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

I think there needs to be more descisions made on an individual basis rather than "this is what we do".

I am currently 40+4 with DS 2. I had a growth scan at 32 weeks as I have measured large throughout my pregnancy which showed he was quite large and although I am fairly tall I am not very wide (if you ignore the bump!).

I was told at my 40 week appointment I couldn't have a sweep until my 41 week appointment as it's "not what they do". I will also not be induced until 41+6.

I can't really fault any of the other care that has been provided, however leaving a fairly small other than bump person with a knowingly large baby with no reassurance etc and a blatent "no" for a sweep (when babies are term at 37 weeks) isn't great. My DS1 was induced on his due date as I had OC (thank god I don't this time), was 8lb 4oz and got stuck on the way out - had a "you get one pull with the vontoose or it's emergency c-section" job - luckily he came out on that first pull.

Now I'm looking forward to being midwifery led this time and trying the birthing pool etc BUT I think I should have been allowed the sweep at 40 weeks due to large baby, previous one getting stuck and me not being the widest person. Just hope he doesn't get too much bigger while he is still in there!

Maples thank you for responding. :)

There was lots of talk of "This should prevent future problems. We're TTC no#2 and I'm scared for my future baby. If my body recognises it as a different blood type and the injections weren't in time or far enough apart, well you know the rest.

Small point in comparison to all the things people are raising on here but I agree with missismac that A5 notes make sense and there is no cost associated with this. It is ill thought out to say 'carry them with you always' and then put them in an A4 ring binder!

My personal experiences echoes those of being told what to do.

As well as this, I feel that the codes etc. on the notes should be clearer so that you actually know what these things written about YOU mean. I was always looking up appreviations etc on the internet!

Re the GTT tests, it was insisted that I have one due to a high BMI, horrible experience of trainee person taking blood (stabbed lots with needles :( ) results came back fine, not even boarderline but a particular midwife was insisting I repeat the test as it's probably wrong(?) I refused and she actually said "well it will be your fault then if you have a poorly baby" which I was so shocked and upset by, was in floods of tears all day. Regret now not making a complaint.

I then had 44 hour labour which ended with emcs, I had no idea at the time WHY I was being taken for CS and was so drugged up on pethedin (sp?) I didn't care at the time. No explaination was given to dp either (to be fair he should've asked these questions but he was too busy shitting himself). I still don't know why I ended up with CS and am in process of getting notes back to try to find out. I would say that I am pretty traumatised by the experience, which is pathetic as I do have a lovely, healthy dd.

I feel that hospitals should have someone come to see you after the birth, or whenever you feel ready to go through what happened and why and whether it is likely to happen again, perhaps even offer counselling? (I am terrified of becoming pregnant and this same thing happening again. I cannot read anything to do with giving birth without getting upset and I can't read or look at anything to do with CS as it makes me feel like I'm going to be sick) :(

Lollipoppet you make a good point, postnatal care should include an automatic debrief and further specialist appointment/counselling if issues are found. I think this would help women's health immensely and promote the "good start to family life".

However, initially I came on to say I agree with those who have stated more midwives would make the biggest difference. Also, what about those who go past 41 weeks? And including testing for other conditions, some mentioned above, but off the top of my head was thinking of GBS and toxoplasmosis?

Some terrible experiences on here

Ime booking in appointments are far too late to deal with a lot of problems. Mine was at 18 weeks. If they are going to give extra help re: obesity for example this should be started in the 1st trimester.

A domino system should be available to all women who want it (ie all care from small team, ante/birth/post).

I think 40 weeks is too early for a sweep for a low risk nulliparous woman. 1st babies tend to arrive a week later than subsequent anyway, this is normal and shouldn't be unneccessarliy be medicalised.

If they are trying to prevent obesity problems in pregnancy then they need to target women before they are pregnant ie when they have an appointment to have coil removed etc. no use waiting until the horse has bolted.

