Quality Standards Advisory Committee 1 Preterm labour and birth – prioritisation meeting th

Minutes of the meeting held on 4 February 2016 at the NICE offices in Manchester Attendees

Apologies

Standing Quality Standards Advisory Committee (QSAC) members Bee Wee (Chair), Ivan Benett, Helen Bromley, Phyllis Dunn, Steve Hajioff,Ian Manifold , Gavin Maxwell, Teresa Middleton,Juliette Millard, Hazel Trender, Hugo Van Woerden, Alyson Whitmarsh, Arnold Zermansky. Specialist committee members Jane Plumb, Louise Weaver-Lowe, Meekai To, Sam Oddie. NICE staff Stephanie Birtles (SB), Sabina Keane (SK), Nick Baillie (NB), Nicola Bodey (NB), Julia Sus (JS) Topic expert advisers None NICE Observers Julie Kennedy Standing Quality Standards Advisory Committee (QSAC) members Gita Bhutani, Jennifer Bostock, Amanda De La Motte, Phillip Dick, Sally Oliver, Jane Worsley.

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1. Welcome, introductions and plan for the day (private session)

The Chair welcomed the attendees and the Quality Standards Advisory Committee (QSAC) members introduced themselves.

2. Welcome and code of conduct for members of the

The Chair welcomed the public observers and reminded them of the code of conduct that they were required to follow. It was stressed that they were not able to contribute to the meeting but were there to observe only. They were also reminded that the Committee is independent and advisory therefore the

The Chair informed the Committee of the apologies and reviewed the agenda for the day.

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public attending the meeting (public session)

discussions and decisions made today may change following final validation by NICE’s guidance executive.

3. Committee business (public session)

Declarations of interest The Chair asked standing QSAC members to declare any interests that were either in addition to their previously submitted declaration or specific to the topic(s) under consideration at the meeting today. The Chair asked the specialist committee members to declare all interests. The following interests were declared: Standing committee members  Steve Hajioff was a member of public health and mortality board. Specialist committee members  Jane Plumb is a spokesperson for Group B strep support where she presented her views on how most early- onset GBS infection in babies could and should be prevented.  Sam Oddie is an author of a review paper advocating increased usage of antenatal magnesium to reduce cerebral palsy in preterm infants. Minutes from the last meeting th The Committee reviewed the minutes of the last meeting held on 7 January 2016 and confirmed them as an accurate record.

4. QSAC updates

NB provided committee with some brief updates.

5 and 5.1 Topic overview and summary of engagement responses

SB and SK presented the topic overview and a summary of responses received during engagement on the topic.

5.2. Prioritisation of quality improvement areas

The Chair and SK led a discussion in which areas for quality improvement were prioritised. The QSAC considered the draft areas as outlined in the briefing paper prepared by the NICE team.

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5.3 Prioritised area – Information and support

The Committee discussed the importance of oral and written information given to women at increased risk of preterm labour. It was agreed by the Committee that ‘increased risk’ should be defined as ‘a history of +0 +0 spontaneous preterm birth or mid-trimester loss between 16 and 34 weeks of pregnancy’ as stated in NICE NG25 recommendation 1.2.1.The Specialist Committee Members (SCMs) highlighted the need for better and more consistent communication between the obstetrician and neonatal team with more involvement by the pregnant women in decision-making.

NICE team to progress 2 statements on information and support for 2 different populations in line with NG25 recommendations 1.1.1 and 1.1.2

The Committee agreed to progress 2 statements on giving information and support to 2 different groups in line with NICE NG25 recommendations 1.1.1 and 1.1.2. 5.4 Prioritised area: Diagnosing preterm labour for women with intact membranes

The Committee discussed the importance of prompt fetal fibronectin testing and transvaginal ultrasound measurement of cervical length for women who are pregnant 30 weeks or over to indicate the likelihood of preterm labour and birth. The SCMs however highlighted that the population most affected by preterm +6 birth and labour are women who are 29 pregnant weeks or less. Therefore the Committee agreed to progress a statement aimed at this specific group in line with NG25 recommendation 1.7.3. The Committee agreed that if the clinical assessment indicates that the woman is in suspected preterm +6 labour and she is 29 weeks pregnant or less she should be advised specific, appropriate treatments such as tocolysis and maternal corticosteroids. Intravenous magnesium sulfate for neuroprotection was also agreed to be progressed for this area in line with NG25 recommendation 1.10.1

5.5 Prioritised area: Maternal corticosteroids

The Committee discussed maternal corticosteroids treatment. It was agreed to progress a statement in line with NG25 recommendation 1.9.3 but to focus this statement on pregnancy weeks 30-33 weeks, because the period before 30 weeks was already covered by the statement discussed above. The Committee also agreed that patient safety on the multiple use of steroids as stated in NG25 recommendation 1.9.6 should be built into the statement to not routinely offer repeated courses of maternal corticosteroids.

