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id="_NBK571568_"><span itemprop="name">Timing of comprehensive assessment</span></h1><div class="subtitle">Postnatal care</div><p><b>Evidence review E</b></p><p><i>NICE Guideline, No. 194</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Guideline Alliance (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2021 Apr</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4078-3</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div></div><div class="bkr_clear"></div></div><div id="niceng194er5.s1"><h2 id="_niceng194er5_s1_">Timing of comprehensive assessment</h2><div id="niceng194er5.s1.1"><h3>Review question</h3><p>When should a comprehensive, routine assessment at the end of the postnatal period occur?</p><div id="niceng194er5.s1.1.1"><h4>Introduction</h4><p>There has traditionally been a routine ‘postnatal check’ for women, marking a somewhat arbitrary end to the postnatal period. Some doubt has been cast on both the value and the timing of this consultation. The aim of this review is to assess the effectiveness and timing of the routine assessment of the woman’s health within the 8 week period of this guideline.</p></div><div id="niceng194er5.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK571568/table/niceng194er5.tab1/?report=objectonly" target="object" rid-figpopup="figniceng194er5tab1" rid-ob="figobniceng194er5tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng194er5tab1"><a href="/books/NBK571568/table/niceng194er5.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng194er5tab1" rid-ob="figobniceng194er5tab1"><img class="small-thumb" src="/books/NBK571568/table/niceng194er5.tab1/?report=thumb" src-large="/books/NBK571568/table/niceng194er5.tab1/?report=previmg" alt="Table 1. Summary of the protocol (PICO table)." /></a><div class="icnblk_cntnt"><h4 id="niceng194er5.tab1"><a href="/books/NBK571568/table/niceng194er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng194er5tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the protocol (PICO table). </p></div></div><p>For further details, see the review protocol in <a href="#niceng194er5.appa">appendix A</a>.</p></div><div id="niceng194er5.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>
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<u>2014</u>. Methods specific to this review question are described in the review protocol in <a href="#niceng194er5.appa">appendix A</a>.</p><p>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 <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">conflicts of interest policy</a>. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).</p></div><div id="niceng194er5.s1.1.4"><h4>Clinical evidence</h4><div id="niceng194er5.s1.1.4.1"><h5>Included studies</h5><p>A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.</p><p>See the literature search strategy in <a href="#niceng194er5.appb">appendix B</a> and study selection flow chart in <a href="#niceng194er5.appc">appendix C</a>.</p></div><div id="niceng194er5.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review with reasons for their exclusion are provided in <a href="#niceng194er5.appk">appendix K</a>.</p></div></div><div id="niceng194er5.s1.1.5"><h4>Summary of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question (and so there are no evidence tables in <a href="#niceng194er5.appd">Appendix D</a>). No meta-analysis was undertaken for this review (and so there are no forest plots in <a href="#niceng194er5.appe">Appendix E</a>).</p></div><div id="niceng194er5.s1.1.6"><h4>Quality assessment of studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question and so there are no evidence profiles in <a href="#niceng194er5.appf">appendix F</a>.</p></div><div id="niceng194er5.s1.1.7"><h4>Economic evidence</h4><div id="niceng194er5.s1.1.7.1"><h5>Included studies</h5><p>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 <a href="#niceng194er5.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng194er5.appg">appendix G</a>.</p></div><div id="niceng194er5.s1.1.7.2"><h5>Excluded studies</h5><p>No economic studies were reviewed at full text and excluded from this review.</p></div></div><div id="niceng194er5.s1.1.8"><h4>Economic model</h4><p>No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.</p></div><div id="niceng194er5.s1.1.9"><h4>Evidence statements</h4><div id="niceng194er5.s1.1.9.1"><h5>Clinical evidence statements</h5><p>No evidence was identified which was applicable to this review question.</p></div><div id="niceng194er5.s1.1.9.2"><h5>Economic evidence statements</h5><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er5.s1.1.10"><h4>The committee’s discussion of the evidence</h4><div id="niceng194er5.s1.1.10.1"><h5>Interpreting the evidence</h5><div id="niceng194er5.s1.1.10.1.1"><h5>The outcomes that matter most</h5><p>The committee rated emotional attachment between mother and baby up to 18 months of baby’s age, maternal mortality, and unplanned attendance for the woman to health services within 3 months after the birth as critical outcomes for decision making. A routine postnatal assessment usually at 6–8 weeks is often the only assessment the woman will have after the initial postnatal period and is important in identifying early signs of serious emotional and or physical health issues that may otherwise be missed, potentially leading to further complications and an increased use of health services.</p><p>The committee wanted to see if a routine postnatal assessment focusing on the woman would improve her overall postnatal care experience and her health related quality of life, so these were rated as important outcomes. For breastfeeding support after the initial postnatal period, the only contact with a healthcare professional a woman will have is the routine postnatal assessment at 6–8 weeks, therefore the committee were interested in whether the routine postnatal assessment would impact on breastfeeding outcomes and prioritised the proportion of women breastfeeding as an important outcome. The proportion of women assessed by a healthcare professional as experiencing moderate to severe depression, PTSD, or anxiety was selected as an important outcome, because mental health problems are known to impact many women in the postnatal period and the committee wanted to see if a routine postnatal assessment could have an impact on this.