Recurring concern

Inadequate guidance for managing large babies in pregnancy and birth

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First reported 12 Apr 2019•Latest report 9 Nov 2021

Definition

What this concern includes

Includes failures in national, Trust or professional guidance specifically governing the assessment, risk communication, counselling, monitoring, delivery planning and management of suspected large babies or fetal macrosomia during pregnancy and birth, including unclear thresholds, conflicting approaches and absent guidance.

Not included

Excludes generic maternity guidance, staffing, communication or governance deficiencies that are not specifically tied to managing suspected large babies.
Excludes pregnancy and birth risk-assessment or planning failures where large-baby management guidance is not the deficient control.
Excludes diabetes management and shoulder-dystocia care unless the assertion specifically concerns guidance for suspected large babies or fetal macrosomia.
Excludes individual clinical decisions made contrary to clear and available large-baby guidance when the guidance itself is not deficient.

Reports: 3
Individual concerns: 3
Date range: 2019–2021
Stated actions: 0

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care1

Gateshead Health NHS Foundation Trust1

National Institute for Health and Care Excellence1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

9 Nov2021
Buckinghamshire
Concerns raised1
1. Lack of a clear national definition of large-for-gestational-age babies
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  No further action is required because introducing a cutoff could convey inappropriate certainty or reassurance despite diagnostic uncertainty.
  Stated by National Institute for Health and Care ExcellenceNo action considered necessary
AI-generated summary

Mollie Daisy DIMMOCK · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mollie Daisy DIMMOCK died 34 minutes after delivery at Stoke Mandeville Hospital from perinatal asphyxia caused by hypoxia associated with umbilical cord compression during shoulder dystocia. The report identified uncertainty in national guidance because there is no definition of a large-for-gestational-age baby, creating variation in decisions about delivery mode and management of shoulder dystocia.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clear national definition of large-for-gestational-age babies
Wider context from the report
“NICE Guidance NG121 last updated 25 April 2019 relates to intrapartum care for women with existing medical conditions or obstetric complications and their babies. Within this Guidance, whilst there is reference at paragraph 1.17 to guidance in respect mode of birth for large-for-gestational-age babies, there is no definition of a large-for-gestational-age baby in the Guidance. There does not appear to be any national guidance or accepted definition of large-for-gestational-age such that application of the Guidance is open to interpretation and variation depending upon an NHS Trust's own policies and guidance, and, in turn, the interpretation of obstetricians and other clinicians advising potential parents in anticipation of delivery modes. It is clear that NG121 is intended to provide guidance in relation to many potential scenarios which may impact upon care and mode of delivery decisions. The uncertainty surrounding when section 1.17 of the Guidance should be relevant arises through the lack of a definition of a large-for-gestational-age baby. Application of section 1.17 of the Guidance includes consideration of shoulder dystocia and options for continuing labour or caesarean section relevant to both the life of the mother and the baby. ”
Source location
Mollie Daisy DIMMOCK · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No further action is required because introducing a cutoff could convey inappropriate certainty or reassurance despite diagnostic uncertainty.

Verbatim wording from the response
“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.”

Source location
2021-0379-Response-from-NICE_Published
Page 1 · response
Published 16 November 2021
Open published response
20 Jul2021
Sunderland
Concerns raised1
1. Lack of national guidance on management and counselling thresholds for large babies in pregnancy
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  Existing NICE guidance adequately covers counselling and birth options for women with suspected large babies.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
1. Position
  Available evidence is insufficient to recommend induction over expectant management for suspected fetal macrosomia without diabetes.
  Stated by Department of Health and Social CareUnable to act
AI-generated summary

