Have your say on antenatal care in the NHS: sweeps, diabetes, maternity notes and more

[RowanMumsnet]

Hello,

The National Institute for Clinical Excellence has recently issued draft quality care standards for antenatal care, and they're currently consulting on them. (If you want to see the full draft standard, please see here.)

As a stakeholder in the process, we at MNHQ are going to feed back to NICE based on your responses on this thread (and on other relevant threads) - so do please let us know what you think. (Unfortunately only registered stakeholders can provide feedback, so unless you are one you won't be able to feed back directly.)

I'm afraid it's difficult to summarise the draft standard concisely, but if you look on pages 4 to 5 here you will see some useful summaries and proposed questions for consideration, including such things as membrane sweeps, treatment of overweight mothers and gestational diabetes.

(Please note that, as NICE points out, this standard doesn't include the inpatient care of pregnant women, the care of specific physical conditions, mental health problems or social problems in pregnant women, or antenatal complications. There is a separate NICE consultation on 'Pain and bleeding in early pregnancy', for which we are a registered stakeholder, and we will alert you to the consultation on that one when it's announced.)

We need to feed back by Tuesday (yikes!), so if you could post any views here by close of play on Monday, that would be great.

Best wishes,
MNHQ

Read this quickly and dont have any particular issue with the statements although there does seem an omission about care for those with high risk pregnancy (may have missed this)

The really striking thing (and this is based on personal experience) is actual access to antenatal care. I ended up going private after waiting 12 weeks for a hospital to be allotted to me (I had gone in at 6 weeks pregnant to my Gp to ask).

I am not suggesting everyone should know instantly where/who they are seeing but there should be a better defined timetable and timeline on when you find out who me is, when you get scans etc.

Now this may well be in place but it does seem that a lot of people have experience of waiting a long time to get check ups and scans . And not everyone has time/energy to chase this up .

nor do I think they should end up going private (assuming they can) - ii don't fault care I received but it shouldn't have come to point where I couldn't trust local pct (particularly as pregnancy in question ended with death of my son due to abnormalities - early Nhs intervention wouldnt change this but I may not have found out at 20 weeks).

By other high risk I mean things like previous issues at birth/pregnancy (only diabetes obesity and pre eclampsia seem to be mentioned but what about spd, issues where may not be able to deliver normally eg vbac)

I'd like to see a sharing of best practice across the UK. Also somehow creating maternity targets for hospitals so that the money-people see it as something worth investing in.

Booking-in is a nightmare too. I phoned up early and still only just got into the local flagship hospital. If my pregnancy hadn't started off as twins I'd have ended up at a different hospital with a higher CS rate that my chosen hospital. As my chosen hospital deals with high-risk cases, it's not surprising that it has a high CS rate - the fact that a local "low risk" maternity unit had a higher rate speaks volumes.

The one thing that would make the greatest difference to antenatal care would be to employ more midwives. I believe this is a nationwide problem, but definitely in this PCT area the lack of staffing is acute.

2 years ago, when I had DS, my community team was down one or 2 members (out of a team of 5) throughout my entire pregnancy. I hear that those vacancies have STILL not been advertised. Consequently, I never had one key midwife throughout my pregnancy. The midwives were under an enormous amount of stress and morale was very low.

I hear that there are similar problems in a lot of the community teams, and also in the county hospital. Certainly, my friend who is a midwife is constantly overstressed and frequently in tears.

I've found that there is great inconsistency in the attitudes of staff with some having no bedside manner at all whereas others have been amazingly supportive even though I must be have been the umpteenth pregnant woman of the day.

I've found that doctors are very dismissive. The things your midwife tells you to keep an eye on and seek help with is often dealt with very brusquely by GPs. This is my first pregnancy and I have been made to feel ridiculous after enquiring about quite severe pain on one side in early pregnancy (I was told "You are still pregnant. That should put your mind at rest" swiftly followed by "I suppose I'd better examine you".) and also an outbreak of chickenpox in workplace ("Have you had it before? Yes, then you're immune" Conversation OVER).

