Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health (NCC-WCH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.
In this update, the recommendations on antenatal information, gestational age assessment, vitamin D supplementation, alcohol consumption, screening for haemoglobinopathies, screening for structural anomalies, screening for Down's syndrome, screening for chlamydia, gestational diabetes, preeclampsia, asymptomatic bacteriuria, placenta praevia, preterm birth, and fetal growth and well-being, as well as the schedule of antenatal appointments, have changed. In addition, some recommendations on smoking cessation and mental health have changed because NICE has produced public health guidance on smoking cessation (see the NICE public health guidance, 'Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities') and a clinical guideline on antenatal and postnatal mental health (NICE clinical guideline 45). Following NICE protocol, the developers have incorporated the relevant recommendations verbatim into this guideline and have marked them clearly. No other recommendations are affected.
New and updated recommendations are marked "New."
Woman-Centred Care and Informed Decision Making
The principles outlined in this section apply to all aspects of the Antenatal Care guideline.
New. Antenatal information should be given to pregnant women according to the following schedule.
At the first contact with a healthcare professional:
- Folic acid supplementation
- Food hygiene, including how to reduce the risk of a food-acquired infection
- Lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy
- All antenatal screening, including screening for haemoglobinopathies, the anomaly scan and screening for Down's syndrome, as well as risks and benefits of the screening tests.
At booking (ideally by 10 weeks):
- How the baby develops during pregnancy
- Nutrition and diet, including vitamin D supplementation for women at risk of vitamin D deficiency, and details of the 'Healthy Start' programme (www.healthystart.nhs.uk )
- Exercise, including pelvic floor exercises
- Place of birth (refer to 'Intrapartum care' [NICE clinical guideline 55], available from http://guidance.nice.org.uk/CG55 )
- Pregnancy care pathway
- Breastfeeding, including workshops
- Participant-led antenatal classes
- Further discussion of all antenatal screening
- Discussion of mental health issues (refer to 'Antenatal and postnatal mental health' [NICE clinical guideline 45], available from http://guidance.nice.org.uk/CG45 ).
Before or at 36 weeks:
- Breastfeeding information, including technique and good management practices that would help a woman succeed, such as detailed in the UNICEF 'Baby Friendly Initiative' (www.babyfriendly.org.uk )
- Preparation for labour and birth, including information about coping with pain in labour and the birth plan
- Recognition of active labour
- Care of the new baby
- Vitamin K prophylaxis
- Newborn screening tests
- Postnatal self-care
- Awareness of 'baby blues' and postnatal depression
At 38 weeks:
- Options for management of prolonged pregnancy. (See the clinical guideline 'Induction of labour' [NICE clinical guideline 70], available from http://guidance.nice.org.uk/CG70 )
This can be supported by information such as 'The pregnancy book' (Department of Health 2007) and the use of other relevant resources such as United Kingdom (UK) National Screening Committee publications and the Midwives Information and Resource Service (MIDIRS) information leaflets (www.infochoice.org ).
New. Information should be given in a form that is easy to understand and accessible to pregnant women with additional needs, such as physical, sensory or learning disabilities, and to pregnant women who do not speak or read English.
New. Information can also be given in other forms such as audiovisual or touch-screen technology; this should be supported by written information.
New. Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care. This information should include where they will be seen and who will undertake their care.
New. At each antenatal appointment, healthcare professionals should offer consistent information and clear explanations, and should provide pregnant women with an opportunity to discuss issues and ask questions.
New. Pregnant women should be offered opportunities to attend participant-led antenatal classes, including breastfeeding workshops.
New. Women's decisions should be respected, even when this is contrary to the views of the healthcare professional.
New. Pregnant women should be informed about the purpose of any test before it is performed. The healthcare professional should ensure the woman has understood this information and has sufficient time to make an informed decision. The right of a woman to accept or decline a test should be made clear.
New. Information about antenatal screening should be provided in a setting where discussion can take place; this may be in a group setting or on a one-to-one basis. This should be done before the booking appointment.
New. Information about antenatal screening should include balanced and accurate information about the condition being screened for.
Provision and Organisation of Care
Who Provides Care?
