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  6. Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)
Announcements and latest updates

Right Decision Service newsletter: September 2024

Welcome to the Right Decision Service (RDS) newsletter for September 2024.

1.Business case for permanent provision of the Right Decision Service from April 2025 onwards

This business case has now been endorsed by the HIS Board and will shortly be submitted to Scottish Government.

2. Management of RDS support tickets

To balance increasing demand with available capacity and financial resource, the RDS team and Tactuum are now working together to  implement closer management of support tickets. As a key part of this, we want to ensure clear, timely and consistent communication with yourselves as requesters.  

Editors will now start seeing new messages come through in response to support ticket requests which reflect this tightening up and improvement of our processes.

Key points to note are:

2.1 Issues confirmed by the RDS and Tactuum teams as meeting the critical/urgent and high priority criteria will continue to be prioritised and dealt with immediately.

Critical/urgent issues are defined as:

  1. The Service as a whole is not operational for multiple users. OR
  2. Multiple core functions of the Service are not operational for multiple users.

Example – RDS website outage.

Please remember to email ann.wales3@nhs.scot and his.decisionsupport@nhs.scot with any critical/urgent issues in addition to raising a support ticket.

High priority issues are defined as:

  1. A single core function of the Service is not operational for multiple users. OR:
  2. Multiple non-core functions of the Service are not operational for multiple users.

Example – Build to app not working.

2.2 Support requests that are outwith the warranty period of 12 weeks since the software was originally developed will not be automatically addressed by Tactuum. The RDS team will consider these requests for costed development work and will obtain estimate of effort and cost from Tactuum for priority issues.

2.3 Support tickets for technical issues that are not classified as bugs will not be automatically addressed by Tactuum. The definition of a bug is ‘a defect in the software that is at variance with documented user requirements.’  Issues that are not bugs will also be considered for costed development work.

The majority of issues currently in support tickets fall into category 2 or 3 above, or both.

2.4 Non-urgent requests that require a deployment (i.e a new release of RDS) will normally be factored into the next scheduled release (currently end of Nov 2024 and end of Feb 2025) unless by special agreement with the RDS team.

Please note that we plan to move in the new year to a new system whereby requests all come to an RDS support portal in the first instance and are triaged from there to Tactuum when appropriate.

We will be organising a webinar in a few weeks’ time to take you through the details of the current support processes and criteria.

3. Next scheduled deployment.

The next scheduled RDS deployment will take place at the end of November 2024.  We are reviewing all outstanding support tickets and feature requests along with estimates of effort and cost to determine which items will be included in this deployment.

We will update you on this in the next newsletter and in the planned webinar about support ticket processes.

4. Contingency arrangements for RDS

Many thanks to those of you who attended our recent webinar on the contingency arrangements being put in place to prevent future RDS outages as far as possible and minimise impact if they do occur.  Please contact ann.wales3@nhs.scot if you would like a copy of the slides from this session.

5. Transfer of CKP pathways to RDS

The NES clinical knowledge pathway (CKP) publisher is now retired and the majority of pathways supported by this tool have been transferred to the RDS. Examples include:

NHS Lothian musculoskeletal pathways

NHS Fife rehabilitation musculoskeletal pathways

NHS Tayside paediatric pathways

6. Other new RDS toolkits

Include:

Focus on frailty (from HIS Frailty improvement programme)

NHS GGC Money advice and support

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

To go live imminently:

  • Focus on dementia
  • NHS Lothian infectious diseases toolkit
  • Dumfries and Galloway Adult Support and Protection procedures
  • SIGN guideline – Prevention and remission of type 2 diabetes

 

7. Evaluation projects

We have recently analysed the results of a survey of users of the Scottish Palliative Care Guidelines toolkit.  Key findings from 61 respondents include:

  • Most respondents (64%) are frequent users of the toolkit, using it either daily or weekly. A further 25% use it once or twice per month.
  • 5% of respondents use the toolkit to deliver direct patient care and 82% use it for learning
  • Impact on practice and decision-making was rated as very high, with 80% of respondents rating these at a 4-5 on a 5 point scale.
  • Impact on time saving was also high, with 74% of respondents rating it from 3-5.
  • 74% also reported that the toolkit improved their knowledge and skills, rating these at 4-5 on the Likert scale

Key strengths identified included:

  • The information is useful, succinct, and easy to understand (31%).
  • Coverage is comprehensive (15%)
  • All information is readily accessible in one place and users value the offline access via mobile app (15%)
  • Information is reliable, evidence-based and up to date (13%)

Users highlighted key areas for improvement in terms of navigation and search functionality. The survey was very valuable in enabling us to uncover the specific issues affecting the user experience. Many of these can be addressed through content management approaches. The issues identified with search results echo other user feedback, and we are costing improvements with a view to implementation in the next RDS deployment.

8.RDS High risk prescribing (polypharmacy) decision support embedded in Vision and EMIS primary care E H R systems

This decision support software, sponsored by Scottish Government Effective Prescribing and Therapeutics Division,  is now available for all primary care clinicians across NHS Tayside. Board-wide implementation is also planned for NHS Lothian, and NHS GGC, NHS Ayrshire and Arran and NHS Dumfries and Galloway have initial pilots in progress. The University of Dundee has been commissioned to evaluate impact of this decision support software on prescribing practice.

9. Video tutorials for RDS editors

Ten bite-size (5 mins or less) video tutorials for RDS editors are now available in the “Resources for providers of RDS tools” section of the RDS.  These cover core functionality including Save and preview, content page and media management, password management and much more.

10. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Wednesday 23rd October 4-5 pm
  • Tuesday 29th October 11 am -12 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

 

Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)

Objectives

The aim of this guideline is to provide information on the management of women with an unknown estimated delivery date, or who book with maternity services after 22+0 weeks gestation.

This does not apply to women who attend NHS GG&C maternity services after 22+0 weeks who have received antenatal care elsewhere.

Audience

This guideline should be used by all Maternity staff working within NHS GG&C.

Please report any inaccuracies or issues with this guideline using our online form

Accurate dating of pregnancy is crucial for determining gestational age. The British Medical Ultrasound Society (BMUS) guidelines state that the most accurate measurement for dating a pregnancy is a crown rump length, taken between 6 and 13+0 weeks gestation. After this the pregnancy should be dated by head circumference (HC) or femur length. Pregnancies without ultrasonic examination before 22+0 weeks should be considered sub-optimally dated.

Booking late is known to be associated with poorer obstetric and neonatal outcomes. These women often have complex social issues.

 

Roles & Responsibilities

It is the role and responsibility of all staff to ensure women who are booking late are offered the first available appointment and have a full history taken at booking, including exploration into the reason for booking late. Appropriate referrals should be made in a timely manner and obstetric review should be sought as required.

First Visit/Point of contact

NICE (2021) guidance recommends women are offered a first (booking) appointment with a Midwife by 10 weeks gestation.

  • Women booking at >22 weeks should receive obstetric led care with universal midwifery care. See Antenatal Pathways.
  • The reason for late booking should also be explored (Sussex Child Protection and Safeguarding Procedures, 2022). (Appendix 1).
  • If there are any concerns in regards to the woman’s mental health or any causes for concern for the welfare of the unborn baby then necessary referrals should be made (Appendix 2).
  • Booking bloods (Appendix 3) including for screening for blood born viruses (BBV’s) should be obtained urgently. This should be performed at first hospital contact which may be in Day Care/Maternity Assessment. This should not be deferred until the next antenatal clinic.
    *Note that the results of communicable diseases can affect the management of pregnancy and birth. See NHS GGC Virology Guidance.
  • Inform patient that an accurate EDD cannot be offered. Explain that they are too late to be offered screening for Down syndrome. First trimester screening period, for Downs, Edwards and Pataus syndrome, is when the crown rump length (CRL) is 45-84mm (approximately 11 to 14+1 weeks gestation). Second trimester screening period for Downs syndrome only is 14+2 to 20 weeks gestation.
  • Perform USS for fetal anomaly and fetal growth.
  • A clinical estimate of gestational age will be provided by the consultant obstetrician following the first scan and this will be used to guide management.

 

Subsequent Visits

  • Women should have serial growth scans every 4 weeks, followed by medical review, within the ANC.
  • Suspected fetal growth restriction, oligohydramnios or abnormal end diastolic flow on umbilical artery Doppler should be managed in keeping with local policy.
  • When Estimated Fetal Weight (EFW) reaches 10th centile for 37 weeks gestation (>2321g), USS for assessment of growth, LV and Doppler should be offered every 2 weeks.

Offer induction of labour for usual obstetric reasons or if the pregnancy has reached 41 weeks by the best clinical estimate. See Induction of labour.

 

Previous Caesarean Birth

  • If patient is suitable and wishes VBAC – manage as per VBAC guideline.
  • If birth by caesarean is required birth at best estimate of 39-40 weeks gestation

Appendix 1: Reasons for late booking

Reasons for late booking could include but are not limited to (Sussex Child Protection & Safeguarding Procedures, 2022):

  • Mental illness
  • Domestic/sexual abuse
  • Exploitation
  • Substance misuse
  • Learning disabilities
  • Fear of social work involvement
  • Desire to minimise or avoid medicalisation of pregnancy and childbirth
  • Incestuous or unknown paternity
  • Where paternity is a result of rape or infidelity
  • Consideration must also be given of women presenting for a termination of pregnancy (TOP) but being unable to have a TOP due to advanced gestation of pregnancy
  • Fear of negative and/or unsupportive reactions from others eg young people
  • Refugees/Asylum Seekers/Undocumented individuals

Appendix 2: Referrals

Referrals should be considered, but not limited to:

  • Special Needs in Pregnancy Services (SNIPS) – via Badger
  • Social Work – via TRAK
  • Maternal and Neonatal Psychology Interventions (MNPI) –via Badger
  • Health Visitor (HV) – via Badger (GP can also provide contact details)
  • Perinatal Mental Health Service – via referral form
  • Family Nurse Partnership (FNP) – via Badger

Appendix 3: Booking bloods

Booking bloods should include:

  • Full blood count (FBC)
  • Ferritin
  • Group and Save (G&S)
  • HIV/Syphilis/Hepatitis B
  • Haemoglobinopathy Screen

Search in ‘item’ box – “Glasgow Antenatal booking set”.
Add on ferritin.

Editorial Information

Last reviewed: 26/02/2024

Next review date: 08/02/2029

Author(s): Rachel Bradnock, Heather Richardson, Emma Ritchie.

Version: 3

Approved By: Maternity Clinical Governance Group

Document Id: 629

References

  1. NICE guideline NG201: Antenatal care 2021

  2. Sussex child protection: Concealed pregnancy 2022

  3. Loughna P, Chitty L, Evans T, Chudleigh T. Fetal size and dating: charts recommended for clinical obstetric practice. Ultrasound 2009; 17(3): 161-167

  4. The American College of Obstetricans and Gynaecologists. Committee Opinion Number 688 – Management of suboptimally dated pregnancies. Vol. 129, No. 3, March 2017