Ectopic pregnancy and miscarriage
Clinical case scenarios for
GPs, A&E services and
healthcare professionals
working in early pregnancy
assessment services.
2013
NICE clinical guideline 154
These clinical case scenarios accompany the clinical guideline: ‘Ectopic
pregnancy and miscarriage’ (available at www.nice.org.uk/guidance/CG154).
Issue date: February 2013
This is a support tool for implementation of the NICE guidance.
It is not NICE guidance.
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Contents
Contents .......................................................................................................... 3
Introduction ...................................................................................................... 4
NICE clinical case scenarios ........................................................................ 4
Ectopic pregnancy and miscarriage ............................................................. 4
Learning objectives ...................................................................................... 5
1: Women presenting with bleeding in early pregnancy ................................... 6
2: Women presenting with bleeding in early pregnancy ................................. 10
3: Women presenting with abdominal pain .................................................... 14
4: Women presenting with a non-viable pregnancy ....................................... 19
Glossary ......................................................................................................... 25
Other implementation tools ............................................................................ 25
Acknowledgements ........................................................................................ 25
Introduction
NICE clinical case scenarios
Clinical case scenarios are an educational resource that can be used for
individual or group learning. Each question should be considered by the
individual or group before referring to the answers.
These 4 clinical case scenarios have been put together to improve your
knowledge of ectopic pregnancy and miscarriage and its application in
practice. They illustrate how the recommendations from Ectopic pregnancy
and miscarriage (NICE clinical guideline 154) can be applied to the care of
women presenting to GPs, A&E services and healthcare professionals
working in early pregnancy assessment services.
The clinical case scenarios are available in 2 formats: this version, which can
be used for individual learning, and a slide set version that can be used for
group learning or training situations.
You will need to refer to the NICE clinical guideline to help you decide what
steps you would need to follow to diagnose and manage each case, so make
sure that you or your users have access to the recommendations via either
the ectopic pregnancy and miscarriage pathway or from the guidance page.
You may also want to refer to the NHS Evidence topic page.
Each case scenario includes details of the woman’s initial presentation, their
medical history and their clinician’s summary of the situation after
examination. The clinical decisions about diagnosis and management are
then examined using a question and answer approach. Links to the relevant
recommendations from the NICE guideline are provided after the answer.
Ectopic pregnancy and miscarriage
Ectopic pregnancy and miscarriage have an adverse effect on the quality of
life of many women. Approximately 20% of pregnancies miscarry, and
miscarriages can cause considerable distress. Early pregnancy loss accounts
for over 50,000 admissions in the UK annually. The rate of ectopic pregnancy
is 11 per 1000 pregnancies, with a maternal mortality of 0.2 per
1000 estimated ectopic pregnancies. About two-thirds of these deaths are
associated with substandard care. Women who do not access medical help
readily (such as women who are recent migrants, asylum seekers, refugees,
or women who have difficulty reading or speaking English) are particularly
vulnerable. Improvement in the diagnosis and management of early
pregnancy loss is therefore of vital importance, in order to reduce the
incidence of the associated psychological morbidity and avoid the
unnecessary deaths of women with ectopic pregnancies.
Learning objectives
After working through these case scenarios, participants should be able to
describe and demonstrate:
when and where to refer women experiencing pain and/or bleeding in early
pregnancy
the information and support needs of women experiencing pain and/or
bleeding in early pregnancy
when to ‘think pregnancy’ for women presenting with non-specific
symptoms, in the context of ectopic pregnancy risk
when to use expectant management of miscarriage
the general information and support needs of women experiencing a
miscarriage.
1: Women presenting with bleeding in early pregnancy
Learning objectives
When to use expectant management for women experiencing bleeding in
early pregnancy.
What advice to give women undergoing expectant management of bleeding
in early pregnancy.
The information and support needs of women undergoing expectant
management of bleeding in early pregnancy.
Case overview
Presentation
Bethan is 28 and pregnant for the first time. She noticed some bleeding that
morning and is understandably concerned.
History
Bethan is 4 weeks into her pregnancy. She and her husband always knew
they wanted a family and decided the time was right 6 months ago. Bethan
had visited her GP to talk about her pregnancy plans. She monitored her
periods closely and when her period was late, she took a pregnancy test and
subsequently booked an appointment with her GP, where the pregnancy was
confirmed 1 week ago.