Midwife- and general practitioner (GP)-led models of care should be offered for women with an uncomplicated pregnancy. Routine involvement of obstetricians in the care of women with an uncomplicated pregnancy at scheduled times does not appear to improve perinatal outcomes compared with involving obstetricians when complications arise.
Continuity of Care
Antenatal care should be provided by a small group of healthcare professionals with whom the woman feels comfortable. There should be continuity of care throughout the antenatal period.
A system of clear referral paths should be established so that pregnant women who require additional care are managed and treated by the appropriate specialist teams when problems are identified.
Where Should Antenatal Appointments Take Place?
Antenatal care should be readily and easily accessible to all women and should be sensitive to the needs of individual women and the local community.
The environment in which antenatal appointments take place should enable women to discuss sensitive issues such as domestic violence, sexual abuse, psychiatric illness, and recreational drug use.
Documentation of Care
Structured maternity records should be used for antenatal care.
Maternity services should have a system in place whereby women carry their own case notes.
A standardised, national maternity record with an agreed minimum data set should be developed and used. This will help healthcare professionals to provide the recommended evidence-based care to pregnant women.
Frequency of Antenatal Appointments
A schedule of antenatal appointments should be determined by the function of the appointments. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of 10 appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of 7 appointments should be adequate.
Early in pregnancy all women should receive appropriate written information about the likely number, timing and content of antenatal appointments associated with different options of care and be given an opportunity to discuss this schedule with their midwife or doctor.
Each antenatal appointment should be structured and have focused content. Longer appointments are needed early in pregnancy to allow comprehensive assessment and discussion. Wherever possible, appointments should incorporate routine tests and investigations to minimize inconvenience to women.
Gestational Age Assessment
New. Pregnant women should be offered an early ultrasound scan between 10 weeks 0 days and 13 weeks 6 days to determine gestational age and to detect multiple pregnancies. This will ensure consistency of gestational age assessment and reduce the incidence of induction of labour for prolonged pregnancy.
New. Crown–rump length measurement should be used to determine gestational age. If the crown–rump length is above 84 mm, the gestational age should be estimated using head circumference.
Working During Pregnancy
Pregnant women should be informed of their maternity rights and benefits.
The majority of women can be reassured that it is safe to continue working during pregnancy. Further information about possible occupational hazards during pregnancy is available from the Health and Safety Executive (www.hse.gov.uk ).
A woman's occupation during pregnancy should be ascertained to identify those at increased risk through occupational exposure.
Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks' gestation, reduces the risk of having a baby with a neural tube defects (for example, anencephaly or spina bifida). The recommended dose is 400 micrograms per day.
Iron supplementation should not be offered routinely to all pregnant women. It does not benefit the mother's or the baby's health and may have unpleasant maternal side effects.
Pregnant women should be informed that vitamin A supplementation (intake above 700 micrograms) might be teratogenic and therefore it should be avoided. Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore consumption of these products should also be avoided.
New. All women should be informed at the booking appointment about the importance for their own and their baby's health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. In order to achieve this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Particular care should be taken to enquire as to whether women at greatest risk are following advice to take this daily supplement. These include:
- Women of South Asian, African, Caribbean or Middle Eastern family origin
- Women who have limited exposure to sunlight, such as women who are predominantly housebound, or usually remain covered when outdoors
- Women who eat a diet particularly low in vitamin D, such as women who consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal
- Women with a pre-pregnancy body mass index above 30 kg/m2
Pregnant women should be offered information on how to reduce the risk of listeriosis by:
- Drinking only pasteurised or ultra-high-temperature processed (UHT) milk
- Not eating ripened soft cheese such as Camembert, Brie and blue-veined cheese (there is no risk with hard cheeses such as Cheddar, or cottage cheese and processed cheese)
- Not eating pâté (of any sort, including vegetable)
- Not eating uncooked or undercooked ready-prepared meals
Pregnant women should be offered information on how to reduce the risk of salmonella infection by:
- Avoiding raw or partially cooked eggs or food that may contain them (such as mayonnaise)
- Avoiding raw or partially cooked meat, especially poultry
Few medicines have been established as safe to use in pregnancy. Prescription medicines should be used as little as possible during pregnancy and should be limited to circumstances in which the benefit outweighs the risk.
