NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Draft quality standard for antenatal care Quality standard advice to the Secretary of State for Health 1 Introduction

Most women who are pregnant in the UK will have an uncomplicated , giving birth to a healthy baby at full term. However, fetal and neonatal problems such as , fetal growth restriction and preterm birth remain common, and rates have changed little in recent years. Maternal complications such as depression, thromboembolism, haemorrhage and sepsis are also still encountered, with the most extreme cases contributing to a UK maternal mortality rate of around 11 per 100,000 maternities (2006–2008 data)1.

Adverse outcomes of pregnancy are sometimes unpredictable events, but can also be associated with risk factors such as obesity, diabetes, hypertension, substance misuse or domestic abuse. The aims of antenatal care are to prepare all women for motherhood whatever their risk status, to offer all women materno-fetal screening, to optimise maternal and fetal health, to make medical or social interventions available to all women where indicated and to improve all women’s experience of pregnancy and birth.

This draft quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for pregnant women in the following ways:

1 Centre for Maternal and Child Enquiries (CMACE) (2011) Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Gynaecology 118 (Suppl. 1): 1–203. Draft quality standard for antenatal care 1 of 44

Preventing people from dying prematurely. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm.

These overarching outcomes are from The NHS Outcomes Framework 2012/13.

The quality standard is also expected to contribute to the following overarching outcome(s) from the Public Health Outcomes Framework 2013– 16:

Health improvement. Healthcare public health and preventing premature mortality.

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2 Draft quality standard for antenatal care

Overview

The draft quality standard for antenatal care requires that services should be commissioned from and coordinated across all relevant agencies encompassing the whole antenatal care pathway. An integrated approach to provision of services is fundamental to the delivery of high quality care to pregnant women.

The theme of this quality standard is that pregnancy is a normal physiological process and that any interventions offered should have known benefits without doing harm and be acceptable to pregnant women. Women should have the opportunity to make informed decisions about their care and treatment based on the current available evidence, in partnership with healthcare professionals.

This quality standard covers the antenatal care of all pregnant women up to 41 weeks of pregnancy, in all settings that routinely provide NHS antenatal care, including primary, community and hospital-based care. It does not include inpatient care of pregnant women, the treatment, care and management (beyond identification and referral to appropriate services) of specific physical conditions, mental health problems or social problems in pregnant women, or antenatal complications.

NICE quality standards are for use by the NHS in England and do not have formal status in the social care sector. However, the NHS will not be able to provide a comprehensive service for all without working with social care communities. In this quality standard care has been taken to make sure that any quality statements that refer to the social care sector are relevant and evidence-based. Social care commissioners and providers may therefore wish to use them, both to improve the quality of their services and support their colleagues in the NHS.

Subject to legislation currently before Parliament, NICE will be given a brief to produce quality standards for social care. These standards will link with Draft quality standard for antenatal care 3 of 44

corresponding topics published for the NHS. They will be developed in full consultation with the social care sector and will be presented and disseminated in ways that meet the needs of the social care community. As we develop this library of social care standards, we will review and adapt any published NICE quality standards for the NHS that make reference to social care.

No. Draft quality statements

1 Pregnant women, including those with complex social needs, are actively supported to access antenatal care.

2 Pregnant women are cared for by a small group of healthcare professionals throughout their pregnancy.

3 Pregnant women have a complete and accurate record of the minimum set of antenatal test results in their hand-held maternity notes.

4 Pregnant women who call maternity services for advice about their pregnancy have the details of their call logged by the service and entered into their maternity record.

5 Pregnant women are offered evidence-based, balanced and consistent information which they understand, have the opportunity to discuss, and which enables them to make informed decisions about their care.

6 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 professional on healthy eating and how to be physically active.

7 Pregnant women with one or more risk factors for gestational diabetes at the time of booking are offered testing for gestational diabetes.

8 Pregnant women at high risk of pre-eclampsia at the time of booking are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks.

9 Pregnant women at intermediate or high risk of venous thromboembolism at the time of booking have specialist advice provided about their care appropriate to the level of risk.

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

11 Pregnant women are offered balanced and consistent information about breastfeeding which they understand and have the opportunity to discuss.

12 Pregnant women reporting a perceived reduction in fetal movements are offered an immediate assessment of fetal wellbeing.

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

14 Nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal appointments, and parous pregnant women are offered this at their 41-week appointment.

In addition, quality standards that should also be considered when commissioning and providing a high-quality antenatal service are listed in section 8.

General questions for consultation:

Question 1 Can you suggest any appropriate healthcare outcomes for each individual quality statement? Question 2 What important areas of care, if any, are not covered by the quality standard? Question 3 What, in your opinion, are the most important quality statements and why? Question 4 Are any of the proposed quality measures inappropriate and, if so, can you identify suitable alternatives? Please refer to Quality standards in development for additional general points for consideration (available from www.nice.org.uk).

Statement-specific questions for consultation:

Question 5 Should there be a separate quality statement addressing smoking cessation for pregnant women? Question 6 For draft quality statement 2: Is it possible to suggest a definition for a “small group of healthcare professionals”?

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Draft quality statement 1: Services – access to antenatal care

Draft quality Pregnant women, including those with complex social needs, are statement actively supported to access antenatal care.

Draft quality Structure: measure a) Evidence of local services that ensure antenatal care is readily and easily accessible, and sensitive to the needs of the local population. b) Evidence of local arrangements to encourage pregnant women with complex social needs to access and maintain contact with antenatal care services. c) Evidence of local audits of women, broken down by different populations, not booking for antenatal care by 12 weeks 6 days. Process: Proportion of pregnant women missing a scheduled antenatal appointment who are followed up within locally defined timescales. Numerator – the number of pregnant women in the denominator followed up within locally defined timescales. Denominator – the number of pregnant women missing a scheduled antenatal appointment. Outcome: a) Proportion of pregnant women accessing antenatal care who are seen for booking by 12 weeks 6 days. Numerator – the number of pregnant women in the denominator being seen for booking by 12 weeks 6 days. Denominator – the number of pregnant women accessing antenatal care. b) Median gestation at booking. c) Proportion of pregnant women accessing antenatal care who attend at least the recommended number of antenatal appointments. Numerator – the number of pregnant women in the denominator attending at least the recommended number of antenatal appointments. Denominator – the number of pregnant women accessing antenatal care. Services should consider breaking down outcomes a)–c) by subgroups of women with complex social needs. These groups should be selected based on the local population.