During that appointment Bethan had been given lifestyle advice and
encouraged to consider folic acid supplementation and the risks and benefits
of antenatal screening. She was asked to return in 2 weeks if all is well for
referral onto antenatal services.
On examination
Bethan confirms that she feels no pain and has not had any other symptoms
apart from slight morning sickness. When asked about the extent of the
bleeding, Bethan describes it as ‘spotting’ that she noticed on her underwear
when going to the toilet. On physical examination there are no signs of
abdominal tenderness or signs of intra-abdominal bleeding.
Next steps for diagnosis/management
As the pregnancy was confirmed by her GP a week ago you do not consider it
necessary to conduct a pregnancy test.
You consider whether a vaginal examination is necessary but given that
Bethan reports no other symptoms and clearly describes the nature of the
bleeding as ‘spotting’, you decide this will not be necessary.
Question 1.1
Does Bethan need an onward referral?
Answer 1.1
Bethan does not need an onward referral, subject to checking for certain risk
factors. You consider whether the gestation period is uncertain, but believe
this is unlikely given the planned nature of the pregnancy and Bethan’s
vigilance while waiting to see if she was pregnant.
Therefore, as her pregnancy is less than 6 weeks’ gestation and there is no
pain, you would aim to see whether the condition will resolve naturally (an
‘expectant management’ approach).
Rationale for this decision
Not all women presenting to a healthcare professional with bleeding in early
pregnancy need to be referred for a transvaginal ultrasound scan. Women
who are reporting to be less than 6 weeks pregnant with bleeding but no pain
can undergo expectant management. At gestations of less than 6 weeks, the
pregnancy is likely to be too small to yield any information about viability. In
addition, many women experience spotting in early pregnancy that resolves
without the need for further intervention.
See recommendation 1.3.10 for details.
Next steps for management
Bethan expresses concern that no further action is being taken.
Question 1.2
How do you explain this decision?
Answer 1.2
You explain that at this stage, the pregnancy is too small to see, and any
further investigations such as scanning are unlikely to yield any information.
You also note that many women experience ‘spotting’ during early pregnancy
that resolves without the need for further intervention. Therefore you advise
waiting to see how things progress during the next week before any further
action can be considered.
Next steps for management
Bethan indicates that she understands and acknowledges that she is a
nervous ‘first-timer’.
Question 1.3
What advice and information do you give to Bethan before she leaves?
Answer 1.3
Bethan will need to know what she should do during the course of the
‘expectant management’ week. You advise her to repeat a urine pregnancy
test after 7–10 days and attend the GP surgery if it is positive. You confirm to
Bethan in a sensitive manner that a negative pregnancy test means that the
pregnancy has miscarried. If this is the case, she may also want to return to
her GP for review. You emphasise that given the nature of Bethan’s
symptoms the outcome of the test is just as likely to be positive.
You advise Bethan to return to be assessed if her symptoms continue or
worsen.
See recommendation 1.3.10 for details.
As well as explaining what changes in her condition should prompt her to seek
medical attention, you make sure that Bethan has information on where to
seek help in an emergency situation.
You are sensitive to the fact that Bethan may be in some distress having
discovered a potentially worrying symptom. It is important that Bethan has
access to information resources that are accurate, and that may provide some
reassurance during this time. You may consider signposting Bethan to some
useful websites and giving her a leaflet detailing the web addresses and
telephone numbers.
See recommendation 1.1.3 for details.
Supporting information
The following organisation provides information, support and resources for
women in early pregnancy:
Early Pregnancy Information Centre
www.earlypregnancy.org.uk
2: Women presenting with bleeding in early pregnancy
Learning objectives
When and where to refer women experiencing bleeding in early pregnancy.
The information and support needs of women being referred to an early
pregnancy assessment service with bleeding in early pregnancy.
Case overview
Presentation
Nisha is 32 and expecting her third child. She complains of bleeding that
began the previous day.
History
Nisha did not experience any complications during her first 2 pregnancies.
She reported that she had had some ‘spotting’ about 3 weeks ago which had
resolved. She recalled that this can be normal so did not visit her GP.
The pregnancy was a surprise, and she has not yet visited her GP to have the
pregnancy confirmed. She believes she is now at 6 weeks gestation based on
when she remembers last having a period.
