1DRAFT FOR CONSULTATION

1Antenatal Assessment Tool – Results from consensus

2 rounds
3Results
4Results from the consensus rounds are presented in Table 1.1.
5
6The first round of voting was via the on-line survey, the second and third rounds
7were undertaken at the consensus conference held at the RCOG and the fourth
8consensus round was conducted with the Antenatal Care Update Guideline
9Development Group. Where there was a median score of 4 from the first round of
10voting, these items (n = 13) were taken to the Antenatal Care Update Guideline
11Development Group where an extra consensus round was conducted. Median
12scores of 4 and above obtained in this extra round meant the item was included
13in the consensus conference. Median scores of 3 and below led to the item being
14excluded at this stage. These additional median scores are given in parentheses
15in the first column of Table 1.1.
16
17During the on-line survey consensus round a number of suggestions were made
18for additional items that should be considered for inclusion in the assessment
19tool. Six of these items were included and voted upon from round 2 onwards.
20
21Table 1.1 Results from consensus rounds
22
Topic Median score Final
decision
Previous First Second Third round Fourth IN / OUT
Pregnancy round round (Consensus round
(On-line (Consensus conference (Consensus
survey) conference round 2) group)
round 1)
3 or more 8 - - - IN
miscarriages
3 or more 7 6 4.5 1 OUT
terminations of
pregnancy
Abnormal antibodies 9 - - - IN
Abnormal cord blood 8 - - - IN
flow
Amniocentesis 6 3 1 - OUT
Anaemia 6 3 1 - OUT
Antenatal depression 8 - - - IN
Antepartum 7 4.5 5 1.5 OUT
haemorrhage – any
blood loss other than
spotting in the first
trimester
Antepartum 7 4 3 - OUT
haemorrhage – any

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blood loss at any

gestation
Antiphospholipid 9 - - - IN
antibodies
Baby with congenital 9 - - - IN
abnormality/disease
Blighted ovum 5 2 - - OUT
Breech at term 7 2 - - OUT
Caesarean section 9 - - - IN
Cervical 9 - - - IN
incompetence
Cervical suture 9 - - - IN
Chorionic villus 6 2 - - OUT
sampling
Complication 7 4 2 - OUT
following miscarriage
Complications 7 4 5.5 2 OUT
following termination
of pregnancy
Chorionic villus N/A 2 - - OUT
sampling**
Deep vein 9 - - - IN
thrombosis
Disseminated 9 - - - IN
intravascular
coagulation
Ectopic pregnancy 7 2 - - OUT
Forceps birth 6 2 - - OUT
Gestational diabetes 8 - - - IN
Gynaecological 8 - - - IN
surgery
HELLP (complication 9 - - - IN
of pre-eclampsia)
Hydatidiform mole 8 - - - IN
Hyperemesis 5 2 - - OUT
gravidarum
Induction of labour 5 2 - - OUT
Labour < 2 hours 5 2 - - OUT
Labour < 3 hours 4 (5)* 1 - - OUT
Labour < 4 hours 4 (3)* - - - OUT
Large baby 6 6.5 2 - OUT
(>4.0 kg)
Large baby (>4.5kg) 8 - - - IN
Late pregnancy N/A 8 - - IN
loss**
Multiple pregnancy 8 - - - IN
Musculo-skeletal 5 1 - - OUT
problems
Obstetric cholestasis 8 - - - IN
Oligohydramnios 8 - - - IN
Parity 4+ 5 3 1 - OUT
Parity 5+ 6 4 2.5 - OUT
Parity 6+ 7 6 6 2.5 OUT
Placenta praevia 8 - - - IN

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Polyhydramnios 7 3 - - OUT
Poor fetal growth 8 - - - IN
Postpartum 8 - - - IN
haemorrhage
Postnatal depression 8 - - - IN
Pre-eclampsia 9 - - - IN
Pregnancy induced 8 - - - IN
hypertension
Pregnancy with IUCD 6 1 - - OUT
in situ
Premature rupture of 7 4 6 8 IN
membranes
Pre-term labour (<36 8 - - - IN
weeks)
Proteinuria 1+ on 6 2 - - OUT
more than one
occasion
Proven cephalopelvic 9 - - - IN
disproportion
Pulmonary embolism 9 - - - IN
Recurrent urinary 7 3 2 - OUT
tract infection
Reduced fetal 7 1 - - OUT
movements
Retained placenta 7 3 2 - OUT
Stillbirth or neonatal 9 - - - IN
death
3rd or 4th degree tear 9 - - - IN
Unstable lie 7 2 - - OUT
Ventouse birth 5 1 - - OUT