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Description of Service providers ensure that systems are in place to actively what the support pregnant women, including those with complex social quality needs, to access antenatal care. statement Health and social care professionals actively support pregnant means for each women, including those with complex social needs, to access audience antenatal care. This includes following up women who have missed or not attended recommended appointments. Commissioners ensure they commission services that are readily and easily accessible, sensitive to the needs of the local population and that actively support pregnant women, including those with complex social needs, to access antenatal care. Pregnant women, including those who need extra support, are encouraged to have regular check-ups from a 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 clinical NICE clinical guideline 62 recommendations 1.2.3.1 and 1.2.5.1. guideline NICE clinical guideline 110 recommendations 1.1.1, 1.1.2 (key references priorities for implementation) and 1.2.8.

Data sources Structure: a), b) and c) Local data collection. The NICE clinical guideline 110 baseline assessment tool. Process: Local data collection. Outcome: a) The operating framework for the NHS in England 2011/12 includes a national performance measure on the percentage of women who have seen a midwife or a maternity healthcare professional for health and social care assessment of needs, risks and choices by 12 weeks and 6 days. a) and b) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on booking appointment dates and estimated dates of delivery. The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many weeks pregnant were you when you had your ‘booking’ appointment (the appointment where you were given your pregnancy notes?)’. Possible responses are: before 8 weeks, 8 or 9 weeks, 10 or 11 weeks, 12 weeks and 13 or more weeks. The total number of respondents is also stated. c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the date of attendance at an antenatal appointment (excluding first contact and booking). The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Roughly how many antenatal check-ups did you have in total?’ Possible responses are: none, 1–6, 7–9, 10–14, 15 or more. The total number of respondents is also stated. a), b) and c) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on substance use and weekly alcohol intake. Draft quality standard for antenatal care 7 of 44

Definitions Prevalence of complex social needs will vary between different areas. Examples of complex social needs include, but are not limited to women who: have a history of substance misuse (including alcohol) 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. NICE clinical guideline 62 recommends that a schedule of antenatal appointments be determined by the function of the appointments. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of 10 appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of 7 appointments should be adequate. ‘Follow-up’ after a missed appointment may be undertaken by the maternity service or other community-based service the woman is in contact with, such as a children’s centre, addiction services or GP. Follow-up should be via a method of contact that is appropriate to the woman, which may include: text message letter telephone community or home visit.

Equality and Women with complex social needs may be less likely to access or diversity maintain contact with antenatal care services. It is therefore considerations appropriate they are given special consideration within the statement and measures.

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Draft quality statement 2: Services – continuity of care

Draft quality Pregnant women are cared for by a small group of healthcare statement professionals throughout their pregnancy.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women are cared for by a small group of healthcare professionals throughout their pregnancy. b) Evidence of local audit of the number of healthcare professionals pregnant women see for their routine antenatal appointments. Outcome: Pregnant women’s perception of continuity in their antenatal care.

Description of Service providers ensure that systems are in place to enable what the pregnant women to be cared for by a small group of healthcare quality professionals throughout their pregnancy. statement Healthcare professionals follow local systems and guidance to means for each provide continuity of care to pregnant women. audience Commissioners ensure they commission services that enable pregnant women to be cared for by a small group of healthcare professionals throughout their pregnancy. Pregnant women are cared for a small group of healthcare professionals throughout their pregnancy.

Source clinical NICE clinical guideline 62 recommendation 1.2.2.1. guideline references

Data sources Structure: a) and b) Local data collection. Outcome: Local data collection. The Care Quality Commission Maternity Services Survey 2010 asks the question ‘If you saw a midwife for your antenatal check-ups, did you see the same one every time?’ Possible responses are: yes, every time; yes, most of the time; or no.

Definitions This statement applies to routine, scheduled antenatal care. Continuity of care is defined as the provision of care by the same small team of healthcare professionals throughout pregnancy. Service models to deliver this should be developed locally. One example of how this might be achieved is a service consisting of four midwives and one consultant obstetrician. Some models may provide a ‘lead’ midwife for women. Further detail on continuity of midwifery care is available in the Department of Health publication ‘Maternity matters: choice, access and continuity of care in a safe service’. This states that Draft quality standard for antenatal care 9 of 44

every woman should be supported by a midwife she knows and trusts throughout her pregnancy and afterwards so as to provide continuity of care. To deliver this: there should be sufficient midwives and support staff working flexibly across community and hospital settings women and their partners should know about all the members of the maternity team supporting them throughout their pregnancy and how to contact them at any time.

Specific Is it possible to suggest a definition for a “small group of question for healthcare professionals”? consultation

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Draft quality statement 3: Services – record keeping

Pregnant women have a complete and accurate record of the Draft quality minimum set of antenatal test results in their hand-held maternity statement notes.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women have a complete and accurate record of the minimum set of antenatal test results in their hand-held maternity notes. b) Evidence of local audit to monitor transcribing accuracy of antenatal test results being entered into women’s hand-held maternity notes. Process: Proportion of pregnant women accessing antenatal care who have a complete and accurate record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy. Numerator – the number of women in the denominator with a complete and accurate record of the minimum set of antenatal test results in their hand-held maternity notes, appropriate to their stage of pregnancy. Denominator – the number of pregnant women accessing antenatal care.

Description of Service providers ensure that systems are in place to maintain a what the complete and accurate record of the minimum set of antenatal quality test results in women’s hand-held maternity notes. statement Healthcare professionals write a complete and accurate record means for each of the minimum set of antenatal test results in women’s hand-held audience maternity notes. Commissioners ensure they commission services that maintain a complete and accurate record of the minimum set of antenatal test results in women’s hand-held maternity notes. Pregnant women are provided with a record of the results of the antenatal tests they have been given in their hand-held maternity notes.

Source clinical NICE clinical guideline 62 recommendation 1.2.4.2. guideline NICE clinical guideline 110 recommendation 1.1.10. references

Data sources Structure: a) and b) Local data collection. Process: Local data collection. The NICE clinical guideline 110 baseline assessment tool and the NICE public health guidance 27 audit support, criterion 3.

Definitions The minimum set of tests for routine scheduled antenatal care has been developed from the appointment schedule in Appendix D of Draft quality standard for antenatal care 11 of 44

NICE clinical guideline 62. 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. Investigation Timing Blood pressure All routine appointments Urine test for proteinuria All routine appointments Blood group and rhesus D status At booking Haemoglobinopathies screen At booking Hepatitis B virus screen At booking HIV screen At booking Rubella susceptibility At booking Syphilis screen At booking MSU for asymptomatic bacteriuria At booking Height, weight and body mass index At booking Haemoglobin At booking and 28 weeks Red-cell alloantibodies At booking and 28 weeks Ultrasound scan to determine gestational Between 10 weeks 0 age days and 13 weeks 6 days Down’s syndrome screen Combined test: between 10 weeks 0 days and 14 weeks 1 day. Serum quadruple test: 14 weeks 2 days to 20 weeks 0 days. Ultrasound screen for structural anomalies Between 18 weeks 0 days and 20 weeks 6 days Measure of symphysis–fundal height All routine appointments from 25 weeks Fetal presentation 36 weeks

Equality and Hand-held maternity notes and the information within them should diversity be accessible to all women, including women who do not speak or considerations read English and those with additional needs such as physical, sensory or learning disabilities. Some maternity services may not use hand-held notes. In this case, the minimum set of antenatal tests results should be recorded in the alternative system (such as an electronic database), which should be available to the woman and anyone caring for her.