On examination
Nisha says that the bleeding is intermittent but more substantial than the
‘spotting’ she had previously experienced. She reports no pain, and no other
symptoms.
Next steps for diagnosis/management
You advise Nisha to have a pregnancy test which is positive. With her
agreement you then conduct a physical examination. This indicates no
abdominal tenderness, pelvic tenderness or cervical motion tenderness.
Question 2.1
Does Nisha need an onward referral?
Answer 2.1
You consider the risk factors for Nisha. Given Nisha’s account, you consider
that the gestation period could be uncertain and that the pregnancy could be
further along than the 6 weeks suggested. You decide to refer Nisha to an
early pregnancy assessment service for further assessment.
Rationale for this decision
For women with a pregnancy of 6 weeks gestation or more with bleeding or
other symptoms and signs of early pregnancy complications, referral to a
dedicated early pregnancy assessment service (or out-of-hours gynaecology
service if the early pregnancy assessment service is not available) should be
made so that an ultrasound scan can be carried out.
See recommendation 1.3.9 for details.
Supporting information
Regional services should be organised so that an early pregnancy
assessment service is available 7 days a week for women with early
pregnancy complications, where scanning can be carried out and decisions
about management made.
The Early Pregnancy Information Centre (www.earlypregnancy.org.uk)
contains details of the early pregnancy assessment units available in each
region.
Question 2.2
How soon should Nisha be seen?
Answer 2.2
In this case it is important to consider that the age of the pregnancy may be
uncertain. You ask Nisha whether she might be further along in her pregnancy
than previously thought, and she thinks it could be possible.
You consider that an appointment within 24 hours would be desirable, and
telephone the local early pregnancy assessment service, who are able to
provide an appointment for the next day.
Rationale for this decision
The urgency of the referral depends on the clinical situation. Nisha does not
have any ‘red flag’ symptoms for ectopic pregnancy such as shoulder tip pain
that would indicate an urgent referral. However, although Nisha is not
experiencing any pain, it is possible that her pregnancy may be further along
than the suggested 6 weeks, so it is important that Nisha has a scan quickly.
See recommendation 1.3.9 for details.
Supporting information
There should be a system in place to enable women referred to their early
pregnancy assessment service to be seen within 24 hours if the clinical
situation warrants this. If this service is not available and the clinical
symptoms warrant further assessment, women should be referred to the
nearest accessible facility that offers specialist clinical assessment and
ultrasound scanning (such as a gynaecology ward or A&E service with access
to specialist gynaecology support).
Next steps for management
You provide Nisha with the details of the local early pregnancy assessment
service – where it is located, a telephone number, and if possible the name of
the person she will see.
Question 2.3
What other information might Nisha need?
Answer 2.3
You explain to Nisha what the early pregnancy assessment service is, and
what she can expect when she arrives. You appreciate that this is an
unfamiliar situation for Nisha and that she may be worried about what the next
steps involve. You emphasise that the staff at the early pregnancy
assessment service are experts in diagnosing and caring for women
experiencing bleeding in early pregnancy, and the service has access to the
scanning equipment needed for further investigations. You advise Nisha to
expect an internal scan and blood test when she arrives.
You also provide Nisha with the website details for relevant organisations
such as the Early Pregnancy Information Centre, which provides general
information for women experiencing complications in early pregnancy.
See recommendation 1.3.12 for details.
Supporting information
An early pregnancy assessment service should be a dedicated service
provided by healthcare professionals competent to diagnose and care for
women with pain and/or bleeding in early pregnancy and offer ultrasound and
assessment of serum human chorionic gonadotrophin (hCG) levels. They
should be staffed by healthcare professionals who have training in how to
communicate sensitively and breaking bad news.
The Early Pregnancy Information Centre (www.earlypregnancy.org.uk) is a
resource for both clinicians and pregnant women, and includes a section on
‘Information about your pregnancy’, such as common worries, as well as links
to other useful resources.
3: Women presenting with abdominal pain
Learning objectives
When to ‘think pregnancy’ for women presenting with non-specific
symptoms, in the context of ectopic pregnancy risk.
Case overview
Presentation
You see Monika at 11.30 pm on a Saturday. She complains of severe
stomach pains.
History
Monika is 22 and has no history of abdominal pain or gastrointestinal
problems. She reports that the pain began after lunchtime. She had thought it
was something she had eaten and expected it to get better. However, during
the course of the evening the pain had got worse to the point where she felt it
was “unbearable”.
