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

My Issues in PG were that I was overweight when I booked in and I was given no real advice on fitness and nutrition, except for 'make sure you don't eat for 2' Also my anti natal care was in our local birth centre, which in the rural area we live in was essential but this is due to be closed soon, we have not been told what will replace it, we are ttc #3 atm, and have no idea what is happening localy, the birth centre care was lovely and always saw the same midwife at appointments, I was due to recover after birth with them but medical issues got in the way of that. I also have an underactive thyoid, I had to wait until my booking in at 10 weeks (our PCT does it as standard at the 10 week stage) before I could get an appointment to the anti natal endo clinic at the hospital which I attended at the same time as my 12 week scan, despite many studies (that I was not aware of at the time) indicating that early testing and adjustment of the drugs is essential, also I was offered no additional testing or drugs while TTC even though this is also reccomended for the early days of PG and my GP was aware we were TTC and of my condition. There was no care or advice offered before the booking in at 10 weeks, I tried to find advice but with the extra health issues I have (also have Crohns disease) I struggled to find the correct suitable advice.

Sorry I rambled on a bit there

Guideline 5, evidence based information on care. All pregnant women that are high risk because of maternal pre-existing serious medical conditions (eg. cardiac) should have access to an obstetric physician, as well as an obstetrician. AFAIK, there are only a handful of these UK wide. Many doctors cannot provide evidence based information for women with rare conditions.

My second pg was managed by an obstetric physician, and I was very happy with my care even if she did have me at the hospital for checkups almost weekly. She co-ordinated tests, specialist consultant appointments, and ensured that I didn't experience delays in referrals.

I'd love to see standardised maternity notes so that all trusts use the saem format. I also really think all maternity notes should be in A5 form so that they really can be put into a handbag and kept with you during pregnancy.

All (low risk) women should have the option of birthing in a midwife led unit, and being cared for by a caseload team for better continuity of care, and more opportunity to build a relationship of trust with the caregivers.

Oh nextphase I totally agree!

I have quite a lot of feedback to give so I'll
mark my place for later when I'm not on my phone

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

Despite two risk factors (large previous baby who suffered hypoglycemia after birth, and diabetes in both father and maternal grandfather) and much hassling, I wasn't able to persuade the consultant to give me a Glucose Tolerance Test until 37 weeks pregnant, when a growth scan revealed this baby is 97th percentile.

Why is the UNICEF Baby Friendly Initiative not referred to anywhere in the standard on antenatal provision of information about breastfeeding?

The NICE postnatal care guideline (CG037) states "All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative (www.babyfriendly.org.uk) as a minimum standard."

It would seem sensible if the antenatal standards were consistent with this, and Baby Friendly have a lot of info about antenatal provision of breastfeeding info as part of their programme (it is Step 3 of becoming accredited by them). See here

Hello,

Just poking nose in - thanks for all your responses so far.

I'll read the thread properly tomorrow and try to come back with any more info that's needed - but if (as maples suggests) you'd like to respond privately, do email [email protected] and it'll get passed on to me.

Thanks
MNHQ

I agree wholeheartedly about communication.

i have never had a sweep 'offered'
I have had 'right, we'll book your sweep for friday'

Three times. Three different Midwives.
no discussion. no evidence mentioned. no choice mentioned.

I find this way of doing things extremely off-putting to the point where it makes me defensive in appointments rather than engaged.

Totally agree with everything said so far - especially the way that mothers to be are treated like a petulant teenager. "you must do xyz" and when asked "why?" the answer may as well have been "because I said so!".
I had twins and wasn't routinely asked to have a diabetes test. This apparently was my fault when I did present for a test. Then the result was that yes I did have gestational diabetes, then I didn't, then "of course you have".
The midwife in charge of dealing with mothers with GB was patronising, condescending and ill informed. She more or less stated that I would "have to have an induction or a CS as they would be too big" and that at 32 weeks I would "have to change my consultant (whom I had been seeing since week 12) to the diabetes consultant who I might get to meet in a couple of weeks"!!!!
I refused, asked her lots of questions she was either unable or unwilling to answer and i was rather pleased that they arrived before she could insist on anything else.
Oh and don't get me started on the fact my "named" midwife swapped with her colleagues without letting me know and then the new one didn't have a clue who I was when she saw me on the delivery suite.

I had a sweep without consent when I had dd1, by an obstetrician. I had no idea what she was doing, or even what a sweep was. All I knew was the doctor was moving her hand around inside me, I had no idea why, it hurt, and when I cried out she stopped, and her glove was covered in blood. The doctor looked very pleased, but I was horrified because I didn't know why the internal exam had been so rough.