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Draft quality statement 4: Services – telephone advice

Pregnant women who call maternity services for advice about Draft quality their pregnancy have the details of their call logged by the service statement and entered into their maternity record.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women who call their booked maternity services for advice about their pregnancy have the details of their call logged by the service and entered into their maternity record. b) Evidence of local arrangements to ensure that pregnant women who call maternity services for advice about their pregnancy outside of where they booked have the details of their call logged by the service and passed to their booked maternity service to be entered into their maternity record. Process: Proportion of calls to maternity services from pregnant women for advice about their pregnancy for which details of the call are entered into the woman’s maternity record. Numerator – the number of calls in the denominator for which details of the call are entered into the woman’s maternity record. Denominator – the number of calls to maternity services from pregnant women for advice about their pregnancy.

Description of Service providers ensure that systems are in place to log details what the of calls from pregnant women who call for advice about their quality pregnancy, and ensure these are entered into the woman’s statement maternity record. means for each Healthcare professionals log details of calls from pregnant audience women who call for advice about their pregnancy, and ensure these are entered into the woman’s maternity record. Commissioners ensure they commission services that log details of calls from pregnant women who call for advice about their pregnancy, and ensure these are entered into the woman’s maternity record. Pregnant women who call maternity services for advice about their pregnancy have the details of their call logged and added to their maternity record.

Source clinical NICE clinical guideline 110 recommendation 1.1.13. guideline references

Data sources Structure: a) and b) Local data collection. Process: Local data collection.

Definitions Logged call details should include, as a minimum: date and time of call

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name of caller name and job title of person taking the call name of booked maternity service reason for calling advice provided any other action taken.

Equality and Pregnant women should have access to an interpreter or diversity advocate if needed. considerations Some women may not have reliable access to a telephone and may be more likely to present at services for advice about their pregnancy.

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Draft quality statement 5: Information – informed decision-making

Pregnant women are offered evidence-based, balanced and Draft quality consistent information which they understand, have the statement opportunity to discuss, and which enables them to make informed decisions about their care.

Draft quality Structure: Evidence of local arrangements to ensure pregnant measure women are offered evidence-based, balanced and consistent information which they understand, have the opportunity to discuss, and which enables them to make informed decisions about their care. Process: a) Proportion of pregnant women presenting to antenatal care services who receive information about options for where they will be seen and who will provide their antenatal care. Numerator – the number of pregnant women in the denominator receiving information about options for where they will be seen and who will provide their antenatal care. Denominator – the number of pregnant women presenting to antenatal care services. b) Proportion of antenatal screening tests offered to pregnant women for which information about the condition(s) being screened for is provided to the woman before she accepts or declines the test. Numerator – the number of antenatal screening tests in the denominator for which information about the condition(s) being screened for is provided to the woman before she accepts or declines the test. Denominator – the number of antenatal screening tests offered to pregnant women. c) Proportion of antenatal screening tests offered to pregnant women for which information about the purpose and process of carrying out the test is provided to the woman before she accepts or declines the test. Numerator – the number of antenatal screening tests in the denominator for which information about the purpose and process of carrying out the test is provided to the woman before she accepts or declines the test. Denominator – the number of antenatal screening tests offered to pregnant women. d) Proportion of antenatal interventions (including diagnostic tests) offered to pregnant women for which evidence-based information about risks, benefits and alternatives is provided to the woman before she accepts or declines the intervention.

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Numerator – the number of interventions (including diagnostic tests) in the denominator for which evidence-based information about risks, benefits and alternatives is provided to the woman before she accepts or declines the intervention. Denominator – the number of antenatal interventions offered to pregnant women. Outcome: Pregnant women’s sense of being sufficiently informed and supported to make decisions about their care.

Description of Service providers ensure that systems are in place to offer what the pregnant women evidence-based, balanced and consistent quality information which they understand, have the opportunity to statement discuss, and which enables them to make informed decisions means for each about their care. audience Healthcare professionals offer pregnant women evidence- based, balanced and consistent information which they understand, have the opportunity to discuss, and which enables them to make informed decisions about their care. Commissioners ensure they commission services that offer pregnant women evidence-based, balanced and consistent information which they understand, have the opportunity to discuss, and which enables them to make informed decisions about their care. Pregnant women are offered evidence-based, balanced and consistent information which they understand, have the chance to discuss, and which lets them make informed decisions about their care.

Source clinical NICE clinical guideline 62 recommendations 1.1.1.1, 1.1.1.2, guideline 1.1.1.4 (key priority for implementation), 1.1.1.5, 1.1.1.8 and references 1.1.1.10. NICE clinical guideline 70 recommendation 1.1.1.1 (key priority for implementation).

Data sources Structure: Local data collection. Process: a), b), c) and d) Local data collection. The Care Quality Commission Maternity Services Survey 2010 asks the questions ‘Were you given a copy of The Pregnancy Book’ and ‘Were you given information about the NHS Choices website?’ The total number of respondents is also stated for each. The NICE clinical guideline 62 audit support, criterion 1. a) The Care Quality Commission Maternity Services Survey 2010 asks the question ‘During your pregnancy were you given a choice about where your antenatal check-ups would take place?’ The total number of respondents is also stated. b) The Care Quality Commission Maternity Services Survey 2010 asks the questions “Was the reason for this scan (the ‘dating scan’) clearly explained to you?”, ‘Were the reasons for having a screening test for Down’s syndrome clearly explained to you?’ and ‘Was the reason for this scan (20 weeks) clearly explained to Draft quality standard for antenatal care 16 of 44

you?’ Possible responses are: yes, definitely; yes, to some extent and no. The total number of respondents is also stated for each. Outcome: The Care Quality Commission Maternity Services Survey 2010 asks the questions ‘Thinking about your antenatal care, were you spoken to in a way you could understand?’ and ‘Thinking about your antenatal care, were you involved enough in decisions about your care?’ Possible responses are: yes, always; yes, sometimes and no. The total number of respondents is also stated for each.

Equality and Information about antenatal care should be culturally appropriate diversity and should also be accessible to people with additional needs considerations such as physical, sensory or learning disabilities, and to people who do not speak or read English. Pregnant women should have access to an interpreter or advocate if needed. Some groups, such as those who do not read English for example, may be under-represented in overall responses to experience surveys. Surveys should be designed to be accessible to all women in order to minimise this.