On examination
You ask if Monika is experiencing any other symptoms. Monika says she has
found it painful when going to the toilet during the past day or two, and
wonders if it might be related. A physical examination reveals some
abdominal tenderness.
You ask if Monika is, or could be, pregnant, to which Monika replies “not that I
know of”.
Next steps for diagnosis
You ask Monika when her last period was. Monika replies that she can’t be
sure as her periods have always been “all over the place”.
Question 3.1
You decide to ask Monika to take a pregnancy test. Why is this?
Answer 3.1
Monika is of reproductive age. You are aware that many symptoms and signs
of ectopic pregnancy are non-specific, and given the dangers of ectopic
pregnancy it is important to exclude this possibility before proceeding.
Rationale for this decision
Ectopic pregnancy occurs in around 1 in 100 pregnancies, and it is a
potentially life-threatening complication of pregnancy. Despite this, morbidity
and mortality attributable to failure to consider the diagnosis, and therefore
missed or delayed diagnosis, continues to be problematic.
Ectopic pregnancy is associated with a wide range of symptoms that can
resemble the common symptoms and signs of other conditions – for example,
gastrointestinal conditions or urinary tract infection. There is value in
healthcare professionals always considering pregnancy in women of
reproductive age presenting with these symptoms, and therefore they should
think about offering a pregnancy test.
See recommendation 1.3.5 for details.
Supporting information
All healthcare professionals involved in the care of women of reproductive age
should have access to pregnancy tests.
Next steps for management
The pregnancy test is positive. You break the news to Monika.
Question 3.2
What action should you now take?
Answer 3.2
Now that you know Monika is pregnant, you contact the on-call gynaecologist
for advice on how to proceed. You describe Monika’s symptoms to the
gynaecologist, who recommends assessing for pelvic or cervical motion
tenderness to establish whether Monika needs to be referred immediately for
specialist assessment.
Rationale for this decision
Risk factors are not an accurate way of identifying an ectopic pregnancy,
because evidence shows that about a third of women with an ectopic
pregnancy have no identifiable risk factors. In the absence of risk factors it is
still necessary for a healthcare professional to rule out the possibility of
ectopic pregnancy, and that women with cervical motion tenderness, pelvic
tenderness, and pain or tenderness in the abdominal region, which are
associated with ectopic pregnancy, should be immediately referred for further
assessment.
See recommendations 1.3.3 and 1.3.4 for details.
Next steps for management
An immediate referral is necessary for Monika. The local early pregnancy
assessment service will not be open until 9 am on Monday, but there is a
service within the region that is available 7 days a week, and will be open from
9 am on Sunday morning.
Question 3.3
Where should Monika be referred to?
Answer 3.3
Given the clinical situation and potential for ectopic pregnancy, and having
taken specialist advice from the on call gynaecologist, you refer Monika to the
out-of-hours gynaecology service for immediate ultrasound scanning.
Rationale for this decision
As immediate referral is indicated, the further assessment should take place
as soon as possible. Ideally, the woman would go directly from the place of
initial assessment to the early pregnancy assessment service, or alternative
out-of-hours gynaecology service if the early pregnancy assessment service is
not available, so as not to incur further delay.
See recommendation 1.3.7 for details.
Supporting information
Regional services should be organised so that an early pregnancy
assessment service is available 7 days a week for women with early
pregnancy complications, and a system should be in place to enable women
to attend within 24 hours if the clinical situation warrants this. If a more urgent
assessment is required and the early pregnancy assessment service is not
available, women should be referred to the nearest available facility that offers
specialist clinical assessment and ultrasound scanning (such as an out-ofhours gynaecology service).
Question 3.4
What information and support might Monika need?
Answer 3.4
Monika may be feeling particularly anxious and uncertain about what is
happening, as well as coming to terms with some unexpected news. It is
important that she is given information about why the referral is necessary and
what she can expect to happen next.
Monika should be treated in a sensitive and sympathetic manner and the
importance of good communication is paramount. Becoming pregnant carries
considerable psychological as well as physical and social significance, and
Monika will be dealing with this as well as the distress associated with early
pregnancy complications. Ectopic pregnancy can be life threatening if it is not
treated, and as this cannot be ruled out at this diagnostic stage Monika may
be feeling very frightened. The need for careful and considerate
communication is crucial, supported by written information where appropriate.