I would have agreed to the sweep, but it would have been nice to have been asked before it was done, and had the procedure explained to me.

Reading this thread makes me feel quite sad that care is so sporadic in parts of the country and women don't get good care in some areas.

I feel lucky I work in a area that has team midwifery, we have allocated surgeries and generally women get continuity, we also rotate from community, to labour ward per shift so can even see women we've looked after in community whilst in labour. Then even at home afterward.

We also run drop in clinics 4 times per week inc sat and Sunday's so if a woman needs anything over a weekend she can just turn up, whether it's antenatal or postnatal care. Some women just want their partner to come along so prefer to be seen at a weekend.

It sounds like other parts of the country could benefit from this type of approach!

I'm 28 weeks pregnant with my first baby and I dread contact with any health professional. Whilst I completely understand why the NHS needs to inform women about some of the things that can go wrong with pregnancy i.e miscarriage and stillbirth my midwife talked about it at my first three appointments. I was told the pain I was experiencing at 5 weeks was not normal and I shouldn't be surprised if I miscarried or there was no heartbeat at my first scan. I spent the next 7 weeks in a state of panic. Missed miscarriage was again bought up at my next appointment. I'm not a high risk case. My other issue which other posters have mentioned is how I am spoken to. I am sick of being spoken to like a child. I was given some literature about breast feeding and it was done as a cartoon story.

I agree about continuity, and I hardly saw the same midwife more than once especially with DD2. I also agree about evidence based practices, although doing studies to gather the evidence is really hard because you can't very well 'experiment' with people - the best you can do is restrospective analysis ie after the fact, since you can't tell group 1 to behave this way and group 2 to behave that way and see what happens. To gather more evidence, maternity notes should be digitised and we should have an opt-out system for letting lots of data on care, lifestyle and choices during pregancy, linked through to data on birth, and baby's health, available to researchers (obviously anonymised!).

I think the NHS should get its story straight on breastfeeding. Midwives: BREAST IS BEST!! It's your choice... but it's BEST! etc etc. Guilt-inducing emotional repetition fed to vulnerable new mums, complete with posters of cute suckling children and smiling young mums. Then after 3 days or whatever they pass you off to the HV who say, oh, just give her formula.. won't hurt her at all. Mothers go through so much over establishing breastfeeding, pumping, feeling terrible if they can't breastfeed, PND and unable to leave baby for a few hours because they're breastfeeding, and it's so inconsistent to then have HV who essentially insist that any child under the 25 percentile should have formula (!! you know a quarter of people are under the 25th percentile and even if they ALL got bigger, a quarter would still be under the 25th percentile... it's a ranking ... I got some very dazed looks). In my view, midwives, HV, GPs and everyone else should take a step back, get some perspective, and get clear about what the evidence really is re breastfeeding - namely (as I understand it), yes, it is probably 'best' all else being equal, but it's very very hard to tell, especially given that formula of a couple of decades ago was very different from what it is now, and loads of other complicating factors. And not all else is equal, for most people! So it's hard to tell.

I did hear from someone I know about CQUINs, or some such thing? Basically the midwive unit or whatever administrative bit of the NHS got more or less funding, according to how many women were still breastfeeding after 6 weeks or however long. I think they should HAVE to inform women if they are basing advice on such direct financial incentives, even if those incentives are broadly in line with evidence, because I think the incentive drives them to push WAY harder than evidence would (when evidence is really, face it, pretty weak, and when of course they aren't accordingly penalised if someone with PND suffers more, or someone's nipples are torn to shreds). It skews care. I felt rather manipulated. And this from someone who still happily breastfeeds, nothing against breastfeeding here, I do it every day.

In general, I think the care standards paper seems very good.

Some things I would add: That the notes that the women carry should contain specific information on how to complain about a midwife or other HCP she deals with and how to change midwives if needed.

Also, for number 5 about giving pregnant women being given evidence-based information to base decisions, I feel that needs to be clarified and that possibly midwives need sheets on particular conditions and risks like diabetes or PPH that they can give as I found that many (in my 4 pregnancies) were quite bad at doing this off the top of their heads. Many will jump to anecdotal events and emotive language that they've seen to get their point of view across rather than objective information and statistics that are needed to make a choice clearly. Having had more than my fair share of scare stories and dead baby cards pulled on me (and in front of my young children) I think a non-emotive paper to hand out when discussing things would help a lot of HCPs and pregnant women.

I was quite underwhelmed by the quality of consultant care I experienced in one of the hospitals (I was booked with 3 at different times). My appointments normally consisted of me answering questions to a junior doctor who would then disappear to show their notes to somebody and if I had any questions I had to go through this game of Chinese whispers when they would disappear and appear again.