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Draft quality statement 6: Risk assessment – body mass index

Pregnant women with a body mass index of 30 kg/m2 or more at Draft quality the booking appointment are offered personalised advice from an statement appropriately trained professional on healthy eating and how to be physically active.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women have their body mass index calculated and recorded at the booking appointment. b) Evidence of local arrangements to ensure that pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment are offered personalised advice from an appropriately trained professional on healthy eating and how to be physically active. Process: a) Proportion of pregnant women accessing antenatal care whose body mass index is calculated and recorded at the booking appointment. Numerator – the number of pregnant women in the denominator whose body mass index is calculated and recorded at the booking appointment. Denominator – the number of pregnant women accessing antenatal care. b) Proportion of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment who are offered personalised advice from an appropriately trained professional on healthy eating and how to be physically active. Numerator – the number of pregnant women in the denominator offered personalised advice from an appropriately trained professional on healthy eating and how to be physically active. Denominator – the number of pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment.

Description of Service providers ensure that systems are in place to offer what the pregnant women with a body mass index of 30 kg/m2 or more at quality the booking appointment personalised advice from an statement appropriately trained professional on healthy eating and how to be means for each physically active. audience 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 how to be physically active, or if they are not appropriately trained to do this, refer them to an appropriately trained professional. Commissioners ensure they commission services that offer Draft quality standard for antenatal care 18 of 44

pregnant women with a body mass index of 30 kg/m2 or more at the booking appointment personalised advice from an appropriately trained professional on healthy eating and how to be physically active. Pregnant women who are overweight (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 professional on healthy eating and physical activity.

Source clinical NICE clinical guideline 62 recommendation 1.2.2.2 and 1.5.1.1. guideline NICE public health guidance 11 recommendation 6. references NICE public health guidance 27 recommendation 2.

Data sources Structure: a) and b) Local data collection. The NICE public health guidance 27 self assessment tool. Process: a) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on maternal height, weight and the booking appointment date. The NICE public health guidance 27 audit support, criteria 1 and 3. b) Local data collection.

Definitions An appropriately trained professional is one with specific expertise and competencies in nutrition or physical activity. This may include, but is not limited to, a registered dietitian. For women with a body mass index of between 30 and 40 kg/m2, midwifery or obstetric staff may be able to provide advice. Women with a body mass index greater than 40 kg/m2 are likely to benefit from more specialist advice.

Equality and The body mass index threshold may need to be adapted for diversity different groups of pregnant women. For example, a body mass considerations index measure is considered unsuitable for use with teenagers, and may also need adjusting for people of certain ethnic family origin (NICE public health guidance is in development on body mass index and waist circumference in black and minority ethnic groups). There is geographical variation in the threshold for offering additional advice and support to women with a raised body mass index. This means that some women are currently excluded from receiving the advice and support they need because of where they live. Additionally, the accuracy of reported body mass indexes may vary depending on the quality of equipment used, such as calibrated scales. This could affect access if a woman’s body mass index is close to the threshold for additional advice and support.

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Draft quality statement 7: Risk assessment – gestational diabetes

Pregnant women with one or more risk factors for gestational Draft quality diabetes at the time of booking are offered testing for gestational statement diabetes.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women have their risk factors for gestational diabetes identified and recorded at the booking appointment. b) Evidence of local arrangements to ensure that pregnant women with at least one risk factor for gestational diabetes at the time of booking are offered testing for gestational diabetes. Process: a) Proportion of pregnant women accessing antenatal care who have their risk factors for gestational diabetes identified and recorded at the booking appointment. Numerator – the number of pregnant women in the denominator whose risk factors for gestational diabetes are identified and recorded at the booking appointment. Denominator – the number of pregnant women accessing antenatal care. b) Proportion of pregnant women with at least one risk factor for gestational diabetes identified at the booking appointment who are offered testing for gestational diabetes. Numerator – the number of pregnant women in the denominator offered testing for gestational diabetes. Denominator – the number of pregnant women with at least one risk factor for gestational diabetes identified at the booking appointment. c) Proportion of pregnant women with at least one risk factor for gestational diabetes identified at the booking appointment who receive testing for gestational diabetes. Numerator – the number of pregnant women in the denominator receiving testing for gestational diabetes. Denominator – the number of pregnant women with at least one risk factor for gestational diabetes identified at the booking appointment.

Description of Service providers ensure that systems are in place to offer what the pregnant women with one or more risk factors for gestational quality diabetes at the time of booking testing for gestational diabetes. statement Healthcare professionals offer pregnant women with one or means for each more risk factors for gestational diabetes at the time of booking

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audience testing for gestational diabetes. Commissioners ensure they commission services that offer pregnant women with one or more risk factors for gestational diabetes at the time of booking 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 time of their booking appointment are offered a test for gestational diabetes.

Source clinical NICE clinical guideline 62 recommendations 1.2.2.2 and 1.9.1.1 guideline (key priority for implementation). references NICE clinical guideline 63 recommendation 1.2.2.4.

Data sources Structure: a) and b) Local data collection. Process: a) The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors: maternal height and weight, maternal family history of diabetes at booking and ethnic group. The booking appointment date will also be available. The NICE clinical guideline 62 audit support, criterion 8. b) Local data collection. The NICE clinical guideline 62 audit support, criterion 9.

Definitions Risk factors are taken from NICE clinical guideline 62: body mass index above 30 kg/m2 previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes family history of diabetes (first-degree relative with diabetes) family origin with a high prevalence of diabetes: - South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh) - black Caribbean - Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt). Testing for gestational diabetes should be carried out in accordance with NICE clinical guideline 63: ‘The 2-hour 75 g oral glucose tolerance test (OGTT) should be used to test for gestational diabetes and diagnosis made using the criteria defined by the World Health Organizationa. Women who have had gestational diabetes in a previous pregnancy should be offered early self-monitoring of blood glucose or an OGTT at 16–18 weeks, and a further OGTT at 28 weeks if the results are normal. Women with any of the other risk factors for gestational diabetes should be offered an OGTT at 24–28 weeks.’

Equality and Any risk assessment for gestational diabetes should be corrected diversity for family origin. Some family origins are risk factors for diabetes considerations (see definitions section above) and people from these groups should be offered testing in accordance with the guidance. There may be a number of approaches that services use to Draft quality standard for antenatal care 21 of 44

identify family origin, such as different questionnaires, and there is likely to be geographical variation. Currently, there is geographical variation in which risk factors are used to determine the need for testing for gestational diabetes. This means that some women who should be offered testing may not be because of where they live. a Fasting plasma venous glucose concentration greater than or equal to 7.0 mmol/litre or 2- hour plasma venous glucose concentration greater than or equal to 7.8 mmol/litre. World Health Organization Department of Noncommunicable Disease Surveillance (1999) Definition, diagnosis and classification of diabetes mellitus and its complications. Report of a WHO consultation. Part 1: diagnosis and classification of diabetes mellitus. Geneva: World Health Organization.