Pregnant women should be informed that few over-the-counter medicines have been established as being safe to take in pregnancy. Over-the-counter medicines should be used as little as possible during pregnancy.
Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy.
Exercise in Pregnancy
Pregnant women should be informed that beginning or continuing a moderate course of exercise during pregnancy is not associated with adverse outcomes.
Pregnant women should be informed of the potential dangers of certain activities during pregnancy, for example, contact sports, high-impact sports, and vigorous racquet sports that may involve the risk of abdominal trauma, falls or excessive joint stress, and scuba diving, which may result in fetal birth defects and fetal decompression disease.
Sexual Intercourse in Pregnancy
Pregnant woman should be informed that sexual intercourse in pregnancy is not known to be associated with any adverse outcomes.
Alcohol Consumption in Pregnancy
New. Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.
New. If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 mL] of spirits. One small [125 mL] glass of wine is equal to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby.
New. Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.
Smoking in Pregnancy*
*Note: The recommendations in this section are from the NICE public health guidance on smoking cessation (http://guidance.nice.org.uk/PH10 ). They replace the recommendation from the original Antenatal care clinical guideline (2003). Following NICE protocol, the recommendations have been incorporated verbatim into this guideline. Where one of these recommendations appears, it is indicated as [NICE PH 2008].
New. At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to secondhand smoke. Address any concerns she and her partner or family may have about stopping smoking. [NICE PH 2008]
Pregnant women should be informed about the specific risks of smoking during pregnancy (such as the risk of having a baby with low birthweight and preterm birth). The benefits of quitting at any stage should be emphasised.
New. Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local National Health Service (NHS) Stop Smoking Services and the NHS pregnancy smoking helpline, by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services. [NICE PH 2008]
New. Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond. [NICE PH 2008]
New. Discuss the risks and benefits of nicotine replacement therapy (NRT) with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription. [NICE PH 2008]
New. Advise women using nicotine patches to remove them before going to bed. [NICE PH 2008]
This supersedes NICE technology appraisal guidance 39 on NRT and bupropion. [NICE PH 2008]
Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking.
Cannabis Use in Pregnancy
The direct effects of cannabis on the fetus are uncertain but may be harmful. Cannabis use is associated with smoking, which is known to be harmful; therefore, women should be discouraged from using cannabis during pregnancy.
Air Travel During Pregnancy
Pregnant women should be informed that long-haul air travel is associated with an increased risk of venous thrombosis, although whether or not there is additional risk during pregnancy is unclear. In the general population, wearing correctly fitted compression stockings is effective at reducing the risk.
Car Travel During Pregnancy
Pregnant women should be informed about the correct use of seat belts (that is, three-point seatbelts "above and below the bump, not over it").
Travelling Abroad During Pregnancy
Pregnant women should be informed that if they are planning to travel abroad, they should discuss considerations such as flying, vaccinations, and travel insurance with their midwife or doctor.
Management of Common Symptoms of Pregnancy
Nausea and Vomiting in Early Pregnancy
Women should be informed that most cases of nausea and vomiting in pregnancy will resolve spontaneously within 16 to 20 weeks of gestation and that nausea and vomiting are not usually associated with a poor pregnancy outcome. If a woman requests or would like to consider treatment, the following interventions appear to be effective in reducing symptoms:
- P6 (wrist) acupressure
Information about all forms of self-help and non-pharmacological treatments should be made available for pregnant women who have nausea and vomiting.
Women who present with symptoms of heartburn in pregnancy should be offered information regarding lifestyle and diet modification.
Antacids may be offered to women whose heartburn remains troublesome despite lifestyle and diet modification.
Women who present with constipation in pregnancy should be offered information regarding diet modification, such as bran or wheat fibre supplementation.
In the absence of evidence of the effectiveness of treatments for haemorrhoids in pregnancy, women should be offered information concerning diet modification. If clinical symptoms remain troublesome, standard haemorrhoid creams should be considered.
Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.
Women should be informed that an increase in vaginal discharge is a common physiological change that occurs during pregnancy. If this is associated with itch, soreness, offensive smell, or pain on passing urine there may be an infective cause and investigation should be considered.
A 1-week course of a topical imidazole is an effective treatment and should be considered for vaginal candidiasis infections in pregnant women.
The effectiveness and safety of oral treatments for vaginal candidiasis in pregnancy is uncertain and these treatments should not be offered.
Women should be informed that exercising in water, massage therapy and group or individual back care classes might help to ease backache during pregnancy.
Clinical Examination of Pregnant Women
Measurement of weight and Body Mass Index
Maternal weight and height should be measured at the first antenatal appointment, and the woman's body mass index calculated (weight [kg]/height[m]2).
Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced.
Routine breast examination during antenatal care is not recommended for the promotion of postnatal breastfeeding.
Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended.
Female Genital Mutilation
Pregnant women who have had female genital mutilation should be identified early in antenatal care through sensitive enquiry. Antenatal examination will then allow planning of intrapartum care.
Healthcare professionals need to be alert to the symptoms or signs of domestic violence and women should be given the opportunity to disclose domestic violence in an environment in which they feel secure.
Prediction, Detection and Initial Management of Mental Disorders*
*Note: The recommendations in this section are from the NICE clinical guideline on antenatal and postnatal mental health (see http://guidance.nice.org.uk/CG45 ). They replace the recommendations from the original Antenatal care clinical guideline (2003). Following NICE protocol, the recommendations have been incorporated verbatim into this guideline. Where one of these recommendations appears, it is indicated as [NICE CG 2007].
New. In all communications (including initial referral) with maternity services, healthcare professionals should include information on any relevant history of mental disorder. [NICE CG 2007]
New. At a woman's first contact with services in both the antenatal and the postnatal periods, healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask about:
- Past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in the postnatal period and severe depression
- Previous treatment by a psychiatrist/specialist mental health team, including inpatient care
- A family history of perinatal mental illness
Other specific predictors, such as poor relationships with her partner, should not be used for the routine prediction of the development of a mental disorder. [NICE CG 2007]
New. At a woman's first contact with primary care, at her booking visit and postnatally (usually at 4 to 6 weeks and 3 to 4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression.
- During the past month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
A third question should be considered if the woman answers 'yes' to either of the initial questions.
- Is this something you feel you need or want help with? [NICE CG 2007]
New. After identifying a possible mental disorder in a woman during pregnancy or the postnatal period, further assessment should be considered, in consultation with colleagues if necessary.
- If the healthcare professional or the woman has significant concerns, the woman should normally be referred for further assessment to her GP.
- If the woman has, or is suspected to have, a severe mental illness (for example, bipolar disorder or schizophrenia), she should be referred to a specialist mental health service, including, if appropriate, a specialist perinatal mental health service. This should be discussed with the woman and preferably with her GP.
- The woman's GP should be informed in all cases in which a possible current mental disorder or a history of significant mental disorder is detected, even if no further assessment or referral is made. [NICE CG 2007]
Screening for Haematological Conditions
Pregnant women should be offered screening for anaemia. Screening should take place early in pregnancy (at the booking appointment) and at 28 weeks when other blood screening tests are being performed. This allows enough time for treatment if anaemia is detected.
Haemoglobin levels outside the normal United Kingdom range for pregnancy (that is, 11 g/100 mL at first contact and 10.5 g/100 mL at 28 weeks) should be investigated and iron supplementation considered if indicated.
Blood Grouping and Red-Cell Alloantibodies
Women should be offered testing for blood group and rhesus D status in early pregnancy.
It is recommended that routine antenatal anti-D prophylaxis is offered to all non-sensitised pregnant women who are rhesus D-negative. (See the technology appraisal guidance 'Guidance on the use of routine antenatal anti-D prophylaxis for RhD-negative women' (NICE technology appraisal 156 http://guidance.nice.org.uk/TA156 ).
Women should be screened for atypical red-cell alloantibodies in early pregnancy and again at 28 weeks regardless of their rhesus D status.
