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  6. Late booking in pregnancy: management of women who book after 22+0 weeks gestation (629)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

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.

 

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.

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.

 

  • 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.

 

  • 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

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

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

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