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Tools for the clinical review of women
Evidence review H
NICE Guideline, No. 194
National Guideline Alliance (UK).
Tools for the clinical review of women
Review question
What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
Introduction
With postnatal care extending across acute and community services, there is a need for consistency in how assessment of the wellbeing of the women is undertaken. Repeated surveys of women’s experience with NHS postnatal services has identified a mismatch between how assessment is undertaken and their expectations. Pain and constipation in the postpartum period are common and can have an impact on daily living and wellbeing and can have severe short- and long-term consequences. The aim of this review is to identify clinical tools that are effective in assessing the woman’s health, pain and constipation in particular, in the first 8 weeks after giving birth.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details, see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy until March 2018. From April 2018 until June 2019, declarations of interest were recorded according to NICE’s 2018 conflicts of interest policy. From July 2019 onwards, the declarations of interest were recorded according to NICE’s 2019 conflicts of interest policy. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).
Clinical evidence
Included studies
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.
Summary of studies included in the evidence review
No studies were identified which were applicable to this review question (and so there are no evidence tables in appendix D). No meta-analysis was undertaken for this review (and so there are no forest plots in appendix E).
Quality assessment of clinical outcomes included in the evidence review
No studies were identified which were applicable to this review question and so there are no evidence profiles in appendix F.
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
No economic studies were reviewed at full text and excluded from this review.
Economic model
No economic modelling was undertaken for this review because, although the review question was considered priority for modelling, no clinical evidence that would allow development of an economic model was identified.
Evidence statements
Clinical evidence statements
No evidence was identified which was applicable to this review question.
Economic evidence statements
No economic evidence was identified which was applicable to this review question.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee rated maternal death, maternal morbidity and maternal re-attendance or admission to hospital as critical outcomes. The committee agreed it would have been important for their decision making to know whether the use of one tool or another results in the identification of signs or symptoms that may lead to any of these critical outcomes. These critical outcomes were chosen as they are often preventable and early warning systems may improve maternal outcomes.
In addition, the committee rated the following outcomes as critical, in respect of specific tools: depression and sexual distress – for a pain assessment tool and constipation severity – for a constipation assessment tool. The committee also rated chronic pain as an important outcome.
The potential long-term impact of sub-optimal postnatal pain management on maternal health, breast feeding rates, mother and baby bonding, sexual distress and chronic pain require these to be identified and addressed.
No relevant evidence was located, therefore the committee had no data on any of these outcomes to use as a basis for discussions or making recommendations.
The quality of the evidence
No studies were identified which were applicable to this review question.
Benefits and harms
Because of the lack of evidence, the committee were not able to recommend any specific tools for the assessment of pain or constipation in women in the first 8 weeks after birth but a research recommendation was made so that future research could identify clinical tools that could be useful in the assessment of the health of women in the postpartum period. See appendix L for more details.
Based on discussion around evidence review J on perineal pain, the committee recommended that a validated pain scale could be used to monitor perineal pain over time. Based on evidence review F on the content of postnatal contacts, the committee drafted recommendations which relate to the assessment of women’s health. The committee agreed that routine postnatal contact by all healthcare professionals should include an assessment of the general health and wellbeing of the woman, including discussion about symptoms and signs of potential postnatal physical and mental health problems. The woman’s psychological and emotional health should also be assessed at every contact. At every postnatal contact with a midwife, there should be an assessment of symptoms and signs of infection, pain, vaginal discharge and bleeding, bladder function, bowel function (including constipation), breast comfort, symptoms and signs of thromboembolism, anaemia and pre-eclampsia, perineal healing for those who had a vaginal birth and wound healing for those who had caesarean section.
The committee discussed that women often suffer needlessly with postnatal pain and discomfort. The committee highlighted that health care professionals are at risk of working on the basis that a significant amount of discomfort post birth is ‘to be expected’ and does not need treating. In fact, these are health issues that should be treated and therefore should be appropriately assessed. The benefit of assessing the woman’s health would be to identify concerns in the early stages and intervening earlier, as opposed to not identifying the problems until later on where the issues have worsened, causing distress and requiring intensive resources. However, there is a small risk of overtreatment if women receive treatment when their symptoms may have naturally resided with time resulting in potentially unnecessary intervention.
The committee agreed that assessing pain was of particular importance, because if women are judged to ‘look comfortable’ they are assessed as not being in pain. Postnatal pain is ‘normalised’ and therefore most often not treated. The committee therefore wanted to ensure that any assessment of a woman’s health in the postnatal period includes talking to the woman about how she is feeling and about how her symptoms are affecting her daily life. The committee were aware that every woman’s experience of pain and distress is different, and their level of discomfort would be subjective too.
The committee acknowledged that certain specific health conditions are covered by other NICE guidelines. Therefore, for women with sepsis, hypertension, diabetes, thromboembolism, and urinary incontinence and pelvic organ prolapse, the committee agreed to cross refer to the NICE guidelines for details specific to assessment in these conditions.
Cost effectiveness and resource use
No economic evidence is available for this review question. The committee agreed that spending time at postnatal contacts to ask women about their physical and mental health and emotional wellbeing, including, for example, assessment of pain, symptoms and signs of infection, bladder and bowel function, and other clinical conditions that may develop after giving birth, has low-to-moderate resource implications (health professional time). However, assessment and monitoring of women’s health may lead to improved health and quality of life for the woman and cost-savings to the health service, because this approach allows symptoms to be managed appropriately at an early stage, before they become more severe and require a more costly intervention. Therefore, the committee agreed that the recommendations ensure efficient use of healthcare resources.
References
No evidence was identified which was applicable to this review question.
Appendices
Appendix A. Review protocol
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Appendix D. Clinical evidence tables
Clinical evidence tables for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No evidence was identified which was applicable to this review question.
Appendix F. GRADE tables
GRADE tables for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded studies for review question: What tools for clinical review of women (including pain scores) are effective during the first 8 weeks after birth?
Clinical studies
Download PDF (202K)
Economic studies
No economic evidence was identified for this review.
Appendix L. Research recommendations
Final
Evidence review underpinning recommendations 1.2.1 to 1.2.3, 1.2.8 to 1.2.12 and 1.2.17
These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Tools for the clinical review of womenTools for the clinical review of women
- Postnatal care up to 8 weeks after birthPostnatal care up to 8 weeks after birth
- Timing of first postnatal contact by health visitorTiming of first postnatal contact by health visitor
- E3 ubiquitin-protein ligase UHRF2 isoform X2 [Homo sapiens]E3 ubiquitin-protein ligase UHRF2 isoform X2 [Homo sapiens]gi|2462622566|ref|XP_054217918.1|Protein
- Fiscal PolicyFiscal PolicyUse of government spending and taxation to influence the economy.<br/>Year introduced: 2017MeSH
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