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Draft quality statement 8: Risk assessment – pre- eclampsia

Pregnant women at high risk of pre-eclampsia at the time of Draft quality booking are offered a prescription of 75 mg of aspirin (unless statement contraindicated) to take daily from 12 weeks until at least 36 weeks.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women have their risk factors for pre-eclampsia identified and recorded at the booking appointment. b) Evidence of local arrangements to ensure that pregnant women at high risk of pre-eclampsia at the time of booking are offered a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks. Process: a) Proportion of pregnant women accessing antenatal care who have their risk factors for pre-eclampsia identified and recorded at the booking appointment. Numerator – the number of pregnant women in the denominator whose risk factors for pre-eclampsia are identified and recorded at the booking appointment. Denominator – the number of pregnant women accessing antenatal care. b) Proportion of pregnant women at high risk of pre-eclampsia at the time of booking who are prescribed 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks. Numerator – the number of pregnant women in the denominator prescribed 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks. Denominator – the number of pregnant women at high risk of pre- eclampsia at the time of booking.

Description of Service providers ensure that systems are in place to offer what the pregnant women at high risk of pre-eclampsia at the time of quality booking a prescription of 75 mg of aspirin (unless contraindicated) statement to take daily from 12 weeks until at least 36 weeks. means for each Healthcare professionals offer pregnant women at high risk of audience pre-eclampsia at the time of booking a prescription of 75 mg of aspirin (unless contraindicated) to take daily from 12 weeks until at least 36 weeks. Commissioners ensure they commission services that offer pregnant women at high risk of pre-eclampsia at the time of booking a prescription of 75 mg of aspirin (unless contraindicated)

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to take daily from 12 weeks until at least 36 weeks. Pregnant women with a higher than normal chance of developing pre-eclampsia, (a serious condition that can occur during pregnancy), at the time of their booking appointment are offered a prescription for aspirin (unless it is not considered safe for them to take aspirin) to take every day from 12 weeks until at least 36 weeks.

Source clinical NICE clinical guideline 107 recommendation 1.1.2.1 (key priority guideline for implementation). references

Data sources Structure: a) and b) Local data collection. b) The NICE clinical guideline 107 baseline assessment tool. Process: a) Local data collection. The Maternity Services Secondary Uses Dataset, once implemented, will collect data on the following risk factors at booking: hypertension, renal disease, diabetes, autoimmune disease. b) Local data collection.

Definitions Pregnant women at high risk of pre-eclampsia are defined in NICE clinical guideline 107 as those with any of the following: hypertensive disease during a previous pregnancy chronic kidney disease autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension. Contraindications to taking aspirin include, but are not limited to: aspirin allergy medical condition precluding the use of aspirin present use of another drug with the potential to interact adversely with aspirin. Note: aspirin did not have UK marketing authorisation for the indication in question at the time of publication of the guideline (August 2010). Informed consent should be obtained and documented.

Equality and This statement does not address aspirin prophylaxis for women at diversity a moderate, rather than high, risk of pre-eclampsia. considerations

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Draft quality statement 9: Risk assessment – venous thromboembolism

Pregnant women at intermediate or high risk of venous Draft quality thromboembolism at the time of booking have specialist advice statement provided about their care appropriate to the level of risk.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women have their risk of venous thromboembolism (VTE) assessed and recorded at the booking appointment. b) Evidence of local arrangements to ensure that pregnant women at high risk of VTE at the time of booking are referred to a specialist service. c) Evidence of local arrangements to ensure that pregnant women at intermediate risk of VTE at the time of booking have specialist advice provided about their care. 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 of pregnant women in the denominator having their risk of VTE assessed and recorded at the booking appointment. Denominator – the number of pregnant women accessing antenatal care. b) Proportion of pregnant women at high risk of VTE at the time of booking who are referred to a specialist service. Numerator – the number of pregnant women in the denominator referred to a specialist service. Denominator – the number of pregnant women at high risk of VTE at the time of booking. c) Proportion of pregnant women at intermediate risk of VTE at the time of booking who have specialist advice provided about their care. Numerator – the number of pregnant women in the denominator with specialist advice provided about their care. Denominator – the number of pregnant women at intermediate risk of VTE at the time of booking. Outcome: Incidence of VTE in pregnant women.

Description of Service providers ensure that systems are in place to provide what the specialist advice for pregnant women who are at intermediate or quality high risk of VTE at the time of booking, that is appropriate to the statement Draft quality standard for antenatal care 25 of 44

means for each level of risk. audience Healthcare professionals refer pregnant women at high risk of VTE at the time of booking to a specialist service and seek or provide specialist advice for pregnant women at intermediate risk of VTE at the time of booking. Commissioners ensure they commission services that provide specialist advice for pregnant women at intermediate or high risk of VTE at the time of booking, that is appropriate to the level of risk. Pregnant women who at the time of their booking appointment have a high chance of developing deep vein thrombosis, (a blood clot in their veins that could get into their lungs), are referred to a specialist service. Pregnant women who at the time of their booking appointment have a moderate risk of developing deep vein thrombosis, (a blood clot in their veins that could get into their lungs), have specialist advice provided about their care.

Source clinical NICE clinical guideline 62 recommendation 1.2.2.2. guideline RCOG green-top guideline 37a recommendations 1, 2, and 6 references (executive summary of recommendations).

Data sources Structure: a), b) and c) Local data collection. Process: a), b) and c) Local data collection. Outcome: The Maternity Services Secondary Uses Dataset, once implemented, will collect data on VTE as a maternal critical incident.

Definitions Definitions are taken from RCOG green-top guideline 37a. High risk of VTE is defined as any of the following: single previous VTE and thrombophilia (inherited or acquired) or family history single previous unprovoked/oestrogen-related VTE previous recurrent VTE (more than one). Intermediate risk of VTE is defined as any of the following: single previous VTE with no family history or thrombophilia (inherited or acquired) thrombophilia (inherited or acquired) and no VTE medical comorbidities such as: - heart or lung disease - systemic lupus erythematosus - cancer - inflammatory conditions - nephrotic syndrome - sickle cell disease - intravenous drug use Surgical procedures such as - appendicectomy. or three or more risk factors from the following list: Draft quality standard for antenatal care 26 of 44

age above 35 years body mass index more than 30kg/m2 parity 3 or more smoker gross varicose veins (symptomatic, above the knee or associated with phlebitis/oedema/skin changes) current systemic infection immobility (for at least 3 days) such as - paraplegia - symphysis pubis dysfunction with reduced mobility long-distance travel (greater than 4 hours) pre-eclampsia dehydration/hyperemesis/ovarian hyperstimulation syndrome multiple pregnancy or assisted reproductive therapy. Women assessed as being at high risk should be referred to a specialist service. Women assessed as being at intermediate risk should have specialist advice provided about their care. A specialist service or specialist advice should be provided by an obstetrician or trust-nominated thrombosis in pregnancy expert or team.