Vinnie William Ord Dodds · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Vinnie William Ord Dodds died at Sunderland Royal Hospital on 14 April 2020 after major shoulder dystocia was recognised following a forceps delivery; he could not be successfully resuscitated. The concerns related to antenatal care, including the lack of national guidance for managing large babies, the content of counselling about shoulder dystocia risks, the timing of glucose tolerance testing, and the omission of the risk of death from shoulder dystocia in current patient information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance on management and counselling thresholds for large babies in pregnancy
Wider context from the report
“Although shoulder dystocia is a medical emergency for which staff are trained, it was the elements of the mother’s antenatal care which gave rise to concerns notwithstanding the obvious impact of the pandemic. The Trust carried out and acted on a full review. However, there are concerns of wider significance: - 1. There is no national guidance for the management of large babies in pregnancy, unless diabetes is present, so it may not be possible to produce a safety recommendation to advise mothers with a suspected large baby. a) should counselling/management be based on 'macrosomia' (i.e. weight estimated >4500g for diabetes and >5000g for non-diabetic) or alternatively should it now be applied to all babies estimated to be >90th centile by scan >34 weeks? b) in counselling women about risk of shoulder dystocia in LGA, should this include formal mention of the rare risk of foetal death and if women are to be fully informed should this be balanced by the rare risk of maternal death with an elective Caesarean section (the only other mode of delivery to be considered)? c) in fact, point b is highly relevant to counselling ALL women about the risks associated with shoulder dystocia and would be very useful to rationalise. 2. NICE in 2015 indicated a glucose tolerance test at 24-28 weeks. Should the optimum be at 26 weeks? 3. The risk of death from shoulder dystocia was not discussed and is not included in the current RCOG shoulder dystocia patient information leaflet (RCOG 2013). ”
Source location
Vinnie William Ord Dodds · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing NICE guidance adequately covers counselling and birth options for women with suspected large babies.

Verbatim wording from the response
“1.17.3 Offer women in labour whose babies are suspected to be large for gestational age a choice between continuing labour, including augmented labour, and caesarean section.”

Source location
2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 3 · response
Published 22 July 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Available evidence is insufficient to recommend induction over expectant management for suspected fetal macrosomia without diabetes.

Verbatim wording from the response
“The aim of the evidence review was to determine if Induction of Labour for suspected fetal macrosomia at, or after, 35 weeks gestation, has benefits and reduces the risk of adverse outcomes for the mother and the baby, compared to expectant management. The review looked at all women apart from those with treated diabetes (pre-existing or gestational). The review looked at the following outcomes; third/fourth degree tears; shoulder dystocia; perinatal death; hypoxic ischaemic encephalopathy; maternal satisfaction; brachial plexus injury; and, caesarean birth.”

Source location
2021-0249-Response-from-Dept-of-Health-and-Social-Care_Published
Page 4 · response
Published 22 July 2021
Open published response
12 Apr2019
Gateshead and South Tyneside
Concerns raised1
1. Lack of clear and consistently applied Trust guidance for managing larger babies
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

ARCHIE RAY GRIEVES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear and consistently applied Trust guidance for managing larger babies
Wider context from the report
“16.Further evidence adduced indicated there was an apparent misunderstanding and/or misinterpretation even level of conflict amongst Obstetric Consultants as to the Trust’s own guidance on potential large baby development risks and the alternative strategies to be followed and in a timely manner for the safe delivery of such children. 17.Evidence was received that large babies were not identified as such a great concern as small babies, that mothers of the latter would be monitored and advised and quite properly so but larger babies size being more indicative of the healthy presentation and more positive outcome, were accordingly considered less at risk 18.Obstetric approach differed depending on the Consultants personal policy and consequently a more cohesive leadership Departmental approach was potentially missing 19.In addition it was acknowledged that there was a study nationally , currently being undertaken with reference to the management of larger babies and their birth. At the time of this matter and indeed now the outcome of that study was still awaited and no definitive guide appears to exist within the Trust. 20.The consequences of this lack of cohesive policy lends itself to a lack of clear understanding and consistent approach which should be the guideline in all cases and for the benefit of all staff both medical and nursing. ”
Source location
ARCHIE RAY GRIEVES · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of a clear national definition of large-for-gestational-age babies

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of national guidance on management and counselling thresholds for large babies in pregnancy

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of clear and consistently applied Trust guidance for managing larger babies

Respondent positions 1

Respondent positions 2