As has already been mentioned before re hypothyroidism. I asked my doctor specifically what effect my underactive thyroid would have on my developing baby, he told me that he didn't know how it affected a pregnant woman and that is what the specialist would discuss with me (my appointment was 6 weeks later, I would have been 11 weeks pregnant).

I then had to go back to see him with proof that I needed my medication upping immediately as it could have a dire effect if he didn't. He told me that looking at my test results he thought I was in the normal range and my medication was fine, but when pregnant, these ranges change and it can be dangerous to be in the 'normal' range.

Madsometimes that is shocking

During most of the course of 2 pregnancies, labor (40 hours followed by an emergency cs for my first) and deliveries I never saw the same midwife or medical professional twice.....I spent hours waiting (in dirty packed waiting rooms with not enough bathrooms or chairs) for appointments which were more than once cancelled at the last minute with no explanation. I was given misinformation, completely medically unsound advice, and no emotional support or information about resources available to me. I had to demand a test for Taysachs (I am of ashkenazi jewish descent), but could not turn down one for sickle cell (I am not of african descent). I had midwives try to feed my baby formula the day he was born, even though he latched on perfectly. I was told to stop breast feeding at 4 months because it was "the best for my baby" and solids would help him sleep through the night (didn't follow that un-informed advice). I got told off for having "too fat" babies (never mind they were exclusively breast fed and therefore the charts being used weren't applicable. No one took my blood pressure or weight before I got pregnant (even though my gp was well aware that this was in the cards as my dh had had vasectomy reversal to get us there), so when I had relatively (for me) high blood pressure during my pregnancy, there was no base to measure against and no one realized that for me the pressure that seemed normal was actually quite high and no one realized that I gained 45 pounds during my pregnancy. No one checked my iron levels (even though I had many symptoms of anemia) and I had to call my gp in the USA to get appropriate asthma medicine to control the severe multiple asthma attacks I was have every night during my pregnancy (uk gp ignored severity of the attacks and told me to continue with current medicine which wasn't working). During my second pregnancy, no one had my notes from the first pregnancy, including me because I was required to hand them over at the hospital. It took me almost 2 years and a formal written complaint to the hospital to finally get a copy of them.

I finally "went on strike" 4 months into my second pregnancy, after having asked for an amnio (I was 39 and had received no adequate risk testing as it "wasn't offered at my hospital") and being reduced to tears by a doctor who insisted I didn't need one. I marched myself into the office of the head midwife of the natural birth section of my assigned hospital. I said that I was not visiting another useless or abusive medical professional and asked if she could help me. She agreed and after that I finally received adequate medical care and only saw her or one other person in her office and had my dd delivered (VBAC) by her in person.

In short. I received abysmal antenatal ( and delivery and postnatal) care. My first is almost 11 and it sounds like things haven't changed one bit from the feedback I am reading in this thread.

SofiaAmes, same happened with me. My blood pressure has climbed quietly but steadily until I had to be suddenly induced because of it.

I think most of these things are done at the moment but I agree with the points above re: the lack of discussing options for care and treatment. This is partly a culture within the NHS generally but also constraints of time mean that this is an impossible dream when I think about the level of work on maternity units at the moment (dangerous & unnacceptable).
Offering dietary & lifestyle advice to women with a BMI>30 would encompass a massive group of women in some areas. Lots of cash needed to implement that one, also the membrane sweeps at 40 weeks would entail longer appointments and have a serious impact on waiting times for women.

My first baby was born in Chelsea and Westminster Hospital. I never saw the same midwife or doctor (I had pre eclampsia) twice. It is a total invasion of privacy to be treated by a different health professionals every time and results in callous uncaring staff. It is also dangerous in terms of not receiving continuity of care. A clinical incident report needed to be raised.The statement about a small group of professionals should be more about the need to see the same midwive / doctor if at all possible or named colleagues (ie, if X is off shift, then you see Y or X). I counted that I saw over 80 different professionals before and after my baby was born. It traumatised me. I had my next baby in Powys where they practice this way. "I won't be here so you will see X, is that okay?" and they came to my house for antenatal appointments. I saw 3 different midwives. This was much less stressful and I made a much better postnatal recovery because of the brilliant care.

I'd just like to see women listened to more.

I'm rhesus negative, told Sunderland hospital over and over (can cause stillbirth in future pregnancies). Got ignored, refused to check my blood type. Kicked up a stink and moved to Durham, consultant there had a rage on my behalf and we had all the injections in a short period of time.

Regardless of weight, diabetes or other medical conditions ante-natal appointments can feel like a cattle market, get in get out, we only have small period of time to get our concerns across, please listen when we do.