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Draft quality statement 10: Screening – national fetal screening programmes

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

Draft quality Structure: Evidence of local NHS-commissioned services to measure ensure that all pregnant women are offered fetal screening in accordance with current UK National Screening Committee programmes. Process: a) Proportion of pregnant women booking before 14 weeks 2 days who are offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day. Numerator – the number of pregnant women in the denominator offered the combined screening test to take place between 10 weeks 0 days and 14 weeks 1 day. Denominator – the number of pregnant women booking before 14 weeks 2 days. b) Proportion of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days who are offered the quadruple screening test for Down’s syndrome to take place between 14 weeks 2 days and 20 weeks 0 days. Numerator – the number of pregnant women in the denominator offered the quadruple screening test for Down’s syndrome to take place between 14 weeks 2 days and 20 weeks 0 days. Denominator – the number of pregnant women booking between 14 weeks 2 days and 20 weeks 0 days. c) Proportion of pregnant women booking before 21 weeks who are offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days. Numerator – the number of pregnant women in the denominator offered ultrasound screening for fetal anomalies to take place between 18 weeks 0 days and 20 weeks 6 days. Denominator – the number of pregnant women booking before 21 weeks.

Description of Service providers ensure that systems are in place to offer fetal what the screening to pregnant women in accordance with current UK quality National Screening Committee programmes. statement Healthcare professionals offer fetal screening to pregnant means for each women in accordance with current UK National Screening audience Committee programmes. Commissioners ensure they commission services to offer fetal screening to pregnant women as part of NHS care, in accordance Draft quality standard for antenatal care 28 of 44

with current UK National Screening Committee programmes. Pregnant women who access antenatal care before 21 weeks are offered an ultrasound scan to screen for various conditions in their unborn baby. In addition, pregnant women who access antenatal care before 20 weeks are offered screening for Down’s syndrome in their unborn baby. The type of tests carried out (for example ultrasound scan and a blood test or just a blood test) will depend on how far along the pregnancy is.

Source NICE clinical guideline 62 recommendations 1.7.1.1 and 1.7.2.1. references UK National Screening Committee Screening for Down’s syndrome: UK NSC Policy recommendations 2011-2014 Model of best practice policy recommendations and supporting information. UK National Screening Committee Fetal anomaly screening programme 18+0 to 20+6 weeks fetal national standards and guidance for England standard 1.

Data sources Structure: a) and b) Local data collection. Process: a), b) and c) Local data collection. QOF indicator MAT1 – Antenatal care and screening are offered according to current local guidelines (Additional services domain). a) The Care Quality Commission Maternity Services Survey 2010 asks the following questions: ‘Did you have a ‘dating scan’? This takes place between 8-14 weeks of pregnancy’ and ‘Did you have any screening tests (a blood test or nuchal scan) to check whether your baby might have Down’s syndrome?’ Possible responses to the latter are: yes, a blood test only, yes, a nuchal scan only, yes, a nuchal scan and blood test and no, I wasn’t offered any screening tests for Down’s syndrome. The total number of respondents is also stated. c) The Care Quality Commission Maternity Services Survey 2010 asks the question ‘Did you have a scan at around 20 weeks of pregnancy?’ The total number of respondents is also stated.

Definitions Current UK National Screening Committee programmes for fetal screening are defined here as the National Screening Committee policy on fetal anomaly screening in pregnancy, which includes both fetal anomaly ultrasound, and Down's syndrome screening. UK National Screening Committee recommendations state that the gestational age window for the combined test runs from 10 weeks 0 days to 14 weeks 1 day. The combined test is made up of linear fetal measurement of the crown–rump length to estimate fetal gestational age (dating scan), measurement of the nuchal translucency space at the back of the fetal neck, and maternal blood to measure the serum markers of pregnancy associated plasma protein A and human chorionic gonadotrophin hormone. In striking a balance between the benefits of all the markers, trusts should consider screening women around 11 weeks 2 days. For women presenting beyond 14 weeks 1 day, the quadruple test Draft quality standard for antenatal care 29 of 44

(maternal serum) window runs from 14 weeks 2 days to 20 weeks 0 days. The fetal anomaly ultrasound scan should be offered at first contact visit or booking visit, to take place between 18 weeks 0 days and 20 weeks 6 days.

Equality and This quality statement states that all fetal screening diversity recommended by the UK National Screening Committee should considerations be available on the NHS for all pregnant women. Currently, some services may charge private fees for the combined screening test for Down’s syndrome, creating inequitable access. Screening should be offered in a sensitive way to all pregnant women. Staff should not discriminate based on age or assumptions about particular cultural or religious beliefs. The offer and implications of screening should be understood by all women to enable them to make informed decisions. This will require the provision of accessible information.

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Draft quality statement 11: Information – preparing for infant feeding

Pregnant women are offered balanced and consistent information Draft quality about breastfeeding which they understand and have the statement opportunity to discuss.

Draft quality Structure: Evidence of local arrangements to ensure that measure pregnant women are offered balanced and consistent information about breastfeeding which they understand and have the opportunity to discuss. Process: Proportion of pregnant women accessing antenatal care who are provided with information about breastfeeding. Numerator – the number of pregnant women in the denominator provided with information about breastfeeding. Denominator - the number of pregnant women accessing antenatal care. Outcome: a) Pregnant women’s sense of being sufficiently informed and supported to prepare for infant feeding. b) Breastfeeding initiation rates.

Description of Service providers ensure that systems are in place to offer what the pregnant women balanced and consistent information about quality breastfeeding which they understand and have the opportunity to statement discuss. means for each Healthcare professionals offer pregnant women balanced and audience consistent information about breastfeeding which they understand and have the opportunity to discuss. Commissioners ensure they commission services that offer pregnant women balanced and consistent information about breastfeeding which they understand and have the opportunity to discuss. Pregnant women are offered balanced and consistent information about breastfeeding which they understand and have the chance to discuss.

Source clinical NICE clinical guideline 62 recommendation 1.1.1.1 and 1.1.1.6. guideline NICE clinical guideline 37 recommendation 1.3.3 (key priority for references implementation).