They also mention domestic abuse in the blurb but it isn't in the actual points- do they not have any ideas about how to tackle this risk factor in pregnancy? I was specifically asked at booking in if I was being abused ( they had a new policy of asking everyone) but don't know if this is nationwide. However one question isn't enough to spot potential red flags - these should be discussed and women should be given a leaflet or similar explaining all types of abuse eg emotional and financial and given a women's aid number to call if they have concerns. It is crazy to think that a pregnant woman has more chance of being murdered by her partner than dying in childbirth but we do so much to prevent one and not the other.

On the debrief point, it should also be routinely offered to women at the start of subsequent pregnancies, which does come under antenatal care.

It would give women and MWs a fighting change of getting things off to a good start by finding out what kind of care style is suitable.

Agree on the hyperthyroid comments. I had to self medicate (raised dosage) while going through two GPs to beg the blood test I needed. I was then told the test results were fine when I knew they were not. Eventually I phoned around until I was able to get my results viewed by the consultant I wasn't supposed to see for another 16 weeks. She told me to up my dose the amount knew it needed to be based on my research.

The first GP refused to test me even when I printed out the information I was looking at. The second merely humoured me then said the results were fine when they weren't.

Unmanaged hypothyroid in early pregnancy can result in miscarriage.

hypothyroid

I strongly believe trusts need to be made to show robust evidence of recruitment and retention of midwives and also made to account for having less midwifery WTE than their birthrate would suggest is required.

Communtity based midwives spend a huge amount of their time in case conferences, chasing social services, investigating child protection issues and also supporting the people these cases involve. Think rtacking down substance abusers, fleeing victims of violence, chaotic mental health instability, failure to attend & engage. Think going to 5 different addresses looking for a pregnant woman with several names and challenging personal circumstances. In a car. In a city. With no parking. It might take a midwife 4 hrs to do one antenatal check.

If those women who do not have these exceptionally demanding and time consuming needs are to be offered the same quality of personlised care we need more midwives. And the sad fact is we have them trained and ready to go - they are just unemployed or working 18 hr contracts as the trusts WILL NOT GIVE THEM JOBS.

Arghhh!

My local hospital does not offer hospital tours due to low midwife numbers. Surely this should be standard in all units? I have no faith in the hospital as a result & do not feel confident giving birth there. I was told instead to look up their virtual tour online

Also hospital notes on previous labour should be shared. I am under dual care because of a note my midwife wrote on my notes without requesting my previous birth notes from my previous hospital I know have to pay £20 to request my previous notes from a separate nhs trust. Surely these should be requested as routine.

I agree with the comments re: treatment of hypothyroidism and pregnancy. 2 months before I found out I was pregnant my TSH was 4+ (within the 'normal' range but outside the recommended range of

Thinking about it - I also think it would be a good move for women to have copies of their own pregnancy notes to keep for themselves. Getting them out of the NHS labyrinth tends to be rather difficult...

I developed pre-ecamplsia at 36 weeks pregnant and was told I had to have a sweep when being induced (despite MW writing question marks in my notes to reflect her disbelief that this would work). I ended up having 2 sweeps which were complete agony (and have subsequently put me off any medical examinations e.g. smears) and ended up with an emergency c-section. I had a debrief with a senior midwife 6 months after the birth which helped with the depression I'd suffered afterwards and think that in the event of a traumatic birth/emergency c-section this should be offered to all women.

I've skimmed the paper and I wondered if it should cover advice given to women to help them choose where they'd like to give birth.

With dc1 I found it was assumed I'd go to the local hospital and no info was given (I had to do my own research) on what my other options might be.

I may be wrong, but I can't see any mention of SPD?

This is a really debilitating condition for some women (ending up with crutches/wheelchair) and all the NHS seems to do is manage the pain with pain killers and belt rather than actually treat the condition. I find this really puzzling.

I know from my own experiences that chiropractic treatment can work wonders getting rid of the pain and regaining mobility, yet all the NHS do is send you to physio who will tell you how to roll out of bed in the least painful way and climb the stairs on your bum

I realise practitioners can't recommend other therapies like chiro/osteo, probably because of lack of data.

But, I think this is one area where the NHS is letting women down.

Apologies in advance for a long post but I have a lot to feed back!