5.6 Non-prioritised area: Prophylactic vaginal

The Committee discussed the importance of offering vaginal progesterone to women at high risk of preterm labour and agreed that this is current practice. Therefore it has been agreed not to progress the statement. th

Quality Standards Advisory Committee 1 meeting 4 February 2016

NICE team to progress a statement on advising treatments tocolysis, maternal corticosteroids and magnesium sulfate for women diagnosed with suspected preterm labour who are between +6 29 pregnant weeks or less. NICE team to progress a statement on offering maternal corticosteroids to women between 30 33 weeks of pregnancy in line with NG25 recommendation 1.9.3 and to include some wording on patient safety in line with NG25 recommendation 1.9.6.

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progesterone and prophylactic cervical cerclage

The Committee also discussed cervical measurement being offered to all pregnant women including those with low risk of preterm labour. Prophylactic treatments are not offered routinely at the moment although there is strong evidence that progesterone use will decrease preterm birth. However, the SCMs highlighted the gap in evidence for transvaginal ultrasound scans followed by the prophylactic treatment. Due to a lack of accredited evidence supporting routine transvaginal ultrasound scan for all pregnant women the Committee agreed not to progress a statement on this but NICE team will ask a question on its variation in practice at consultation stage.

5.7 Non-prioritised area: Identifying infection in women with PROM

The Committee discussed use of the following clinical assessments and tests in diagnosing infection in women with P-Prom; C-reactive protein, white blood cell count and measurement of fetal heart rate using cardiotocorapgraphy. The Committee queried the reliability of these tests to diagnose preterm birth and labour. It was therefore it agreed not to prioritise this area.

5.8 Non-prioritised area: Timing of cord clamping for preterm babies (both vaginally or by caesarean section)

The Committee discussed timely cord clamping practices having an impact on the baby. Committee members agreed that timely cord clamping can reduce Intraventricular hemorrhage (IVH), reduce blood transfusion and reduce anemia but the quality of evidence on the significance of this procedure was low to very low. Therefore it was agreed not to progress the statement.

6. Additional areas

The Committee discussed the following additional areas that were suggested by stakeholders: A number of suggestions were received from stakeholders about possible additional quality statements. The Committee discussed there in turn, but agreed that none of the suggested areas should be progressed as new statements, either because the areas were felt to be covered by existing statements or because there were no source guideline recommendations.   

NICE team to draft a question about implementation of specialist preterm birth clinics for consultation.

PAMG-1 protein test- This was not progressed because there is no specific guideline recommendation. Maternity unit affiliated to NICU level 3 facilities- There is a guideline being developed on neonatal care Implementation of specialist preterm birth clinics- The committee agreed that a question about this area should be asked at the consultation phase. th

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Centres equipped to provide full neonatal intensive care- There is a guideline being developed on neonatal care. Practical information- This area will be covered by the statement on information and support. Psychological parental support- This area will be covered by the statement on information and support. Post-natal ward layout- There is a guideline being developed on Neonatal care. Multidisciplinary team care -This was not progressed because there is no specific guideline recommendation. Experiences of neonatal care- There is a guideline being developed on Neonatal care.

7. Overarching outcomes

The NICE team explained that the quality standard would describe overarching outcomes that could be improved by implementing a quality standard on preterm labour and birth. It was agreed that the Committee would contribute suggestions as the quality standard was developed.

8. Equality and diversity

The NICE team explained that equality and diversity considerations should inform the development of the quality standard, and asked the Committee to consider any relevant issues. It was agreed that the Committee would contribute suggestions as the quality standard was developed.

9. QSAC specialist committee members (part 1 – open session)

NB asked the QSAC to consider the constituency of specialist committee members on the group and whether any additional specialist members were required.

11. Next steps and timescales (part 1 – open session)

JS outlined what will happen following the meeting and key dates for the preterm labour and birth quality standard.

10. Any other business (part 1 – open session)

There were no items of AOB raised

Specialist members: It was agreed that we no further specialist members were required for next meeting.

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Date of next meeting for Preterm labour and birth: Thursday 7 July 2016 rd Date of next QSAC1 meeting: Thursday 3 March 2016

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