Data sources Structure: Local data collection. Process: Local data collection. The Care Quality Commission Maternity Services Survey 2010 asks the following question: ‘During your pregnancy did your midwife discuss infant feeding

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with you?’ Possible responses are yes, definitely, yes, to some extent and no. The total number of respondents is also stated. Outcome: The Public Health Outcomes Framework for England 2013-16 includes an indicator on breastfeeding (2.2). The Maternity Services Secondary Uses Dataset, once implemented, will collect data on whether babies’ first food was breast milk and whether babies were being fed with breast milk at discharge from hospital. The Care Quality Commission Maternity Services Survey 2010 asks the following questions: ‘In the first few days after the birth how was your baby fed?’ and ‘’Did you ever put your baby to the breast (even if it was only once)?’ Possible responses to the former are breast milk or both breast and formula milk.

Definitions Information about breastfeeding should include technique and good management practices that will help a woman to successfully initiate breastfeeding.

Equality and Information about breastfeeding should be culturally appropriate diversity and should also be accessible to people with additional needs considerations such as physical, sensory or learning disabilities, and to people who do not speak or read English. Pregnant women should have access to an interpreter or advocate if needed. Some women may be advised not to breastfeed their baby on medical grounds, for example women with HIV. In these cases, individualised support and information on preparing for infant feeding should be provided.

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Draft quality statement 12: Fetal wellbeing – reduced fetal movements

Pregnant women reporting a perceived reduction in fetal Draft quality movements are offered an immediate assessment of fetal statement wellbeing.

Draft quality Structure: Evidence of local arrangements to ensure that measure pregnant women reporting a perceived reduction in fetal movements are offered an immediate assessment of fetal wellbeing. Process: Proportion of pregnant women reporting a perceived reduction in fetal movements who receive an immediate assessment of fetal wellbeing. Numerator – the number of pregnant women in the denominator receiving an immediate assessment of fetal wellbeing. Denominator – the number of pregnant women reporting a perceived reduction in fetal movements. Outcome: Pregnant women reporting a perceived reduction in fetal movements feel reassured that their concerns are being addressed.

Description of Service providers ensure that systems are in place to offer what the pregnant women reporting a perceived reduction in fetal quality movements an immediate assessment of fetal wellbeing. statement Healthcare professionals offer pregnant women reporting a means for each perceived reduction in fetal movements an immediate assessment audience of fetal wellbeing. Commissioners ensure they commission services that offer pregnant women reporting a perceived reduction in fetal movements an immediate assessment of fetal wellbeing. Pregnant women who feel that their baby is moving less often are offered an immediate check to see if there are any problems with their baby.

Source clinical RCOG green-top guideline 57 recommendations 7.3 (good guideline practice point), 8.2, 8.4.2 (good practice point), 11.1 (good references practice point) and 12.1 (good practice point).

Data sources Structure: Local data collection. Process: Local data collection. Outcome: Local data collection.

Definitions The definition of ‘immediate’ will vary as follows, according to individual circumstances and in accordance with RCOG green-top guideline 57: Women who are concerned about reduced fetal movements Draft quality standard for antenatal care 33 of 44

should not have to wait until the next day for assessment of fetal wellbeing. If a woman presents with reduced fetal movements in the community setting with no facility to auscultate the fetal heart, she should be referred immediately to her maternity unit for auscultation. If an ultrasound scan assessment is deemed necessary, it should be performed when the service is next available – preferably within 24 hours. Details on appropriate assessment for women presenting with reduced fetal movements after 28 weeks are available in Appendix 1 of RCOG green-top guideline 57. Appropriate assessment will require referral to a maternity unit. If a woman presents with reduced fetal movements prior to 28 weeks, assessment should consist of confirmation of a fetal heartbeat by auscultation with a Doppler handheld device.

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Draft quality statement 13: Fetal wellbeing – external cephalic version

Pregnant women with an uncomplicated singleton breech Draft quality presentation at 36 weeks or later (until labour begins) are offered statement external cephalic version.

Draft quality Structure: measure a) Evidence of local arrangements to ensure that pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) are offered referral for confirmatory ultrasound assessment. b) Evidence of local arrangements to ensure that pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) are offered external cephalic version. Process: a) Proportion of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins) who are referred for confirmatory ultrasound assessment. Numerator – the number of pregnant women in the denominator referred for confirmatory ultrasound assessment. Denominator – the number of pregnant women with a suspected breech presentation at 36 weeks or later (until labour begins). b) Proportion of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) who are offered external cephalic version. Numerator – the number of pregnant women in the denominator offered external cephalic version. Denominator – the number of pregnant women with a confirmed uncomplicated singleton breech presentation at 36 weeks or later (until labour begins). Outcome: External cephalic version rates.

Description of Service providers ensure that systems are in place to offer what the pregnant women with an uncomplicated singleton breech quality presentation at 36 weeks or later (until labour begins) external statement cephalic version. means for each Healthcare professionals offer pregnant women with an audience uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version. Commissioners ensure they commission services that offer pregnant women with an uncomplicated singleton breech presentation at 36 weeks or later (until labour begins) external cephalic version.

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Pregnant women with a single baby in the breech position (bottom first) but with no other problems at 36 weeks or later in their pregnancy are offered external cephalic version (a procedure to move the baby round to the head first position), which includes first having an ultrasound scan to confirm the baby’s position.

Source clinical NICE clinical guideline 62 recommendations 1.10.5 and 1.11.2.1. guideline references

Data sources Structure: Local data collection. Process: Local data collection. Outcome: Local data collection.

Definitions Exceptions to this statement include: women in labour women with: - a uterine scar or abnormality - fetal compromise - ruptured membranes - vaginal bleeding - medical conditions.

Equality and Access to external cephalic version for pregnant women with a diversity breech presentation is currently variable and may be influenced considerations by the attitudes and individual opinions of healthcare professionals caring for the woman. There may be some women whose breech presentation is not identified and subsequently are not offered an external cephalic version.

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Draft quality statement 14: Fetal wellbeing – membrane sweeping for prolonged pregnancy

Nulliparous pregnant women are offered a vaginal examination for Draft quality membrane sweeping at their 40- and 41-week antenatal statement appointments, and parous pregnant women are offered this at their 41-week appointment.

Draft quality Structure: Evidence of local arrangements to ensure that measure nulliparous pregnant women are offered a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women are offered this at their 41-week appointment. Process: a) Proportion of nulliparous pregnant women attending a 40-week antenatal appointment who are offered a vaginal examination for membrane sweeping. Numerator – the number of pregnant women in the denominator offered a vaginal examination for membrane sweeping. Denominator – the number of nulliparous pregnant women attending a 40-week antenatal appointment. b) Proportion of nulliparous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping. Numerator – the number of pregnant women in the denominator offered a vaginal examination for membrane sweeping. Denominator – the number of nulliparous pregnant women attending a 41-week antenatal appointment. c) Proportion of parous pregnant women attending a 41-week antenatal appointment who are offered a vaginal examination for membrane sweeping. Numerator – the number of pregnant women in the denominator offered a vaginal examination for membrane sweeping. Denominator – the number of parous pregnant women attending a 41-week antenatal appointment. Outcome: Rates of induction of labour for prolonged pregnancy.