It is important that there is rapid communication between the gynaecologist
and the GP and the early pregnancy assessment service as to the outcome of
the investigations to ensure that Monika is followed up appropriately. The
gynaecologist may refer Monika directly to the early pregnancy assessment
service for subsequent follow-up and assessment. You may also encourage
Monika to make an appointment with her GP, who can have a role in providing
her with the information she needs as well as contact details for organisations
providing further support.
See recommendations 1.1.1, 1.1.2 and 1.1.3 for details.
4: Women presenting with a non-viable pregnancy
Learning objectives
When to use expectant management of miscarriage
What advice to give women undergoing expectant management of
miscarriage
The general information and support needs of women experiencing a
miscarriage.
Case overview
History
Sarah had experienced pain and bleeding during the early stages of her
pregnancy and was referred for specialist assessment. Further investigations
determined that the pregnancy was not viable at 7 weeks gestation.
Following this diagnosis you consult with Sarah, who is accompanied by her
husband, to discuss the next steps.
Next steps for management
You will need to explain the most appropriate treatment options available to
Sarah for the completion of the miscarriage, so that she can make an
informed decision about her preferred choice for further management.
Question 4.1
Sarah asks what will happen next. What are Sarah’s options?
Answer 4.1
Expectant management for 7–14 days is the first-line management strategy
for women with a confirmed diagnosis of miscarriage, although other
management options should be explored in certain situations.
See recommendations 1.5.2 and 1.5.3 for details.
Next steps for management
Although Sarah is not in the late first trimester and therefore not at increased
risk of haemorrhage, you consider other factors such as whether she is at
increased risk from the effects of haemorrhage (for example, if she has
coagulopathies or is unable to have a blood transfusion). You also check for
any evidence of infection, by for example asking Sarah whether she has, or
has had, a temperature, or chills.
Question 4.2
What information about expectant management do you need to provide to
Sarah to inform her decision?
Answer 4.2
You explain what expectant management involves and why this is
recommended. This is to ensure that Sarah does not feel that she might be
sent away to endure what will be a distressing experience. You emphasise
that this is the least risky option in terms of any complications that might arise
from medical or surgical management. You explain that this approach negates
the risk of intervening and accidentally terminating a viable pregnancy. In
addition, you emphasise that this is a ‘gentler’, non-invasive approach where,
for most women, no further treatment will be needed.
You also emphasise that Sarah has a choice in this matter, that alternatives
are available, and that it is important that Sarah is comfortable with her
decision. At all times it is essential that you communicate sensitively and
remain aware that Sarah may be in significant distress.
Rationale for this decision
The most important clinical outcomes in miscarriage are the need for an
unplanned intervention, the incidence of infection, gastrointestinal side effects
and the need for a blood transfusion, as well emotional and psychological
outcomes. For most women, expectant management may be an acceptable or
even preferable alternative, as it negates the risk of intervening and
accidentally terminating a viable pregnancy.
For some women, however, expectant management will be unacceptable, and
it is important that the woman is offered a choice. If expectant management is
unacceptable, medical management should be offered.
See recommendations 1.5.3 and 1.5.4 for details.
Supporting information
Healthcare professionals providing care for these women should be given
training in how to communicate sensitively and breaking bad news.
BMJ Learning has a podcast on the management of miscarriage in primary
care. The Royal College of Obstetricians and Gynaecologists also provides a
tutorial on early pregnancy loss – breaking bad news.
See The Association of Early Pregnancy Units and the Miscarriage
Association websites for available resources.
Individual trusts may also offer in-house training.
Next steps for management
Sarah agrees to expectant management as she knows her partner Steve will
be there to support her during the weeks ahead.
Sarah will need to know what to expect throughout the process and also when
she might need to get further help.
Question 4.3
What advice does Sarah need to equip her for the period of expectant
management?
Answer 4.3
You give information to Sarah about where to seek help in an emergency (for
example, if the amount of bleeding is concerning, there is unmanageable pain
or vomiting, or if she is feeling faint or dizzy).
You provide Sarah with oral and written information about what to expect
throughout the process (for example, in terms of pain and bleeding) and what
pain relief she might use. You advise her that if the bleeding and pain have
stopped in 7–14 days, indicating that the miscarriage has completed, she
should take a urine pregnancy test after 3 weeks and return to you if it is
positive.