Pregnant women with clinically significant atypical red-cell alloantibodies should be offered referral to a specialist centre for further investigation and advice on subsequent antenatal management.
If a pregnant woman is rhesus D-negative, consideration should be given to offering partner testing to determine whether the administration of anti-D prophylaxis is necessary.
Screening for Haemoglobinopathies
New. Pre-conception counselling (supportive listening, advice-giving and information) and carrier testing should be available to all women who are identified as being at higher risk of haemoglobinopathies, using the Family Origin Questionnaire from the NHS Antenatal and Newborn Screening Programme.
New. Information about screening for sickle cell diseases and thalassaemias, including carrier status and the implications of these, should be given to pregnant women at the first contact with a healthcare professional. Refer to the section "Antenatal Information," above, for more information about giving antenatal information.
New. Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks). The type of screening depends upon the prevalence and can be carried out in either primary or secondary care.
New. Where prevalence of sickle cell disease is high (fetal prevalence above 1.5 cases per 10,000 pregnancies), laboratory screening (preferably high-performance liquid chromatography) should be offered to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia.
New. Where prevalence of sickle cell disease is low (fetal prevalence 1.5 cases per 10,000 pregnancies or below), all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire.
- If the Family Origin Questionnaire indicates a high risk of sickle cell disorders, laboratory screening (preferably high-performance liquid chromatography) should be offered.
- If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening (preferably high-performance liquid chromatography) should be offered.
New. If the woman is identified as a carrier of a clinically significant haemoglobinopathy then the father of the baby should be offered counselling and appropriate screening without delay.
For more details about haemoglobinopathy variants refer to the NHS Antenatal and Newborn Screening Programme.
Screening for Fetal Anomalies
Screening for Structural Anomalies
New. Ultrasound screening for fetal anomalies should be routinely offered, normally between 18 weeks 0 days and 20 weeks 6 days.
New. At the first contact with a healthcare professional, women should be given information about the purpose and implications of the anomaly scan to enable them to make an informed choice as to whether or not to have the scan. The purpose of the scan is to identify fetal anomalies and allow:
- Reproductive choice (termination of pregnancy)
- Parents to prepare (for any treatment/disability/palliative care/termination of pregnancy)
- Managed birth in a specialist centre
- Intrauterine therapy
New. Women should be informed of the limitations of routine ultrasound screening and that detection rates vary by the type of fetal anomaly, the woman's body mass index and the position of the unborn baby at the time of the scan.
New. If an anomaly is detected during the anomaly scan pregnant women should be informed of the findings to enable them to make an informed choice as to whether they wish to continue with the pregnancy or have a termination of pregnancy.
New. Fetal echocardiography involving the four-chamber view of the fetal heart and outflow tracts is recommended as part of the routine anomaly scan.
New. Routine screening for cardiac anomalies using nuchal translucency is not recommended.
New. When routine ultrasound screening is performed to detect neural tube defects, alpha-fetoprotein testing is not required.
New. Participation in regional congenital anomaly registers and/or UK National Screening Committee-approved audit systems is strongly recommended to facilitate the audit of detection rates.
Screening for Down's Syndrome
New. All pregnant women should be offered screening for Down's syndrome. Women should understand that it is their choice to embark on screening for Down's syndrome.
New. Screening for Down's syndrome should be performed by the end of the first trimester (13 weeks 6 days), but provision should be made to allow later screening (which could be as late as 20 weeks 0 days) for women booking later in pregnancy.
New. The 'combined test' (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down's syndrome between 11 weeks 0 days and 13 weeks 6 days. For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.
New. When it is not possible to measure nuchal translucency, owing to fetal position or raised body mass index, women should be offered serum screening (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days.
New. Information about screening for Down's syndrome should be given to pregnant women at the first contact with a healthcare professional. This will provide the opportunity for further discussion before embarking on screening. Refer to "Antenatal Information," above, for more information about giving antenatal information. Specific information should include:
- The screening pathway for both screen-positive and screen-negative results
- The decisions that need to be made at each point along the pathway and their consequences
- The fact that screening does not provide a definitive diagnosis and a full explanation of the risk score obtained following testing
- Information about chorionic villus sampling and amniocentesis
- Balanced and accurate information about Down's syndrome
New. If a pregnant woman receives a screen-positive result for Down's syndrome, she should have rapid access to appropriate counselling by trained staff.