Description of Service providers ensure that systems are in place to offer what the nulliparous pregnant women a vaginal examination for membrane quality sweeping at their 40- and 41-week antenatal appointments, and statement parous pregnant women the same at their 41-week appointment. means for each Healthcare professionals offer nulliparous pregnant women a audience vaginal examination for membrane sweeping at their 40- and 41- week antenatal visits, and parous pregnant women the same at their 41-week appointment. Commissioners ensure they commission services that offer Draft quality standard for antenatal care 37 of 44

nulliparous pregnant women a vaginal examination for membrane sweeping at their 40- and 41-week antenatal visits, and parous pregnant women the same at their 41-week appointment. Pregnant women having their first baby are offered a vaginal examination at their 40- and 41-week antenatal visits to carry out a membrane sweep, in which a healthcare professional moves a finger around the cervix or massaging the cervix, to help start labour. Pregnant women having their second or more baby are offered a vaginal examination at their 41-week appointment to carry out membrane sweep to help start labour.

Source clinical NICE clinical guideline 62 recommendation 1.11.1.1. guideline NICE clinical guideline 70 recommendations 1.3.1.2 and 1.3.1.3. references

Data sources Structure: Local data collection. Process: a), b) and c) Local data collection. Outcome: Local data collection.

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3 Notes on the scope

NICE quality standards are developed in accordance with a scope that defines what the standard will and will not cover. This quality standard covers the antenatal care of all pregnant women up to 41 weeks of pregnancy, in all settings that routinely provide NHS antenatal care, including primary, community and hospital-based care. It does not include inpatient care of pregnant women, the treatment, care and management (beyond identification and referral to appropriate services) of specific physical conditions, mental health problems or social problems in pregnant women, or antenatal complications.

The scope of this quality standard is available from the NICE website.

4 Status of this quality standard

This is the draft quality standard released for consultation from 23 March 2012 until 24 April 2012. This document is not NICE’s final quality standard on antenatal care. The statements and measures presented in this document are provisional and may change after consultation with stakeholders.

Comments on the content of the draft standard must be submitted by 5pm on 24 April 2012. All eligible comments received during consultation will be reviewed by the Topic Expert Group and the quality statements and measures will be refined in line with the Topic Expert Group considerations. The final quality standard will then be available on the NICE website in September 2012.

5 Using the quality standard

It is important that the quality standard is considered alongside current policy and guidance documents listed in the evidence sources section.

The quality measures accompanying the quality statements aim to improve the structure, process and outcomes of healthcare. They are not a new set of targets or mandatory indicators for performance management.

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Expected levels of achievement for quality measures are not specified. As quality standards are intended to drive up the quality of care, achievement levels of 100% should be aspired to (or 0% if the quality statement states that something should not be done). However, we recognise that this may not always be appropriate in practice when taking account of patient safety, patient choice and clinical judgement and therefore desired levels of achievement should be defined locally.

We have indicated where national indicators currently exist and measure the quality statement. National indicators include those developed by the Health and Social Care Information Centre through their Indicators for Quality Improvement Programme. For statements where national quality indicators do not exist, the quality measures should form the basis for audit criteria developed and used locally to improve the quality of healthcare.

For further information, including guidance on using quality measures, please see What makes up a NICE quality standard.

6 Diversity, equality and language

During the development of this quality standard, equality issues have been considered and equality assessments will be published on the NICE website with the final version of the quality standard.

Good communication between health professionals and pregnant women is essential. Treatment and care, and the information given about it, 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. Pregnant women should have access to an interpreter or advocate if needed.

7 How this quality standard was developed

The evidence sources used to develop this quality standard are listed in appendix 1, along with relevant policy context, definitions and data sources.

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Further explanation of the methodology used can be found in the Quality Standards Programme interim process guide.

8 Related NICE quality standards

Patient experience in adult NHS services. NICE quality standard (2012).

Intrapartum care. NICE quality standard. Publication date to be confirmed.

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Appendix 1: References

Evidence sources

The documents below contain clinical guideline recommendations or other recommendations that were used by the TEG to develop the quality standard statements and measures.

UK National Screening Committee (2011) Screening for Down’s syndrome: UK NSC Policy recommendations 2011-2014 Model of best practice.

Royal College of Obstetricians and Gynaecologists (2011; NHS Evidence accredited) Reduced fetal movements. Green-top guideline 57

Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors . NICE clinical guideline 110 (2010; NHS Evidence accredited).

Hypertension in pregnancy: the management of hypertensive disorders during pregnancy . NICE clinical guideline 107 (2010; NHS Evidence accredited).

Weight management before, during and after pregnancy. NICE public health guidance 27 (2010; NHS Evidence accredited).

Royal College of Obstetricians and Gynaecologists (2009; NHS Evidence accredited) Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top guideline 37a.

Maternal and child nutrition. NICE public health guidance 11 (2008).

Induction of labour. NICE clinical guideline 70 (2008; NHS Evidence accredited).

Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period . NICE clinical guideline 63 (2008; NHS Evidence accredited).

Antenatal care: routine care for the healthy pregnant woman. NICE clinical guideline 62 (2008; NHS Evidence accredited).

Postnatal care: routine postnatal care of women and their babies. NICE clinical guideline 37 (2006).

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Policy context

It is important that the quality standard is considered alongside current policy documents, including:

Department of Health (2010) Maternity and early years: making a good start to family life.

Department of Health (2009) Healthy Child Programme: pregnancy and the first five years of life (Update of Standard One (incorporating Standard Two) of the National Service Framework for Children, Young People and Maternity Services [2004]).

Department of Health (2009) Delivering high quality midwifery care: the priorities, opportunities and challenges for midwives.

Department of Health (2007) Maternity matters: choice, access and continuity of care in a safe service.

UK National Screening Committee (2006) The UK NSC policy on fetal anomaly screening in pregnancy.

UK National Screening Committee (2006) The UK NSC policy on down's syndrome screening in pregnancy.

Definitions, and data sources for the quality measures

References included in the definitions and data sources sections can be found below:

Department of Health (2012) Public Health Outcomes Framework for England 2013-16

Quality and Outcomes Framework (QOF) indicators

Department of Health (2010) The operating framework for the NHS in England 2011/12

Care Quality Commission Maternity Services Survey 2010

Department of Health (2007) Maternity matters: choice, access and continuity of care in a safe service

BMI and waist circumference - black and minority ethnic groups NICE public health guidance (publication date to be confirmed)

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Maternity Services Secondary Uses Dataset

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