National Institute for Health and Care Excellence
Other
Noted
NICE acknowledges the coroner's concerns regarding the lack of a standard definition for "large for gestational age" in its guideline on intrapartum care, but argues that providing a specific cut-off would convey inappropriate certainty. (AI summary)
View full response
Dear Mr Butler,
I write in response to your regulation 28 report of 9 November 2021 regarding the very sad death of Molly Dimmock. I would like to express my sincerest condolences to her family.
In your report you state that, while NICE’s clinical guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies [NG121] makes recommendations on the mode of birth for large-for-gestational-age babies, as there is no standard definition of large for gestational age, the guidance is open to interpretation and is inconsistently applied.
During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.
Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.
We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.
I write in response to your regulation 28 report of 9 November 2021 regarding the very sad death of Molly Dimmock. I would like to express my sincerest condolences to her family.
In your report you state that, while NICE’s clinical guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies [NG121] makes recommendations on the mode of birth for large-for-gestational-age babies, as there is no standard definition of large for gestational age, the guidance is open to interpretation and is inconsistently applied.
During the development of NG121, the committee acknowledged that there is a lot of uncertainty around the diagnosis of large for gestational age. There is no standardised definition and clinical suspicion of large for gestational age, particularly during labour, is subjective and often inaccurate. While ultrasound estimation of fetal weight is likely to be more accurate, it is difficult to perform accurately during labour.
Given this uncertainty the committee felt it was important to give the woman balanced information to support shared decision making. The discussion between healthcare professionals and a woman with a baby suspected of being large for gestational age should focus not only on the potential risk of adverse outcomes for the woman and the baby, but also on the uncertainty around the diagnosis of a large-for-gestational-age baby and what it might mean for the woman and her baby if such problems did occur.
We believe that if the guideline were to provide a cut off it would be liable to convey inappropriate certainty, or reassurance if the cut off is not reached. As such, we do not believe that any action is required of NICE.