If NICE are saying that they want to be "Ensuring that people have a positive experience of care", can MNHQ please ask the DoH what they are going to do about the fact that the ratio of pregnant ladies to midwives is continuing to worsen? The RCM says that there should be a ratio of 1:28. In my area (Colchester) last year it was 1:32 and is now 1:34. Knowing that the service is operating under considerable pressure makes me very concerned. What is the DoH doing about ensuring that enough midwives (WTE) are working at the frontline (i.e not in training/on any type of absence) and actually "in post" to cope with the rising birth rate?

Here are my comments about some of the new quality standard:

Quality statement (QS) 1 "Pregnant women, including those with complex social needs, are actively supported to access antenatal care."

Antenatal care appointments

If you make it easy for people to attend appointments (e.g. by offering a range of times and at accessible locations - and by sending text reminders of appointments) then they are more likely to turn up. Some areas offer evening/ weekend appointments - IMO this could and should be rolled out nationwide.

Bit of context: As a commuter it drives me mental that I can't be offered an appointment in the City which i could pop to easily - instead I have to see the community midwife local to my home who is based at the GP practice and where the appointments are between 2-4 on a weekday afternoon, which means writing off a whole afternoon. Or if I have to see the endocrinologist/obstetric consultant that means going to the hospital and waiting AGES for an appointment which is never on time. Last time I was pregnant this caused some understandable frustration to my employer...

QS3 "Pregnant women have a complete and accurate record of the minimum set of antenatal test results in their hand-held maternity notes."

Antenatal notes

Is there any reason why we cannot implement a standard set of maternity notes (preferably in A5 format as suggested upthread) across England? I've seen so many threads over the years where pregnant women have been caused upset and/or actual harm as things have been missed between sets of notes, as different hospitals use different formats. It would be particulalrly helpful for women who have to move while pregnant (e.g. if their DH/DP is in the forces).

Is there any reason why women cannot keep their notes? Or at the very least be given a copy once they are discharged after the birth to keep (perhaps for a very small fee to cover stationery costs). Charging people £20 or whatever to see a copy of notes they were entrusted with for 9 months and which then have to be handed over to the hospital after the birth seems crazy.

Routine testing

There are a lot of posts on here about hypothyroidism. The guidelines state that antenatal care should involve "Treating and caring for people in a safe environment and protecting them from avoidable harm." Bloods are taken at booking in, why not (a) getting booking in done at at 8 weeks or therabouts and (b) routinely test TSH levels at the same time as Rhesus D status/blood type? It would seem a sensible way to avoid harm to the fetus (undertreated hypothyroidism has been linked to miscarriage, and to low birthweights of term babies - so not treating it promptly would count as "avoidable harm" IMO).

QS5 "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."

This is an interesting one, particularly with regard to the sweeps and ECV's which NICE propose to "offer" routinely. IMO HCP's have a tendency to work along the lines of "and we'll book you in for [procedure], ok" rather than explaining the pros and cons of the procedure and asking "would you like me to book you in?". thing1andthing2 made several excellent points around this!

"have the opportunity to discuss" - going back to my first point that at the moment the shortage of midwives means that each midwife must have a large case load...does anyone at NICE seriously think that those midwives they will have time to discuss things?

If we are talking about women being able to make informed decision about their care for second/subsequent babies then being allowed to keep their notes from previous pregnancies would be a start. I also think that if the woman had any problems during the first delivery that they should be given a debrief appointment as soon as possible into the next pregnancy so that any concerns about their next delivery can be discussed and hopefully allayed.

Bit of an essay, sorry

The Nhs should have standard list of tests and scans available, regardless of where you live ( so no postcode lottery).

Community midwife appointments only seem available at restricted times, employers happy to give paid time off to attend but surgeries should be more flexible with appointment times.

At hospitals, it seems a lottery whether you get a midwife who actually listens to the mother's wishes and birth plan. Whilst theoretically midwife led care should be best, but in reality doctors seem more happy to reduce mother's level of pain. Midwives seem to promote their non medical intervention approach or analgesia, over the mother's wishes. It should be the mother's choice but in reality you are at your most vulnerable and at the mercy of the midwives. Their attitudes and being respectful of the mother's wishes should be changed. With low risk pregnancies, birth plans should be followed or mothers writing them is just paying lip service to these.