This may include the number of the NHS Smokefree helpline (0300 123 1044), details of the NHS quit smoking webpage and a number for a local helpline if one is available. [Expert opinion]

Risk assessment – gestational diabetes

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

Quality statement

Pregnant women are offered testing for gestational diabetes if they are identified as at risk of gestational diabetes at the booking appointment.

Quality 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 ensure that pregnant women have their risk factors for gestational diabetes identified and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women identified as at risk of gestational diabetes at the booking appointment are offered testing for gestational diabetes.
Data source: Local data collection.
Process
a) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who are offered testing for gestational diabetes.
Numerator – the number in the denominator offered testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Data source: Local data collection.
b) Proportion of pregnant women identified as at risk of gestational diabetes at the booking appointment who receive testing for gestational diabetes.
Numerator – the number of women in the denominator receiving testing for gestational diabetes.
Denominator – the number of pregnant women identified as at risk of gestational diabetes at the booking appointment.
Data source: Local data collection.
Outcome
Early identification of women with gestational diabetes.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Healthcare professionals offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Commissioners ensure they commission services that offer pregnant women identified as at risk of gestational diabetes at the booking appointment testing for gestational diabetes.
Pregnant women with a higher than normal chance of developing gestational diabetes (a type of diabetes that occurs during pregnancy) at the booking appointment are offered a test for gestational diabetes.

Source guidance

Definitions of terms used in this quality statement

At risk of gestational diabetes
Risk factors are:
  • body mass index above 30 kg/m2
  • previous macrosomic baby weighing 4.5 kg or more
  • previous gestational diabetes
  • family history of diabetes (first-degree relative with diabetes)
  • an ethnicity with a high prevalence of diabetes.
Women with any of these risk factors should be offered testing for gestational diabetes. [NICE’s guideline on diabetes in pregnancy, recommendation 1.2.2]
Testing for gestational diabetes
Use the 75-g 2-hour oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors.
Offer women who have had gestational diabetes in a previous pregnancy:
  • early self-monitoring of blood glucose or
  • a 75-g 2-hour OGTT as soon as possible after booking (whether in the first or second trimester), and a further 75-g 2-hour OGTT at 24–28 weeks if the results of the first OGTT are normal.
Offer women with any of the other risk factors for gestational diabetes a 75-g 2-hour OGTT at 24–28 weeks. [NICE’s guideline on diabetes in pregnancy, recommendations 1.2.5, 1.2.6 and 1.2.7]

Equality and diversity considerations

Any risk assessment for gestational diabetes should be corrected for ethnicity. Some ethnicities are risk factors for diabetes and people from these groups should be offered testing in accordance with the guidance.

Risk assessment – pre-eclampsia

This statement has been removed. For more details see update information in NICE's quality standard on antenatal care.

Risk assessment – venous thromboembolism

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

Quality statement

Pregnant women at risk of venous thromboembolism at the booking appointment are referred to an obstetrician for further management.

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 ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women at risk of VTE at the booking appointment are referred to an obstetrician for further management.
Data source: Local data collection.
Process
a) Proportion of pregnant women accessing antenatal care who have their risk of VTE assessed and recorded at the booking appointment.
Numerator – the number in the denominator who have their risk of VTE assessed and recorded at the booking appointment.
Denominator – the number of pregnant women accessing antenatal care.
Data source: Local data collection.
b) Proportion of pregnant women at risk of VTE at the booking appointment who are referred to an obstetrician for further management.
Numerator – the number in the denominator referred to an obstetrician for further management.
Denominator – the number of pregnant women at risk of VTE at the booking appointment.
Data source: Local data collection.
Outcome
Incidence of VTE in pregnant women.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Healthcare professionals refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Commissioners ensure they commission services which refer pregnant women at risk of VTE at the booking appointment to an obstetrician for further management.
Pregnant women who at the time of their booking appointment have a high or moderate chance of developing VTE (a blood clot) are referred to an obstetrician for support.