I recently had decreased movement over a few days and my local midwife-led practice said I needed monitoring immediately by larger hospital. I was passed through four departments before I was advised to drink Coke and wait an hour. Which did nothing. Thank goodness small hospital took pity and offered to check.

One thing would have made a big difference to me - flexibility in time and or location of the appointments for antenatal care.

Yes, I am entitled to time off work to attend antenatal appointments, but I still need to carry out my job. Giving me no choice in appointment time - your next appointment is in 4 weeks. Tues at 10.40, and not allowing me to move it by an hour either way is not helpful when I have a dairy scheduled several months in advance.

Or would it be possible for me to have the earlier appointments close to work, and then move closer to home when I started ML? As it was I didn't see the same midwife more than twice, and after care was again by different people, so continuity of care would not have been compromised for me.

I think consistency is the thing. Antenatal care seems to be one long round of being told by one person this is the way it is done, and then being told by another person that "you mustn't worry, but you've done it wrong, you should have done it this way" - no matter how you try to explain you've just done precisely what their other colleague told you to do!

This is my second pregnancy and it's still happening - I have no notes, I was told I would get them back at my GPs surgery at my 16 week check - presenting there I was told I should have picked them up from the local hospital at my 12 week scan. Having told them it was subcontracted out to a private provider it still seems I should have had them a month ago, and should have known this somehow.

I think weaning / breastfeeding guidelines are seriously damaged by a lack of consistent training. Could the NHS consider regular online courses to keep staff up to date? Mothers always say "the guidelines change all the time" and of course they don't, it's just that midwives say different things all the time. Like the midwife who told my sister that grobags can cause cot death when they're recommended by the FSID. And there's no end of peculiar advice on breastfeeding from Health Visitors recounted on this forum. Although my own Health Visitors I have to say, are excellent.

The single key things for me, that cuts across EVERY aspect of care is recognising that in dealing with the pregnant woman, you are by definition dealing with an adult woman who should be offered investigations and interventions with full information about the risks, benefits and purpose of such and who should CONSENT to everything that occurs.

How many posts on this site begin with 'My hospital induces at/my hospital will book me for, my consultant said they would....' Normal pregnancy is medicialised - and it's hard to see how you can avoid that because things do wrong for some people and when they do medical care saves lives. So medicalisation is to some degree inevitable but infantilisation of the patient is not.

Postnatal - not sending me (type1 diabetic) for a GTT because "once you've given birth you won't be diabetic any more" would be a start. If I'd known that, I'd have started having kids ASAP after diagnosis (which was aged 9)

The most stand out point for me is point 5 as IME, so much of the 'advice' given to pg women is based on hospital policy, with very little attention given to the facts and individual circumstances of that pregnancy / pregnant woman.

I am confident enough to ask questions based on my own research and reading and therefore was able to avoid a advised induction at 40+5 with my son. I went on to experience spontaneous labour at 41 weeks exactly and enjoyed a quick and straightforward birth experience. When I asked 'what is the specific risk to my baby and to me if I refuse induction at 40+5?' and the consultant admitted there was none!

I absolutely appreciate the need fir hospitals to have baseline policies, but the application of these policies and discussion of them alongside case-specific information and individual preferences, is crucially important.

Agree with limiting ante natal care to a small group of hcps where possible (ideally one mw plus a consultant if needed and then specialists as required, maybe x2 mws if the same one every time is not possible) As mws have such a high caseload it is difficult as I saw the same mw for all of my pg but she still managed to get my name wrong at my 36 week check

More antenatal tests during first trimester IMO. For example toxoplasmosis is standard in most EU countries. Also an additional routine scan at 8 weeks to confirm intra uterine pregnancy and presence of heartbeat.

Does this document also apply in Wales? I can only see England mentioned but I haven't got time to read 44 pages sorry!