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1
Topic Median score Final
decision
Current First round Second Third round Fourth IN / OUT
pregnancy (On-line round (Consensus round
survey) (Consensus conference (Consensus
conference round 2) group)
round 1 )
Antepartum 8 - - - IN
haemorrhage – any
blood loss other
than spotting in the
first trimester
Antepartum 7 8 - - IN
haemorrhage – any
blood loss to date
Any illness in 7 2 - - OUT
current pregnancy
including ‘flu-like
symptoms and rash
Contact with chicken 7 3 2 - OUT
pox
Contact with rubella 8 - - - IN
Contraception used 3 - - - OUT
in year prior to
pregnancy
Depression 7 8 - - IN
Early minor 3 - - - OUT
pregnancy
symptoms (urinary
incontinence,
morning sickness)
Exposure to toxic 7 7 - - IN
agents
Fertility treatment for 5 2 - - OUT
current pregnancy
(other than IVF)
IVF pregnancy 6 3 2 - OUT
Long inter- 5 2 - - OUT
pregnancy interval
(< 10 years)
Pain passing urine 6 2 - - OUT
Planned pregnancy 2 - - - OUT
Reaction to 4 (3)* - - - OUT
pregnancy
Short inter- 5 2 - - OUT
pregnancy interval
Surgery during 8 - - - IN
pregnancy
Vaginal discharge 6 2 - - OUT
other than white,
odourless discharge
2

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1
Topic Median score Final
decision
Personal First round Second Third round Fourth IN / OUT
factors (On-line round (Consensus round
survey) (Consensus conference (Consensus
conference round 2) group)
round 1 )
Adolescent 6 5.5 5 2 OUT
Alcohol misuse 8 - - - IN
Born outside the 4 (4)* 2 - - OUT
UK
Cigarette smoking 7 2 - - OUT
Deafness/hearing 5 2 - - OUT
impairment
Drug 8 - - - IN
misuse/recreational
drug misuse
Ethnicity 4 (7)* 2 - - OUT
Fluency in English 4 (5)* 2 - - OUT
Genital mutilation 8 - - - IN
Height 4 (3)* - - - OUT
High BMI >35 8 - - - IN
Jehova’s Witness 6 5 5 8 IN
Learning disability 6 2.5 - - OUT
Level of 5 2 - - OUT
understanding of
English
Low BMI < 18 7 6 7 - IN
Need assistance 4 1 - - OUT
with reading/writing
Occupation 3 - - - OUT
Older woman 35+ 4 (7)* 2 - - OUT
Older woman 40+ 7 6 8 - IN
Taking regular 3 - - - OUT
exercise
Visual impairment 4 (6)* 1 - - OUT
Worry about mess, 4 (1)* - - - OUT
being out of control
2

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1
Topic Median score Final
decision
Social factors First round Second Third round Fourth IN / OUT
(On-line round (Consensus round
survey) (Consensus conference) (Consensus
conference ) group)
Abuse of partner 7 2 - - OUT
by woman
Afraid of partner 7 3 2 - OUT
Attending a 8 - - - IN
detoxification
programme
Availability of 6 1 - - OUT
practical support
eg. Child care
whilst in hospital
Alone/isolated – 7 2 - - OUT
little or no social
support
Asylum seeker or N/A 5 7 - IN
refugee**
Booking after 20 6 5 5 8 IN
weeks
Conflict with 6 3 1 - OUT
partner
Controlled by 6 3 1 - OUT
partner
Couple’s 5 1 - - OUT
relationship
Declined or quit 4 (2)* - - - OUT
antenatal classes
Does partner 6 2 - - OUT
misuse alcohol
Does partner 6 3 2 - OUT
misuse drugs
Does partner 5 1 - - OUT
smoke
Feeling unsafe 6 2 - - OUT
where you live
Forced to 7 2 - - OUT
perform a sexual
act by someone
you know
Homeless 8 - - - IN
Living in poverty 7 2 - - OUT
Lone parent 5 1 - - OUT
Marital status 2 - - - OUT
Other children 4 (2)* - - - OUT
living with you
Partner 5 1 - - OUT
associated stress
Partner’s 3 - - - OUT
employment