New. The routine anomaly scan (at 18 weeks 0 days to 20 weeks 6 days) should not be routinely used for Down's syndrome screening using soft markers.
New. The presence of an isolated soft marker, with the exception of increased nuchal fold, on the routine anomaly scan, should not be used to adjust the a priori risk for Down's syndrome.
New. The presence of an increased nuchal fold (6 millimetres or above) or two or more soft markers on the routine anomaly scan should prompt the offer of a referral to a fetal medicine specialist or an appropriate healthcare professional with a special interest in fetal medicine.
Screening for Infections
New. Women should be offered routine screening for asymptomatic bacteriuria by midstream urine culture early in pregnancy. Identification and treatment of asymptomatic bacteriuria reduces the risk of pyelonephritis.
Asymptomatic Bacterial Vaginosis
Pregnant women should not be offered routine screening for bacterial vaginosis because the evidence suggests that the identification and treatment of asymptomatic bacterial vaginosis does not lower the risk for preterm birth and other adverse reproductive outcomes.
New. At the booking appointment, healthcare professionals should inform pregnant women younger than 25 years about the high prevalence of chlamydia infection in their age group and give details of their local National Chlamydia Screening Programme (www.chlamydiascreening.nhs.uk ).
New. Chlamydia screening should not be offered as part of routine antenatal care.
The available evidence does not support routine cytomegalovirus screening in pregnant women, and it should not be offered.
Hepatitis B Virus
Serological screening for hepatitis B should be offered to pregnant women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to-child transmission.
Hepatitis C Virus
Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence on its effectiveness and cost effectiveness.
Pregnant women should be offered screening for HIV infection early in antenatal care because appropriate antenatal interventions can reduce mother-to- child transmission of HIV infection.
A system of clear referral paths should be established in each unit or department so that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams.
Rubella-susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies.
Group B Streptococcus
Pregnant women should not be offered routine antenatal screening for group B streptococcus (GBS) because evidence of its clinical effectiveness and cost effectiveness remains uncertain.
Screening for syphilis should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and baby.
Because syphilis is a rare condition in the UK and a positive result does not necessarily mean that a woman has syphilis, clear paths of referral for the management of women testing positive for syphilis should be established.
Routine antenatal serological screening for toxoplasmosis should not be offered because the harms of screening may outweigh the potential benefits.
Pregnant women should be informed of primary prevention measures to avoid toxoplasmosis infection, such as:
- Washing hands before handling food
- Thoroughly washing all fruit and vegetables, including ready-prepared salads, before eating
- Thoroughly cooking raw meats and ready-prepared chilled meals
- Wearing gloves and thoroughly washing hands after handling soil and gardening
- Avoiding cat faeces in cat litter or in soil
Screening for Clinical Conditions
New. Screening for gestational diabetes using risk factors is recommended in a healthy population. At the booking appointment, the following risk factors for gestational diabetes should be determined:
- Body mass index above 30 kg/m2
- Previous macrosomic baby weighing 4.5 kg or above
- Previous gestational diabetes (refer to 'Diabetes in pregnancy' [NICE clinical guideline 63], available from http://guidance.nice.org.uk/CG63 )
- Family history of diabetes (first-degree relative with diabetes)
- Family origin with a high prevalence of diabetes:
- South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh)
- Black Caribbean
- Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
Women with any one of these risk factors should be offered testing for gestational diabetes (refer to 'Diabetes in pregnancy' [NICE clinical guideline 63], http://guidance.nice.org.uk/CG63 ).