Up to now (21 weeks) my care has been excellent, I've certainly seen improvements since having dd 4 years ago - I'm not sure if that's just because I've got a different mw this time round though. My main issue is the lack of standardised care throughout the uk - despite NICE guidelines NT scans are still not offered on the NHS in my area, surely if it's offered to one it should be offered to all?

I think NICE applies to England and Wales - I KNOW it doesn't apply in Scotland

I have no NHS experience but I find the comments on spoken English interesting as I teach a compulsory English module to trainee MWs in an EU country. Is there a minimum standard? And if not why not?

Just read the NMC guidance on English for EU candidates. Am quite shocked!

Agree about spoken English and it's not just EU to be fair

I may have misunderstood this (struggling to go back and see but is this just antenatal?) but what about postnatal care?

Routinely described as awful on these pages!

It states that EU legislation prevents then from requiring evidence if English for registration but employers do have the right to request evidence.

I know that the MWs I teach have to pass an internationally recognised exam and achieve a level which is at B2 on the CE Framework, lower than the C1 required for international applicants, and that this exam is a specialism totally unrelated to being an HCP.

Whilst I teach some professional English that is to enable them to communicate with an anglophone who pitches up in an emergency and get by until an interpreter can be found. The idea that they could go to the UK, register and get a job on the strength of a Business English exam taken in their second year of training is scary. And it will happen because it's one of the most widely used exams there is but I doubt Trusts have someone who has a sufficiently in depth knowledge of this to assess what it actually means in terms of English ability and capacity to communicate as an HCP.

MNHQ Would be happy to comment further if you want but I'm a tad scared of outing myself so won't say any more.

I agree with maples that there needs to be discussion much earlier in pregnancy about conditions that can harm the foetus.

Some conditions, such as improperly treated hypothyroid, can have done damage to the developing foetus - and/or caused a miscarriage - long before any tests are done (in the current system). IMO such conditions should be considered and if necessary tested for at the first GP appointment. At present no tests happen until the booking in appointment or a consultant referral, which may well be too late.

As a positive comment, I have been very impressed with the ready availability of early scans in my local area - much appreciated and very reassuring. Though I gather this is not consistent throughout the country.

Agree totally with northern lurker. The thing I would like to see changed is the language used at every stage.
There is currently too much "next appointment we will do this" and "you will see the consultant for this" and "we won't allow you to do that".
The language which should be used is:
"based on current evidence we are constrained to recommend x (but ultimately it is your choice)" or
"based on policy I need to recommend that you do y (but ultimately it is your choice)"
"we prefer to offer an appointment with a consultant to discuss z issue (but ultimately it is your choice)"
"next appointment I would like to offer you abc test, the benefits of this are x and the risks are y (and ultimately it is your choice)".
"our policy means that I have to recommend x, but if you decline this, I will just document it in your notes that I offered it and you declined".
And last but not least, women should be given the evidence for and against every recommendation.
E.g. " we recommend continuous monitoring during a VBAC. The reasons for this are X and Y. The evidence shows it is safer e.g. because it can mean a scar rupture is found earlier. The risks are e.g. it will stop you moving around which may slow labour or make it more painful (and ultimately it is your choice). "
Instead at the moment women get "we insist on CTG monitoring for a VBAC".

If all maternity workers have to go on communication courses to learn to talk like this IMO it would be money well spent.

My PhD research suggests a lot of birth trauma results from poor communication practices during labour and birth and I wouldn't be surprised if similarly women have more anxiety in pregnancy when they feel out of control and their concerns dismissed (happy to PM links to published research but don't want to out myself publicly).

This is a different thing - but related to the language. I did want to find out the sex of DD1 and my PCT doesn't do it. That's not a can of worms I'm going to open at the moment but it infuriated me (when I asked why they didn't, as so many other areas did) that it was "better" I didn't find out. Better for who? For me? I'll be the judge of that!