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status
Partner’s - - - - OUT
occupation
Receiving 3 - - - OUT
benefits
Recent 5 1 - - OUT
loss/bereavement
Relationship with 2 - - - OUT
parents during
childhood
Seen by social 5 1 - - OUT
worker
Social worker 6 2 - - OUT
seeing children
Someone to talk 5 1 - - OUT
to
Support from 5 1 - - OUT
family
Support from 5 1 - - OUT
friends
Support from 6 1 - - OUT
partner
Threatened by 7 1 - - OUT
someone at
home
Unable to get to 7 1 - - OUT
antenatal
appointments
Victim of abuse 8 - - - IN
including
domestic
violence; past
abuse; childhood
abuse
1

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1
Topic Median score Final
decision
Past and First round Second Third round Fourth IN / OUT
existing (On-line round (Consensus round
survey) (Consensus conference) (Consensus
medical conference ) group)
problems
Abdominal 7 5 2 - OUT
surgery
Allergies 7 3 - - OUT
Anaemia 7 5 8 - IN
Anaesthetic 8 - - - IN
problems
Any blood 8 - - - IN
disorder
Any surgery 6 2 - - OUT
Auto-immune 8 - - - IN
disease
Back surgery 7 6 5 8 IN
Blood transfusion 7 2 - - OUT
Cardiac disease 9 - - - IN
Cervical surgery N/A 7 - - IN
including LLETZ
and colposcopy**
Clotting disorder 9 - - - IN
Deep vein 9 - - - IN
thrombosis
Dental health 4 (3)* - - - OUT
Diabetes 9 - - - IN
Endocrine 9 - - - IN
disorder
Epilepsy 9 - - - IN
Genital infections 8 - - - IN
incl. herpes
Hernia 6 4 1 - OUT
HIV/AIDS 9 - - - IN
Hypertension 9 - - - IN
Infertility problems 6 2 - - OUT
Inflammatory 6 7 - - IN
bowel disease
Jaundice 8 - - - IN
Liver disease 9 - - - IN
Medications 8 - - - IN
Musculo-skeletal 6 3 2 - OUT
problems
Neurological 8 - - - IN
disease
Pelvis injury 8.5 - - - IN
Prolapse* N/A 7 - - IN
Psychiatric illness 8 - - - IN
including anxiety
and/or depression;
treatment for

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emotional
problems
Recurrent urinary 7 6 7 - IN
tract infection
Reported stress 6 2 - - OUT
Renal disease 9 - - - IN
Respiratory 8 - - - IN
problems
Sexually 8 - - - IN
transmitted
infections
Sickle cell 9 - - - IN
anaemia
Sickle cell trait 8 - - - IN
Symphysis pubis 7 3 3 - OUT
dysfunction
Thalassaemia 9 - - - IN
Thalassaemia trait 8 - - - IN
Thromboembolism 9 - - - IN
Tuberculosis 9 - - - IN
Urinary or faecal N/A 8 - - IN
incontinence**
Uterine 8 - - - IN
abnormality inc.
fibroids
Uterine surgery 9 - - - IN
Varicose veins 5 2 - - OUT
1
2
3
Topic Median score Final
decision
Family medical First Second Third round Fourth IN / OUT
history round round (Consensus round
(On-line (Consensus conference) (Consensus
survey) conference ) group)
Blood disorder incl. 9 - - - IN
clotting disorder
Blood relative to 7 6 7 - IN
baby’s
father/consanguinity
Cardiac disease/ 8 - - - IN
abnormality
Congenital 6 2 - - OUT
dislocation of the
hip
Congenital heart 8 - - - IN
disease
Cystic fibrosis 8 - - - IN
Diabetes 8 - - - IN
Eclampsia 8 - - - IN
Genetic/inherited 9 - - - IN
disorder
Multiple birth 6 1 - - OUT

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Muscular dystrophy 8 - - - IN
Neonatal death 8 - - - IN
Postnatal 7 2 - - OUT
depression
Problems with 8 - - - IN
general anaesthetic
Psychiatric 7 2 - - OUT
disorder/mental
illness
Raised blood 7 2 - - OUT
pressure
Recurrent 6 1 - - OUT
miscarriage
Stillbirth 8 - - - IN
Sudden infant death 7 2 - - OUT
Thyroid disease 7 2 - - OUT
Tuberculosis 7 4 2 - OUT
1
2 * Figure in parentheses is median from additional voting round carried out by the Antenatal
3 Care GDG for all scores of 4 from first consensus round.
4 ** Topics added following first consensus round
5
6