Source guidance

Antenatal care. NICE guideline NG201 (2021), recommendations 1.2.18 and 1.2.20

Definitions of terms used in this quality statement

At risk of VTE
High risk of VTE is defined as any previous VTE except a single event related to major surgery.
Intermediate risk of VTE is defined as any of the following:
  • hospital admission
  • single previous VTE related to major surgery
  • high-risk thrombophilia and no VTE
  • medical comorbidities, for example, cancer, heart failure, active lupus, inflammatory bowel disease, or inflammatory polyarthropathy, nephrotic syndrome, type 1 diabetes mellitus with nephropathy, sickle cell disease, current intravenous drug use
  • any surgical procedure, for example, appendicectomy
  • ovarian hyperstimulation syndrome (first trimester only).
Or 4 or more risk factors from the following list (or 3 risk factors from 28 weeks):
  • obesity (BMI above 30 kg/m2)
  • age above 35 years
  • parity 3 or more
  • smoking
  • gross varicose veins
  • current pre-eclampsia
  • immobility, for example, paraplegia, pelvic girdle pain with reduced mobility
  • family history of unprovoked or oestrogen-provoked VTE in first-degree relative
  • low-risk thrombophilia
  • multiple pregnancy
  • in vitro fertilisation or assisted reproductive technology
  • transient risk factors: dehydration/hyperemesis, current systemic infection, long-distance travel.

Risk assessment – high risk of venous thromboembolism

This statement has been merged with statement 8. For more details see update information in NICE's quality standard on antenatal care.

Screening – national fetal anomaly screening programmes

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

Quality statement

Pregnant women are offered fetal anomaly screening in accordance with current UK National Screening Committee programmes.

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 NHS-commissioned services to ensure that all pregnant women are offered fetal anomaly screening in accordance with current UK National Screening Committee programmes.
Data source: Local data collection.
Process
a) Proportion of pregnant women booking before 21 weeks who are offered the NHS fetal anomaly screening programme at the booking appointment.
Numerator – the number in the denominator who are offered the NHS fetal anomaly screening programme.
Denominator – the number of pregnant women accessing antenatal care before 21 weeks.
Data source: Local data collection.
b) Proportion of pregnant women booking before 14 weeks 2 days that agreed to fetal anomaly screening who are offered an ultrasound scan to screen for Down’s syndrome, Edward’s syndrome and Patau’s syndrome to take place between 11 weeks 2 days and 14 weeks 1 day.
Numerator – the number in the denominator who are offered an ultrasound screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome to take place between 11 weeks 2 days and 14 weeks 1 day.
Denominator – the number of pregnant women booking before 14 weeks 2 days that agreed to fetal anomaly screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme publishes data on first trimester combined screening for Down’s syndrome (T21), Edwards’ syndrome (T18) and Patau’s syndrome (T13).
c) Proportion of pregnant women booking before 21 weeks that agreed to fetal anomaly screening who are offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Numerator – the number in the denominator offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days.
Denominator – the number of pregnant women booking before 21 weeks that agreed to fetal anomaly screening.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme publishes data on fetal anomaly ultrasound screening.
Outcome
a) Pregnant women feel they have made an informed decision about whether to undergo fetal anomaly screening.
Data source: Local data collection, for example, local survey.
b) Screening uptake rates.
Data source: Public Health England’s NHS Fetal Anomaly Screening Programme includes data on screening uptake rates.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer fetal anomaly screening to pregnant women in accordance with current UK National Screening Committee programmes.
Healthcare professionals offer fetal anomaly screening to pregnant women in accordance with current UK National Screening Committee programmes.
Commissioners ensure they commission services that offer fetal anomaly screening to pregnant women as part of NHS care, in accordance with current UK National Screening Committee programmes.
Pregnant women who access antenatal care before 14 weeks 2 days are offered ultrasound screening for Down’s syndrome, Edward’s syndrome and Patau’s syndrome.
Pregnant women who access antenatal care before 21 weeks are offered an ultrasound scan to screen for various conditions in their unborn baby.