If bleeding and pain have not started during this time or are persisting and/or
increasing, Sarah should contact her GP or early pregnancy assessment
service for a repeat scan and to discuss the further options available.
Rationale for this decision
For some women, a lengthy period of expectant management will not be
acceptable. Therefore it is important to designate an endpoint, after which
women could choose to undergo an intervention to make the miscarriage
complete more quickly.
Expectant management may be an unfamiliar concept to some women. It is
vital they are informed about the process, including what to expect in terms of
pain and bleeding, what pain-relieving measures they might use, and what
options are available in case the miscarriage does not complete.
See recommendations 1.5.6, 1.5.7 and 1.5.8 for details.
Question 4.4
What other information and support needs might Sarah have?
Answer 4.4
You recognise that at this stage Sarah will be coming to terms with her
miscarriage and may not be ready to think about the future. However, it is
important that Sarah has the information she needs so that she can access it
when she is ready.
You offer Sarah a follow-up appointment if the miscarriage proceeds as
expected, while acknowledging that she may not choose to accept the offer at
this time. Sarah may need support or counselling at a later time, and so the
information provided should include the details of websites and contact
numbers for support groups, counselling services and helpline numbers so
that she has easy access to this information for future reference.
You should provide some information about what to expect during the
recovery period – for example, when it will be possible to resume sexual
activity and/or try to conceive again, and what to do if she becomes pregnant
again. You give information about the likely impact of her treatment on future
fertility.
You ensure that sufficient time is made available to discuss all of the relevant
issues and that Sarah has enough written information to take away. This
might mean arranging an additional appointment if more time is needed.
Rationale for this decision
It is important that women are given details of support organisations so that
they can access support and counselling services when they are ready.
Women react to complications or the loss of a pregnancy in different ways.
Information and support should be given in a sensitive manner, taking into
account their individual circumstances and emotional response.
A miscarriage can mean different things to different women. While some
women will adjust with minimal distress, others will experience it as the loss of
a baby with all of the sadness and grief that that entails. Others may see it as
the loss of a potential relationship or the loss of an opportunity to become a
mother, and some may be fearful and concerned that they may not be able to
have children in the future. In a minority the miscarriage may precipitate a
psychological disorder such anxiety or depression. Pregnancy loss is not just
about physical recovery and being ready to become pregnant again. Good
care includes sensitivity to the psychological impact of miscarriage.
See recommendations 1.1.1 and 1.1.3 for details.
Supporting information
Helpful resources for women experiencing miscarriage are detailed below:
The Miscarriage Association, 01924 200 799
www.miscarriageassociation.org.uk
The Ectopic Pregnancy Trust, 020 7733 2653
www.ectopic.org.uk
Glossary
Early pregnancy
Pregnancy in the first trimester – that is, up to 13 completed weeks of
pregnancy.
Expectant management
A management approach in which treatment is not administered, with the aim
of seeing whether the condition will resolve naturally.
See the glossary on the NICE website for terms not defined above.
Other implementation tools
NICE has developed tools to help organisations implement the clinical
guideline on ectopic pregnancy and miscarriage (listed below). These are
available on the NICE website (NICE clinical guideline 154).
Costing report and costing template
Baseline assessment tool
Clinical audit tools and electronic audit tools
A practical guide to implementation, How to put NICE guidance into practice:
a guide to implementation for organisations, is also available.
Acknowledgements
NICE would like to thank the members of the National Collaborating Centre for
Women’s and Children’s Health and the Guideline Development Group,
especially:
Mary Ann Lumsden (Chair), Professor of Medical Education &
Gynaecology, University of Glasgow
Caroline Overton, Consultant Obstetrician and Gynaecologist, St Michael’s
University Hospital, Bristol
Helen Wilkinson, National Director of The Ectopic Pregnancy Trust, London
Karen Easton, Consultant Nurse Gynaecology, Gloucestershire Hospitals
NHS Foundation Trust
Nicola Davies, GP Partner, Bute House Medical Centre, Luton
Roy Farquharson, Consultant Gynaecologist, Liverpool Women’s Hospital
Roz Ullman, Senior Research Fellow and Clinical Lead (Midwifery),
National Collaborating Centre for Women’s and Children’s Health
Rupert Franklin, Project Manager, National Collaborating Centre for
Women’s and Children’s Health.