</p><p>No evidence was identified, therefore the committee had no data on any of these outcomes to use as a basis for discussions or making recommendations.</p></div><div id="niceng194er5.s1.1.10.1.2"><h5>The quality of the evidence</h5><p>No evidence was identified.</p></div><div id="niceng194er5.s1.1.10.1.3"><h5>Benefits and harms</h5><p>In view of the lack of evidence, the committee made the recommendations through informal consensus, based on their knowledge and experience. The committee agreed to recommend a routine postnatal assessment for the woman at 6–8 weeks after the birth as there was no evidence to support a change in what is done most commonly in current practice. The committee agreed a routine postnatal assessment is an opportunity for the woman to raise any concerns pertaining to herself that may otherwise be missed as this is usually the only scheduled appointment after the initial postnatal period that the woman has. The benefit of a routine postnatal assessment would identify emotional, physical, social, or sexual concerns in the early stages and intervening earlier, as opposed to not identifying the problems until later on where the issues have worsened, potentially become chronic and may require interventions and additional resources. The committee also discussed the harms of not conducting a routine postnatal assessment and the risk of women “falling through the net”, which currently happens in practice as a postnatal assessment of the woman is not mandated.</p><p>The committee discussed the timing of the routine postnatal assessment for the woman and agreed that the optimal timing would be at 6–8 weeks after the birth, coinciding with the newborn and infant physical examination (NIPE) screening programme as well as the assessment of the baby at 6–8 weeks recommended by this guideline (see evidence review F). The benefit of timing the routine postnatal assessment at 6–8 weeks would be to leave an adequate gap between previous midwife and health visitor appointments, giving time for the woman to consolidate concerns and address new issues, but equally not leaving too much time so that the woman’s issues are unaddressed for too long. Additionally, coordinating the assessment of the baby at 6–8 weeks would avoid the need for 2 separate appointments for the mother and baby, benefiting both the mother and health service in terms of time and resources. The committee discussed that separate appointments may be appropriate, particularly if requested by the woman but that on balance this was outweighed by the benefit of coordinating the two assessments.</p><p>The committee were aware that this examination should be performed by the GP as per the recent GP contract between NHS England and the British Medical Association. Benefits of having the woman’s GP conduct the assessment would be that a positive relationship may already be established so the GP may be more likely to identify concerns and the woman may be more likely to raise concerns. Additionally, if any problems are identified the GP may be able to initiate treatment or directly refer to specialist care, as opposed to another healthcare professional conducting the assessment and then having to refer to the GP for further assessment thus saving the woman time and initiating treatment sooner.</p><p>The committee agreed that the content of the comprehensive assessment should be aligned with the recommendations based on evidence review F about the essential content of postnatal care contacts.</p><p>Despite, no evidence being identified for this review, the committee agreed to not write a research recommendation on the timing of a comprehensive assessment. This was because changing the timeframe of a relatively narrow window is unlikely to make a significant difference to women’s and baby’s outcomes and would therefore be unlikely to support a change in clinical practice. On balance the committee agreed to prioritise other areas for research recommendations.</p></div></div><div id="niceng194er5.s1.1.10.2"><h5>Cost effectiveness and resource use</h5><p>No economic evidence on the optimal timing for routine assessment at the end of the postnatal period was identified. The committee expressed the view that a routine postnatal assessment usually at 6–8 weeks postnatally is often the only assessment the woman will have after the initial postnatal period and is important in identifying early signs of serious emotional and/or physical health issues that may otherwise be missed, potentially leading to further complications and an increased use of health services. Therefore, the committee agreed that the recommendation ensures efficient use of healthcare resources.</p></div><div id="niceng194er5.s1.1.10.3"><h5>Other factors the committee took into account</h5><p>The committee noted during protocol development that certain subgroups of women may require special consideration due to their potential vulnerability:
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<ul><li class="half_rhythm"><div>young women (19 years or under)</div></li><li class="half_rhythm"><div>women with physical or cognitive disabilities</div></li><li class="half_rhythm"><div>women with severe mental health illness</div></li><li class="half_rhythm"><div>women who have difficulty accessing postnatal care services.</div></li></ul></p><p>A stratified analysis was therefore predefined in the protocol based on these subgroups. However, no evidence was identified. The committee agreed separate recommendations were not needed as the same recommendations would apply to these groups.</p></div></div><div id="niceng194er5.s1.1.11"><h4>References</h4><p>No evidence was identified which was applicable to this review question.</p></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng194er5.appa"><h3>Appendix A. Review protocol</h3><p id="niceng194er5.appa.et1"><a href="/books/NBK571568/bin/niceng194er5-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</a><span class="small"> (PDF, 228K)</span></p></div><div id="niceng194er5.