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