Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guidelines
  3. Maternity
  4. Back
  5. Antenatal, general
  6. Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)
Announcements and latest updates

Right Decision Service newsletter: October 2024

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

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

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

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

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

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 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.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

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