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng194er5.appb.et1"><a href="/books/NBK571568/bin/niceng194er5-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</a><span class="small"> (PDF, 248K)</span></p></div><div id="niceng194er5.appc"><h3>Appendix C. Clinical evidence study selection</h3><p id="niceng194er5.appc.et1"><a href="/books/NBK571568/bin/niceng194er5-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: When should a comprehensive, routine assessment at the end of the postnatal period occur?</a><span class="small"> (PDF, 127K)</span></p></div><div id="niceng194er5.appd"><h3>Appendix D. Clinical evidence tables</h3><div id="niceng194er5.appd.s1"><h4>Evidence tables for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er5.appe"><h3>Appendix E. Forest plots</h3><div id="niceng194er5.appe.s1"><h4>Forest plots for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No meta-analysis was conducted for this review question and so there are no forest plots.</p></div></div><div id="niceng194er5.appf"><h3>Appendix F. GRADE tables</h3><div id="niceng194er5.appf.s1"><h4>GRADE tables for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er5.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng194er5.appg.et1"><a href="/books/NBK571568/bin/niceng194er5-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence study selection for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</a><span class="small"> (PDF, 234K)</span></p></div><div id="niceng194er5.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng194er5.apph.s1"><h4>Economic evidence tables for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No economic evidence was identified which was applicable to this review question</p></div></div><div id="niceng194er5.appi"><h3>Appendix I. Economic evidence profiles</h3><div id="niceng194er5.appi.s1"><h4>Economic evidence profiles for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er5.appj"><h3>Appendix J. Economic analysis</h3><div id="niceng194er5.appj.s1"><h4>Economic analysis for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng194er5.appk"><h3>Appendix K. Excluded studies</h3><div id="niceng194er5.appk.s1"><h4>Excluded studies for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4></div><div id="niceng194er5.appk.s2"><h4>Clinical studies</h4><p id="niceng194er5.appk.et1"><a href="/books/NBK571568/bin/niceng194er5-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (176K)</span></p></div><div id="niceng194er5.appk.s3"><h4>Economic studies</h4><p>No economic evidence was identified for this review.</p></div></div><div id="niceng194er5.appl"><h3>Appendix L. Research recommendations</h3><div id="niceng194er5.appl.s1"><h4>Research recommendations for review question: When should a comprehensive, routine assessment at the end of the postnatal period occur?</h4><p>No research recommendations were made for this review question</p></div></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence review underpinning recommendation 1.2.7</p><p>These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists</p></div><div><p><b>Disclaimer</b>: 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.</p><p>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.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div><div class="small"><span class="label">Bookshelf ID: NBK571568</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/34191439" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">34191439</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng194er5tab1"><div id="niceng194er5.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571568/table/niceng194er5.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng194er5.tab1_lrgtbl__"><table class="no_bottom_margin"><tbody><tr><th id="hd_b_niceng194er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng194er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Women who have given birth, from the birth of the baby to 8 weeks after birth.</td></tr><tr><th id="hd_b_niceng194er5.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng194er5.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Routine assessment of the woman’s health and wellbeing. A routine assessment may take into account physical, emotional, social, or sexual postnatal concerns.</td></tr><tr><th id="hd_b_niceng194er5.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng194er5.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Comparator 1. No routine assessment of the woman</p>
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<p>Comparator 2. Same routine assessment of the woman at a different time.</p>
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</td></tr><tr><th id="hd_b_niceng194er5.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng194er5.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><b>Critical</b>
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<ul><li class="half_rhythm"><div>emotional attachment between mother and baby up to 18 months of baby’s age</div></li><li class="half_rhythm"><div>maternal mortality</div></li><li class="half_rhythm"><div>proportion of unplanned attendance for woman to health services including admission to hospital for problems within 3 months after the birth.</div></li></ul>
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<b>Important</b>
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<ul><li class="half_rhythm"><div>proportion of women satisfied with their postnatal care</div></li><li class="half_rhythm"><div>health related quality of life</div></li><li class="half_rhythm"><div>proportion of women breastfeeding (exclusively or partially) at 6 weeks, 12 weeks or 6 months after the birth</div></li><li class="half_rhythm"><div>proportion of women assessed by a healthcare professional as experiencing moderate to severe depression or PTSD or anxiety at 6 to 8 weeks, 3 months or 6 months after the birth.</div></li></ul></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">PTSD: post-traumatic stress disorder</p></div></dd></dl></dl></div></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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