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1
2Following all consensus rounds the topics for inclusion in the antenatal
3assessment tool have been confirmed as follows (N = 92 items):
4
5Previous Pregnancies (n = 31)
6
7  3 or more miscarriages
8  Abnormal antibodies
9  Abnormal cord blood flow
10  Antenatal depression
11  Antiphospholipid antibodies
12  Baby with congenital abnormality/disease
13  Caesarean section
14  Cervical incompetence
15  Cervical suture
16  Deep vein thrombosis
17  Disseminated intravascular dissemination
18  Gestational diabetes
19  Gynaecological sugery
20  HELLP (complication of pre-eclampsia)
21  Hydatidiform mole
22  Large baby > 4.5 kg
23  Late pregnancy loss
24  Multiple pregnancy
25  Obstetric cholestasis
26  Oligohydramnios
27  Placenta praevia
28  Poor foetal growth
29  Postpartum haemorrhage >500ml
30  Postnatal depression
31  Pre-eclampsia
32  Pregnancy induced hypertension
33  Pre-term labour (36 weeks or before)
34  Proven cephalopelvic disproportion
35  Pulmonary embolism
36  Stillbirth or neonatal death
37  Third or fourth degree tear
38
39Current Pregnancy (n = 5)
40
41  Antepartum haemorrhage – any blood loss to date
42  Contact with rubella
43  Depression
44  Exposure to toxic agents

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1  Surgery during pregnancy

2
3Personal Factors (n = 6)
4
5  Alcohol misuse
6  Drug misuse
7  Genital mutilation
8  High BMI – 35 or above
9  Low BMI – 18 or below
10  Older woman (40+)
11
12Social Factors (n = 4)
13
14  Asylum seeker or refugee
15  Attending detoxification programme
16  Homeless
17  Victim of abuse inc. domestic violence; past abuse; childhood abuse
18
19Past and existing medical problems (n = 35)
20
21  Anaemia
22  Anaesthetic problems
23  Any blood disorder
24  Auto-immune disease
25  Cardiac disease
26  Cervical surgery (including large loop excision of the transformation zone
27 (LLETZ) and colposcopy)
28  Clotting disorder
29  Deep vein thrombosis
30  Diabetes
31  Endocrine disorder
32  Epilepsy
33  Genital infection including herpes
34  Hepatitis
35  HIV/AIDS
36  Hypertension
37  Inflammatory bowel disease
38  Jaundice
39  Liver disease
40  Medications
41  Neurological disease
42  Pelvis injury
43  Prolapse

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1  Psychiatric illness incl. anxiety and/or depression; treatment for emotional

2 problems
3  Recurrent urinary tract infection
4  Renal disease
5  Respiratory problems
6  Sexually transmitted infections
7  Sickle cell anaemia
8  Sickle cell trait
9  Thalassaemia
10  Thalassaemia trait
11  Thromboembolism
12  Tuberculosis
13  Urinary or faecal incontinence
14  Uterine abnormality including fibroids
15
16Family Medical History (n = 11)
17
18  Blood relative to baby’s father / consanguinity
19  Cardiac disease
20  Congenital heart disease
21  Cystic fibrosis
22  Diabetes
23  Eclampsia
24  Genetic/inherited disorder
25  Muscular dystrophy
26  Neonatal death
27  Problems with general anaesthetic
28  Stillbirth
29
30These items will be included in the final version of the assessment tool and used
31to identify which women would need referral to obstetric care.
32
33Further work
34The next developmental stage for the antenatal assessment tool will identify
35items for inclusion to determine which women would benefit from further
36specialist referral during pregnancy e.g. to social workers, mental health
37specialists, medical specialists, nutritionists/dieticians, physiotherapists etc. The
38same list of items will be included as used in the first stage of developmental
39work (reported above) and consensus methods used to identify those women
40who would benefit from this “enhanced” care. Following this phase of work the
41structure and wording of the assessment tool would then be developed in
42consultation with a wide range of stakeholders, including women’s
43representatives. The draft assessment tool would then be ready for validation
44and feasibility-testing in clinical practice.
45

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1It is intended that the tool would be used at the first antenatal appointments to
2help identify the most appropriate care pathway for pregnancy ie.
3baseline/standard midwifery care (as outlined in the NICE Antenatal Care
4Guideline update), “enhanced” midwifery care (which may involve additional
5antenatal appointments with a midwife, care from a specialist midwife or
6additional care from other health care professionals or social care agencies), or
7referral to obstetric care. It is recognised that the precise nature of such referrals
8and the number of antenatal appointments necessary will depend upon local
9availability of services and the individual needs of each woman.

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