New. In order to make an informed decision about screening and testing for gestational diabetes, women should be informed that:
- In most women, gestational diabetes will respond to changes in diet and exercise
- Some women (between 10% and 20%) will need oral hypoglycaemic agents or insulin therapy if diet and exercise are not effective in controlling gestational diabetes
- If gestational diabetes is not detected and controlled there is a small risk of birth complications such as shoulder dystocia
- A diagnosis of gestational diabetes may lead to increased monitoring and interventions during both pregnancy and labour
New. Screening for gestational diabetes using fasting plasma glucose, random blood glucose, glucose challenge test and urinalysis for glucose should not be undertaken.
New. Blood pressure measurement and urinalysis for protein should be carried out at each antenatal visit to screen for pre-eclampsia.
New. At the booking appointment, the following risk factors for pre-eclampsia should be determined:
- Age 40 years or older
- Pregnancy interval of more than 10 years
- Family history of pre-eclampsia
- Previous history of pre-eclampsia
- Body mass index 30 kg/m2 or above
- Pre-existing vascular disease such as hypertension
- Pre-existing renal disease
- Multiple pregnancy
More frequent blood pressure measurements should be considered for pregnant women who have any of the above risk factors.
New. The presence of significant hypertension and/or proteinuria should alert the healthcare professional to the need for increased surveillance.
New. Blood pressure should be measured as outlined below:
- Remove tight clothing, ensure arm is relaxed and supported at heart level
- Use cuff of appropriate size
- Inflate cuff to 20–30 mmHg above palpated systolic blood pressure
- Lower column slowly, by 2 mmHg per second or per beat
- Read blood pressure to the nearest 2 mmHg
- Measure diastolic blood pressure as disappearance of sounds (phase V)
New. Hypertension in which there is a single diastolic blood pressure of 110 mmHg or two consecutive readings of 90 mmHg at least 4 hours apart and/or significant proteinuria (1+) should prompt increased surveillance.
New. If the systolic blood pressure is above 160 mmHg on two consecutive readings at least 4 hours apart, treatment should be considered.
New. All pregnant women should be made aware of the need to seek immediate advice from a healthcare professional if they experience symptoms of pre-eclampsia. Symptoms include:
- Severe headache
- Problems with vision, such as blurring or flashing before the eyes
- Severe pain just below the ribs
- Sudden swelling of the face, hands or feet
New. Although there is a great deal of material published on alternative screening methods for pre-eclampsia, none of these has satisfactory sensitivity and specificity, and therefore they are not recommended.
New. Routine screening for preterm labour should not be offered.
New. Because most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born, only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 32 weeks. If the transabdominal scan is unclear, a transvaginal scan should be offered.
Fetal Growth and Well-being
New. Symphysis–fundal height should be measured and recorded at each antenatal appointment from 24 weeks.
New. Ultrasound estimation of fetal size for suspected large-for-gestational-age unborn babies should not be undertaken in a low-risk population.
New. Routine Doppler ultrasound should not be used in low-risk pregnancies.
Fetal presentation should be assessed by abdominal palpation at 36 weeks or later, when presentation is likely to influence the plans for the birth. Routine assessment of presentation by abdominal palpation should not be offered before 36 weeks because it is not always accurate and may be uncomfortable.
Suspected fetal malpresentation should be confirmed by an ultrasound assessment.
Routine formal fetal-movement counting should not be offered.
Auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value and routine listening is therefore not recommended. However, when requested by the mother, auscultation of the fetal heart may provide reassurance.
The evidence does not support the routine use of antenatal electronic fetal heart rate monitoring (cardiotocography) for fetal assessment in women with an uncomplicated pregnancy, and, therefore, it should not be offered.
The evidence does not support the routine use of ultrasound scanning after 24 weeks of gestation; therefore, it should not be offered.
Management of Specific Clinical Conditions
Pregnancy After 41 Weeks
Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping.
Women with uncomplicated pregnancies should be offered induction of labour beyond 41 weeks. (see the clinical guideline 'Induction of labour' http://guidance.nice.org.uk/CG70 .)
From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth.
Breech Presentation at Term
All women who have an uncomplicated singleton breech pregnancy at 36 weeks should be offered external cephalic version. Exceptions include women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding and medical conditions.
Where it is not possible to schedule an appointment for external cephalic version at 37 weeks, it should be scheduled at 36 weeks.