Source guidance

Definitions of terms used in this quality statement

Fetal anomaly screening in accordance with current UK National Screening Committee programmes
The UK National Screening Committee recommends all eligible pregnant women in England are offered fetal anomaly screening. The NHS fetal anomaly screening programme has responsibility for implementing this policy.
The combined test uses maternal age, gestational age calculated from the crown-rump length measurement, nuchal translucency measurement, and two biochemical markers of pregnancy – associated plasma protein A and free beta human chorionic gonadotrophin hormone. The optimal time to perform the combined test is between 11 weeks 2 days and 14 weeks 1 day but a maternal blood specimen may be taken from 10 weeks onwards.
For women presenting too late for first trimester testing, the quadruple test (maternal age and four biochemical markers) window runs from 14 weeks 2 days to 20 weeks 0 days.
The fetal anomaly ultrasound scan should be offered to take place between 18 weeks 0 days and 20 weeks 6 days.

Equality and diversity considerations

The offer and implications of screening should be understood by all women to enable them to make informed decisions. This will necessitate provision of information in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Fetal wellbeing – external cephalic version

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

Quality statement

Pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth are offered external cephalic version.

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 ensure that pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) are referred for confirmatory ultrasound assessment.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth are offered external cephalic version.
Data source: Local data collection.
Process
a) Proportion of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) who are referred for confirmatory ultrasound assessment.
Numerator – the number in the denominator referred for confirmatory ultrasound assessment.
Denominator – the number of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins).
Data source: Local data collection.
b) Proportion of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth who are offered external cephalic version.
Numerator – the number in the denominator offered external cephalic version.
Denominator – the number of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth.
Data source: Local data collection.
Outcome
a) External cephalic version rates.
Data source: Local data collection.
b) Mode of delivery including:
  • rates of vaginal birth, emergency and elective caesarean section after successful external cephalic version
  • rates of vaginal birth, emergency and elective caesarean section after unsuccessful external cephalic version
  • rates of vaginal birth and emergency caesarean section after diagnosis of breech presentation in labour.
Data source: The NHS Digital Maternity Services Data Set collects data on delivery method.

What the quality statement means for different audiences

Service providers ensure that systems are in place to offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Healthcare professionals offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Commissioners ensure they commission services that offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who prefer cephalic vaginal birth external cephalic version.
Pregnant women with a single baby in the breech position (bottom first with knees either flexed or extended) but with no other problems at 36 weeks or later in their pregnancy who prefer a vaginal birth are offered external cephalic version (a procedure to move the baby round to the head-down position), which includes first having an ultrasound scan to confirm the baby’s position.

Source guidance

Definitions of terms used in this quality statement

Pregnant women who prefer cephalic vaginal birth
For women with an uncomplicated singleton pregnancy with breech presentation confirmed after 36 weeks plus 0 days discuss the different options available and their benefits, risks and implications, including:
  • external cephalic version (to turn the baby from bottom to head down)
  • breech vaginal birth
  • elective caesarean birth.
[NICE’s guideline on antenatal care, recommendation 1.2.38]

Equality and diversity considerations

There may be some women whose breech presentation is not identified and who are not offered an external cephalic version.

Fetal wellbeing – membrane sweeping for prolonged pregnancy

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

Glossary

(examples of complex social factors in pregnancy include poverty, homelessness, substance misuse, recent arrival as a migrant, asylum seeker or refugee status, difficulty speaking or understanding English, age under 20 and domestic abuse; complex social factors may vary, in both type and prevalence, across different local populations)
(an incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality; it can also include forced marriage, female genital mutilation and 'honour violence')
(women who moved to the UK within the previous 12 months)
(morbidity that has a lasting impact on either the woman or the child)
(regular use of recreational drugs, misuse of over-the-counter medications, misuse of prescription medications, misuse of alcohol or misuse of volatile substances (such as solvents or inhalants) to an extent where physical dependence or harm is a risk (to the woman and/or her unborn baby))

Paths in this pathway

Pathway created: March 2012 Last updated: August 2021

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